Edísio Pereira

Marcapasso cardíaco artificial: considerações pré e per-operatórias

BACKGROUND AND OBJECTIVES Technological medical diagnosis advances in cardiology have markedly increased indications for temporary or permanent artificial cardiac pacemakers (PM). This means that, in addition to cardiologists, other specialists have become involved in the handling of these devices. When PM patients undergo surgery, anesthesiologists participation may be decisive for the success of the procedure. This review aimed at familiarizing anesthesiologists with major clinical indications and operation of these devices, as well as with PM-related pre and intraoperative cares. CONTENTS Classification, operation, and major clinical indications for PM implants are covered. In addition, primary PM-related pre and intraoperative cares required for success are explained. CONCLUSIONS Basic understanding of PM operation and indications should be part of anesthesiologists daily practice. Hence, handling and indication of temporary PM broadens these specialists scope, in addition to saving lives in emergency situations. Electric cautery should be avoided in artificial cardiac pacemaker patients.JUSTIFICATIVA Y OBJETIVOS: El progreso tecnologico de la propedeutica medica diagnostica en cardiologia difundio grandemente la indicacion de marcapaso (MP) cardiaco artificial, definitivo o temporario. Esto hizo con que otros especialistas, ademas de los cardiologistas, se envolvieran todavia mas en el manoseo de eses aparatos. Cuando pacientes portadores de MP se presentan para cirugia, la participacion del anestesista puede ser decisiva para el suceso del procedimiento. El objetivo de la actual revision es familiarizar al anestesista con las principales indicaciones clinicas y con el funcionamiento de eses dispositivos, ademas de los cuidados pre y per-operatorios que se debe tener. CONTENIDO: Fueron tratadas la clasificacion, funcionamiento y las principales indicaciones clinicas para la implantacion de MP. De la misma forma, se pretendio elucidar los principales cuidados pre y per-operatorios relativos al uso de MP para lograr exito en el procedimiento indicado. CONCLUSIONES: Los principales conocimientos sobre el funcionamiento del MP y sus indicaciones clinicas deben hacer parte de la practica diaria del anestesista. De esa forma, el manoseo y la indicacion del MP temporario amplia la actuacion de eses especialistas, ademas de que puede salvar vidas, inclusive en situaciones de emergencia dentro del centro quirurgico. El uso de eletrocauterio deberia ser evitado en portadores de MP.

Does alkalinization of 0.75% ropivacaine promote a lumbar peridural block of higher quality?

Background and Objectives We did not find clinical studies of the alkalization of ropivacaine in the literature. The objectives of this study were: (1) to determine the quantity of sodium bicarbonate (NaHCO3), which alkalinizes 0.75% ropivacaine (with and without adrenaline); (2) to verify the physico-chemical alterations arising from this alkalization; and (3) to determine whether alkalinized ropivacaine produces a higher-quality epidural block measured via sensory-motor onset, block spread and anesthesia duration. Methods It was determined in the laboratory that 0.012 and 0.015 mEq of NaHCO3, respectively, alkalinized 10 mL of the 0.75% ropivacaine solutions without and with adrenaline (1:200,000). In the second phase, the study was random and double-blind and involved 60 patients divided into 3 groups of 20 (G1, G2, and G3). Via epidural lumbar blocks, these groups received, respectively, 10 mL of 0.75% ropivacaine plus 0.5 mL of 0.9% NaCl (solution A), 10 mL of 0.75% ropivacaine plus 0.0012 mEq of NaHCO3 (solution B), and 10 mL of 0.75% ropivacaine (with adrenaline) plus 0.015 mEq of NaHCO3 (solution C). The pH, PCO2 (partial CO2 pressure), and the nonionized fractions of the 0.75% ropivacaine solutions were compared before and after the addition of 0.9% NaCl or NaHCO3 or adrenaline plus NaHCO3. The motor and sensory onsets, block spread, and the duration of the block were evaluated. Results The values of the pH, PCO2, and nonionized fractions increased significantly in solutions B and C in relation to solution A. No differences among the groups were observed in relation to block spread and sensory-motor onset. The duration of the sensory blocks was significantly greater in the patients in groups G2 and G3. Conclusions This study indicates that the quantity of NaHCO3 needed to alkalize 10 mL of 0.75% ropivacaine at room temperature is 0.012 mEq. When the solution contains adrenaline 1:200,000 (mg · mL−1), up to 0.015 mEq of NaHCO3 may be added. The alkalization of the 0.75% ropivacaine solution did not cause a reduction of sensory-motor onset, but did provide a significant increase in the duration of the epidural block with no significant differences between the solutions with and without adrenaline.

