Brazilian Journal of Anesthesiology (Edicion en Espanol)最新文献

Background and objectives

Percutaneous tracheotomy has become a good alternative for patients thought to have prolonged intubation in intensive care units. The most important benefits of tracheotomy are early discharge of the patient from the intensive care unit and shortening of the time spent in the hospital. Prolonged endotracheal intubation has complications such as laryngeal damage, vocal cord paralysis, glottic and subglottic stenosis, infection and tracheal damage. The objective of our study was to evaluate potential advantages of early percutaneous tracheotomy over late percutaneous tracheotomy in intensive care unit.

Methods

Percutaneous tracheotomies applied to 158 patients in adult intensive care unit have been analyzed retrospectively. Patients were divided into two groups as early and late tracheotomy according to their endotracheal intubation time before percutaneous tracheotomy. Tracheotomies at the 0-7th days of endotracheal intubation were grouped as early and after the 7th day of endotracheal intubation as late tracheotomies. Patients having infection at the site of tracheotomy, patients with difficult or potential difficult intubation, those under 18 years old, patients with positive end-expiratory pressure above 10 cmH₂O and those with bleeding diathesis or platelet count under 50,000 dL⁻¹ were not included in the study. Durations of mechanical ventilation and intensive care stay were noted.

Results

There was no statistical difference among the demographic data of the patients. Mechanical ventilation time and time spent in intensive care unit in the group with early tracheotomy was shorter and the difference was statistically significant (p < 0.05).

Conclusion

Early tracheotomy shortens mechanical ventilation duration and intensive care unit stay. For that reason we suggest early tracheotomy in patients thought to have prolonged intubation.

Background and objectives

Emergence agitation is a common postanaesthetic problem in children after sevoflurane anaesthesia. We aimed to compare the effects of ketamine and midazolam administered intravenously, before the end of surgery, for prevention of emergence agitation in children who received caudal block for pain relief under sevoflurane anaesthesia.

Methods

62 American Society of Anesthesiologists patient classification status i children, aged 2-7 years, scheduled for inguinal hernia repair, circumcision or orchidopexy were enrolled to the study. Anaesthesia was induced with sevoflurane 8% in a mixture of 50% oxygen and nitrous oxide. After achieving adequate depth of anaesthesia, a laryngeal mask was placed and then caudal block was performed with 0.75 mL kg⁻¹, 0.25% bupivacaine. At the end of the surgery, ketamine 0.25 mg kg⁻¹, midazolam 0.03 mg kg⁻¹ and saline were given to ketamine, midazolam and control groups, respectively. Agitation was assessed using Paediatric Anaesthesia Emergence Delirium scale and postoperative pain was evaluated with modified Children's Hospital of Eastern Ontario Pain Scale.

Results and conclusions

Modified Children's Hospital of Eastern Ontario Pain Scale scores were found higher in control group than in ketamine and midazolam groups. Paediatric Anaesthesia Emergence Delirium scores were similar between groups. Modified Children's Hospital of Eastern Ontario Pain Scale and Paediatric Anaesthesia Emergence Delirium scores showed a significant decrease by time in all groups during follow-up in postanaesthesia care unit. The present study resulted in satisfactory Paediatric Anaesthesia Emergence Delirium scores which are below 10 in all groups. As a conclusion, neither ketamine nor midazolam added to caudal block under sevoflurane anaesthesia did show further effect on emergence agitation. In addition, pain relief still seems to be the major factor in preventing emergence agitation after sevoflurane anaesthesia.

Background and objectives

Even a small amount of bleeding during endoscopic sinus surgery can corrupt the endoscopic field and complicate the procedure. Various techniques, including induced hypotension, can minimize bleeding during endoscopic sinus surgery. The aim of this study was to compare the surgical vision quality, haemodynamic parameters, postoperative pain, and other effects of magnesium, a hypotensive agent, with that of dexmedetomidine, which was initially developed for short-term sedation in the intensive care unit but also is an alpha 2 agonist sedative.

Method

60 patients between the ages of 18 and 45 years were divided into either the magnesium group (Group M) or the dexmedetomidine group (Group D). In Group M, magnesium sulphate was given at a pre-induction loading dose of 50 mg kg⁻¹ over 10 min and maintained at 15 mg kg⁻¹ h⁻¹; in Group D, dexmedetomidine was given at 1 μg kg⁻¹ 10 min before induction and maintained at 0.6 μg kg⁻¹ h⁻¹. Intraoperatively, the haemodynamic and respiratory parameters and 6-point intraoperative surgical field evaluation scale were recorded. During the postoperative period, an 11-point numerical pain scale, the Ramsay sedation scale, the nausea/vomiting scale, the adverse effects profile, and itching parameters were noted.

Results

Group D showed a significant decrease in intraoperative surgical field evaluation scale score and heart rate. The average operation time was 50 min, and Group M had a higher number of prolonged surgeries. No significant difference was found in the other parameters.

Conclusions

Due to its reduction of bleeding and heart rate in endoscopic sinus surgery and its positive impacts on the duration of surgery, we consider dexmedetomidine to be a good alternative to magnesium.

Background and objectives

The aim of this study was to evaluate the effects of remote ischemic preconditioning by brief ischemia of unilateral hind limb when combined with dexmedetomidine on renal ischemia-reperfusion injury by histopathology and active caspase-3 immunoreactivity in rats.

