Adrenergic signaling molecular complexes. / Complejos moleculares de la señalización adrenérgica.

Adrenaline and noradrenaline bind to membrane receptors of the superfamily of G protein-coupled receptors (GPCR) in target cells, where they modulate physiological responses such as metabolism, vasoconstriction, vasodilation and proliferation. Alteration in their function is associated with conditions such as hypertension, benign prostatic hyperplasia and cardiac hypertrophy. In response to adrenaline, receptors form signaling complexes, which enables adrenergic action to be specific, rapid and efficient. These signaling complexes or signalosomes are composed of kinases, phosphatases, and adapter and scaffold proteins, which together modulate the receptor function. Manipulation of each protein-protein interaction of the adrenergic signaling complex emerges as a promising therapeutic strategy for the design of drugs that modulate adrenergic action and help to define its pathophysiological significance. An important biological model to perform these investigations is the heart, since it expresses all adrenergic receptors; to date, several heart signalosomes have been described. Mass spectrometry (proteomics), genetic manipulation and biochemical assays, such as two-hybrid and co-immunoprecipitation assays, are tools that are used in these studies.

La adrenalina y la noradrenalina se unen a receptores membranales de la superfamilia de receptores acoplados a proteínas G (GPCR) en las células blanco, donde modulan respuestas fisiológicas tales como el metabolismo, vasoconstricción, vasodilatación y proliferación. La alteración en su función está asociada con hipertensión, hiperplasia prostática benigna e hipertrofia cardiaca. En respuesta a la adrenalina, los receptores forman complejos de señalización, lo que permite que la acción adrenérgica sea específica, rápida y eficiente. Estos complejos de señalización o signalosomas están integrados por cinasas, fosfatasas, proteínas adaptadoras y de andamio, que en conjunto modulan la función del receptor. La manipulación de cada interacción proteína-proteína del complejo de señalización adrenérgico emerge como una estrategia terapéutica prometedora para el diseño de fármacos que modulen la acción adrenérgica y ayuden a definir su significado fisiopatológico. Un modelo biológico importante para realizar estos estudios es el corazón, ya que expresa todos los receptores adrenérgicos; en la actualidad se han descrito varios signalosomas cardiacos. La espectrometría de masas (proteómica), manipulación genética y ensayos bioquímicos como el doble híbrido o la coinmunoprecipitación son herramientas que se emplean en estos estudios.

In-hospital cardiac arrest: Incidence, prognostic factors and results.

BACKGROUND AND AIMS: In-hospital cardiac arrest (CA) is a clinical entity with high morbidity and mortality that occurs in up to 2% of hospitalized patients. It is a public health problem with important economic, social, and medical repercussions, and as such its incidence needs to be reviewed and improved. The aim of this study was to determine the incidence of in-hospital CA, return of spontaneous circulation (ROSC), and survival rates at Hospital de la Princesa, and to define the clinical and demographic characteristics of patients with in-hospital CA. PATIENTS AND METHODS: Retrospective observational chart review of patients presenting in-hospital CA and treated by anaesthesiologists from the hospital's rapid intervention team. Data were collected over 1 year. RESULTS: Forty four patients were included in the study, of which 22 (50%) were women. Mean age was 75.7 years (±15.78 years), and incidence of in-hospital CA was 2.88 per 100,000 hospital admissions. Twenty two patients (50%) achieved ROSC and 11 patients (25%) survived until discharge home. The most prevalent comorbidity was arterial hypertension (63.64%); 66.7% of cases were not witnessed, and only 15.9% presented a shockable rhythm. CONCLUSIONS: These results are similar to those reported in other larger studies. We recommend introducing immediate intervention teams and devoting time to training hospital staff in in-hospital CA.

Amoxicillin-clavulanic acid-induced type II Kounis syndrome during general anaesthesia complicated with hypoxic-ischaemic encephalopathy. / Síndrome de Kounis del tipo II inducido por amoxicilina-ácido clavulánico complicado con encefalopatía hipóxico-isquémica durante anestesia general.

Anaphylaxis is a severe acute multisystem syndrome involving massive mediator release from mast cells and basophils. Although the entire arterial system can be affected, when coronary arteries are the main targets, Kounis syndrome needs to be considered. Cerebral artery involvement has also been suggested in rarer MC-mediator release episodes; so-called 'Kounis-like' syndrome. Cerebral ischaemic lesions can then result from low blood pressure or direct proinflammatory and/or vasoconstrictive mediator action in the cerebral arterial system. Diagnosis can be difficult in anaesthetised patients, as low blood pressure can have multiple causes. Treatment is also challenging, as administering adrenaline can worsen ischaemia. We report the first case of amoxicillin-clavulanic acid-induced type II Kounis syndrome under general anaesthesia, complicated with severe, irreversible and subsequently fatal encephalopathy of ischaemic origin. This case can contribute to awareness of less common Kounis syndrome manifestations, including severe cerebral involvement, or other anaphylactic reactions with atypical presentations.

