Magda Lourenço Fernandes

Preanesthesia Evaluation and Reduction of Preoperative Care Costs

BACKGROUND AND OBJECTIVES Preanesthesia evaluation (PAE) is fundamental in the preparation of a surgical patient. Among its advantages is the reduction of preoperative care costs. Although prior studies had observed this benefit, it is not clear whether it can be taken into consideration among us. The objective of the present study was to compare the costs of preoperative care performed by the surgeon with estimated costs based on PAE. In parallel, we compared the American Society of Anesthesiologists (ASA) physical status classification determined by the anesthesiologist with that estimated by other specialists. METHODS Two hundred patients scheduled for elective surgery or diagnostic procedures whose preoperative care was made by the surgeon underwent PAE after hospital admission. The anesthesiologist determined which ancillary exams or referrals necessary for each patient. The number and cost of ancillary exams or referrals requested by the anesthesiologist were compared with those of the preoperative preparation. The ASA classification according to the anesthesiologist was also compared to that of the physician in charge of the consultation. RESULTS Out of 1,075 ancillary exams performed, 55.8% were not indicated, which corresponded to 50.8% of the total cost of exams. The anesthesiologist considered that 37 patients (18.5%) did not require exams. The cost of surgeon-oriented preoperative care was higher than that based on the preanesthesia evaluation and this difference in costs was statistically significant (p < 0.01). In 9.3% of the patients discordance in ASA classification according to the specialist was observed. CONCLUSIONS Preoperative care based on judicious preanesthesia evaluation can result in significant reduction in costs when compared to that oriented by the surgeon. Good concordance in ASA classification was observed.

Anesthesia for Tonsillectomy in a Child with Klippel-Feil Syndrome Associated with Down Syndrome. Case Report

BACKGROUND AND OBJECTIVES Craniofacial abnormalities present in Klippel-Feil Syndrome (KFS) and Down Syndrome (DS) can hinder access to the airways. Oropharyngeal surgeries also require special attention with the airways. The association of both syndromes in a patient scheduled for tonsillectomy is a rare condition that imposes challenges to the anesthetic-surgical treatment. The objective of this report was to discuss the approach of the airways and the risks of cervical manipulation in a patient with KFS and DS undergoing tonsillectomy. CASE REPORT This is a 5 years old child with diagnosis of KFS and DS and instability of the atlantoaxial joint who underwent tonsillectomy under general balanced anesthesia. Ventilation under face mask and tracheal intubation were done with the neck in the neutral position. The perfect visualization of the epiglottis and vocal cords allowed tracheal intubation with conventional laryngoscopy. The surgery was also performed without cervical extension and without intercurrences. CONCLUSIONS Although access to the airways can be easy, anatomical changes presuppose the presence of difficult airways in patients with KFS and DS. Differentiated care and adequate resources are mandatory to avoid complications during approach of the airways. Cervical manipulation should be avoided in the presence of instability of the atlantoaxial joint due to the risk of neurological damage.

Sedation with dexmedetomidine for conducting electroencephalogram in a patient with Angelman syndrome: a case report

INTRODUCTION Angelman syndrome is characterized by severe mental retardation and speech and seizure disorders. This rare genetic condition is associated with changes in GABAA receptor. Patients with Angelman syndrome need to be sedated during an electroencephalogram ordered for diagnostic purposes or evolutionary control. Dexmedetomidine, whose action is independent of GABA receptor, promotes a sleep similar to physiological sleep and can facilitate the performing of this examination in patients with Angelman syndrome. CASE REPORT Female patient, 14 years old, with Angelman syndrome; electroencephalogram done under sedation with dexmedetomidine. The procedure was uneventful and bradycardia or respiratory depression was not recorded. The examination was successfully interpreted and epileptiform activity was not observed. CONCLUSION Dexmedetomidine promoted satisfactory sedation, was well tolerated and enabled the interpretation of the electroencephalogram in a patient with Angelman syndrome and seizure disorder.

