Gilson Cassem Ramos

Bloqueio do nervo supraescapular: procedimento importante na prática clínica. Parte II

The suprascapular nerve block is a reproducible, reliable, and extremely effective treatment method in shoulder pain control. This method has been widely used by professionals in clinical practice such as rheumatologists, orthopedists, neurologists, and pain specialists in the treatment of chronic diseases such as irreparable rotator cuff injury, rheumatoid arthritis, stroke sequelae, and adhesive capsulitis, which justifies the present review (Part II). The objective of this study was to describe the techniques and complications of the procedure described in the literature, as the first part reported the clinical indications, drugs, and volumes used in single or multiple procedures. We present in details the accesses used in the procedure: direct and indirect, anterior and posterior, lateral and medial, upper and lower. There are several options to perform suprascapular nerve block. Although rare, complications can occur. When properly indicated, this method should be considered.

Marcapasso cardíaco artificial: considerações pré e per-operatórias

BACKGROUND AND OBJECTIVES Technological medical diagnosis advances in cardiology have markedly increased indications for temporary or permanent artificial cardiac pacemakers (PM). This means that, in addition to cardiologists, other specialists have become involved in the handling of these devices. When PM patients undergo surgery, anesthesiologists participation may be decisive for the success of the procedure. This review aimed at familiarizing anesthesiologists with major clinical indications and operation of these devices, as well as with PM-related pre and intraoperative cares. CONTENTS Classification, operation, and major clinical indications for PM implants are covered. In addition, primary PM-related pre and intraoperative cares required for success are explained. CONCLUSIONS Basic understanding of PM operation and indications should be part of anesthesiologists daily practice. Hence, handling and indication of temporary PM broadens these specialists scope, in addition to saving lives in emergency situations. Electric cautery should be avoided in artificial cardiac pacemaker patients.JUSTIFICATIVA Y OBJETIVOS: El progreso tecnologico de la propedeutica medica diagnostica en cardiologia difundio grandemente la indicacion de marcapaso (MP) cardiaco artificial, definitivo o temporario. Esto hizo con que otros especialistas, ademas de los cardiologistas, se envolvieran todavia mas en el manoseo de eses aparatos. Cuando pacientes portadores de MP se presentan para cirugia, la participacion del anestesista puede ser decisiva para el suceso del procedimiento. El objetivo de la actual revision es familiarizar al anestesista con las principales indicaciones clinicas y con el funcionamiento de eses dispositivos, ademas de los cuidados pre y per-operatorios que se debe tener. CONTENIDO: Fueron tratadas la clasificacion, funcionamiento y las principales indicaciones clinicas para la implantacion de MP. De la misma forma, se pretendio elucidar los principales cuidados pre y per-operatorios relativos al uso de MP para lograr exito en el procedimiento indicado. CONCLUSIONES: Los principales conocimientos sobre el funcionamiento del MP y sus indicaciones clinicas deben hacer parte de la practica diaria del anestesista. De esa forma, el manoseo y la indicacion del MP temporario amplia la actuacion de eses especialistas, ademas de que puede salvar vidas, inclusive en situaciones de emergencia dentro del centro quirurgico. El uso de eletrocauterio deberia ser evitado en portadores de MP.

Bloqueio do nervo supraescapular: procedimento importante na prática clínica

JUSTIFICATIVA E OBJETIVOS: A dor no ombro e uma queixa frequente que ocasiona grande incapacidade funcional no membro acometido, assim como reducao na qualidade de vida dos pacientes. O bloqueio do nervo supraescapular e um metodo terapeutico eficaz e vem sendo cada vez mais utilizado pelos anestesiologistas tanto para anestesia regional quanto para analgesia pos-operatoria de cirurgias realizadas nesta articulacao, o que justifica a presente revisao, cujo objetivo principal e descrever a tecnica aplicada e as indicacoes clinicas. CONTEUDO: Apresenta-se a anatomia do nervo supraescapular, desde a sua origem do plexo braquial ate os seus ramos terminais, assim como as caracteristicas gerais e a tecnica empregada na execucao do bloqueio deste nervo, as principais drogas utilizadas e o volume e as situacoes em que se faz jus a sua aplicacao. CONCLUSOES: O bloqueio do nervo supraescapular e um procedimento seguro e extremamente eficaz na terapia da dor no ombro. Tambem de facil reprodutibilidade, esta sendo muito utilizado por profissionais de varias especialidades medicas. Quando bem indicado, este metodo deve ser considerado

