Adriano Bechara de Souza Hobaika

Combined spinal-epidural block in a patient with amyotrophic lateral sclerosis: case report

BACKGROUND AND OBJECTIVES Amyotrophic lateral sclerosis starts between the fifth and sixth decades of life, causing degeneration and death of upper and lower motor neurons. When the muscles responsible for ventilation are affected, the patient dies of respiratory failure within a few years. CASE REPORT This is a 63 years old female with amyotrophic lateral sclerosis who underwent surgical treatment of a transtrochanteric fracture of the femur. The patient presented weakness of upper and lower limbs and dysarthria, and she was awake and oriented. Respiratory function: ineffective cough, decreased strength of the intercostal muscles and diaphragm, and reduction of the breath sounds in both lung bases. Initially, the L3/L4 epidural space was punctured and a silicon catheter was introduced to 5 cm. This was followed by a spinal puncture in the L4/L5 space and the administration of 7.5 mg of hyperbaric bupivacaine. This was followed by the administration of 37 mg of 0.37% ropivacaine through the epidural catheter for a sensitive blockade up to T10. The procedure evolved without complications and the patient was discharged from the hospital after three days. CONCLUSIONS The evidence has demonstrated that neuroaxis blocks can be safely performed in patients with amyotrophic lateral sclerosis since it avoids manipulation of the airways and respiratory complications.

Anestesia para paciente portador da equência de moebius: relato de caso

BACKGROUND AND OBJECTIVES Moebius sequence (MS) is a rare paralysis of the VI and VII cranial nerves. Craniofacial changes, which can hinder tracheal intubation considerably, are seen in approximately 90% of the patients. CASE REPORT A male patient, 2 years and 5 months old, with MS, underwent flexible bronchoscopy for evaluation of laryngotracheomalacia. Comorbidities: bronchospasm and interventricular communication. Anesthesia was induced with sevoflurane in 100% O2, followed by venoclysis. A number 2.5 laryngeal AMBU mask was inserted and the fiberbronchoscope scope introduced through the mask. The procedure evolved without complications and bronchoscopy was normal. The patient was discharged home after two hours. CONCLUSIONS Airways management is a great challenge in those patients with a report of failure or difficult intubation in 13 out of 41 patients. Micrognathia, retrognathia, mandibular hypoplasia, and palatine cleft are some of the manifestations seen in those patients. The use of a laryngeal mask was reported in one patient in a large series with 106 anesthesias in patients with MS. There does not seem to be contraindications to perform the procedure in an outpatient setting. Pulmonary aspiration and respiratory obstruction in the recovery room due to difficulty swallowing and eliminating mouth secretions have been reported, and the use of anti-sialagogues recommended.JUSTIFICATIVA Y OBJETIVOS: La secuencia de Moebius (SM) es una rara paralisis del VI y VII nervios cranianos. Las alteraciones craneofaciales estan presentes en aproximadamente un 90% de esos pacientes, lo que puede hacer con que la intubacion traqueal sea muy dificil. RELATO DEL CASO: Paciente del sexo masculino, 2 anos y 5 meses, portador de SM, sometido a la broncoscopia flexible para la evaluacion de laringotraqueomalacia. Comorbidades: crisis de broncoespasmo y comunicacion interventricular. Se realizo la induccion anestesica con sevoflurano en O2 a 100% y venoclisis. Se introdujo la mascara laringea AMBU® numero 2,5 y el fibrobroncoscopio fue introducido a traves de ella. El procedimiento fue realizado sin complicaciones y la broncoscopia fue normal. El paciente recibio alta despues de dos horas. CONCLUSIONES: El control de las vias aereas es el gran reto para esos pacientes, habiendo relatos de falla o de dificultad de intubacion en 13 pacientes de una serie de 41 casos analizados. Micrognatia, retrognatia, hipoplasia mandibular y la hendidura palatina, son algunas de las caracteristicas de esos pacientes. En otra gran serie con 106 anestesias en pacientes con SM, hay una descripcion del uso de la mascara laringea en un caso. En regimen ambulatorial, parece no haber contraindicacion para realizar el procedimiento. Existe un relato de aspiracion pulmonar y obstruccion respiratoria en la sala de recuperacion, a causa de la dificultad de deglutir y eliminar las secreciones de la boca y para ese caso se recomienda administrar antisialogogos.

