Revista brasileira de anestesiologia最新文献

Introduction

The association between Local Anesthetics (LAs) and Neuromuscular Blocking (NMB) drugs in clinical practice, and the possibility of interaction between these drugs has been investigated. LAs act on neuromuscular transmission in a dose‐dependent manner and may potentiate the effects of NMB drugs.

Objective

The aim of this study was to evaluate, in an experimental model, the effect of lidocaine and racemic bupivacaine on neuromuscular transmission and the influence on neuromuscular blockade produced by atracurium.

Methods

Male Wistar rats, weighing from 250 g to 300 g were used. The preparation was set up based on a technique proposed by Bülbring. Groups were formed (n = 5) according to the drug studied: lidocaine 20 μg.mL^‐1 (Group I); racemic bupivacaine 5 μg.mL^‐1 (Group II); atracurium 20 μg.mL^‐1 (Group III); atracurium 20 μg.mL^‐1 in a preparation previously exposed to lidocaine 20 μg.mL^‐1 and racemic bupivacaine 5 μg.mL^‐1, Groups IV and V, respectively. The following parameters were assessed: 1) Amplitude of hemi diaphragmatic response to indirect stimulation before and 60 minutes after addition of the drugs; 2) Membrane Potentials (MP) and Miniature Endplate Potentials (MEPPs).

Results

Lidocaine and racemic bupivacaine alone did not alter the amplitude of muscle response. With previous use of lidocaine and racemic bupivacaine, the neuromuscular blockade (%) induced by atracurium was 86.66 ± 12.48 and 100, respectively, with a significant difference (p = 0.003), in comparison to the blockade produced by atracurium alone (55.7 ± 11.22). These drugs did not alter membrane potential. Lidocaine initially increased the frequency of MEPPs, followed by blockade. With the use of bupivacaine, the blockade was progressive.

Conclusions

Lidocaine and racemic bupivacaine had a presynaptic effect expressed by alterations in MEPPs, which may explain the interaction and potentiation of NMB produced by atracurium.

The use of ultrasonography is well established in several anesthesia sub‐specialties. Recently, there has been a major expansion of the POC (Point‐Of‐Care) ultrasound technique in intensive care, surgery, and emergency medicine, corroborating that USPOC in perioperative medicine has a much more comprehensive capability for both providing improved hemodynamic monitoring and early diagnosis of complications. The objective of the present article was to describe the use of a USPOC modality (focused cardiac US) that can be used for bedside assessment of unstable patients. Within a specific list of diagnoses, clinical treatment for a given situation can be tailored according to ultrasound findings, and by using binary and simple questions. Perioperative focused cardiac US use by the anesthesiologist has been related to lower rates of complications and mortality in high‐risk patients.

Background and objectives

Sedation for endoscopic procedures aims to provide high quality sedation, lower risks, short recovery time, superior recovery quality and absence of side effects, seeking high patient level of satisfaction. The goal of the study was to assess administration of remifentanil combined with propofol regarding the effects of the drug association during sedation and recovery for patients submitted to upper GI diagnostic endoscopy.

Method

One hundred and five patients were assessed, randomly divided into three groups of 35 patients. The Control Group was sedated with propofol alone. Study Group 1 was sedated with a fixed dose of 0.2 μg.kg^‐1 remifentanil combined with propofol. Study Group 2 was sedated with 0.3 μg.kg^‐1 remifentanil combined with propofol. We assessed the quality of sedation, hemodynamic parameters, incidence of significant hypoxemia, time for spontaneous eye opening, post‐anesthetic recovery time, quality of post‐anesthetic recovery, presence of side effects and patient satisfaction.

Results

Study Group 1 showed better quality of sedation. The groups in which remifentanil was administered combined with propofol showed shorter eye‐opening time and shorter post‐anesthetic recovery time compared to the control group. The three groups presented hemodynamic changes at some of the moments assessed. The incidence of significant hypoxemia, the quality of post‐anesthetic recovery, the incidence of side effects and patient satisfaction were similar in the three groups.

Conclusions

The combination of propofol with remifentanil at a dose of 0.2 μg.kg^‐1 was effective in improving the quality of sedation, and at doses of 0.2 μg.kg^‐1 and 0.3 μg.kg^‐1 reduced the time to spontaneous eye opening and post‐anesthetic recovery in comparison to sedation with propofol administered alone.

