Gastão F. Duval Neto

Anesthetics, cerebral protection and preconditioning.

BACKGROUND AND OBJECTIVES Several studies demonstrate that cerebral preconditioning is a protective mechanism against a stressful situation. Preconditioning determinants are described, as well as the neuroprotection provided by anesthetic and non-anesthetics agents. CONTENT Review based on the main articles addressing the pathophysiology of ischemia-reperfusion and neuronal injury and pharmacological and non-pharmacological factors (inflammation, glycemia, and temperature) related to the change in response to ischemia-reperfusion, in addition to neuroprotection induced by anesthetic use. CONCLUSIONS The brain has the ability to protect itself against ischemia when stimulated. The elucidation of this mechanism enables the application of preconditioning inducing substances (some anesthetics), other drugs, and non-pharmacological measures, such as hypothermia, aimed at inducing tolerance to ischemic lesions.

Nitrous oxide use in children

1. MSc, Rehabilitation Sciences; Anesthesiologist, Hospital SARAH 2. PhD, Cardiovascular Surgery, Universidade Federal de Sao Paulo; Full Professor, Anesthesiology, Departament of General Surgery, Faculdade de Medicina, Universidade Federal de Pelotas (UFPel) 3. PhD, Surgery, Faculdade de Ciencias Medicas da Santa Casa de Sao Paulo; Specialist in Pain Management, Universidade Federal do Rio Grande do Sul; Assistant Professor, Anesthesiology, Departament of Surgical Clinic, Universidade Federal de Ciencias da Saude de Porto Alegre; Head of the Teaching and Training Center (CET), Universidade Federal de Ciencias da Saude de Porto Alegre

Distúrbios esfincterianos secundários a tumor epidermóide intramedular: registro de um caso

A case of intraspinal epidermoid tumor of the lower thoracic and lumbar area resulting in bladder and bowell disturbances in a 10-year-old boy is reported. A brief review of literature is done and clinical and radiological aspects of this condition are discussed.

Occupational fatigue: impact on anesthesiologist's health and the safety of surgical patients. As anesthesiologists we are frequently working in a stressful environment. Do you disagree with this?

Anesthesiology is a medical specialty that has been singled out as having made major advances in patient care safety over the past few decades. Both morbidity and mortality rates have undergone signifi cant improvements due to innovations in pharmacology, monitoring and clinical approaches. However, patient harm secondary to errors made by anesthesia practitioners continues to exist in spite of the many other advances. One key cause for practitioner error that is well documented in the medical literature is the practitioner’s level of fatigue . Increasing work pressure demands coupled with personal and social commitments can be very heavy at times, frequently resulting in Fatigue Syndrome in clinical anesthesiologists. Interestingly, “fatigue” (also called exhaustion, tiredness, lethargy, languidness, languor, lassitude, and listlessness) can be differentiated into physical and mental categories. Physical fatigue can be defi ned as the inability to continue functioning at the level of one’s normal abilities, and usually becomes particularly noticeable during heavy exercise, though varying from a general state of lethargy to a specifi c work-induced burning sensation within one’s muscles . Though anesthesiologists may experience physical fatigue in the course of a busy workday, it is mental fatigue that serves as the primary causative agent for committing medical error among anesthesia practitioners. Mental fatigue manifests as somnolence (sleepiness) with the inability to concentrate or make rapid assessments and decisions. It is this mental state that is impacting anesthesiologists’ performance and putting the safety of surgical patients at risk! For decades the job of an anesthesiologist has been described as hours of boredom, interspersed with moments of terror. The key issue is to determine approaches that can be taken to prevent hours of boredom from interfering with good medical judgment when moments of terror occur. One study showed that the risk of an accident (medical err) increases exponentially with each hour after nine consecutive hours of work. At 24 hours of sustained wakefulness, the impairment in physicians’ psychomotor function may be equivalent to a blood alcohol concentration of 0.1%, which is at or above the legal limit for driving in most states in the USA . Christopher P. Landrigan highlights the importance of this subject, when he mentions in the American Joint Commission Sentinel Event Alert that “We, anesthesiologists, have a culture of working long hours and the impact of fatigue has not been a part of our consciousness”. On the other hand, The Institute of Medicine’s report “To Err Is Human: Building a Safer Health System,” reveals that medical errors contribute to many hospital deaths and serious adverse events . Studying fatigue, whether in the laboratory or clinical setting, is highly complex and diffi cult due to the multifactorial nature of fatigue, the variance over time with different individuals and the overlap of other associated conditions such as Burnout Syndrome, Chemical Dependence, Suicidality and Stress. Nevertheless, the need to study fatigue and the best ways to control it in our medical practices is paramount. Physicians are trained to practice with a patient-centered focus. This often means we ignore our own health and well being. However, when the health of the medical practitioner directly impacts on patient well being, we must turn our attention toward ourselves. In regard to fatigue this means learning to recognize it and learning ways to mitigate its effects, lest this latent threat evolve into patient harm . In regard to fatigue and long work hours, there are a few countries that have taken this issue head on. The Association of Anaesthetists of Great Britain and Ireland produced a 25-page document specifi cally dealing with the problem of fatigue in their members and made recommendations to alleviate the personal and patient safety issues of this problem . Similarly, the Australian and New Zealand College of Anaesthetists also produced a statement on fatigue where specifi c principles and responsibilities are defi ned for individual anesthesiologists, anesthesia departments and hospitals in order to reduce fatigue and attendant medical errors resulting from fatigue . In fact, specifi c recommendations in the United States concerning stringent limitations in work hours of medical residents in training came directly from the recognition that fatigue in the trainee was not only harmful to the trainee, Rev Bras Anestesiol. 2013;63(2):167-169 S0034-7094(13)70209-5 DOI: 10.1016/ S0034-7094(13)70209-5

