Epidemiology and treatment of priapism in sickle cell disease.

Ischemic priapism is a common but underrecognized morbidity affecting about 33% of adult men with sickle cell disease (SCD). The onset of priapism occurs in the prepubertal period and tends to be recurrent with increasing age. Significantly, priapism is associated with an unrecognized high burden of mental duress and sexual dysfunctions. The diagnosis of priapism is clinical. Many episodes of priapism will resolve spontaneously, but when an episode lasts longer than 4 hours, the episode is considered a urologic emergency requiring quick intervention with either corporal aspiration or shunt surgery. Only 3 randomized clinical trials (stilbesterol, ephedrine or etilefrine, and sildenafil) have been conducted for secondary priapism prevention in SCD. All 3 trials were limited with small sample sizes, selection biases, and inconclusive results after completion. The current molecular understanding of the pathobiology of priapism suggests a relative nitric oxide (NO) deficiency secondary to chronic hemolysis in SCD and associated phosphodiesterase type 5 dysregulation. We posit an increase in NO levels will restore the normal homeostatic relationship between voluntary erection and detumescence. Currently, 2 randomized phase 2 trials (1 double-blind, placebo-controlled trial and 1 open-label, single-arm intervention) are being conducted for secondary priapism prevention in men at high risk for recurrent priapism (NCT03938454 and NCT05142254). We review the epidemiology and pathobiology of priapism, along with mechanistic therapeutic approaches for secondary prevention of priapism in SCD.

Effects of adding hypertonic saline solutions and/or etilefrine to standard diuretics therapy in cirrhotic patients with ascites.

OBJECTIVE: The renin-angiotensin-aldosterone system (RAAS) activation is the milestone in ascites formation. Hypertonic saline solution (HSS) has attracted considerable interest over the last years in ascites control. Other therapeutic models and concepts have been introduced to overcome diuretic resistance and control ascites. We aimed to evaluate the effects of adding HSS infusion and/or etilefrine to oral diuretics therapy on inflammatory and metabolic pathways, renal and systemic hemodynamics, and clinical outcomes by estimating the changes in selected biochemical and biological markers in cirrhotic patients with ascites. PATIENTS AND METHODS: Ninety cirrhotic patients with ascites were studied after administration of HSS infusion (n=25) or etilefrine tablets (n=25), or both (n=25) plus standard diuretics therapy (SDT), or SDT alone (n=15). Serum levels of interleukin-6 (IL-6), aldosterone, leptin, and C-reactive protein (CRP). Hepatic and renal functions were measured at baseline, after eight days, then after 38 days. RESULTS: A significant reduction in serum IL-6, serum aldosterone, Child-Pugh score, MELD-Na score, and increase in serum leptin, and mean arterial pressure (p<0.05) were noted after 38 days in HSS and combination groups. A significant improvement in diuresis, in all groups, urinary sodium excretion, and creatinine clearance (p<0.05) were increased after 38 days in all groups except the SDT group. CONCLUSIONS: The results suggest that HSS, etilefrine, and their combination plus SDT are superior to SDT alone for ascites control and can exert some benefits on clinical, systemic, inflammatory, renal, and metabolic pathways without renal or hepatic dysfunction.

Treatments for priapism in boys and men with sickle cell disease.

