Luiz Marciano Cangiani

Eficácia do emprego da metadona ou da clonidina no intraoperatório para controle da dor pós-operatória imediata após uso de remifentanil

BACKGROUND AND OBJECTIVES Due to its pharmacokinetic characteristics, remifentanil does not promote residual analgesia in the immediate postoperative period. The objective of this study was to compare the efficacy of methadone and clonidine in the control of postoperative pain of videolaparoscopic surgeries under total intravenous anesthesia with target-controlled remifentanil infusion. METHODS One hundred and twenty-six patients, ages 18 to 65 years, ASA I and II, of both genders, scheduled for laparoscopic surgeries, participated in this randomized, double- blind, placebo-controlled study. After venipuncture, intravenous ketoprofen and dypirone were administered. Target-controlled infusion of remifentanil and propofol was used for induction and maintenance of anesthesia. Before beginning the procedure, an intravenous solution containing 0.1 mg.kg-1 of methadone (methadone group), 2.0 (1/4)g.kg-1 of clonidine (clonidine group), or NS (placebo group) was administered. In the post-anesthetic care unit, postoperative pain was evaluated by the Verbal Numeric Scale (VNS). Absence of pain was defined as a score < 2, and pain as a score of > 3. RESULTS The incidence of pain in the methadone group was significantly lower than in the clonidine and placebo groups (11, 21, and 23, respectively; p < 0.02). Significant differences in the incidence of pain in the placebo and clonidine groups were not observed. CONCLUSIONS Methadone was more effective than clonidine in the control of postoperative pain in videolaparoscopic surgeries under total intravenous anesthesia with remifentanil; and using clonidine was not better than not using it.

Efficacy Of Intraoperative Methadone And Clonidine In Pain Control In The Immediate Postoperative Period After The Use Of Remifentanil

BACKGROUND AND OBJECTIVES Due to its pharmacokinetic characteristics, remifentanil does not promote residual analgesia in the immediate postoperative period. The objective of this study was to compare the efficacy of methadone and clonidine in the control of postoperative pain of videolaparoscopic surgeries under total intravenous anesthesia with target-controlled remifentanil infusion. METHODS One hundred and twenty-six patients, ages 18 to 65 years, ASA I and II, of both genders, scheduled for laparoscopic surgeries, participated in this randomized, double- blind, placebo-controlled study. After venipuncture, intravenous ketoprofen and dypirone were administered. Target-controlled infusion of remifentanil and propofol was used for induction and maintenance of anesthesia. Before beginning the procedure, an intravenous solution containing 0.1 mg.kg-1 of methadone (methadone group), 2.0 (1/4)g.kg-1 of clonidine (clonidine group), or NS (placebo group) was administered. In the post-anesthetic care unit, postoperative pain was evaluated by the Verbal Numeric Scale (VNS). Absence of pain was defined as a score < 2, and pain as a score of > 3. RESULTS The incidence of pain in the methadone group was significantly lower than in the clonidine and placebo groups (11, 21, and 23, respectively; p < 0.02). Significant differences in the incidence of pain in the placebo and clonidine groups were not observed. CONCLUSIONS Methadone was more effective than clonidine in the control of postoperative pain in videolaparoscopic surgeries under total intravenous anesthesia with remifentanil; and using clonidine was not better than not using it.

Tampão sangüíneo peridural em pacientes testemunhas de Jeová: relato de dois casos

