Eneida Maria Vieira

Spinal anesthesia in children with isobaric local anesthetics: report on 307 patients under 13 years of age.

Background:  Spinal anesthesia in expert hands is an excellent method for children for appropriate surgery. The aim of this study was to evaluate the effects of spinal anesthesia with isobaric solutions in 307 consecutive cases from May 2001 to August 2002.

Raquianestesia posterior para cirurgias anorretais em regime ambulatorial: estudo piloto

JUSTIFICATIVA Y OBJETIVOS: El aumento del numero de cirugias ambulatoriales exige el empleo de metodos anestesicos que permitan la liberacion del paciente despues de la cirugia. Frecuentemente, las cirugias anorrectales son realizadas con los pacientes hospitalizados. Este estudio examina la posibilidad de que esos procedimientos puedan ser realizados en regimen ambulatorial con bajas dosis de bupivacaina hipobarica. METODO: Treinta pacientes, estado fisico ASA I y II, fueron sometidos a la raquianestesia con solucion hipobarica de bupivacaina a 0,15% a traves de aguja 27G Quincke para cirugias anorrectales. La puncion subaracnoidea fue realizada con el paciente en decubito ventral con auxilio de un cojin en su abdomen para corregir la lordosis lumbar y el espacio intervertebral. RESULTADOS: El bloqueo sensitivo fue logrado en todos los pacientes. Su dispersion vario de T10 a L2 con moda en T12. Apenas tres pacientes presentaron algun grado de bloqueo motor. La duracion del bloqueo fue de 122,17 ± 15,35 minutos. Estabilidad hemodinamica fue observada en todos los pacientes. Ningun paciente desarrollo cefalea despues de puncion de la dura-mater. CONCLUSIONES: Seis miligramos de bupivacaina a 0,15% en solucion hipobarica proporcionaron un bloqueo predominantemente sensitivo, cuando inyectados en decubito ventral. Las principales ventajas son la rapida recuperacion, estabilidad hemodinamica y satisfaccion del paciente, siendo una buena indicacion para anestesia ambulatorial.

Raquianestesia com a mistura enantiomérica de bupivacaína a 0,5% isobárica (S75-R25) em crianças com idades de 1 a 5 anos para cirurgia ambulatorial

BACKGROUND AND OBJECTIVES Commercially available bupivacaine is a racemic mixture of S(-) and R(+) enantiomers. Although the S(-) bupivacaine enantiomer is less toxic than R(+) bupivacaine to cardiovascular and central nervous systems, its relative efficacy has not yet been determined in spinal anesthesia for pediatric surgery. The aim of this study was to evaluate the effects of spinal anesthesia with a 0.5% isobaric mixture of S(-) bupivacaine(75%) + R(+) bupivacaine(25%) in 40 children aged 1 to 5 years scheduled for outpatient surgery. METHODS Participated in this prospective study 40 patients aged 1 to 5 years submitted to spinal anesthesia with 0.5 mg.kg-1 of a 0.5% isobaric mixture of 75% S(-) bupivacaine + 25% R(+) bupivacaine. The following parameters were observed: onset of analgesia, degree of motor block, duration of effects, cephalad spread of analgesia, cardiovascular changes, incidence of headache and transient neurological symptoms. RESULTS Mean onset time was 2.29 +/- 0.64 min. Duration of analgesia was 4.13 +/- 0.89 h. Time to ambulate was 3.50 +/- 0.81 h. Mean PACU stay was 43.80 +/- 31.34 min. Motor block duration was 1.89 +/- 0.78 h. Sensory block level varied from T9 to T4 (Mode=T6). Motor block onset time was less than two minutes in all children, all reaching grade 3 motor block (modified Bromage scale) in the beginning of surgery. Over 55% of all patients recovered to motor block 1 or zero at the end of the surgery. No patient developed oxygen desaturation or arterial hypotension. Bradycardia was observed in one patient. There were two block failures. There were no headache or transient neurological symptoms. CONCLUSIONS Isobaric 0.5% levobupivacaine (R25-S75) induces a safe spinal anesthesia in patients aged 1 to 5 years scheduled for outpatient procedures, with a high success rate, short-lasting motor block, relatively low incidence of side effects and at a lower cost. Headache seems to be rare in patients below five years of age when a thin needle is used. Our results have shown that spinal anesthesia is a safe and easy technique for children between 1 and 5 years of age in outpatient procedures.

