Eduardo Toshiyuki Moro

Ansiedade, a criança e os pais

JUSTIFICATIVA Y OBJETIVOS: La ansiedad pre-operatoria en los ninos es caracterizada por tension, aprension, nerviosismo y preocupacion y puede ser expresa de diversas formas. Alteraciones de comportamiento en el post operatorio como enuresis nocturna, disturbios alimentares, apatia, insomnia, pesadillas y sueno agitado pueden ser resultado de esta ansiedad. En algunos ninos, estas alteraciones persisten hasta por un ano. El objetivo de este trabajo es evaluar los aspectos envueltos con la ansiedad que afecta a los ninos y los padres durante el periodo que antecede a la cirugia, bien como las intervenciones, farmacologicas o no, para reducirla. CONTENIDO: El articulo aborda la ligacion entre la ansiedad pre-operatoria en ninos y las alteraciones de comportamiento que pueden ocurrir en el periodo post-operatorio, bien como la influencia de variables como edad, temperamento, experiencia hospitalar previa y dolor. Medidas para reducir la ansiedad pre-operatoria en ninos como la presencia de los padres durante la induccion de la anestesia o programas de informacion y la utilizacion de medicacion pre-anestesica tambien son revisadas. CONCLUSIONES: El periodo que antecede a la cirugia se acompana de gran carga emocional para toda la familia, sobretodo para el nino. Un pre-operatorio turbulento significa, para muchos ninos, alteraciones de comportamiento que se manifiestan de forma variada y por periodos prolongados en algunas veces. La presencia de los padres durante la induccion de la anestesia y programas de preparacion pre-operatorios para el nino y para los padres pueden ser utiles para casos seleccionados, tomando en cuenta la edad, temperamento y experiencia hospitalar previa. La medicacion pre-anestesica con benzodiazepinicos, en especial el midazolam, es claramente el metodo mas eficaz para la reduccion de la ansiedad pre-operatoria en ninos y de las alteraciones de comportamiento por ella inducidas.BACKGROUND AND OBJECTIVES Preoperative pediatric anxiety is characterized by stress, worry, nervosism and concern and may be expressed in different ways. Postoperative behavior changes, such as nocturnal enuresis, dietary problems, apathy, insomnia, nightmares and agitated sleep may be results of this anxiety. In some children, these changes persist for one year. This study aimed at evaluating anxiety-related aspects affecting children and parents in the preoperative period, as well as pharmacological or non-pharmacological interventions to minimize them. CONTENTS The relationship between preoperative anxiety in children and postoperative behavior changes, as well as the influence of variables such as age, temperament, previous hospital experience and pain are discussed. Approaches to decrease childrens preoperative anxiety, such as the presence of parents during anesthetic induction or information programs and preanesthetic medication are reviewed. CONCLUSIONS The preoperative period is accompanied of an emotional overload for the whole family, especially the child. For many children, a turbulent preoperative period may translate into several behavior changes lasting for long periods of time. The presence of parents during anesthetic induction and the preoperative preparation of children and parents may be useful for selected cases, taking into account age, temperament and previous hospital experience. Preanesthetic medication with benzodiazepines, especially midazolam, is clearly the most effective method to decrease postoperative anxiety in children and their related behavior changes.