JUSTIFICATIVA Y OBJETIVOS: Existen relatos del empleo del tampon sanguineo peridural en pacientes Testigos de Jehova, utilizando un sistema cerrado que permite que se pueda recoger sangre y la inyeccion en el espacio peridural, sin perdida de continuidad. El objetivo de este relato es presentar dos casos de pacientes Testigos de Jehova que presentaron cefalea despues de anestesia subaracnoidea y que fueron tratados con tampon sanguineo peridural con un sistema cerrado de transfusion de sangre venoso para el espacio peridural. Los casos acontecieron en hospitales de dos diferentes ciudades. RELATO DE LOS CASOS: Un paciente del sexo masculino, de 21 anos, y una paciente del sexo femenino, de 32 anos, presentaron cefalea pos-raquianestesia para cirugia ambulatorial. Como los pacientes eran Testigos de Jehova, el tampon sanguineo fue realizado con un sistema cerrado. El sistema fue preparado en condiciones esteriles, utilizandose los siguientes materiales: dos equipos de suero cortados en segmentos de 60 cm, una conexion de dos vias, una llave de tres vias y una jeringa de 20 ml. El sistema fue montado de manera que pudiera permitir una conexion con la aguja de la venopuncion (20G), una conexion a la llave de tres vias, siendo que a las otras dos vias fueron conectados una jeringa de 20 ml y el otro segmento del equipo de suero, que seria conectado a la aguja de peridural. Con los pacientes posicionados en decubito lateral izquierdo fue hecha la anti-sepsia de la region lumbar y del miembro superior derecho en la region escogida para la venopuncion. Inicialmente fue hecha puncion peridural en el espacio L2-L3, con aguja 17G, siendo que la misma fue mantenida fija y el equipo de suero conectado a ella. A seguir fue hecha venopuncion con la aguja conectada a la otra extremidad del equipo de suero con el direccionamento de la llave de tres vias en el sentido de la vena para la jeringa. Fueron aspirados 15 ml de sangre. Con el redireccionamento de la llave en el sentido de la jeringa para la aguja de peridural fueron inyectados los 15 ml de sangre. CONCLUSIONES: En pacientes Testigos de Jehova, que rehuyen al tratamiento clinico, la inyeccion de sangre autologa podra ser hecha con la tecnica presentada, despues de la debida informacion al paciente y su consentimiento.BACKGROUND AND OBJECTIVES There are reports on epidural blood patch in Jehovahs Witness patients using a closed system which allows blood collection and epidural injection without loss of continuity. This report aimed at presenting two cases of Jehovahs Witness patients with post-dural puncture headache and treated with epidural blood patch in a closed venous blood transfusion system to the epidural space. Cases were reported by two different hospitals in two different cities. CASE REPORTS One 21 years old male patient and one 32 years old female patient, with post-dural puncture headache after outpatient procedures. Since they were Jehovahs Witnesses, blood patch was performed with a closed system. System was prepared in sterile conditions using the following materials: two serum catheters cut in 60 cm segments, one two-way connection, one three-way tap and one 20 ml syringe. System was assembled to allow one connection to the puncture needle (20G), one connection to the three-way tap and the remaining two ways were connected to a 20 ml syringe and to the other serum catheter segment, which would be connected to the epidural needle. Lumbar region and right upper limb were disinfected with patients in the left lateral position. Epidural puncture was performed at L2-L3 interspace with 17G needle which was maintained fixed and connected to the serum catheter. Then, venous puncture was performed with a needle connected to the other edge of the serum catheter with the three-way tap directed from the vein to the syringe and 15 ml blood were aspirated. Redirecting the tap from the syringe to the epidural needle, the same 15 ml blood were re-injected. CONCLUSIONS In Jehovahs Witness patients refractory to clinical treatment, autologous blood injection may be performed through the above-described technique after patients informed consent.

Clinical Evaluation of Two Ke0 in the same Pharmacokinetic Propofol Model: Study on Loss and Recovery of Consciousness

BACKGROUND AND OBJECTIVE The constant equilibrium between the plasma and effect site (ke0) is used by pharmacokinetic models to calculate a drug concentration in its site of action (Ce). It would be interesting if Ce of propofol was similar at loss and recovery of consciousness. The objective of this study was to evaluate the clinical performance of two different ke0 (fast = 1.21 min(-1), and slow = 0.26 min(-1)) in relation to Ce during loss and recovery of consciousness using Marsh pharmacokinetic model. METHODS Twenty healthy adult male volunteers participated in this study. In all volunteers propofol was administered as target-controlled infusion, Marsh pharmacokinetic model for fast ke0 and, at a different time, the same pharmacokinetic model with slow ke0 was used. Initially, propofol was infused with a serum target-controlled infusion of 3.0 μg.mL(-1). Loss of consciousness and recovery of consciousness were based on response to verbal stimulus. Ce was recorded at the moment of loss and recovery of consciousness. RESULTS On loss and recovery of consciousness, the Ce for fast ke0 was different (3.64 ± 0.78 and 1.47 ± 0.29 μg.mL(-1), respectively, p < 0.0001), while with slow ke0 the Ce was similar (2.20 ± 0.70 and 2.14 ± 0.43 μg.mL(-1), respectively, p = 0.5425). CONCLUSIONS Clinically, the slow ke0 (0.26 min(-1)) incorporated in the Marsh pharmacokinetic model showed better performance than the fast ke0 (1.21 min(-1)), since the calculated concentration of propofol at the effect site on loss and recovery of consciousness was similar.

