Carlos Eduardo David de Almeida

Glass ampoules: risks and benefits

BACKGROUND AND OBJECTIVES Glass ampoules have been widely used in packaging injection drugs. Glass has important characteristics that allow it to be widely used in fabrication of recipients for drugs and other sterile substances. However, contamination of solutions with glass microparticles on breaking open glass ampoules, the presence of metals, percutaneous injury, and biological contamination justify the need of educational materials to orient the manipulation of ampoules. CONTENTS Glass microparticles generated in the snap-opening of ampoules, as well as metals that contaminate their contents can be aspirated and injected through several routes. Exogenous contaminations by glass and metals can reach several sites in the organism. They trigger organic reactions that may give rise to injuries. Opening ampoules can expose professionals to the risk of percutaneous injuries. These lesions increase the biological risk as they are the gateway for viruses and bacteria. Ampoules opening systems (VIBRAC and OPC) have been developed to reduce the incidence of such accidents. Alternative materials to glass may represent an interesting strategy to increase safety. The use of prefilled syringes may represent an evolution regarding safety. CONCLUSIONS Team training and information provided by the pharmaceutical industry on the use of ampoules are fundamental in the prophylaxis of accidents and contaminations. The search for safer materials to replace glass is also important.

Fire in the surgical center.

BACKGROUND AND OBJECTIVES There are several factors in operating rooms that increase the risk of fire. Besides being an oxygen-enriched environment, it contains combustible materials and equipment with available ignition sources. Although fires in operating rooms are a relatively rare event, the consequences are potentially serious and mostly avoidable. We present a case report of a fire occurring in the surgical drape during a blepharoplasty in which oxygen was supplemented by nasal catheter. CASE REPORT Female patient, 52-years old, without comorbidities, admitted to hospital for a bilateral blepharoplasty. After monitoring and venoclysis, the patient underwent intravenous sedation and additional oxygen given via spectacle-type catheter at a flow rate of4 L.min(-1), followed by local anesthesia in the eyelids. During surgery, the use of electric scalpel provoked combustion in the surgical drapes and burns on the patients face. CONCLUSIONS Anesthesiologists play an important role preventing fire in operating rooms, as they can recognize possible ignition sources and rationally administer the oxygen, especially in open systems. The first step toward prevention is to be constantly aware of potential fire.

Thyrotoxic crisis associated with gestational trophoblastic disease

BACKGROUND AND OBJECTIVES Human chorionic gonadotropin (HCG) and thyrotrophic hormone (TSH) have analogies in their structures, as well as in their receptors. The high levels of HCG seen in gestational trophoblastic diseases may induce secondary hyperthyroidism. The objective of this report was to present a case in which the administration of iodinated contrast triggered a thyrotoxic crisis. CASE REPORT Patient with complete hydatidiform mole who was admitted to the operating room with severe vaginal bleeding after a tomographic exam with iodinated contrast. During anesthetic induction, the patient presented symptoms compatible with thyrotoxic crisis. CONCLUSIONS The incidence of severe presentations associated with gestational trophoblastic disease tends to decrease with early diagnosis. Still, the anesthesiologist should be aware of the possibility of those patients developing thyrotoxic crisis.

Incêndio no centro cirúrgico

BACKGROUND AND OBJECTIVES: There are several factors in operating rooms that increase the risk of fire. Besides being an oxygen-enriched environment, it contains combustible materials and equipment with available ignition sources. Although fires in operating rooms are a relatively rare event, the consequences are potentially serious and mostly avoidable. We present a case report of a fire occurring in the surgical drape during a blepharoplasty in which oxygen was supplemented by nasal catheter. CASE REPORT: Female patient, 52-years old, without comorbidities, admitted to hospital for a bilateral blepharoplasty. After monitoring and venoclysis, the patient underwent intravenous sedation and additional oxygen given via spectacle-type catheter at a flow rate of 4 L.min-1, followed by local anesthesia in the eyelids. During surgery, the use of electric scalpel provoked combustion in the surgical drapes and burns on the patients face. CONCLUSIONS: Anesthesiologists play an important role preventing fire in operating rooms, as they can recognize possible ignition sources and rationally administer the oxygen, especially in open systems. The first step toward prevention is to be constantly aware of potential fire.