Prevenção da aspiração pulmonar do conteúdo gástrico

BACKGROUND AND OBJECTIVES Despite its low incidence, aspiration of pulmonary gastric contents may have devastating consequences. Esophageal sphincter function and protective airway reflexes decrease caused by conscience depression, predisposes patients to this severe complication. This article is a review of physiological aspects associated to gastroesophageal reflux, as well as of the methods to prevent it. CONTENTS Comments are made about the mechanisms involved in gastric contents aspiration, its consequences and preventive methods, including recent preoperative fasting guidelines developed after review of the literature, the reasonable use of drugs acting on gastric pH and volume, and finally the effects of different airway control methods on pulmonary aspiration prevention. CONCLUSIONS Aspiration of pulmonary gastric contents, despite its low frequency, demands special preventive care. Recently developed preoperative fasting guidelines suggest shorter fasting periods especially for liquids, allowing more comfort to patients and less risk of hypoglycemia and dehydration, without increasing the incidence of perioperative pulmonary aspiration. The routine use of drugs decreasing gastric acidity and volume seems to be indicated only for poor risk patients. The best method to protect airways against aspiration is still tracheal intubation. Other airway control methods have been adopted, but their efficacy in preventing aspiration is lower, although representing major alternatives in cases of intubation failure.JUSTIFICATIVA E OBJETIVOS: Apesar da baixa incidencia, a aspiracao pulmonar do conteudo gastrico pode ter consequencias devastadoras para o individuo. A diminuicao na funcao do esfincter esofagico e dos reflexos protetores das vias aereas causadas pela depressao da consciencia, predispoe os pacientes a esta grave complicacao. Neste artigo, foi realizada uma revisao dos aspectos fisiologicos associados ao refluxo gastroesofagico, bem como os metodos utilizados para preveni-lo. CONTEUDO: Sao feitos comentarios sobre os mecanismos envolvidos na aspiracao do conteudo gastrico, suas consequencias e metodos de prevencao, incluindo recentes guias de jejum pre-operatorio elaborados apos revisao da literatura, o uso racional de drogas que atuam no pH e volume gastrico e, finalmente, o efeito de diferentes metodos de manutencao da via aerea na prevencao da aspiracao pulmonar. CONCLUSOES: A aspiracao pulmonar do conteudo gastrico, apesar de pouco frequente, exige cuidados especiais para sua prevencao. Guias de jejum pre-operatorio elaborados recentemente sugerem periodos menores de jejum, principalmente para liquidos, permitindo mais conforto aos pacientes e menor risco de hipoglicemia e desidratacao, sem aumentar a incidencia de aspiracao pulmonar perioperatoria. O uso rotineiro de drogas que diminuem a acidez e volume gastrico parece estar indicado apenas para pacientes de risco. O melhor metodo de protecao da via aerea contra a aspiracao continua sendo a intubacao traqueal. Outros metodos de manutencao da via aerea vem sendo adotados, mas a eficacia na prevencao da aspiracao ainda e inferior, embora representem importante alternativa em casos de falha de intubacao traqueal.

Anesthetic management of a patient with hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome): case report

BACKGROUND AND OBJECTIVES Hereditary hemorrhagic telangiectasia (HHT), also known as Rendu-Osler-Weber syndrome, is an autosomal dominant disorder characterized by mucocutaneous and visceral vascular dysplasia associated with frequent episodes of epistaxis and gastrointestinal bleeding. The objective of this report was to describe the anesthesia of a patient with this syndrome. CASE REPORT A 25 years old male patient underwent surgical correction of an orbital fracture. He had the triad of recurrent epistaxis, family history and telangiectasia, and had been diagnosed with HHT. Pulmonary, brain, or gastrointestinal tract vascular malformations were not detected in the preoperative investigation. The patient underwent total venous anesthesia one hour after the administration of an antifibrinolytic drug. Bleeding was considered normal for this type of surgery, and hemodynamic instability or the need of perioperative blood transfusion was not detected. The patient was extubated in the operating room; he was transferred to the room after 60 minutes and discharged from the hospital after 24 hours. CONCLUSIONS Hereditary hemorrhagic telangiectasia is an autosomal dominant disorder that leads to mucocutaneous and visceral vascular dysplasia. Perioperative blood loss can be greater than expected in patients with this syndrome. Since bleeding does not result from a defect in the coagulation cascade but from the surgical exposure of malformed vascular structures, perioperative conduct includes the use of antifibrinolytics, adequate homeostasis, and induced hypotension in the absence of contraindications. Preanesthetic evaluation should include the search for brain, lung, and gastrointestinal vascular malformation.