Experiencia en el manejo de anafilaxia en un Departamento de Emergencias Pediátricas

Introducción: La anafilaxia es una reacción multisistémica potencialmente mortal; su reconocimiento temprano y abordaje oportuno son fundamentales. La variabilidad de presentación y gravedad requieren la utilización de criterios diagnósticos para la mejora de la atención en urgencias. Objetivo: Describir las características clínicas, criterios de diagnóstico y tratamiento de los pacientes con anafilaxia atendidos en un Departamento de Emergencias Pediátricas (DEP). Materiales y métodos: Revisión retrospectiva, descriptiva, de casos ingresados en el DEP de enero 2015 a diciembre 2020. Los criterios diagnósticos fueron aplicados por dos observadores emergentólogos evaluando la concordancia con el índice к de Cohen. Se utilizó estadística descriptiva: proporciones, medianas y rango intercuartílico. Resultados: Se aplicaron los criterios NIAID/FAAN a 65 historias clínicas con diagnóstico de egreso de anafilaxia encontrándose una concordancia de 0,64 (IC 95%: 0,41-0,88). De ellos, 35 (54%) cumplieron los criterios diagnósticos. El 66% (23/35) recibió adrenalina. La mediana de edad fue de 7 años (RIC: 3-11,5). Antecedente de asma en 9/35, atopia en 7/35 y anafilaxia previa en 7/35. Como factor desencadenante se constató consumo de medicamentos en 16/35, alimentos en 8/35. La estadía hospitalaria tuvo una mediana de 18 horas (RIC: 12-24). Conclusiones: Los resultados sugieren una brecha entre identificación precisa de los casos de anafilaxia y el tratamiento oportuno con adrenalina cuando se utilizan criterios estandarizados.

Introduction: Anaphylaxis is a potentially fatal multisystem reaction; early recognition and timely approach are essential. The variability in its presentation and severity requires the use of diagnostic criteria to improve emergency care. Objective: To describe the clinical characteristics, diagnostic criteria and treatment of patients with anaphylaxis treated in a Pediatric Emergency Department (PED). Materials and methods: This was a retrospective and descriptive review of cases admitted to the PED from January 2015 to December 2020. The diagnostic criteria were applied by two emergentologist observers; Cohen's к index was used to evaluate their agreement. Descriptive statistics were used: proportions, medians and interquartile range. Results: The NIAID/FAAN criteria were applied to 65 medical records with a discharge diagnosis of anaphylaxis, finding an agreement of 0.64 (95% CI: 0.41-0.88). Of these, 35 (54%) met the diagnostic criteria. 66% (23/35) received adrenaline. The median age was 7 years (IQR: 3-11.5). 9/35 had a history of asthma, 7/35 had atopy and previous anaphylaxis was noted in 7/35. As a triggering factor, medication consumption was found in 16/35, and food in 8/35. The hospital stay had a median of 18 hours (IQR: 12-24). Conclusions: The results suggest a gap between accurate recognition of anaphylaxis cases and timely treatment with adrenaline when standardized criteria are used.

Enfrentamiento de la anafilaxia en el servicio de urgencia / Approach of Anaphylaxis in the emergency room

La anafilaxia es una reacción en su mayoría de hipersensibilidad tipo I, que estimula la activación generalizada de mastocitos, y provoca un cuadro clínico multisistémico que puede ser fatal. Se estima que tiene una incidencia de 0,03-0,1% y una prevalencia de vida de 0,5-2% en la población general. Generalmente, la reacción inmunológica ocurre posterior a la ingesta de alimentos, uso de medicamentos o picaduras de insectos, pero también se han descrito mecanismos no inmunológicos (no IgE) que actúan directamente sobre los mastocitos, llamadas en la literatura "reacciones anafilactoideas". La anafilaxia fue descrita por Paul Portier y Charles Robert Richet en 1902 en perros, los cuales desarrollaban esta reacción posterior a la inyección repetida de veneno de anémonas (medusas). Sin embargo, esta entidad no tuvo criterios diagnósticos ni pilares de manejo estructurado hasta el año 2006. En ese año en se publicó el segundo simposio de manejo de la anafilaxia, en donde se definieron criterios diagnósticos clínicos claros y el rol fundamental de la adrenalina en su manejo; la única droga que cambia el pronóstico del paciente.

Anaphylaxis is mainly a type I hypersensitivity reaction. It triggers a widespread activation of mast cells, causing a multisystemic clinical scenario that can be fatal. It is estimated to have an incidence of 0.03-0.1% and a lifetime prevalence of 0.5-2%. Most immunological reactions occur after food ingestion, medication, or insect stings, but non-immunological (non-IgE) mechanisms that act directly on mast cells, called Anaphylactoid Reactions, have been also described. Anaphylaxis was described by Paul Portier and Charles Robert Richet in 1902 in dogs, that developed this disease after repeated injections of anemones (jellyfish) venom. However, this entity didn't have established diagnostic criteria or an standarized management until 2006. In this year, the second anaphylaxis management sym-posium took place and clear clinical diagnostic criteria were defined. The fundamental role of adrenaline in its management was also established. The former is the only drug that has demonstrated to improve prognosis of the patient

Evolución clínica de niños con shock séptico refractario a fluidos tratados con dopamina o adrenalina. Estudio retrospectivo en un servicio de emergencias pediátrico de Argentina / Clinical outcome of children with fluid-refractory septic shock treated with dopamine or epinephrine. A retrospective study at a pediatric emergency department in Argentina

