Bridging Learning in Medicine and Citizenship During the COVID-19 Pandemic: A Telehealth-Based Case Study.

BACKGROUND: COVID-19 presented great challenges for not only those in the field of health care but also those undergoing medical training. The burden on health care services worldwide has limited the educational opportunities available for medical students due to social distancing requirements. OBJECTIVE: In this paper, we describe a strategy that combines telehealth and medical training to mitigate the adverse effects of the COVID-19 pandemic. METHODS: A toll-free telescreening service, Telecoronavirus, began operations in March 2020. This service was operated remotely by supervised medical students and was offered across all 417 municipalities (14.8 million inhabitants) in the Brazilian state of Bahia. Students recorded clinical and sociodemographic data by using a web-based application that was simultaneously accessed by medical volunteers for supervision purposes, as well as by state health authorities who conducted epidemiological surveillance and health management efforts. In parallel, students received up-to-date scientific information about COVID-19 via short educational videos prepared by professors. A continuously updated triage algorithm was conceived to provide consistent service. RESULTS: The program operated for approximately 4 months, engaging 1396 medical students and 133 physicians. In total, 111,965 individuals residing in 343 municipalities used this service. Almost 70,000 individuals were advised to stay at home, and they received guidance to avoid disease transmission, potentially contributing to localized reductions in the spread of COVID-19. Additionally, the program promoted citizenship education for medical students, who were engaged in a real-life opportunity to fight the pandemic within their own communities. The objectives of the education, organization, and assistance domains of the Telecoronavirus program were successfully achieved according to the results of a web-based post-project survey that assessed physicians' and students' perceptions. CONCLUSIONS: In a prolonged pandemic scenario, a combination of remote tools and medical supervision via telehealth services may constitute a useful strategy for maintaining social distancing measures while preserving some practical aspects of medical education. A low-cost tool such as the Telecoronavirus program could be especially valuable in resource-limited health care scenarios, in addition to offering support for epidemiological surveillance actions.

[Neurolitic block of the lumbar sympathetic chain improves chronic pain in a patient with critical lower limb ischemia]. / Bloqueio neurolítico da cadeia simpática lombar melhora dor crônica em paciente portadora de isquemia crítica de membro inferior.

BACKGROUND AND OBJECTIVES: Sympathectomy is one of the therapies used in the treatment of chronic obstructive arterial disease (COAD). Although not considered as first-line strategy, it should be considered in the management of pain difficult to control. This clinical case describes the evolution of a patient with inoperable COAD who responded properly to the lumbar sympathetic block. CASE REPORT: A female patient, afro-descendant, 69 years old, ASA II, admitted to the algology service due to refractory ischemic pain in the lower limbs. The patient had undergone several surgical procedures and conservative treatments without success. Vascular surgery considered the case as out of therapeutic possibility, unless limb amputation. At that time, sympathectomy was indicated. After admission to the operating room, the patient was monitored, positioned and sedated. The blockade was performed with the aid of radioscopy, bilaterally, at L2-L3-L4 right and L3 left levels. On the right side, at each level cited, 3mL of absolute alcohol with 0.25% bupivacaine were injected without vasoconstrictor, and on the left side only local anesthetic. The procedure was performed uneventfully. The patient was discharged with complete remission of the pain. CONCLUSION: Neurolitic block of the lumbar sympathetic chain is an effective and safe treatment option for pain control in patients with critical limb ischemia patients in whom the only possible intervention would be limb amputation.

Agreement between three perioperative risk scores.

OBJECTIVE: To evaluate the agreement between the three scores proposed by the II Guideline for Perioperative Evaluation of the Brazilian Society of Cardiology (SBC): the American College of Physicians algorithm (ACP), the Multicenter Study of Perioperative Evaluation (EMAPO) and Lee's Revised Cardiac Risk Index (RCRI). METHOD: Patients evaluated preoperatively for non-cardiac surgery by the anesthesiology service were classified as low, moderate or high-risk according to the 3 algorithms suggested by the II Guideline. To calculate the strength of agreement between the scores, the kappa agreement index was used. RESULTS: Four hundred and one patients were included in the sample. Cohen's kappa inter-rater agreement between scores was 0.270 (CI: 0.222 to 0.318), corresponding to a weak agreement. Analyzing in pairs, the best correlation was between EMAPO and ACP, with kappa = 0.327. Lee's score was the one that classified more patients as low-risk: 98.3%, while EMAPO and ACP classified as low risk 91.3% and 92.5%, respectively. CONCLUSION: There is poor correlation among the risk scores proposed by the II Perioperative Evaluation Guideline of the SBC.

Efeitos do treinamento muscular respiratório em pacientes após acidente vascular cerebral: uma revisão sistemática / Effects of respiratory muscle training in patients after cerebral vascular accident: a systematic review

O Acidente Vascular Cerebral (AVC) é o resultado da interrupção aguda do suprimento sanguíneo ao cérebro por meio de entupimento ou rompimento dos vasos podendo provocar lesões celulares e alterações nas funções neurológicas. Essas alterações são relevantes para a ineficiência dos mecanismos orofaríngeos da deglutição, respiração, fonação e reflexos protetores das vias aéreas inferiores culminando em alta incidência de pneumonia por aspiração. O Treinamento Muscular Respiratório tem como função restabelecer a função muscular que esteja comprometida, treinar tanta a força quanto à endurance muscular, melhorar a eficácia na desobstrução das vias aéreas, condicionar e adaptar ao exercício e prevenir a fadiga muscular respiratória. OBJETIVO: O objetivo desse estudo é sistematizar o efeito do treinamento muscular respiratório sobre os volumes e capacidades pulmonares em indivíduos que sofreram acidente vascular cerebral. MATERIAIS E MÉTODOS: Esta revisão sistemática foi realizada pela busca nas bases de dados BVS (Scielo, Lilacs, IBECS, Medline), PubMed e análise das referências. RESULTADOS: Um total de 4834 estudos foram rastreados e analisados, onde fizeram parte desta revisão 17 estudos publicados entre 2010 e 2019. CONCLUSÃO: Estudos comprovaram que o uso de TMR em pacientes pós-AVC gera efeitos positivos nos volumes e capacidades pulmonares, apesar de terem um tamanho amostral pequeno. A busca por criar novos estudos que possam auxiliar na prescrição e padronização dos treinamentos desses indivíduos em diversos ambientes deve ser um caminho a se pensar.