Avaliação clínica de duas ke0 no mesmo modelo farmacocinético de propofol: estudo da perda e recuperação da consciência

JUSTIFICATIVA Y OBJETIVOS: La constante de equilibrio entre el plasma y el sitio efector (ke0), se usa por los modelos farmacocineticos para prever la concentracion del farmaco en su region de accion (Ce). Seria interesante que el Ce de propofol fuese similar en la perdida y en la recuperacion de la conciencia. El objetivo de este estudio, fue evaluar el desempeno clinico de dos diferentes ke0 (rapida = 1,21 min-1 y lenta = 0,26 min-1), con relacion a la Ce durante la perdida y la recuperacion de la conciencia, usando el modelo farmacocinetico de Marsh. MeTODO: Participaron en este estudio, 20 voluntarios adultos sanos del sexo masculino. A todos los voluntarios se les administro propofol en regimen de infusion objeto controlada, modelo farmacocinetico de Marsh ke0 rapida y en otro momento, se uso el mismo modelo farmacocinetico con a ke0 lenta. Inicialmente, el propofol se infundio en concentracion-objeto plasmatica de 3,0 µg.mL-1. La perdida de la conciencia y la recuperacion de la conciencia estuvieron basadas en la respuesta al estimulo verbal. La Ce fue anotada en el momento de la perdida y de la recuperacion de la conciencia. RESULTADOS: En la perdida y en la recuperacion de la conciencia, la Ce por la ke0 rapida, fue diferente (3,64 ± 0,78 y 1,47 ± 0,29 µg.mL-1, respectivamente, p < 0,0001), mientras que con la ke0 lenta la Ce fue parecida (2,20 ± 0,70 y 2,13 ± 0,43 µg.mL-1, respectivamente, p = 0,5425). CONCLUSIONES: Desde el punto de vista clinico, la ke0 lenta (0,26 min-1) incorporada al modelo farmacocinetico de Marsh, presento un mejor desempeno que la ke0 rapida (1,21 min-1), pues la concentracion de propofol prevista en su region de accion en la perdida y en la recuperacion de la conciencia fue similar.

Epidural blood patch in Jehovah´s witness: two cases report

JUSTIFICATIVA Y OBJETIVOS: Existen relatos del empleo del tampon sanguineo peridural en pacientes Testigos de Jehova, utilizando un sistema cerrado que permite que se pueda recoger sangre y la inyeccion en el espacio peridural, sin perdida de continuidad. El objetivo de este relato es presentar dos casos de pacientes Testigos de Jehova que presentaron cefalea despues de anestesia subaracnoidea y que fueron tratados con tampon sanguineo peridural con un sistema cerrado de transfusion de sangre venoso para el espacio peridural. Los casos acontecieron en hospitales de dos diferentes ciudades. RELATO DE LOS CASOS: Un paciente del sexo masculino, de 21 anos, y una paciente del sexo femenino, de 32 anos, presentaron cefalea pos-raquianestesia para cirugia ambulatorial. Como los pacientes eran Testigos de Jehova, el tampon sanguineo fue realizado con un sistema cerrado. El sistema fue preparado en condiciones esteriles, utilizandose los siguientes materiales: dos equipos de suero cortados en segmentos de 60 cm, una conexion de dos vias, una llave de tres vias y una jeringa de 20 ml. El sistema fue montado de manera que pudiera permitir una conexion con la aguja de la venopuncion (20G), una conexion a la llave de tres vias, siendo que a las otras dos vias fueron conectados una jeringa de 20 ml y el otro segmento del equipo de suero, que seria conectado a la aguja de peridural. Con los pacientes posicionados en decubito lateral izquierdo fue hecha la anti-sepsia de la region lumbar y del miembro superior derecho en la region escogida para la venopuncion. Inicialmente fue hecha puncion peridural en el espacio L2-L3, con aguja 17G, siendo que la misma fue mantenida fija y el equipo de suero conectado a ella. A seguir fue hecha venopuncion con la aguja conectada a la otra extremidad del equipo de suero con el direccionamento de la llave de tres vias en el sentido de la vena para la jeringa. Fueron aspirados 15 ml de sangre. Con el redireccionamento de la llave en el sentido de la jeringa para la aguja de peridural fueron inyectados los 15 ml de sangre. CONCLUSIONES: En pacientes Testigos de Jehova, que rehuyen al tratamiento clinico, la inyeccion de sangre autologa podra ser hecha con la tecnica presentada, despues de la debida informacion al paciente y su consentimiento.BACKGROUND AND OBJECTIVES There are reports on epidural blood patch in Jehovahs Witness patients using a closed system which allows blood collection and epidural injection without loss of continuity. This report aimed at presenting two cases of Jehovahs Witness patients with post-dural puncture headache and treated with epidural blood patch in a closed venous blood transfusion system to the epidural space. Cases were reported by two different hospitals in two different cities. CASE REPORTS One 21 years old male patient and one 32 years old female patient, with post-dural puncture headache after outpatient procedures. Since they were Jehovahs Witnesses, blood patch was performed with a closed system. System was prepared in sterile conditions using the following materials: two serum catheters cut in 60 cm segments, one two-way connection, one three-way tap and one 20 ml syringe. System was assembled to allow one connection to the puncture needle (20G), one connection to the three-way tap and the remaining two ways were connected to a 20 ml syringe and to the other serum catheter segment, which would be connected to the epidural needle. Lumbar region and right upper limb were disinfected with patients in the left lateral position. Epidural puncture was performed at L2-L3 interspace with 17G needle which was maintained fixed and connected to the serum catheter. Then, venous puncture was performed with a needle connected to the other edge of the serum catheter with the three-way tap directed from the vein to the syringe and 15 ml blood were aspirated. Redirecting the tap from the syringe to the epidural needle, the same 15 ml blood were re-injected. CONCLUSIONS In Jehovahs Witness patients refractory to clinical treatment, autologous blood injection may be performed through the above-described technique after patients informed consent.