Avaliação da função pulmonar após colecistectomias laparoscópicas e convencionais

BACKGROUND: To evaluate pulmonary function after laparoscopic and subcostal cholecystectomies. METHODS: This was a randomized study, in which postoperative spirometries in two groups of fifteen patients each were evaluated. Group GL underwent laparoscopic chlecystectomies. Group GA underwent open subcostal cholecystectomies by means of mini-laparatomy, in abbreviated anesthetic-surgical time. The two groups´ variables were compared using ANOVA. Within the same group, before and after the operations, the paired Student-t test was used. A value of p < 0.05 was considered statistically significant. RESULTS: All patients from both groups presented restrictive postoperative ventilatory disturbances, with a faster spirometric normalization for those patients operated through laparoscopy. Groups GL vs. GA, in immediate post-operative: Forced Vital Capacity (p < 0.001) and Forced Expiratory Volume in one second (p < 0.001). CONCLUSION: Postoperative harm to pulmonary function was significantly less in laparoscopic than in open cholecystectomies, even with mini-laparotomies and abbreviated anesthetic-surgical time.Background: To evaluate pulmonar y function after lapar oscopic and subcostal cholecystectomies . Methods: This was a randomized study , in which postoperative spir ometries in two gr oups of fifteen patients each wer e evaluated. Gr oup GL underwent lapar oscopic chlecystectomies. Gr oup GA underwent open subcostal cholecystectomies by means of mini-laparatomy , in abbreviated anesthetic-sur gical time. The two gr oups ́ variables wer compar ed using ANOVA. Within the same gr oup, before and after the operations, the paired Student-t test was used. A value of p < 0.05 was considered statistically significant. Results: All patients from both groups presented restrictive postoperative ventilatory disturbances, with a faster spirometric normalization for those patients operated thr ough lapar oscopy. Groups GL vs. GA, in immediate post-operative: For ced Vital Capacity (p < 0.001) and For ced Expirator y Volume in one second (p < 0.001). Conclusion: Postoperative harm to pulmonar y function was significantly less in laparoscopic than in open cholecystectomies, even with mini-laparotomies and abbreviated anesthetic-surgical time.

Does alkalinization of 0.75% ropivacaine promote a lumbar peridural block of higher quality?

Background and Objectives We did not find clinical studies of the alkalization of ropivacaine in the literature. The objectives of this study were: (1) to determine the quantity of sodium bicarbonate (NaHCO3), which alkalinizes 0.75% ropivacaine (with and without adrenaline); (2) to verify the physico-chemical alterations arising from this alkalization; and (3) to determine whether alkalinized ropivacaine produces a higher-quality epidural block measured via sensory-motor onset, block spread and anesthesia duration. Methods It was determined in the laboratory that 0.012 and 0.015 mEq of NaHCO3, respectively, alkalinized 10 mL of the 0.75% ropivacaine solutions without and with adrenaline (1:200,000). In the second phase, the study was random and double-blind and involved 60 patients divided into 3 groups of 20 (G1, G2, and G3). Via epidural lumbar blocks, these groups received, respectively, 10 mL of 0.75% ropivacaine plus 0.5 mL of 0.9% NaCl (solution A), 10 mL of 0.75% ropivacaine plus 0.0012 mEq of NaHCO3 (solution B), and 10 mL of 0.75% ropivacaine (with adrenaline) plus 0.015 mEq of NaHCO3 (solution C). The pH, PCO2 (partial CO2 pressure), and the nonionized fractions of the 0.75% ropivacaine solutions were compared before and after the addition of 0.9% NaCl or NaHCO3 or adrenaline plus NaHCO3. The motor and sensory onsets, block spread, and the duration of the block were evaluated. Results The values of the pH, PCO2, and nonionized fractions increased significantly in solutions B and C in relation to solution A. No differences among the groups were observed in relation to block spread and sensory-motor onset. The duration of the sensory blocks was significantly greater in the patients in groups G2 and G3. Conclusions This study indicates that the quantity of NaHCO3 needed to alkalize 10 mL of 0.75% ropivacaine at room temperature is 0.012 mEq. When the solution contains adrenaline 1:200,000 (mg · mL−1), up to 0.015 mEq of NaHCO3 may be added. The alkalization of the 0.75% ropivacaine solution did not cause a reduction of sensory-motor onset, but did provide a significant increase in the duration of the epidural block with no significant differences between the solutions with and without adrenaline.

