Américo Massafuni Yamashita

Anestesia para tratamento intraparto extraútero (EXIT) em fetos com diagnóstico pré-natal de malformações cervical e oral: relato de casos

JUSTIFICATIVA Y OBJETIVOS: El feto con diagnostico prenatal de masa cervical, o cualquier otra enfermedad que obstruya las vias aereas, no debe ser abordado de forma convencional por presentar dos retos para el medico asistente inmediatamente despues del parto: a) el tiempo limitado para establecer el acceso a las vias aereas potencialmente dificiles y b) la ausencia de anestesia del neonato en el caso de que sea necesaria la instrumentacion de las vias aereas. El procedimiento EXIT (ex utero intrapartum treatment - EXIT procedure), consiste en mantener la circulacion feto-placentaria durante la cesarea hasta que las vias aereas del feto esten aseguradas. RELATO DE LOS CASOS: Mujer de 37 anos, G3P2, 38 semanas de embarazo, presentando un polihidramnios y feto con gran masa cervical diagnosticada por ultrasonido prenatal. La cesarea fue realizada con el procedimiento EXIT para posibilitar el acceso seguro a las vias aereas. Despues de la histerotomia, el feto fue intubado bajo laringoscopia directa. Fue transferido inmediatamente a otra sala de cirugia, donde se le hizo la reseccion del tumor cervical y la traqueostomia, ambos con exito. Mujer de 27 anos, G3P1A1, edad gestacional de 32 semanas, cuyo feto tenia un diagnostico prenatal de gran tumor en la region oral. El tumor obstruia las vias aereas del feto y fue programada la traqueostomia con tecnica EXIT. Sin embargo, se pudo intubar al recien nacido bajo laringoscopia directa, siendo entonces sometido a la reseccion del tumor y derivado a la UCI neonatal. CONCLUSIONES: Los relatos describen el uso exitoso de la anestesia general con el isoflurano para la realizacion de la cesarea seguida de procedimiento EXIT en fetos con tumores obstruyendo las vias aereas.

Anestesia e apnéia obstrutiva do sono

BACKGROUND AND METHODS Maintaining the patency of the upper airways is fundamental to anesthesia and patients with obstructive sleep apnea (OSA). During anesthesia and while a person is sleeping, the tonus of the pharyngeal muscles is reduced. It is important to identify patients with OSA to prevent risks in the perioperative period. The objective of this report was to present a revision of the relationship between OSA and anesthesia regarding planning of anesthesia, stressing the importance of identifying the obstructive sleep apnea hypopnea syndrome (OSAHS). CONTENTS OSAHS is caused mainly by total or partial pharyngeal collapse, which may cause a reduction in hemoglobin saturation and cardiovascular complications. The main predisposing factors include male gender, obesity, and cranial and orofacial characteristics. It is diagnosis by its clinical and polysomnographic characteristics, which also determine its severity. Patients with severe OSAHS may present problems during tracheal intubation and sedation, and may be more susceptible to hypoxia and hypercapnia, even in the presence of normal lungs. The authors discuss the importance of diagnosing and treating OSAHS before surgeries in order to reduce the anesthetic risk. CONCLUSION Prior diagnosis and treatment of OSAHS with continuous positive pressure in the upper airways may reduce perioperative complications and influence the anesthetic and postanesthetic management.JUSTIFICATIVA E OBJETIVOS: A manutencao da permeabilidade das vias aereas superiores (VAS) e fundamental para anestesia e para pacientes com apneia obstrutiva do sono (AOS). Durante ambos os estados ocorre uma reducao do tonus da musculatura faringea. Identificar pacientes com AOS e importante a fim de prevenir riscos durante o periodo perioperatorio. O objetivo deste trabalho foi apresentar uma revisao sobre a relacao entre AOS e anestesia, levando em conta o planejamento da anestesia, enfatizando a importância da identificacao da sindrome da apneia e hipopneia obstrutiva do sono (SAHOS). CONTEUDO: A SAHOS ocorre principalmente por colapso total ou parcial da faringe, podendo levar a diminuicao na saturacao da oxiemoglobina e complicacoes cardiovasculares. Os principais fatores predisponentes sao sexo masculino, obesidade, caracteristicas crânio e orofaciais. Seu diagnostico e clinico e polissonografico, o que tambem quantifica a gravidade da AOS. Os pacientes com SAHOS especialmente acentuada podem apresentar problemas durante a intubacao traqueal e sedacao, estando alguns mais susceptiveis a ocorrencia de hipoxia e hipercapnia, mesmo na vigencia de pulmoes normais. Os autores discutem a importância do diagnostico previo e tratamento da SAHOS na tentativa de reduzir o risco anestesico. CONCLUSOES: O diagnostico e tratamento previo da SAHOS com pressao positiva continua nas VAS podem reduzir complicacoes perioperatorias e influenciar na conduta anestesica e na recuperacao pos-anestesica.