The influence of the bispectral index in hospital time of patients undergoing ophthalmic procedures

Study objective: assessing whether drug titration guided by the bispectral index in patients submitted to outpatient ophthalmological surgeries is associated with a decreased time of hospital discharge. Method: one hundred and eleven patients submitted to outpatient ophthalmological procedures performed under intravenous sedation associated with peribulbar block were selected for this study. Patients were randomized in two groups. In the control group, the anesthetist in charge administered sedation according to clinical parameters: maintaining the patient between 2 and 4 points in the Ramsay’s sedation scale. In the other group, the bispectral index was monitored and sedation was performed with the purpose of maintaining its values between 70 and 85. Demographic data, drug dosage, length of procedures, post-surgical complications and time of hospital discharge were compared between the two groups. Results: groups have not shown statistical differences regarding demographic data, dosage of intravenous drugs and the dosage of local anesthetic administered. No difference was observed between groups regarding the length of the procedures, and the time of hospital discharge. The post-surgical complications detected were nausea and vomiting and post-surgical pain, however, with no statistically significant difference between groups. Conclusions: bispectral index monitoring has not been more effective than clinical monitorThe influence of the bispectral index in hospital time of patients undergoing ophthalmic procedures Adriano Bechara de Souza Hobaika1, Marcus Vinicius Gomez2, João Agostini Netto3, Kléber Costa de Castro Pires4 A influência do índice bispectral no tempo de alta hospitalar de pacientes submetidos a procedimentos oftalmológicos DOI: 10.5935/2238-3182.20150056

Two cases of thoracic spinal anaesthesia in patients with severe diseases

Abstract This manuscript describes two cases of thoracic spinal anaesthesia for patients with severe diseases, with satisfying results. Patient 1: female, 57 years old, submitted to a surgical gastrostomy. She had squamous cell carcinoma of the hypopharynx involving the C6 vertebra, carotid and thyroid, with a fistula in the cervical region. After sedation, an epidural puncture was performed in the T7–T8 interspace and an epidural catheter was introduced. Then, a 25G Quinke needle was introduced 5.4 cm in the subarachnoid T8–T9 interspace and 5.0 mg of isobaric bupivacaine was administered. The dermatome level of anaesthesia was established from T3 to T12, preserving the movement of lower limbs. Patient 2: male, 41 years old, with alcohol-related brain atrophy, progressive strength loss in both lower and upper limbs, with spastic tetraparesis and tetrahyperreflexia. After sedation, a 25G Quinke needle was introduced in the subarachnoid T8–T9 interspace, and 5.0 mg of isobaric bupivacaine was introduced. Both patients were transferred to the post-anaesthesia recovery room. The greatest cause for concern in the administration of spinal anaesthesia is the possibility of an accidental medullary puncture. In a recent study, it was found a larger distance between the dura mater and the spinal cord in T6. In another study, the largest distance between the dura mater and the spinal cord was found in T5. Thoracic spinal anaesthesia technique is another anaesthetic technique that may be used in some special situations.

A case of trigeminal hypersensitivity after administration of intrathecal sufentanil and bupivacaine for labor analgesia