BACKGROUND: Sickle cell disease comprises a group of genetic haemoglobin disorders. The predominant symptom associated with sickle cell disease is pain resulting from the occlusion of small blood vessels by abnormally 'sickle-shaped' red blood cells. There are other complications, including chronic organ damage and prolonged painful erection of the penis, known as priapism. Severity of sickle cell disease is variable, and treatment is usually symptomatic. Priapism affects up to half of all men with sickle cell disease, however, there is no consistency in treatment. We therefore need to know the best way of treating this complication in order to offer an effective interventional approach to all affected individuals. This is an update of a previously published review. OBJECTIVES: To assess the benefits and risks of different treatments for stuttering (repeated short episodes) and fulminant (lasting for six hours or more) priapism in sickle cell disease. SEARCH METHODS: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Haemoglobinopathies Trials Register, which comprises references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. We also searched trial registries. Date of the most recent search of the Group's Haemoglobinopathies Trials Register: 09 September 2019. Date of most recent search of trial registries and of Embase: 01 October 2019. SELECTION CRITERIA: All randomised or quasi-randomised controlled trials comparing non-surgical or surgical treatment with placebo or no treatment, or with another intervention for stuttering or fulminant priapism. DATA COLLECTION AND ANALYSIS: The authors independently extracted data and assessed the risk of bias of the trials. MAIN RESULTS: Three trials with 102 participants were identified and met the criteria for inclusion in this review. These trials compared stilboestrol to placebo, sildenafil to placebo and a four-arm trial which compared ephedrine or etilefrine to placebo and ranged in duration from two weeks to six months. All of the trials were conducted in an outpatient setting in Jamaica, Nigeria and the UK. None of the trials measured our first primary outcome, detumescence. However, all three trials reported on the reduction in frequency of stuttering priapism, our second primary outcome; and from the evidence included in this review, we are uncertain whether stilboestrol, etilefrine or ephedrine reduce the frequency of stuttering priapism as the certainty of the evidence has been assessed as very low. Additionally, we conclude that sildenafil may make little or no difference (low-certainty evidence). Two trials reported on immediate side effects and we are uncertain whether etilefrine or ephedrine reduce the occurrence of these (very low-certainty of evidence) and also conclude that sildenafil may make little or no difference in side effects (low-quality evidence). Given that all of the trials were at risk of bias and all had low participant numbers, we considered the certainty of the evidence to be low to very low. AUTHORS' CONCLUSIONS: There is a lack of evidence for the benefits or risks of the different treatments for both stuttering and fulminant priapism in sickle cell disease. This systematic review has clearly identified the need for well-designed, adequately-powered, multicentre randomised controlled trials assessing the effectiveness of specific interventions for priapism in sickle cell disease.

Successful Management of Chylothorax With Etilefrine: Case Report in 2 Pediatric Patients.

Chylothorax is defined as the accumulation of chyle within the pleural space. Originally described in 1917 by Pisek, it is the most common cause of pleural effusion in the neonatal period. The leading cause of chylothorax is laceration of the thoracic duct during surgery, which occurs in 0.85% to 6.6% of children undergoing cardiothoracic surgery. Few authors of reports in the literature have looked at etilefrine, a relatively unknown sympathomimetic, as an option for the medical treatment of chylothorax. In this case report, we review the clinical course of 2 infants with type III esophageal atresia who developed chylothorax after thoracic surgery and were successfully treated with intravenous etilefrine after failing initial dietary and pharmacological management.

New Combined Medical Treatment With Etilefrine and Octreotide for Chylothorax After Esophagectomy: A Case Report and Review of the Literature.

Postoperative chylothorax is a rare but well-known complication of general thoracic surgery. Medical treatment of chylothorax was reported in the past, but there is still considerable controversy on the appropriate management strategies.Two patients with esophageal cancer underwent esophagectomy, 2-field lymph node dissection, and resection of thoracic duct together with ileocolic reconstruction via the retrosternal route at our hospital. Chylothorax developed on the 32nd postoperative day (POD) in 1 patient and the 12th POD in the other, manifesting as a change in the character of thoracic drainage to turbid white. Both were immediately started on octreotide (300 µg/ day) and etilefrine (120 mg/day). When the amount of pleural effusion decreased to <50 mL/day, we performed pleurodesis with Picibanil (OK432). Thereafter, the patients gradually made satisfactory progress and resumed oral food intake, and the thoracotomy tubes were eventually removed. They have remained recurrence-free at the time of writing.In this report, we demonstrated the clinical efficacy of etilefrine for the management of postesophagectomy chylothorax. New medical treatment options for this condition are now broad and the usefulness of combined therapy consisting of a sclerosing agent, etilefrine, and octreotide is underscored, regardless of the status of the thoracic duct.

