Claudia Marquez Simões

Effects of preanesthetic administration of midazolam, clonidine, or dexmedetomidine on postoperative pain and anxiety in children

Background:  A growing interest in the possible influences of pre‐ and postoperative anxiety and pain scores as outcomes of surgical treatment and benefits of anxiety or pain‐reducing interventions has emerged. The aim of this study was to evaluate the influence of three different premedication regimens on postoperative pain and anxiety in children.

Use of Sugammadex after Neostigmine Incomplete Reversal of Rocuronium-Induced Neuromuscular Blockade

BACKGROUND AND OBJECTIVES Neuromuscular blockers (NMB) have been used for more than half of a century in anesthesia and have always been a challenge for anesthesiologists. Until recently, the reversal of nondepolarizing neuromuscular blockers had only one option: the use of anticholinesterase agents. However, in some situations, such as deep neuromuscular blockade after high doses of relaxant, the use of anticholinesterase agents does not allow adequate reversal of neuromuscular blockade. Recently, sugammadex, a gamma-cyclodextrin, proved to be highly effective for reversal of NMB induced by steroidal agents. CASE REPORT A female patient who underwent an emergency exploratory laparotomy after rapid sequence intubation with rocuronium 1.2mg.kg(-1). At the end of surgery, the patient received neostigmine reversal of NMB. However, neuromuscular junction monitoring did not show the expected recovery, presenting residual paralysis. Sugammadex 2mg.kg(-1) was used and the patient had complete reversal of NMB in just 2 minutes time. CONCLUSION Adequate recovery of residual neuromuscular blockade is required for full control of the pharynx and respiratory functions in order to prevent complications. Adequate recovery can only be obtained by neuromuscular junction monitoring with TOF ratio greater than 0.9. Often, the reversal of NMB with anticholinesterase drugs may not be completely reversed. However, in the absence of objective monitoring this diagnosis is not possible. The case illustrates the diagnosis of residual NMB even after reversal with anticholinesterase agents, resolved with the administration of sugammadex, a safe alternative to reverse the NMB induced by steroidal non-depolarizing agents.

Recomendações da Sociedade Brasileira de Anestesiologia para segurança em anestesia regional

Foram realizadas buscas em múltiplas bases de dados (Medline de 1965 a 2011, Cochrane Library, e LILACS) e em referências cruzadas com o material levantado para identificação de artigos com melhor desenho metodológico. Após estas buscas, seguiu-se avaliação crítica de seu conteúdo e classificação de acordo com a força da evidência. As buscas foram realizadas entre dezembro de 2010 e abril de 2011. Para buscas no PubMed, foram utilizadas as seguintes estratégias de pesquisa:

Brazilian Society of Anesthesiology Recommendations for safety in regional anesthesia

1. MD, PhD, Anesthesiologist; Professor at the Medical School of Universidade de Fortaleza (UNIFOR); Responsible for the Centro de Ensino e Treinamento (CET/MEC/SBA) at Hospital Universitario Walter Cantidio, Universidade Federal do Ceara (UFC); President of the Perioperatative Medicine Committee of SBA 2. MD, PhD, Anesthesiologist; Professor at the Anesthesiology Department of Faculdade de Medicina da Universidade Federal de Uberlândia (FMUFU); Responsible for the CET/SBA at FMUFU 3. MD, Anesthesiologist at Instituto Nacional do Câncer (INCA); Co-responsible for the CET/SBA at Hospital Universitario Pedro Ernesto (HUPE), Universidade do Estado do Rio de Janeiro (UERJ); Instructor at the Curso Suporte Avancado de Vida em Anestesia – SAVA/SBA 4. MD, Anesthesiologist; Coordinator of the Anesthesiology Service at Instituto do Câncer de Sao Paulo (ICESP); Member of the SBA Malignant Hyperthermia Committee 5. MD, Anesthesiologist at Hospital Universitario Oswaldo Cruz, Universidade Estadual de Pernambuco (UPE); Co-responsible for the CET/SBA of Hospital da Restauracao, Hospital Getulio Vargas and Hospital Oswaldo Cruz, UPE; President of the Brazilian Society of Anesthesiology, 2011

Estamos preparados para diagnosticar e conduzir um episódio de hipertermia maligna