Stroke is the result of the interruption of blood supply to the brain and can cause cellular damage and changes in neurological functions. These changes are relevant to the inefficiency of the oropharyngeal mechanisms of swallowing, breathing, phonation and protective reflexes of the lower airways culminating in a high incidence of aspiration pneumonia. Respiratory Muscle Training has the function of restoring muscle function that is compromised, training both strength and muscle endurance, better effectiveness in clearing the airways, conditioning and adapting to exercise and preventing respiratory muscle fatigue. OBJECTIVE: The aim of this study is to verify the effect of respiratory muscle training on individuals who have suffered a stroke. MATERIALS AND METHODS: This systematic review was carried out by searching the VHL databases (Scielo, Lilacs, IBECS, Medline), PubMed and analyzing the references. RESULTS: A total of 4834 studies were screened and analyzed, where 17 studies published between 2010 and 2019 were part of this review. CONCLUSION: Studies have shown that the use of TMR in post-stroke patients has positive effects on lung volumes and capacities, despite have a small sample size. The search for creating new studies that can assist in the prescription and standardization of the training of these individuals in different environments should be a way to think.

Neurolitic block of the lumbar sympathetic chain improves chronic pain in a patient with critical lower limb ischemia / Bloqueio neurolítico da cadeia simpática lombar melhora dor crônica em paciente portadora de isquemia crítica de membro inferior

Abstract Background and objectives Sympathectomy is one of the therapies used in the treatment of chronic obstructive arterial disease (COAD). Although not considered as first-line strategy, it should be considered in the management of pain difficult to control. This clinical case describes the evolution of a patient with inoperable COAD who responded properly to the lumbar sympathetic block. Case report A female patient, afro-descendant, 69 years old, ASA II, admitted to the algology service due to refractory ischemic pain in the lower limbs. The patient had undergone several surgical procedures and conservative treatments without success. Vascular surgery considered the case as out of therapeutic possibility, unless limb amputation. At that time, sympathectomy was indicated. After admission to the operating room, the patient was monitored, positioned and sedated. The blockade was performed with the aid of radioscopy, bilaterally, at L2-L3-L4 right and L3 left levels. On the right side, at each level cited, 3 mL of absolute alcohol with 0.25% bupivacaine were injected without vasoconstrictor, and on the left side only local anesthetic. The procedure was performed uneventfully. The patient was discharged with complete remission of the pain. Conclusion Neurolitic block of the lumbar sympathetic chain is an effective and safe treatment option for pain control in patients with critical limb ischemia patients in whom the only possible intervention would be limb amputation.

Resumo Justificativa/objetivos A simpatectomia é uma das terapêuticas usadas no tratamento dadoença arterial obstrutiva crônica (DAOP). Embora não seja considerada como estratégia de primeira linha, deve ser lembrada no manejo dos quadros de dor de difícil controle. Este caso clínico descreve a evolução de uma paciente portadora de DAOP inoperável que respondeu adequadamente ao bloqueio simpático lombar. Relato de caso Paciente do sexo feminino, parda, 69 anos, estado físico II, acompanhada no serviço de algologia devido a dor isquêmica refratária em membros inferiores. A paciente já havia sido submetida a diversas abordagens cirúrgicas e tratamentos conservadores, sem sucesso. A cirurgia vascular considerou o caso como fora de possibilidade terapêutica, a não ser amputação do membro. Nesse momento, foi indicada simpatectomia. Após admissão no centro cirúrgico, a paciente foi monitorada, posicionada e sedada. O bloqueio foi feito com auxílio da radioscopia, bilateralmente, nos níveis L2-L3-L4 à direita e L3 à esquerda. Do lado direito, em cada nível citado, foram injetados 3 mL de álcool absoluto com bupivacaína 0,25% sem vasoconstritor e do lado esquerdo somente o anestésico local. O procedimento foi feito sem intercorrências. A paciente recebeu alta com completa remissão da dor. Conclusão O bloqueio neurolítico da cadeia simpática lombar é uma opção de tratamento eficaz e segura para controle da dor em pacientes portadores de isquemia crítica, nos quais a única intervenção possível seria a amputação do membro.

Topical analgesics.

BACKGROUND AND OBJECTIVES: Pain treatment involves the usage of common and opioid analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs) and adjuvant analgesics. Traditionally, these drugs are administered systemically or into the neuraxis. However, when analgesics are applied through these pathways, they are associated with significant side effects, which can hinder its use. Topical administration of analgesics is an alternative. The objective of this paper is to discuss topical analgesics, the mechanisms of action and clinical efficacy. CONTENT: This is a review paper addressing the usage of the topical local anesthetics: capsaicin, clonidine, tricyclic antidepressants, ketamine, opioids and cannabinoids, discussing mechanism of action and effectiveness. CONCLUSIONS: Topical analgesics are promising as a strategy for pain treatment, as they are associated with lower incidence of side effects. The benefit of local anesthetics, NSAID's and capsaicin is well established. However, the efficacy of clonidine, tricyclic antidepressants, ketamine, opioids and cannabinoids is still questionable. Studies have shown that the multimodal approach is an alternative, but studies are needed to confirm this hypothesis.