Estudo comparativo entre levobupivacaína a 0,5% e bupivacaína racêmica a 0,5% associadas ao sufentanil na anestesia peridural para cesariana

JUSTIFICATIVA Y OBJETIVOS: A pesar del uso frecuente de anestesicos locales en procedimientos quirurgicos y obstetricos, la bupivacaina racemica es asociada a la cardiotoxicidad potencialmente fatal. Estudios sugieren que la levobupivacaina presenta accion anestesica local semejante a la bupivacaina racemica, con la ventaja de menor toxicidad tanto en el sistema nervioso central como cardiovascular. Los trabajos han demostrado mejor calidad anestesica con el uso de bupivacaina racemica asociada al sufentanil, via peridural para cesarea. El presente estudio compara la eficacia de la bupivacaina racemica 0,5% con levobupivacaina 0,5%, ambas asociadas al sufentanil, via peridural, en parturientas sometidas a cesarea. METODO: Fueron investigadas 52 mujeres embarazadas, sometidas a anestesia peridural para cesarea electiva. En este estudio duplamente encubierto, las pacientes fueron distribuidas aleatoriamente en dos grupos: Grupo I (n = 26): recibieron 27 ml de levobupivacaina 0,5% y 30 µg de sufentanil, Grupo II (n = 26) recibieran 27 ml de bupivacaina 0,5% y 30 µg de sufentanil. Fueron evaluadas las caracteristicas de los bloqueos motor y sensorial, el tiempo necesario para solicitacion de analgesicos y la incidencia de efectos adversos en el periodo pos-operatorio. RESULTADOS: Los bloqueos motor y sensorial, el tiempo para solicitacion de analgesicos y los efectos adversos no divergieron entre los grupos. Entretanto, cuando se comparo la duracion del bloqueo motor de la levobupivacaina con el de la bupivacaina racemica, se observo duracion significantemente prolongada para levobupivacaina (p < 0,05). CONCLUSIONES: A pesar de la duracion del bloqueo motor ser mas prolongado para la levobupivacaina asociada al sufentanil, la eficacia anestesica de ambos anestesicos locales investigados, asociados al sufentanil en cesarea por via peridural, fueron iguales.

Efeitos da infusão contínua profilática de fenilefrina sobre a estratégia de redução da massa de anestésico local em pacientes submetidas à raquianestesia para cesariana