Avaliação pré-anestésica e redução dos custos do preparo pré-operatório

JUSTIFICATIVA Y OBJETIVOS: La evaluacion preanestesica (EPA), es fundamental para la preparacion del paciente quirurgico. Entre sus muchas ventajas tenemos la reduccion de los costes con la preparacion del preoperatorio. Aunque algunos estudios previos hayan constatado ese beneficio, no es correcto decir que el se pueda aplicar adecuadamente a nuestro medio. El objetivo de este estudio fue comparar los costes de la preparacion del preoperatorio realizado por el cirujano con los costes estimados a partir de la EPA. En paralelo, comparamos la clasificacion del estado fisico de la American Society of Anesthesiologists (ASA) determinada por el anestesiologo o por otros especialistas. METODO: Doscientos pacientes candidatos a procedimientos quirurgicos o diagnosticos electivos, cuya preparacion preoperatoria estuvo orientada por el cirujano, se sometieron a la EPA despues de su ingreso. El anestesiologo determino los examenes complementarios o las consultas especializadas pertinentes para cada paciente. Se comparo el numero y los costes de los examenes o consultas indicados por el anestesiologo con los realizados durante la preparacion del preoperatorio. Tambien comparamos la clasificacion de la ASA determinada por el anestesiologo o por el medico que realizo la consulta especializada. RESULTADOS: De los 1.075 examenes complementarios realizados 55,8% no estaban indicados, lo que equivalio a una fraccion de un 50,8% del coste total con los examenes. El anestesiologo considero que 37 pacientes (18,5%) no necesitarian realizar examenes. El coste de la preparacion orientada por el cirujano fue un 25,11% mayor que el coste estimado a partir de la evaluacion preanestesica, siendo esa la diferencia entre los costes estadisticamente significantes: (p < 0,01). Se registro una discordancia en la clasificacion de la ASA en 9,3% de los pacientes evaluados por el experto. CONCLUSIONES: La preparacion del preoperatorio con base en la evaluacion preanestesica de criterio puede resultar en una significativa reduccion de los costes cuando se le compara a la preparacion orientada por el cirujano. Se observo una buena concordancia en la determinacion de la puntuacion de la ASA.

Anestesia para amigdalectomia em criança portadora de síndrome de Klippel-Feil associada à síndrome de down: Relato de caso

JUSTIFICATIVA Y OBJETIVOS: Las anormalidades craneofaciales presentes en el Sindrome de Klippel-Feil (SKF) y en el Sindrome de Down (SD), pueden dificultar el acceso a la via aerea. Las cirugias en la orofaringe tambien exigen una atencion especial con la via aerea. La asociacion de los dos sindromes en paciente candidato a la amigdalectomia es una condicion rara, que impone retos al tratamiento anestesico-quirurgico. El objetivo de este relato es discutir los cuidados para el abordaje de la via aerea y los riesgos de la manipulacion cervical en un paciente portador de sindrome de SKF y SD, sometido a la amigdalectomia. RELATO DEL CASO: Nino de cinco anos, con diagnostico previo de SKF, SD e inestabilidad de la articulacion atlantocervical, que fue sometido a la amigdalectomia bajo anestesia general balanceada. La ventilacion bajo mascara y la intubacion traqueal fueron realizadas con la cabeza en posicion neutra. La perfecta visualizacion de la epiglotis y de las cuerdas vocales, permitio la intubacion traqueal con laringoscopia convencional. La cirugia tambien se hizo sin la extension cervical, y transcurrio sin intercurrencias. CONCLUSIONES: Aunque el acceso a la via aerea pueda ser facil, las alteraciones anatomicas nos avisan que existe una via aerea dificil en pacientes portadores de SKF y SD. Los cuidados diferenciados y los recursos adecuados son indispensables para evitar las complicaciones durante el abordaje de la via aerea. La manipulacion cervical debe ser evitada en presencia de una inestabilidad de la articulacion atlanto-occipital, por el riesgo de lesion neurologica.

Síndrome de compartimento abdominal durante pinçamento por via endoscópica de perfuração intestinal secundária à colonoscopia