Methods

28 Wistar albino male rats were divided into 4 groups. Group I (Sham, n = 7): laparotomy and renal pedicle dissection were performed at 65th minute of anesthesia and the rats were observed under anesthesia for 130 min. Group II (ischemia-reperfusion, n = 7): at 65th minute of anesthesia bilateral renal pedicles were clamped. After 60 min ischemia 24 h of reperfusion was performed. Group III (ischemia-reperfusion + dexmedetomidine, n = 7): at the fifth minute of reperfusion (100 μg/kg intra-peritoneal) dexmedetomidine was administered with ischemia-reperfusion group; reperfusion lasted 24 h. Group IV (ischemia-reperfusion + remote ischemic preconditioning + dexmedetomidine, n = 7): after laparotomy, three cycles of ischemic preconditioning (10 min ischemia and 10 min reperfusion) were applied to the left hind limb and after 5 min with group iii.

Results

Histopathological injury scores and active caspase-3 immunoreactivity were significantly lower in the Sham group compared to the other groups. Histopathological injury scores in groups iii and iv were significantly lower than group ii (P = .03 and P = .05). Active caspase-3 immunoreactivity was significantly lower in the group iv than group ii (P = .01) and there was no significant difference between group ii and group iii (P = .06).

Conclusions

Pharmacologic conditioning with dexmedetomidine and remote ischemic preconditioning when combined with dexmedetomidine significantly decreases renal ischemia-reperfusion injury histomorphologically. Combined use of two methods prevents apoptosis via active caspase-3.

Background

The difficulties with airway management is the main reason for pediatric anesthesia-related morbidity and mortality.

Objective

To assess the value of modified Mallampati test, Upper-Lip-Bite test, thyromental distance and the ratio of height to thyromental distance to predict difficult intubation in pediatric patients.

Design

Prospective analysis.

Measurements and results

Data were collected from 5 to 11 years old 250 pediatric patients requiring tracheal intubation. The Cormack and Lehane classification was used to evaluate difficult laryngoscopy. Sensitivity, specificity, positive predictive value and AUC values for each test were measured.

Results

The sensitivity and specificity of modified Mallampati test were 76.92% and 95.54%, while those for ULBT were 69.23% and 97.32%. The optimal cutoff point for the ratio of height to thyromental distance and thyromental distance for predicting difficult laryngoscopy was 23.5 (sensitivity, 57.69%; specificity, 86.61%) and 5.5 cm (sensitivity, 61.54%; specificity, 99.11%). The modified Mallampati was the most sensitive of the tests. The ratio of height to thyromental distance was the least sensitive test.

Conclusion

These results suggested that the modified Mallampati and Upper-Lip-Bite tests may be useful in pediatric patients for predicting difficult intubation.

Background and objectives

The intense trauma response triggered by cardiopulmonary bypass can lead to increased morbidity and mortality. The present study evaluated whether clonidine, a drug of the class of α-2 agonists, administered by spinal route, without association with local anesthetics or opioids, reduces this response in cardiac surgery with cardiopulmonary bypass.

Method

A total of 27 patients between 18 and 75 years old, divided by non-blinded fashion into a control group (15) and a clonidine group (12), were studied. All patients underwent identical technique of general anesthesia. Then, only the clonidine group received 1 μg kg⁻¹ clonidine by spinal route. Levels of blood glucose, lactate and cortisol were measured at three consecutive times: T1, at the time of installation of invasive arterial pressure; T2, 10 min after the first dose for cardioplegia; and T3, at the time of skin suture; and troponin i values at T1 and T3. The variation of results between T2-T1, T3-T2, and T3-T1 was also evaluated.

Results

There was a statistically significant difference only with respect to the variation in blood glucose in the clonidine group: T3-T2, P = .027, and T3-T1, P = .047.

Conclusions

Spinal clonidine at a dose of 1 μg kg⁻¹ did not decrease blood measurements of troponin, cortisol, or lactate. Blood glucose suffered a more moderate variation during the procedure in the clonidine group. This fact, already reported in the literature, requires further investigation to be clarified.

Background and objectives

Emergence delirium is a distressing complication of the use of sevoflurane for general anesthesia. This study sought to determine the incidence of emergence delirium and risk factors in patients at a specialist pediatric hospital in Kingston, Jamaica.

Methods

This was a cross-sectional, observational study including pediatric patients aged 3-10 years, ASA I and II, undergoing general anesthesia with sevoflurane for elective day-case procedures. Data collected included patients’ level of anxiety pre-operatively using the modified Yale Preoperative Anxiety Scale, surgery performed, anesthetic duration and analgesics administered. Postoperatively, patients were assessed for emergence delirium, defined as agitation with non-purposeful movement, restlessness or thrashing; inconsolability and unresponsiveness to nursing and/or parental presence. The need for pharmacological treatment and post-operative complications related to emergence delirium episodes were also noted.

Results

145 children were included, with emergence delirium occurring in 28 (19.3%). Emergence delirium episodes had a mean duration of 6.9 ± 7.8 min, required pharmacologic intervention in 19 (67.8%) children and were associated with a prolonged recovery time (49.4 ± 11.9 versus 29.7 ± 10.8 min for non-agitated children; P < .001). Factors positively associated with emergence delirium included younger age (P = .01, OR: 3.3, 95% CI: 1.2-8.6) and moderate and severe anxiety prior to induction (P < .001, OR: 5.6, 95% CI: 2.3-13.0). Complications of emergence delirium included intravenous line removal (n = 1), and surgical site bleeding (n = 3).

Conclusion

Children of younger age with greater preoperative anxiety are at increased risk of developing emergence delirium following general anesthesia with sevoflurane. The overall incidence of emergence delirium was 19%.

Pulmonary artery catheter is an invasive monitor usually placed in high-risk cardiac surgical patients to optimize the cardiac functions. We present this case of blood oozing from the oximetry connection port of the pulmonary artery catheter that resulted in the inability to monitor continuous cardiac output requiring replacement of the catheter. The cause of this abnormal bleeding was later confirmed to be due to a manufacturing defect.