Revista brasileira de anestesiologia最新文献

The erector spinae plane block is a safe and effective regional anesthesia technique, which has earned new indications perioperatively since its description. We introduce two pediatric anesthesia cases in which we performed the erector spinae plane block during intermediate/major orthopedic surgeries. The first patient is a 2 year‐old girl submitted to surgical treatment of developmental dysplasia of the hip. The second patient is a 14 year‐old boy submitted to surgical treatment of bilateral clubfoot. This last patient is potentially the first published case in which the erector spinae plane block was performed for ankle and foot surgery. Both cases experienced excellent analgesia, avoiding opiate requirement completely.

Introduction

Tranexamic Acid (TXA), an antifibrinolytic that inhibits the fibrinolytic activity of plasmin is used to decrease perioperative blood loss and transfusion requirements in orthopedic surgery. The aim of our study was to compare postoperative bleeding in two intra‐articular doses (1 g and 2 g) of tranexamic acid in adult patients undergoing unilateral total knee replacement.

Method

We conducted a single‐operator, randomized, and controlled, double‐blind study in two groups. The G1 group received 1 g of intra‐articular TXA and the G2 group 2 g of intra‐articular TXA. Both groups received 15 mg.kg^‐1 IV before the surgical incision (TXA induction dose) and then 10 mg.kg^‐1, orally, 6 and 12 hours after the induction dose of TXA. The primary endpoint was bleeding measured by blood loss in postoperative drainage. Secondary outcomes were change in hemoglobin and hematocrit levels on the first and third postoperative days, and the need for transfusion during hospitalization.

Results

In total, 100 patients were randomized, and 100 were included in the analysis. Blood loss in postoperative drainage was similar in both groups (200 ± 50 vs. 250 ± 50 mL, G1 and G2 groups respectively). Change in hematocrit and hemoglobin values (% of change) between preoperative and day 3 were not statically significant between groups G1 and G2 (18 ± 5 vs. 21 ± 4; 21 ± 7 vs. 22 ± 5 respectively). No patients received blood transfusion.

Conclusions

Our study did not show superiority of 2 g of intra‐articular tranexamic acid compared to 1 g.

ClinicalTrials.gov Identifier NCT04085575

Background

There are various approaches to perform an ultrasound guided Quadratus Lumborum Block (QLB). The lateral, posterior, anterior or trans muscular and subcostal paramedian are the various approaches described for performing a QLB. Each of these blocks are aimed to achieve a maximum spread with high volume and low concentration of local anesthetics.

Case report

In this novel approach a curvilinear ultrasound probe was used with the patient lying in supine position. The probe was placed longitudinally in the mid axillary line to visualize Quadratus Lumborum Muscle (QLM) in the coronal plane. The needle was then introduced from cranial to caudal direction and catheters were inserted in the Anterior Thoracolumbar Fascia (ATLF) up to a distance of 4−5 cm in 24 patients for an anterior approach to acetabulum fractures. The needle tip and the Local Anesthetic (LA) spread was visible in all patients. All patients except 4 had excellent perioperative pain relief considering stable hemodynamics and VAS 2−3/10 for the first 48 hours. All patients received 1 g intravenous paracetamol each 8 hours. VAS in postoperative period was 2−3/10, in 20/24 patients. In the postoperative period, 4 patients complained of persistent pain, requiring intravenous fentanyl boluses and multimodal analgesia. Mean VAS score was 2.87 from 0−12 hours, 3.14 from 12−24 hours, and 3.35 from 24−48 hours. There were no block‐related complications in any patient.

Conclusion

The supine midaxillary coronal approach to anterior QLB is an effective and feasible approach to QLB which can be performed in supine position.

Purpose

This study aimed to investigate factors associated with postoperative Acute Kidney Injury (AKI) focusing on intraoperative hypotension and blood loss volume.