Rostral spread of intrathecal drugs and sensitization of supraspinal sites may provoke several adverse effects. This case describes a patient with right hemifacial paresthesia, trismus and dysphasia on the trigeminal nerve distribution after intrathecal sufentanil administration. Primigravida, 34 years, 39 weeks of pregnancy, with hypothyroidism and pregnancy induced hypertension. Allergic to latex. In the use of puran T4, 50 μg /day. When the patient presented cervical dilatation of 4 cm, she requested analgesia. She was placed in the sitting position and a spinal puncture was performed with a 27G needle pencil point in L4/L5 (1.5 mg of bupivacaine plus 7.5 μg of sufentanil). Next, was performed an epidural puncture in the same space. It was injected bupivacaine 0.065%, 10 ml, to facilitate the passage of the catheter. After 5 min lying down in the lateral upright position, she complained of perioral and right hemifacial paresthesia, mainly maxillary and periorbital, as well as trismus and difficulty to speak. The symptoms lasted for 30 min and resolved spontaneously. After 1 h, patient requested supplementary analgesia (12 ml of bupivacaine 0.125%) and a healthy baby girl was born. Temporary mental alterations have been described with the use of fentanyl and sufentanil in combined epidural-spinal analgesia, such as aphasia, difficulty of swallowing, mental confusion and even unconsciousness. In this patient, facial areas with paresthesia indicated by patient appear in clear association with the ophthalmic and maxillary branches of the trigeminal nerve and the occurrence of trismus and dysphagia are in association with the mandibular motor branch. The exact mechanism of rostral spread is not known, but it is speculated that after spinal drug administration, a subsequent epidural dose may reduce the intratecal space and propel the drug into the supraspinal sites.Rostral spread of intrathecal drugs and sensitization of supraspinal sites may provoke several adverse effects. This case describes a patient with right hemifacial paresthesia, trismus and dysphasia on the trigeminal nerve distribution after intrathecal sufentanil administration. Primigravida, 34 years, 39 weeks of pregnancy, with hypothyroidism and pregnancy induced hypertension. Allergic to latex. In the use of puran T4, 50 μg /day. When the patient presented cervical dilatation of 4 cm, she requested analgesia. She was placed in the sitting position and a spinal puncture was performed with a 27G needle pencil point in L4/L5 (1.5 mg of bupivacaine plus 7.5 μg of sufentanil). Next, was performed an epidural puncture in the same space. It was injected bupivacaine 0.065%, 10 ml, to facilitate the passage of the catheter. After 5 min lying down in the lateral upright position, she complained of perioral and right hemifacial paresthesia, mainly maxillary and periorbital, as well as trismus and difficulty to speak. The symptoms lasted for 30 min and resolved spontaneously. After 1 h, patient requested supplementary analgesia (12 ml of bupivacaine 0.125%) and a healthy baby girl was born. Temporary mental alterations have been described with the use of fentanyl and sufentanil in combined epidural-spinal analgesia, such as aphasia, difficulty of swallowing, mental confusion and even unconsciousness. In this patient, facial areas with paresthesia indicated by patient appear in clear association with the ophthalmic and maxillary branches of the trigeminal nerve and the occurrence of trismus and dysphagia are in association with the mandibular motor branch. The exact mechanism of rostral spread is not known, but it is speculated that after spinal drug administration, a subsequent epidural dose may reduce the intratecal space and propel the drug into the supraspinal sites.

Amphetamine and atropine interaction: A reason for concern?

1. Sharma SB, Nath MP, Pasari C, Chakrabarty A, Choudhury D. Hard palate tumor. Role of modifi ed molar approach. Indian J Anaesth 2013;57:83-4. 2. Ramani MN, Shah SK, Parikh U, Mehta P, Vakil SD. Infant with palatal swelling and anesthetic challenge. Indian J Anaesth 2002:46:217-8. 3. Mishra SK, Kavitha J, Kumaravel S, Lalatendu KK. Anesthetic management of newborn for pedunculated teratoma of oral cavity. Anesth Essay Res 2010:4:124-5. 4. Henderson JJ, Popat MT, Latto IP, Pearce AC. Diffi cult airway Society guidelines for management of the unanticipated diffi cult intubation. Anesthesia 2004:59:675-94.

Anesthesia in a patient with moebius sequence: case report

BACKGROUND AND OBJECTIVES Moebius sequence (MS) is a rare paralysis of the VI and VII cranial nerves. Craniofacial changes, which can hinder tracheal intubation considerably, are seen in approximately 90% of the patients. CASE REPORT A male patient, 2 years and 5 months old, with MS, underwent flexible bronchoscopy for evaluation of laryngotracheomalacia. Comorbidities: bronchospasm and interventricular communication. Anesthesia was induced with sevoflurane in 100% O2, followed by venoclysis. A number 2.5 laryngeal AMBU mask was inserted and the fiberbronchoscope scope introduced through the mask. The procedure evolved without complications and bronchoscopy was normal. The patient was discharged home after two hours. CONCLUSIONS Airways management is a great challenge in those patients with a report of failure or difficult intubation in 13 out of 41 patients. Micrognathia, retrognathia, mandibular hypoplasia, and palatine cleft are some of the manifestations seen in those patients. The use of a laryngeal mask was reported in one patient in a large series with 106 anesthesias in patients with MS. There does not seem to be contraindications to perform the procedure in an outpatient setting. Pulmonary aspiration and respiratory obstruction in the recovery room due to difficulty swallowing and eliminating mouth secretions have been reported, and the use of anti-sialagogues recommended.JUSTIFICATIVA Y OBJETIVOS: La secuencia de Moebius (SM) es una rara paralisis del VI y VII nervios cranianos. Las alteraciones craneofaciales estan presentes en aproximadamente un 90% de esos pacientes, lo que puede hacer con que la intubacion traqueal sea muy dificil. RELATO DEL CASO: Paciente del sexo masculino, 2 anos y 5 meses, portador de SM, sometido a la broncoscopia flexible para la evaluacion de laringotraqueomalacia. Comorbidades: crisis de broncoespasmo y comunicacion interventricular. Se realizo la induccion anestesica con sevoflurano en O2 a 100% y venoclisis. Se introdujo la mascara laringea AMBU® numero 2,5 y el fibrobroncoscopio fue introducido a traves de ella. El procedimiento fue realizado sin complicaciones y la broncoscopia fue normal. El paciente recibio alta despues de dos horas. CONCLUSIONES: El control de las vias aereas es el gran reto para esos pacientes, habiendo relatos de falla o de dificultad de intubacion en 13 pacientes de una serie de 41 casos analizados. Micrognatia, retrognatia, hipoplasia mandibular y la hendidura palatina, son algunas de las caracteristicas de esos pacientes. En otra gran serie con 106 anestesias en pacientes con SM, hay una descripcion del uso de la mascara laringea en un caso. En regimen ambulatorial, parece no haber contraindicacion para realizar el procedimiento. Existe un relato de aspiracion pulmonar y obstruccion respiratoria en la sala de recuperacion, a causa de la dificultad de deglutir y eliminar las secreciones de la boca y para ese caso se recomienda administrar antisialogogos.

