Fabiano Soares Carneiro

Síndrome de Tako-Tsubo em decorrência de bloqueio neuromuscular residual: relato de caso

JUSTIFICATIVA Y OBJETIVOS: El Sindrome de Tako-Tsubo es una complicacion postoperatoria rara con una mortalidad en torno de un 5%. El objetivo de este relato es presentar el bloqueo neuromuscular residual como factor desencadenante del referido sindrome, discutir sobre el y alertar sobre el bloqueo neuromuscular residual. RELATO DEL CASO: Paciente del sexo femenino, 61 anos, estado fisico ASA I, sometida a la anestesia general asociada al bloqueo paravertebral cervical para la reparacion artroscopica de lesion de manguito de los rotadores. Despues de la extubacion, quedo demostrado el bloqueo neuromuscular residual a traves del examen clinico. En la sala de recuperacion postanestesica, evoluciono con somnolencia, taquicardia, hipertension arterial y acidosis respiratoria grave. Despues de la reintubacion evoluciono con parada cardiaca en actividad electrica sin pulso, revertida con adrenalina y masaje cardiaco externo. En el postoperatorio presento una elevacion de segmento ST, aumento de troponina y acinesia de segmento medio-apical del ventriculo izquierdo, con fraccion de eyeccion estimada en un 30%. La cineangiocoronariografia mostro coronarias exentas de ateromatosis significativa y un grave comprometimiento de la funcion sistolica con acinesia inferior y antero-septo-apical, con hipercontratilidad compensatoria de sus porciones basales. Con el tratamiento iniciado, hubo una recuperacion funcional completa. CONCLUSIONES: El bloqueo neuromuscular residual asociado a la paralisis diafragmatica y la posible atelectasia pulmonar, que conlleva a la insuficiencia respiratoria, hipercapnia y descarga adrenergica, fueron los factores desencadenantes del sindrome de Tako-Tsubo con su grave repercusion clinica.BACKGROUND AND OBJECTIVES Tako-Tsubo syndrome is a rare postoperative complication with a 5% mortality rate. The objective of this report was to present residual neuromuscular blockade as a trigger for this syndrome, discuss this disorder, and call attention to the risks of residual neuromuscular blockade. CASE REPORT A 61-year old female, physical status ASA I, who underwent general anesthesia associated with paravertebral cervical block for arthroscopic repair of a rotator cuff lesion. Physical exam after extubation detected residual neuromuscular blockade. In the post-anesthetic care unit the patient developed somnolence, tachycardia, hypertension, and severe respiratory acidosis. After reintubation the patient evolved for cardiac arrest with electrical activity without a pulse, which was reverted with the administration of adrenaline and external cardiac massage. In the postoperative period the patient presented elevation of the ST segment, increased troponin, and left ventricular medial-apical akinesia with an estimated ejection fraction of 30%. Cardiac catheterization showed absence of significant atheromatous lesions in the coronary vessels, and severe disruption of the systolic function with inferior and antero-septo-apical akinesia and compensatory basal hypercontractility. The patient had complete functional recovery with the treatment instituted. CONCLUSIONS Residual neuromuscular blockade associated with diaphragmatic paralysis and possible pulmonary atelectasis leading to respiratory failure, hypercapnia, and adrenergic discharge triggered the Tako-Tsubo syndrome with severe clinical repercussion.

Central pontine myelinolysis after liver transplantation: is sodium the only villain? Case report

