Florentino Fernandes Mendes

S(+) cetamina em baixas doses: atualização

JUSTIFICATIVA E OBJETIVOS: A utilizacao, em baixas doses, de cetamina e de seus isomeros apresenta perspectivas promissoras em anestesia e na analgesia pos-operatoria. O objetivo desse trabalho foi revisar as propriedades do uso de baixas doses de cetamina que justifiquem seu uso em anestesia e em analgesia pos-operatoria. CONTEUDO: Varios artigos da literatura sugerem que a cetamina apresenta propriedades de analgesia preemptiva e preventiva em relacao a dor pos-operatoria, diminuindo o consumo de opioides e melhorando a satisfacao dos pacientes. Os fenomenos de tolerância e de hiperalgesia induzidos pela utilizacao de opioides podem ser atenuados pelo uso da cetamina em baixas doses. Ela diminui o consumo de anestesicos inalatorios e possivelmente apresenta propriedades que podem ser interessantes na protecao da celula nervosa isquemica. Efeitos promissores, como a neuroprotecao e a melhora de resultados, em longo prazo, necessitam de mais estudos. CONCLUSOES: Em baixas doses a S(+) cetamina apresenta, na maioria dos estudos, efeito preventivo, diminuindo a sensibilizacao do SNC, a tolerância e a hiperalgesia induzida por opioides, o consumo de anestesicos, o uso de analgesicos e a incidencia de efeitos adversos pos-operatorios.

Impacto da implantação de clínica de avaliação pré-operatória em indicadores de desempenho

BACKGROUND AND OBJECTIVES This study aimed at evaluating the effects of implementing a Preoperative Outpatient Evaluation Clinic (POEC) based on operating center performance indicators. METHODS The following data were prospectively followed for five years: total POEC evaluations and surgeries performed; total and reasons for surgeries cancellation; inpatient or outpatient surgeries performed; procedures cancellation rate and mean hospital stay of admitted patients. Reasons for procedure cancellations were divided in medical and administrative reasons. Cancellation rate is presented in percentage. Mean hospital stay is presented in days. Other indicators are presented in total figures. The study was divided in five periods: Pre-POEC, POEC 1, 2, 3 and 4, corresponding, respectively, to the years of 1998, 1999, 2000, 2001 and 2002. For each year, indicators percentage was compared to previous year and to the year Pre-POEC. Reasons were defined to check interactions among indicators. RESULTS Except for total performed procedures, POEC has improved all tracked indicators. This improvement was low at the beginning and more significant in the year POEC 4. There has been decrease in the total number of cancelled procedures due to administrative reasons. There was also a decrease in procedures cancellation rate and mean hospital stay. These decreases were progressive and more marked in POEC 4. There is correlation (r = 0.977) between procedures cancellation rate and mean stay of admitted patients. CONCLUSIONS There are significant changes in indicators. Improvement is gradual and progressive as years go by with regard to POEC development, and positively affects indicators improvement.JUSTIFICATIVA E OBJETIVOS: O objetivo deste estudo foi avaliar os efeitos da implantacao de Clinica de Avaliacao Pre-Operatoria Ambulatorial (APOA) em indicadores de desempenho do centro cirurgico. METODO: Durante cinco anos acompanhou-se, prospectivamente, o total de consultas APOA; o total de cirurgias realizadas; o total e os motivos de suspensao das cirurgias; as cirurgias realizadas em regime ambulatorial ou com o paciente internado; a taxa de suspensao das cirurgias e a media de permanencia dos pacientes internados. Os motivos de suspensao das cirurgias foram divididos em causas medicas e administrativas. A taxa de suspensao foi apresentada em percentual, a media de permanencia, em dias de permanencia. Os demais indicadores foram apresentados como total. O estudo foi dividido em cinco periodos - Pre-APOA, APOA 1, 2, 3 e 4 - correspondendo, respectivamente, aos anos de 1998, 1999, 2000, 2001 e 2002. Em cada ano, a variacao percentual dos indicadores foi comparada com o ano anterior e com o Ano Pre-APOA. Para verificar as interacoes entre os indicadores, foram estabelecidas razoes. RESULTADOS: A Clinica de APOA, exceto para o total de cirurgias realizadas, apresentou melhora de todos os indicadores acompanhados. Essa melhora foi menor no inicio, crescente e mais significativa no ano APOA4. Houve diminuicao do numero total de cirurgias suspensas, principalmente por causas administrativas, diminuicao da taxa de suspensao de cirurgias e da media de permanencia, sendo essa diminuicao crescente e mais acentuada no ano APOA4. Existe correlacao (r = 0,977) entre a taxa de suspensao de cirurgias e a media de permanencia dos pacientes internados. CONCLUSOES: Existem alteracoes significativas nos indicadores. A melhora e gradual e progressiva, a medida que se avanca em anos em relacao ao desenvolvimento da Clinica de APOA, e repercute na melhoria dos indicadores.