Compressão da cartilagem cricóide: aspectos atuais

BACKGROUND AND OBJECTIVES Sellick described the importance of applying pressure in the cricoid cartilage during anesthesia induction to prevent regurgitation of gastric contents. Since then, the maneuver has been widely accepted by anesthesiologists as a fundamental step during induction with the rapid sequence technique. The objective of the present report was to discuss the indications, technique, complications, and reasons why some authors have refuted the efficacy of this technique. CONTENTS The indications, technique, and complications of compression of the cricoid cartilage were reviewed. The aspects that have motivated some authors to abandon the Sellick maneuver during anesthetic induction with the rapid sequence technique are also discussed. CONCLUSIONS The cricoid cartilage pressure maneuver requires knowledge of the anatomy of upper airways and the correct force to be used. Endoscopic and radiologic studies, as well as patients who developed pulmonary aspiration despite the use of Sellick maneuver, have raised doubts about the usefulness of this technique. Besides, can cause deformity of the cricoid cartilage, closure of the vocal cords, and difficulty to ventilate if it is not used properly. Despite the importance given to Sellick maneuver in preventing pulmonary aspiration, there are no guarantees it will protect the airways of all patients, especially when the technique is not properly used.JUSTIFICATIVA E OBJETIVOS: Sellick descreveu a importância da pressao aplicada na cartilagem cricoide para a prevencao da regurgitacao do conteudo gastrico durante a inducao da anestesia. Desde entao a manobra tem sido universalmente aceita pelos anestesiologistas como um passo fundamental durante a inducao com a tecnica de sequencia rapida. O presente artigo teve como objetivo discutir as indicacoes, a tecnica, as complicacoes e os motivos pelos quais alguns autores tem contestado a eficacia dessa tecnica. CONTEUDO: Foram revisadas as indicacoes, a tecnica e as complicacoes da manobra de compressao da cartilagem cricoide. Tambem foram discutidos os aspectos que tem motivado alguns autores a abandonar a manobra de Sellick durante a inducao anestesica com a tecnica de sequencia rapida. CONCLUSOES: A aplicacao da manobra de compressao da cartilagem cricoide exige o conhecimento da anatomia da via aerea superior e da forca correta a ser empregada. Estudos endoscopicos e radiologicos, assim como pacientes que apresentaram aspiracao pulmonar a despeito da aplicacao da manobra de Sellick, tem colocado em questao a utilidade da tecnica. Alem disso, quando mal empregada, pode causar deformidade dessa cartilagem, fechamento das cordas vocais e dificuldade de ventilacao. Apesar do papel de destaque representado pela manobra de Sellick na prevencao da aspiracao pulmonar, nao ha garantia de protecao das vias aereas para todos os pacientes, sobretudo quando a tecnica nao e corretamente aplicada.

Subarachnoid blockade for cesarean section in a patient with ventriculoperitoneal shunt: case report