JUSTIFICATIVA E OBJETIVOS: A Hipertermia Maligna e doenca rara e potencialmente fatal associada a exposicao a agentes halogenados e succinilcolina. A mortalidade e morbidade resultante pode ser reduzida pelo diagnostico precoce e tratamento especifico, o que inclui o dantrolene sodico. A populacao brasileira e de aproximadamente 160 milhoes de habitantes assistidos por mais de 6000 anestesiologistas. Na ultima decada, sobretudo, consideravel atencao foi dada a esta doenca, disto resultando especialistas melhor informados e mais hospitais aparelhados para trata-la. Este estudo visa avaliar o nivel atual de informacao acerca da Hipertermia Maligna entre os anestesiologistas brasileiros, de sorte a orientar novas iniciativas voltadas para o controle desta afeccao. METODO: Vinte questoes sobre diagnostico, prevencao e tratamento da Hipertermia Maligna foram enviadas aos 6164 membros da Sociedade Brasileira de Anestesiologia (SBA). RESULTADOS: Seiscentos e quarenta e seis anestesiologistas (10,4%) responderam as questoes. Foram obtidas mais de 90% das respostas corretas sobre diagnostico e tratamento. Por outro lado, aproximadamente 50% das respostas sobre indicacao da biopsia muscular e farmacologia do dantrolene estavam erradas. CONCLUSOES: Os resultados acima refletem nivel satisfatorio de informacao sobre este assunto, indicando alguns relevantes aspectos da doenca que merecem atencao adicional. O numero de respostas e significativo para avaliacao do grau de conhecimento sobre este assunto, mas denota insuficiente motivacao. Destes achados conclui-se ser necessario ampliar os esforcos de educacao continuada, contemplando todo os diferentes topicos deste importante tema da Anestesiologia.BACKGROUND AND OBJECTIVES Malignant Hyperthermia (MH) is an uncommon but potentially lethal disease associated to halogenate agents and/or succinylcholine exposure. Resulting mortality and morbidity may be decreased by early diagnosis and specific treatment, including sodium dantrolene. Brazil has approximately 160 million inhabitants assisted by more than 6000 anesthesiologists. In the last decade, special attention was given to this disease, resulting in better informed anesthesiologists and more prepared hospitals to treat malignant hyperthermia (MH). This study aimed at measuring the level of information of Brazilian anesthesiologists regarding MH, in order to develop new approaches to control this disease. METHODS A questionnaire with 20 questions on malignant hyperthermia diagnosis, prevention and treatment was mailed to the 6,164 members of the Brazilian Society of Anesthesiology. RESULTS Questionnaires were returned by 646 anesthesiologists (10.4%). More than 90% of correct answers about clinical diagnosis and treatment were obtained. On the other hand, nearly 50% of anesthesiologists gave incorrect answers about muscle biopsy indication and clinical pharmacology of dantrolene. CONCLUSIONS Results have indicated adequate knowledge about this topic, but has shown that some relevant issues need additional attention. The number of answers was significant to evaluate MH understanding of Brazilian anesthesiologists, but has also shown poor motivation. From these results it is possible to conclude that it is essential to intensify continuing education programs, contemplating all issues of this major anesthetic subject.

Transesophageal Echocardiography in Anesthesiology: Characterization of Use Profile in a Tertiary Hospital

BACKGROUND AND OBJECTIVE Since its introduction in the 80s, transesophageal echocardiography (TEE) not only gained popularity but also experienced great advances in technology and currently it is an extremely valuable tool in the intraoperative period. In Brazil, there are no published data on the profile of its use in the intraoperative period by anesthesiologists. The objective of this study was to describe the use of intraoperative TEE in an Anesthesiology Service in a tertiary private hospital. PATIENTS AND METHODS Retrospective study from completed medical charts in all cases where the patient was monitored with TEE. Monitoring was applied in patients classified as I-II according to the American Society of Echocardiography and presenting no contraindication to the examination. At the end of procedure, after examination, a note on the chart classified monitoring according to its usefulness in the intraoperative period into three groups: group 1, no interference of TEE in anesthetic or surgical approach; group 2, TEE prompted change in anesthetic approach regarding the administration of volume, introduction and/or modification of vasoactive drugs (here, TEE generated change of anesthetic approach in conjunction with other monitors, but it was the deciding factor); group 3, TEE led to a change in approach or review of surgical procedure performed. RESULTS From January 2009 to January 2011, 164 intraoperative TEE were performed in our service, with 41 pediatric and 123 adult patients. In all patients, the test was successful and there were no problems regarding the introduction of transesophageal tube. In pediatric sample, group I had 10 patients (24.4%), group II had 27 patients (65.8%), and group III had 4 patients (9.8%). Among adults, group I had 38 patients (30.9%), group II had 81 patients (65.9%), and group III had 4 patients (3.2%). CONCLUSION Despite this small sample size compared to the literature, and the limitations of this study, there was agreement with other reports related to changes in anesthetic-surgical approach based on intraoperative TEE. Our data also strongly suggest that transesophageal echocardiography is an extremely useful tool for monitoring patients at high cardiovascular risk, even when undergoing noncardiac surgery. Larger studies conducted in our country are needed, as there are no other studies in literature defining the use profile of TEE or even clearly setting out how it has been used in our field.