Levobupivacaína versus bupivacaína em anestesia peridural para cesarianas: estudo comparativo

JUSTIFICATIVA Y OBJETIVOS: El anestesico local bupivacaina es encontrado en la forma de dos enantiomeros: levobupivacaina - S (-) y dextrobupivacaina - R (+). Basado en estudios que demuestran que la cardiotoxicidad es menor con el enantiomero S(-), fue difundido el uso de este agente en la practica clinica. El objetivo de este estudio es comparar la eficacia y la efectividad del uso de bupivacaina racemica con levobupivacaina en anestesia peridural de pacientes sometidas a cesarea electiva. METODO: Ensayo clinico eventual, doblemente encubierto, con gestantes estado fisico ASA I y II. Las pacientes fueron distribuidas para recibir 20 mL de bupivacaina a 0,5% racemica o 20 mL de levobupivacaina a 0,5%, ambas con 10 µg de sufentanil y vasoconstrictor. RESULTADOS: Participaron del estudio 47 pacientes, 24 en el grupo de la levobupivacaina y 23 en el grupo de la bupivacaina. Los grupos eran comparables entre si en lo que se refiere a las caracteristicas materno-fetales. Transcurridos 15 minutos despues del termino de la puncion peridural, 62,5% de las pacientes del grupo de la levobupivacaina tenian Bromage 2 o 3 contra 72,7% en el grupo de la bupivacaina (p = 0,83). Transcurridos veinte minutos, 66,7% de las pacientes del grupo de la levobupivacaina tenian Bromage 2 o 3 contra 86,3% del grupo de la bupivacaina (p = 0,21). La complicacion mas frecuente fue la hipotension arterial, encontrada en 16 (66,7%) pacientes del grupo de la levobupivacaina y en 10 (43,5%) pacientes del grupo de la bupivacaina (p = 0,11). CONCLUSIONES: La levobupivacaina y la bupivacaina fueron igualmente efectivas en el bloqueo peridural de pacientes sometidas a cesarea.BACKGROUND AND OBJECTIVES Local anesthetic bupivacaine is found in two different enantiomers: levobupivacaine - S (-) and dextrobupivacaine - R (+). Based on studies showing that S(-) enantiomers are less cardiotoxic, their use has been increasing in clinical practice. This study aimed at comparing racemic bupivacaine and levobupivacaine in epidural anesthesia for elective cesarean section. METHODS Randomized, double blind clinical trial enrolling physical status ASA I and II parturients. Patients were assigned to receive either 20 mL of 0.5% racemic bupivacaine or 20 mL of 0.5% levobupivacaine, both with 10 microg sufentanil and epinephrine 1:200,000. RESULTS Participated in this study 47 patients being 24 in the levobupivacaine group and 23 in the bupivacaine group. Both groups were comparable regarding maternal-fetal characteristics. Fifteen minutes after epidural anesthesia, 62.5% of levobupivacaine group patients experienced Bromage 2 or 3 motor block, whereas the same event was documented in 72.7% of bupivacaine group patients (p = 0.83). After 20 minutes, 66.7% of levobupivacaine group patients experienced Bromage 2 or 3 motor block versus 86.3% of bupivacaine group patients (p = 0.21). Most common complication was hypotension, detected in 16 (66.7%) levobupivacaine group patients and in 10 (43.5%) bupivacaine group patients (p = 0.11). CONCLUSIONS Levobupivacaine and bupivacaine were equally effective for epidural block in patients undergoing cesarean section.

