Alexandre Palmeira Goulart

Anesthetic management of a patient with hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome): case report

BACKGROUND AND OBJECTIVES Hereditary hemorrhagic telangiectasia (HHT), also known as Rendu-Osler-Weber syndrome, is an autosomal dominant disorder characterized by mucocutaneous and visceral vascular dysplasia associated with frequent episodes of epistaxis and gastrointestinal bleeding. The objective of this report was to describe the anesthesia of a patient with this syndrome. CASE REPORT A 25 years old male patient underwent surgical correction of an orbital fracture. He had the triad of recurrent epistaxis, family history and telangiectasia, and had been diagnosed with HHT. Pulmonary, brain, or gastrointestinal tract vascular malformations were not detected in the preoperative investigation. The patient underwent total venous anesthesia one hour after the administration of an antifibrinolytic drug. Bleeding was considered normal for this type of surgery, and hemodynamic instability or the need of perioperative blood transfusion was not detected. The patient was extubated in the operating room; he was transferred to the room after 60 minutes and discharged from the hospital after 24 hours. CONCLUSIONS Hereditary hemorrhagic telangiectasia is an autosomal dominant disorder that leads to mucocutaneous and visceral vascular dysplasia. Perioperative blood loss can be greater than expected in patients with this syndrome. Since bleeding does not result from a defect in the coagulation cascade but from the surgical exposure of malformed vascular structures, perioperative conduct includes the use of antifibrinolytics, adequate homeostasis, and induced hypotension in the absence of contraindications. Preanesthetic evaluation should include the search for brain, lung, and gastrointestinal vascular malformation.

Compressão da cartilagem cricóide: aspectos atuais

BACKGROUND AND OBJECTIVES Sellick described the importance of applying pressure in the cricoid cartilage during anesthesia induction to prevent regurgitation of gastric contents. Since then, the maneuver has been widely accepted by anesthesiologists as a fundamental step during induction with the rapid sequence technique. The objective of the present report was to discuss the indications, technique, complications, and reasons why some authors have refuted the efficacy of this technique. CONTENTS The indications, technique, and complications of compression of the cricoid cartilage were reviewed. The aspects that have motivated some authors to abandon the Sellick maneuver during anesthetic induction with the rapid sequence technique are also discussed. CONCLUSIONS The cricoid cartilage pressure maneuver requires knowledge of the anatomy of upper airways and the correct force to be used. Endoscopic and radiologic studies, as well as patients who developed pulmonary aspiration despite the use of Sellick maneuver, have raised doubts about the usefulness of this technique. Besides, can cause deformity of the cricoid cartilage, closure of the vocal cords, and difficulty to ventilate if it is not used properly. Despite the importance given to Sellick maneuver in preventing pulmonary aspiration, there are no guarantees it will protect the airways of all patients, especially when the technique is not properly used.JUSTIFICATIVA E OBJETIVOS: Sellick descreveu a importância da pressao aplicada na cartilagem cricoide para a prevencao da regurgitacao do conteudo gastrico durante a inducao da anestesia. Desde entao a manobra tem sido universalmente aceita pelos anestesiologistas como um passo fundamental durante a inducao com a tecnica de sequencia rapida. O presente artigo teve como objetivo discutir as indicacoes, a tecnica, as complicacoes e os motivos pelos quais alguns autores tem contestado a eficacia dessa tecnica. CONTEUDO: Foram revisadas as indicacoes, a tecnica e as complicacoes da manobra de compressao da cartilagem cricoide. Tambem foram discutidos os aspectos que tem motivado alguns autores a abandonar a manobra de Sellick durante a inducao anestesica com a tecnica de sequencia rapida. CONCLUSOES: A aplicacao da manobra de compressao da cartilagem cricoide exige o conhecimento da anatomia da via aerea superior e da forca correta a ser empregada. Estudos endoscopicos e radiologicos, assim como pacientes que apresentaram aspiracao pulmonar a despeito da aplicacao da manobra de Sellick, tem colocado em questao a utilidade da tecnica. Alem disso, quando mal empregada, pode causar deformidade dessa cartilagem, fechamento das cordas vocais e dificuldade de ventilacao. Apesar do papel de destaque representado pela manobra de Sellick na prevencao da aspiracao pulmonar, nao ha garantia de protecao das vias aereas para todos os pacientes, sobretudo quando a tecnica nao e corretamente aplicada.