Hiperreflexia autonômica em gestante tetraplégica: relato de caso

BACKGROUND AND OBJECTIVES Complications of pregnant patients with medullary injury include urinary infection, renal stones, anemia, decubitus ulcers, muscle spasms, sepsis, uterine hyperactivity and autonomic hyperreflexia. Autonomic hyperreflexia is the most severe anesthetic complication and should, before all, be prevented. It is often developed in patients with medullary transection at the level of the 5th to 7th thoracic vertebra or above. This report aims at presenting a case of tetraplegic pregnant patient with injury at the level of the 6th cervical vertebra, submitted to Cesarean section under continuous epidural anesthesia with 0.25% bupivacaine without vasoconstrictor associated to fentanyl. CASE REPORT Caucasian, tetraplegic primiparous term patient, 39 weeks of gestational age, 22 years old, 63 kg, 168 cm, physical status ASA II, admitted for elective Cesarean section. Patient reported spinomedullary trauma at C6, three years ago. After previous hydration with 1500 ml saline, epidural anesthesia was induced with medial puncture at L3-L4 interspace with the patient in the lateral position, disposable 17G Tuohy needle and without previous local infiltration anesthesia. Immediately after needle insertion, there was adjacent paravertebral muscles contraction, blood pressure increase (BP = 158 x 72 mmHg) and heart rate increase (HR = 90 bpm). Patient, however, did not refer pain. Needle was removed and local anesthesia was induced. Epidural block proceeded with 20 ml of 0.25% bupivacaine without vasoconstrictor associated to 100 microg spinal fentanyl and epidural catheter insertion in the cephalad direction (3 to 4 cm). Surgery went on without intercurrences with no need for blockade complementation. There were two arterial hypotension episodes in the first 24 postoperative hours, which were treated with lactated Ringers solution. Epidural catheter was maintained for 48 hours. Patient was discharged three days after. CONCLUSIONS For paraplegic or tetraplegic pregnant patients, continuous epidural anesthesia with low local anesthetic concentration without vasoconstrictor and associated to fentanyl is a good indication for instrumented or not vaginal delivery, and Cesarean sections to prevent autonomic hyperreflexia. It is also important that the epidural catheter remains for at least 24 hours after delivery to block sympathetic afference in case a crisis is triggered.JUSTIFICATIVA Y OBJETIVOS: En las complicaciones de la embarazada con una lesion medular se incluyen infecciones urinarias, calculosis renal, anemia, ulceras de decubito, espasmos musculares, sepsis, hiperactividad uterina y la hiperreflexia autonomica. Durante la anestesia la hiperreflexia autonomica es la complicacion mas importante, que debe ser, antes de todo, prevenida. Ella es frecuentemente desarrollada en pacientes con transeccion medular al nivel de la quinta a la septima vertebra toracica, o encima. Nuestro relato tiene como objetivo presentar un caso de embarazada tetraplejica, con lesion al nivel de la sexta vertebra cervical, que se sometio a operacion cesariana bajo anestesia peridural continua con bupivacaina a 0,25% sin vasoconstrictor, asociada al fentamil. RELATO DE CASO: Paciente tetraplejica, primigesta a termino, edad gestacional de 39 semanas, blanca, 22 anos, 63 kg, 168 cm de altura, estado fisico ASA II, internada para ser sometida a cesariana electiva. Relataba trauma raquimedular al nivel de C6 hace 3 anos. Despues de hidratacion previa con 1500 ml de solucion fisiologica, siguio anestesia peridural con puncion mediana en el espacio L3-L4 con la paciente en decubito lateral, aguja Tuohy desechable calibre 17G y sin boton anestesico previo. Inmediatamente despues de la introduccion de la aguja, se observo contraccion de la musculatura paravertebral adyacente, aumento de la presion arterial (PA = 158 x 72 mmHg) y aumento de la frecuencia cardiaca (FC = 90 bpm). No obstante, la paciente no relataba dolor. Se retiro la aguja y se hizo boton anestesico, dandose secuencia al bloqueo peridural, con inyeccion de 20 ml de bupivacaina a 0,25% sin vasoconstrictor asociados a 100 µg de fentamil espinal y pasaje de cateter peridural en sentido cefalico (3 a 4 cm). La cirugia transcurrio sin interocurrencias, no habiendo necesidad de complementacion de bloqueo en ningun momento. Hubo dos episodios de hipotension arterial en las primeras 24 horas del pos-operatorio, tratados con infusion de solucion de Ringer con lactato. El cateter peridural fue mantenido por 48 horas. El alta hospitalar ocurrio despues de tres dias de internacion. CONCLUSIONES: Para embarazadas paraplejicas o tetraplejicas, la anestesia peridural continua con baja concentracion de anestesico local sin vasoconstrictor asociado al fentamil, es una buena indicacion para la conduccion del parto normal instrumentado o no, como el parto cesariano, con la finalidad de evitar la hiperreflexia autonomica. Tambien se debe dar importancia a la permanencia del cateter peridural en el pos-operatorio por lo menos 24 horas despues del parto, con la intencion de bloquear la aferencia simpatica, en el caso de que pueda suceder alguna crisis.