Malfunction of the extracorporeal circulation system: case report.

BACKGROUND AND OBJECTIVES The introduction of extracorporeal circulation in clinical practice was decisive for the development of modern cardiovascular surgery. Addition of new procedures and equipment, however, brings inherent risks and complications. The objective of this report is to describe a malfunction of the oxygenation system and emphasize the importance of the interaction among the medical team members to prevent errors and complications. CASE REPORT During valve replacement and IVC correction surgery, we observed a darker shade of red in the blood on the exit of the oxygenator. Laboratory tests demonstrated severe acidosis and hypoxemia. The entire system was evaluated, but the cause of the malfunction was not found. Measures to reduce damage were successfully instituted. After the surgery, the whole system underwent technical evaluation. CONCLUSIONS Interaction among the medical team members, early diagnosis, and immediate intervention were fundamental for a favorable outcome.

Uso de bloqueador brônquico em toracotomia de emergência na presença de hemorragia das vias aéreas superiores e fratura cervical: uma decisão difícil

Female, 85 y.o., weighting 60kg, multiple trauma patient. After an initial laparotomy, an emergent thoracotomy was performed using a bronchial blocker for lung isolation (initial active suction was applied). During surgery, bronchial cuff was deflated, causing a self-limited tracheal blood flooding. A second lung isolation was attempted but it was not as effective as initially. Probably, a lung collapse with the same bronchial blocker was impaired in the second attempt because of the obstruction of bronchial blocker lumen by intraoperative endobronchial hemorrhage. Bronchial blocker active suction may contribute to obtain or accelerate lung collapse, particularly in patients that do not tolerate ventilator disconnection technique or lung surgical compression. The use of bronchial blockers technology was a valuable alternative to double lumen tubes in this case of emergent thoracotomy in the context of a patient having thoracic, abdominal trauma, severe laceration of tongue and apophysis odontoid fracture associated to massive hemorrhage, despite several pitfalls that could compromise its use. The authors intend to discuss the advantages and disadvantages of bronchial blockers comparing to double-lumen tubes for lung isolation, and the risks of our approach, in this complex multitrauma case.

Hipotensão associada ao bloqueio bilateral do quadrado lombar realizado para analgesia pós‐operatória em caso de cirurgia aórtica aberta

BACKGROUND AND OBJECTIVES Bilateral quadratus lumborum block has been described for major abdominal procedures when sepsis is present, because risks associated to epidural are considered elevated. In an open aortic surgery, a single-shot bilateral quadratus lumborum block type 1 may be an alternative to thoracic epidural block for post-operative analgesia in a patient having an increased cumulative risk for thoracic epidural hematoma. CASE REPORT A 56-year-old female patient presenting controlled hypertension, chronic renal disease stage 3b, dyslipidemia and a platelet count of 102,000/μl, and taking aspirin, was scheduled for bilateral aortoiliac endarterectomy. She was submitted to a sole general anesthesia plus, at end of the surgery, a bilateral quadratus lumborum block type 1 for post-operative analgesia with 20mL of ropivacaine 0.5%, per side, before extubation. Immediately after post anesthesia care unit admission, patient developed moderate hypotension (dopamine infusion was needed during 18h), concomitantly with a rapid reduction in the pain scores. Low numeric rating scale and opioid consumption were noted, particularly in the first 24h post-operatively. CONCLUSIONS Quadratus lumborum block was an effective analgesic technique for open aortic surgery in this case, although hypotension associated to bilateral quadratus lumborum block type 1 may occur. Associated sympathetic block probably related to the bilateral paravertebral extension of the block, may contribute for post-operative hypotension associated to reperfusion-ischemia syndrome in a patient that had long-lasting intraoperative aortic cross-clamping. The use of high concentration of local anesthetic to obtain longer duration of action of a single-shot quadratus lumborum block to avoid thoracic epidural or bilateral quadratus lumborum block catheterization should be used judiciously.

