Beatriz Lemos da Silva Mandim

Pneumothorax Post Brachial Plexus Block Guided by Ultrasound: a Case Report

BACKGROUND AND OBJECTIVES Brachial plexus block is used for upper limbs anesthesia. The use of ultrasound-guided (USG) technique for blockade has become popular in recent years, facilitating its execution by providing real-time images of the plexus and surrounding structures while minimizing complications. The purpose of this report is to describe a case of pneumothorax following ultrasound-guided interscalene block. CASE REPORT Male patient, 49 years old, weight 62kg and height 1.72m, slender, smoker, asymptomatic, ASA II E. The patient underwent surgical repair of right ulna open fracture through USG-guided interscalene brachial plexus block with axillary supplementation. After sedation and antisepsis, the linear probe of the USG apparatus was placed perpendicular to the interscalene groove (12 Hz), and stimucath A50 introduced in plane. After visualization of nerve trunks, 20mL of ropivacaine 0.5% was administered with axillary block supplementation (same volume and concentration of anesthetic). At the end of surgery, the patient complained of respiratory-dependent chest pain associated with dyspnea and decreased pulse oximetry (91% in room air), but hemodynamic stable (BP=130/70 and HR=84 bpm). Although pulmonary auscultation was normal, chest X-ray showed the presence of right pneumothorax. Water seal chest drainage was performed, after which the patient reported improvement of symptoms and was discharged from hospital in good general condition after 8 days. CONCLUSION Despite the dynamic visualization of cervical structures with USG, interscalene block may result in pneumothorax. An unusual higher pleural dome due to the hyperinflated lung (smoking) probably facilitated the accidental pleural puncture.

Frequency of colonization and isolated bacteria from the tip of epidural catheter implanted for postoperative analgesia

BACKGROUND AND OBJECTIVE The increased use of epidural analgesia with catheter leads to the need to demonstrate the safety of this method and know the incidence of catheter colonization, inserted postoperatively for epidural analgesia, and the bacteria responsible for this colonization. METHODS From November 2011 to April 2012, patients electively operated and maintained under epidural catheter for postoperative analgesia were evaluated. The catheter tip was collected for semiquantitative and qualitative microbiological analysis. RESULTS Of 68 cultured catheters, six tips (8.8%) had positive cultures. No patient had superficial or deep infection. The mean duration of catheter use was 43.45 h (18-118) (p=0.0894). The type of surgery (contaminated or uncontaminated), physical status of patients, and surgical time showed no relation with the colonization of catheters. Microorganisms isolated from the catheter tip were Staphylococcus aureus, Pseudomonas aeruginosa and Sphingomonas paucimobilis. CONCLUSION Postoperative epidural catheter analgesia, under these study conditions, was found to be low risk for bacterial colonization in patients at surgical wards.

Analgesia pós-toracotomia com associação de morfina por via peridural e venosa

JUSTIFICATIVA E OBJETIVOS: Analgesia apos cirurgia de torax e feita por diferentes metodos. O objetivo do estudo foi avaliar a analgesia pos-operatoria com associacao de morfina por via venosa e peridural, comparada ao uso por via isolada. METODO: Foram estudados 20 pacientes submetidos a cirurgia de torax, ambos os sexos, estado fisico ASA I a III. Foi feita medicacao pre-anestesica com midazolam por via venosa (3 a 3,5 mg) na SO. A monitorizacao constou de ECG continuo, pressao arterial invasiva, oximetria de pulso, capnografia, PVC, diurese e temperatura. Primeiramente foi realizada anestesia peridural continua, T7-T8 com 10 ml de bupivacaina a 0,25% e, em seguida, inducao com fentanil (5 µg.kg-1), etomidato (0,2 a 0,3 mg.kg-1) e succinilcolina (1 mg.kg-1). Foi feita IOT com tubo de duplo lume, complementacao com pancuronio (0,08 a 0,1 mg.kg-1) e ventilacao controlada mecânica. Os pacientes foram entao distribuidos aleatoriamente em tres grupos. Ao Grupo I, administrou-se pelo cateter peridural, 2 mg de morfina 0,1% na inducao da anestesia (M1), apos 12 horas (M2) e 24 horas (M3) do final da cirurgia, ao Grupo II, morfina por via venosa em bomba de infusao (15 µg.kg.h-1) precedida de bolus de 50 µg.kg-1, durante 30 horas e ao Grupo III, morfina por via peridural na dose de 0,5 mg em M1, M2 e M3, associada com morfina venosa em bomba de infusao (8 µg.kg.h-1) precedida de bolus de 25 µg.kg-1, por 30 horas. Analise de gases arteriais, frequencias cardiaca e respiratoria, presenca de prurido, nauseas, vomitos e analgesia pos-operatoria foram avaliados a cada 6 horas, ate um total de 30 horas do pos-operatorio. A analgesia foi avaliada por escala de graduacao numerica (EGN) de 0 a 10. RESULTADOS: A EGN apresentou reducao no grupo I apenas no momento M2 nao ocorrendo nos demais intervalos. Nos grupos II e III ocorreu reducao da dor a partir de 18 horas em relacao aos valores iniciais e em relacao ao grupo I. Houve maior necessidade de analgesia complementar no grupo I do que nos outros grupos. CONCLUSOES: Observou-se melhor efeito analgesico com morfina venosa ou com a associacao de vias venosa e peridural utilizando-se menores doses de morfina. Esta diferenca foi expressiva quando menores quantidades de analgesicos complementares foram utilizados nestes grupos, oferecendo um efetivo metodo de analgesia para o pos-operatorio de cirurgia de torax com menores efeitos depressores respiratorios e emetogenicos.