Eficacia del empleo de la metadona o de la clonidina en el intraoperatorio para control del dolor postoperatorio inmediato después del uso de remifentanil

BACKGROUND AND OBJECTIVES Due to its pharmacokinetic characteristics, remifentanil does not promote residual analgesia in the immediate postoperative period. The objective of this study was to compare the efficacy of methadone and clonidine in the control of postoperative pain of videolaparoscopic surgeries under total intravenous anesthesia with target-controlled remifentanil infusion. METHODS One hundred and twenty-six patients, ages 18 to 65 years, ASA I and II, of both genders, scheduled for laparoscopic surgeries, participated in this randomized, double- blind, placebo-controlled study. After venipuncture, intravenous ketoprofen and dypirone were administered. Target-controlled infusion of remifentanil and propofol was used for induction and maintenance of anesthesia. Before beginning the procedure, an intravenous solution containing 0.1 mg.kg-1 of methadone (methadone group), 2.0 (1/4)g.kg-1 of clonidine (clonidine group), or NS (placebo group) was administered. In the post-anesthetic care unit, postoperative pain was evaluated by the Verbal Numeric Scale (VNS). Absence of pain was defined as a score < 2, and pain as a score of > 3. RESULTS The incidence of pain in the methadone group was significantly lower than in the clonidine and placebo groups (11, 21, and 23, respectively; p < 0.02). Significant differences in the incidence of pain in the placebo and clonidine groups were not observed. CONCLUSIONS Methadone was more effective than clonidine in the control of postoperative pain in videolaparoscopic surgeries under total intravenous anesthesia with remifentanil; and using clonidine was not better than not using it.