Uso de etilefrina y fluidos intravenosos para el manejo de la hipotensión arterial secundaria a la anestesia raquídea, en pacientes sometidas a cesáreas en el Instituto Nacional Materno Perinatal 2013 / Use of etilefrine and intravenous fluids for the management of secondary arterial hypotension to spinal anesthesia in patients submitted to cesarean section at the National Institute Materno Perinatal 2013

OBJETIVO: Determinar si el uso de etilefrina y fluidos intravenosos previene la hipotensión arterial secundaria a la anestesia raquídea, en pacientes sometidas a cesáreas en el INMP 2013. METODOLOGIA: Estudio de tipo observacional descriptivo, transversal, prospectivo. Realizado en un total de 320 pacientes aproximadamente, las cuales fueron sometidas a cesárea con la técnica de bloqueo subaracnoideo que cumplan con los criterios de inclusión y exclusión durante el periodo de Setiembre a Octubre del 2013. RESULTADOS: Entre las características sociodemográficas que predominaron fueron: mujer en edad reproductiva de 19-35 años (79,6 por ciento). estado civil conviviente (53,1 por ciento) y ocupación ama de casa (71,4 por ciento). Entre las principales características clínicas encontradas, la mayoría tuvo al menos sobrepeso (57,1 por ciento), fueron gestantes con embarazos a término (89,8 por ciento), en su mayoría primíparas (36,7 por ciento) y con antecedente de cesárea previa (40,8 por ciento). A la evaluación de las funciones vitales previo al bloqueo raquídeo se encontró en el 100 por ciento de casos valores normales de Saturación de oxígeno y frecuencia cardíaca, a excepción de la frecuencia respiratoria que se solo encontró normal en el 98,0 por ciento de casos y la presión arterial en un 95,9 por ciento, cuya diferencia (4,1 por ciento) tenia hipertensión; administrándose de manera paralela una dosis precarga única de 5 cc de etilefrina a 85,7 por ciento de gestantes y 1000 ml de cristaloides al 69,4 por ciento. Las cuales según monitoreo de funciones vitales, se registró una incidencia de hipotensión en 22,4 por ciento de gestantes, requiriendo de 1 a más dosis adicionales de etilefrina (14,2 por ciento) y cristaloides (30,6 por ciento) durante el procedimiento quirúrgico. Para reducirse a un 2,0 por ciento de casos de hipotensión al término de la cesárea. Finalmente, el volumen efectivo medio estimado de cristaloides administrados fue de 14,03 ml/kg...

OBJECTIVE: To determine if the use of etilefrine and intravenous f1uids prevents the hypotension secondary to spinal anesthesia, in patients who undergo to caesarean section in the INMP during the period 2013. METHODOLOGY: Was an observational, descriptive, transversal, prospective study. This study done in a total of approximately 320 patients, who were undergoing cesarean section with spinal block technique meeting the inclusion and exclusion standard in the period September to October 2013. RESULTS: Among the sociodemographic characteristics were predominant: Women in reproductive age 19-35 years (79.6 per cent), marital status: cohabiting (53.1 per cent) and occupation housewife (71.4 per cent). The main clinical features found, most had overweight (57.1 per cent) were pregnant women with term pregnancies (89.8 per cent), primiparous (36.7 per cent) with a history of previous cesarean (40.8 per cent). To the evaluation of vital functions previous to spinal block was found in 100 per cent of the cases had normal oxygen saturation and heart rate, except for respiratory rate is only found normal in 98.0 per cent of cases and arterial pressure by 95.9 per cent, the difference (4.1 per cent) had hypertension parallel administered a single dose of 5 cc preload etilefrine to 85.7 per cent of pregnant women and 1000 mi of crystalloid in the 69.4 per cent. Which as monitoring of vital functions, an incidence of hypotension in 22.4 per cent of pregnant women registered, requiring 1 to further doses of etilefrine (14.2 per cent) and crystalloid (30.6 per cent) during the surgical procedure. To be reduced to 2.0 per cent of cases of hypotension at the end of caesarean. Finally, the volume estimated average effective administered of crystalloid was 14.03 ml/kg. CONCLUSIONS: The administration of etilefrine begore subarachnoid block, previous the caesarean reduce the hypotension, evidence of this is the 22.4 per cent of cases of pregnant women with at least 1 episode...