RESUMEN Objetivo: Analizar la evolución clínica de niños con shock séptico refractario a volumen tratados inicialmente con dopamina o adrenalina. Métodos: Estudio de cohorte retrospectivo con ámbito en un servicio de urgencias pediátrico de un hospital de tercer nivel. Población: niños ingresados con shock séptico refractario a volumen. Se comparó la evolución clínica entre 2 grupos: Grupo Dopamina y Grupo Adrenalina. Las variables de interés fueron: uso de ventilación mecánica invasiva, días de inotrópicos, estancia hospitalaria, estancia en cuidados intensivos y mortalidad. Para variables numéricas y categóricas utilizamos medidas de tendencia central y para comparación las pruebas de U Mann Whitney y χ2 test. Resultados: Incluimos 118 pacientes. El 58,5% recibió dopamina y 41,5% adrenalina. El uso de ventilación mecánica invasiva fue 38,8% para adrenalina versus 40,6% para dopamina (p = 0,84) con una mediana de 4 días para adrenalina y 5,5 para dopamina (p = 0,104). La mediana para días de inotrópicos fue de 2 días para ambos grupos (p = 0,714). La mediana de estancia hospitalaria fue de 11 para adrenalina y 13 para dopamina (p = 0,554) y de estancia en cuidados intensivos se registró una mediana de 4 días (0 - 81 días) siendo igual en ambos grupos (p = 0,748). La mortalidad fue de 5% para el Grupo Adrenalina versus 9% para el Grupo Dopamina (p = 0,64). Conclusiones: En nuestro centro, no observamos diferencias en uso de ventilación mecánica invasiva y tiempo de inotrópicos, estancia hospitalaria y cuidados intensivos y mortalidad entre niños ingresados al servicio de urgencias pediátrico con diagnóstico de shock séptico refractario a volumen tratados inicialmente con dopamina o adrenalina.

Abstract Objective: To analyze the clinical outcome of children with fluid-refractory septic shock initially treated with dopamine or epinephrine. Methods: A retrospective cohort study was conducted at a pediatric emergency department of a tertiary hospital. Population: children admitted because of fluid-refractory septic shock. Clinical outcome was compared between two groups: Dopamine and Epinephrine. Variables evaluated were use of invasive mechanical ventilation, days of inotropic therapy, length of hospital stay, intensive care stay, and mortality. For numerical and categorical variables, we used measures of central tendency. They were compared by the Mann-Whitney U-test and the (2 test. Results: We included 118 patients. A total of 58.5% received dopamine and 41.5% received epinephrine. The rate of invasive mechanical ventilation was 38.8% for epinephrine versus 40.6% for dopamine (p = 0.84), with a median of 4 days for the Epinephrine Group and 5.5 for the Dopamine Group (p = 0.104). Median time of inotropic therapy was 2 days for both groups (p = 0.714). Median hospital stay was 11 and 13 days for the Epinephrine and Dopamine groups, respectively (p = 0.554), and median stay in intensive care was 4 days (0 - 81 days) in both groups (p = 0.748). Mortality was 5% for the Epinephrine Group versus 9% for the Dopamine Group (p = 0.64). Conclusions: At our center, no differences in use of invasive mechanical ventilation, time of inotropic therapy, length of hospital stay, length of intensive care unit stay, or mortality were observed in children admitted to the pediatric emergency department with a diagnosis of fluid-refractory septic shock initially treated with dopamine versus epinephrine.

Terapia endoscópica combinada en hemorragia diverticular de colon / Combined endoscopic therapy for colonic diverticular bleeding

La hemorragia diverticular es la causa más frecuente de hemorragia digestiva baja. La hemorragia es abrupta, indolora, abundante. La mayoría de los divertículos que sangran se localizan en el lado derecho, este sangrado se autolimita hasta en un 80% de los casos. Cuando no se autolimita su manejo puede llegar a ser complejo. El manejo de estos sangrados, pueden variar desde conservador, endoscópico, arteriografía más embolización y el quirúrgico. Entre las alternativas de manejo endoscópico, tenemos la terapia de inyección, la térmica, hemoclips, ligadura con banda. El presente caso es de un paciente con hemorragia diverticular en el que se realizó terapia endoscopica combinada, infiltración de adrenalina, aplicación indirecta de hemoclips y aplicación tópica de ácido tranexámico que es un antifibrinolítico.

Diverticular bleeding is the most common cause of lower GI bleeding. The bleeding is most often abrupt, painless and abundant. Most of the bleeding diverticula are located on the right side of the colon, this bleeding is self-limited in up to 80% of cases. When it is not, it could turn into a difficult situation to manage. The management of these bleeds can vary from conservative to an endoscopic, arteriography plus embolization and surgical. Among the endoscopic management alternatives, we have injection therapy, thermal therapy, hemoclips, band ligation. The present case is about a patient with diverticular bleeding who underwent combined endoscopic therapy, adrenaline infiltration, indirect application of hemoclips, and topical application of tranexamic acid, which is an antifibrinolytic.

Atualização sobre reações de hipersensibilidade perioperatória: Documento conjunto da Sociedade Brasileira de Anestesiologia e Associação Brasileira de Alergia e Imunologia ­ Parte II: etiologia e diagnóstico / Update on perioperative hypersensitivity reactions: Joint document from the Brazilian Society of Anesthesiology and Brazilian Association of Allergy and Immunology ­ Part II: Etiology and diagnosis

A anafilaxia perioperatória é manifestação importante no contexto de eventos adversos relacionados à cirurgia. Embora frequentemente relacionada à indução anestésica, pode ocorrer por outros agentes administrados por outras vias. A anafilaxia pode se apresentar como colapso cardiovascular, obstrução da via aérea e/ou insuficiência respiratória com ou sem manifestação cutânea, com consequências fatais em muito casos. Apesar de considerada inevitável em alguns casos, a sua incidência poderia (e deveria) ser reduzida através da busca por fármacos mais seguros. A avaliação abrangente de um episódio é um dos elementos primordiais para tornar a exposição subsequente mais segura, com orientações derivadas dessa investigação. Entretanto, representa um desafio estatístico por ser reação rara, randômica e muitas vezes independente de exposições sucessivas dos pacientes a procedimentos de baixo risco. Neste documento são revisados os mecanismos fisiopatológicos, agentes desencadeantes (adultos e crianças), assim como a abordagem diagnóstica durante a crise e após o episódio. Uma avaliação abrangente, a identificação das medicações, antissépticos e outras substâncias usadas em cada região, registros detalhados e nomenclatura padronizada são pontos fundamentais para a obtenção de dados epidemiológicos mais fidedignos sobre a anafilaxia perioperatória.