JUSTIFICATIVA E OBJETIVOS: A colonoscopia e um exame muito utilizado nos dias atuais para diagnostico, tratamento e controle de doencas intestinais. A perfuracao intestinal, embora rara, e a mais temida complicacao deste exame. A correcao da perfuracao pode ser feita atraves do uso de clipes posicionados por via endoscopica. O objetivo deste relato de caso foi alertar os especialistas para a ocorrencia e o tratamento de sindrome de compartimento abdominal durante pincamento endoscopio de perfuracao intestinal secundario a colonoscopia. RELATO DO CASO: Paciente do sexo feminino, 60 anos, estado fisico ASA II, submetida a colonoscopia sob sedacao. Durante o exame constatou-se perfuracao acidental do intestino e optou-se por tentar pincar a perfuracao por via endoscopica. A paciente evoluiu entao com dor e distensao abdominal, pneumoperitonio, sindrome de compartimento abdominal, dispneia e instabilidade cardiovascular. Realizou-se puncao abdominal de emergencia, o que determinou a melhora clinica da paciente ate que laparotomia de urgencia fosse realizada. Apos laparotomia exploradora e sutura da perfuracao a paciente evoluiu clinicamente bem. CONCLUSOES: O pincamento por via endoscopica de perfuracao intestinal secundaria a colonoscopia pode contribuir para a formacao de pneumoperitonio hipertensivo e sindrome de compartimento abdominal, com repercussoes clinicas graves que exigem tratamento imediato. Profissionais capacitados e recursos tecnicos adequados podem ser fatores determinantes do prognostico do paciente.

Abdominal compartment syndrome during endoscopic clamping of an intestinal perforation secondary to colonoscopy

BACKGROUND AND OBJECTIVES Colonoscopy is widely used for diagnosis, treatment, and control of intestinal disorders. Intestinal perforation, although rare, is the most feared complication. Perforations can be treated by endoscopic clamping. The objective of this report was to alert specialists for the development and treatment of abdominal compartment syndrome during endoscopic clamping of an intestinal perforation secondary to colonoscopy. CASE REPORT This is a 60 years old female, physical status ASA II, who underwent colonoscopy under sedation. During the exam, an accidental intestinal perforation was observed, and it was decided to attempt the endoscopic clamping of the perforation. The patient developed abdominal pain and distension, pneumoperitoneum, abdominal compartment syndrome, dyspnea, and cardiovascular instability. Emergency abdominal puncture was done with clinical improvement until urgent laparotomy was performed. After exploratory laparotomy and stitching of the perforation, the patient presented good clinical evolution. CONCLUSIONS Endoscopic clamping of an intestinal perforation secondary to colonoscopy can contribute for the development of hypertensive pneumoperitoneum and abdominal compartment syndrome with severe clinical repercussions that demand immediate treatment. Capable professionals and adequate technical resources can be determinant of the prognosis of the patient.

Anestesia para paciente portador da equência de moebius: relato de caso

BACKGROUND AND OBJECTIVES Moebius sequence (MS) is a rare paralysis of the VI and VII cranial nerves. Craniofacial changes, which can hinder tracheal intubation considerably, are seen in approximately 90% of the patients. CASE REPORT A male patient, 2 years and 5 months old, with MS, underwent flexible bronchoscopy for evaluation of laryngotracheomalacia. Comorbidities: bronchospasm and interventricular communication. Anesthesia was induced with sevoflurane in 100% O2, followed by venoclysis. A number 2.5 laryngeal AMBU mask was inserted and the fiberbronchoscope scope introduced through the mask. The procedure evolved without complications and bronchoscopy was normal. The patient was discharged home after two hours. CONCLUSIONS Airways management is a great challenge in those patients with a report of failure or difficult intubation in 13 out of 41 patients. Micrognathia, retrognathia, mandibular hypoplasia, and palatine cleft are some of the manifestations seen in those patients. The use of a laryngeal mask was reported in one patient in a large series with 106 anesthesias in patients with MS. There does not seem to be contraindications to perform the procedure in an outpatient setting. Pulmonary aspiration and respiratory obstruction in the recovery room due to difficulty swallowing and eliminating mouth secretions have been reported, and the use of anti-sialagogues recommended.JUSTIFICATIVA Y OBJETIVOS: La secuencia de Moebius (SM) es una rara paralisis del VI y VII nervios cranianos. Las alteraciones craneofaciales estan presentes en aproximadamente un 90% de esos pacientes, lo que puede hacer con que la intubacion traqueal sea muy dificil. RELATO DEL CASO: Paciente del sexo masculino, 2 anos y 5 meses, portador de SM, sometido a la broncoscopia flexible para la evaluacion de laringotraqueomalacia. Comorbidades: crisis de broncoespasmo y comunicacion interventricular. Se realizo la induccion anestesica con sevoflurano en O2 a 100% y venoclisis. Se introdujo la mascara laringea AMBU® numero 2,5 y el fibrobroncoscopio fue introducido a traves de ella. El procedimiento fue realizado sin complicaciones y la broncoscopia fue normal. El paciente recibio alta despues de dos horas. CONCLUSIONES: El control de las vias aereas es el gran reto para esos pacientes, habiendo relatos de falla o de dificultad de intubacion en 13 pacientes de una serie de 41 casos analizados. Micrognatia, retrognatia, hipoplasia mandibular y la hendidura palatina, son algunas de las caracteristicas de esos pacientes. En otra gran serie con 106 anestesias en pacientes con SM, hay una descripcion del uso de la mascara laringea en un caso. En regimen ambulatorial, parece no haber contraindicacion para realizar el procedimiento. Existe un relato de aspiracion pulmonar y obstruccion respiratoria en la sala de recuperacion, a causa de la dificultad de deglutir y eliminar las secreciones de la boca y para ese caso se recomienda administrar antisialogogos.

