Hélio Halpern

Carbon dioxide is a cost-effective contrast medium to guide revascularization of TASC A and TASC B femoropopliteal occlusive disease.

BACKGROUND Iodine contrast medium (ICM) is considered gold standard in endovascular revascularization procedures. However, nephrotoxicity and hypersensitivity to ICM are causes that limit its indiscriminate use. Carbon dioxide (CO2) contrast angiography has been used as an alternative in patients with formal contraindication to ICM. However, no studies to the present date have compared in a randomized and prospective way, outcomes of revascularization procedures performed with either ICM or CO2 in patients eligible for use of both contrasts. METHODS Between April 2012 and April 2013, 35 patients with peripheral arterial disease with arterial lesions classified as Trans-Atlantic Inter-Society Consensus A or B (identified on preoperative angio computed tomography scan) and adequate runoff underwent femoropopliteal revascularization by endovascular technique in a prospective, randomized, and controlled study. Patients were randomized into 2 groups: CO2 group and ICM group, according to the contrast media selected of the procedure. We evaluated the following outcomes in both groups: feasibility of the procedures, complications, surgical outcomes (ankle-brachial index [ABI]), glomerular filtration rate using the Cockcroft-Gault formula, relationship between the volume of injected iodine and postoperative creatinine clearance, quality of the angiographic images obtained with CO2, costs of the endovascular materials, and finally, cost of contrast agents. RESULTS We were able to perform the proposed procedures in all patients treated in this series (ICM group and CO2). There were no CO2-related complications. No procedures required conversion to open surgery. Clinical results were satisfactory, with regression of ischemia and increased levels of ABI in both groups. Variations in creatinine clearance levels showed a numerical increase in the CO2 group and a decrease in ICM group, however, with no statistically significant difference between the delta clearance in each group. All CO2 arteriograms of the supragenicular arteries were graded as good or fair by both observers with high interobserver image quality concordance. There was no statistical difference between endovascular material costs between the groups, but the contrast cost was significantly lower in CO2 group (P < 0.001). CONCLUSIONS The use of CO2 in patients with no restriction for ICM is an alternative that does not limit the feasibility of the procedures. Similar outcomes were observed with CO2 when compared with the gold standard contrast (ICM) regarding quality of images produced, with no associated changes in creatinine clearance or hypersensitivity reactions and also allows a reduction in contrast-related costs in angioplasty procedures.

Infrarenal aortic aneurysm repair by retroperitoneal approach combined with laparoscopic cholecystectomy: Two case reports

Simultaneous repair of abdominal aortic aneurysm and treatment of cholelithiasis by the transperitoneal approach is controversial because of the risk of prosthesis infection. We report two patients who underwent a successful combined procedure using a retroperitoneal approach for the aortic aneurysm repair and a laparoscopic approach to the cholecystectomy. This combined approach reduces the risk of infection of the aortic prosthesis and is associated with a rapid return of normal peristalsis.