Hypobaric 0.15% bupivacaine versus hyperbaric 0.5% bupivacaine for posterior (dorsal) spinal block in outpatient anorectal surgery

BACKGROUND AND OBJECTIVES The aim of this study was to study low dose hypobaric 0.15% bupivacaine and hyperbaric 0.5% bupivacaine in outpatient anorectal surgical procedures. METHODS Two groups of 50 patients, physical status ASA I and II, undergoing anorectal surgical procedures in a jackknife position, received 6 mg of hypobaric 0.15% bupivacaine in the surgical position (Group 1) or 6 mg of hyperbaric 0.5% bupivacaine in the sitting position for 5 minutes, after which they were placed in a jackknife position (Group 2). Sensitive and motor blockade, time of first urination, ambulation, complications, and the need for analgesics were evaluated. Patients were followed until the third postoperative day and questioned whether they experienced post-puncture headache or temporary neurological symptoms, and until the 30th day and questioned about permanent neurological complications. The test t Student, Moods median, and Fisher Exact test were used for statistical analysis, and a p < 0.05 was considered significant. RESULTS Every patient in Group 1 presented selective blockade of the posterior sacral nerve roots, while patients in Group 2 experienced blockade of the anterior and posterior nerve roots. Blockade was significantly higher in Group 1. Motor blockade was significantly less severe in Group 1. Forty-nine patients in Group 1 transferred to the stretcher unassisted while only 40 patients in Group 2 were able to do so. Recovery in Group 1 occurred in 105 +/- 25 minutes and in 95 +/- 15 minutes in Group 2, and this difference was not statistically significant. There were no hemodynamic changes, nausea or vomiting, urine retention, or post-puncture headache. CONCLUSIONS Anorectal surgical procedures under spinal block with low dose bupivacaine, hyperbaric or hypobaric, can be safely done.BACKGROUND AND OBJECTIVES: The aim of this study was to study low dose hypobaric 0.15% bupivacaine and hyperbaric 0.5% bupivacaine in outpatient anorectal surgical procedures. METHODS: Two groups of 50 patients, physical status ASA I and II, undergoing anorectal surgical procedures in a jackknife position, received 6 mg of hypobaric 0.15% bupivacaine in the surgical position (Group 1) or 6 mg of hyperbaric 0.5% bupivacaine in the sitting position for 5 minutes, after which they were placed in a jackknife position (Group 2). Sensitive and motor blockade, time of first urination, ambulation, complications, and the need for analgesics were evaluated. Patients were followed until the third postoperative day and questioned whether they experienced post-puncture headache or temporary neurological symptoms, and until the 30th day and questioned about permanent neurological complications. The test t Student, Moods median, and Fisher Exact test were used for statistical analysis, and a p < 0.05 was considered significant. RESULTS: Every patient in Group 1 presented selective blockade of the posterior sacral nerve roots, while patients in Group 2 experienced blockade of the anterior and posterior nerve roots. Blockade was significantly higher in Group 1. Motor blockade was significantly less severe in Group 1. Forty-nine patients in Group 1 transferred to the stretcher unassisted while only 40 patients in Group 2 were able to do so. Recovery in Group 1 occurred in 105 ± 25 minutes and in 95 ± 15 minutes in Group 2, and this difference was not statistically significant. There were no hemodynamic changes, nausea or vomiting, urine retention, or post-puncture headache. CONCLUSIONS: Anorectal surgical procedures under spinal block with low dose bupivacaine, hyperbaric or hypobaric, can be safely done.