Anesthesia in a patient with Marshall-Smith syndrome: case report

BACKGROUND AND OBJECTIVES The Marshall-Smith Syndrome is a rare disease characterized by facial dysmorphism, accelerated osseous maturation, retarded neuropsychomotor development, and abnormalities of the airways. Patients with this syndrome have a high risk of developing anesthetic complications, especially concerning the maintenance of the airways. There are very few data in the anesthetic literature regarding this syndrome. The objective of this report was to show the difficulties and anesthetic management in a 28-day old child with this syndrome, who underwent surgery for correction of choanal atresia under general anesthesia. CASE REPORT A male child, 28 days old, weighing 2.8 kg, undergoing general anesthesia for surgical correction of choanal atresia. The child presented the typical manifestations of the Marshall-Smith syndrome, with a narrow thorax, pectus excavatum, large hands and feet, long neck, facial dysmorphism, high and arched palate, and accelerated osseous maturation. Anesthetic induction was done with a mask with 100% O2 associated with sevoflurane. Due to the possibility of a difficult intubation, tracheal intubation with a fibrobronchoscope was scheduled. After tracheal intubation and assisted manual ventilation, 1.5 mg of rocuronium were administered and, after ten minutes, the patient developed bradycardia (80 bpm), severe hypoxemia (O2 saturation of 30%), and manual ventilation through the tracheal tube became impossible. An urgent tracheostomy was done and the surgical procedure was cancelled. CONCLUSION In cases of anesthetic-surgical emergencies, in which the child does not ventilate and tracheal intubation is not possible, there is desaturation and bradycardia, requiring fast and appropriate decision making to guarantee adequate pulmonary ventilation. These patients need careful evaluation of the airways to identify upper and lower airways obstruction. During anesthesia, spontaneous ventilation should be maintained during induction until control of the airways is possible, avoiding the use of neuromuscular blockers.

Tibial and Common Fibular Nerve Block in the Popliteal Fossa with Single Puncture Using Percutaneous Nerve Stimulator: Anatomical Considerations and Ultrasound Description

BACKGROUND AND OBJECTIVES Techniques of peripheral nerve block have gained popularity over the last two decades becoming a growing anesthetic option for limb surgeries. This study proposes a technical approach of the tibial and common fibular nerves in the popliteal fossa with single puncture using percutaneous nerve stimulator, considering the correlation with an anatomical and ultrasound study. METHODS This prospective, observational, randomized study was performed with 28 patients scheduled for foot surgeries. After localizing the tibial and common fibular nerves through percutaneous stimulation, the puncture was performed at the point of tibial nerve stimulation with a 5-cm needle (B.Braun, Stimuplex 50), and 10 mL of levobupivacaine were injected. The needle was pulled back and redirected to the point of common fibular nerve stimulation looking for the corresponding motor response, and 10 mL of the local anesthetic were injected. Imaging study of the popliteal region was performed by ultrasound to correlate the anatomy with the technique used. RESULTS Adequate anesthesia was obtained in all cases. The mean time to localize the tibial and common fibular nerves suing the percutaneous stimulator was 57.1 and 32.8 seconds, respectively, and with the nerve stimulator it was 2.22 and 1.79 minutes, respectively. The mean depth of the needle into the tibial nerve was 10.7 mm. CONCLUSIONS The approach for tibial and common fibular nerves with single puncture in the popliteal fossa using peripheral nerve stimulator is a good option for anesthesia and analgesia for foot surgeries.