JUSTIFICATIVA E OBJETIVOS: Pacientes portadores de derivacao ventriculoperitoneal (DVP) causam preocupacao adicional quando o bloqueio do neuroeixo e indicado, sobretudo em obstetricia. Atualmente nao existe consenso na literatura sobre a tecnica anestesica de escolha nesses casos. O objetivo deste relato foi descrever o caso de paciente com DVP submetida a cesariana sob anestesia subaracnoidea. RELATO DO CASO: Paciente de 28 anos, secundigesta, um parto anterior sem historia de aborto, de termo, pre-natal sem intercorrencias, em trabalho de parto ha cinco horas, uma cesariana ha sete anos. Evoluiu com sofrimento fetal agudo, indicada cesariana de emergencia. Portadora DVP ha cinco anos, devido a hipertensao intracraniana (sic) de etiologia desconhecida. Exame neurologico normal. Foi submetida a anestesia subaracnoidea com bupivacaina a 0,5% pesada 15 mg e morfina 80 ¼g. Nascimento fetal com Apgar 8 (1 minuto) e 10 (5 minutos) apos nascimento. Alta apos dois dias em excelente condicao clinica. CONCLUSOES: A abordagem anestesica de pacientes obstetricas com DVP e complexa, devendo-se comparar o risco e o beneficio das tecnicas no momento e circunstância da indicacao. O bloqueio do neuroeixo tem sido relatado com sucesso em portadoras de doencas neurologicas. Quanto a DVP, nao existe na literatura contraindicacao formal ao bloqueio. Os casos devem ser individualizados. Neste relato, diante da emergencia obstetrica e do quadro neurologico vigente, optou-se pelo bloqueio no neuroeixo. A tecnica proporcionou adequado manuseio da via aerea, boa condicao materno-fetal e analgesia pos-operatoria. A evolucao foi favoravel, sem alteracoes neurologicas decorrentes da tecnica escolhida.BACKGROUND AND OBJECTIVES Patients with ventriculoperitoneal shunt (VPS) represent an additional concern when neuroaxis block is indicated, especially in obstetrics. Currently, a consensus on the anesthetic technique of choice in those cases does not exist in the literature. The objective of this report was to describe the case of a cesarean section under subarachnoid blockade in a patient with VPS. CASE REPORT This is a 28 years old pregnant patient at term, in her second pregnancy, one prior delivery, a cesarean section seven years ago, no history of miscarriages, and pre-natal care without intercurrences, in labor for five hours. The patient evolved with acute fetal distress and an emergency cesarean section was indicated. She had had a VPS for five years due to intracranial hypertension (sic) of unknown etiology. Neurological exam was normal. She underwent subarachnoid block with 15 mg of 0.5% hyperbaric bupivacaine and 80 (1/4)g of morphine. The newborn had an Apgar of 8 (in the first minute) and 10 (in the 5th minute). The patient was discharged two days later in excellent clinical condition. CONCLUSIONS The anesthetic approach of obstetric patients with VPS is complex, and the risk and benefits of anesthetic techniques, as well as the circumstances that led to this indication, should be considered at the time of the indication. Successful of neuroaxis block in patients with neurological diseases has been reported. As for VPS, formal contraindication for neuroaxis block does not exist in the literature. Cases should be individualized. In the present report, due to an obstetric emergency and the neurologic condition of the patient, a decision to use neuroaxis blockade was made. The technique provided adequate management of the airways, good maternal-fetal condition, and postoperative analgesia. The evolution was favorable and the patient did not show any neurologic changes secondary to the technique used.

Anestesia subaracnoidea para cesariana em paciente com derivação ventriculoperitoneal: relato de caso

