Bruno Salomé de Morais

Termo de consentimento informado: a visão dos advogados e tribunais

JUSTIFICATIVA E OBJETIVOS: Nos ultimos anos, houve no Brasil um aumento do numero de acoes judiciais em funcao de erros medicos, devido, sobretudo, a uma conscientizacao cada vez maior da populacao em busca de qualidade no atendimento que lhe e oferecido. De acordo com a Constituicao da Republica de 1988 e o Codigo de Defesa do Consumidor, o medico nao pode submeter o seu paciente a tratamento ou procedimento terapeutico sem antes obter seu consentimento. O objetivo deste artigo foi conferir aos profissionais da medicina uma visao juridica acerca do universo do consentimento informado. CONTEUDO: O texto aborda o historico, conceitos e fundamentos do Termo de Consentimento, requisitos para validade, a saber: capacidade do paciente, voluntariedade, compreensao e prestacao das informacoes relevantes, assim como circunstâncias que dispensam o consentimento. CONCLUSOES: Por meio da assinatura do Termo de Consentimento Informado o paciente declara estar ciente da natureza da intervencao medica e dos correspondentes riscos, assumindo-os livremente. Espera-se com este artigo tornar a classe medica mais consciente dos aspectos legais que giram em torno do tema, para que, a partir dai, sejam evitados os equivocos que costumeiramente transferem a sagrada relacao medico-paciente dos consultorios e hospitais para os foruns e tribunais.

Central pontine myelinolysis after liver transplantation: is sodium the only villain? Case report

JUSTIFICATIVA Y OBJETIVOS: El aparecimiento de sintomas neurologicos en pacientes gravemente enfermos es comun y muchas veces, es un reto propedeutico. Descrita hace cerca de 50 anos, la desmielinizacion de las neuronas de la region pontina, es una alteracion patologica asociada a cuadros neurologicos y psiquiatricos posteriores al transplante hepatico. El objetivo de este relato, fue presentar la mielinolisis pontina central diagnosticada en el postoperatorio de transplante hepatico y discutir su fisiopatologia. RELATO DEL CASO: Paciente del sexo femenino, 29 anos, sometida a transplante hepatico debido a un fracaso hepatico fulminante. En el postoperatorio, presento un cuadro neurologico caracteristico de Sindrome Locked In y lesiones compatibles con la mielinolisis pontina central a la resonancia nuclear magnetica. La paciente no presento oscilaciones exageradas del sodio plasmatico, que es el ion frecuentemente acusado de ser el agente causador, y evoluciono con una mejoria significativa en algunas semanas. CONCLUSIONES: La mielinolisis pontina central tiene una etiologia multifactorial, y una atencion especial debe darsele al grupo de pacientes con mayor riesgo, tales como los sometidos a alteraciones abruptas de la natremia, transplantados de higado, etilistas cronicos y desnutridos. Es importante reconocer, que los sindromes de desmielinizacion osmosticos pueden surgir en pacientes con niveles sericos de sodio bajo, normal o elevado, evidenciando la contribucion de otros factores desencadenantes.BACKGROUND AND OBJECTIVES Critically ill patients frequently develop neurologic symptoms, which frequently become a clinical challenge. Described approximately 50 years ago, pontine neuronal demyelination is a pathologic change associated with neurologic and psychiatric problems after liver transplantation. The objective of this report was to present a case of central pontine myelinolysis diagnosed after liver transplantation and to discuss its pathophysiology. CASE REPORT A 29 years old female patient underwent liver transplantation for fulminant hepatic failure. Postoperatively, she developed neurologic symptoms characteristic of the Locked In Syndrome and the MRI showed changes compatible with central pontine myelinolysis. The patient did not develop dramatic changes in sodium plasma levels, which is frequently incriminated as the causal agent, and improved considerably within a few weeks. CONCLUSIONS The etiology of central pontine myelinolysis is multifactorial, and special attention should be given to the group of patients at greater risk, such as those with sudden changes in the plasma levels of sodium, liver transplantation, chronic alcoholics, and malnourished. It is important to recognize that osmotic demyelination can develop in patients with low, normal, or elevated plasma levels of sodium, indicating the contribution of other trigger factors.