JUSTIFICATIVA E OBJETIVOS: A reducao da massa de anestesico local minimiza os efeitos da hipotensao arterial pos-raquianestesia para cesariana e a incidencia de eventos adversos maternos preservando o bem-estar fetal, mas pode resultar em anestesia insuficiente. A hipotensao associada as maiores massas de anestesico subaracnoideo pode ser controlada com infusao continua profilatica de fenilefrina. Foram avaliados os efeitos da infusao continua profilatica de fenilefrina para controle pressorico sobre os resultados maternos e conceptuais em cesarianas com diferentes doses de bupivacaina hiperbarica na raquianestesia. METODO: Realizou-se ensaio clinico prospectivo, nao aleatorio, com 60 gestantes a termo admitidas para cesariana eletiva. Alocaram-se as pacientes em dois grupos, na dependencia da dose de bupivacaina hiperbarica administrada na raquianestesia, 12 ou 8 mg, acrescida de 5 µg de sufentanil e 100 µg de morfina. Realizou-se hidratacao com 10 mL.kg-1 de solucao lactato de Ringer antes do bloqueio. Logo apos, iniciou-se infusao continua de 100 µg.min-1 de fenilefrina, mantendo a pressao arterial nos valores basais. Avaliaram-se: nivel de bloqueio anestesico, o consumo de vasopressores, incidencia de eventos adversos maternos e condicoes do recem-nascido. RESULTADOS: Os dados maternos foram semelhantes entre os grupos quanto a: nivel de bloqueio anestesico, consumo de fenilefrina por tempo, incidencias de hipotensao, hipertensao, bradicardia, nauseas, vomitos, dispneia, dor e tremores. Os dados conceptuais evidenciaram semelhanca entre os grupos quanto a gasometria e a dosagem de lactato nos vasos umbilicais. Todos os recem-nascidos apresentaram pH > 7,2. CONCLUSOES: Mantendo-se a pressao arterial com infusao profilatica continua de fenilefrina, a incidencia de eventos adversos maternos e as condicoes de nascimento conceptuais nao diferem quando a raquianestesia e realizada com 12 mg ou 8 mg de bupivacaina hiperbarica.

Effects of Prophylactic Continuous Infusion of Phenylephrine on Reducing the Mass of Local Anesthetic in Patients Undergoing Spinal Anesthesia for Cesarean Section

BACKGROUND AND OBJECTIVES Reducing the mass of local anesthetic minimizes the effects of hypotension after spinal anesthesia for cesarean section and the incidence of maternal adverse events preserving fetal well-being, but it may result in insufficient anesthesia. Hypotension associated with greater masses of subarachnoid anesthesia can be controlled by prophylactic continuous infusion of phenylephrine. The effects of prophylactic continuous infusion of phenylephrine on pressure control on maternal and fetus results in cesarean sections with different doses of hyperbaric bupivacaine in spinal anesthesia. METHODS A non-randomized prospective study of 60 gravidas at term scheduled for elective cesarean sections was undertaken. Patients were allocated into two groups depending on hyperbaric bupivacaine dose administered for spinal anesthesia, 12 or 8 mg, along with 5 μg of sufentanil and 100 μg of morphine. Patients were hydrated with 10 mL.kg(-1) of Ringers lactate before the anesthesia. Shortly after, continuous infusion of 100 μg.min(-1) of phenylephrine was initiated to maintain blood pressure at baseline levels. The following parameters were evaluated: level of anesthetic blockade, consumption of vasopressors, incidence of maternal events, and conditions of the newborn. RESULTS Maternal data was similar in both groups regarding the level of anesthetic blockade, phenylephrine consumption along time, incidence of hypotension, hypertension, bradycardia, nausea, vomiting, dyspnea, pain, and tremors. Conceptual data showed similarities between both groups regarding blood gases and umbilical vein lactate levels. The pH of all newborns was > 7.2. CONCLUSIONS On maintaining the blood pressure with prophylactic continuous infusion of phenylephrine the incidence of maternal adverse events and conditions of birth do not differ whether spinal anesthesia is performed with 12 mg or 8 mg of hyperbaric bupivacaine.

The Almodin–Moron Trocar for Uterine Entry during Fetal Surgery

Objective: Compare the use of a newly designed and reusable metal trocar for initial uterine entry with the disposable Tulipan–Bruner trocar in creation of a hysterotomy for fetal surgery. Methods: Six consecutive patientsundergoing hysterotomy for intrauterine repair of myelomeningocele were randomized to uterine entry either with the Tulipan–Bruner trocar or with the Almodin–Moron trocar. Blood loss was estimated by the primary surgeon. Results: There was no statistically significant difference in the uterine entry times between the trocars. Blood loss was estimated to be approximately the same. The Almodin–Moron trocar was judged to provide easy handling with good safety. Conclusions: The Almodin–Moron trocar provides a uterine entry during creation of a hysterotomy that is as quick and causes as little trauma as the Tulipan–Bruner trocar.