Rapid inhalation induction with halothane-nitrous oxide for myasthenic patients

Rapid inhalation induction (RII) was successfully employed for patients without myopathy. Inhalatory agents can be used for anaesthetic induction of myasthenics, avoiding the use of neuromuscular blocking agents. We studied the use of RII in 15 myasthenics (MG) and in 15 normal subjects (nMG), measuring induction time (TI), cardiorespiratory effects, complications, and evaluated the patient’s reaction to RII. The patients were submitted to elective transsternal thymectomy (MG) and gynaecological or lower abdominal surgery (nMG). No premedication was used. After preoxygenation, RII was started using a mixture of 4% halothane and O2:N2O (1:2). They performed three vital capacity breaths, followed by normal spontaneous ventilation. The TI was assessed by timing the loss of verbal command (TLVC) and loss of eyelid reflex (TLER). Systolic and diastolic pressure, pulse oximetry, capnometry, respiratory rate (RR) and heart rate (HR) were measured during induction at each minute, for four minutes. After a postanaesthetic questionnaire only two normal subjects did not like the RII technique. Mean values for TLVC and TLER were 67 and 73 sec for MG and 64 and 69 sec for nMG, respectively. There was no change in HR for MG or blood pressure. The RR increased in both groups, but no change inPetCO2 was observed; SaO2 was > 97%. In conclusion, RII can be performed rapidly and safely in myasthenic patients and is a technique that should be considered for the induction of anaesthesia in myasthenic patients.RésuméL’induction rapide par inhalation (IIR) a été utilisée avec succès chez des patients non myasthéniques. On peut administrer des inhalatoires pour l’induction de l’anesthésie chez le myasthénique et éviter ainsi d’utiliser des myorésolutifs. Nous avons comparé l’IIR chez 15 myasthéniques (MG) et 15 sujets normaux (nMG). Nous avons mesuré le temps d’induction (TI), le retentissement cardiovasculaire, les complications et la réaction du patient à ce type d’induction. Les MG ont subi une thymectomie programmée trans-sternale et les nMG une chirurgie programmée abdominale basse ou gynécologique. Aucun des patients n’a reçu de prémédication. Après préoxygénation, l’IIR est initiée avec un mélange d’halothane 4% et de O2:N2O (1:2). Les patients ont exécuté trois capacités vitales et poursuivi en respirant normalement. Le TI a été évalué par la perte de la réponse aux ordres et du réflexe palpébral. A l’induction, la TA systolique et diastolique, l’oxymétrie puisée, la capnométrie, la fréquence respiratoire (Fr) et cardiaque (Fc) ont été mesurés à la minute pendant quatre minutes. Au questionnaire postanesthésique, deux des malades (nMG) seulement ont répondu qu’ils n’avaient pas aimé la technique de IIR. Les valeurs moyennes pour la perte de réponse aux ordres et du réflexe palpébral pour les MG étaient de 67 et 73 sec et pour les nMG, de 64 et 69 sec. La Fc et la TA n’ont pas changé dans le groupe MG. La Fr a augmenté dans les deux groupes, mais on n’a pas noté de changement de laPetCO2; la SaO2 était > 97%. Pour conclure, la IIR est réalisée rapidement et en toute sécurité chez les myasthéniques et représente une technique qui mérite considération chez ces patients.

Fenoldopam: novo antihipertensivo parenteral; alternativa ao nitroprussiato

JUSTIFICATIVA E OBJETIVOS: O fenoldopam e um agonista dopaminergico seletivo para os receptores dopaminergicos tipo 1 (DA-1) que causa vasodilatacao periferica e o objetivo deste artigo e reunir as informacoes clinicas sobre este farmaco. CONTEUDO: Neste artigo foram revisadas as experiencias em urgencias e emergencias hipertensivas, mostrando que o fenoldopam apresenta vantagens sobre o nitroprussiato de sodio (NPS) no tratamento das mesmas. Ao contrario do NPS, o fenoldopam causa vasodilatacao periferica, ao mesmo tempo que induz diurese e natriurese em pacientes com hipertensao grave sem causar os efeitos deleterios pelo tiocianato. CONCLUSOES: O fenoldopam parenteral, pelos seus efeitos renais e menor impacto de efeitos colaterais, pode ser considerado uma boa alternativa ao nitroprussiato de sodio no tratamento de emergencias hipertensivas.JUSTIFICATIVA Y OBJETIVOS: El fenoldopam es un agonista dopaminergico selectivo para los receptores dopaminergicos tipo 1 (DA-1) que causa vasodilatacion periferica y el objetivo de este articulo es reunir las informaciones clinicas sobre este farmaco. CONTENIDO: En este articulo fueron revisadas las experiencias en urgencias y emergencias hipertensivas, mostrando que el fenoldopam presenta ventajas sobre el nitroprusiato de sodio (NPS) en el tratamiento de las mismas. Al contrario del NPS, el fenoldopam causa vasodilatacion periferica, al mismo tiempo que induce diuresis y natriuresis en pacientes con hipertension grave sin causar los efectos deleterios por el tiocianato. CONCLUSIONES: El fenoldopam parenteral, por sus efectos renales y menor impacto de efectos colaterales, pode ser considerado una buena alternativa al nitroprusiato de sodio en tratamiento de emergencias hipertensivas.