Postoperative analgesia for hemorrhoidectomy with bilateral pudendal blockade on an ambulatory patient: a controlled clinical study

BACKGROUND AND OBJECTIVES: Reducing postoperative pain in hemorrhoidectomy is still a challenge. This prospective, randomized, double-blind study was conducted to compare bilateral pudendal blockade with peripheral nerve stimulator to relieve postoperative pain with the method commonly used. METHOD: 200 patients scheduled for hemorrhoidectomy were randomly divided into Control Group and Pudendal Group. Bilateral pudendal block was performed with levobupivacaine enantiomeric excess (S75:R25) after location with a peripheral nerve stimulator. The parameters evaluated were pain intensity, duration of analgesia, rescue analgesia, complications, patient satisfaction and pain at first defecation. Data were recorded at 6, 12, 18 and 24 hours after the surgery. RESULTS: Bilateral pudendal nerves with mean 23.4±4.4 hours provided better relief of postoperative pain (p<0.001), reducing the need for analgesics and residual analgesia for more than 24 hours in 41% of patients. All patients in Pudental Group had spontaneous micturition versus 96 in the control group. There was no local or systemic complications. CONCLUSIONS: Bilateral blockade of the pudendal nerve using a neurostimulator provided better pain relief with less need for rescue dose and no local or systemic complications.

Bupivacaína a 0,15% hipobárica para raquianestesia posterior (dorsal) versus bupivacaína a 0,5% hiperbárica para procedimentos cirúrgicos anorretais em regime ambulatorial

BACKGROUND AND OBJECTIVES The aim of this study was to study low dose hypobaric 0.15% bupivacaine and hyperbaric 0.5% bupivacaine in outpatient anorectal surgical procedures. METHODS Two groups of 50 patients, physical status ASA I and II, undergoing anorectal surgical procedures in a jackknife position, received 6 mg of hypobaric 0.15% bupivacaine in the surgical position (Group 1) or 6 mg of hyperbaric 0.5% bupivacaine in the sitting position for 5 minutes, after which they were placed in a jackknife position (Group 2). Sensitive and motor blockade, time of first urination, ambulation, complications, and the need for analgesics were evaluated. Patients were followed until the third postoperative day and questioned whether they experienced post-puncture headache or temporary neurological symptoms, and until the 30th day and questioned about permanent neurological complications. The test t Student, Moods median, and Fisher Exact test were used for statistical analysis, and a p < 0.05 was considered significant. RESULTS Every patient in Group 1 presented selective blockade of the posterior sacral nerve roots, while patients in Group 2 experienced blockade of the anterior and posterior nerve roots. Blockade was significantly higher in Group 1. Motor blockade was significantly less severe in Group 1. Forty-nine patients in Group 1 transferred to the stretcher unassisted while only 40 patients in Group 2 were able to do so. Recovery in Group 1 occurred in 105 +/- 25 minutes and in 95 +/- 15 minutes in Group 2, and this difference was not statistically significant. There were no hemodynamic changes, nausea or vomiting, urine retention, or post-puncture headache. CONCLUSIONS Anorectal surgical procedures under spinal block with low dose bupivacaine, hyperbaric or hypobaric, can be safely done.BACKGROUND AND OBJECTIVES: The aim of this study was to study low dose hypobaric 0.15% bupivacaine and hyperbaric 0.5% bupivacaine in outpatient anorectal surgical procedures. METHODS: Two groups of 50 patients, physical status ASA I and II, undergoing anorectal surgical procedures in a jackknife position, received 6 mg of hypobaric 0.15% bupivacaine in the surgical position (Group 1) or 6 mg of hyperbaric 0.5% bupivacaine in the sitting position for 5 minutes, after which they were placed in a jackknife position (Group 2). Sensitive and motor blockade, time of first urination, ambulation, complications, and the need for analgesics were evaluated. Patients were followed until the third postoperative day and questioned whether they experienced post-puncture headache or temporary neurological symptoms, and until the 30th day and questioned about permanent neurological complications. The test t Student, Moods median, and Fisher Exact test were used for statistical analysis, and a p < 0.05 was considered significant. RESULTS: Every patient in Group 1 presented selective blockade of the posterior sacral nerve roots, while patients in Group 2 experienced blockade of the anterior and posterior nerve roots. Blockade was significantly higher in Group 1. Motor blockade was significantly less severe in Group 1. Forty-nine patients in Group 1 transferred to the stretcher unassisted while only 40 patients in Group 2 were able to do so. Recovery in Group 1 occurred in 105 ± 25 minutes and in 95 ± 15 minutes in Group 2, and this difference was not statistically significant. There were no hemodynamic changes, nausea or vomiting, urine retention, or post-puncture headache. CONCLUSIONS: Anorectal surgical procedures under spinal block with low dose bupivacaine, hyperbaric or hypobaric, can be safely done.