Morbid obesity is associated with various pathophysiological changes which affect the outcome of anesthesia and surgery. So it's challenging to give anesthesia to such patients. We present a 59‐year‐old adult morbidly obese, hypertensive, diabetic female with hypothyroidism operated for proximal humerus fracture and now presented with non‐union of fracture, requiring percutaneous injection of bone marrow aspirate from the iliac crest to the site of non‐union. The patient was extremely anxious and refused to undergo the procedure under local anesthesia or sedation and demanded anesthesia. Given her comorbidities general anesthesia (GA) was avoided and the procedure was accomplished using Ultrasound (USG) guided Transversus abdominis plane (TAP) block and Lateral Femoral Cutaneous Nerve (LFCN) block for the bone marrow aspirate from the iliac crest and Intercostobrachial nerve block (T2) was given to prevent pain while injecting the aspirate into the non‐union site. Dexmedetomidine and ketamine were given for deep level sedation and analgesia. TAP block and LFCN block is generally used for post‐op analgesia but can be also used for surgical anesthesia instead of General anesthesia in specific scenarios. Its perioperative application and its potential use instead of GA have been discussed.

Background and objective

Sore throat is well recognized complaint after receiving general anesthesia. This study is conducted to compare the severity and frequency of postoperative sore throat in children undergoing elective surgery – following the use of Ambu laryngeal mask airway) or I‐gel® – who are able to self‐report postoperative sore throat.

Method

Seventy children, 6 to 16 years‐old, undergoing elective surgery randomly allocated to either Ambu laryngeal mask (Ambu Group) or I‐gel® (I‐gel Group). After the procedure, patients were interviewed in the recovery room immediately, after one hour, 6 and 24 hours postoperatively by an independent observer blinded to the device used intra‐operatively.

Results

On arrival in the recovery room 17.1% (n = 6) of children of the Ambu Group complained of postoperative sore throat, against 5.7% in I‐gel Group (n = 2). After one hour, the results were similar. After 6 hours, postoperative sore throat was found in 8.6% (n = 3) of the children in Ambu group vs. 2.9% (n = 1) in I‐gel Group. After 24 hours, 2.9% (n = 1) of the kids in Ambu Group compared to none in I‐gel Group. There was no significant difference found in the incidence of postoperative sore throat in both devices on arrival (p = 0.28); after 1 hour (p = 0.28); after 6 hours (p = 0.30); and after 24 hours (p = 0.31). The duration of the insertion was shorter in Ambu Group and it was easier to insert the I‐gel® (p = 0.029). Oropharyngeal seal pressure of I‐gel® was higher than that of Ambu laryngeal mask (p = 0.001).

Conclusion

The severity and frequency of postoperative sore throat in children is not statistically significant in the I‐gel Group compared to Ambu Group.

Background and objectives

The lumbar plexus block (LPB) is a key technique for lower limb surgery. All approaches to the LPB involve a number of complications. We hypothesized that Chayen's approach, which involves a more caudal and more lateral needle entry point than the major techniques described in the literature, would be associated with a lower rate of epidural spread.

Method

We reviewed the electronic medical records and chart of all adult patients who underwent orthopedic surgery for total hip arthroplasty (THA) and hip hemiarthroplasty due to osteoarthritis and femoral neck fracture with LPB and sciatic nerve block (SNB) between January 1, 2002, and December 31, 2017, in our institute. The LPB was performed according to Chayen's technique using a mixture of mepivacaine and levobupivacaine (total volume, 25 mL) and a SNB by the parasacral approach. The sensory and motor block was evaluated bilaterally during intraoperative and postoperative period.

Results

A total number of 700 patients with American Society of Anesthesiologists (ASA) physical status I to IV who underwent LPB met the inclusion criteria. The LPB and SNB was successfully performed in all patients. Epidural spread was reported in a single patient (0.14%; p < 0.05), accounting for an 8.30% reduction compared with the other approaches described in the literature. No other complications were recorded.

Conclusions

This retrospective study indicates that more caudal and more lateral approach to the LPB, such as the Chayen's approach, is characterized by a lower epidural spread than the other approach to the LPB.

Background and objectives

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a genetic cardiomyopathy characterized by potentially lethal ventricular tachycardia. Here we describe a patient with ARVC and an Implantable Cardioverter Defibrillator (ICD) in whom maxillary sinus surgery was performed under general anesthesia.

Case report

The patient was a 59 year‐old man who was scheduled to undergo maxillary sinus surgery under general anesthesia. He had been diagnosed as having ARVC 15 years earlier and had undergone implantation of an ICD in the same year. Electrocardiography showed an epsilon wave in leads II, aVR, and V1–V3. Cardiac function was within normal range on transthoracic echocardiography. The ICD was temporarily deactivated after the patient arrived in the operating room and an intravenous line was secured. An external defibrillator was kept on hand for immediate defibrillation if any electrocardiographic abnormality was detected. Remifentanil 0.3 μg/kg/min, fentanyl 0.1 mg, propofol 154 mg, and rocuronium 46 mg were administered for induction of anesthesia. Tracheal intubation was performed orally. Anesthesia was maintained oxygen 1.0 L.min^‐1, air 2.0 L.min^‐1, propofol 5.0–7.0 mg.kg^‐1.h^‐1, and remifentanil 0.1–0.25 μg.kg^‐1.min^‐1. The surgery was completed as scheduled and the ICD was reactivated. The patient was then extubated after administration of sugammadex 200 mg.