Mielinólise pontina central após transplante hepático: o sódio é o único vilão? Relato de caso

JUSTIFICATIVA Y OBJETIVOS: El aparecimiento de sintomas neurologicos en pacientes gravemente enfermos es comun y muchas veces, es un reto propedeutico. Descrita hace cerca de 50 anos, la desmielinizacion de las neuronas de la region pontina, es una alteracion patologica asociada a cuadros neurologicos y psiquiatricos posteriores al transplante hepatico. El objetivo de este relato, fue presentar la mielinolisis pontina central diagnosticada en el postoperatorio de transplante hepatico y discutir su fisiopatologia. RELATO DEL CASO: Paciente del sexo femenino, 29 anos, sometida a transplante hepatico debido a un fracaso hepatico fulminante. En el postoperatorio, presento un cuadro neurologico caracteristico de Sindrome Locked In y lesiones compatibles con la mielinolisis pontina central a la resonancia nuclear magnetica. La paciente no presento oscilaciones exageradas del sodio plasmatico, que es el ion frecuentemente acusado de ser el agente causador, y evoluciono con una mejoria significativa en algunas semanas. CONCLUSIONES: La mielinolisis pontina central tiene una etiologia multifactorial, y una atencion especial debe darsele al grupo de pacientes con mayor riesgo, tales como los sometidos a alteraciones abruptas de la natremia, transplantados de higado, etilistas cronicos y desnutridos. Es importante reconocer, que los sindromes de desmielinizacion osmosticos pueden surgir en pacientes con niveles sericos de sodio bajo, normal o elevado, evidenciando la contribucion de otros factores desencadenantes.BACKGROUND AND OBJECTIVES Critically ill patients frequently develop neurologic symptoms, which frequently become a clinical challenge. Described approximately 50 years ago, pontine neuronal demyelination is a pathologic change associated with neurologic and psychiatric problems after liver transplantation. The objective of this report was to present a case of central pontine myelinolysis diagnosed after liver transplantation and to discuss its pathophysiology. CASE REPORT A 29 years old female patient underwent liver transplantation for fulminant hepatic failure. Postoperatively, she developed neurologic symptoms characteristic of the Locked In Syndrome and the MRI showed changes compatible with central pontine myelinolysis. The patient did not develop dramatic changes in sodium plasma levels, which is frequently incriminated as the causal agent, and improved considerably within a few weeks. CONCLUSIONS The etiology of central pontine myelinolysis is multifactorial, and special attention should be given to the group of patients at greater risk, such as those with sudden changes in the plasma levels of sodium, liver transplantation, chronic alcoholics, and malnourished. It is important to recognize that osmotic demyelination can develop in patients with low, normal, or elevated plasma levels of sodium, indicating the contribution of other trigger factors.

Estudo comparativo da eficácia analgésica pós-operatória de 20 mL de ropivacaína a 0,5, 0,75 ou 1% no bloqueio de plexo braquial pela via posterior

JUSTIFICATIVA Y OBJETIVOS: Las intervenciones quirurgicas por via artroscopica en el hombro se relacionan con el dolor postoperatorio de gran intensidad. Entre las tecnicas de analgesia, el bloqueo del plexo braquial es la que ofrece los mejores resultados. El objetivo de este estudio fue determinar cual concentracion de anestesico local en el bloqueo de plexo braquial por la via posterior, propicia analgesia postoperatoria mas prolongada para esas operaciones. METODO: Noventa pacientes sometidos al bloqueo del plexo braquial por la via posterior se dividieron aleatoriamente en tres grupos de 30. Grupo 1: 20 mL de ropivacaina a 0,5%; Grupo 2: 20 mL de ropivacaina a 0,75%; Grupo 3: 20 mL de ropivacaina a 1%. El bloqueo se evaluo a traves de la investigacion de sensibilidad termica utilizando algodon con alcohol y el dolor postoperatorio se evaluo segun una escala numerico verbal (ENV) en las primeras 48 horas. RESULTADOS: En los tres grupos la analgesia postoperatoria fue similar segun los parametros evaluados; ENV de dolor medio, tiempo hasta el primer quejido de dolor y consumo de opioides en el postoperatorio. CONCLUSIONES: Este estudio mostro que el bloqueo del plexo braquial por la via posterior es una tecnica que promueve una analgesia eficaz para intervenciones quirurgicas en el hombro. Utilizando 20 mL de ropivacaina, las tres diferentes concentraciones estudiadas promueven analgesia similar.