Type IV reaction due to phenylephrine administered nasally with cross-reactivity with ethylephrine.

Type IV hypersensitivity eye reactions have been described after the administration of the sympathomimetic agent phenylephrine. We report the case of an atopic woman who developed nasal congestion and discharge, dysphagia, and dyspnea 1 hour after the administration of Stopcold pills and Disneumon Pernasal nasal spray for otitis. The same symptoms reappeared after the accidental administration of Rinobanedif ointment in the nasal mucosa. Skin patch tests were performed with a standard True Test panel, preservatives, Disneumon Pernasal, pseudoephedrine, eyedrops (tropicamide, cyclopentolate, and phenylephrine), and other sympathomimetic agents. The patient also underwent oral, ocular, and nasal controlled challenges with the same drugs. Finally, patch tests were performed in 11 controls with phenylephrine and ethylephrine. Our patient had a positive outcome in patch testing with nickel sulphate, fragrance mix, phenylephrine, and ethylephrine. To our knowledge, this is the first report of a type IV reaction to nasally administered phenylephrine with cross-reactivity with ethylephrine detected by patch testing.

A prospective diary study of stuttering priapism in adolescents and young men with sickle cell anemia: report of an international randomized control trial--the priapism in sickle cell study.

Priapism is defined as a prolonged, persistent, and purposeless penile erection. It is a common (35%) but frequently understated complication in young men and adults with sickle cell disease. We had previously demonstrated an association between stuttering attacks (<4 hours) and an acute catastrophic event with its consequent problems of erectile dysfunction and impotence. We describe a randomized, placebo-controlled, clinical study looking at medical prophylaxis with 2 oral α-adrenergic agonists, etilefrine and ephedrine, in preventing stuttering attacks of priapism. One hundred thirty-one patients were registered into a 2-phase (observational and intervention phase) study, and 86 patients (66%) completed Phase A diary charts. Forty-six patients (59%) completed a 6-month treatment phase (Phase B), and the remaining patients were lost to follow-up despite persistent efforts to contact them. Various reasons are postulated for the high attrition rates. The drugs were well tolerated, and no serious adverse events were reported. There was no significant difference among the 4 treatment groups in the weekly total number of attacks in Phase B (analysis of covariance P = .99) nor among the average pain score per attack after adjusting for attack rates and pain scores in Phase A (analysis of covariance P = .33). None of the patients who completed the study required penile aspiration at study sites while on medical prophylaxis. Young men with sickle cell disease are not comfortable engaging with health care providers about issues relating to their sexual health. The full impact of an improved awareness campaign and early presentation to hospital merits further standardized study. Priapism still contributes seriously to the comorbidity experienced by this previously inaccessible group of patients and medical prophylaxis with oral α-adrenergic agonists is feasible. Future international collaborative efforts using some of the lessons learnt in this study should be undertaken.

Vasopressores em bloqueios do neuroeixo para cesariana / Vasopressors in neuraxial anesthesia at cesarean sections

Justificativa e objetivos: Os fármacos vasopressores sempre apresentaram um lugar de destaque no controle da hipotensão arterial relacionada aos bloqueios do neuroeixo em anestesia obstétrica. Este artigo tem o objetivo de discutir os diversos fármacos utilizados na prática clínica e as inúmeras estratégias descritas na literatura para a prevenção e tratamento da hipotensão arterial pós-raquianestesia para cesariana. Conteúdo: Com a popularização da raquianestesia como técnica mais utilizada em anestesia para cesariana, os vasopressores tornaram-se pedra angular para a melhoria dos resultados maternos e fetais. Várias mudanças de paradigmas se apresentam nos dias atuais, destacando-se a segurança na utilização de fármacos alfa-agonistas, particularmente a fenilefrina. A efedrina já não tem sido mais considerada a primeira escolha em anestesia obstétrica, pois pode causar redução no pH fetal. Conclusões: A administração pro-filática e/ou terapêutica de agonistas alfa-adrenérgicos mostra-se segura e eficaz para o controle da hipotensão arterial pós-raquianestesia, otimizando os resultados maternos e fetais. Portanto, sugere-se revisão de conceitos.