JUSTIFICATIVA Y OBJETIVOS: El aparecimiento de sintomas neurologicos en pacientes gravemente enfermos es comun y muchas veces, es un reto propedeutico. Descrita hace cerca de 50 anos, la desmielinizacion de las neuronas de la region pontina, es una alteracion patologica asociada a cuadros neurologicos y psiquiatricos posteriores al transplante hepatico. El objetivo de este relato, fue presentar la mielinolisis pontina central diagnosticada en el postoperatorio de transplante hepatico y discutir su fisiopatologia. RELATO DEL CASO: Paciente del sexo femenino, 29 anos, sometida a transplante hepatico debido a un fracaso hepatico fulminante. En el postoperatorio, presento un cuadro neurologico caracteristico de Sindrome Locked In y lesiones compatibles con la mielinolisis pontina central a la resonancia nuclear magnetica. La paciente no presento oscilaciones exageradas del sodio plasmatico, que es el ion frecuentemente acusado de ser el agente causador, y evoluciono con una mejoria significativa en algunas semanas. CONCLUSIONES: La mielinolisis pontina central tiene una etiologia multifactorial, y una atencion especial debe darsele al grupo de pacientes con mayor riesgo, tales como los sometidos a alteraciones abruptas de la natremia, transplantados de higado, etilistas cronicos y desnutridos. Es importante reconocer, que los sindromes de desmielinizacion osmosticos pueden surgir en pacientes con niveles sericos de sodio bajo, normal o elevado, evidenciando la contribucion de otros factores desencadenantes.BACKGROUND AND OBJECTIVES Critically ill patients frequently develop neurologic symptoms, which frequently become a clinical challenge. Described approximately 50 years ago, pontine neuronal demyelination is a pathologic change associated with neurologic and psychiatric problems after liver transplantation. The objective of this report was to present a case of central pontine myelinolysis diagnosed after liver transplantation and to discuss its pathophysiology. CASE REPORT A 29 years old female patient underwent liver transplantation for fulminant hepatic failure. Postoperatively, she developed neurologic symptoms characteristic of the Locked In Syndrome and the MRI showed changes compatible with central pontine myelinolysis. The patient did not develop dramatic changes in sodium plasma levels, which is frequently incriminated as the causal agent, and improved considerably within a few weeks. CONCLUSIONS The etiology of central pontine myelinolysis is multifactorial, and special attention should be given to the group of patients at greater risk, such as those with sudden changes in the plasma levels of sodium, liver transplantation, chronic alcoholics, and malnourished. It is important to recognize that osmotic demyelination can develop in patients with low, normal, or elevated plasma levels of sodium, indicating the contribution of other trigger factors.

Tako-Tsubo syndrome secondary to residual neuromuscular blockade: case report

JUSTIFICATIVA Y OBJETIVOS: El Sindrome de Tako-Tsubo es una complicacion postoperatoria rara con una mortalidad en torno de un 5%. El objetivo de este relato es presentar el bloqueo neuromuscular residual como factor desencadenante del referido sindrome, discutir sobre el y alertar sobre el bloqueo neuromuscular residual. RELATO DEL CASO: Paciente del sexo femenino, 61 anos, estado fisico ASA I, sometida a la anestesia general asociada al bloqueo paravertebral cervical para la reparacion artroscopica de lesion de manguito de los rotadores. Despues de la extubacion, quedo demostrado el bloqueo neuromuscular residual a traves del examen clinico. En la sala de recuperacion postanestesica, evoluciono con somnolencia, taquicardia, hipertension arterial y acidosis respiratoria grave. Despues de la reintubacion evoluciono con parada cardiaca en actividad electrica sin pulso, revertida con adrenalina y masaje cardiaco externo. En el postoperatorio presento una elevacion de segmento ST, aumento de troponina y acinesia de segmento medio-apical del ventriculo izquierdo, con fraccion de eyeccion estimada en un 30%. La cineangiocoronariografia mostro coronarias exentas de ateromatosis significativa y un grave comprometimiento de la funcion sistolica con acinesia inferior y antero-septo-apical, con hipercontratilidad compensatoria de sus porciones basales. Con el tratamiento iniciado, hubo una recuperacion funcional completa. CONCLUSIONES: El bloqueo neuromuscular residual asociado a la paralisis diafragmatica y la posible atelectasia pulmonar, que conlleva a la insuficiencia respiratoria, hipercapnia y descarga adrenergica, fueron los factores desencadenantes del sindrome de Tako-Tsubo con su grave repercusion clinica.BACKGROUND AND OBJECTIVES Tako-Tsubo syndrome is a rare postoperative complication with a 5% mortality rate. The objective of this report was to present residual neuromuscular blockade as a trigger for this syndrome, discuss this disorder, and call attention to the risks of residual neuromuscular blockade. CASE REPORT A 61-year old female, physical status ASA I, who underwent general anesthesia associated with paravertebral cervical block for arthroscopic repair of a rotator cuff lesion. Physical exam after extubation detected residual neuromuscular blockade. In the post-anesthetic care unit the patient developed somnolence, tachycardia, hypertension, and severe respiratory acidosis. After reintubation the patient evolved for cardiac arrest with electrical activity without a pulse, which was reverted with the administration of adrenaline and external cardiac massage. In the postoperative period the patient presented elevation of the ST segment, increased troponin, and left ventricular medial-apical akinesia with an estimated ejection fraction of 30%. Cardiac catheterization showed absence of significant atheromatous lesions in the coronary vessels, and severe disruption of the systolic function with inferior and antero-septo-apical akinesia and compensatory basal hypercontractility. The patient had complete functional recovery with the treatment instituted. CONCLUSIONS Residual neuromuscular blockade associated with diaphragmatic paralysis and possible pulmonary atelectasis leading to respiratory failure, hypercapnia, and adrenergic discharge triggered the Tako-Tsubo syndrome with severe clinical repercussion.

