Adilson Hamaji

Volume replacement therapy during hip arthroplasty using hydroxyethyl starch (130/0.4) compared to lactated Ringer decreases allogeneic blood transfusion and postoperative infection

BACKGROUND AND OBJECTIVES Hydroxyethyl starch (HES) 130/0.4 is considered an effective plasma expander when compared to crystalloids. There is controversy around its superiority regarding hemodynamic optimization and about possible detrimental effects on coagulation. The aim of this study was to compare the effects of HES 130/0.4 to lactated Ringer solution during hip arthroplasty in adult patients under spinal anesthesia regarding intraoperative bleeding, hemodynamic parameters, coagulation profile, transfusion requirements and clinical outcomes. METHODS In this randomized, controlled trial, 48 patients scheduled for hip arthroplasty with spinal anesthesia were randomized into two groups: 24 patients were allocated to receive a preload of 15 mL.kg(-1) of HES 130/0.4 and 24 patients received a preload of 30 mL.kg(-1) lactated Ringer solution before surgery. Hemodynamic measurements, hemoglobin concentrations, biochemical parameters and coagulation tests were evaluated in three periods during surgical procedure. Patients received medical follow-up during their hospital stay and up to postoperative 30 days. Primary outcome was the requirement of red blood cell transfusion between groups during hospital stay. Secondary outcome were hemodynamic parameters, length of hospital stay, mortality and occurrence of clinical postoperative complications. RESULTS Red blood cell transfusion was required in 17% of patients in the HES group and in 46% in the Ringer group (p = .029). Postoperative infections were more frequently observed in the Ringer group (17%) compared to the HES group (0), p = .037. There were no significant differences between groups in mortality, hospital length of stay and clinical complications other than infection. CONCLUSIONS During hip arthroplasty, patients treated with hypervolemic hemodilution with hydroxyethyl starch 130/0.4 required less transfusion and presented lower infection rate compared to patients who received lactated Ringer.

Terapia de reposição volêmica durante artroplastia de quadril usando hidroxietilamido (130/0,4) comparado com Ringer lactato diminui transfusão de sangue alogênico e infecção pós-operatória

JUSTIFICATIVA Y OBJETIVOS: El hidroxietilalmidon 130/0,4 (HES 130/0,4) esta considerado como un expansivo plasmatico efectivo cuando se le compara con los cristaloides. Existen controversias sobre su superioridad con relacion a la optimizacion hemodinamica y sobre posibles efectos perjudiciales en la coagulacion. El objetivo de este estudio, fue comparar los efectos del HES 130/0,4 con los de la solucion de lactato de Ringer durante la artroplastia de cadera en pacientes adultos bajo raquianestesia, considerando el sangramiento intraoperatorio, los parametros hemodinamicos, el coagulograma, la necesidad de transfusion y los resultados clinicos. METODOS: En este estudio aleatorio y controlado, 48 pacientes citados para la artroplastia de cadera con raquianestesia fueron aleatoriamente divididos en dos grupos: 24 pacientes fueron ubicados para recibir una pre-carga de HES 130/0,4 (15 mL.kg-1) y 24 pacientes recibieron una pre-carga de solucion de lactato de Ringer (30 mL.kg-1) antes de la cirugia. Las medidas hemodinamicas, concentracion de hemoglobina, parametros bioquimicos y los test de coagulacion fueron evaluados en tres periodos durante el procedimiento quirurgico. Los pacientes recibieron un acompanamiento medico durante el ingreso y de 30 dias en el periodo del postoperatorio. El principal factor fue la necesidad de transfusion de hematies entre los grupos durante el ingreso. Los factores secundarios fueron los parametros hemodinamicos, tiempo de ingreso, mortalidad y aparecimiento de complicaciones clinicas. RESULTADOS: La transfusion de hematies fue necesaria en un 17% de los pacientes del grupo HES y en un 46% de los pacientes del grupo lactato de Ringer (p = 0,029). Las infecciones postoperatorias fueron observadas con mas frecuencia en el grupo lactato de Ringer (17%) en comparacion con el grupo HES (0), p = 0,037. No hubo diferencias significativas entre los grupos con relacion a la mortalidad, tiempo de ingreso y complicaciones clinicas, excepto en la infeccion. Conclusiones: Durante la artroplastia de cadera, los pacientes tratados con hemodilucion hipervolemica normal con hidroxietilalmidon 130/0.4 necesitaron menos transfusion y presentaron un indice menor de infeccion en comparacion con los pacientes que recibieron lactato de Ringer.