Anestesia para Paciente Portador de la Secuencia de Moebius: relato de Caso

BACKGROUND AND OBJECTIVES Moebius sequence (MS) is a rare paralysis of the VI and VII cranial nerves. Craniofacial changes, which can hinder tracheal intubation considerably, are seen in approximately 90% of the patients. CASE REPORT A male patient, 2 years and 5 months old, with MS, underwent flexible bronchoscopy for evaluation of laryngotracheomalacia. Comorbidities: bronchospasm and interventricular communication. Anesthesia was induced with sevoflurane in 100% O2, followed by venoclysis. A number 2.5 laryngeal AMBU mask was inserted and the fiberbronchoscope scope introduced through the mask. The procedure evolved without complications and bronchoscopy was normal. The patient was discharged home after two hours. CONCLUSIONS Airways management is a great challenge in those patients with a report of failure or difficult intubation in 13 out of 41 patients. Micrognathia, retrognathia, mandibular hypoplasia, and palatine cleft are some of the manifestations seen in those patients. The use of a laryngeal mask was reported in one patient in a large series with 106 anesthesias in patients with MS. There does not seem to be contraindications to perform the procedure in an outpatient setting. Pulmonary aspiration and respiratory obstruction in the recovery room due to difficulty swallowing and eliminating mouth secretions have been reported, and the use of anti-sialagogues recommended.JUSTIFICATIVA Y OBJETIVOS: La secuencia de Moebius (SM) es una rara paralisis del VI y VII nervios cranianos. Las alteraciones craneofaciales estan presentes en aproximadamente un 90% de esos pacientes, lo que puede hacer con que la intubacion traqueal sea muy dificil. RELATO DEL CASO: Paciente del sexo masculino, 2 anos y 5 meses, portador de SM, sometido a la broncoscopia flexible para la evaluacion de laringotraqueomalacia. Comorbidades: crisis de broncoespasmo y comunicacion interventricular. Se realizo la induccion anestesica con sevoflurano en O2 a 100% y venoclisis. Se introdujo la mascara laringea AMBU® numero 2,5 y el fibrobroncoscopio fue introducido a traves de ella. El procedimiento fue realizado sin complicaciones y la broncoscopia fue normal. El paciente recibio alta despues de dos horas. CONCLUSIONES: El control de las vias aereas es el gran reto para esos pacientes, habiendo relatos de falla o de dificultad de intubacion en 13 pacientes de una serie de 41 casos analizados. Micrognatia, retrognatia, hipoplasia mandibular y la hendidura palatina, son algunas de las caracteristicas de esos pacientes. En otra gran serie con 106 anestesias en pacientes con SM, hay una descripcion del uso de la mascara laringea en un caso. En regimen ambulatorial, parece no haber contraindicacion para realizar el procedimiento. Existe un relato de aspiracion pulmonar y obstruccion respiratoria en la sala de recuperacion, a causa de la dificultad de deglutir y eliminar las secreciones de la boca y para ese caso se recomienda administrar antisialogogos.