Aspectos históricos da pressão arterial de oxigênio e espirometria relacionados à operação abdominal

INTRODUCTION: Operations, particularly those of the upper abdomen, can be accompanied by hypoxemia and restrictive ventilatory disturbances. The objectives of the present review were: a) to provide a retrospective of spirometric techniques and laboratory assessment of hypoxemia by means of arterial oxygen pressure; b) to review the main factors responsible for alterations in postoperative pulmonary function. METHODS: A historical overview is given of the main aspects of spirometry and PaO2, measurement, considering these exams as measures of pulmonary function after abdominal operations. CONCLUSION: Operations on the upper part of the abdomen may be followed by hypoxemia and restrictive ventilatory disturbances, whose principal cause is diaphragmatic dysfunction which can be minimized by means of laparoscopy and effective post-operative pain treatment.

Neuropathic pain after epidural needle trauma

BACKGROUND AND OBJECTIVES Neurologic complications secondary to epidural block are uncommon. Direct mechanical trauma to nerve roots may cause neuropathic pain that, usually, has a favorable evolution; however, it is a potentially severe complication that can evolve into a chronic disorder. The objective of this study was to discuss acute traumatic neuropathic pain and, especially, its treatment. CASE REPORT A male patient was admitted for surgical treatment of gastroesophageal reflux via laparoscopy and scheduled to be discharged on the first postoperative (PO) day. He underwent epidural block associated with general anesthesia. During the localization of the epidural space, the patient complained of severe pain in the left lower limb. The needle was repositioned and the epidural space was located. In the PO, the patient developed allodynia and hyperesthesia. Neuropathic pain was diagnosed. Treatment included antidepressant, anticonvulsant, corticosteroids, tramadol, and vitamin B complex. On the 28th PO the patient was asymptomatic and presented a normal physical exam, being discharged from the hospital. CONCLUSIONS The patient presented a favorable evolution with the treatment instituted. Early diagnosis and treatment can avoid irreversible lesions, change the prognosis, and avoid social and medical-legal consequences.

Dor neuropática após trauma com agulha de peridural

BACKGROUND AND OBJECTIVES Neurologic complications secondary to epidural block are uncommon. Direct mechanical trauma to nerve roots may cause neuropathic pain that, usually, has a favorable evolution; however, it is a potentially severe complication that can evolve into a chronic disorder. The objective of this study was to discuss acute traumatic neuropathic pain and, especially, its treatment. CASE REPORT A male patient was admitted for surgical treatment of gastroesophageal reflux via laparoscopy and scheduled to be discharged on the first postoperative (PO) day. He underwent epidural block associated with general anesthesia. During the localization of the epidural space, the patient complained of severe pain in the left lower limb. The needle was repositioned and the epidural space was located. In the PO, the patient developed allodynia and hyperesthesia. Neuropathic pain was diagnosed. Treatment included antidepressant, anticonvulsant, corticosteroids, tramadol, and vitamin B complex. On the 28th PO the patient was asymptomatic and presented a normal physical exam, being discharged from the hospital. CONCLUSIONS The patient presented a favorable evolution with the treatment instituted. Early diagnosis and treatment can avoid irreversible lesions, change the prognosis, and avoid social and medical-legal consequences.

Influência da morfina peridural na função pulmonar de pacientes submetidos à colecistectomia aberta