Os clientes e a avaliação pré-operatória ambulatorial

JUSTIFICATIVA E OBJETIVOS: A avaliacao pre-operatoria vem sendo realizada com maior frequencia pelo anestesiologista. O objetivo deste trabalho foi pesquisar de forma transversal a satisfacao de clientes externos e internos do servico de avaliacao pre-operatoria ambulatorial do Complexo Hospitalar Santa Casa de Porto Alegre (APOA). METODO: Foi feita aplicacao de questionarios para verificar a satisfacao de clientes externos (pacientes) antes e apos consulta e clientes internos (anestesiologistas e cirurgioes), durante um mes. RESULTADOS: Os pacientes apresentaram um grau de satisfacao de 99%, os anestesiologistas 97% e os cirurgioes 76%. CONCLUSOES: As principais dificuldades ocorreram e foram salientadas no contexto das sugestoes dos clientes, principalmente na organizacao logistica das etapas do processo e na aceitacao de condutas pre-operatorias embasadas em evidencias clinico-epidemiologicas por parte dos demais anestesiologistas.BACKGROUND AND OBJECTIVES Increasingly, anesthesiologists are performing preoperative evaluation. This study aimed at transversally evaluating external and internal clients satisfaction with Santa Casa de Porto Alegre outpatient preoperative evaluation department (APOA). METHODS A questionnaire was applied for one month to external clients (patients) before and after evaluation, and internal clients (anesthesiologists and surgeons) to evaluate their satisfaction with the preoperative evaluation department. RESULTS Ninety-nine percent of patients, 97% of anesthesiologists and 76% of surgeons were happy with the service. CONCLUSIONS Major issues were identified through clients suggestions and were primarily related to process logistics and to the difficulties of other anesthesiologists in accepting preoperative approaches based on APOAs clinical and epidemiological evidences.

Low S(+) ketamine doses: a review

JUSTIFICATIVA E OBJETIVOS: A utilizacao, em baixas doses, de cetamina e de seus isomeros apresenta perspectivas promissoras em anestesia e na analgesia pos-operatoria. O objetivo desse trabalho foi revisar as propriedades do uso de baixas doses de cetamina que justifiquem seu uso em anestesia e em analgesia pos-operatoria. CONTEUDO: Varios artigos da literatura sugerem que a cetamina apresenta propriedades de analgesia preemptiva e preventiva em relacao a dor pos-operatoria, diminuindo o consumo de opioides e melhorando a satisfacao dos pacientes. Os fenomenos de tolerância e de hiperalgesia induzidos pela utilizacao de opioides podem ser atenuados pelo uso da cetamina em baixas doses. Ela diminui o consumo de anestesicos inalatorios e possivelmente apresenta propriedades que podem ser interessantes na protecao da celula nervosa isquemica. Efeitos promissores, como a neuroprotecao e a melhora de resultados, em longo prazo, necessitam de mais estudos. CONCLUSOES: Em baixas doses a S(+) cetamina apresenta, na maioria dos estudos, efeito preventivo, diminuindo a sensibilizacao do SNC, a tolerância e a hiperalgesia induzida por opioides, o consumo de anestesicos, o uso de analgesicos e a incidencia de efeitos adversos pos-operatorios.

Comparison between 0.125% and 0.25% bupivacaine associated to fentanyl for epidural labor analgesia

BACKGROUND AND OBJECTIVES: Epidural analgesia aims at decreasing or even abolishing maternal suffering during labor. It is considered a safe and effective method for pain relief. This study aimed at comparing two bupivacaine concentrations (0.25% and 0.125%) associated to fentanyl in epidural labor analgesia to determine its efficacy on pain relief and its effect on motor block. We have also observed the influence of these two concentrations on labor duration, fetal outcome and maternal satisfaction. METHODS: Participated in this prospective and double blind study 51 primiparous women who were randomized to receive one out of two bupivacaine concentrations for epidural labor analgesia (0.25% [n = 23] or 0.125% [n = 28]). Analgesia was measured using a numeric pain scale, and motor block was verified using Bromage scale. Means were compared using Students t test, while proportions were compared using Qui-square test, with p < 0.05. RESULTS: There has been no statistical difference in pain, degree of motor block and fetal outcome between groups. Cesarean delivery rate was statistically higher in the group receiving 0.25% bupivacaine (p < 0.05). Lower concentration group patients were more satisfied with the procedure (p < 0.01). CONCLUSIONS: The association of fentanyl and 0.125% bupivacaine proved to be more beneficial as compared to 0.25% concentration. With this dose, there has been a lower incidence of adverse effects without compromising analgesia, and yet a higher rate of maternal satisfaction.