Methods

This was a retrospective cohort study of patients undergoing pancreas surgery between January 2013 and December 2018. The primary outcome was AKI within 7 days after surgery and the secondary outcome was the length of hospital stay. Multivariate analysis was used to determine explanatory factors associated with AKI; the interaction between the integrated value of hypotension and blood loss volume was evaluated. The differences in length of hospital stay were compared using the Mann‐Whitney U‐test.

Results

Of 274 patients, 22 patients had experienced AKI. The cube root of the area under intraoperative mean arterial pressure of < 65 mmHg (Odds Ratio = 1.21; 95% Confidence Interval 1.01–1.45; p = 0.038) and blood loss volume of > 500 mL (Odds Ratio = 3.81; 95% Confidence Interval 1.51–9.58; p = 0.005) were independently associated with acute kidney injury. The interaction between mean arterial hypotension and the blood loss volume in relation to acute kidney injury indicated that the model was significant (p < 0.0001) with an interaction effect (p = 0.0003). AKI was not significantly related with the length of hospital stay (19 vs. 28 days, p = 0.09).

Conclusion

The area under intraoperative hypotension and blood loss volume of > 500 mL was associated with postoperative AKI. However, if the mean arterial pressure is maintained even in patients with large blood loss volume, the risk of developing postoperative AKI is comparable with that in patients with small blood loss volume.

Background and objectives

The measurement of Hb by co‐oximetry is an innovative technique that offers efficiency and agility in the processing of information regarding the measurement of Hemoglobin concentration (Hb) obtained through continuous, non‐invasive and rapid monitoring. Because of this attribute, it avoids unnecessary exposures of the patient to invasive procedures by allowing a reduction in the number of blood samples for evaluation and other unnecessary therapies. It also helps to make decisions about the need for transfusion and how to handle it. The objective of this study is to compare the performance offered to obtain Hb values between the Masimo Corporation (Irvine, CA, USA) instrument and the standard gold tool (laboratory examination).

Contents

The study corresponds to a systematic review followed by meta‐analysis, which included fully registered full‐text clinical trials published from 1990 to 2018. PubMed, Cochrane, Medline, Embase and Web of Science databases were investigated. The mean overall difference found between the non‐invasive and invasive methods of hemoglobin monitoring was 0.23 (95% CI ‐0.16, 0.62), that is, it did not present statistical significance (p  =  0.250). The results of the analysis of heterogeneity within and between the studies indicated high levels of inconsistency (Q  =  461.63, p  <  0.0001, I²  =  98%), method for Hb values.

Conclusions

Although the mean difference between noninvasive measurements of Hb and the gold standard method is small, the co‐oximeter can be used as a non‐invasive “trend” monitor in detecting unexpected responses at Hb levels.

Background and objectives

Postoperative pain is still a major concern in several surgical procedures. Multimodal analgesia is best for postoperative pain management; however, opioid therapy is still the main treatment for pain after surgical procedures. Transdermal buprenorphine is a partial μ agonist opioid widely used for chronic pain syndromes, with limited evidence for acute postoperative pain. A systematic review of studies examining transdermal buprenorphine for acute pain management after surgery was conducted.

Contents

Data from PubMed, Embase, The Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL via EBSCOhost, and LILACS were reviewed, including randomized clinical trials that evaluated total postoperative pain, postoperative analgesic consumption, drug‐related side effects and patient satisfaction with analgesia regimen. Data from nine studies (615 patients) were included in this review. Most studies initiated transdermal buprenorphine use 6 to 48 hours before surgery, maintaining use from 1 to 8 days after the procedure. Most studies showed lower or similar postoperative pain scores, postoperative analgesic consumption and patient satisfaction comparing buprenorphine to placebo, tramadol, celecoxib, flurbiprofen and parecoxib. The incidence of side effects varied between studies, with most showing no increase in drug‐related side effects with buprenorphine use, except one study, which compared buprenorphine to oral tramadol, and one to transdermal fentanyl. However, most results were derived from evidence with an overall high or unclear risk of bias.