Bloqueio neuromuscular residual após o uso de rocurônio ou cisatracúrio

JUSTIFICATIVA E OBJETIVOS: O bloqueio neuromuscular residual na sala de recuperacao pos-anestesica (SRPA) e um fenomeno que pode aumentar a morbidade pos-operatoria, com incidencia variando entre 0% e 93%. O objetivo deste estudo foi avaliar a incidencia do bloqueio neuromuscular residual na SRPA. METODO: Foram estudados 93 pacientes submetidos a cirurgia geral com o uso de cisatracurio ou rocuronio. Apos a admissao na SRPA foi realizada a monitorizacao objetiva da funcao neuromuscular (aceleromiografia - TOF GUARD). O bloqueio neuromuscular residual foi definido como SQE < 0,9. RESULTADOS: Do total de 93 pacientes, 53 receberam cisatracurio e 40 rocuronio. As caracteristicas demograficas, duracao do procedimento e o uso de antagonista foram comparaveis em ambos os grupos. O bloqueio neuromuscular residual foi de 32% no subgrupo C (cisatracurio) e 30% no subgrupo R (rocuronio). O bloqueio neuromuscular residual nao foi associado a dose, idade, ou uso de antagonista, porem apresentou relacao com a duracao do procedimento cirurgico. No subgrupo C o tempo medio de cirurgia foi 135 minutos nos pacientes com bloqueio neuromuscular e 161 minutos nos pacientes sem bloqueio, p < 0,029. No subgrupo R o tempo medio de cirurgia foi 122 e 150 minutos, respectivamente, p < 0,039. CONCLUSOES: Os pacientes de ambos os grupos apresentaram incidencia elevada de bloqueio neuromuscular residual na SRPA. A curarizacao residual pos-operatoria continua um problema mesmo com os novos bloqueadores neuromusculares de acao intermediaria. E de suma importância a monitorizacao objetiva de todos os pacientes submetidos a anestesia geral com uso de bloqueador neuromuscular.BACKGROUND AND OBJECTIVES Residual neuromuscular block in the post-anesthetic recovery unit (PACU) may increase postoperative morbidity from 0% to 93%. This study aimed at evaluating the incidence of residual neuromuscular block in the PACU. METHODS Participated in this study 93 patients submitted to general anesthesia with cisatracurium or rocuronium. After PACU admission, neuromuscular function was objectively monitored (acceleromyography - TOF GUARD). Residual neuromuscular block was defined as TOF < 0.9. RESULTS From 93 patients, 53 received cisatracurium and 40 rocuronium. Demographics, procedure length and the use of antagonists were comparable between groups. Residual neuromuscular block was 32% in subgroup C (cisatracurium) and 30% in subgroup R (rocuronium). Residual neuromuscular block was unrelated to dose, age and use of antagonists, but was related to procedure length. In subgroup C, mean procedure length was 135 minutes for patients with neuromuscular block and 161 minutes for patients without (p < 0.029). In subgroup R, mean surgery length was 122 and 150 minutes, respectively (p < 0.039). CONCLUSIONS Both groups had high incidence of residual neuromuscular block in the PACU. Residual postoperative curarization is still a problem even with new intermediary action neuromuscular blockers. It is highly important to objectively monitor all patients submitted to general anesthesia with neuromuscular blockers.

Accidental subarachnoid administration of 4 mg of morphine: case report

JUSTIFICATIVA E OBJETIVOS: A administracao de morfina por via subaracnoidea e tecnica bem estabelecida para analgesia pos-operatoria devido a sua eficacia, seguranca e baixo custo. A administracao inadvertida de 4 mg de morfina por via subaracnoidea complicada por fibrilacao atrial apos administracao de naloxona foi o objetivo desse relato. RELATO DO CASO: Paciente do sexo masculino, 45 anos, 75 kg, 1,72 m, estado fisico ASA II, hipertenso, a ser submetido a reconstrucao do ligamento cruzado anterior do joelho esquerdo. Apos a realizacao da raquianestesia, foi constatada troca da ampola de morfina, com administracao de 4 mg (0,4 mL da ampola de 10 mg) por via subaracnoidea. A frequencia respiratoria oscilou entre 12 e 16 incursoes respiratorias por minuto e o paciente manteve-se estavel hemodinamicamente sem queixas no intra-operatorio. Apos 30 minutos da admissao na SRPA, apresentou vomitos e sudorese, tratados com 0,4 mg de naloxona seguidos de infusao continua de 0,2 mg.h-1 ate o desaparecimento dos sintomas. A infusao continua de naloxona foi mantida na Unidade de Terapia Intensiva (UTI), onde a pressao arterial, frequencia cardiaca, frequencia respiratoria, saturacao de oxigenio foram monitoradas, assim como a presenca de nausea, prurido, vomito, sedacao, dor e retencao urinaria observadas. Apos 2 horas de admissao na UTI, o paciente apresentou fibrilacao atrial aguda sem instabilidade hemodinâmica. O ritmo sinusal foi restabelecido apos 150 mg de amiodarona e interrupcao da infusao de naloxona. Nas 18 horas seguintes apresentou estabilidade hemodinâmica e evoluiu sem outras intercorrencias ate a alta hospitalar. CONCLUSOES: O presente relato alerta para o risco de troca de medicamentos durante o ato anestesico e ressalta a importância do encaminhamento dos pacientes em tratamento de sobredose de opioides a UTI em virtude de seus potenciais efeitos adversos.