[Isobaric 0.5% bupivacaine for spinal anesthesia in pediatric outpatient surgery of 6 to 12 year old children: a prospective study.].

JUSTIFICATIVA Y OBJETIVOS: En ninos, la raquianestesia produce profunda analgesia y, cuando combinada con anestesia general, reduce la necesidad de los agentes anestesicos y de los opioides. El objetivo de este estudio prospectivo fue evaluar las caracteristicas clinicas de la raquianestesia con bupivacaina a 0,5% racemica en 40 ninos, con edades entre 6 e 12 anos. METODO: Participaron del estudio prospectivo 40 ninos con edades entre seis y 12 anos, sometidos a raquianestesia con bupivacaina a 0,5% isobarica, en la dosis de 0,5 mg.kg-1. Fueron evaluados los siguientes parametros: latencia de la analgesia, bloqueo motor, duracion de los efectos, dispersion craneal de la analgesia, alteraciones cardiovasculares, cefalea, sintomas neurologicos transitorios. RESULTADOS: El tiempo de latencia fue de 2,60 ± 1,28 minutos. La duracion de la analgesia fue de 4,51 ± 0,89 h. El tiempo para la deambulacion fue de 4,04 ± 0,83 h. El tiempo de permanencia en la SRPA fue de 44,39 ± 43,13 minutos. La duracion del bloqueo motor fue de 2,50 ± 0,83 h. El nivel sensitivo del bloqueo vario entre T9 y T4 (Moda=T6). El inicio del bloqueo motor fue menor que tres minutos en todos los ninos. Luego en el inicio de la cirugia, todos los pacientes presentaron bloqueo motor grado 3 (escala modificada de Bromage). Setenta por ciento de los pacientes presentaron bloqueo motor grados 3 o 2 en el final de la cirugia. No fue observada desaturacion o hipotension arterial. Bradicardia fue observada en dos pacientes. Ocurrio una falla. Cefalea y SNT no fueron observadas. CONCLUSIONES: En las condiciones de este estudio la bupivacaina a 0,5% isobarica produjo anestesia segura en pacientes de 6 a 12 anos en regimen ambulatorial, con alto indice de suceso, bloqueo motor de duracion intermediaria y baja incidencia de efectos colaterales. Los resultados mostraron que la raquianestesia es segura y facilmente realizable en ninos de 6 a 12 anos en regimen ambulatorial.

Anestesia e artrite reumatoide

JUSTIFICATIVA Y OBJETIVOS: La artritis reumatoide (AR), es una enfermedad inflamatoria cronica y de etiologia desconocida. Los pacientes con AR son reconocidos como personas que tienen una reduccion en la expectativa de vida, en comparacion con la poblacion en general. Las enfermedades reumaticas son numerosas y ocurren con una alta variabilidad; algunas son desarrolladas rapidamente; otras, cronicamente, provocando incapacidades durante toda la vida. Los riesgos anestesicos, en los desordenes osteoarticulares, involucran ademas de las deformidades mecanicas causadas por la enfermedad, los sistemas cardiovascular, respiratorio, renal y digestivo. CONTENIDO: La propuesta de la presente revision fue destacar la importancia de las fases de la enfermedad en proceso, que pueden influir en el control de la anestesia antes, durante y despues de la cirugia, destacando la experiencia de los autores en una evaluacion retrospectiva de los casos de pacientes portadores de artritis reumatoide juvenil (ARJ), sometidos a protesis ortopedicas, con enfasis en las tecnicas de intubacion. CONCLUSIONES: Los pacientes con artritis reumatoide pueden presentar un buen numero de problemas complejos para el anestesiologo. Eso requiere una cuidadosa evaluacion preoperatoria; la anestesia necesita tener ya una experiencia con la tecnica y el cuidado postoperatorio debe ser juiciosamente elegido para atender a la necesidad especifica del paciente. El procedimiento exige una efectiva comunicacion entre el cirujano, el reumatologo y el anestesiologo, para que cada miembro del grupo multidisciplinario contribuya con su experiencia, y asi lograr un mejor beneficio para el paciente.