Mielinólise pontina central após transplante hepático: o sódio é o único vilão? Relato de caso

JUSTIFICATIVA Y OBJETIVOS: El aparecimiento de sintomas neurologicos en pacientes gravemente enfermos es comun y muchas veces, es un reto propedeutico. Descrita hace cerca de 50 anos, la desmielinizacion de las neuronas de la region pontina, es una alteracion patologica asociada a cuadros neurologicos y psiquiatricos posteriores al transplante hepatico. El objetivo de este relato, fue presentar la mielinolisis pontina central diagnosticada en el postoperatorio de transplante hepatico y discutir su fisiopatologia. RELATO DEL CASO: Paciente del sexo femenino, 29 anos, sometida a transplante hepatico debido a un fracaso hepatico fulminante. En el postoperatorio, presento un cuadro neurologico caracteristico de Sindrome Locked In y lesiones compatibles con la mielinolisis pontina central a la resonancia nuclear magnetica. La paciente no presento oscilaciones exageradas del sodio plasmatico, que es el ion frecuentemente acusado de ser el agente causador, y evoluciono con una mejoria significativa en algunas semanas. CONCLUSIONES: La mielinolisis pontina central tiene una etiologia multifactorial, y una atencion especial debe darsele al grupo de pacientes con mayor riesgo, tales como los sometidos a alteraciones abruptas de la natremia, transplantados de higado, etilistas cronicos y desnutridos. Es importante reconocer, que los sindromes de desmielinizacion osmosticos pueden surgir en pacientes con niveles sericos de sodio bajo, normal o elevado, evidenciando la contribucion de otros factores desencadenantes.BACKGROUND AND OBJECTIVES Critically ill patients frequently develop neurologic symptoms, which frequently become a clinical challenge. Described approximately 50 years ago, pontine neuronal demyelination is a pathologic change associated with neurologic and psychiatric problems after liver transplantation. The objective of this report was to present a case of central pontine myelinolysis diagnosed after liver transplantation and to discuss its pathophysiology. CASE REPORT A 29 years old female patient underwent liver transplantation for fulminant hepatic failure. Postoperatively, she developed neurologic symptoms characteristic of the Locked In Syndrome and the MRI showed changes compatible with central pontine myelinolysis. The patient did not develop dramatic changes in sodium plasma levels, which is frequently incriminated as the causal agent, and improved considerably within a few weeks. CONCLUSIONS The etiology of central pontine myelinolysis is multifactorial, and special attention should be given to the group of patients at greater risk, such as those with sudden changes in the plasma levels of sodium, liver transplantation, chronic alcoholics, and malnourished. It is important to recognize that osmotic demyelination can develop in patients with low, normal, or elevated plasma levels of sodium, indicating the contribution of other trigger factors.

Postoperative Analgesic Efficacy of Different Volumes and Masses of Ropivacaine in Posterior Brachial Plexus Block

