Revista brasileira de anestesiologia最新文献

This second joint document, written by experts from the Brazilian Association of Allergy and Immunology (ASBAI) and Brazilian Society of Anesthesiology (SBA) concerned with perioperative anaphylaxis, aims to review the pathophysiological reaction mechanisms, triggering agents (in adults and children), and the approach for diagnosis during and after an episode of anaphylaxis. As anaphylaxis assessment is extensive, the identification of medications, antiseptics and other substances used at each setting, the comprehensive data documentation, and the use of standardized nomenclature are key points for obtaining more consistent epidemiological information on perioperative anaphylaxis.

Background and objectives

In this study, we aimed to investigate the predictive value of different airway assessment tools, including parts of the Simplified Predictive Intubation Difficulty Score (SPIDS), the SPIDS itself and the Thyromental Height Test (TMHT), in intubations defined as difficult by the Intubation Difficulty Score (IDS) in a group of patients who have head and neck pathologies.

Methods

One hundred fifty‐three patients who underwent head and neck surgeries were included in the study. The Modified Mallampati Test (MMT) result, Thyromental Distance (TMD), Ratio of the Height/Thyromental Distance (RHTMD), TMHT, maximum range of head and neck motion, and mouth opening were measured. The SPIDSs were calculated, and the IDSs were determined.

Results

A total of 25.4% of the patients had difficult intubations. SPIDS scores > 10 had 86.27% sensitivity, 71.57% specificity and 91.2% Negative Predictive Value (NPV). The results of the Receiver Operating Curve (ROC) analysis for the airway screening tests and SPIDS revealed that the SPIDS had the highest area under the curve; however, it was statistically similar to other tests, except for the MMT.

Conclusions

The current study demonstrates the practical use of the SPIDS in predicting intubation difficulty in patients with head and neck pathologies. The performance of the SPIDS in predicting airway difficulty was found to be as efficient as those of the other tests evaluated in this study. The SPIDS may be considered a comprehensive, detailed tool for predicting airway difficulty.

Background and objectives

The mechanisms by which local anaesthetics cause neurotoxicity are very complicated. Apoptosis and autophagy are highly coordinated mechanisms that maintain cellular homeostasis against stress. Studies have shown that autophagy activation serves as a protective mechanism in vitro. However, whether it also plays the same role in vivo is unclear. The aim of this study was to explore the role of autophagy in local anaesthetic‐induced neurotoxicity and to elucidate the mechanism of neurotoxicity in an intrathecally injected rat model.

Methods

Eighteen healthy adult male Sprague‐Dawley rats were randomly divided into three groups. Before receiving an intrathecal injection of 1% bupivacaine, each rat received an intraperitoneal injection of vehicle or rapamycin (1 mg.kg^‐1) once a day for 3 days. The pathological changes were examined by Haematoxylin and Eosin (HE) staining. Apoptosis was analysed by TdT‐mediated dUTP Nick‐End Labelling (TUNEL) staining. Caspase‐3, Beclin1 and LC3 expression was examined by Immunohistochemical (IHC) staining. Beclin1 and LC3 expression and the LC3‐II/LC3‐I ratio were detected by western blot analysis.

Results

After bupivacaine was injected intrathecally, pathological damage occurred in spinal cord neurons, and the levels of apoptosis and caspase‐3 increased. Enhancement of autophagy with rapamycin markedly alleviated the pathological changes and decreased the levels of apoptosis and caspase‐3 while increasing the expression of LC3 and Beclin1 and the ratio of LC3‐II to LC3‐I.

Conclusions

Enhancement of autophagy decreases caspase‐3‐dependent apoptosis and improves neuronal survival in vivo. Activation of autophagy may be a potential therapeutic strategy for local anaesthetic‐induced neurotoxicity.

Background

Opioid‐free anesthesia decreases the incidence of opioid adverse events, but its optimal antinociceptive depth has not been clearly defined. Personalizing intraoperative opioid‐free infusions with a nociception monitor may be the solution.

Case report

We describe the feasibility and potential limitations of titrating opioid‐free antinociception during major abdominal surgery using the Analgesia Nociception Index (Mdoloris, Lille, France) in an obese patient. After stabilizing the patient's nociception‐antinociception balance intraoperatively we quickly reversed anesthesia and the patient did not require postoperative opioids.

Conclusion

Personalizing opioid‐free antinociception with a nociception monitor is feasible. It may optimize intraoperative antinociception and improve postoperative comfort.

Background and objectives

Several airway complications can occur during shoulder arthroscopy including airway obstruction, pleural puncture, and subcutaneous emphysema. It was hypothesized that the irrigation fluid used during a shoulder arthroscopic procedure might increase the cuff pressure of the endotracheal tube, which can cause edema and ischemic damage to the endotracheal mucosa. Therefore, this study aimed to evaluate the relationship between irrigation fluid and endotracheal tube cuff pressures.

Methods

Forty patients aged 20 to 70 years with an American Society of Anesthesiologists (ASA) score I or II, scheduled for elective arthroscopic shoulder surgery under general anesthesia, participated in our study. We recorded endotracheal tube cuff pressures and neck circumferences every hour from the start of the operation. We also recorded the total duration of the anesthesia, operation, and the total volume of fluid used for irrigation.

Results

A positive correlation was shown between endotracheal tube cuff pressures and the amount of irrigation fluid (r = 0.385, 95% CI 0.084 to 0.62, p = 0.0141). The endotracheal tube cuff pressure significantly increased at 2 and 3 hours after starting the operation (p = 0.0368 and p = 0.0245, respectively). However, neck circumference showed no significant difference.

Conclusions

Endotracheal tube cuff pressures increased with operation time and with increased volumes of irrigation fluid used in patients who underwent shoulder arthroscopy. We recommend close monitoring of endotracheal tube cuff pressures during shoulder arthroscopy, especially during long operations using a large amount of irrigation fluid, to prevent complications caused by raised cuff pressures.

Objectives

Positioning during endotracheal intubation (ETI) is critical to ensure its success. We aimed to determine if the ramping position improved laryngeal exposure and first attempt success at intubation when compared to the sniffing position.

Methods

PubMed, EMBASE, and Cochrane CENTRAL databases were searched systematically from inception until January 2020. Our primary outcomes included laryngeal exposure as measured by Cormack‐Lehane Grade 1 or 2 (CLG 1/2), CLG 3 or 4 (CLG 3/4), and first attempt success at intubation. Secondary outcomes were intubation time, use of airway adjuncts, ancillary maneuvers and complications during ETI.

Results

Seven studies met our inclusion criteria, of which 4 were RCTs and 3 were cohort studies. The meta‐analysis was conducted by pooling the effect estimates for all 4 included RCTs (n = 632). There were no differences found between ramping and sniffing positions for odds of CLG 1/2, CLG 3/4, first attempt success at intubation, intubation time, use of ancillary airway maneuvers and use of airway adjuncts, with evidence of high heterogeneity across studies. However, the ramping position in surgical patients is associated with increased likelihood of CLG 1/2 (OR = 2.05, 95% CI 1.26 to 3.32, p = 0.004) and lower likelihood of CLG 3/4 (OR = 0.49, 95% CI 0.30 to 0.79, p = 0.004), moderate quality of evidence.

Conclusion

Our meta‐analysis demonstrated that the ramping position may benefit surgical patients undergoing ETI by improving laryngeal exposure. Large‐scale well‐designed multicentre RCTs should be carried out to further elucidate the benefits of the ramping position in the surgical and intensive care unit patients.