Chikungunya: vision of the pain clinician / Chikungunya: a visão do clínico de dor

ABSTRACT BACKGROUND AND OBJECTIVES: Chikungunya is a viral disease of tropical distribution which affects individuals in different countries of the world and is associated to variable clinical presentations, characterized by the existence of two phases: acute and chronic. The acute phase is short-lasting with nonspecific symptoms. The chronic phase is marked by persistent pain, impairing patients' quality of life. This study aimed at discussing Chikungunya, from the pain clinician point of view, paying attention to its epidemiological, pathophysiological, diagnostic and therapeutic aspects, especially with regard to pain management. CONTENTS: Chikyngunya's pathophysiology is poorly understood and involves predominantly peripheral mechanisms. It is diagnosed by observation of suggestive clinical presentation associated to specific laboratory exams. Management of patients with confirmed diagnosis involves common analgesics and anti-inflammatory drugs, in addition to steroids, antidepressants and anticonvulsants for refractory cases. Patients with chronic inflammatory rheumatic disease seem to benefit from methotrexate. CONCLUSION: Chikungunya is a complex and still poorly understood entity. There are different therapeutic schemes to treat pain associated to it, however 40% of patients evolve with chronic pain and impairment of quality of life.

RESUMO JUSTIFICATIVA E OBJETIVOS: A chikungunya é uma doença viral de distribuição tropical que acomete indivíduos em diferentes países do mundo e está associada a quadro clinico variável, caracterizado pela existência de duas fases: aguda e crônica. A fase aguda é de curta duração e de sintomas inespecíficos. A fase crônica é marcada pela presença de dor persistente, com comprometimento da qualidade de vida dos pacientes. O objetivo deste estudo foi discutir a chikungunya sob a ótica do clinico de dor, atentando para os seus aspectos epidemiológicos, fisiopatológicos, diagnósticos e terapêuticos, principalmente no que diz respeito ao tratamento dos sintomas álgicos. CONTEÚDO: A fisiopatologia da chikungunya é pouco compreendida e envolve mecanismos predominantemente periféricos. O seu diagnóstico é feito por meio da observação de quadro clinico sugestivo, associado a realização de exames laboratoriais específicos. A condução dos pacientes com diagnóstico confirmado envolve a utilização de analgésico comum e anti-inflamatório, além de corticosteroides, antidepressivos e anticonvulsivantes nos casos refratários. Pacientes com doença reumática inflamatória crônica parecem se beneficiar do uso de metotrexato. CONCLUSÃO: A chikungunya é uma entidade complexa e ainda pouco compreendida. Diferentes esquemas terapêuticos estão disponíveis para o tratamento do quadro álgico a ela associado, entretanto 40% dos pacientes evoluem com dor crônica e comprometimento da qualidade de vida.

Agreement between three perioperative risk scores / Concordância entre três escores de risco perioperatório

SUMMARY Objective: To evaluate the agreement between the three scores proposed by the II Guideline for Perioperative Evaluation of the Brazilian Society of Cardiology (SBC): the American College of Physicians algorithm (ACP), the Multicenter Study of Perioperative Evaluation (EMAPO) and Lee’s Revised Cardiac Risk Index (RCRI). Method: Patients evaluated preoperatively for non-cardiac surgery by the anesthesiology service were classified as low, moderate or high-risk according to the 3 algorithms suggested by the II Guideline. To calculate the strength of agreement between the scores, the kappa agreement index was used. Results: Four hundred and one patients were included in the sample. Cohen’s kappa inter-rater agreement between scores was 0.270 (CI: 0.222 to 0.318), corresponding to a weak agreement. Analyzing in pairs, the best correlation was between EMAPO and ACP, with kappa = 0.327. Lee’s score was the one that classified more patients as low-risk: 98.3%, while EMAPO and ACP classified as low risk 91.3% and 92.5%, respectively. Conclusion: There is poor correlation among the risk scores proposed by the II Perioperative Evaluation Guideline of the SBC.

RESUMO Objetivo: avaliar a concordância entre os três escores propostos pela II Diretriz de Avaliação Perioperatória da Sociedade Brasileira de Cardiologia (SBC): algoritmo do American College of Physicians (ACP), Estudo Multicêntrico de Avaliação Perioperatória (Emapo) e Índice de Risco Cardíaco Revisado de Lee (IRCR). Método: pacientes avaliados no pré-operatório para cirurgia não cardíaca em serviço de anestesiologia foram classificados em baixo, moderado ou alto risco pelas três escalas sugeridas pela II Diretriz. Para avaliar o grau de concordância entre as classificações, calculou-se o índice de concordância kappa. Resultados: quatrocentos e um pacientes foram incluídos. O índice kappa de Cohen de concordância entre os três escores foi de 0,270 (IC: 0,222-0,318), correspondendo a uma concordância fraca. Analisando aos pares, a melhor correlação foi entre Emapo e ACP, com kappa de 0,327. O escore de Lee foi o que classificou mais pacientes como baixo risco: 98,3%, ao passo que Emapo e ACP classificaram como baixo risco 91,3 e 92,5%, respectivamente. Conclusão: há uma baixa concordância entre os escores de risco propostos pela II Diretriz de Avaliação Perioperatória da SBC.

Sedation with sufentanil and clonidine in patients undergoing heart catheterization.

BACKGROUND: Sedation for heart catheterization has been a cause for concern. Benzodiazepines, alpha-2 adrenergic agonists and opioids are used for this purpose. However, each drug has advantages and disadvantages. OBJECTIVE: To evaluate the efficacy of sufentanil and clonidine as sedative in patients undergoing heart catheterization, observing their impact on hemodynamic and respiratory parameters, the presence of side effects and satisfaction of the patient and interventional cardiologist with the examination. METHODS: This is a prospective, double-blind, randomized and controlled clinical trial involving 60 patients who received 0.1 µg/kg of sufentanil or 0.5 µg/kg of clonidine before heart catheterization. The score of sedation according to the Ramsay scale, the need for use of midazolam, side effects and hemodynamic and respiratory parameters were recorded, with the data being analyzed at 06 different moments. RESULTS: The behavior of blood pressure, heart rate and respiratory rate was similar in both groups, but, at moment 2, the patients in the sufentanil group (Group S) had a lower sedation score on the Ramsay scale, and the peripheral oxyhemoglobin saturation was lower than in the clonidine group (Group C) at time 6. Patients in Group S had higher incidence of nausea and vomiting after surgery than patients in Group C. Patient satisfaction was higher in the clonidine group. The interventional cardiologists were satisfied in both groups. CONCLUSION: Sufentanil and clonidine were effective as sedative in patients undergoing heart catheterization.