Ampolas de vidro: riscos e benefícios

JUSTIFICATIVAS E OBJETIVOS: Ampolas de vidro tem sido amplamente utilizadas no acondicionamento de farmacos. O vidro apresenta importantes caracteristicas que lhe conferem o uso amplo na fabricacao de recipientes para o acondicionamento de farmacos e outras substâncias estereis. No entanto, a contaminacao das solucoes com microparticulas de vidro durante a abertura, a presenca de metais, acidentes perfuro-cortantes e contaminacoes biologicas justificam a necessidade de materiais educativos que orientem a manipulacao dessas ampolas. CONTEUDO: As microparticulas de vidro geradas na abertura das ampolas podem ser aspiradas e injetadas nas mais diversas vias, assim como os metais que contaminaram o conteudo das ampolas. As contaminacoes exogenas por vidros e metais podem alcancar diversos sitios no organismo. Desencadeiam-se reacoes orgânicas que podem dar origem a lesoes. Abrir ampolas pode expor o profissional ao risco de lesoes perfuro-cortantes. Essas lesoes aumentam o risco biologico em razao de serem a porta de entrada para virus e bacterias. Sistemas de abertura de ampolas (VIBRAC E OPC) foram desenvolvidos para reduzir a incidencia de tais acidentes. Materiais alternativos ao vidro podem representar uma estrategia interessante para aumentar a seguranca. O uso de seringas esterilizadas pre-preparadas pelo fabricante pode consistir em uma evolucao em relacao a seguranca. CONCLUSAO: O treinamento da equipe e o esclarecimento por parte da industria farmaceutica quanto ao uso de ampolas mostram-se fundamentais na profilaxia de acidentes e contaminacoes. Ainda e necessario descobrir novos sistemas de abertura de ampolas de forma mais segura. Nao menos importante sera a busca de materiais seguros que sirvam de alternativa ao uso do vidro.

Mau Funcionamento do Sistema de Circulação Extracorpórea: Relato de Caso

JUSTIFICATIVA E OBJETIVOS: A introducao da circulacao extracorporea (CEC) na pratica clinica foi decisiva para o desenvolvimento da cirurgia cardiovascular moderna. A adicao de novos procedimentos e equipamentos, entretanto, traz riscos e complicacoes inerentes. O objetivo deste relato e descrever um caso de mau funcionamento do sistema de oxigenacao e enfatizar a importância da interacao entre a equipe medica para prevenir erros e reduzir complicacoes. RELATO DO CASO: Durante a realizacao de cirurgia para troca valvar e correcao de CIV, observou-se coloracao escura do sangue na saida do oxigenador. Exames laboratoriais demonstraram acidose e hipoxemia grave. Todo o sistema foi reavaliado, mas a causa do mau funcionamento nao foi encontrada. Medidas para a reducao do dano foram instituidas com sucesso. Apos a cirurgia, todo o sistema de CEC foi submetido a avaliacao tecnica. CONCLUSOES: A interacao entre a equipe, o diagnostico precoce e a intervencao imediata mostraram-se fundamentais para o desfecho favoravel.

Crise tireotóxica associada à doença trofoblástica gestacional

JUSTIFICATIVA E OBJETIVOS: A gonadotrofina corionica humana (HCG) e o hormonio tireotrofico (TSH) apresentam analogia entre suas estruturas, assim como seus receptores. Os altos niveis de HCG encontrados nas doencas trofoblasticas gestacionais podem induzir um quadro de hipertireoidismo secundario. O objetivo deste relato e apresentar um caso em que a administracao de contraste iodado precipitou um quadro de crise tireotoxica. RELATO DO CASO: Paciente com mola hidatiforme completa foi admitida no centro cirurgico com sangramento vaginal intenso apos realizacao de tomografia com contraste iodado. Durante inducao anestesica, paciente apresentou quadro compativel com crise tireotoxica. CONCLUSOES: A incidencia de quadros graves associados a doenca trofoblastica gestacional tende a diminuir com seu diagnostico precoce. Ainda que isso aconteca, o anestesiologista deve estar atento a possibilidade de crise tireotoxica nesses pacientes.