Fenoldopan: a new parenteral anti-hypertensive; an alternative to nitroprusside

JUSTIFICATIVA E OBJETIVOS: O fenoldopam e um agonista dopaminergico seletivo para os receptores dopaminergicos tipo 1 (DA-1) que causa vasodilatacao periferica e o objetivo deste artigo e reunir as informacoes clinicas sobre este farmaco. CONTEUDO: Neste artigo foram revisadas as experiencias em urgencias e emergencias hipertensivas, mostrando que o fenoldopam apresenta vantagens sobre o nitroprussiato de sodio (NPS) no tratamento das mesmas. Ao contrario do NPS, o fenoldopam causa vasodilatacao periferica, ao mesmo tempo que induz diurese e natriurese em pacientes com hipertensao grave sem causar os efeitos deleterios pelo tiocianato. CONCLUSOES: O fenoldopam parenteral, pelos seus efeitos renais e menor impacto de efeitos colaterais, pode ser considerado uma boa alternativa ao nitroprussiato de sodio no tratamento de emergencias hipertensivas.JUSTIFICATIVA Y OBJETIVOS: El fenoldopam es un agonista dopaminergico selectivo para los receptores dopaminergicos tipo 1 (DA-1) que causa vasodilatacion periferica y el objetivo de este articulo es reunir las informaciones clinicas sobre este farmaco. CONTENIDO: En este articulo fueron revisadas las experiencias en urgencias y emergencias hipertensivas, mostrando que el fenoldopam presenta ventajas sobre el nitroprusiato de sodio (NPS) en el tratamiento de las mismas. Al contrario del NPS, el fenoldopam causa vasodilatacion periferica, al mismo tiempo que induce diuresis y natriuresis en pacientes con hipertension grave sin causar los efectos deleterios por el tiocianato. CONCLUSIONES: El fenoldopam parenteral, por sus efectos renales y menor impacto de efectos colaterales, pode ser considerado una buena alternativa al nitroprusiato de sodio en tratamiento de emergencias hipertensivas.

Fenoldopam: nuevo antihipertensivo parenteral; alternativa al nitroprusiato

JUSTIFICATIVA E OBJETIVOS: O fenoldopam e um agonista dopaminergico seletivo para os receptores dopaminergicos tipo 1 (DA-1) que causa vasodilatacao periferica e o objetivo deste artigo e reunir as informacoes clinicas sobre este farmaco. CONTEUDO: Neste artigo foram revisadas as experiencias em urgencias e emergencias hipertensivas, mostrando que o fenoldopam apresenta vantagens sobre o nitroprussiato de sodio (NPS) no tratamento das mesmas. Ao contrario do NPS, o fenoldopam causa vasodilatacao periferica, ao mesmo tempo que induz diurese e natriurese em pacientes com hipertensao grave sem causar os efeitos deleterios pelo tiocianato. CONCLUSOES: O fenoldopam parenteral, pelos seus efeitos renais e menor impacto de efeitos colaterais, pode ser considerado uma boa alternativa ao nitroprussiato de sodio no tratamento de emergencias hipertensivas.JUSTIFICATIVA Y OBJETIVOS: El fenoldopam es un agonista dopaminergico selectivo para los receptores dopaminergicos tipo 1 (DA-1) que causa vasodilatacion periferica y el objetivo de este articulo es reunir las informaciones clinicas sobre este farmaco. CONTENIDO: En este articulo fueron revisadas las experiencias en urgencias y emergencias hipertensivas, mostrando que el fenoldopam presenta ventajas sobre el nitroprusiato de sodio (NPS) en el tratamiento de las mismas. Al contrario del NPS, el fenoldopam causa vasodilatacion periferica, al mismo tiempo que induce diuresis y natriuresis en pacientes con hipertension grave sin causar los efectos deleterios por el tiocianato. CONCLUSIONES: El fenoldopam parenteral, por sus efectos renales y menor impacto de efectos colaterales, pode ser considerado una buena alternativa al nitroprusiato de sodio en tratamiento de emergencias hipertensivas.