Tampón sanguíneo peridural en pacientes testigos de Jehová: relato de dos casos

JUSTIFICATIVA Y OBJETIVOS: Existen relatos del empleo del tampon sanguineo peridural en pacientes Testigos de Jehova, utilizando un sistema cerrado que permite que se pueda recoger sangre y la inyeccion en el espacio peridural, sin perdida de continuidad. El objetivo de este relato es presentar dos casos de pacientes Testigos de Jehova que presentaron cefalea despues de anestesia subaracnoidea y que fueron tratados con tampon sanguineo peridural con un sistema cerrado de transfusion de sangre venoso para el espacio peridural. Los casos acontecieron en hospitales de dos diferentes ciudades. RELATO DE LOS CASOS: Un paciente del sexo masculino, de 21 anos, y una paciente del sexo femenino, de 32 anos, presentaron cefalea pos-raquianestesia para cirugia ambulatorial. Como los pacientes eran Testigos de Jehova, el tampon sanguineo fue realizado con un sistema cerrado. El sistema fue preparado en condiciones esteriles, utilizandose los siguientes materiales: dos equipos de suero cortados en segmentos de 60 cm, una conexion de dos vias, una llave de tres vias y una jeringa de 20 ml. El sistema fue montado de manera que pudiera permitir una conexion con la aguja de la venopuncion (20G), una conexion a la llave de tres vias, siendo que a las otras dos vias fueron conectados una jeringa de 20 ml y el otro segmento del equipo de suero, que seria conectado a la aguja de peridural. Con los pacientes posicionados en decubito lateral izquierdo fue hecha la anti-sepsia de la region lumbar y del miembro superior derecho en la region escogida para la venopuncion. Inicialmente fue hecha puncion peridural en el espacio L2-L3, con aguja 17G, siendo que la misma fue mantenida fija y el equipo de suero conectado a ella. A seguir fue hecha venopuncion con la aguja conectada a la otra extremidad del equipo de suero con el direccionamento de la llave de tres vias en el sentido de la vena para la jeringa. Fueron aspirados 15 ml de sangre. Con el redireccionamento de la llave en el sentido de la jeringa para la aguja de peridural fueron inyectados los 15 ml de sangre. CONCLUSIONES: En pacientes Testigos de Jehova, que rehuyen al tratamiento clinico, la inyeccion de sangre autologa podra ser hecha con la tecnica presentada, despues de la debida informacion al paciente y su consentimiento.BACKGROUND AND OBJECTIVES There are reports on epidural blood patch in Jehovahs Witness patients using a closed system which allows blood collection and epidural injection without loss of continuity. This report aimed at presenting two cases of Jehovahs Witness patients with post-dural puncture headache and treated with epidural blood patch in a closed venous blood transfusion system to the epidural space. Cases were reported by two different hospitals in two different cities. CASE REPORTS One 21 years old male patient and one 32 years old female patient, with post-dural puncture headache after outpatient procedures. Since they were Jehovahs Witnesses, blood patch was performed with a closed system. System was prepared in sterile conditions using the following materials: two serum catheters cut in 60 cm segments, one two-way connection, one three-way tap and one 20 ml syringe. System was assembled to allow one connection to the puncture needle (20G), one connection to the three-way tap and the remaining two ways were connected to a 20 ml syringe and to the other serum catheter segment, which would be connected to the epidural needle. Lumbar region and right upper limb were disinfected with patients in the left lateral position. Epidural puncture was performed at L2-L3 interspace with 17G needle which was maintained fixed and connected to the serum catheter. Then, venous puncture was performed with a needle connected to the other edge of the serum catheter with the three-way tap directed from the vein to the syringe and 15 ml blood were aspirated. Redirecting the tap from the syringe to the epidural needle, the same 15 ml blood were re-injected. CONCLUSIONS In Jehovahs Witness patients refractory to clinical treatment, autologous blood injection may be performed through the above-described technique after patients informed consent.