Evaluation of transoperatory ventilation modalities by a questionnaire

BACKGROUND AND OBJECTIVES Anesthesia devices have been making it possible to reduce the physiological repercussions and problems caused by mechanical ventilation. The objective of this study was to evaluate, retrospectively, ventilatory methods and support resources used by a group of anesthesiologists in patients without prior lung damage in the intraoperative period. METHODS A non-identifiable questionnaire composed of 27 questions was applied to a group of anesthesiologists and anesthesiology residents who work at different private hospitals in the city of São Paulo. The questionnaires were applied over a 15-day period. Ventilation patterns, positive end-expiratory pressure (PEEP), alveolar recruitment maneuvers, and the calculation of the tidal volume used with tracheal intubation were observed. RESULTS Participants were predominantly males, 40.5% bearing the Anesthesiology Superior Title (TSA), and the majority concluded their residency less than 10 years ago. Most anesthesiologists used PEEP, between 5 and 10 cmH(2)O, routinely. Fresh gas flow above 1,000 mL.min(-1) is still used by most anesthesiologists. Alveolar recruitment maneuvers were performed by 80% of those interviewed, shortly after intubation and before removing the ET tube with the most common strategy insufflation with 40 cmH(2)O for 15 seconds. As for strategies to protect ventilation, only 30% used a tidal volume with less than 7 mL.kg(-1) with inspired oxygen fraction between 40% and 60%. CONCLUSIONS This descriptive study allows us to state that in the hospitals evaluated the majority of anesthesiologists uses resources to minimize eventual repercussions of controlled mechanical ventilation. This data can orient the development of continuing medical education programs in mechanical ventilation associated with anesthesia aiming to safety and improvement of patient care.

Transesophageal echocardiography and intraoperative diagnosis of persistent left superior vena cava

BACKGROUND AND OBJECTIVES Isolated persistent left superior vena cava has an incidence of 0.5% in the normal population, but in patients with congenital cardiopathy its incidence ranges from 3% to 10%. The objective of this report was to present a case of intraoperative diagnosis with transesophageal echocardiography and to emphasize the importance of its routine use in surgical procedures for correction of congenital cardiopathies. CASE REPORT This is a 16-year old male patient, ASA II, with a diagnosis of superior sinus venosus interatrial communication (IAC) with partial anomalous drainage of the pulmonary veins scheduled for the surgical correction of the cardiopathy. After induction of general anesthesia, transesophageal echocardiography (TEE) showed initially a dilation of the right cardiac chambers, a 17-mm superior sinus venosus IAC, anomalous drainage of the right superior pulmonary vein draining into the right superior vena cava (SVC), and dilation of the coronary sinus raising the possibility of persistent left superior vena cava. To confirm this suspicion, 10 mL of NS (works as a contrast in echocardiography) were injected in the venous access of the left arm, and microbubbles crossing the coronary sinus were observed immediately afterwards confirming the diagnosis of persistent left superior vena cava. CONCLUSIONS Routine intraoperative transesophageal echocardiography in patients with congenital cardiopathy is a fundamental auxiliary method, not only for the surgeon, often having direct influence on the surgical technique used, but also for the anesthesiologist, who can get useful information for the hemodynamic management of the patient.

Brazilian Consensus on perioperative hemodynamic therapy goal guided in patients undergoing noncardiac surgery: fluid management strategy - produced by the São Paulo State Society of Anesthesiology (Sociedade de Anestesiologia do Estado de São Paulo - SAESP)

Enis Donizetti Silvaa,b,c, Albert Carl Perrinod, Alexandre Teruyae,f,g, Bobbie Jean Sweitzerh, Chiara Scaglioni Tessmer Gatto i, Claudia Marquez Simõesa,b,j, Ederlon Alves Carvalho Rezendek, Filomena Regina Barbosa Gomes Galas j, Francisco Ricardo Lobol,m, João Manoel da Silva Juniork, Leandro Ultino Taniguchin,o, Luciano Cesar Pontes de Azevedoa,o,p, Ludhmila Abrahão Hajjara,i,j, Luiz Antônio Mondadoriq, Marcelo Gama de Abreur, Marcelo Vaz Perezs,t, Regina El Dibu, Paulo do Nascimento Junioru, Roseny dos Reis Rodrigues f,p, Suzana Margareth Lobol,m,v, Rogean Rodrigues Nunesc,w,x, Murillo Santucci Cesar de Assunçãof,∗

Consenso Brasileiro sobre terapia hemodinâmica perioperatória guiada por objetivos em pacientes submetidos a cirurgias não cardíacas: estratégia de gerenciamento de fluidos – produzido pela Sociedade de Anestesiologia do Estado de São Paulo (SAESP)

Enis Donizetti Silva , Albert Carl Perrino, Alexandre Teruya, Bobbie Jean Sweitzer, Chiara Scaglioni Tessmer Gatto , Claudia Marquez Simões , Ederlon Alves Carvalho Rezende , Filomena Regina Barbosa Gomes Galas , Francisco Ricardo Lobo , João Manoel da Silva Junior , Leandro Ultino Taniguchi, Luciano Cesar Pontes de Azevedo , Ludhmila Abrahão Hajjar , Luiz Antônio Mondadori, Marcelo Gama de Abreu , Marcelo Vaz Perez , Regina El Dib, Paulo do Nascimento Junior, Roseny dos Reis Rodrigues , Suzana Margareth Lobo , Rogean Rodrigues Nunes c,w,x e Murillo Santucci Cesar de Assunção f,∗