Postoperative Analgesic Efficacy of Different Volumes and Masses of Ropivacaine in Posterior Brachial Plexus Block

BACKGROUND AND OBJECTIVES The efficacy of posterior brachial plexus block for shoulder surgeries is demonstrated by different authors. However, there is no consensus on the ideal mass and volume of local anesthetic to be employed. The objetive of this study was to compare different volumes and masses of ropivacaine in posterior brachial plexus block in arthroscopic surgeries of the shoulder. METHOD Sixty patients > 18 years, physical status ASA I and II, scheduled for unilateral arthroscopic surgeries of the shoulder were randomly placed in three groups: A (10 mL to 0.5%), B (20 mL to 0.5%), C (5 mL to 1%). The block was performed with a 22G needle of 100 mm connected to neurostimulator, in a point 3 cm lateral to the midpoint of C6 and C7 interspace, being injected the solution corresponding to each group. The postoperative pain was evaluated at the recovery room and within the first 24 hours of the postoperative period. The groups were compared on length of time until the first complaint of pain, visual numeric scale (VNS) score and morphine consumption within the first 24 hours. RESULTS There was no statistically significant difference between the three groups related to age, weight and height. There was no difference in length of time until the first complaint of pain, VNS scores over three and morphine consumption in the postoperative period between the groups. CONCLUSIONS This study concluded that 5 mL of 1% ropivacaine promoted analgesic efficacy similar to 10 mL or 20 mL of 0.5% ropivacaine in the posterior brachial plexus block using neurostimulator.

Influence of preoperative propranolol on cardiac index during the anhepatic phase of liver transplantation

INTRODUCTION Liver transplantation is the best therapeutic option for end-stage liver disease. Non-selective beta-blocker medications such as propranolol act directly on the cardiovascular system and are often used in the prevention of gastrointestinal bleeding resulting from HP. The effects of propranolol on cardiovascular system of cirrhotic patients during liver transplantation are not known. OBJECTIVE Evaluate the influence of propranolol used preoperatively on cardiac index during the anhepatic phase of liver transplantation. METHOD 101 adult patients (73 male [72.2%]) who underwent cadaveric donor orthotopic liver transplantation by piggyback technique with preservation of the retrohepatic inferior vena cava performed at Hospital das Clinicas, Federal University of Minas Gerais were evaluated. There was no difference in severity between groups by the MELD system, p=0.70. The preoperative use of propranolol and the cardiac index outcome were compared during the anhepatic phase of liver transplantation in 5 groups (I: increased cardiac index, II: cardiac index reduction lower than 16%, III: cardiac index reduction equal to or greater than 16% and less than 31%, IV: cardiac index reduction equal to or greater than 31% and less than 46%, V: cardiac index reduction equal to or greater than 46%). RESULTS Patients in group I (46.4%) who received propranolol preoperatively were statistically similar to groups II (60%), III (72.7%), IV (50%) and V (30.8%), p=0.57. CONCLUSION The use of propranolol before transplantation as prophylaxis for gastrointestinal bleeding may be considered safe, as it was not associated with worsening of cardiac index in anhepatic phase of liver transplantation.