Hiperreflexia autonómica en embarazada tetrapléjica: relato de caso

BACKGROUND AND OBJECTIVES Complications of pregnant patients with medullary injury include urinary infection, renal stones, anemia, decubitus ulcers, muscle spasms, sepsis, uterine hyperactivity and autonomic hyperreflexia. Autonomic hyperreflexia is the most severe anesthetic complication and should, before all, be prevented. It is often developed in patients with medullary transection at the level of the 5th to 7th thoracic vertebra or above. This report aims at presenting a case of tetraplegic pregnant patient with injury at the level of the 6th cervical vertebra, submitted to Cesarean section under continuous epidural anesthesia with 0.25% bupivacaine without vasoconstrictor associated to fentanyl. CASE REPORT Caucasian, tetraplegic primiparous term patient, 39 weeks of gestational age, 22 years old, 63 kg, 168 cm, physical status ASA II, admitted for elective Cesarean section. Patient reported spinomedullary trauma at C6, three years ago. After previous hydration with 1500 ml saline, epidural anesthesia was induced with medial puncture at L3-L4 interspace with the patient in the lateral position, disposable 17G Tuohy needle and without previous local infiltration anesthesia. Immediately after needle insertion, there was adjacent paravertebral muscles contraction, blood pressure increase (BP = 158 x 72 mmHg) and heart rate increase (HR = 90 bpm). Patient, however, did not refer pain. Needle was removed and local anesthesia was induced. Epidural block proceeded with 20 ml of 0.25% bupivacaine without vasoconstrictor associated to 100 microg spinal fentanyl and epidural catheter insertion in the cephalad direction (3 to 4 cm). Surgery went on without intercurrences with no need for blockade complementation. There were two arterial hypotension episodes in the first 24 postoperative hours, which were treated with lactated Ringers solution. Epidural catheter was maintained for 48 hours. Patient was discharged three days after. CONCLUSIONS For paraplegic or tetraplegic pregnant patients, continuous epidural anesthesia with low local anesthetic concentration without vasoconstrictor and associated to fentanyl is a good indication for instrumented or not vaginal delivery, and Cesarean sections to prevent autonomic hyperreflexia. It is also important that the epidural catheter remains for at least 24 hours after delivery to block sympathetic afference in case a crisis is triggered.JUSTIFICATIVA Y OBJETIVOS: En las complicaciones de la embarazada con una lesion medular se incluyen infecciones urinarias, calculosis renal, anemia, ulceras de decubito, espasmos musculares, sepsis, hiperactividad uterina y la hiperreflexia autonomica. Durante la anestesia la hiperreflexia autonomica es la complicacion mas importante, que debe ser, antes de todo, prevenida. Ella es frecuentemente desarrollada en pacientes con transeccion medular al nivel de la quinta a la septima vertebra toracica, o encima. Nuestro relato tiene como objetivo presentar un caso de embarazada tetraplejica, con lesion al nivel de la sexta vertebra cervical, que se sometio a operacion cesariana bajo anestesia peridural continua con bupivacaina a 0,25% sin vasoconstrictor, asociada al fentamil. RELATO DE CASO: Paciente tetraplejica, primigesta a termino, edad gestacional de 39 semanas, blanca, 22 anos, 63 kg, 168 cm de altura, estado fisico ASA II, internada para ser sometida a cesariana electiva. Relataba trauma raquimedular al nivel de C6 hace 3 anos. Despues de hidratacion previa con 1500 ml de solucion fisiologica, siguio anestesia peridural con puncion mediana en el espacio L3-L4 con la paciente en decubito lateral, aguja Tuohy desechable calibre 17G y sin boton anestesico previo. Inmediatamente despues de la introduccion de la aguja, se observo contraccion de la musculatura paravertebral adyacente, aumento de la presion arterial (PA = 158 x 72 mmHg) y aumento de la frecuencia cardiaca (FC = 90 bpm). No obstante, la paciente no relataba dolor. Se retiro la aguja y se hizo boton anestesico, dandose secuencia al bloqueo peridural, con inyeccion de 20 ml de bupivacaina a 0,25% sin vasoconstrictor asociados a 100 µg de fentamil espinal y pasaje de cateter peridural en sentido cefalico (3 a 4 cm). La cirugia transcurrio sin interocurrencias, no habiendo necesidad de complementacion de bloqueo en ningun momento. Hubo dos episodios de hipotension arterial en las primeras 24 horas del pos-operatorio, tratados con infusion de solucion de Ringer con lactato. El cateter peridural fue mantenido por 48 horas. El alta hospitalar ocurrio despues de tres dias de internacion. CONCLUSIONES: Para embarazadas paraplejicas o tetraplejicas, la anestesia peridural continua con baja concentracion de anestesico local sin vasoconstrictor asociado al fentamil, es una buena indicacion para la conduccion del parto normal instrumentado o no, como el parto cesariano, con la finalidad de evitar la hiperreflexia autonomica. Tambien se debe dar importancia a la permanencia del cateter peridural en el pos-operatorio por lo menos 24 horas despues del parto, con la intencion de bloquear la aferencia simpatica, en el caso de que pueda suceder alguna crisis.