Changes in purines concentration in the cerebrospinal fluid of patients experiencing pain: A case-control study

This study analyzes the relationship between extracellular purines and pain perception in humans. Cerebrospinal fluid (CSF) levels of purines and their metabolites were compared between patients displaying acute and/or chronic pain syndromes and control subjects. The CSF levels of IMP, inosine, guanosine and uric acid were significantly increased in the chronic pain group and correlated with pain severity (P<0.05). Patients displaying both chronic and acute pain presented similar changes in the CSF purines concentration (P<0.05). However, in the acute pain group, only CSF inosine and uric acid levels were significantly increased (P<0.05). These findings suggest that purines, in special inosine, guanosine and uric acid, are associated with the spinal mechanisms underlying nociception.

Hematoma após raquianestesia tratado conservadoramente: relato de caso e revisão da literatura

BACKGROUND AND OBJECTIVES Spinal anesthesia caries the risk of bleeding. Compression of nervous tissue secondary to the formation of a hematoma can cause neurological damage, which, if not diagnosed and treated in a timely fashion, can be permanent. The identification of risk factors, diagnosis, and early treatment are important for the prognosis. The objective of this report was to describe the case of a hematoma after spinal anesthesia treated conservatively, and review the literature. CASE REPORT Male patient, 73 years old, 65 kg, 1.67 m, and ASA physical status III, underwent spinal anesthesia for removal of a peritoneal dialysis catheter. During the puncture, the patient experienced paresthesia of the right lower limb. Fifteen milligrams of 0.5% hyperbaric bupivacaine without vasoconstrictor were administered. Twenty-four hours later, saddle anesthesia and lumbar pain persisted and, after 48 hours, the patient presented urinary incontinence. An MRI demonstrated the presence of an expansive subarachnoid process compressing the nerve roots (L4 and S1). After evaluation by the neurosurgeon, conservative treatment was instituted. The patient was discharged from the hospital on the 18th postoperative day, asymptomatic. CONCLUSIONS The case reported here presented a good evolution with the conservative treatment.JUSTIFICATIVA E OBJETIVOS: Durante a realizacao de anestesia espinal existe o risco de ocorrer sangramentos. A compressao do tecido nervoso, secundaria a formacao de hematoma, pode determinar o surgimento de lesao neurologica que se nao for diagnosticada e tratada a tempo pode ser permanente. A identificacao dos fatores de risco, o diagnostico e o tratamento precoce da compressao sao importantes para o prognostico do paciente. O objetivo deste trabalho foi descrever um caso de hematoma apos raquianestesia tratado de forma conservadora e revisar os trabalhos na literatura. RELATO DO CASO: Paciente do sexo masculino, 73 anos, 65 kg, 1,67 m, estado fisico ASA III. Foi submetido a raquianestesia para retirada de cateter de dialise peritoneal. Durante a realizacao da puncao ocorreram parestesias no membro inferior direito. Foram injetados 15 mg de bupivacaina hiperbarica a 0,5% sem vasoconstritor. Vinte e quatro horas apos a realizacao do bloqueio o paciente permanecia com anestesia em sela e com dor lombar, e 48 horas apos o procedimento apresentou incontinencia urinaria. A ressonância nuclear magnetica demonstrou existencia de processo expansivo subaracnoideo, com compressao de raizes nervosas (L4 a S1). Apos avaliacao do neurocirurgiao, instituiu-se tratamento conservador. O paciente recebeu alta hospitalar no 18° dia de pos-operatorio, assintomatico. CONCLUSOES: O caso apresentado mostrou boa evolucao com o tratamento conservador.