Osteogenesis imperfecta in pregnancy. Case report.

BACKGROUND AND OBJECTIVES: Osteogenesis Imperfecta is a rare condition, especially in obstetric patients. It has an estimated prevalence of 1/10,000 in the general population, and 1/25,000 to 30,000 in obstetric patients. The objective of this report was to present a rare case of a pregnant woman with Osteogenesis Imperfecta undergoing cesarean section. CASE REPORT: This is a 23 years old gravida on the 38th week, admitted to the maternity ward with loss of amniotic fluid and contractions for four hours, associated with the absence of fetal movements for four days. The patient had a mild form of Osteogenesis Imperfecta without other comorbidities. She was not taking any medication, and she did not have prenatal follow-up. The patient underwent spinal anesthesia in the L(3)-L(4) space, median approach, with a single puncture with a 27G Quincke needle and the administration of hyperbaric 0.5% bupivacaine (10 mg) and morphine (60 microg). She was discharged in the second postoperative day without complaints. CONCLUSIONS: Fertility is preserved, especially in those patients with type I of the disease, and pregnancy can be carried to term. Delivery is usually surgical due to pelvic deformities in the gravida, cephalopelvic disproportion, and increased incidence of abnormal fetal presentation. The importance of the anesthesiologist in the surgical team relies on the perioperative management and the choice of the most appropriate anesthetic technique for each patient.

Analgésicos tópicos / Topical analgesics / Analgésicos tópicos

JUSTIFICATIVA E OBJETIVOS: O tratamento da dor envolve a utilização de analgésicos opioides, analgésicos comuns, anti-inflamatórios não hormonais (AINH's) e analgésicos adjuvantes. Tradicionalmente, estes fármacos são administrados por via sistêmica ou no neuroeixo. Entretanto, quando aplicados por estas vias, estão associados a efeitos colaterais importantes, os quais podem inviabilizar o seu uso. A administração tópica de analgésicos é uma alternativa. O objetivo deste trabalho é discutir os analgésicos tópicos, seus mecanismos de ação e eficácia clínica. CONTEÚDO: Trata-se de um trabalho de revisão que aborda a utilização tópica de anestésicos locais, capsaicina, clonidina, antidepressivos tricíclicos, cetamina, opioides e canabinoides, discutindo o seu mecanismo de ação e a sua eficácia. CONCLUSÕES: Os analgésicos tópicos são promissores como estratégia para o tratamento da dor, já que estão associados à menor incidência de efeitos colaterais. O benefício dos anestésicos locais, dos AINH's e da capsaicina está bem estabelecido, entretanto, a eficácia de clonidina, antidepressivos tricíclicos, cetamina, opioides e canabinoides ainda é questionável. Trabalhos demonstram que a abordagem multimodal é uma alternativa, porém estudos são necessários para confirmar esta hipótese.

BACKGROUND AND OBJECTIVES: Pain treatment involves the usage of common and opioid analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs) and adjuvant analgesics. Traditionally, these drugs are administered systemically or into the neuraxis. However, when analgesics are applied through these pathways, they are associated with significant side effects, which can hinder its use. Topical administration of analgesics is an alternative. The objective of this paper is to discuss topical analgesics, the mechanisms of action and clinical efficacy. CONTENT: This is a review paper addressing the usage of the topical local anesthetics: capsaicin, clonidine, tricyclic antidepressants, ketamine, opioids and cannabinoids, discussing mechanism of action and effectiveness. CONCLUSIONS: Topical analgesics are promising as a strategy for pain treatment, as they are associated with lower incidence of side effects. The benefit of local anesthetics, NSAID's and capsaicin is well established. However, the efficacy of clonidine, tricyclic antidepressants, ketamine, opioids and cannabinoids is still questionable. Studies have shown that the multimodal approach is an alternative, but studies are needed to confirm this hypothesis.

JUSTIFICATIVA Y OBJETIVOS: El tratamiento del dolor involucra la utilización de analgésicos opioides, analgésicos comunes, antiinflamatorios no hormonales (AINH's) y analgésicos adyuvantes. Tradicionalmente, esos fármacos son administrados por vía sistémica o en el neuro eje. Sin embargo, cuando se aplican por esas vías, están asociados a los efectos colaterales importantes, los cuales pueden impedir su uso. La administración tópica de analgésicos es una alternativa. El objetivo de este trabajo es discutir los analgésicos tópicos, sus mecanismos de acción y la eficacia clínica. CONTENIDO: Se trata de un trabajo de revisión que aborda la utilización tópica de anestésicos locales, capsaicina, clonidina, antidepresivos tricíclicos, cetamina, opioides y canabinoides, discutiendo su mecanismo de acción y su eficacia. CONCLUSIONES: Los analgésicos tópicos son promisorios como una estrategia para el tratamiento del dolor, ya que están asociados con una menor incidencia de efectos colaterales. El beneficio de los anestésicos locales, de los AINH's y de la capsaicina está muy bien establecido, sin embargo, la eficacia de la clonidina, los antidepresivos tricíclicos, cetamina, opioides y canabinoides, todavía es cuestionable. Algunos trabajos demuestran que el abordaje multimodal es una alternativa, pero más estudios son necesarios para poder confirmar esa hipótesis.