Estudo comparativo entre bupivacaína (S75-R25) e ropivacaína para avaliar a segurança cardiovascular em bloqueio do plexo braquial

BACKGROUND AND OBJECTIVES Bupivacaine is a fi rst choice for regional anesthesia considering its effectiveness, long duration and less motor blockade. Bupivacaine (S75-R25) is a mixture of optical isomers containing 75% levobupivacaine (S-) and 25% dextrobupivacaine (R+) created by a Brazilian pharmaceutical company. This investigation compared cardiac safety and efficacy of bupivacaine S75-R25 with vasoconstrictor and ropivacaine for brachial plexus blockade. METHODS Patients were randomized to receive brachial plexus anesthesia with either bupivacaine S75-R25 with epinephrine 1:200,000 (bupi) or ropivacaine (ropi), both at 0.50%, in 30 mL solution.We registered a continuous Holter ECG throughout the procedure, as well as the Lovett scale of force in addition to monitoring (heart rate, pulse oximetry and non-invasive blood pressure). The incidence of adverse events was compared with the chi-square or Fisher test. RESULTS We allocated forty-four patients into two groups. They did not show any difference related to age, weight or height, gender, as well as for surgical duration. Supraventricular arrhythmias were not different before or after the plexus blockade, independent of the local anestheticchosen. Loss of sensitivity was faster for the bupivacaine group (23.1 ± 11.7 min) compared to the ropivacaine one (26.8 ± 11.5 min), though not significant (p = 0.205, Student t). There was a reduction in the cardiac rate, observed during the twenty-four-hour Holter monitoring. CONCLUSIONS This study showed similar efficacy between bupivacaine S75-R25 for brachial plexus blockade and ropivacaine, with similar incidences of supraventricular arrhythmias.

Comparative study related to cardiovascular safety between bupivacaine (S75-R25) and ropivacaine in brachial plexus block.

BACKGROUND AND OBJECTIVES Bupivacaine is a first choice for regional anesthesia considering its effectiveness, long duration and less motor blockade. Bupivacaine (S75-R25) is a mixture of optical isomers containing 75% levobupivacaine (S-) and 25% dextrobupivacaine (R+) created by a Brazilian pharmaceutical company. This investigation compared cardiac safety and efficacy of bupivacaine S75-R25 with vasoconstrictor and ropivacaine for brachial plexus blockade. METHODS Patients were randomized to receive brachial plexus anesthesia with either bupivacaine S75-R25 with epinephrine 1:200,000 (bupi) or ropivacaine (ropi), both at 0.50%, in 30 mL solution. We registered a continuous Holter ECG throughout the procedure, as well as the Lovett scale of force in addition to monitoring (heart rate, pulse oximetry and non-invasive blood pressure). The incidence of adverse events was compared with the chi-square or Fisher test. RESULTS We allocated forty-four patients into two groups. They did not show any difference related to age, weight or height, gender, as well as for surgical duration. Supraventricular arrhythmias were not different before or after the plexus blockade, independent of the local anesthetic chosen. Loss of sensitivity was faster for the bupivacaine group (23.1 ± 11.7 min) compared to the ropivacaine one (26.8 ± 11.5 min), though not significant (p = 0.205, Student t). There was a reduction in the cardiac rate, observed during the twenty-four-hour Holter monitoring. CONCLUSIONS This study showed similar efficacy between bupivacaine S75-R25 for brachial plexus blockade and ropivacaine, with similar incidences of supraventricular arrhythmias.