Impact of preoperative outpatient evaluation clinic on performance indicators

BACKGROUND AND OBJECTIVES This study aimed at evaluating the effects of implementing a Preoperative Outpatient Evaluation Clinic (POEC) based on operating center performance indicators. METHODS The following data were prospectively followed for five years: total POEC evaluations and surgeries performed; total and reasons for surgeries cancellation; inpatient or outpatient surgeries performed; procedures cancellation rate and mean hospital stay of admitted patients. Reasons for procedure cancellations were divided in medical and administrative reasons. Cancellation rate is presented in percentage. Mean hospital stay is presented in days. Other indicators are presented in total figures. The study was divided in five periods: Pre-POEC, POEC 1, 2, 3 and 4, corresponding, respectively, to the years of 1998, 1999, 2000, 2001 and 2002. For each year, indicators percentage was compared to previous year and to the year Pre-POEC. Reasons were defined to check interactions among indicators. RESULTS Except for total performed procedures, POEC has improved all tracked indicators. This improvement was low at the beginning and more significant in the year POEC 4. There has been decrease in the total number of cancelled procedures due to administrative reasons. There was also a decrease in procedures cancellation rate and mean hospital stay. These decreases were progressive and more marked in POEC 4. There is correlation (r = 0.977) between procedures cancellation rate and mean stay of admitted patients. CONCLUSIONS There are significant changes in indicators. Improvement is gradual and progressive as years go by with regard to POEC development, and positively affects indicators improvement.JUSTIFICATIVA E OBJETIVOS: O objetivo deste estudo foi avaliar os efeitos da implantacao de Clinica de Avaliacao Pre-Operatoria Ambulatorial (APOA) em indicadores de desempenho do centro cirurgico. METODO: Durante cinco anos acompanhou-se, prospectivamente, o total de consultas APOA; o total de cirurgias realizadas; o total e os motivos de suspensao das cirurgias; as cirurgias realizadas em regime ambulatorial ou com o paciente internado; a taxa de suspensao das cirurgias e a media de permanencia dos pacientes internados. Os motivos de suspensao das cirurgias foram divididos em causas medicas e administrativas. A taxa de suspensao foi apresentada em percentual, a media de permanencia, em dias de permanencia. Os demais indicadores foram apresentados como total. O estudo foi dividido em cinco periodos - Pre-APOA, APOA 1, 2, 3 e 4 - correspondendo, respectivamente, aos anos de 1998, 1999, 2000, 2001 e 2002. Em cada ano, a variacao percentual dos indicadores foi comparada com o ano anterior e com o Ano Pre-APOA. Para verificar as interacoes entre os indicadores, foram estabelecidas razoes. RESULTADOS: A Clinica de APOA, exceto para o total de cirurgias realizadas, apresentou melhora de todos os indicadores acompanhados. Essa melhora foi menor no inicio, crescente e mais significativa no ano APOA4. Houve diminuicao do numero total de cirurgias suspensas, principalmente por causas administrativas, diminuicao da taxa de suspensao de cirurgias e da media de permanencia, sendo essa diminuicao crescente e mais acentuada no ano APOA4. Existe correlacao (r = 0,977) entre a taxa de suspensao de cirurgias e a media de permanencia dos pacientes internados. CONCLUSOES: Existem alteracoes significativas nos indicadores. A melhora e gradual e progressiva, a medida que se avanca em anos em relacao ao desenvolvimento da Clinica de APOA, e repercute na melhoria dos indicadores.

Anestesia no paciente usuário de cocaína

BACKGROUND AND OBJECTIVES: Cocaine is the illicit drug most frequently associated with death, and the anesthesiologist should be aware of the perioperative complications of this drug in patients with acute intoxication or with a history of chronic use. The knowledge of the neurophysiology, pharmacology, and physiopathological consequences of cocaine abuse may facilitate the care of these patients. The objective of this work was to review the information on cocaine and its interactions with anesthesia. CONTENTS: This paper discusses the pharmacology, physiopathological consequences of cocaine use, and its interactions with anesthesia. CONCLUSIONS: The knowledge and early recognition of the complications associated with the use of cocaine are essential for the adequate management of cocaine users. The anesthesiologist should be prepared because both regional and general anesthesia carry significant risks in those patients.BACKGROUND AND OBJECTIVES Cocaine is the illicit drug most frequently associated with death, and the anesthesiologist should be aware of the perioperative complications of this drug in patients with acute intoxication or with a history of chronic use. The knowledge of the neurophysiology, pharmacology, and physiopathological consequences of cocaine abuse may facilitate the care of these patients. The objective of this work was to review the information on cocaine and its interactions with anesthesia. CONTENTS This paper discusses the pharmacology, physiopathological consequences of cocaine use, and its interactions with anesthesia. CONCLUSIONS The knowledge and early recognition of the complications associated with the use of cocaine are essential for the adequate management of cocaine users. The anesthesiologist should be prepared because both regional and general anesthesia carry significant risks in those patients.