Sedative and cardiovascular effects of midazolam and diazepam alone or combined with clonidine in patients undergoing hemodynamic studies for suspected coronary artery disease.

BACKGROUND: Sedation during coronary angiography has been rarely studied, and it is important to know which drug is the best to sedate these patients. OBJECTIVE: To evaluate the quality of sedation and the effects of midazolam and diazepam alone or combined with clonidine on the heart rate (HR) and blood pressure (BP) of patients with suspected coronary artery disease. METHODS: This is a controlled, randomized, double-blind, prospective clinical study of 160 patients divided into five groups of 32 patients each, according to the drug used: group C (clonidine 0.5 microg/kg); group M (midazolam 40 microg/kg); group MC (combination of midazolam 40 microg/kg and clonidine 0.5 microg/kg); group D (diazepam 40 microg/kg); and group DC (combination of diazepam 40 microg/kg and clonidine 0.5 microg/kg). Sedation was evaluated based on the Ramsay scale and on the use of meperidine 0.04 mg.kg-1. Invasive BP monitoring, HR and the sedation score were analyzed every five minutes at four different time points. RESULTS: Patients who received midazolam presented higher sedation scores as well as HR and BP variation (p < 0.05). Those who received diazepam or clonidine had lower sedation scores, which were more satisfactory for the performance of the procedure, and presented a lower BP and HR variation (p > 0.05). CONCLUSION: Midazolam was associated with a greater sedative and cardiovascular effect, whereas for diazepam these effects were less intense. Clonidine and diazepam had similar effects on BP, HR and sedation.

Ácido zoledrônico como tratamento para síndrome dolorosa complexa regional tipo I em adulto: relato de caso / Zoledronic acid to treat complex regional painful syndrome type I in adult: case report

JUSTIFICATIVA E OBJETIVOS: A síndrome dolorosa complexa regional (SDCR) é incapacitante e de difícil tratamento.Resultados positivos com a utilização de bifosfonatos em pacientes com SDCR tipo I refratária a terapêutica multimodal tem sido descritos. O objetivo deste estudo foi relatar a utilização do ácido zoledrônico em paciente portadorde SDCR tipo I refratária à terapêutica tradicional.RELATO DO CASO: Paciente do sexo feminino, 31 anos, com história de SDCR há 16 anos, refratária ao tratamento multiprofissional e multimodal. Diante da persistência dos sintomas foi proposta a administraçãode ácido zoledrônico, com controle efetivo dos sintomase sem a presença de efeitos adversos.CONCLUSÃO: O ácido zoledrônico foi efetivo notratamento da SDCR tipo I refrataria ao tratamento convencional.

BACKGROUND AND OBJECTIVES: Complex regional painful syndrome (CRPS) is a difficult to treat disabling.Positive results with bisphosphonates in CRPS type I patients refractory to multimodal therapy have been described. This study aimed at reporting the useof zoledronic acid in CRPS type I patient refractory totraditional therapy. CASE REPORT: Female patient, 31 years old, with CRPS for 16 years, refractory to multiprofessional and multimodal treatment. Due to persistence of symptoms, zoledronic acid administration was proposed with effective control of symptoms and without adverse effects.CONCLUSION: Zoledronic acid was effective to treat CRPS type I refractory to conventional treatment.

Clonidine in cineangiocardiography: sedative effects on blood pressure and heart rate.

OBJECTIVE: To evaluate the effects of clonidine on heart rate (HR), and blood pressure (BP) as well as its sedative effect on patients submitted to a cineangiocardiography. METHODS: A randomized, controlled, double blind, prospective clinical trial was conducted on 62 patients submitted to an elective cineangiocardiography. The patients were divided in two groups: the clonidine group, that were administered a 0.8 microg/kg dose of this drug and the control group, that were administered a 0.9% saline solution. Sedation was evaluated based on the Ramsay Scale and the administration of a 0.04 mg/kg dose of meperidine that was given to the patients who were agitated or anxious during the procedure. The invasive BP, HR and sedation score based on the Ramsay Scale were analyzed every 5 minutes and four different intervals were considered for the assessment: I1- start of the test; I2- 5 minutes after the start of the test; I3- median time of the test and I4- end of the test. RESULTS: The clonidine group presented better BP and HR stability and sedation efficacy while the control group presented a higher intake of meperidine (p<0.05). In the statistical analysis, the inference of the continuous variables was calculated using the Student's t-test or Mann-Whitney test and the chi2 or Fisher Exact Probability test was used for the categorical variables. CONCLUSION: This study demonstrated that clonidine was an efficient means to control BP and HR and provided a conscious sedation for patients submitted to a cineangiocardiography.

Sedação com sufentanil e clonidina em pacientes submetidos a cateterismo cardíaco / Sedation with sufentanil and clonidine in patients undergoing heart catheterization / Sedación con sufentanil y clonidina en pacientes sometidos a cateterismo cardíaco

FUNDAMENTO: A sedação para a realização de cateterismo cardíaco tem sido alvo de preocupação. Benzodiazepínicos, agonistas alfa-2 adrenérgicos e opioides são utilizados para esse fim, entretanto, cada um destes medicamentos possui vantagens e desvantagens. OBJETIVO: Avaliar a eficácia do sufentanil e da clonidina como sedativos em pacientes submetidos a cateterismo cardíaco, observando o impacto dos mesmos sobre os parâmetros hemodinâmicos e respiratórios, a presença de efeitos colaterais, além da satisfação do paciente e do hemodinamicista com o exame. MÉTODOS: Trata-se de um ensaio clínico prospectivo, duplo-cego, randomizado e controlado, que envolveu 60 pacientes que receberam 0,1 µg/kg de sufentanil ou 0,5 µg/kg de clonidina antes da realização do cateterismo cardíaco. O escore de sedação segundo a escala de Ramsay, a necessidade de utilização de midazolam, os efeitos colaterais, os parâmetros hemodinâmicos e respiratórios foram registrados, sendo os dados analisados em 06 diferentes momentos. RESULTADOS: O comportamento da pressão arterial, da frequência cardíaca e da frequência respiratória foi semelhante nos dois grupos, entretanto, no momento 2, os pacientes do grupo sufentanil (Grupo S) apresentaram menor escore de sedação segundo a escala de Ramsay, e a saturação periférica da oxihemoglobina foi menor que o grupo clonidina (Grupo C) no momento 6. Os pacientes do Grupo S apresentaram maior incidência de náusea e vômito pós-operatório que os pacientes do Grupo C. A satisfação dos pacientes foi maior no grupo clonidina. Os hemodinamicistas mostraram-se satisfeitos nos dois grupos. CONCLUSÃO: O sufentanil e a clonidina foram efetivos como sedativos em pacientes submetidos a cateterismo cardíaco.