BACKGROUND AND OBJECTIVES The efficacy of posterior brachial plexus block for shoulder surgeries is demonstrated by different authors. However, there is no consensus on the ideal mass and volume of local anesthetic to be employed. The objetive of this study was to compare different volumes and masses of ropivacaine in posterior brachial plexus block in arthroscopic surgeries of the shoulder. METHOD Sixty patients > 18 years, physical status ASA I and II, scheduled for unilateral arthroscopic surgeries of the shoulder were randomly placed in three groups: A (10 mL to 0.5%), B (20 mL to 0.5%), C (5 mL to 1%). The block was performed with a 22G needle of 100 mm connected to neurostimulator, in a point 3 cm lateral to the midpoint of C6 and C7 interspace, being injected the solution corresponding to each group. The postoperative pain was evaluated at the recovery room and within the first 24 hours of the postoperative period. The groups were compared on length of time until the first complaint of pain, visual numeric scale (VNS) score and morphine consumption within the first 24 hours. RESULTS There was no statistically significant difference between the three groups related to age, weight and height. There was no difference in length of time until the first complaint of pain, VNS scores over three and morphine consumption in the postoperative period between the groups. CONCLUSIONS This study concluded that 5 mL of 1% ropivacaine promoted analgesic efficacy similar to 10 mL or 20 mL of 0.5% ropivacaine in the posterior brachial plexus block using neurostimulator.

Eficácia analgésica pós-operatória de diferentes volumes e massas de ropivacaína no bloqueio de plexo braquial pela via posterior

JUSTIFICATIVA Y OBJETIVOS: El bloqueo del plexo braquial por la via posterior ya posee su eficacia bien demostrada por diferentes autores para las cirugias de hombro. Sin embargo, no existe un consenso sobre la masa y el volumen ideal de anestesico local a ser usado. El objetivo de este estudio, es comparar los diferentes volumenes y masas de ropivacaina en el bloqueo del plexo braquial por la via posterior en cirugias artroscopicas de hombro. METODO: Sesenta pacientes con una edad superior a los 18 anos, estado fisico ASA 1 y 2, programados para cirugias artroscopicas de hombro unilateral, fueron ubicados aleatoriamente en tres grupos: A (10 mL a 0,5%), B (20 mL a 0,5%), C (5 mL a 1%). El bloqueo fue realizado con una aguja 22G de 100 mm conectada al neuroestimulador, en un punto 3 cm lateral al punto medio del interespacio de C6 y C7, siendo inyectada la solucion correspondiente a cada grupo. El dolor postoperatorio fue evaluado en la SRPA y en las primeras 24 horas del postoperatorio. Los grupos se compararon en cuanto al tiempo al sentir el primer quejido de dolor, en cuanto a la puntuacion en la ENV, y al consumo de morfina en las primeras 24 horas. RESULTADOS: No hubo una diferencia estadisticamente significativa entre los tres grupos con relacion a la edad, al peso y a la altura. No hubo una diferencia en el tiempo hasta que el paciente sintio el primer quejido de dolor, ENV superior a tres y consumo de morfina en el postoperatorio entre los grupos. CONCLUSIONES: El presente estudio concluye que 5 mL de ropivacaina al 1% promueve la eficacia analgesica similar a 10 mL o 20 mL de ropivacaina al 0,5% en el bloqueo del plexo braquial por la via posterior con el uso del neuroestimulador

Correlation between the inspired fraction of oxygen, maternal partial oxygen pressure, and fetal partial oxygen pressure during cesarean section of normal pregnancies

JUSTIFICATIVA E OBJETIVOS: Apesar das alteracoes na funcao pulmonar, a oxigenacao materna se mantem nas anestesias regionais para obstetricia. Mesmo assim, nessas situacoes, o fornecimento de oxigenio suplementar para a mae e pratica disseminada. A principal justificativa e a boa oxigenacao fetal; entretanto, nao ha devida comprovacao. Este estudo prospectivo e com distribuicao randomica das pacientes teve o objetivo de testar a hipotese da existencia ou nao de correlacao entre hiperoxia materna e elevacao de parâmetros gasometricos fetais na cesariana eletiva. METODO: Foram estudadas vinte pacientes gravidas, submetidas a raquianestesia, atraves de gasometrias arteriais, com diferentes fracoes inspiradas de oxigenio e correlacionadas com a gasometria fetal. RESULTADOS: O aumento da fracao inspirada de oxigenio materno nao se correlacionou com o aumento da pressao parcial de oxigenio fetal. CONCLUSOES: A inducao de hiperoxia materna atraves de oxigenoterapia suplementar nao foi capaz de aumentar a pressao parcial de oxigenio no feto. Nao houve modificacao nos parâmetros gasometricos fetais, mesmo em caso de mudanca desses parâmetros na parturiente, induzidos pela hiperoxia durante a cesariana sob raquianestesia.BACKGROUND AND OBJECTIVES Despite changes in pulmonary function, maternal oxygenation is maintained during obstetric regional blocks. But in those situations, the administration of supplementary oxygen to parturients is a common practice. Good fetal oxygenation is the main justification; however, this has not been proven. The objective of this randomized, prospective study was to test the hypothesis of whether maternal hyperoxia is correlated with an increase in fetal gasometric parameters in elective cesarean sections. METHODS Arterial blood gases of 20 parturients undergoing spinal block with different inspired fractions of oxygen were evaluated and correlated with fetal arterial blood gases. RESULTS An increase in maternal inspired fraction of oxygen did not show any correlation with an increase of fetal partial oxygen pressure. CONCLUSIONS Induction of maternal hyperoxia by the administration of supplementary oxygen did not increase fetal partial oxygen pressure. Fetal gasometric parameters did not change even when maternal parameters changed, induced by hyperoxia, during cesarean section under spinal block.