Perioperative anaphylaxis is an important manifestation in the context of surgery-related adverse events. Although often related to anesthetic induction, it may be caused by other agents administered by other routes. Anaphylaxis may manifest as cardiovascular collapse, airway obstruction and/or respiratory failure with or without skin manifestation, resulting often in death. Although this reaction is considered inevitable in some cases, its incidence could (and should) be reduced by the search for safer drugs. Comprehensive assessment of an allergic reaction is a key element to make subsequent exposure safer, with guidance derived from this investigation. However, surveillance of perioperative anaphylaxis represents a statistical challenge because this is a rare, random reaction and often independent of successive patient exposures to low-risk procedures. This paper reviews pathophysiological mechanisms, triggering agents (adults and children), as well as therapeutic and diagnostic approach during and after an allergic reaction. Comprehensive assessment, identification of medications/antiseptics used in each region and detailed records with standardized terminology are key points for obtaining more reliable epidemiological data on perioperative anaphylaxis.

Abordagem das reações de hipersensibilidade perioperatória: Orientações da Sociedade Brasileira de Anestesiologia e da Associação Brasileira de Alergia e Imunologia - Parte II: etiologia e diagnóstico / Approach to perioperative hypersensitivity reactions: Guidelines from the Brazilian Society of Anesthesiology and the Brazilian Association of Allergy and Immunology - Part II: etiology and diagnosis

A anafilaxia perioperatória é manifestação importante no contexto de eventos adversos relacionados à cirurgia. Embora frequentemente relacionada à indução anestésica, pode ocorrer por outros agentes administrados por outras vias. A anafilaxia pode se apresentar como colapso cardiovascular, obstrução da via aérea e/ou insuficiência respiratória com ou sem manifestação cutânea, com consequências fatais em muito casos. Apesar de considerada inevitável em alguns casos, a sua incidência poderia (e deveria) ser reduzida através da busca por fármacos mais seguros. A avaliação abrangente de um episódio é um dos elementos primordiais para tornar a exposição subsequente mais segura, com orientações derivadas dessa investigação. Entretanto, representa um desafio estatístico por ser reação rara, randômica e muitas vezes independente de exposições sucessivas dos pacientes a procedimentos de baixo risco. Neste documento são revisados os mecanismos fisiopatológicos, agentes desencadeantes (adultos e crianças), assim como a abordagem diagnóstica durante a crise e após o episódio. Uma avaliação abrangente, a identificação das medicações, antissépticos e outras substâncias usadas em cada região, registros detalhados e nomenclatura padronizada são pontos fundamentais para a obtenção de dados epidemiológicos mais fidedignos sobre a anafilaxia perioperatória.

Perioperative anaphylaxis is an important manifestation in the context of surgery-related adverse events. Although often related to anesthetic induction, it may be caused by other agents administered by other routes. Anaphylaxis may manifest as cardiovascular collapse, airway obstruction and/or respiratory failure with or without skin manifestation, resulting often in death. Although this reaction is considered inevitable in some cases, its incidence could (and should) be reduced by the search for safer drugs. Comprehensive assessment of an allergic reaction is a key element to make subsequent exposure safer, with guidance derived from this investigation. However, surveillance of perioperative anaphylaxis represents a statistical challenge because this is a rare, random reaction and often independent of successive patient exposures to low-risk procedures. This paper reviews pathophysiological mechanisms, triggering agents (adults and children), as well as therapeutic and diagnostic approach during and after an allergic reaction. Comprehensive assessment, identification of medications/antiseptics used in each region and detailed records with standardized terminology are key points for obtaining more reliable epidemiological data on perioperative anaphylaxis.

Regression of dark color in subterranean fishes involves multiple mechanisms: response to hormones and neurotransmitters

Organisms with source-populations restricted to the subterranean biotope (troglobites) are excellent models for comparative evolutionary studies, due to their specialization to permanent absence of light. Eye and dark pigment regression are characteristics of most troglobites. In spite of the advance in knowledge on the mechanisms behind eye regression in cave fishes, very little is known about pigmentation changes. Studies were focused on three species of the genus Pimelodella. Exemplars of the troglobitic P. spelaea and P. kronei were compared with the epigean (surface) P. transitoria, putative sister-species of the latter. Melanophore areas and densities are significantly lower in the troglobitic species. Evaluating the in vitro response of these cells to adrenaline, acetylcholine and MCH, we observed a reduced response in both troglobites to adrenaline. The same trend was observed with MCH, but not statistically significant. No response to acetilcholine was detected in all the three. Contrary to expectations, even though eye-regression in P. spelaea was much lower than in P. kronei, pigmentation regression was more advanced. Multiple mechanisms of loss showing a mosaic of traits in troglobitic fishes are discussed here.(AU)