JUSTIFICATIVA E OBJETIVOS: Pacientes portadores de derivacao ventriculoperitoneal (DVP) causam preocupacao adicional quando o bloqueio do neuroeixo e indicado, sobretudo em obstetricia. Atualmente nao existe consenso na literatura sobre a tecnica anestesica de escolha nesses casos. O objetivo deste relato foi descrever o caso de paciente com DVP submetida a cesariana sob anestesia subaracnoidea. RELATO DO CASO: Paciente de 28 anos, secundigesta, um parto anterior sem historia de aborto, de termo, pre-natal sem intercorrencias, em trabalho de parto ha cinco horas, uma cesariana ha sete anos. Evoluiu com sofrimento fetal agudo, indicada cesariana de emergencia. Portadora DVP ha cinco anos, devido a hipertensao intracraniana (sic) de etiologia desconhecida. Exame neurologico normal. Foi submetida a anestesia subaracnoidea com bupivacaina a 0,5% pesada 15 mg e morfina 80 ¼g. Nascimento fetal com Apgar 8 (1 minuto) e 10 (5 minutos) apos nascimento. Alta apos dois dias em excelente condicao clinica. CONCLUSOES: A abordagem anestesica de pacientes obstetricas com DVP e complexa, devendo-se comparar o risco e o beneficio das tecnicas no momento e circunstância da indicacao. O bloqueio do neuroeixo tem sido relatado com sucesso em portadoras de doencas neurologicas. Quanto a DVP, nao existe na literatura contraindicacao formal ao bloqueio. Os casos devem ser individualizados. Neste relato, diante da emergencia obstetrica e do quadro neurologico vigente, optou-se pelo bloqueio no neuroeixo. A tecnica proporcionou adequado manuseio da via aerea, boa condicao materno-fetal e analgesia pos-operatoria. A evolucao foi favoravel, sem alteracoes neurologicas decorrentes da tecnica escolhida.BACKGROUND AND OBJECTIVES Patients with ventriculoperitoneal shunt (VPS) represent an additional concern when neuroaxis block is indicated, especially in obstetrics. Currently, a consensus on the anesthetic technique of choice in those cases does not exist in the literature. The objective of this report was to describe the case of a cesarean section under subarachnoid blockade in a patient with VPS. CASE REPORT This is a 28 years old pregnant patient at term, in her second pregnancy, one prior delivery, a cesarean section seven years ago, no history of miscarriages, and pre-natal care without intercurrences, in labor for five hours. The patient evolved with acute fetal distress and an emergency cesarean section was indicated. She had had a VPS for five years due to intracranial hypertension (sic) of unknown etiology. Neurological exam was normal. She underwent subarachnoid block with 15 mg of 0.5% hyperbaric bupivacaine and 80 (1/4)g of morphine. The newborn had an Apgar of 8 (in the first minute) and 10 (in the 5th minute). The patient was discharged two days later in excellent clinical condition. CONCLUSIONS The anesthetic approach of obstetric patients with VPS is complex, and the risk and benefits of anesthetic techniques, as well as the circumstances that led to this indication, should be considered at the time of the indication. Successful of neuroaxis block in patients with neurological diseases has been reported. As for VPS, formal contraindication for neuroaxis block does not exist in the literature. Cases should be individualized. In the present report, due to an obstetric emergency and the neurologic condition of the patient, a decision to use neuroaxis blockade was made. The technique provided adequate management of the airways, good maternal-fetal condition, and postoperative analgesia. The evolution was favorable and the patient did not show any neurologic changes secondary to the technique used.

Indução anestésica com a técnica de seqüência rápida

JUSTIFICATIVA Y OBJETIVOS: La induccion de la anestesia por medio de la tecnica de secuencia rapida es utilizada, principalmente, para proteger las vias aereas, cuando hay riesgo de aspiracion del contenido gastrico. El objetivo de este articulo es revisar a tecnica y los diferentes protocolos que buscan del uso racional de los farmacos disponibles, visando condiciones ideales de intubacion traqueal, sin aumentar el riesgo de aspiracion del contenido gastrico o de otras complicaciones. CONTENIDO: Presenta una revision de la tecnica de la induccion con secuencia rapida, enfatizando el uso racional de los hipnoticos, opioides y bloqueadores neuromusculares (BNM), para reducir el periodo entre la perdida de la consciencia y el correcto posicionamiento del tubo traqueal, o sea, diminuir el periodo de mayor riesgo para aspiracion y aun mantener excelentes condiciones de intubacion traqueal. CONCLUSIONES: La intubacion traqueal despues de induccion anestesica por medio de la tecnica de secuencia rapida esta indicada en aquellos pacientes, con riesgo de aspiracion gastrica, en que no hay sospecha de intubacion traqueal dificil. La indicacion correcta de la tecnica, su aplicacion criteriosa y la utilizacion racional de las drogas disponibles pueden promover condiciones excelentes de intubacion, con corto periodo de latencia, rapido retorno de la consciencia y de la respiracion espontanea, caso haya falla en la intubacion traqueal.BACKGROUND AND OBJECTIVES Rapid sequence induction anesthesia is primarily used to protect airways when there is gastric content aspiration risk. This study aimed at reviewing the technique and different protocols looking for the rational use of available drugs, in the search for ideal tracheal intubation conditions without increasing the risk of gastric content aspiration or other complications. CONTENTS A technical review of rapid sequence induction of anesthesia is presented, emphasizing the rational use of hypnotics, opioids and neuromuscular blockers (NMB) to shorten the period between loss of consciousness and correct tracheal tube positioning, that is, shorten the period of highest risk for aspiration while maintaining excellent intubation conditions. CONCLUSIONS Tracheal intubation after rapid sequence induction of anesthesia is indicated for patients at risk for gastric content aspiration without suspicion of difficult intubation. The adequate indication of the technique, its judicious application and the rational use of available drugs may promote excellent intubation conditions, with fast onset, early return to consciousness and spontaneous breathing in case of tracheal intubation failure.