Aspectos históricos da pressão arterial de oxigênio e espirometria relacionados à operação abdominal

INTRODUCTION: Operations, particularly those of the upper abdomen, can be accompanied by hypoxemia and restrictive ventilatory disturbances. The objectives of the present review were: a) to provide a retrospective of spirometric techniques and laboratory assessment of hypoxemia by means of arterial oxygen pressure; b) to review the main factors responsible for alterations in postoperative pulmonary function. METHODS: A historical overview is given of the main aspects of spirometry and PaO2, measurement, considering these exams as measures of pulmonary function after abdominal operations. CONCLUSION: Operations on the upper part of the abdomen may be followed by hypoxemia and restrictive ventilatory disturbances, whose principal cause is diaphragmatic dysfunction which can be minimized by means of laparoscopy and effective post-operative pain treatment.

Avaliação pré-operatória do pneumopata

BACKGROUND AND OBJECTIVES Lung complications are the most frequent causes of postoperative morbidity-mortality, especially in lung disease patients. So, those patients should be preoperatively carefully evaluated and prepared, both clinically and laboratorially. This review aimed at determining surgical risk and at establishing preoperative procedures to minimize peri and postoperative morbidity-mortality in lung disease patients. CONTENTS Major anesthetic-surgical repercussions in lung function have already been described. Similarly, we tried to select higher-risk patients, submitted or not to lung resection. To that end, clinical and laboratorial propedeutics were used. Finally, a proposal of a preoperative algorithm was presented for procedures with lung resection. CONCLUSIONS Lung disease patients, especially those with chronic evolution, need to be preoperatively thoroughly evaluated. ASA physical status and Goldmans cardiac index are important risk forecasting factors for lung disease patients not candidates for lung resection. Adding to these criteria, estimated postoperative max VO2, FEV1 and diffusion capacity are mandatory for some patients submitted to lung resection. beta2-agonists and steroids should be considered in the preoperative period of these patients.JUSTIFICATIVA E OBJETIVOS: As complicacoes pulmonares sao as causas mais frequentes de morbimortalidade pos-operatoria, especialmente nos pneumopatas. Por essa razao, esses pacientes devem ser criteriosamente avaliados e preparados no pre-operatorio, tanto do ponto de vista clinico como laboratorial. O objetivo da presente revisao e determinar o risco cirurgico e estabelecer condutas pre-operatorias para minimizar a morbimortalidade per e pos-operatorias, nos portadores de doencas respiratorias. CONTEUDO: As principais repercussoes do ato anestesico-cirurgico na funcao pulmonar foram relatadas. Da mesma forma, procurou-se selecionar os pacientes de maior risco, envolvidos ou nao em resseccao pulmonar. Para esse fim, utilizou-se da propedeutica clinica e laboratorial. Finalmente, foi apresentada uma proposta de algoritmo pre-operatorio para os procedimentos com resseccao pulmonar. CONCLUSOES: O portador de doenca respiratoria, especialmente as de evolucao cronica, necessita ser rigorosamente avaliado no pre-operatorio. A classificacao do estado fisico (ASA) e o indice de Goldman sao fatores de previsao de risco importantes nos pneumopatas nao-candidatos a resseccao pulmonar. Somando-se a esses criterios, nos candidatos a resseccao pulmonar, o VO2 max, o VEF1e capacidade de difusao estimados para o pos-operatorio, sao imprescindiveis, em algumas situacoes. Os b2-agonistas e corticoides devem ser considerados nos pre-operatorios desses pacientes.