Organismos com populações-fonte restritas ao biótopo subterrâneo (troglóbios) são excelentes modelos para estudos evolutivos comparativos, devido à especialização resultante do isolamento sob um regime seletivo particular, com ênfase na permanente falta de luz. A regressão do olho e da pigmentação são características dos troglobites. Apesar do avanço do conhecimento sobre os mecanismos subjacentes à regressão ocular em peixes de caverna, pouco se sabe sobre mudanças de pigmentação. Os estudos foram focados em três espécies do gênero Pimelodella. Exemplares das espécies troglóbias P. spelaea e P. kronei foram comparados com a epígea P. transitoria, provável espécie-irmã dessa última. As áreas e densidades dos melanóforos são significativamente menores nas espécies troglóbias. Avaliando a resposta in vitro dessas células à adrenalina, acetilcolina e MCH, observamos uma resposta reduzida em ambos os troglóbios à adrenalina. A mesma tendência foi observado com o MCH, mas não estatisticamente. Nenhuma resposta à acetilcolina foi detectada três. Contrariamente às expectativas, embora a regressão ocular em P. spelaea seja bem menor do que em P. kronei, a regressão na pigmentação foi mais acentuada. Múltiplos mecanismos de regressão, mostrando um mosaico de características em peixes troglóbios, são discutidos aqui.(AU)

[Epidural anaesthesia: Simulated intravascular test dose with S(+) ketamine, lidocaine and adrenaline. A prospective, randomized, double blind and placebo controlled study]. / Anestesia epidural: dosis test intravascular simulada con S(+)-ketamina, lidocaína y adrenalina. Estudio prospectivo, aleatorizado, doble ciego, controlado con placebo.

OBJECTIVE: The use of a test dose in epidural anaesthesia is a safety recommendation. However specificity and sensitivity of the drugs used with this indication have been not conclusive. The main objective of this study was to compare the effectiveness and the adverse effects of a simulated intravascular test dose of adrenaline, lidocaine and S(+)-ketamine. MATERIAL AND METHODS: A prospective, randomized, double blinded, placebo controlled study was designed. ASA I patients scheduled for elective surgery were included. These were randomized to the following study groups: S(+)-ketamine 0.5 mg.kg-1 (S+K group), 5% lidocaine 1.5 mg.kg-1 (L5% group), adrenaline 15µg (ADR group), and physiological saline 3 ml (SF group; control group). An evaluation was made during the first 15 minutes after the study drug was administered. Variables including heart rate (HR) systolic and diastolic blood pressure (sBP and dBP), mean arterial pressure (MAP), and SpO2 were recorded at 0 min (baseline) and at 2, 5, 8, 10 and 15 minutes after drug injection. An increase of at least 20 beats per minute (bpm) in relation to the baseline measurement was considered a positive result, as was an increase sBP >15 mmHg. The clinical effects described as related to iv injection of the study drugs recorded were: sedation-hypnosis, dizziness, nystagmus, metallic taste perception, perioral or facial paresthesias, tinnitus, as well as any other effect the patients mentioned. Sensitivity and specificity were calculated as was the percent increase in the parameters in order to see if these were clinically useful. RESULTS: A total of 80 patients, 20 per group, were included. The sBP, dBP, and MAP were significantly raised at the 2, 5, 8 and 10 minutes measurements in the S(+)K group compared to the rest of the groups (P<.05), as well as HR in the 2, 5, 8, 10 and 15 minute measurements in the S(+)K compared to the rest of the groups (P<.05). Sensitivity and specificity were high, and significant in the S(+)K group from minute 2 to minute 8 compared with the placebo group, as well as percentage points differences in the same interval. There were significant differences in the incidence of sedation-hypnosis, nystagmus and dizziness, which were more frequent in the S(+)K group. There were no differences in the incidence of metallic taste, perioral and facial paresthesias or tinnitus. The effects in the S(+)K group always occurred before minute 5 after drug injection. CONCLUSION: Both lidocaine an adrenaline at the scheduled doses showed low sensitivity and specificity as a simulated iv epidural test dose. S(+)-ketamine could be a feasible marker after accidental iv injection during epidural anaesthesia or analgesia.

Infiltración periarticular y ácido tranexámico tópico para control de pérdida sanguínea en artroplastia total de rodilla / Periarticular injection and topical tranexamic acid for blood loss control in total knee arthroplasty

Introducción La pérdida sanguínea durante el remplazo total de rodilla es una de las principales variables que influyen en los resultados de esta cirugía para lo cual se han implementado varios métodos para reducirla. Objetivo Cuantificar el cambio en el hematocrito y hemoglobina a las 24 horas postoperatorias en pacientes a quienes se les realizó reemplazo total de rodilla primario entre marzo del 2016 y agosto del 2017. Metodología Se realizó un estudio observacional a partir de una cohorte retrospectiva. Los criterios de inclusión fueron aquellos pacientes a quienes se les realizó reemplazo total de rodilla primaria con infiltración periarticular con bupivacaina con epinefrina, ketorolaco y morfina e intrarticular con ácido tranexámico. Se midieron hemoglobina y hematocrito pre y post operatorio, cálculo de pérdida sanguínea y transfusiones. Resultados Se analizaron un total de 159 reemplazos totales de rodilla (75 prótesis convencionales, 84 prótesis navegadas). El porcentaje de transfusión fue de 0,69% (1 paciente). La disminución del hematocrito promedio fue de 7,36% y la disminución de la hemoglobina de 2,49 gr/dl para una pérdida sanguínea calculada de 780ml. Se usó torniquete en 147 pacientes. Discusión La combinación de uso de torniquete, infiltración periarticular e intra articular de ácido tranexamico reduce la pérdida sanguínea y la necesidad de tranfusiones.