Instabilidade hemodinâmica grave durante o uso de isoflurano em paciente portador de escoliose idiopática: relato de caso

JUSTIFICATIVA E OBJETIVOS: O isoflurano e considerado um anestesico inalatorio seguro. Apresenta reduzido grau de biotransformacao, baixa toxicidade hepatica e renal. Em concentracoes clinicas apresenta efeito inotropico negativo minimo, diminuicao da resistencia vascular sistemica e, raramente, pode provocar disritmias cardiacas. O objetivo deste relato foi apresentar um caso de instabilidade hemodinâmica grave em paciente portador de escoliose idiopatica. RELATO DO CASO: Paciente do sexo masculino, 13 anos, estado fisico ASA I, sem antecedente de alergia a medicamentos, agendado para correcao cirurgica de escoliose idiopatica. Apos inducao da anestesia com fentanil, midazolam, propofol e atracurio, isoflurano a 1%, em 100% de oxigenio foi entao iniciado para manutencao. Cinco minutos depois, o paciente apresentou hipotensao arterial grave (PAM = 26 mmHg) associada a taquicardia sinusal (FC = 166 bpm) que nao respondeu ao uso de vasopressores e infusao de volume. A ausculta pulmonar e precordial, oximetria, capnografia, temperatura nasofaringea e gasometria arterial revelaram-se sem alteracoes. O paciente recebeu tratamento para anafilaxia e a intervencao cirurgica foi interrompida. A clara relacao temporal entre a administracao de isoflurano e a ocorrencia dos sintomas sugeriu um diagnostico de intolerância cardiovascular a administracao inalatoria de isoflurano. Duas semanas depois a anestesia venosa total foi administrada sem intercorrencias. CONCLUSOES: Nao ha relatos de instabilidade hemodinâmica grave causada por isoflurano em pacientes previamente sadios. Anafilaxia, taquicardia supraventricular com repercussao hemodinâmica e sensibilidade cardiaca aumentada ao isoflurano sao discutidas como possiveis causas da instabilidade hemodinâmica. Atualmente, ha evidencias que o isoflurano pode interferir no sistema de acoplamento-desacoplamento da contratilidade miocardica por meio da reducao do Ca2+ citosolico e/ou deprimindo a funcao das proteinas contrateis. Os mecanismos moleculares fundamentais desse processo ainda devem ser elucidados. O relato sugere que a administracao do isoflurano foi a causa das alteracoes hemodinâmicas apresentadas pelo paciente e que este, provavelmente, apresentou uma incomum sensibilidade cardiovascular ao farmaco.BACKGROUND AND OBJECTIVES Isoflurane is considered a safe inhalational anesthetic. It has a low level of biotransformation, and low hepatic and renal toxicity. In clinical concentrations, it has minimal negative inotropic effect, causes a small reduction in systemic vascular resistance, and, rarely, can cause cardiac arrhythmias. The objective of this report was to present a case of severe hemodynamic instability in a patient with idiopathic scoliosis. CASE REPORT Male patient, 13 years old, ASA physical status I, with no prior history of allergy to medications, scheduled for surgical repair of idiopathic scoliosis. After anesthetic induction with fentanyl, midazolam, propofol, and atracurium, 1% isoflurane with 100% oxygen was initiated for anesthesia maintenance. After five minutes, the patient presented severe hypotension (MAP = 26 mmHg) associated with sinus tachycardia (HR = 166 bpm) that did not respond to the administration of vasopressors and fluids. Lung and heart auscultation, pulse oxymetry, capnography, nasopharyngeal temperature, and arterial blood gases did not change. The patient was treated for anaphylaxis and the surgery was cancelled. The clear temporal relationship between the administration of isoflurane and the symptoms suggested the diagnosis of cardiovascular intolerance to inhalational isoflurane. Two weeks later, total intravenous anesthesia was administered without complications. CONCLUSIONS There are no reports of severe hemodynamic instability caused by isoflurane in previously healthy individuals. Anaphylaxis, supraventricular tachycardia with hemodynamic consequences, and increased cardiac sensitivity to isoflurane are discussed as possible causes of the hemodynamic instability. Currently, there is evidence that isoflurane can interfere in the coupling-uncoupling system of myocardial contractility by reducing cytosolic Ca2+ and/or depressing the function of contractile proteins. The fundamental molecular mechanisms of this process remain to be elucidated. This report suggests that the administration of isoflurane was the cause of the hemodynamic changes; the patient probably developed an unusual cardiovascular sensitivity to the drug.