Uso do óxido nitroso em pediatria

Resumen: Duarte LTD, Duval Neto GF, Mendes FF – Uso del Oxido Nitroso en Pediatria. DESCRIPCION DEL METODO DE RECOLECCION DE EVIDENCIA Fueron realizadas busquedas en multiples bases de datos (Medline desde 1965 a 2009; Cochrane Library ; LILACS) y referencias cruzadas con el material investigado para la iden-tificacion de los articulos con el mejor esquema metodologico, seguidas de una evaluacion critica de su contenido y clasifi-cacion de acuerdo con la fuerza de la evidencia. Las busquedas fueron realizadas entre diciembre de 2007 y abril de 2008. Para las busquedas en el PubMed , fueron utilizadas las siguientes estrategias de investigacion: 1. Nitrous Oxide [MeSH] AND Pharmacology [MeSH] AND Toxicology [MeSH]2. Nitrous Oxide [MeSH] AND Toxicology [MeSH]3. Nitrous Oxide [MeSH] AND toxicity [subheading]4. Nitrous Oxide [MeSH] AND Acute Toxicity Tests [MeSH] OR Toxicity Tests [MeSH]5. Nitrous Oxide [MeSH] AND Drug Toxicity [MeSH] OR Toxic Actions [MeSH]6. Nitrous Oxide [MeSH] AND Drug Interactions

Professional Well-being Work Party of WFSA: It is Time to Think and Take Action Regarding the Occupational Health of Anesthesiologists

The nature and intensity of the work performed by anesthesiologists have changed dramatically in recent decades. The advent of new technologies has expanded the surgical horizon, allowing intervention in more challenging medical conditions. The pressure of a growing economic competitiveness and the need to do more with a reduced workforce are associated with the emergence of more difficult cases. This transformation impacted occupational well-being of anesthesiologists. Occupational well-being is a reflex of work satisfaction, leading to overall improvement in quality of life. Finding a healthy solution to integrate the work into our life in order to provide personal balance and satisfaction will result in greater general well-being. Current epidemiological studies on occupational health of physicians are focused primarily on the investigation and analysis of somatic and/or psychological pathologies, such as degenerative, cardiovascular, toxic, and infectious pathologies, fatigue and nervous breakdown, depression, and chemical dependency 1,2. On the other hand, it is evident how little has been dome regarding the prevention of these adverse occupational problems and the continuous maintenance of occupational well-being of physicians. The need for prevention is increased by the growing risks related to occupational health of anesthesiologists, as is common knowledge, a vulnerable group. Recently, on the area of occupational health of anesthesiologists, the knowledge about the risks of somatic and/or psychological pathologies, worsened by the stress of clinical practice, has improved the diagnosis, prevention, and management of these adverse conditions 3,4. However, it is very important that anesthesiologists be aware of the aspects of their work that is causing more stress and they should know how better working conditions can be implemented to maintain their occupational health. The need for such improvements is more evident when one considers whether support systems for anesthesiologists with any deficiency have been established by professional defense associations, the state, or governmental organizations.