Background The blood loss during the total knee replacement is one of the main variables that influence the outcomes of this surgery, and several methods have been implemented to reduce it. The aim of the study is to quantify the change in haematocrit and haemoglobin at 24hours post-surgery in patients subjected to a total primary knee replacement at the Clinica Colombia between March 2016 and August 2017. Methods An observational study was conducted on a retrospective cohort. The inclusion criteria were those patients who had a total primary knee replacement with periarticular infiltration with bupivacaine, with adrenaline, ketorolac, and morphine, and intra-articular with tranexamic acid. Haemoglobin and pre- and post-operative haematocrit, blood loss calculation, and transfusions were measured. Results The analysis included a total of 159 total knee replacements (75 conventional prostheses, 84 navigated prostheses). The percentage of transfusion was 0.69% (1 patient). The decrease in mean haematocrit was 7.36%, and the mean decrease in haemoglobin was 2.49g / dl for a calculated blood loss of 780ml. A tourniquet was used in 147 patients. Discussion The combination of tourniquet use, periarticular, and intra-articular injection of tranexamic acid reduces blood loss and the need for tranfusions.

[Anaphylactic shock lasting 4 days]. / Shock anafiláctico prolongado de 4 días de duración.

We present a case of a 62 year-old male scheduled for radical cystectomy, who, ten minutes into the surgery, presented with severe hypotension, tachycardia and increased airway pressure. There was no response to the administration of vasoactive drugs such as, ephedrine, phenylephrine, dopamine and norepinephrine. After ruling out several causes, we evaluated the possibility of an anaphylactic reaction. Adrenaline was given, and the patient stabilized. An adrenaline infusion and mechanical ventilation was required for four days in the critical care unit.

Anafilaxia: estado del arte / Anaphylaxis: state of the art

RESUMEN La anafilaxia se define como una reacción de hipersensibilidad, sistémica, de instauración rápida y potencialmente fatal, con manifestaciones clínicas y severidad variable, que resulta de la liberación súbita de mediadores de mastocitos y basófilos. El diagnóstico de esta entidad es fundamentalmente clínico, basándose en los patrones de manifestación y la exposición a un posible detonante. Actualmente varios estudios indican deficiencias en la identificación y manejo de esta enfermedad, lo que genera un riesgo elevado de mortalidad. En esta revisión presentamos puntos prácticos del manejo e identificamos las principales consideraciones a tener en cuenta en el primer nivel de atención.

SUMMARY Anaphylaxis is defined as a systemic, rapid onset, and potentially fatal hypersensitivity reaction, with variable clinical manifestations and severity resulting from the sudden reléase of mast cell and basophil mediators. The diagnosis of this entity is fundamentally clinical, based on the patterns of manifestation and the exposure to a possible trigger. Currently several studies indicate deficiencies in the identification and management of this disease, which generates an increase in mortality. In this review we present practical points of management and identify the main considerations to be taken into account in the first level care.

Anafilaxia na sala de emergência: tão longe do desejado! / Anaphylaxis in the emergency room: still a long way to go

Objetivo: Anafilaxia é a mais dramática condição clínica da emergência em alergia. O objetivo deste estudo foi verificar o conhecimento de médicos em serviços de urgência e emergência sobre o manejo da anafilaxia. Métodos: Estudo transversal, onde foi aplicado questionário escrito para 119 médicos em oito hospitais (grupo Hospital) e 210 médicos de nove Unidades de Pronto Atendimento/Serviço de Atendimento Móvel de Urgência (grupo UPA/SAMU) entre abril e setembro/2016. Resultados: Entre os convidados, responderam ao questionário 79 (66,4%) médicos que atuavam em Hospital, e 78 (37,1%) em UPA/SAMU. Cento e vinte e dois participantes (78,7%) se formaram há até 10 anos. Sessenta e nove médicos (43,9%) acertaram o diagnóstico de anafilaxia, e apenas 29 (18,5%) identificaram os sistemas que podem ser acometidos na reação anafilática. A adrenalina intramuscular foi referida como primeira opção de tratamento da anafilaxia por 64 (40,7%), e o glucagon foi escolhido como opção em pacientes que utilizam ß-bloqueadores por 19 (12,1%) dos médicos. A orientação quanto aos autoinjetores foi referida por 71 (45,3%) dos médicos. Conclusão: O nível de conhecimento médico em serviços de urgência e emergência sobre o manejo da anafilaxia é baixo. As diretrizes não são seguidas e podem resultar em desfecho desfavorável ao paciente com reação anafilática.

Objective: Anaphylaxis is the most dramatic clinical presentation of allergy in the emergency setting. The aim of this study was to assess knowledge on anaphylaxis management among physicians working at emergency services. Methods: A cross-sectional study was carried out and a written questionnaire was applied to 119 physicians working at eight hospitals (Hospital group) and to 210 physicians working at nine emergency services/mobile emergency services (UPA/SAMU group) between April and September 2016. Results: Among the respondents, 79 (66.4%) physicians worked at hospitals and 78 (37.1%) at emergency services. One hundred twenty-two participants (78.7%) had graduated less than ten years earlier. Sixty-nine physicians (43.9%) correctly diagnosed anaphylaxis, and only 29 (18.5%) identified the systems that could be affected in an anaphylactic reaction. Intramuscular adrenaline was reported as the first treatment option for anaphylaxis by 64 physicians (40.7%), and glucagon was chosen as an option in patients using ß-blockers by 19 (12.1%). The use of auto-injectors was referred by 71 (45.3%) of the physicians. Conclusion: The level of medical knowledge on anaphylaxis management in emergency departments is low. Guidelines are not followed and may result in an unfavorable outcome for patients presenting with an anaphylactic reaction.