Subarachnoid blockade for cesarean section in a patient with ventriculoperitoneal shunt: case report

JUSTIFICATIVA E OBJETIVOS: Pacientes portadores de derivacao ventriculoperitoneal (DVP) causam preocupacao adicional quando o bloqueio do neuroeixo e indicado, sobretudo em obstetricia. Atualmente nao existe consenso na literatura sobre a tecnica anestesica de escolha nesses casos. O objetivo deste relato foi descrever o caso de paciente com DVP submetida a cesariana sob anestesia subaracnoidea. RELATO DO CASO: Paciente de 28 anos, secundigesta, um parto anterior sem historia de aborto, de termo, pre-natal sem intercorrencias, em trabalho de parto ha cinco horas, uma cesariana ha sete anos. Evoluiu com sofrimento fetal agudo, indicada cesariana de emergencia. Portadora DVP ha cinco anos, devido a hipertensao intracraniana (sic) de etiologia desconhecida. Exame neurologico normal. Foi submetida a anestesia subaracnoidea com bupivacaina a 0,5% pesada 15 mg e morfina 80 ¼g. Nascimento fetal com Apgar 8 (1 minuto) e 10 (5 minutos) apos nascimento. Alta apos dois dias em excelente condicao clinica. CONCLUSOES: A abordagem anestesica de pacientes obstetricas com DVP e complexa, devendo-se comparar o risco e o beneficio das tecnicas no momento e circunstância da indicacao. O bloqueio do neuroeixo tem sido relatado com sucesso em portadoras de doencas neurologicas. Quanto a DVP, nao existe na literatura contraindicacao formal ao bloqueio. Os casos devem ser individualizados. Neste relato, diante da emergencia obstetrica e do quadro neurologico vigente, optou-se pelo bloqueio no neuroeixo. A tecnica proporcionou adequado manuseio da via aerea, boa condicao materno-fetal e analgesia pos-operatoria. A evolucao foi favoravel, sem alteracoes neurologicas decorrentes da tecnica escolhida.BACKGROUND AND OBJECTIVES Patients with ventriculoperitoneal shunt (VPS) represent an additional concern when neuroaxis block is indicated, especially in obstetrics. Currently, a consensus on the anesthetic technique of choice in those cases does not exist in the literature. The objective of this report was to describe the case of a cesarean section under subarachnoid blockade in a patient with VPS. CASE REPORT This is a 28 years old pregnant patient at term, in her second pregnancy, one prior delivery, a cesarean section seven years ago, no history of miscarriages, and pre-natal care without intercurrences, in labor for five hours. The patient evolved with acute fetal distress and an emergency cesarean section was indicated. She had had a VPS for five years due to intracranial hypertension (sic) of unknown etiology. Neurological exam was normal. She underwent subarachnoid block with 15 mg of 0.5% hyperbaric bupivacaine and 80 (1/4)g of morphine. The newborn had an Apgar of 8 (in the first minute) and 10 (in the 5th minute). The patient was discharged two days later in excellent clinical condition. CONCLUSIONS The anesthetic approach of obstetric patients with VPS is complex, and the risk and benefits of anesthetic techniques, as well as the circumstances that led to this indication, should be considered at the time of the indication. Successful of neuroaxis block in patients with neurological diseases has been reported. As for VPS, formal contraindication for neuroaxis block does not exist in the literature. Cases should be individualized. In the present report, due to an obstetric emergency and the neurologic condition of the patient, a decision to use neuroaxis blockade was made. The technique provided adequate management of the airways, good maternal-fetal condition, and postoperative analgesia. The evolution was favorable and the patient did not show any neurologic changes secondary to the technique used.