BACKGROUND: Sedation for heart catheterization has been a cause for concern. Benzodiazepines, alpha-2 adrenergic agonists and opioids are used for this purpose. However, each drug has advantages and disadvantages. OBJECTIVE: To evaluate the efficacy of sufentanil and clonidine as sedative in patients undergoing heart catheterization, observing their impact on hemodynamic and respiratory parameters, the presence of side effects and satisfaction of the patient and interventional cardiologist with the examination. METHODS: This is a prospective, double-blind, randomized and controlled clinical trial involving 60 patients who received 0.1 µg/kg of sufentanil or 0.5 µg/kg of clonidine before heart catheterization. The score of sedation according to the Ramsay scale, the need for use of midazolam, side effects and hemodynamic and respiratory parameters were recorded, with the data being analyzed at 06 different moments. RESULTS: The behavior of blood pressure, heart rate and respiratory rate was similar in both groups, but, at moment 2, the patients in the sufentanil group (Group S) had a lower sedation score on the Ramsay scale, and the peripheral oxyhemoglobin saturation was lower than in the clonidine group (Group C) at time 6. Patients in Group S had higher incidence of nausea and vomiting after surgery than patients in Group C. Patient satisfaction was higher in the clonidine group. The interventional cardiologists were satisfied in both groups. CONCLUSION: Sufentanil and clonidine were effective as sedative in patients undergoing heart catheterization.

FUNDAMENTO: La sedación para la realización de cateterismo cardíaco ha sido blanco de preocupación. Benzodiazepínicos, agonistas alfa-2 adrenérgicos y opioides son utilizados para ese fin, entre tanto, cada uno de estos medicamentos posee ventajas y desventajas. OBJETIVO: Evaluar la eficacia del sufentanil y de la clonidina como sedativos en pacientes sometidos a cateterismo cardíaco, observando el impacto de los mismos sobre los parámetros hemodinámicos y respiratorios, la presencia de efectos colaterales, además de la satisfacción del paciente y del hemodinamista con el examen. MÉTODOS: Se trata de un ensayo clínico prospectivo, doble ciego, randomizado y controlado, que incluyó 60 pacientes que recibieron 0,1 µg/kg de sufentanil o 0,5 µg/kg de clonidina antes de la realización del cateterismo cardíaco. El escore de sedación según la escala de Ramsay, la necesidad de utilización de midazolam, los efectos colaterales, los parámetros hemodinámicos y respiratorios fueron registrados, siendo los datos analizados en 6 diferentes momentos. RESULTADOS: El comportamiento de la presión arterial, de la frecuencia cardíaca y de la frecuencia respiratoria fue semejante en los dos grupos, entre tanto, en el momento 2, los pacientes del grupo sufentanil (Grupo S) presentaron menor escore de sedación según la escala de Ramsay, y la saturación periférica de la oxihemoglobina fue menor que el grupo clonidina (Grupo C) en el momento 6. Los pacientes del Grupo S presentaron mayor incidencia de náusea y vomito post operatorio que los pacientes del Grupo C. La satisfacción de los pacientes fue mayor en el grupo clonidina. Los hemodinamistas se mostraron satisfechos en los dos grupos. CONCLUSIÓN: El sufentanil y la clonidina fueron efectivos como sedativos en pacientes sometidos a cateterismo cardíaco.

Osteogenesis Imperfecta em obstetrícia: relato de caso / Osteogenesis imperfecta in pregnancy. Case report

JUSTIFICATIVA E OBJETIVOS: Osteogenesis Imperfecta é uma condição rara, principalmente em pacientes obstétricas. A prevalência estimada é de 1/10.000 na população geral e 1/25.000 a 30.000 em pacientes obstétricas. O objetivo deste artigo foi relatar caso raro de gestante a termo, portadora de Osteogenesis Imperfecta, submetida à operação cesariana. RELATO DO CASO: Gestante de 23 anos, idade gestacional 38 semanas, admitida na maternidade com quadro de perda de líquido amniótico e contrações há 4 horas da admissão associado à ausência de movimentos fetais há 4 dias. Portadora de Osteogenesis Imperfecta forma leve, sem outras comorbidades associadas, não fazia uso de medicações nem acompanhamento pré-natal. Submetida à raquianestesia no interespaço L3-L4, mediana, punção única com agulha de Quincke 27G e injeção de bupivacaína 0,5 por cento hiperbárica (10 mg) e morfina (60 µg). Alta no segundo dia pós-operatório sem queixas. CONCLUSÕES: A fertilidade está preservada, principalmente naquelas pacientes com o tipo I da doença, e a gestação pode ser conduzida até o termo. O parto geralmente é cirúrgico devido a deformidades pélvicas da gestante, desproporção cefalopélvica e incidência aumentada de anormalidades na apresentação fetal. A importância do anestesiologista na equipe está no manejo perioperatório e na escolha da técnica anestésica mais apropriada a cada paciente.