Anafilaxia / Anaphylaxis

A anafilaxia constitui uma reação sistêmica, severa, potencialmente fatal e com importante impacto na qualidade de vida dos pacientes. Recentes estudos mostram aumento da incidência e prevalência da doença. O manejo inicial é baseado nas manifestações clínicas. Os exames complementares são indicados para a investigação do agente desencadeante. A adrenalina, base de seu tratamento, apresenta boa resposta clínica quando devidamente administrada. Com abordagem emergencial, a anafilaxia é tema de necessário domínio entre os clínicos. Esse trabalho tem o objetivo de revisar o diagnóstico e abordagem terapêutica da anafilaxia incluindo os últimos consensos sobre o tema.

Anaphylaxis is a systemic reaction, severe, potentially fatal and with important impact on the quality of life of people affected. Recent studies show increases in incidence and prevalence of the disease. The initial management is based on the clinical manifestations. The complementary examinations are indicated for the investigation of the triggering agent. The adrenaline, the basis of their treatment, presents good clinical response when properly administered. With emergency approach, this disease is the subject of necessary domain between clinicians. This article aims to review to diagnosis and treatment of anaphylaxis including the recent consensus on the topic.

Is it safe to use local anesthesia with adrenaline in hand surgery? WALANT technique / É seguro o uso de anestésico local com adrenalina na cirurgia da mão? Técnica WALANT

ABSTRACT In the past it was taught that local anesthetic should not be used with adrenaline for procedures in the extremities. This dogma is transmitted from generation to generation. Its truth has not been questioned, nor the source of the doubt. In many situations the benefit of use was not understood, because it was often thought that it was not necessary to prolong the anesthetic effect, since the procedures were mostly of short duration. After the disclosure of studies of Canadian surgeons, came to understand that the benefits went beyond the time of anesthesia. The WALANT technique allows a surgical field without bleeding, possibility of information exchange with the patient during the procedure, reduction of waste material, reduction of costs, and improvement of safety. Thus, after passing through the initial phase of the doubts in the use of this technique, the authors verified its benefits and the patients' satisfaction in being able to immediately return home after the procedures.

RESUMO Aprendemos que não deveríamos usar um anestésico local com adrenalina para procedimentos nas extremidades. Esse dogma é transmitido de geração em geração. Não questionávamos a sua veracidade ou a origem da dúvida. Em muitas situações não entendíamos o benefício do uso, pois muitas vezes pensávamos não ser necessário prolongar o efeito anestésico, já que os procedimentos eram, na sua maioria, de curta duração. Após a divulgação de estudos dos cirurgiões canadenses, passamos a entender que os benefícios se estendiam além do tempo de anestesia. A técnica WALANT permite um campo cirúrgico sem sangramento, possibilidade de troca de informações com o paciente durante o procedimento, redução de material de descarte, redução de custos e melhoria da segurança. Dessa forma, após passar pela fase inicial das dúvidas quanto ao uso dessa técnica, verificamos os seus benefícios e a satisfação dos pacientes em poderem retornar de imediato para casa após os procedimentos.

Epinephrine in cardiac arrest: systematic review and meta-analysis / A adrenalina durante parada cardíaca: revisão sistemática e meta-análise / Adrenalina en el paro cardíaco: revisión sistemática y metaanálisis

abstract Objective: evaluate the effectiveness of epinephrine used during cardiac arrest and its effect on the survival rates and neurological condition. Method: systematic review of scientific literature with meta-analysis, using a random effects model. The following databases were used to research clinical trials and observational studies: Medline, Embase and Cochrane, from 2005 to 2015. Results: when the Return of Spontaneous Circulation (ROSC) with administration of epinephrine was compared with ROSC without administration, increased rates were found with administration (OR 2.02. 95% CI 1.49 to 2.75; I2 = 95%). Meta-analysis showed an increase in survival to discharge or 30 days after administration of epinephrine (OR 1.23; 95% IC 1.05-1.44; I2=83%). Stratification by shockable and non-shockable rhythms showed an increase in survival for non-shockable rhythm (OR 1.52; 95% IC 1.29-1.78; I2=42%). When compared with delayed administration, the administration of epinephrine within 10 minutes showed an increased survival rate (OR 2.03; 95% IC 1.77-2.32; I2=0%). Conclusion: administration of epinephrine appears to increase the rate of ROSC, but when compared with other therapies, no positive effect was found on survival rates of patients with favorable neurological status.

resumo Objetivo: avaliar a efetividade da adrenalina na parada cardíaca e seu efeito na sobrevivência e no estado neurológico. Métodos: revisão sistemática da literatura científica com meta-análise utilizando um modelo de efeitos aleatórios. Revisão em Medline, Embase e Cochrane, desde 2005 até 2015 de ensaios clínicos e estudos observacionais. Resultados: observou-se aumento nas taxas de retorno de circulação espontânea com a administração de adrenalina (OR 2,02; 95% IC 1,49-2,75; I2=95%) comparadas com a não administração de adrenalina. A meta-análise mostrou um aumento da sobrevivência na alta ou depois de 30 dias da administração de adrenalina (OR 1,23; 95% IC 1,05-1,44; I2=83%). Quando estratificados por ritmos desfibrilháveis e não desfibrilháveis apareceu um aumento da sobrevivência nos ritmos não desfibrilháveis (OR 1,52; 95% IC 1,29-1,78; I2=42%). Também observou-se um incremento de sobrevivência na alta ou depois de 30 dias, quando administrada a adrenalina antes de 10 minutos, isto comparado com administração tardia (OR 2,03; 95% IC 1,77-2,32; I2=0%). Conclusão: a administração de adrenalina parece incrementar a taxa de retorno da circulação espontânea, mas não se tem encontrado um efeito positivo nas taxas de sobrevivência nem nas taxas de pacientes com estado neurológico favorável, em comparação com outras terapias.