Conclusions

Although more studies are necessary, initial results show that transdermal buprenorphine seems to be an effective and safe opioid choice for management of acute postoperative pain.

Background and objectives

In patients with elbow fractures, when there is suspected injury to underlying nerves, it is imperative for surgeons to elicit the function in the immediate postoperative period. Brachial plexus blocks like interscalene, supraclavicular and infraclavicular approaches can be a hurdle in such situations. The block planned should allow assessment of integrity of the nerves immediately in the postoperative period.

Case report

We describe two cases in which we administered a block not yet described in literature. We blocked the cutaneous and articular branches innervating the elbow under ultrasound guidance. General anesthesia was administered in both cases. The block provided stable intraoperative hemodynamics, good postoperative analgesia and also allowed surgeons to test the viability of the nerve.

Conclusion

In situations where nerves are injured during elbow fractures, selective articular cutaneous block at elbow can be used as it provides good perioperative analgesia, besides allowing evaluation of motor and sensory components in the postoperative period.

Background

Anxiety is a state of worry caused by the anticipation of external or internal danger. Awareness During Anesthesia (ADA) is an unexpected memory recall during anesthesia. In this study, we aimed to determine the factors that affect preoperative anxiety and observe the incidence of ADA, as well as to determine the anxiety levels of these patients with a history of ADA.

Methods

This study was planned to be prospective, observational, and cross‐sectional. Patients in whom septoplasty was planned, who was admitted to the anesthesiology outpatients between March 2018 and September 2018, were ASA I−II, and aged 18−70 years were included in the study. The demographic characteristics of patients were recorded. The State‐Trait Anxiety Inventory (STAI) was used to determine anxiety during a preoperative evaluation. The modified Brice awareness score was used simultaneously to determine previous ADA.

Results

The anxiety scores of patients who were conscious during anesthesia were higher than other patients. The mean STAI score was 40.85±14.8 in the 799 patients who met the inclusion criteria of this study. When the anxiety scores were compared, the scores were higher in females than in males (p < 0.05). The mean STAI score was found as 40.3±13.8 in patients who dreamed during anesthesia.

Conclusion

It is important to determine the anxiety levels of patients in the preoperative period to prevent the associated complications. Preoperative anxiety, besides preventing ADA, should be dealt with in a multidisciplinary manner. ADA should be carefully questioned while evaluating previous anesthesia experiences.

Background

Several interventional cardiology procedures are required in neonates with congenital heart disease. Interventional cardiology procedures have a higher risk of cardiac arrest compared to other interventions. At present, there is great heterogeneity in the perioperative management of congenital heart disease neonates undergoing diagnostic cardiac catheterization or therapeutic cardiac catheterization.

Study objectives

Primary aim: Provide a systematic review of the most effective and/or safe anesthetic and perioperative management in neonates with congenital heart disease who undergo diagnostic cardiac catheterization or therapeutic cardiac catheterization. Secondary aim: Identify the medications, monitoring parameters and airway management used in the same population.

Design

Systematic literature review.

Setting

Catheterization laboratory.

Methods

Literature was searched (December 2017) in electronic databases Medline, EMBASE, ScienceDirect, BIREME‐Lilacs‐Biblioteca Virtual de la Salud, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and Health Technology Assessment Database.

Main results

From 130 records identified, four studies met inclusion criteria and quality assessment. None of the studies were relevant to the primary objective. Regarding the secondary objectives, one study compared the efficacy and adverse effects of racemic ketamine and its S(+) ketamine enantiomer, one study reported the efficacy of subarachnoid anesthesia for high‐risk children undergoing diagnostic cardiac catheterization, one study identified the factors associated to high severity adverse events related to sedation, anesthesia and airway, and one study retrospectively analyzed cardiac catheterization procedures in neonates weighing less than 2.5 kg.

Conclusion

There are no evidence‐based recommendations available for congenital heart disease neonates undergoing cardiac catheterization. More studies are required to evaluate the ideal anesthetic and perioperative management in this population.