Anestesia subaracnoidea para cesariana em paciente com derivação ventriculoperitoneal: relato de caso

JUSTIFICATIVA E OBJETIVOS: Pacientes portadores de derivacao ventriculoperitoneal (DVP) causam preocupacao adicional quando o bloqueio do neuroeixo e indicado, sobretudo em obstetricia. Atualmente nao existe consenso na literatura sobre a tecnica anestesica de escolha nesses casos. O objetivo deste relato foi descrever o caso de paciente com DVP submetida a cesariana sob anestesia subaracnoidea. RELATO DO CASO: Paciente de 28 anos, secundigesta, um parto anterior sem historia de aborto, de termo, pre-natal sem intercorrencias, em trabalho de parto ha cinco horas, uma cesariana ha sete anos. Evoluiu com sofrimento fetal agudo, indicada cesariana de emergencia. Portadora DVP ha cinco anos, devido a hipertensao intracraniana (sic) de etiologia desconhecida. Exame neurologico normal. Foi submetida a anestesia subaracnoidea com bupivacaina a 0,5% pesada 15 mg e morfina 80 ¼g. Nascimento fetal com Apgar 8 (1 minuto) e 10 (5 minutos) apos nascimento. Alta apos dois dias em excelente condicao clinica. CONCLUSOES: A abordagem anestesica de pacientes obstetricas com DVP e complexa, devendo-se comparar o risco e o beneficio das tecnicas no momento e circunstância da indicacao. O bloqueio do neuroeixo tem sido relatado com sucesso em portadoras de doencas neurologicas. Quanto a DVP, nao existe na literatura contraindicacao formal ao bloqueio. Os casos devem ser individualizados. Neste relato, diante da emergencia obstetrica e do quadro neurologico vigente, optou-se pelo bloqueio no neuroeixo. A tecnica proporcionou adequado manuseio da via aerea, boa condicao materno-fetal e analgesia pos-operatoria. A evolucao foi favoravel, sem alteracoes neurologicas decorrentes da tecnica escolhida.BACKGROUND AND OBJECTIVES Patients with ventriculoperitoneal shunt (VPS) represent an additional concern when neuroaxis block is indicated, especially in obstetrics. Currently, a consensus on the anesthetic technique of choice in those cases does not exist in the literature. The objective of this report was to describe the case of a cesarean section under subarachnoid blockade in a patient with VPS. CASE REPORT This is a 28 years old pregnant patient at term, in her second pregnancy, one prior delivery, a cesarean section seven years ago, no history of miscarriages, and pre-natal care without intercurrences, in labor for five hours. The patient evolved with acute fetal distress and an emergency cesarean section was indicated. She had had a VPS for five years due to intracranial hypertension (sic) of unknown etiology. Neurological exam was normal. She underwent subarachnoid block with 15 mg of 0.5% hyperbaric bupivacaine and 80 (1/4)g of morphine. The newborn had an Apgar of 8 (in the first minute) and 10 (in the 5th minute). The patient was discharged two days later in excellent clinical condition. CONCLUSIONS The anesthetic approach of obstetric patients with VPS is complex, and the risk and benefits of anesthetic techniques, as well as the circumstances that led to this indication, should be considered at the time of the indication. Successful of neuroaxis block in patients with neurological diseases has been reported. As for VPS, formal contraindication for neuroaxis block does not exist in the literature. Cases should be individualized. In the present report, due to an obstetric emergency and the neurologic condition of the patient, a decision to use neuroaxis blockade was made. The technique provided adequate management of the airways, good maternal-fetal condition, and postoperative analgesia. The evolution was favorable and the patient did not show any neurologic changes secondary to the technique used.

Compression of the cricoid cartilage. Current aspects.