Correlação entre a fração inspirada de oxigênio, a pressão parcial de oxigênio materno e a pressão parcial de oxigênio fetal durante parto cesáreo em gestações normais

JUSTIFICATIVA E OBJETIVOS: Apesar das alteracoes na funcao pulmonar, a oxigenacao materna se mantem nas anestesias regionais para obstetricia. Mesmo assim, nessas situacoes, o fornecimento de oxigenio suplementar para a mae e pratica disseminada. A principal justificativa e a boa oxigenacao fetal; entretanto, nao ha devida comprovacao. Este estudo prospectivo e com distribuicao randomica das pacientes teve o objetivo de testar a hipotese da existencia ou nao de correlacao entre hiperoxia materna e elevacao de parâmetros gasometricos fetais na cesariana eletiva. METODO: Foram estudadas vinte pacientes gravidas, submetidas a raquianestesia, atraves de gasometrias arteriais, com diferentes fracoes inspiradas de oxigenio e correlacionadas com a gasometria fetal. RESULTADOS: O aumento da fracao inspirada de oxigenio materno nao se correlacionou com o aumento da pressao parcial de oxigenio fetal. CONCLUSOES: A inducao de hiperoxia materna atraves de oxigenoterapia suplementar nao foi capaz de aumentar a pressao parcial de oxigenio no feto. Nao houve modificacao nos parâmetros gasometricos fetais, mesmo em caso de mudanca desses parâmetros na parturiente, induzidos pela hiperoxia durante a cesariana sob raquianestesia.BACKGROUND AND OBJECTIVES Despite changes in pulmonary function, maternal oxygenation is maintained during obstetric regional blocks. But in those situations, the administration of supplementary oxygen to parturients is a common practice. Good fetal oxygenation is the main justification; however, this has not been proven. The objective of this randomized, prospective study was to test the hypothesis of whether maternal hyperoxia is correlated with an increase in fetal gasometric parameters in elective cesarean sections. METHODS Arterial blood gases of 20 parturients undergoing spinal block with different inspired fractions of oxygen were evaluated and correlated with fetal arterial blood gases. RESULTS An increase in maternal inspired fraction of oxygen did not show any correlation with an increase of fetal partial oxygen pressure. CONCLUSIONS Induction of maternal hyperoxia by the administration of supplementary oxygen did not increase fetal partial oxygen pressure. Fetal gasometric parameters did not change even when maternal parameters changed, induced by hyperoxia, during cesarean section under spinal block.

Mielinólisis pontina central después del transplante hepático: ¿es el sodio el único villano? Relato de caso