[Children, parents and anxiety.].

JUSTIFICATIVA Y OBJETIVOS: La ansiedad pre-operatoria en los ninos es caracterizada por tension, aprension, nerviosismo y preocupacion y puede ser expresa de diversas formas. Alteraciones de comportamiento en el post operatorio como enuresis nocturna, disturbios alimentares, apatia, insomnia, pesadillas y sueno agitado pueden ser resultado de esta ansiedad. En algunos ninos, estas alteraciones persisten hasta por un ano. El objetivo de este trabajo es evaluar los aspectos envueltos con la ansiedad que afecta a los ninos y los padres durante el periodo que antecede a la cirugia, bien como las intervenciones, farmacologicas o no, para reducirla. CONTENIDO: El articulo aborda la ligacion entre la ansiedad pre-operatoria en ninos y las alteraciones de comportamiento que pueden ocurrir en el periodo post-operatorio, bien como la influencia de variables como edad, temperamento, experiencia hospitalar previa y dolor. Medidas para reducir la ansiedad pre-operatoria en ninos como la presencia de los padres durante la induccion de la anestesia o programas de informacion y la utilizacion de medicacion pre-anestesica tambien son revisadas. CONCLUSIONES: El periodo que antecede a la cirugia se acompana de gran carga emocional para toda la familia, sobretodo para el nino. Un pre-operatorio turbulento significa, para muchos ninos, alteraciones de comportamiento que se manifiestan de forma variada y por periodos prolongados en algunas veces. La presencia de los padres durante la induccion de la anestesia y programas de preparacion pre-operatorios para el nino y para los padres pueden ser utiles para casos seleccionados, tomando en cuenta la edad, temperamento y experiencia hospitalar previa. La medicacion pre-anestesica con benzodiazepinicos, en especial el midazolam, es claramente el metodo mas eficaz para la reduccion de la ansiedad pre-operatoria en ninos y de las alteraciones de comportamiento por ella inducidas.BACKGROUND AND OBJECTIVES Preoperative pediatric anxiety is characterized by stress, worry, nervosism and concern and may be expressed in different ways. Postoperative behavior changes, such as nocturnal enuresis, dietary problems, apathy, insomnia, nightmares and agitated sleep may be results of this anxiety. In some children, these changes persist for one year. This study aimed at evaluating anxiety-related aspects affecting children and parents in the preoperative period, as well as pharmacological or non-pharmacological interventions to minimize them. CONTENTS The relationship between preoperative anxiety in children and postoperative behavior changes, as well as the influence of variables such as age, temperament, previous hospital experience and pain are discussed. Approaches to decrease childrens preoperative anxiety, such as the presence of parents during anesthetic induction or information programs and preanesthetic medication are reviewed. CONCLUSIONS The preoperative period is accompanied of an emotional overload for the whole family, especially the child. For many children, a turbulent preoperative period may translate into several behavior changes lasting for long periods of time. The presence of parents during anesthetic induction and the preoperative preparation of children and parents may be useful for selected cases, taking into account age, temperament and previous hospital experience. Preanesthetic medication with benzodiazepines, especially midazolam, is clearly the most effective method to decrease postoperative anxiety in children and their related behavior changes.