Tromboprofilaxia e bloqueio regional

SUMMARY Yamashita AM,Yassuda H -Thromboprophilaxis and NeuraxialBlockade BackgroundandObjectives -Amongperipheralvasculardis-eases, thromboembolytic venous disease has gained signifi-cant importance due to its high frequency, morbidity andmortality,and,moreover,duetothepossibilityofinterruptingitsevolution when there is anadequate diagnosis and treatment.Theincreasinguseofthromboprophylaxishasbecomeaproblemfor anesthesiologists since those agents have increased the in-cidence of spinal hematoma when associated to regional anes-thesia. After a broad literature review, this study aimed atpresenting to anesthesiologists the biochemistry and pharma-cology ofmostcommonlyusedanticoagulantsaswellasrecom-mendations for regional blockade in patients underanticoagulants. Contents - Characteristics of different anticoagulants and re-gional anesthesia implications are presented. After each drugdescription there are considerations about the most importantrecommendations. Conclusions -Regionalanesthesiaunderthromboprophylaxisdemands lots of caution, especially as to the use of epiduralcatheters and repeated and traumatic punctures because, inthosecases,thereisanincreasedriskforspinalhematomas.Inaddition, communication between the clinical and nursing staffinvolved in the management of patients receiving anticoagu-lantsisessentialinordertodecreasetheriskforseverehemor-rhagic complications. Patients should be closely monitored forearly signs of cord compression. If spinal hematoma is sus-pected, radiographic confirmation must be immediately soughtdue to the risk for irreversible cord ischemia.

Assessment of induction, recovery, agitation upon awakening, and consumption with the use of two brands of sevoflurane for ambulatory anesthesia

BACKGROUND AND OBJECTIVES Due to its pharmacological characteristics, sevoflurane is the ideal anesthetic for short-duration procedures. There are two brands of sevoflurane in the Brazilian market, Sevocris® and Sevorane®, with different formulations and packaging. The objective of this study was to assess whether there are differences between the two anesthetics regarding induction, maintenance, recovery, and consumption. METHODS One hundred and thirty children were included, divided into two groups according to the brand used: Group 1 was assigned to sevoflurane Cristália® and Group 2 to sevoflurane Abbott®. The following parameters were assessed: heart rate, systolic and diastolic blood pressure, fraction of inspired and expired sevoflurane, BIS values, tympanic temperature, induction and recovery time, agitation upon awakening measured by the PAED scale, and anesthetic consumption by weighing the vaporizers. Anesthesia was induced with 1 MAC and increased every three breaths at 0.5 MAC, up to 3 MAC. RESULTS There was no difference between groups regarding the duration of the procedure, the anesthesia, and the parameters evaluated at induction. In Group 1, the number of children who required additional bolus of sevoflurane for anesthesia maintenance was higher than in Group 2 (p<0.05). The fraction of inspired and expired sevoflurane at the end of the procedure was lower in Group 1 (p<0.001). Upon awakening, BIS value was lower in Group 1 (p=0.045). Other parameters evaluated in recovery showed no difference between groups. The use of anesthesia was similar between groups.