Justification and objectives: vasopressor drugs have always been highlighted for the control of hypotension related to neuraxial blockade in obstetrical anesthesia. This article purpose is arguing the several drugs used in the clinical practice and the countless strategies described in the literature for the prevention and treatment of arterial hypotension after spinal anesthesia for caesarian section. Content: With the popularization of spinal anesthesia as the technique most used in anesthesia for caesarian section, vasopressors became the angular stone for the improvement of the maternal and fetal outcomes. Several changes of paradigms are introduced currently, highlighting the safe use of alpha-agonist drugs, particularly phenylephrine. Ephedrine has no longer been considered the unique first choice in obstetrical anesthesia, because it may cause reduction in fetal pH. Conclusions: The alpha adrenergic prophylactic and/or therapeutic administration proved to be a safe and effective option for the hypotension control after spinal anesthesia, optimizing the maternal and fetal outcomes. Therefore, that is the time for reviewing old concepts.

alpha-Adrenoceptor agonists for the treatment of vasovagal syncope: a meta-analysis of worldwide published data.

AIM: The present study was aimed at evaluating present randomized controlled trials (RCTs) regarding the effect of alpha-adrenoceptor agonists on vasovagal syncope (VVS). METHODS: According to inclusion and exclusion criteria, articles were selected from medical electronic databases. RCTs were then assessed based on the Juni assessment, and meta-analysis was completed using the Review Manager 4.2 software. Indication to further evaluate effects was the recurrence of syncope during follow-up treatment or a response in the head-up tilt test (HUT) after treatment. The results were stated as odd ratio (OR), with a 95% confidence interval (CI) and a p < 0.05 significant level. RESULTS: In total, six RCTs were selected. Funnel plot analysis showed possible publication bias. Meta-analysis of the six RCTs, including all 165 patients in the treatment group and 164 patients in the control group, indicated that alpha-adrenoceptor agonists were more effective than placebos in treating VVS (OR = 0.21, 95% CI: 0.06-0.77, p = 0.02). The further, weighted independent t-test disclosed that the weighted mean percentage of responders for midodrine (76.3%+/- 7.7%) was significantly higher than that for etilefrine (65.5%+/- 15.4%) (t = 5.863, p < 0.001). CONCLUSION: The currently published RCTs support that alpha-adrenoceptor agonists might be effective for VVS. Midodrine can be regarded as a better choice compared with etilefrine.

From methylene blue (methylthionine chloride) to Al-Ghorab procedure: the therapy of priapism (our experience).

OBJECTIVE: The better knowledge concerning the anatomo-physiology of erection has brought important changes to the management of priapism. We experimented with a staged therapeutic protocol forthis condition. MATERIALS AND METHODS: 17 patients, aged from 27 to 71 (mean age 43) were treated for ischemic priapism; the pathogenesis was idiopathic in 9 cases, in 4 cases secondary to intracavernous injection (IcI) of PGE1, in 2 cases to papaverine Icd, in 1 case to haemolympho-pathy and in another patient to treatement with heparin. Cavernous PO2, PCO2 and pH were checked. All patients underwent removal of 100 cc of blood, irrigation with NaHCO3 solution of the cavernous corpora and Methylen blue (MB) IcI 10 mg every 5 minutes 10 times, repeated twice. RESULTS: From 3 to 6 hours from the beginning of therapy, detumescence was achieved in 10 cases. In 5 cases the priapism persisted and we administered adrenaline 20 pg every 5-10 minutes: 2 cases had detumescence respectively in 5 and 7 hours whereas in the patient with leukaemia the erection persisted and we desisted from further therapy; in 2 other cases the erection persisted and we did a distal cavernosum-glans shunt and the detumescence a was achieved in 30 and 58 hours respectively. In the last 2 cases, before adrenaline we administered an IcI of ethylephrine 5 mg every 5 minutes for 4-5 times but finally we had to perform a shunt. In all cases, during the treatment, and during the following 6-8 hours, we administered 200 mg of MB intravenous. CONCLUSIONS: The introduction of oral drugs has changed the epidemiology of priapism. A better knowledge of the molecular mechanisms that govern the cavernous contraction and myorelaxation has allowed us to use adrenergic drugs and also the MB. This staged therapeutic protocol goes from a less invasive therapy (irrigation with NaHCO3, MB, ethylephrine, adrenaline) to a surgical procedure which must not be delayed and this progression could allow a reduction in the collateral effects.