Repercussão respiratória funcional após colecistectomia com incisão subcostal: efeito analgésico da morfina

OBJETIVO: Avaliar a funcao pulmonar pos-colecistectomias subcostais abertas de pacientes sob acao da morfina no pos-operatorio imediato. METODOS: Tratou-se de um estudo prospectivo, onde se avaliaram espirometrias pos-operatorias de 15 pacientes submetidas a colecistectomias abertas subcostais, que receberam dose unica de morfina peridural na anestesia. Os dados pos-operatorios foram comparados aos pre-operatorios pelo teste t-Student emparelhado. Um valor de p < 0,05 foi considerado estatisticamente significativo. RESULTADOS: Existiram diferencas significativas para as variaveis Capacidade Vital Forcada (p = 0,007) e Volume Expiratorio Forcado no 1o segundo (p = 0,008) no pre e pos-operatorio imediato, indicando disturbios ventilatorios restritivos. Todas as pacientes apresentaram espirometrias normais no 3o dia de pos-operatorio. CONCLUSAO: Mesmo sob acao analgesia da morfina peridural, no pos-operatoria imediato, foram observados disturbios ventilatorios restritivos leves pos-colecistectomias subcostais abertas. Contudo, observou-se uma rapida recuperacao da funcao pulmonar, o que pode diminuir a morbidade pulmonar pos-operatoria.OBJECTIVE To evaluate pulmonary function after open subcostal cholecystecomy under action of the morphine in the immediate post-operative. METHODS This was a prospective study, in which the post-operative spirometries of fifteen patients who underwent open subcostal cholecystectomies which received peridural morphine anesthesia. Post- and pre-operative data were compared using a paired student-t test. A value of p < 0,05 was considered statistically significant. RESULTS Significant differences existed for the Forced Vital Capacity variable (p = 0,007) and Forced Expiratory Volume in the first second (p = 0,008) between pre- and immediate post-operative, indicating restrictive ventilatory disturbances. All of the patients presented normal espirometries in the third day of post-operative. CONCLUSION Even under action morphine peridural analgesia, in the immediate post-operative, light restrictive post-cholecystectomy ventilatory disturbances were observed. However, it was observed abbreviated recovery of pulmonary function, which may lower post-operative pulmonary morbidity.

Função pulmonar pós-colecistectomia laparoscópica e abreviado tempo anestésico-cirúrgico

OBJECTIVE: To evaluate pulmonary function after laparoscopic cholecystectomies. MEHTODS: Prospective study, in which the post-operative spirometries of 15 patients who underwent laparoscopic cholecystectomies with abbreviated anesthetic-surgical time were analyzed. RESULTS: Significant differences existed for the Forced Vital Capacity variable (p=0,020) and Forced Expiratory Volume in the first second (p=0,022) between pre- and immediate post-operative, indicating restrictive ventilatory disturbances. CONLCUSION: Light restrictive laparoscopic post-cholecystectomy ventilatory disturbances were observed, with rapid recovery of pulmonary function, which may lower post-operative pulmonary morbidity.

Manoseo peri-operatorio del paciente en uso de amiodarona

BACKGROUND AND OBJECTIVES Amiodarone is quite an effective anti-arrhythmic drug indicated for controlling ventricular and supra-ventricular arrhythmias, and it is being widely administered in clinical practice. However, its chronic use may be associated to severe side effects which may be worsened by anesthetic-surgical acts, thus increasing the risk of such procedures. This study aimed at reviewing major amiodarone effects and relating them to anesthetic procedures. CONTENTS The study covers major amiodarone properties, its clinical use, as well as major adverse effects, which may increase patients surgical risk. CONCLUSIONS Amiodarone, although normally safe and effective, may present adverse effects, especially on cardiovascular system, during anesthetic-surgical procedures. This is possibly due to interactions between this drug and anesthetic agents mainly related to general anesthesia. There are reports on severe, treatment - resistant bradycardias as well as on different degrees of atrioventricular block (AVB). Patients should be carefully monitored, especially during major procedures, and vasoactive drugs (isoproterenol) and temporary artificial pacemaker, should be available because they may be critical during the adverse effects treatment.JUSTIFICATIVA Y OBJETIVOS: La amiodarona es un antidisritmico bastante eficaz y indicado en el tratamiento de disritmias ventriculares y supraventriculares, motivo por el cual viene siendo extensamente administrada en la practica clinica. Entretanto, su uso cronico puede estar asociado con serios efectos colaterales, que pueden ser agravados por actos anestesico-cirugicos, aumentando el riesgo de los procedimientos. El presente estudio objetiva revisar los principales efectos de la amiodarona y asociarlos a la practica clinica del anestesista. CONTENIDO: Se trato de las principales propiedades de la amiodarona, su uso clinico, bien como los mas importantes efectos adversos que pueden aumentar el riesgo quirurgico de los pacientes en uso de este antidisritmico. CONCLUSIONES: La amiodarona, a pesar de habitualmente segura y eficiente, puede presentar efectos adversos exacerbados, especialmente para el aparato cardiovascular, durante procedimientos anestesico-cirugicos. Esto se debe posiblemente a las interacciones entre ese farmaco y agentes anestesicos, asociados principalmente a la anestesia general. Hay relatos de bradicardias graves y resistentes a la terapeutica, bien como bloqueo atrioventricular (BAV) en grados variados. El paciente debe ser rigurosamente monitorizado, especialmente en los procedimientos de grande porte, y el anestesista debe estar amparado en el peri-operatorio con drogas vasoactivas (isoproterenol) y marcapaso cardiaco artificial temporario, que pueden ser fundamentales durante el procedimiento.