Prevention of pulmonary gastric contents aspiration

BACKGROUND AND OBJECTIVES Despite its low incidence, aspiration of pulmonary gastric contents may have devastating consequences. Esophageal sphincter function and protective airway reflexes decrease caused by conscience depression, predisposes patients to this severe complication. This article is a review of physiological aspects associated to gastroesophageal reflux, as well as of the methods to prevent it. CONTENTS Comments are made about the mechanisms involved in gastric contents aspiration, its consequences and preventive methods, including recent preoperative fasting guidelines developed after review of the literature, the reasonable use of drugs acting on gastric pH and volume, and finally the effects of different airway control methods on pulmonary aspiration prevention. CONCLUSIONS Aspiration of pulmonary gastric contents, despite its low frequency, demands special preventive care. Recently developed preoperative fasting guidelines suggest shorter fasting periods especially for liquids, allowing more comfort to patients and less risk of hypoglycemia and dehydration, without increasing the incidence of perioperative pulmonary aspiration. The routine use of drugs decreasing gastric acidity and volume seems to be indicated only for poor risk patients. The best method to protect airways against aspiration is still tracheal intubation. Other airway control methods have been adopted, but their efficacy in preventing aspiration is lower, although representing major alternatives in cases of intubation failure.JUSTIFICATIVA E OBJETIVOS: Apesar da baixa incidencia, a aspiracao pulmonar do conteudo gastrico pode ter consequencias devastadoras para o individuo. A diminuicao na funcao do esfincter esofagico e dos reflexos protetores das vias aereas causadas pela depressao da consciencia, predispoe os pacientes a esta grave complicacao. Neste artigo, foi realizada uma revisao dos aspectos fisiologicos associados ao refluxo gastroesofagico, bem como os metodos utilizados para preveni-lo. CONTEUDO: Sao feitos comentarios sobre os mecanismos envolvidos na aspiracao do conteudo gastrico, suas consequencias e metodos de prevencao, incluindo recentes guias de jejum pre-operatorio elaborados apos revisao da literatura, o uso racional de drogas que atuam no pH e volume gastrico e, finalmente, o efeito de diferentes metodos de manutencao da via aerea na prevencao da aspiracao pulmonar. CONCLUSOES: A aspiracao pulmonar do conteudo gastrico, apesar de pouco frequente, exige cuidados especiais para sua prevencao. Guias de jejum pre-operatorio elaborados recentemente sugerem periodos menores de jejum, principalmente para liquidos, permitindo mais conforto aos pacientes e menor risco de hipoglicemia e desidratacao, sem aumentar a incidencia de aspiracao pulmonar perioperatoria. O uso rotineiro de drogas que diminuem a acidez e volume gastrico parece estar indicado apenas para pacientes de risco. O melhor metodo de protecao da via aerea contra a aspiracao continua sendo a intubacao traqueal. Outros metodos de manutencao da via aerea vem sendo adotados, mas a eficacia na prevencao da aspiracao ainda e inferior, embora representem importante alternativa em casos de falha de intubacao traqueal.

Quality of recovery from anesthesia in patients undergoing orthopedic surgery of the lower limbs

BACKGROUND AND OBJECTIVES For patients undergoing regional anesthesia for orthopedic surgery, a common situation in our work environment, the quality of recovery may be influenced in different ways, which justifies studies to identify possible predictive factors of dissatisfaction. The aim of this study was to assess the opinion of patients on recovery from anesthesia for lower limb orthopedic surgeries. We also identified potential predictive factors for poor quality of recovery. METHODS We evaluated patients undergoing lower limb orthopedic surgeries and able to participate in the study. Data related to surgery, anesthesia, possible complications in the post-anesthetic care unit (PACU) and in the ward were recorded. In the morning after surgery, patients were evaluated by a medical student who applied the QoR-40 questionnaire. The resulted score-between 40 and 200-was used to determine the quality of recovery and identify the potential predictors. RESULTS We evaluated 172 patients. The questionnaire average score was 192 points. The chance to have lower scores in the QoR-40 was two times higher among males. Patients who remained under sedation, classified as greater than or equal to 4 on the scale proposed by Ramsay, had a 3.5 times higher risk of having lower scores in the QoR-40 compared to those who remained with level 1 or 2 of sedation. Regarding pain, at every increase of one unit in the numerical scale (0-10), there was a 19% increase in risk for QoR-40≤195. Similarly, the risk for a score below the median was 2.3 times higher among those presenting with nausea and/or vomiting in the ward. CONCLUSION Male, nausea, vomiting, pain while in the ward, and deeper levels of sedation are possible predictive factors for lower scores according to the adopted instrument.