Stuttering priapism--a review of the therapeutic options.

INTRODUCTION: Priapism is a urological emergency which is commonly classified into low-flow and high-flow priapism. Immediate intervention is required for low-flow cases as the development of ischaemia ultimately leads to long-term erectile dysfunction. Stuttering or recurrent priapism is less well understood. This subtype is characterised by short-lived painful erections and is commonly encountered in patients with sickle cell disease. METHODS: A systematic review of the treatment options available for stuttering priapism is presented combined with our own experience in managing this condition over a period of 25 years. RESULTS: Although numerous medical treatment options have been reported, the majority are through small trials or anecdotal reports. CONCLUSIONS: Stuttering priapism is a condition which is still not well understood and there is no standardised algorithm for the management of this condition. A multicentre randomised trial is required to evaluate the treatment options.

Dissociation between cortical activation and cognitive performance under pharmacological blood pressure elevation in chronic hypotension.

The present study explored the impact of pharmacological blood pressure elevation on cortical activation and reaction time in chronic hypotension. Effects of the sympathomimetic etilefrine were investigated in 50 hypotensive persons based on a randomized, placebo-controlled double blind design. As an indicator of cortical excitability, the contingent negative variation (CNV), induced by a constant foreperiod reaction time task, was assessed at frontal (F3, Fz, F4) and central (C3, Cz, C4) scalp sites. Etilefrine provoked a decrease in the frontal and central CNV. In contrast, shorter reaction times were observed following drug administration. The degree of pharmacologically induced blood pressure elevation was correlated to CNV attrition as well as to performance enhancement. Inhibitory effects of baroreceptor activation on cortical excitability and enhanced cerebral blood flow are considered to be involved in mediating the effects of blood pressure elevation on cerebral functioning. Implications for the treatment of chronic hypotension are discussed.

Chylothorax.

Chylothorax is a rare complication of pulmonary resection. It requires prompt treatment, which is initially conservative. This treatment consists of drainage, nutritional support, and measures to diminish chyle flow. Surgical intervention is indicated when conservative management is ineffective. Delay in surgical intervention leads not only to serious metabolic, nutritional, and immunologic disturbances from the loss of chyle but also increases the risk for adhesion formation, loculation, organization, and infection of the chylothorax, making subsequent surgical attempts difficult and increasing postoperative morbidity and mortality. VATS provides a minimally invasive approach for the treatment of chylothorax complicating pulmonary resection. Clipping of the thoracic duct or chemical pleurodesis may be performed with minimal morbidity and mortality. Conservative treatment is expensive and fails in most patients who have high-output chylous fistulae. On the other hand, VATS is uniformly effective, is less expensive, and has low morbidity. Indeed, VATS is rapidly becoming the preferred approach for the management of chylothorax complicating pulmonary resection. The need to prevent the occurrence of a chylothorax by careful dissection techniques and liberal clipping of lymphatic vessels particularly in areas of high anatomic risk during the initial operation cannot be overemphasized.

Investigational agents for sickle cell disease.