Peri-operative management of amiodarone patients

BACKGROUND AND OBJECTIVES Amiodarone is quite an effective anti-arrhythmic drug indicated for controlling ventricular and supra-ventricular arrhythmias, and it is being widely administered in clinical practice. However, its chronic use may be associated to severe side effects which may be worsened by anesthetic-surgical acts, thus increasing the risk of such procedures. This study aimed at reviewing major amiodarone effects and relating them to anesthetic procedures. CONTENTS The study covers major amiodarone properties, its clinical use, as well as major adverse effects, which may increase patients surgical risk. CONCLUSIONS Amiodarone, although normally safe and effective, may present adverse effects, especially on cardiovascular system, during anesthetic-surgical procedures. This is possibly due to interactions between this drug and anesthetic agents mainly related to general anesthesia. There are reports on severe, treatment - resistant bradycardias as well as on different degrees of atrioventricular block (AVB). Patients should be carefully monitored, especially during major procedures, and vasoactive drugs (isoproterenol) and temporary artificial pacemaker, should be available because they may be critical during the adverse effects treatment.JUSTIFICATIVA Y OBJETIVOS: La amiodarona es un antidisritmico bastante eficaz y indicado en el tratamiento de disritmias ventriculares y supraventriculares, motivo por el cual viene siendo extensamente administrada en la practica clinica. Entretanto, su uso cronico puede estar asociado con serios efectos colaterales, que pueden ser agravados por actos anestesico-cirugicos, aumentando el riesgo de los procedimientos. El presente estudio objetiva revisar los principales efectos de la amiodarona y asociarlos a la practica clinica del anestesista. CONTENIDO: Se trato de las principales propiedades de la amiodarona, su uso clinico, bien como los mas importantes efectos adversos que pueden aumentar el riesgo quirurgico de los pacientes en uso de este antidisritmico. CONCLUSIONES: La amiodarona, a pesar de habitualmente segura y eficiente, puede presentar efectos adversos exacerbados, especialmente para el aparato cardiovascular, durante procedimientos anestesico-cirugicos. Esto se debe posiblemente a las interacciones entre ese farmaco y agentes anestesicos, asociados principalmente a la anestesia general. Hay relatos de bradicardias graves y resistentes a la terapeutica, bien como bloqueo atrioventricular (BAV) en grados variados. El paciente debe ser rigurosamente monitorizado, especialmente en los procedimientos de grande porte, y el anestesista debe estar amparado en el peri-operatorio con drogas vasoactivas (isoproterenol) y marcapaso cardiaco artificial temporario, que pueden ser fundamentales durante el procedimiento.