resumen Objetivo: evaluar la efectividad de la adrenalina en el paro cardíaco y su efecto en la supervivencia y en el estado neurológico. Métodos: revisión sistemática de la literatura científica con metaanálisis utilizando un modelo de efectos aleatorios. Revisión en Medline, Embase y Cochrane, desde 2005 hasta 2015, de ensayos clínicos y estudios observacionales. Resultados: se observó aumento en las tasas de retorno de circulación espontánea cuando administrada adrenalina (OR 2,02; 95% IC 1,49-2,75; I2=95%) comparada con la no administración de adrenalina. El metaanálisis mostró un aumento de la supervivencia al alta hospitalaria o a los 30 días cuando administrada adrenalina (OR 1,23; 95% IC 1,05-1,44; I2=83%). La estratificación por ritmos desfibrilables y no desfibrilables mostró un aumento de la supervivencia en ritmos no desfibrilables (OR 1,52; 95% IC 1,29-1,78; I2=42%). También, se observó un incremento en la supervivencia al alta hospitalaria o a los 30 días en la administración de adrenalina antes de 10 minutos comparada con la administración tardía (OR 2,03; 95% IC 1,77-2,32; I2=0%). Conclusión: la administración de adrenalina parece incrementar la tasa de retorno de circulación espontánea, pero no se ha encontrado un efecto positivo en tasas de supervivencia ni en tasas de pacientes con estado neurológico favorable, en comparación con otras terapias.

Actualización en las recomendaciones del tratamiento del choque anafiláctico: novedades sobre el uso de adrenalina / Update on anaphylactic shock treatment recommendations: What's new in the use of epinephrine?

En 1998, la Sociedad Argentina de Pediatría publicó la recomendación del tratamiento del choque anafiláctico. Mientras en dicha recomendación se sugería el uso de adrenalina por vía subcutánea, actualmente se considera la vía intramuscular como la más adecuada. Aspectos farmacodinámicos determinan esta preferencia. Para el tratamiento extrahospitalario, el uso de autoinyectores de manera correcta puede colaborar en el control rápido y eficaz de la afección. El uso del resto de las medicaciones propuestas en la recomendación de 1998 se mantiene sin cambios.

In 1998, the Sociedad Argentina de Pediatría issued the recommendation of the treatment of anaphylactic shock. While this recommendation suggested the use of subcutaneous epinephrine, currently the intramuscular via is considered the most appropriate one. Pharmacological aspects determine this preference. For outpatient treatment, the correct use of autoinjectors can control anaphylaxis quickly and effectively. The use of other medications in the proposed 1998 recommendation remains unchanged.

Inducers and autoinducers on Salmonella enterica serovar Typhimurium motility, growth and gene expression / Indutores e autoindutores na motilidade, no crescimento e na expressão gênica de Salmonella enterica serovar Typhimurium

Genus Salmonella bacteria are among the major pathogenic microorganisms in food. This bacterium pathogenicity is related to a number of virulence factors, among which its flagella. Flagellum expression is one of the virulence factors modulated by Quorum Sensing. Epinephrine produced by mammals uses the same signaling pathway of the 3 bacteria autoinducer. This study evaluated the effect of molecules inducer (epinephrine) and autoinducers (autoinducer 2 and autoinducer 3) and their association with the motility, growth and expression genes flhC, fliA, fliY, motA, motB e fliC of Salmonella Typhimurium (ST). Initially, ST was inoculated in BHI. Then, motility assays, growth curves and gene expression were performed by testing different concentrations of epinephrine (50, 125, 250, 500µM), conditioned medium (10 and 50%) and a combination of these. ST was exposed to different concentrations of epinephrine, conditioned medium and an association of both. Following, motility assays, bacterial growth and gene expression were performed. The results obtained showed that the combination of 500uM epinephrine with 50% conditioned medium increased ST bacterial motility by increasing the expression of genes involved in flagellum assembly.

Salmonella está entre os principais micro-organismos patogênicos veiculados por alimentos. A patogenicidade dessa bactéria está relacionada a uma série de fatores de virulência e, dentre estes, podemos citar os flagelos. A expressão do flagelo está entre os fatores de virulência modulados por Quorum Sensing. A adrenalina produzida pelos mamíferos utiliza a mesma via de sinalização do autoindutor 3 das bactérias. Nesse sentido, este trabalho teve como objetivo avaliar o efeito de moléculas indutora (adrenalina) e autoindutoras (auto-indutor 2 e auto-indutor 3) e a associação destas na motilidade, no crescimento celular e na expressão dos genes flhC, fliA, fliY, motA, motB e fliC de SalmonellaTyphimurium (ST). Inicialmente, ST foi semeada em caldo BHI. Após, ensaios de motilidade, curvas de crescimento e expressão gênica foram feitos, testando diferentes concentrações de adrenalina (50, 125, 250, 500µM), meio condicionado (10 e 50%) e a associação destes. A partir dos resultados obtidos, observou-se que o tratamento que utilizou 50% de meio condicionado + 500µM de adrenalina aumentou a motilidade de ST, em decorrência do aumento de genes envolvidos com montagem do flagelo.