Developments in the treatment of sickle cell disease (SCD) have not kept pace with advances in understanding the pathophysiology of this haemoglobinopathy. Drugs undergoing preclinical and clinical assessment for the therapy of these globin gene disorders are discussed in this article. Beginning with investigational agents for treatment of SCD as a whole, the discussion proceeds to drugs being developed for specific manifestations or iatrogenic complications. Despite being licensed in the USA, the prototype antisickling agent, hydroxycarbamide, has not attained worldwide clinical use because of concerns about long-term toxicity. The less toxic decitabine, which (as with hydroxycarbamide) increases fetal haemoglobin level, cannot be administered orally; therefore, the search continues for effective and safe antisickling drugs that can be taken orally. The naturally occurring benzaldehyde 5-hydroxymethyl-2-furfural has shown promising antisickling properties in vitro, and when administered to transgenic sickle mice. These effects are surpassed by the new synthetic pyridyl derivatives of benzaldehyde. Studies in humans with SCD are required to assess the clinical efficacy of these benzaldehydes. Niprisan, another antisickling agent with significant clinical efficacy and an attractive safety profile, is undergoing further development. The prospects of antiadhesion therapy in SCD are demonstrated by a recombinant protein containing the Fc fragment of IgG fused to the natural ligand for selectins: the conjugate significantly inhibited blood vessel occlusion in transgenic sickle mice. Whereas the orally administrable iron-chelating agent deferasirox is likely to increasingly take the place of desferioxamine (which can only be given parenterally), effective treatment of priapism in SCD remains a distressing challenge.

[Management of postoperative chylothorax]. / Prise en charge des chylothorax post opératoires.

INTRODUCTION: A chylothorax can occur following any intrathoracic procedure. It is generally straightforward to make the diagnosis but optimal management can be problematic. METHODS: Between 1995 and 2002, three women and one man aged from 13 to 58 years were treated for chylothorax after thoracic surgery. Their initial illnesses were a right pulmonary hydatid cyst associated with hepatic disease, a tumour of the posterior mediastinum, an oesophageal carcinoma and metastases in the left lung. RESULTS: These patients had: a pulmonary and hepatic cystectomies, a resection of the mediastinal tumor, an Akyama oesophagectomy and a resection of four left pulmonary metastases. Chylothorax became apparent post operatively between the 1st and the 4th day. All patients were treated with a medium-chain triglyceride diet. Two patients were re-explored with ligation of lymphatic vessels. One woman who did not have further surgery was treated with etilefrine. In the patient who had had an oesophagectomy, chylothorax persisted after re-operation. He was successfully treated by talc pleurodesis via a chest drain, which prevented further recurrence. CONCLUSIONS: In the management of postoperative chylothorax, medical treatment must be started early but surgery should not be delayed as operative risk is increased by the development of malnutrition and immune deficiency.

Estudo comparativo entre efedrina e etilefrina como vasopressor para correção da hipotensão arterial materna em cesarianas eletivas com raquianestesia / Ephedrine and etilefrine as vasopressor to correct maternal arterial hypotension during elective cesarean section under spinal anesthesia. Comparative study

JUSTIFICATIVA E OBJETIVOS: A efedrina é o vasopressor mais utilizado em obstetrícia e a etilefrina é muito usada em anestesia regional. O objetivo deste estudo foi comparar a efedrina com a etilefrina para correção de hipotensão arterial materna durante raquianestesia para cesariana eletiva. MÉTODO: Foram estudadas 120 gestantes divididas de forma aleatoria em dois grupos iguais. Todas receberam raquianestesia com bupivacaína, fentanil e morfina. Foi medida a pressão arterial não-invasiva e a freqüência cardíaca. Os recém-nascidos foram avaliados com o índice de Apgar. A incidência de hipotensão arterial, a quantidade de vasopressor necessária para correção e os efeitos adversos foram anotados. RESULTADOS: Ocorreu hipotensão arterial materna com freqüência nos dois grupos, sendo 68 por cento do grupo etilefrina e 63 por cento do grupo efedrina. Na maioria das gestantes foi corrigida com a primeira dose do vasopressor, sem diferença entre os grupos (66 por cento etilefrina, 58 por cento efedrina). A hipotensão arterial necessitou de duas ou mais doses de vasopressor para ser corrigida ou houve hipertensão reativa em poucas pacientes (24 por cento e 10 por cento do grupo etilefrina e 34 por cento e 8 por cento do grupo efedrina, respectivamente) sem diferença estatística significativa. Não houve diferença nos efeitos adversos e nos testes dos recém-nascidos. CONCLUSÕES: Com o método de administração empregado e com as doses de vasopressor selecionadas não houve diferença entre a efedrina e a etilefrina quando utilizadas para corrigir a hipotensão arterial materna em cesarianas com raquianestesia.