Conclusion

We report the successful management of anesthesia without lethal arrhythmia in a patient with ARVC and an ICD. An adequate amount of analgesia should be administered during general anesthesia to maintain adequate anesthetic depth and to avoid stress and pain.

Background and objectives

To assess the agreement between the epidural depth measured from the surgical site with the epidural depths estimated with magnetic resonance imaging (MRI) and ultrasound scanning.

Methods

Fifty patients of either sex, scheduled for L4‐5 lumbar disc surgery under general anesthesia were enrolled in this prospective observational study, and the results of 49 patients were analyzed. The actual epidural depth was measured from the surgical site with a sterile surgical scale. The MRI‐derived epidural depth was measured from the MRI scan. The ultrasound estimated epidural depth was measured from the ultrasound image obtained just before surgery.

Results

The mean epidural depth measured from the surgical site was 53.80 ± 7.67 mm, the mean MRI‐derived epidural depth was 54.06 ± 7.36 mm, and the ultrasound‐estimated epidural depth was 53.77 ± 7.94 mm. The correlation between the epidural depth measured from the surgical site and MRI‐derived epidural depth was 0.989 (r² = 0.979, p < 0.001), and the corresponding correlation with the ultrasound‐estimated epidural depth was 0.990 (r² = 0.980, p < 0.001).

Conclusions

Both ultrasound‐estimated epidural depth and MRI‐derived epidural depth have a strong correlation with the epidural depth measured from the surgical site. Preprocedural MRI‐derived estimates of epidural depth are slightly deeper than the epidural depth measured from the surgical site, and the ultrasound estimated epidural depths are somewhat shallower. Although both radiologic imaging techniques provided reliable preprocedural estimates of the actual epidural depth, the loss of resistance technique cannot be discarded while inserting epidural needles.

Background and objectives

It is suggested that 38‐45% of patients experience preoperative anxiety. We observe that patients undergoing living donor nephrectomy suffer from anxiety. Preoperative anxiety may complicate a patient's recovery from anesthesia and postoperative pain control. This study investigates the preoperative anxiety rate and its effect on anesthetic recovery and postoperative pain in patients undergoing donor nephrectomy.

Methods

Forty‐eight individuals undergoing living‐related renal donor nephrectomy were included in this analytic prospective observational cohort study. Their preoperative anxiety was measured with the STAI‐I and STAI‐II inventories. The relationships between anxiety scores with data regarding demographics, recovery from anesthesia, and postoperative pain scores were investigated.

Results

The findings were remarkable in that the anxiety scores of living renal donors were significantly correlated with their recovery variables, which are spontaneous respiration time, sufficient respiration time, extubation time, and PACU discharge time (p < 0.01). Anxiety scores were significantly positively correlated with the pain scores of the 30th minute, 1st, 2nd, 4th, 8th, 12th, 24th hours, and the total amounts of analgesic administered in 24 hours (p < 0.05). A significantly negative correlation was also determined between anxiety scores and patients’ satisfaction.

Conclusion

Our study showed that patients undergoing living‐related donor nephrectomy with high anxiety levels had late recovery times and high postoperative pain scores. Thus, determining those patients with high preoperative anxiety level is crucial to providing patients with satisfactory emerging from anesthesia and the control of their postoperative pain during donor nephrectomy.

Background

Surgery generates a neuroendocrine stress response, resulting in undesirable hemodynamic instability, alterations in metabolic response and malfunctioning of the immune system.

Objectives

The aim of this research was to determine the effectiveness of caudal blocks in intra‐ and postoperative pain management and in reducing the stress response in children during the same periods.

Methods

This prospective, randomized clinical trial included 60 patients scheduled for elective herniorrhaphy. One group (n = 30) received general anesthesia and the other (n = 30) received general anesthesia with a caudal block. Hemodynamic parameters, drug consumption and pain intensity were measured. Blood samples for serum glucose and cortisol level were taken before anesthesia induction and after awakening the patient.

Results

Children who received a caudal block had significantly lower serum glucose (p < 0.01), cortisol concentrations (p < 0.01) and pain scores 3 hours (p = 0.002) and 6 hours (p = 0.003) after the operation, greater hemodynamic stability and lower drug consumption. Also, there were no side effects or complications identified in that group.

Conclusions

The combination of caudal block with general anesthesia is a safe method that leads to less stress, greater hemodynamic stability, lower pain scores and lower consumption of medication.