Manuseio peri-operatório do paciente em uso de amiodarona

BACKGROUND AND OBJECTIVES Amiodarone is quite an effective anti-arrhythmic drug indicated for controlling ventricular and supra-ventricular arrhythmias, and it is being widely administered in clinical practice. However, its chronic use may be associated to severe side effects which may be worsened by anesthetic-surgical acts, thus increasing the risk of such procedures. This study aimed at reviewing major amiodarone effects and relating them to anesthetic procedures. CONTENTS The study covers major amiodarone properties, its clinical use, as well as major adverse effects, which may increase patients surgical risk. CONCLUSIONS Amiodarone, although normally safe and effective, may present adverse effects, especially on cardiovascular system, during anesthetic-surgical procedures. This is possibly due to interactions between this drug and anesthetic agents mainly related to general anesthesia. There are reports on severe, treatment - resistant bradycardias as well as on different degrees of atrioventricular block (AVB). Patients should be carefully monitored, especially during major procedures, and vasoactive drugs (isoproterenol) and temporary artificial pacemaker, should be available because they may be critical during the adverse effects treatment.JUSTIFICATIVA Y OBJETIVOS: La amiodarona es un antidisritmico bastante eficaz y indicado en el tratamiento de disritmias ventriculares y supraventriculares, motivo por el cual viene siendo extensamente administrada en la practica clinica. Entretanto, su uso cronico puede estar asociado con serios efectos colaterales, que pueden ser agravados por actos anestesico-cirugicos, aumentando el riesgo de los procedimientos. El presente estudio objetiva revisar los principales efectos de la amiodarona y asociarlos a la practica clinica del anestesista. CONTENIDO: Se trato de las principales propiedades de la amiodarona, su uso clinico, bien como los mas importantes efectos adversos que pueden aumentar el riesgo quirurgico de los pacientes en uso de este antidisritmico. CONCLUSIONES: La amiodarona, a pesar de habitualmente segura y eficiente, puede presentar efectos adversos exacerbados, especialmente para el aparato cardiovascular, durante procedimientos anestesico-cirugicos. Esto se debe posiblemente a las interacciones entre ese farmaco y agentes anestesicos, asociados principalmente a la anestesia general. Hay relatos de bradicardias graves y resistentes a la terapeutica, bien como bloqueo atrioventricular (BAV) en grados variados. El paciente debe ser rigurosamente monitorizado, especialmente en los procedimientos de grande porte, y el anestesista debe estar amparado en el peri-operatorio con drogas vasoactivas (isoproterenol) y marcapaso cardiaco artificial temporario, que pueden ser fundamentales durante el procedimiento.

Artificial cardiac pacemaker: pre and intraoperative considerations

BACKGROUND AND OBJECTIVES Technological medical diagnosis advances in cardiology have markedly increased indications for temporary or permanent artificial cardiac pacemakers (PM). This means that, in addition to cardiologists, other specialists have become involved in the handling of these devices. When PM patients undergo surgery, anesthesiologists participation may be decisive for the success of the procedure. This review aimed at familiarizing anesthesiologists with major clinical indications and operation of these devices, as well as with PM-related pre and intraoperative cares. CONTENTS Classification, operation, and major clinical indications for PM implants are covered. In addition, primary PM-related pre and intraoperative cares required for success are explained. CONCLUSIONS Basic understanding of PM operation and indications should be part of anesthesiologists daily practice. Hence, handling and indication of temporary PM broadens these specialists scope, in addition to saving lives in emergency situations. Electric cautery should be avoided in artificial cardiac pacemaker patients.JUSTIFICATIVA Y OBJETIVOS: El progreso tecnologico de la propedeutica medica diagnostica en cardiologia difundio grandemente la indicacion de marcapaso (MP) cardiaco artificial, definitivo o temporario. Esto hizo con que otros especialistas, ademas de los cardiologistas, se envolvieran todavia mas en el manoseo de eses aparatos. Cuando pacientes portadores de MP se presentan para cirugia, la participacion del anestesista puede ser decisiva para el suceso del procedimiento. El objetivo de la actual revision es familiarizar al anestesista con las principales indicaciones clinicas y con el funcionamiento de eses dispositivos, ademas de los cuidados pre y per-operatorios que se debe tener. CONTENIDO: Fueron tratadas la clasificacion, funcionamiento y las principales indicaciones clinicas para la implantacion de MP. De la misma forma, se pretendio elucidar los principales cuidados pre y per-operatorios relativos al uso de MP para lograr exito en el procedimiento indicado. CONCLUSIONES: Los principales conocimientos sobre el funcionamiento del MP y sus indicaciones clinicas deben hacer parte de la practica diaria del anestesista. De esa forma, el manoseo y la indicacion del MP temporario amplia la actuacion de eses especialistas, ademas de que puede salvar vidas, inclusive en situaciones de emergencia dentro del centro quirurgico. El uso de eletrocauterio deberia ser evitado en portadores de MP.