BACKGROUND AND OBJECTIVES Sellick described the importance of applying pressure in the cricoid cartilage during anesthesia induction to prevent regurgitation of gastric contents. Since then, the maneuver has been widely accepted by anesthesiologists as a fundamental step during induction with the rapid sequence technique. The objective of the present report was to discuss the indications, technique, complications, and reasons why some authors have refuted the efficacy of this technique. CONTENTS The indications, technique, and complications of compression of the cricoid cartilage were reviewed. The aspects that have motivated some authors to abandon the Sellick maneuver during anesthetic induction with the rapid sequence technique are also discussed. CONCLUSIONS The cricoid cartilage pressure maneuver requires knowledge of the anatomy of upper airways and the correct force to be used. Endoscopic and radiologic studies, as well as patients who developed pulmonary aspiration despite the use of Sellick maneuver, have raised doubts about the usefulness of this technique. Besides, can cause deformity of the cricoid cartilage, closure of the vocal cords, and difficulty to ventilate if it is not used properly. Despite the importance given to Sellick maneuver in preventing pulmonary aspiration, there are no guarantees it will protect the airways of all patients, especially when the technique is not properly used.JUSTIFICATIVA E OBJETIVOS: Sellick descreveu a importância da pressao aplicada na cartilagem cricoide para a prevencao da regurgitacao do conteudo gastrico durante a inducao da anestesia. Desde entao a manobra tem sido universalmente aceita pelos anestesiologistas como um passo fundamental durante a inducao com a tecnica de sequencia rapida. O presente artigo teve como objetivo discutir as indicacoes, a tecnica, as complicacoes e os motivos pelos quais alguns autores tem contestado a eficacia dessa tecnica. CONTEUDO: Foram revisadas as indicacoes, a tecnica e as complicacoes da manobra de compressao da cartilagem cricoide. Tambem foram discutidos os aspectos que tem motivado alguns autores a abandonar a manobra de Sellick durante a inducao anestesica com a tecnica de sequencia rapida. CONCLUSOES: A aplicacao da manobra de compressao da cartilagem cricoide exige o conhecimento da anatomia da via aerea superior e da forca correta a ser empregada. Estudos endoscopicos e radiologicos, assim como pacientes que apresentaram aspiracao pulmonar a despeito da aplicacao da manobra de Sellick, tem colocado em questao a utilidade da tecnica. Alem disso, quando mal empregada, pode causar deformidade dessa cartilagem, fechamento das cordas vocais e dificuldade de ventilacao. Apesar do papel de destaque representado pela manobra de Sellick na prevencao da aspiracao pulmonar, nao ha garantia de protecao das vias aereas para todos os pacientes, sobretudo quando a tecnica nao e corretamente aplicada.

Anestesia subaracnoidea para cesárea en paciente con derivación ventriculoperitoneal: relato de caso

JUSTIFICATIVA E OBJETIVOS: Pacientes portadores de derivacao ventriculoperitoneal (DVP) causam preocupacao adicional quando o bloqueio do neuroeixo e indicado, sobretudo em obstetricia. Atualmente nao existe consenso na literatura sobre a tecnica anestesica de escolha nesses casos. O objetivo deste relato foi descrever o caso de paciente com DVP submetida a cesariana sob anestesia subaracnoidea. RELATO DO CASO: Paciente de 28 anos, secundigesta, um parto anterior sem historia de aborto, de termo, pre-natal sem intercorrencias, em trabalho de parto ha cinco horas, uma cesariana ha sete anos. Evoluiu com sofrimento fetal agudo, indicada cesariana de emergencia. Portadora DVP ha cinco anos, devido a hipertensao intracraniana (sic) de etiologia desconhecida. Exame neurologico normal. Foi submetida a anestesia subaracnoidea com bupivacaina a 0,5% pesada 15 mg e morfina 80 ¼g. Nascimento fetal com Apgar 8 (1 minuto) e 10 (5 minutos) apos nascimento. Alta apos dois dias em excelente condicao clinica. CONCLUSOES: A abordagem anestesica de pacientes obstetricas com DVP e complexa, devendo-se comparar o risco e o beneficio das tecnicas no momento e circunstância da indicacao. O bloqueio do neuroeixo tem sido relatado com sucesso em portadoras de doencas neurologicas. Quanto a DVP, nao existe na literatura contraindicacao formal ao bloqueio. Os casos devem ser individualizados. Neste relato, diante da emergencia obstetrica e do quadro neurologico vigente, optou-se pelo bloqueio no neuroeixo. A tecnica proporcionou adequado manuseio da via aerea, boa condicao materno-fetal e analgesia pos-operatoria. A evolucao foi favoravel, sem alteracoes neurologicas decorrentes da tecnica escolhida.BACKGROUND AND OBJECTIVES Patients with ventriculoperitoneal shunt (VPS) represent an additional concern when neuroaxis block is indicated, especially in obstetrics. Currently, a consensus on the anesthetic technique of choice in those cases does not exist in the literature. The objective of this report was to describe the case of a cesarean section under subarachnoid blockade in a patient with VPS. CASE REPORT This is a 28 years old pregnant patient at term, in her second pregnancy, one prior delivery, a cesarean section seven years ago, no history of miscarriages, and pre-natal care without intercurrences, in labor for five hours. The patient evolved with acute fetal distress and an emergency cesarean section was indicated. She had had a VPS for five years due to intracranial hypertension (sic) of unknown etiology. Neurological exam was normal. She underwent subarachnoid block with 15 mg of 0.5% hyperbaric bupivacaine and 80 (1/4)g of morphine. The newborn had an Apgar of 8 (in the first minute) and 10 (in the 5th minute). The patient was discharged two days later in excellent clinical condition. CONCLUSIONS The anesthetic approach of obstetric patients with VPS is complex, and the risk and benefits of anesthetic techniques, as well as the circumstances that led to this indication, should be considered at the time of the indication. Successful of neuroaxis block in patients with neurological diseases has been reported. As for VPS, formal contraindication for neuroaxis block does not exist in the literature. Cases should be individualized. In the present report, due to an obstetric emergency and the neurologic condition of the patient, a decision to use neuroaxis blockade was made. The technique provided adequate management of the airways, good maternal-fetal condition, and postoperative analgesia. The evolution was favorable and the patient did not show any neurologic changes secondary to the technique used.