BACKGROUND AND OBJECTIVES Upper abdominal surgeries may cause postoperative respiratory dysfunction. The objective of this study was to evaluate the pulmonary function after laparoscopic and open cholecystectomies, with and without epidural morphine. METHODS In this randomized, double-blind clinical trial, 45 patients undergoing cholecystectomies were divided in three groups: GL, GA, and GAM, composed of 15 patients each. The GL group underwent laparoscopic surgery, while GA and GAM underwent open cholecystectomy, but the former received epidural morphine. Pre- and postoperative spirometry and arterial blood gases were performed. ANOVA was used to verify the hypothesis of equality of the means among the groups. When results were statistically significant, the Tukey test was performed. Paired test t Student was used to verify the hypothesis of equality within a group. A p < 0.05 was considered significant. RESULTS The pre and immediately postoperative spirometry results were used to determine: a) forced vital capacity (FVC) in GL versus GA (p = 0.000) and GL versus GAM (p = 0.000); percentage of the reduction of FVC in GA versus GAM (p = 0.001); b) within each group: in GL, FVC (p = 0.020) and forced expiratory volume in 1 second (FEV1) (p = 0.022); in GA, FVC (p < 0.001) and FEV1 (p < 0.001); and in GAM, FVC (p = 0.007) and FEV1 (p = 0.001). The arterial oxygen pressure (PaO2) was reduced in all three groups. CONCLUSIONS One can conclude that respiratory dysfunction was less severe in patients operated by laparoscopy and that epidural morphine reversed, partially, the postoperative ventilatory disturbances of open cholecystectomy.BACKGROUND AND OBJECTIVES: Upper abdominal surgeries may cause postoperative respiratory dysfunction. The objective of this study was to evaluate the pulmonary function after laparoscopic and open cholecystectomies, with and without epidural morphine. METHODS: In this randomized, double-blind clinical trial, 45 patients undergoing cholecystectomies were divided in three groups: GL, GA, and GAM, composed of 15 patients each. The GL group underwent laparoscopic surgery, while GA and GAM underwent open cholecystectomy, but the former received epidural morphine. Pre- and postoperative spirometry and arterial blood gases were performed. ANOVA was used to verify the hypothesis of equality of the means among the groups. When results were statistically significant, the Tukey test was performed. Paired test t Student was used to verify the hypothesis of equality within a group. A p < 0.05 was considered significant. RESULTS: The pre and immediately postoperative spirometry results were used to determine: a) forced vital capacity (FVC) in GL versus GA (p = 0.000) and GL versus GAM (p = 0.000); percentage of the reduction of FVC in GA versus GAM (p = 0.001); b) within each group: in GL, FVC (p = 0.020) and forced expiratory volume in 1 second (FEV1) (p = 0.022); in GA, FVC (p < 0.001) and FEV1 (p < 0.001); and in GAM, FVC (p = 0.007) and FEV1 (p = 0.001). The arterial oxygen pressure (PaO2) was reduced in all three groups. CONCLUSIONS: One can conclude that respiratory dysfunction was less severe in patients operated by laparoscopy and that epidural morphine reversed, partially, the postoperative ventilatory disturbances of open cholecystectomy.

Avaliação pré-operatória do pneumopata

BACKGROUND AND OBJECTIVES Lung complications are the most frequent causes of postoperative morbidity-mortality, especially in lung disease patients. So, those patients should be preoperatively carefully evaluated and prepared, both clinically and laboratorially. This review aimed at determining surgical risk and at establishing preoperative procedures to minimize peri and postoperative morbidity-mortality in lung disease patients. CONTENTS Major anesthetic-surgical repercussions in lung function have already been described. Similarly, we tried to select higher-risk patients, submitted or not to lung resection. To that end, clinical and laboratorial propedeutics were used. Finally, a proposal of a preoperative algorithm was presented for procedures with lung resection. CONCLUSIONS Lung disease patients, especially those with chronic evolution, need to be preoperatively thoroughly evaluated. ASA physical status and Goldmans cardiac index are important risk forecasting factors for lung disease patients not candidates for lung resection. Adding to these criteria, estimated postoperative max VO2, FEV1 and diffusion capacity are mandatory for some patients submitted to lung resection. beta2-agonists and steroids should be considered in the preoperative period of these patients.JUSTIFICATIVA E OBJETIVOS: As complicacoes pulmonares sao as causas mais frequentes de morbimortalidade pos-operatoria, especialmente nos pneumopatas. Por essa razao, esses pacientes devem ser criteriosamente avaliados e preparados no pre-operatorio, tanto do ponto de vista clinico como laboratorial. O objetivo da presente revisao e determinar o risco cirurgico e estabelecer condutas pre-operatorias para minimizar a morbimortalidade per e pos-operatorias, nos portadores de doencas respiratorias. CONTEUDO: As principais repercussoes do ato anestesico-cirurgico na funcao pulmonar foram relatadas. Da mesma forma, procurou-se selecionar os pacientes de maior risco, envolvidos ou nao em resseccao pulmonar. Para esse fim, utilizou-se da propedeutica clinica e laboratorial. Finalmente, foi apresentada uma proposta de algoritmo pre-operatorio para os procedimentos com resseccao pulmonar. CONCLUSOES: O portador de doenca respiratoria, especialmente as de evolucao cronica, necessita ser rigorosamente avaliado no pre-operatorio. A classificacao do estado fisico (ASA) e o indice de Goldman sao fatores de previsao de risco importantes nos pneumopatas nao-candidatos a resseccao pulmonar. Somando-se a esses criterios, nos candidatos a resseccao pulmonar, o VO2 max, o VEF1e capacidade de difusao estimados para o pos-operatorio, sao imprescindiveis, em algumas situacoes. Os b2-agonistas e corticoides devem ser considerados nos pre-operatorios desses pacientes.