Fator de risco para falha do bloqueio: perda da integridade do isolamento da agulha

INTRODUCAO Os avancos na area da anestesia regional tem propiciado qualidade e efetividade superior, principalmente nas tecnicas de multiplo estimulo e nos bloqueios de dificil acesso. Entretanto, e sempre possivel a ocorrencia de falhas de bloqueio, considerando que existem outros fatores envolvidos. O presente relato vem ilustrar a ocorrencia de uma falha de bloqueio devido a trauma na agulha de bloqueio. RELATO DE CASO Paciente masculino, 46 anos, P1 (antigo ASA I), indice de massa corporea 27,70, submetido a bloqueio do plexo lombar por via posterior, segundo a tecnica de Winnie, para tratamento cirurgico de retardo de consolidacao do femur esquerdo. A introducao da agulha transcorreu com leve resistencia e facil progressao ate 6,5 cm, quando apresentou grande resisten-cia e falta de progressao, provavelmente devido ao processo transverso da vertebra. Depois de varias manobras, a melhor resposta de contracao do quadriceps femoral foi conseguida com 1,5 mA. Optou-se pela troca da agulha e nova puncao a 1 cm rostral dos pontos de referencia pela tecnica de Winnie, obtendo-se contracao de quadriceps femoral com 0,38 mA. Aspiracao negativa, dose-teste negativa e injecao da solucao de anestesico sem intercorrencias. O bloqueio foi efetivo, sem intercorrencias intra- e pos-operatorias. A observacao da primeira agulha evidenciou ranhuras no isolamento a 1,5 cm da ponta. Essas ranhuras fechavam o circuito ao serem testadas com o estimulador de nervo periferico. Ja na segunda agulha so ocorria o fechamento do circuito na ponta da agulha. DISCUSSAO As causas relatadas de falha de bloqueio foram a formacao de hematoma e o contato da agulha com o osso. Acredita-se que esse contato levou a perda da camada isolante, reduzindo o campo eletrico, uma vez que a troca da agulha levou ao blo-queio efetivo. Assim sendo, recomendamos que se, ao realizar um bloqueio, ocorrer contato com estrutura ossea, deve-se pensar em perda da integridade do isolamento e optar como conduta a troca da agulha. REFERENCIAS

Falha no uso do estimulador de nervo periférico no bloqueio interescalênico

INTRODUCAO A tecnica de anestesia regional periferica com o uso de estimulador de nervo periferico (ENP) e uma realidade e tem como caracteristica evitar o contato mecânico direto da agulha com o nervo, possibilitando facil localizacao do mesmo, sem ocasionar lesao. RELATO DO CASO Paciente de 47anos, sexo masculino, P1 (antigo ASA I), com programacao cirurgica de artroscopia do ombro direito. Conduta anestesica efetuada com bloqueio interescalenico D com ENP, seguido de anestesia geral com intubacao orotraqueal. Apos diver-sas tentativas de localizacao do nervo, com estimulos de l mA, o paciente passou a referir parestesia sem resposta motora. Optou-se pela troca do aparelho sem retirada da agulha do local paretico, com obtencao de resposta motora atraves de estimulo inferior a 0,15 mA, sugerindo que a agulha estaria em contacto direto com o nervo. A agulha foi entao afastada, ate a afericao de resposta motora com 0,35 mA, seguida de infusao do anestesico local sem intercorrencias. A evolucao no pos-operatorio se deu com bloqueio efetivo, sem sequelas.DISCUSSAO Houve, neste relato de caso, exposicao do paciente a com-plicacoes anestesicas graves por falha de aparelhagem, provan-do a importância do conhecimento das tecnicas adequadas, da anatomia da regiao e da avaliacao de forma rotineira dos materiais disponiveis. Na literatura nao foi encontrado relato com esse tipo de intercorrencia, contudo existem alguns es-tudos comparativos entre realizacao de bloqueios perifericos com ou sem o uso de estimuladores de nervo, discorrendo sobre vantagens e desvantagens de cada tecnica. REFERENCIAS