JUSTIFICATIVA Y OBJETIVOS: El aparecimiento de sintomas neurologicos en pacientes gravemente enfermos es comun y muchas veces, es un reto propedeutico. Descrita hace cerca de 50 anos, la desmielinizacion de las neuronas de la region pontina, es una alteracion patologica asociada a cuadros neurologicos y psiquiatricos posteriores al transplante hepatico. El objetivo de este relato, fue presentar la mielinolisis pontina central diagnosticada en el postoperatorio de transplante hepatico y discutir su fisiopatologia. RELATO DEL CASO: Paciente del sexo femenino, 29 anos, sometida a transplante hepatico debido a un fracaso hepatico fulminante. En el postoperatorio, presento un cuadro neurologico caracteristico de Sindrome Locked In y lesiones compatibles con la mielinolisis pontina central a la resonancia nuclear magnetica. La paciente no presento oscilaciones exageradas del sodio plasmatico, que es el ion frecuentemente acusado de ser el agente causador, y evoluciono con una mejoria significativa en algunas semanas. CONCLUSIONES: La mielinolisis pontina central tiene una etiologia multifactorial, y una atencion especial debe darsele al grupo de pacientes con mayor riesgo, tales como los sometidos a alteraciones abruptas de la natremia, transplantados de higado, etilistas cronicos y desnutridos. Es importante reconocer, que los sindromes de desmielinizacion osmosticos pueden surgir en pacientes con niveles sericos de sodio bajo, normal o elevado, evidenciando la contribucion de otros factores desencadenantes.BACKGROUND AND OBJECTIVES Critically ill patients frequently develop neurologic symptoms, which frequently become a clinical challenge. Described approximately 50 years ago, pontine neuronal demyelination is a pathologic change associated with neurologic and psychiatric problems after liver transplantation. The objective of this report was to present a case of central pontine myelinolysis diagnosed after liver transplantation and to discuss its pathophysiology. CASE REPORT A 29 years old female patient underwent liver transplantation for fulminant hepatic failure. Postoperatively, she developed neurologic symptoms characteristic of the Locked In Syndrome and the MRI showed changes compatible with central pontine myelinolysis. The patient did not develop dramatic changes in sodium plasma levels, which is frequently incriminated as the causal agent, and improved considerably within a few weeks. CONCLUSIONS The etiology of central pontine myelinolysis is multifactorial, and special attention should be given to the group of patients at greater risk, such as those with sudden changes in the plasma levels of sodium, liver transplantation, chronic alcoholics, and malnourished. It is important to recognize that osmotic demyelination can develop in patients with low, normal, or elevated plasma levels of sodium, indicating the contribution of other trigger factors.

Correlación entre la fracción inspirada de oxígeno, la presión parcial de oxígeno materno y la presión parcial de oxígeno fetal durante el parto por cesárea en embarazos normales

JUSTIFICATIVA E OBJETIVOS: Apesar das alteracoes na funcao pulmonar, a oxigenacao materna se mantem nas anestesias regionais para obstetricia. Mesmo assim, nessas situacoes, o fornecimento de oxigenio suplementar para a mae e pratica disseminada. A principal justificativa e a boa oxigenacao fetal; entretanto, nao ha devida comprovacao. Este estudo prospectivo e com distribuicao randomica das pacientes teve o objetivo de testar a hipotese da existencia ou nao de correlacao entre hiperoxia materna e elevacao de parâmetros gasometricos fetais na cesariana eletiva. METODO: Foram estudadas vinte pacientes gravidas, submetidas a raquianestesia, atraves de gasometrias arteriais, com diferentes fracoes inspiradas de oxigenio e correlacionadas com a gasometria fetal. RESULTADOS: O aumento da fracao inspirada de oxigenio materno nao se correlacionou com o aumento da pressao parcial de oxigenio fetal. CONCLUSOES: A inducao de hiperoxia materna atraves de oxigenoterapia suplementar nao foi capaz de aumentar a pressao parcial de oxigenio no feto. Nao houve modificacao nos parâmetros gasometricos fetais, mesmo em caso de mudanca desses parâmetros na parturiente, induzidos pela hiperoxia durante a cesariana sob raquianestesia.BACKGROUND AND OBJECTIVES Despite changes in pulmonary function, maternal oxygenation is maintained during obstetric regional blocks. But in those situations, the administration of supplementary oxygen to parturients is a common practice. Good fetal oxygenation is the main justification; however, this has not been proven. The objective of this randomized, prospective study was to test the hypothesis of whether maternal hyperoxia is correlated with an increase in fetal gasometric parameters in elective cesarean sections. METHODS Arterial blood gases of 20 parturients undergoing spinal block with different inspired fractions of oxygen were evaluated and correlated with fetal arterial blood gases. RESULTS An increase in maternal inspired fraction of oxygen did not show any correlation with an increase of fetal partial oxygen pressure. CONCLUSIONS Induction of maternal hyperoxia by the administration of supplementary oxygen did not increase fetal partial oxygen pressure. Fetal gasometric parameters did not change even when maternal parameters changed, induced by hyperoxia, during cesarean section under spinal block.