Analysis of brain hemometabolism behavior during carotid endarterectomy with temporary clamping

BACKGROUND AND OBJECTIVES Carotid endarterectomy with temporary clamping changes cerebral blood flow and cerebral metabolic oxygen demand ratio with consequent oligemic hypoxia or hemometabolic uncoupling. This study aimed at identifying changes in brain hemometabolism, evaluated through changes in oxyhemoglobin saturation in internal jugular vein bulb (SvjO2) during carotid endarterectomy with clamping, and at correlating these changes with potentially interfering factors, mainly end tidal CO2 pressure (P ET CO2) and cerebral perfusion pressure (CPP). METHODS Sixteen patients with unilateral carotid stenotic disease scheduled to carotid endarterectomy with carotid arterial clamping were enrolled in this study. Parameters including internal jugular bulb oxyhemoglobin saturation, stump pressure and end tidal CO2 pressure were measured at the following moments: M1 - pre-clamping; M2 - 3 minutes after clamping; M3 - pre-unclamping; M4 - post-unclamping). RESULTS The comparison among SvjO2 (%, mean +/- SD) in all studied periods has shown differences between those recorded in moments M1 (52.25 +/- 7.87) and M2 (47.43 +/- 9.19). This initial decrease stabilized during temporary clamping, showing decrease in the comparison between M2 and M3 (46.56 +/- 9.25), without statistical significance (p = ns). At post-unclamping, M4 (47.68 +/- 9.12), SvjO2 was increased as compared to M2 and M3 clamping stages, however it was still lower than that of pre-clamping stage M1.(M4 x M1 - p < 0.04) This SvjO2 decrease was followed by significant cerebral perfusion pressure (stump pressure) decrease. Factors influencing this brain hemometabolic uncoupling trend were correlated to P ET CO2. The comparison between CPP and SvjO2 showed weak correlation devoid of statistical significance. CONCLUSIONS In the conditions of our study, SvjO2 measurement is a fast and effective way of clinically monitoring changes in CBF/CMRO2 ratio. Temporary carotid clamping implies in a trend towards brain hemometabolic uncoupling and, as a consequence, to oligemic ischemia; cerebral perfusion pressure does not assesses brain hemometabolic status (CBF and CMRO2 ratio); hypocapnia, may lead to brain hemometabolic uncoupling; P ET CO2 monitoring is an innocuous and efficient way to indirectly monitor PaCO2 preventing inadvertent hypocapnia and its deleterious effects on CBF/CMRO2 ratio during temporary carotid clamping.

Dependência química em anestesiologistas: atualidade

a Emory University School of Medicine, Atlanta, USA b Professional Wellbeing Committee WFSA, USA c Harvard University, Department of Anesthesia, Boston, USA d Committee of Chemical Dependence Massachusetts General Hospital, Harvard University, Boston, USA e Penn Medicine University, Department of Anesthesia, Philadelphia, USA f Occupational Health Committee of Brazilian Society of Anesthesiology, USA

Bem‐estar ocupacional em anestesiologistas: sua relação com a metodologia educacional

¡El momento ha llegado! Ha llegado el momento de que los anestesistas se despierten y vean la necesidad inmediata que hay de obtener una satisfacción en el trabajo y un saldo positivo en la vida. A través de varias iniciativas de la World Federation of Societies of Anaesthesiologists (WFSA) (Comité de Bienestar Profesional), ASA (Comité de Salud Ocupacional) y Brazilian Society of Anesthesiology (SBA)/Confederation of Latin American Societies of Anaesthesiology (CLASA), las sociedades de anestesia en todo el mundo están intentando crear una conciencia sobre la problemática crucial del bienestar en el trabajo. Con el actual interés en la Weingology, la ciencia que estudia el bienestar, un término establecido por los autores en un capítulo anterior sobre el bienestar ocupacional, el presente editorial es un intento del Comité de Bienestar Profesional de la WFSA de identificarse con el bienestar ocupacional. En la segunda sección de este editorial, discutimos el rol de las metodologías educativas en la reducción del estrés y en la promoción del bienestar en el trabajo. El bienestar ocupacional puede definirse como un estado de gran satisfacción y realización en el trabajo. Se caracteriza por un compromiso de trabajo positivo y por una disponibilidad de recursos adecuados para afrontar las situaciones estresantes. Una integración armónica del trabajo con la vida personal que ofrezca un buen equilibrio y la satisfacción personal pueden repercutir en un bienestar general bastante eficiente. Sin embargo, cada vez está siendo más difícil ofrecer un ambiente de trabajo que esté completamente libre del estrés físico y mental. La exposición a los agentes físicos como radiación y láser, ruidos y gases anestésicos en el quirófano, el riesgo de la exposición a infecciones/contaminaciones, y el trabajo en ambientes hostiles pueden causar estrés y afectan el bienestar ocupacional. Algunos de los factores más estresantes que los propios anestesistas sienten son: la falta de control sobre la jornada de trabajo, vida familiar perjudicada, aspectos médicos y jurídicos, problemas de comunicación y problemas clínicos. Otros factores también relatados son: normas de trabajo, tratamiento de pacientes críticos, tratamiento de crisis, lidiar con la muerte, problemas relacionados con el estándar (organizacional) del trabajo, responsabilidades administrativas, conflictos personales, conflictos en las relaciones profesionales y conflictos fuera del ambiente de trabajo. Entre los residentes de anestesiología, algunas de las principales preocupaciones son manejar a los pacientes críticos, afrontar los decesos de los pacientes y equilibrar la vida personal con las exigencias profesionales. La falta de bienestar en el trabajo puede manifestarse como falta de interés por el trabajo, absentismo, insatisfacción, baja calidad del trabajo, posibilidad de cometer errores médicos (lo que puede ocurrir por negligencia y traer como resultado problemas judiciales). Todas esas situaciones denigran la imagen del profesional y a veces pueden conllevar el abandono de la carrera, la jubilación anticipada y, en casos más extremos, demandas civiles o criminales que pueden incluso llevar al suicidio. El fracaso en el mantenimiento de una relación sana con los hijos, perturbación de la vida familiar, abuso de sustancias, depresión, discapacidad mental y física, son algunas de las consecuencias sociales. Además de eso, vale la pena mencionar aquí el hecho de que no solo los factores externos, sino también los mecanismos individuales de enfrentamiento y los rasgos de personalidad, también determinan la respuesta al estrés de diferentes individuos cuando están frente a situaciones estresantes similares. Los rasgos de personalidad primarios como idealismo, perfeccionismo, timidez, inseguridad, inestabilidad emocional e incapacidad para relajarse pueden debilitar la capacidad de afrontar el estrés. Los factores negativos como las estrategias inadecuadas o la falta de estrategias para trabajar con el estrés, expectativas decepcionantes/experiencias