Bilateral blockade of the pudend nerve to hemorrhoidectomy in achondroplasic patient: case report

BACKGROUND AND OBJECTIVES: The achondroplasic dwarfism or achondroplasia is the most common form of dwarfism and occurs, in most of the cases, as a result of spontaneous genetic alteration. The anesthesia in these patients presents several particularities. The objective of the present report was to describe an achondroplasic patient case, with a previous history of surgical procedure of the vertebral column for medullar decompression, submitted to haemorrhoidectomy through the bilateral blockade of the pudend nerves. CASE REPORT: Male patient, 47 years old, achondroplasic, hospitalized to perform hemorrhoidectomy. Upon physical examination, he presented a shortened neck with limited extension of the head, Mallampati class IV, thyromental distance of 6 cm and opening of the mouth of 3.5 cm. The vertebral column presented thoracic kyphosis and severe lumbar lordosis, in addition to a surgical scar in the lumbar region. A bilateral blockade of the pudend nerves was performed with ropivacaine at 1%, via transperineal, with isolated needle measuring 0.8 mm x 100 mm 21G (Stimuplex A100 BBraun, Melsungen, Germany) connected to the peripheral nerve stimulator (Stimuplex-DIG, BBraun).The patient was positioned in ventral decubitus and the surgery started after 15 minutes of anesthetic administration. During the entire procedure, the patient remained conscious and did not report pain or discomfort. Up to the moment his hospital discharge (22 hours after the performance of the blockade), the patient did not mention pain, discomfort, nausea, vomit, motor blockade, urinary retention or incontinence. After his discharge from the hospital, he evolved well presenting evacuation after 31 hours from surgery. CONCLUSIONS: The case illustrated the use of the bilateral blockade of the pudend nerves, with the help of the neurostimulator, as an isolated anesthetic techniques for hemorrhoidectomy.

Residual neuromuscular block after rocuronium or cisatracurium

JUSTIFICATIVA E OBJETIVOS: O bloqueio neuromuscular residual na sala de recuperacao pos-anestesica (SRPA) e um fenomeno que pode aumentar a morbidade pos-operatoria, com incidencia variando entre 0% e 93%. O objetivo deste estudo foi avaliar a incidencia do bloqueio neuromuscular residual na SRPA. METODO: Foram estudados 93 pacientes submetidos a cirurgia geral com o uso de cisatracurio ou rocuronio. Apos a admissao na SRPA foi realizada a monitorizacao objetiva da funcao neuromuscular (aceleromiografia - TOF GUARD). O bloqueio neuromuscular residual foi definido como SQE < 0,9. RESULTADOS: Do total de 93 pacientes, 53 receberam cisatracurio e 40 rocuronio. As caracteristicas demograficas, duracao do procedimento e o uso de antagonista foram comparaveis em ambos os grupos. O bloqueio neuromuscular residual foi de 32% no subgrupo C (cisatracurio) e 30% no subgrupo R (rocuronio). O bloqueio neuromuscular residual nao foi associado a dose, idade, ou uso de antagonista, porem apresentou relacao com a duracao do procedimento cirurgico. No subgrupo C o tempo medio de cirurgia foi 135 minutos nos pacientes com bloqueio neuromuscular e 161 minutos nos pacientes sem bloqueio, p < 0,029. No subgrupo R o tempo medio de cirurgia foi 122 e 150 minutos, respectivamente, p < 0,039. CONCLUSOES: Os pacientes de ambos os grupos apresentaram incidencia elevada de bloqueio neuromuscular residual na SRPA. A curarizacao residual pos-operatoria continua um problema mesmo com os novos bloqueadores neuromusculares de acao intermediaria. E de suma importância a monitorizacao objetiva de todos os pacientes submetidos a anestesia geral com uso de bloqueador neuromuscular.BACKGROUND AND OBJECTIVES Residual neuromuscular block in the post-anesthetic recovery unit (PACU) may increase postoperative morbidity from 0% to 93%. This study aimed at evaluating the incidence of residual neuromuscular block in the PACU. METHODS Participated in this study 93 patients submitted to general anesthesia with cisatracurium or rocuronium. After PACU admission, neuromuscular function was objectively monitored (acceleromyography - TOF GUARD). Residual neuromuscular block was defined as TOF < 0.9. RESULTS From 93 patients, 53 received cisatracurium and 40 rocuronium. Demographics, procedure length and the use of antagonists were comparable between groups. Residual neuromuscular block was 32% in subgroup C (cisatracurium) and 30% in subgroup R (rocuronium). Residual neuromuscular block was unrelated to dose, age and use of antagonists, but was related to procedure length. In subgroup C, mean procedure length was 135 minutes for patients with neuromuscular block and 161 minutes for patients without (p < 0.029). In subgroup R, mean surgery length was 122 and 150 minutes, respectively (p < 0.039). CONCLUSIONS Both groups had high incidence of residual neuromuscular block in the PACU. Residual postoperative curarization is still a problem even with new intermediary action neuromuscular blockers. It is highly important to objectively monitor all patients submitted to general anesthesia with neuromuscular blockers.