Cardiac arrhythmias and ST changes in the perioperative period of elderly patients submitted to transurethral prostatectomy under spinal anesthesia: comparative study

BACKGROUND AND OBJECTIVES Elderly account for 25% of surgical patients. Several patients with arterial heart disease have normal preoperative ECG and a high incidence of silent myocardial acute infarction in the first postoperative week. Arrhythmias increase with age and supraventricular and ventricular premature complexes, atrial fibrillation and intraventricular conduction abnormalities are observed. This study aimed at evaluating the prevalence of perioperative arrhythmias and ST changes through Holter System in elderly patients submitted to transurethral prostatectomy and inguinal hernia repair under spinal anesthesia. METHODS Participated in this study 21 patients aged 65 to 84 years submitted to transurethral prostatectomy (TUP) and 16 patients aged 63 to 86 years submitted to inguinal hernia repair under spinal anesthesia. Monitoring with Holter System was performed in the preoperative (12 hours), intraoperative (3 hours) and postoperative (12 hours) periods. RESULTS The prevalence of supraventricular premature complex was 85.7% vs. 93.7% in the preoperative period, 85.7% vs. 81.2% in the intraoperative and 76.2% vs. 100% in the postoperative period, respectively for groups TUP and control. The prevalence of ventricular premature complex was 76.2% vs. 81.2% in the preoperative period, 80.9% vs. 68.7% in the intraoperative period, and 80.9% vs. 81.2% in the postoperative period, respectively for groups TUP and control. The prevalence of ST changes was 19% vs. 18.7% in the preoperative period, 4.7% vs. 18.7% in the in the intraoperative period, and 14.3% vs. 18.7% in the postoperative period between groups TUP and control, without statistical significance. CONCLUSIONS Elderly patients have a high prevalence of supraventricular and ventricular cardiac arrhythmias. The total number of preoperative arrhythmias and ST changes was not changed as a function of transurethral prostatectomy surgery or inguinal hernia repair, in the intra and postoperative periods.JUSTIFICATIVA Y OBJETIVOS: Ancianos representan 25% del total de los pacientes quirurgicos. Muchos pacientes con enfermedad arterial coronariana (DAC) presentan electrocardiograma (ECG) pre-operatorio normal, y alta incidencia de infarto agudo del miocardio (IAM) silencioso en la 1a semana de pos-operatorio. Las disritmias aumentan con la edad, siendo observadas extrasistoles supraventriculares (ESSV) y ventriculares (ESV), fibrilacion atrial y disturbios de la conduccion intraventricular. El objetivo de este estudio fue evaluar la prevalencia de disritmias cardiacas y de alteraciones del segmento ST en el perioperatorio por intermedio del Holter en pacientes ancianos sometidos a cirugia de reseccion transuretral de la prostata (RTU) y herniorrafia inguinal bajo raquianestesia. METODO: Fueron evaluados 21 pacientes con edades entre 65 y 84 anos, sometidos a RTU de la prostata y 16 pacientes con edades de 65 a 86 anos, sometidos a herniorrafia inguinal, bajo raquianestesia. Evaluacion por el Sistema Holter en el pre-operatorio (12 horas), intra-operatorio (3 horas) y pos-operatorio (12 horas). RESULTADOS: La prevalencia de extrasistoles supraventriculares (ESSV) entre los grupos RTU el control fue, en el pre-operatorio 85,7% vs. 93,7%, en el intra-operatorio 85,7% vs. 81,2% y en el pos operatorio de 76,2% vs. 100%. Las extrasistoles ventriculares (ESV) tuvieron prevalencia de 76,2% vs. 81,2% en el pre, 80,9% vs. 68,7% en el per y 80,9% vs. 81,2% en el pos-operatorio. La prevalencia de alteraciones del segmento ST entre los grupos RTU y control fue, no pre-operatorio 19% vs. 18,7%, en el intra-operatorio 4,7% vs. 18,7% y en el pos-operatorio de 14,3% vs. 18,7%, sin significancia estadistica. CONCLUSIONES: Los pacientes ancianos presentan alta prevalencia de ESSV y ESV. El numero total de ESSV y ESV, y alteraciones del segmento ST, presentes en el periodo pre-operatorio, no fue alterado por la cirugia de reseccion transuretral de la prostata, bien como por la herniorrafia inguinal, en los periodos intra y pos-operatorio.