Occupational wellbeing in anaesthesiologists: its relationship with educational methodology

The time has come! It is time that anaesthesiologists wake up to the pressing need of work satisfaction and positive balance in life. Through various initiatives by WFSA (Professional Wellbeing Committee), ASA (Committee on Occupational Health) and SBA/CLASA, anesthesia societies all over the world are trying to create awareness on the Burning Issue of wellness at work. ‘‘With present interest in Weingology, that is the science of studying well-being, a term coined by the authors in an earlier chapter on Occupational Wellbeing, the present editorial is an attempt by the Professional Wellbeing Committee at WFSA to identify with Occupational Wellbeing. In the second section of this editorial, we discuss the role of educational methodologies in reducing stress and promoting wellness at work. Occupational wellbeing maybe defined as a state of high job satisfaction and fulfillment at work. It is characterized by a positive job engagement and availability of adequate resources to cope with stressful situations. A sweet integration of work with personal life that provides a good balance and personal satisfaction can lead to an enhanced overall wellbeing. However, it is getting extremely difficult to provide a work environment that is completely free from physical and mental stress. Exposure to physical agents like radiation/lasers/theater noise/anesthetic gases, risk of exposure to infections/contaminations, working in hostile environments can all cause stress and affect the occupational wellbeing. Some of the most stressful factors as perceived by anesthesiologists themselves are: lack of control over their workday, jeopardized family life, medical and legal aspects, communication problems and clinical problems. Other factors also reported are: work standards, management of critical patients, crisis management, dealing with death, problems related to work pattern (organizational), administrative responsibilities, personal conflicts, conflicts in professional relationships and conflicts outside the work environment. Among anesthesiology residents, some of the main concerns are managing critical patients, dealing with patients’ deaths and balancing personal life with professional demands. Lack of occupational wellbeing may manifest as lack of interest in work, absenteeism, dissatisfaction, low-quality work, possibility of medical malpractice (which may occur through negligence and result in legal problems). All these situations denigrate the professionals image and may sometimes result in career abandonment, premature retirement and, in extreme cases, civil or criminal issues that can even lead to suicide. Failure in maintaining a healthy relationship with children, disruption of family life, substance abuse, depression, physical and mental impairment are some of the social consequences. Also, worth mentioning here is the fact that not only the external factors, but individual coping mechanisms and personality traits also determine the stress response from different individuals when faced with similar stressful situations. Primary personality traits like idealism, perfectionism, timidity, insecurity, emotional instability and inability to relax can all weaken the coping ability to stress. Negative factors like inadequate or lacking strategies to deal with stress, disappointed expectations/negative experiences, inadequate support due to a lack of social relationships/partnerships, lack of patient gratitude for medical care provided, risks of litigation can also affect our occupational wellbeing. Hence, what we need at the individual level is the development of well functioning coping strategies. We have to train ourselves in identifying stressful factors at work. Next step can be to identify areas which we can modify to mitigate the stress effects. Development of positive job traits during anesthesiology training can also contribute toward a healthy, motivated anesthetist of tomorrow.