Anestesia para implante de marca-passo em paciente adulto com ventrículo único não-operado: relato de caso

BACKGROUND AND OBJECTIVES: Single ventricle is a rare abnormality, affecting 1% of the patients with congenital cardiopathy. Only 11 cases of patients with unoperated univentricular heart older than 50 years were reported in the literature. The aim of this report was to describe the anesthetic conduct in a patient with univentricular heart undergoing pacemaker implant. CASE REPORT: A female patient, 47 years old, with double outlet left ventricle, L-transposition of the great vessels, and pulmonary stenosis, without prior surgical correction, was scheduled for definitive implant of a sequential dual-chamber pacemaker. The ABPM demonstrated second degree atrioventricular block and a mean heart rate of 45 bpm. Preoperative exams showed a hematocrit of 57%, normal coagulation studies, and preserved ventricular function. Monitoring consisted of pulse oxymeter, ECG on DII and V5, IBP, capnograph, and gas analyzer. A temporary transcutaneous pacemaker was available in case of severe bradycardia. Anesthesia was induced with fentanyl (0.25 mg), etomidate (20 mg), and atracurium (35 mg). Four minutes after anesthetic induction, the heart rate decreased to 30 bmp and 1 mg of atropine was administered with reversal of the bradycardia. Anesthesia was maintained with 2.5% sevoflurane, 60% room air, and 40% oxygen. Hemodynamic parameters and oxygen saturation remained stable. The patient was transferred to the intensive care unit in stable condition and extubated at the end of the procedure. CONCLUSIONS: The anesthetic conduct for pacemaker implant in a 47-year old patient with non-operated double outlet left ventricle and pulmonary stenosis was appropriate, since it allowed the procedure to be performed.BACKGROUND AND OBJECTIVES Single ventricle is a rare abnormality, affecting 1% of the patients with congenital cardiopathy. Only 11 cases of patients with unoperated univentricular heart older than 50 years were reported in the literature. The aim of this report was to describe the anesthetic conduct in a patient with univentricular heart undergoing pacemaker implant. CASE REPORT A female patient, 47 years old, with double outlet left ventricle, L-transposition of the great vessels, and pulmonary stenosis, without prior surgical correction, was scheduled for definitive implant of a sequential dual-chamber pacemaker. The ABPM demonstrated second degree atrioventricular block and a mean heart rate of 45 bpm. Preoperative exams showed a hematocrit of 57%, normal coagulation studies, and preserved ventricular function. Monitoring consisted of pulse oxymeter, ECG on D(II) and V5, IBP, capnograph, and gas analyzer. A temporary transcutaneous pacemaker was available in case of severe bradycardia. Anesthesia was induced with fentanyl (0.25 mg), etomidate (20 mg), and atracurium (35 mg). Four minutes after anesthetic induction, the heart rate decreased to 30 bmp and 1 mg of atropine was administered with reversal of the bradycardia. Anesthesia was maintained with 2.5% sevoflurane, 60% room air, and 40% oxygen. Hemodynamic parameters and oxygen saturation remained stable. The patient was transferred to the intensive care unit in stable condition and extubated at the end of the procedure. CONCLUSIONS The anesthetic conduct for pacemaker implant in a 47-year old patient with non-operated double outlet left ventricle and pulmonary stenosis was appropriate, since it allowed the procedure to be performed.