BACKGROUND AND OBJECTIVES: Osteogenesis Imperfecta is a rare condition, especially in obstetric patients. It has an estimated prevalence of 1/10,000 in the general population, and 1/25,000 to 30,000 in obstetric patients. The objective of this report was to present a rare case of a pregnant woman with Osteogenesis Imperfecta undergoing cesarean section. CASE REPORT: This is a 23 years old gravida on the 38th week, admitted to the maternity ward with loss of amniotic fluid and contractions for four hours, associated with the absence of fetal movements for four days. The patient had a mild form of Osteogenesis Imperfecta without other comorbidities. She was not taking any medication, and she did not have prenatal follow-up. The patient underwent spinal anesthesia in the L3-L4 space, median approach, with a single puncture with a 27G Quincke needle and the administration of hyperbaric 0.5 percent bupivacaine (10 mg) and morphine (60 µg). She was discharged in the second postoperative day without complaints. CONCLUSIONS: Fertility is preserved, especially in those patients with type I of the disease, and pregnancy can be carried to term. Delivery is usually surgical due to pelvic deformities in the gravida, cephalopelvic disproportion, and increased incidence of abnormal fetal presentation. The importance of the anesthesiologist in the surgical team relies on the perioperative management and the choice of the most appropriate anesthetic technique for each patient.

JUSTIFICATIVA Y OBJETIVOS: La Osteogénesis imperfecta es una condición rara, principalmente en pacientes obstétricas. La prevalencia estimada es de 1/10.000 en la población general y 1/25.000 a 30.000 en pacientes obstétricas. El objetivo de este artículo, fue relatar un caso raro de gestante a término portadora de osteogénesis imperfecta sometida a operación por cesárea. RELATO DEL CASO: Gestante de 23 años, edad gestacional 38 semanas, admitida en maternidad con un cuadro de pérdida de líquido amniótico y contracciones hacía ya 4 horas desde que llegó a admisión, asociado a la ausencia de movimientos fetales hacía 4 días. Paciente portadora de osteogénesis imperfecta forma leve, sin otras comorbidades asociadas, no usaba medicaciones ni poseía seguimiento prenatal. Fue sometida a la raquianestesia en el interespacio L3-L4, mediana, punción única con aguja de Quincke 27G e inyección de bupivacaína 0,5 por ciento hiperbárica (10 mg) y morfina (60 µg). Recibió alta en el 2º día del postoperatorio sin quejidos de dolor. CONCLUSIONES: La fertilidad está preservada, principalmente en las pacientes con el tipo I de la enfermedad, y la gestación puede ser conducida hasta el final. El parto generalmente es quirúrgico y debido a deformidades pélvicas de la embarazada, desproporción céfalopélvica, e incidencia aumentada de anormalidades en la presentación fetal. La importancia del anestesista en el equipo está en el manejo perioperatorio y en la elección de la técnica anestésica más apropiada para cada paciente.

Sedative and cardiovascular effects of midazolam and diazepam alone or combined with clonidine in patients undergoing hemodynamic studies for suspected coronary artery disease / Efeitos sedativos e cardiovasculares do midazolam e do diazepam, associados ou não a clonidina, em pacientes submetidos a estudos hemodinâmicos por suspeita de doença arterial coronariana

FUNDAMENTO: A sedação durante a cineangiocoronariografia tem sido pouco estudada e saber qual é a melhor droga para sedar esses pacientes é um questionamento importante. OBJETIVO: Avaliar a qualidade da sedação e os efeitos sobre a freqüência cardíaca (FC) e a pressão arterial (PA) do midazolam e do diazepam, associados ou não a clonidina, em pacientes com suspeita de doença coronariana. MÉTODOS: Foi desenvolvido ensaio clínico prospectivo, duplo-cego, randomizado, controlado, com 160 pacientes divididos em cinco grupos de 32 pacientes cada, de acordo com o fármaco utilizado: grupo C (clonidina 0,5 µg/kg); grupo M (midazolam 40 µg/kg); grupo MC (associação de midazolam 40 µg/kg e clonidina 0,5 µg/kg); grupo D (diazepam 40 µg.kg); e grupo DC (associação de diazepam 40 µg/kg e clonidina 0,5 µg/kg). A sedação foi avaliada com base na escala de Ramsay e no consumo de meperidina 0,04 mg.kg-1. A PA invasiva, a FC e o escore de sedação foram analisados a cada cinco minutos em quatro diferentes momentos. RESULTADOS: Os pacientes que utilizaram midazolam apresentaram maiores escores de sedação e variação da FC e da PA (p < 0,05). Os que utilizaram diazepam ou clonidina tiveram menores escores de sedação e mais satisfatórios para a realização do exame e apresentaram menor variação da PA e da FC (p > 0,05). CONCLUSÃO: O midazolam foi associado a maior efeito sedativo e cardiovascular enquanto o diazepam causou menor efeito sedativo e cardiovascular. A clonidina e o diazepam tiveram efeitos semelhantes na PA, na FC e na sedação.

BACKGROUND: Sedation during coronary angiography has been rarely studied, and it is important to know which drug is the best to sedate these patients. OBJECTIVE: To evaluate the quality of sedation and the effects of midazolam and diazepam alone or combined with clonidine on the heart rate (HR) and blood pressure (BP) of patients with suspected coronary artery disease. METHODS: This is a controlled, randomized, double-blind, prospective clinical study of 160 patients divided into five groups of 32 patients each, according to the drug used: group C (clonidine 0.5 µg/kg); group M (midazolam 40 µg/kg); group MC (combination of midazolam 40 µg/kg and clonidine 0.5 µg/kg); group D (diazepam 40 µg/kg); and group DC (combination of diazepam 40 µg/kg and clonidine 0.5 µg/kg). Sedation was evaluated based on the Ramsay scale and on the use of meperidine 0.04 mg.kg-1. Invasive BP monitoring, HR and the sedation score were analyzed every five minutes at four different time points. RESULTS: Patients who received midazolam presented higher sedation scores as well as HR and BP variation (p < 0.05). Those who received diazepam or clonidine had lower sedation scores, which were more satisfactory for the performance of the procedure, and presented a lower BP and HR variation (p > 0.05). CONCLUSION: Midazolam was associated with a greater sedative and cardiovascular effect, whereas for diazepam these effects were less intense. Clonidine and diazepam had similar effects on BP, HR and sedation.