Compresión del cartílago cricoides: aspectos actuales

BACKGROUND AND OBJECTIVES Sellick described the importance of applying pressure in the cricoid cartilage during anesthesia induction to prevent regurgitation of gastric contents. Since then, the maneuver has been widely accepted by anesthesiologists as a fundamental step during induction with the rapid sequence technique. The objective of the present report was to discuss the indications, technique, complications, and reasons why some authors have refuted the efficacy of this technique. CONTENTS The indications, technique, and complications of compression of the cricoid cartilage were reviewed. The aspects that have motivated some authors to abandon the Sellick maneuver during anesthetic induction with the rapid sequence technique are also discussed. CONCLUSIONS The cricoid cartilage pressure maneuver requires knowledge of the anatomy of upper airways and the correct force to be used. Endoscopic and radiologic studies, as well as patients who developed pulmonary aspiration despite the use of Sellick maneuver, have raised doubts about the usefulness of this technique. Besides, can cause deformity of the cricoid cartilage, closure of the vocal cords, and difficulty to ventilate if it is not used properly. Despite the importance given to Sellick maneuver in preventing pulmonary aspiration, there are no guarantees it will protect the airways of all patients, especially when the technique is not properly used.JUSTIFICATIVA E OBJETIVOS: Sellick descreveu a importância da pressao aplicada na cartilagem cricoide para a prevencao da regurgitacao do conteudo gastrico durante a inducao da anestesia. Desde entao a manobra tem sido universalmente aceita pelos anestesiologistas como um passo fundamental durante a inducao com a tecnica de sequencia rapida. O presente artigo teve como objetivo discutir as indicacoes, a tecnica, as complicacoes e os motivos pelos quais alguns autores tem contestado a eficacia dessa tecnica. CONTEUDO: Foram revisadas as indicacoes, a tecnica e as complicacoes da manobra de compressao da cartilagem cricoide. Tambem foram discutidos os aspectos que tem motivado alguns autores a abandonar a manobra de Sellick durante a inducao anestesica com a tecnica de sequencia rapida. CONCLUSOES: A aplicacao da manobra de compressao da cartilagem cricoide exige o conhecimento da anatomia da via aerea superior e da forca correta a ser empregada. Estudos endoscopicos e radiologicos, assim como pacientes que apresentaram aspiracao pulmonar a despeito da aplicacao da manobra de Sellick, tem colocado em questao a utilidade da tecnica. Alem disso, quando mal empregada, pode causar deformidade dessa cartilagem, fechamento das cordas vocais e dificuldade de ventilacao. Apesar do papel de destaque representado pela manobra de Sellick na prevencao da aspiracao pulmonar, nao ha garantia de protecao das vias aereas para todos os pacientes, sobretudo quando a tecnica nao e corretamente aplicada.