Prospective study of ultrasound-guided peri-plexus interscalene block with continuous infusion catheter for arthroscopic rotator cuff repair and postoperative pain control

Objective This trial investigated postoperative analgesia in arthroscopic rotator cuff repair surgery patients under general anesthesia, associated with ultrasound-guided peri-plexus interscalene brachial plexus block (US-IBPB), and compared single injection to elastomeric pump continuous infusion of local anesthetics. Complications associated to both techniques are described. Methods In this prospective, quasi-randomized controlled clinical trial, 68 adults scheduled for elective arthroscopic rotator cuff repair were assigned to receive Group 1 (G1 = 41) US-IBPB with a 20 mL injection of 0.5% peri-plexus ropivacaine, introduction of catheter, injection of 20 mL of 0.5% ropivacaine through continuous catheter infusion of local anesthetic by elastomeric pump (ropivacaine 0.2%, infusion of 5 mL/h). In Group 2 (G2 = 27), US-IBPB, with a single peri-plexus injection of 40 mL ropivacaine 0.5%. In both groups oral analgesics were prescribed, paracetamol 500 mg associated to codeine 30 mg for patients with VAS between 3 and 5, and also oxycodone 20 mg for VAS ≥ 6. The anesthesiology team was available through contact telephones and the patients received a table to complete in order to report pain intensity according to VAS, use of oral medication, and complications related to the catheter and pump, until the third postoperative day. Results The intensity of pain was higher on second day after surgery than on days 1 and 3, in both groups confirmed by the ANOVA test (p = 0.00006) Among the groups, G1 patients had lower pain intensity than G2, (p = 0.000197). G2 patients presented greater pain intensity during all periods studied (days 1, 2, and 3) than G1 patients. Postoperatively, G2 patients had higher consumption of rescue analgesics, nausea, and vomiting (40.74%) vs. G1 (5%) and dizziness (25.92%). No patient with catheter and elastomeric pump (G1) had complications regarding its insertion and maintenance during postoperative period. Conclusion The quality of analgesia for arthroscopic rotator cuff repair with peri-plexus US-IBPB and continuous infusion with elastomeric pump presented superior postoperative analgesia quality to single puncture IBPB on postoperative days 2 and 3, with lower consumption of rescue opioids in this period.

Preoperative evaluation in pediatric anesthesia

The pre-operative consultation for Pediatric Anesthesia has vital importance in assessment of patient’s preoperative clinical condition and seeks to define risks and eligibility of anesthesia and surgery, with essential information to decision-making, regarding to anamnesis and physical examination, which aim to complement anesthesia planning, as well as the need for pharmacologic and non-pharmacological preoperative preparation. The responsibility of the anesthesiologist is non-transferable, and from this evaluation, it is possible to define the physical state of the child, anesthetic and surgical risks and the need to request preoperatively complementary examination, treatment or special preparation, favoring the perioperative planning, based on the appropriate use of hospital resources and programming surgical activities according to the clinical characteristics of the patient.

Renal injury after anesthesia: what is in evidence

Perioperative acute kidney injury (AKI) is globally responsible for a large number of deaths each year, although being a well known disease, it does not have a precise diagnosis, which contributes to increase morbidity and mortality, since plasma creatinine (PCr) increases, hours or days after surgery, it is already associated with a considerable loss on glomerular function. Evaluation of urinary output during surgery, although widely used, does not guarantee its diagnosis, but allows to observe the dissociation between glomerular filtration and the elevation of PCr, which will occur later. As methods of early diagnosis, new stricter classifications, as well as laboratory tests using biomarkers such as C-cysteine have been used. Advanced age, emergency surgery, obesity, transoperative hypotension and hypovolemia are conditions associated with a higher risk of renal damage. Impaired renal function may occur both preand intraor post-renal, such as when there is tissue hypoperfusion, ischemia, nephrotoxins use or obstruction to the urinary flow, among other causes. The current review aims to address the issues related to AKI in the perioperative period, based on the latest scientific evidence to be applied in the anesthesiologist’s daily life.

Total intravenous anesthesia in children

Total venous anesthesia (AVT) has shown a great advance in the last two decades in both adults and children, after the development of anesthetics with pharmacokinetic and pharmacodynamic properties that allow its use in continuous infusion. Despite the rapid evolution of AVT and target controlled anesthesia for maintenance of general anesthesia in adults, its practice in the pediatric population was initially limited. The advantages of AVT are rapid recovery time, significant reduction of nausea and vomiting, decreased incidence of postoperative delirium, and reduced environmental pollution. Studies have shown that this technique can be used with relative safety in the pediatric population, however, the devices available for continuous infusion and pharmacokinetic models suitable for the pediatric population are still incipient. The development of hardware and software suitable for all age groups, respecting the pharmacokinetic and pharmacodynamic particularities of each of them, still requires more studies.