Clonidina na cineangiocoronariografia: efeitos sedativos sobre a pressão arterial e freqüência cardíaca / Clonidine in cineangiocardiography: sedative effects on blood pressure and heart rate

OBJETIVO: Avaliar os efeitos da clonidina sobre a freqüência cardíaca (FC), pressão arterial (PA) e sedação de pacientes submetidos à cineangiocoronariografia. MÉTODOS: Um ensaio clínico prospectivo, duplo cego, randomizado, controlado, foi realizado com 62 pacientes submetidos a cineangiocoronariografias eletivas, divididos em dois grupos: grupo clonidina que utilizou 0,8 æg/kg desta droga, e o grupo controle que utilizou solução fisiológica a 0,9 por cento. A sedação foi avaliada com base na escala de Ramsay e o consumo de meperidina 0,04 mg/kg que foi utilizada nos pacientes que apresentaram agitação ou ansiedade durante o procedimento. A PA invasiva, a FC e o escore de sedação, de acordo com a escala de Ramsay, foram analisados a cada 5 minutos e quatro diferentes momentos foram considerados para avaliação: M1- inicio do exame; M2- 5 minutos após o início do exame; M3- mediana do tempo do exame e M4 - final do exame. RESULTADOS: O grupo clonidina apresentou maior estabilidade da PA e FC e eficácia na sedação, enquanto o grupo controle apresentou um maior consumo de meperidina (p<0,05). Na análise estatística, para inferência das variáveis contínuas foi utilizado o teste T ou Mann-Whitney e chi2 ou Teste Exato de Fisher para as variáveis categóricas. CONCLUSÃO: Este trabalho mostrou que, nos pacientes submetidos à cineangiocoronariografia, a utilização da clonidina foi eficaz tanto no controle da PA e FC quanto em proporcionar uma sedação consciente.

OBJECTIVE: To evaluate the effects of clonidine on heart rate (HR), and blood pressure (BP) as well as its sedative effect on patients submitted to a cineangiocardiography. METHODS: A randomized, controlled, double blind, prospective clinical trial was conducted on 62 patients submitted to an elective cineangiocardiography. The patients were divided in two groups: the clonidine group, that were administered a 0.8 æg/kg dose of this drug and the control group, that were administered a 0.9 percent saline solution. Sedation was evaluated based on the Ramsay Scale and the administration of a 0.04 mg/kg dose of meperidine that was given to the patients who were agitated or anxious during the procedure. The invasive BP, HR and sedation score based on the Ramsay Scale were analyzed every 5 minutes and four different intervals were considered for the assessment: I1- start of the test; I2- 5 minutes after the start of the test; I3- median time of the test and I4- end of the test. RESULTS: The clonidine group presented better BP and HR stability and sedation efficacy while the control group presented a higher intake of meperidine (p<0.05). In the statistical analysis, the inference of the continuous variables was calculated using the Student's t-test or Mann-Whitney test and the chi2 or Fisher Exact Probability test was used for the categorical variables. CONCLUSION: This study demonstrated that clonidine was an efficient means to control BP and HR and provided a conscious sedation for patients submitted to a cineangiocardiography.

Efeitos sedativos e cardiovasculares do midazolam e do diazepam associados ou não a clonidina, em pacientes submetidos a estudos hemodinâmicos por suspeita de doença arterial coronariana / Medazolam and diazepam associated or not with clonidine cardiovascular and sedative effects on patients submitted to hemodynamic study in suspected of coronary arterial disease

Objetivo: Avaliar a qualidade da sedação e os efeitos sobre a frequência cardíaca e a pressão arterial do midazolam e do diazepam associados ou não a clonidina, em pacientes com suspeita de doença coronariana. Métodos - Foi desenvolvido ensaio clínico prospectivo, duplo cego, randomizado, controlado, com 160 pacientes. Estes apresentavam teste ergométrico ou cintilografia positivos para isquemia miocárdica e foram submetidos a cineangiocoronariografias diagnósticas eletivas, divididos em cinco grupos de 32 pacientes cada, de acordo com o fármaco utilizado: grupo : (clonidina 0,5 micrograma.kg-1); grupo M (midazolam 40 micrograma.kg-1); grupo MC associação do midazolam 40 micrograma.kg-1 e da clonidina 0,5 micrograma.kg-1); grupo D diazepam 40 micrograma.kg-1); grupo DC (associação do diazepam 40 micrograma.kg-1 e da clonidina 0,5 micrograma.kg-1). A sedação foi avaliada com base na escala de Ramsay e no consumo de meperidina (0,04 mg.kg-1) que foi utilizada nos pacientes que apresentaram agitação ou ansiedade durante o procedimento. A PA invasiva, a FC e o escore de sedação, foram analisados a cada 5 minutos em 4 diferentes momentos: M1 - início do exame; M2 - 5 minutos após o início do exame; M3 ­metade do tempo do exame e M4 - final do exame. Resultados - Os grupos foram homogêneos com relação à PA, FC e sedação 10 momento controle (M1). Os pacientes que utilizaram o midazolam apresentaram maiores escores de sedação e variação da FC e PA (p menor que 0,05). Os que utilizaram o diazepam ou a clonidina exibiram menores e mais apropriados escores de sedação para a realização do exame e apresentaram menor variação da PA e da FC (p maior que 0,05). A associação com a clonidina potencializou de forma mais precoce e acentuada os efeitos sedativos do midazolam em relação ao diazepam (p menor que 0,05). O consumo de meperidina não diferiu entre os grupos estudados (p maior que 0,10).