Anestesia y apnea obstructiva del sueño

BACKGROUND AND METHODS Maintaining the patency of the upper airways is fundamental to anesthesia and patients with obstructive sleep apnea (OSA). During anesthesia and while a person is sleeping, the tonus of the pharyngeal muscles is reduced. It is important to identify patients with OSA to prevent risks in the perioperative period. The objective of this report was to present a revision of the relationship between OSA and anesthesia regarding planning of anesthesia, stressing the importance of identifying the obstructive sleep apnea hypopnea syndrome (OSAHS). CONTENTS OSAHS is caused mainly by total or partial pharyngeal collapse, which may cause a reduction in hemoglobin saturation and cardiovascular complications. The main predisposing factors include male gender, obesity, and cranial and orofacial characteristics. It is diagnosis by its clinical and polysomnographic characteristics, which also determine its severity. Patients with severe OSAHS may present problems during tracheal intubation and sedation, and may be more susceptible to hypoxia and hypercapnia, even in the presence of normal lungs. The authors discuss the importance of diagnosing and treating OSAHS before surgeries in order to reduce the anesthetic risk. CONCLUSION Prior diagnosis and treatment of OSAHS with continuous positive pressure in the upper airways may reduce perioperative complications and influence the anesthetic and postanesthetic management.JUSTIFICATIVA E OBJETIVOS: A manutencao da permeabilidade das vias aereas superiores (VAS) e fundamental para anestesia e para pacientes com apneia obstrutiva do sono (AOS). Durante ambos os estados ocorre uma reducao do tonus da musculatura faringea. Identificar pacientes com AOS e importante a fim de prevenir riscos durante o periodo perioperatorio. O objetivo deste trabalho foi apresentar uma revisao sobre a relacao entre AOS e anestesia, levando em conta o planejamento da anestesia, enfatizando a importância da identificacao da sindrome da apneia e hipopneia obstrutiva do sono (SAHOS). CONTEUDO: A SAHOS ocorre principalmente por colapso total ou parcial da faringe, podendo levar a diminuicao na saturacao da oxiemoglobina e complicacoes cardiovasculares. Os principais fatores predisponentes sao sexo masculino, obesidade, caracteristicas crânio e orofaciais. Seu diagnostico e clinico e polissonografico, o que tambem quantifica a gravidade da AOS. Os pacientes com SAHOS especialmente acentuada podem apresentar problemas durante a intubacao traqueal e sedacao, estando alguns mais susceptiveis a ocorrencia de hipoxia e hipercapnia, mesmo na vigencia de pulmoes normais. Os autores discutem a importância do diagnostico previo e tratamento da SAHOS na tentativa de reduzir o risco anestesico. CONCLUSOES: O diagnostico e tratamento previo da SAHOS com pressao positiva continua nas VAS podem reduzir complicacoes perioperatorias e influenciar na conduta anestesica e na recuperacao pos-anestesica.

Avaliação da indução, recuperação, agitação ao despertar e consumo com uso de duas marcas de sevoflurano para anestesia ambulatorial

JUSTIFICATIVA Y OBJETIVOS: El sevoflurano, por sus caracteristicas farmacologicas, es el anestesico ideal para procedimientos de corta duracion. Existen dos marcas de sevoflurano en el mercado brasileno, el Sevocris® y el Sevorane®, con diferentes formulaciones y envases. El objetivo de este estudio, fue analizar si existen diferencias entre los dos anestesicos en la induccion, mantenimiento, recuperacion y consumo. METODO: Se incluyeron 130 ninos divididos en dos grupos segun la marca del agente utilizado: Grupo 1 sevoflurano de Cristalia® y Grupo 2 de Abbott®. Se analizaron los siguientes parametros: frecuencia cardiaca, presion arterial sistolica y diastolica, fraccion inspirada y espirada de sevoflurano, valores de BIS, temperatura timpanica, tiempos de induccion y recuperacion, agitacion al despertar por la escala PAED, y consumo del anestesico por pesaje de los vaporizadores. La induccion fue realizada con 1 CAM e incrementada a cada tres movimientos respiratorios en 0,5 CAM, hasta el maximo de 3 CAM. RESULTADO: No hubo diferencia entre los grupos en cuanto al tiempo de procedimiento y de anestesia y en los parametros evaluados en la induccion. En el Grupo 1, el numero de ninos que necesitaron bolos adicionales de sevoflurano en el mantenimiento de la anestesia, fue mayor que en el 2 (p < 0,05). La fraccion inspirada y espirada de sevoflurano al final del procedimiento fue menor en el Grupo 1 (p < 0,001). Al momento del despertar, el valor del BIS fue menor en el Grupo 1 (p = 0,045). Otros parametros evaluados en la recuperacion no arrojaron diferencia entre los grupos. El consumo de anestesico fue similar entre los grupos.