Continuous Bilateral Posterior Lumbar Plexus Block with a Disposable Infusion Pump. Case Report

BACKGROUND AND OBJECTIVES The number of bilateral total hip arthroplasties (THA) has been increasing every year. Postoperative analgesia by continuous perineural infusion of local anesthetic has been shown favorable results when compared to systemic analgesia. The use of elastomeric pumps has increased patient satisfaction when compared to electronic models. The objective of this report was to describe a case of continuous bilateral posterior lumbar plexus block with an elastomeric infusion pump in a patient submitted to bilateral hip arthroplasty. CASE REPORT This is a 46 year-old female patient weighing 65 kg, 162 cm, with rheumatoid arthritis and hypertension, physical status ASA II, scheduled for bilateral THA in a single stage. She had been on corticosteroids for 13 years. Hemoglobin=10.1 g.dL⁻¹, hematocrit=32.7%. Routine monitoring. Spinal anesthesia with 15 mg of 0.5% isobaric bupivacaine. General anesthesia with propofol (PFS) and remifentanil, and intubation without neuromuscular blockers. Right THA and, at the end, lumbar plexus block with a stimulator and a set of 150 mm needle and injection of 20 mL of 0.2% bupivacaine and introduction of a catheter. Left THA and, at the end, the same procedure. Anesthetic dispersion and contrast were investigated. Elastomeric pump was installed with 0.1% bupivacaine (400 mL) at a rate of 14 mL.h⁻¹. The patient was transferred to the Intensive Care Unit (ICU). After 24 hour, a new pump was installed with the same solution. She did not receive any boluses for 50 hours. After removal of the catheter, pain was controlled with oral ketoprofen and dypirone. CONCLUSIONS Continuous peripheral blockade with infusion of 0.1% bupivacaine with elastomeric pumps is a safe and effective procedure in adults.

Restricted dorsal spinal anesthesia for ambulatory anorectal surgery: a pilot study

JUSTIFICATIVA Y OBJETIVOS: El aumento del numero de cirugias ambulatoriales exige el empleo de metodos anestesicos que permitan la liberacion del paciente despues de la cirugia. Frecuentemente, las cirugias anorrectales son realizadas con los pacientes hospitalizados. Este estudio examina la posibilidad de que esos procedimientos puedan ser realizados en regimen ambulatorial con bajas dosis de bupivacaina hipobarica. METODO: Treinta pacientes, estado fisico ASA I y II, fueron sometidos a la raquianestesia con solucion hipobarica de bupivacaina a 0,15% a traves de aguja 27G Quincke para cirugias anorrectales. La puncion subaracnoidea fue realizada con el paciente en decubito ventral con auxilio de un cojin en su abdomen para corregir la lordosis lumbar y el espacio intervertebral. RESULTADOS: El bloqueo sensitivo fue logrado en todos los pacientes. Su dispersion vario de T10 a L2 con moda en T12. Apenas tres pacientes presentaron algun grado de bloqueo motor. La duracion del bloqueo fue de 122,17 ± 15,35 minutos. Estabilidad hemodinamica fue observada en todos los pacientes. Ningun paciente desarrollo cefalea despues de puncion de la dura-mater. CONCLUSIONES: Seis miligramos de bupivacaina a 0,15% en solucion hipobarica proporcionaron un bloqueo predominantemente sensitivo, cuando inyectados en decubito ventral. Las principales ventajas son la rapida recuperacion, estabilidad hemodinamica y satisfaccion del paciente, siendo una buena indicacion para anestesia ambulatorial.