Marco Antonio Cardoso de Resende

Perfil da dor Neuropática: a propósito do exame neurológico mínimo de 33 pacientes

JUSTIFICATIVA E OBJETIVOS: Ha poucos textos na literatura a lidar com o exame neurologico do paciente com dor neuropatica (DN). O objetivo deste estudo foi avaliar o perfil de pacientes com DN atraves de exame clinico neurologico. METODO: Em estudo observacional, uma serie de casos de pacientes com DN foi acompanhada no periodo de um ano. A avaliacao do exame neurologico foi efetuada durante visita ao ambulatorio e atraves de analise prospectiva. Foram incluidos pacientes cuja intensidade da dor era igual ou maior que seis, segundo a Escala Analogica Visual. RESULTADOS: A dor em queimacao predominou como descritor em 54,5% dos pacientes. A polineuropatia foi o padrao clinico-topografico predominante (48%) com padrao distal e simetrico, em oposicao a quadros de neuropatia multifocal (15,15%). As modalidades termoalgesica e tatil do exame de sensibilidade foram as mais comprometidas, logo acompanhadas por alteracoes motoras e reflexos profundos, enquanto modalidades de sensibilidade proprioceptiva vieram a seguir. Apesar de nenhum sinal ou sintoma ser especifico de DN, a queimacao como sintoma costuma ser atribuida ao acometimento de fibras finas, assim como o padrao tipico destas e a alteracao termico-dolorosa. CONCLUSOES: A historia e os achados do exame fisico sao a chave para o diagnostico de DN. O registro das alteracoes encontradas ao exame deve ressaltar o comprometimento observado e assim nortear a abordagem diagnostica e terapeutica, se curativa ou paliativa.

Manuseio anestésico de paciente com gastrosquise

INTRODUCAOA gastrosquise e um defeito congenito da parede abdominal anterior, que permite a herniacao das visceras abdominais, usual-mente do lado direito, sem a cobertura do saco herniario. Raramente e associada a outras anomalias congenitas. Cuidados no controle hidroeletrolitico, glicemico e ventilatorio devem ser tomados. RELATO DO CASORN do sexo feminino, 2,775 kg, 60 cm, 6 horas de vida, apos gestacao de 40 semanas, P3 (antigo ASA III), nascido de parto cesario, sem intercorrencias logo apos o nascimento. Na sala de operacao foram usadas compressas umedecidas, com solucao de cloreto de sodio 0,9% aquecida para proteger as visceras expos-tas. O RN foi mantido sobre colchao termico. Drenou-se o con-teudo gastrico e foram realizadas venoclises com jelco n

Ischemic Postconditioning and Subanesthetic S(+)-Ketamine Infusion: Effects on Renal Function and Histology in Rats

Background. Ischemic postconditioning (IP) in renal Ischemia reperfusion injury (IRI) models improves renal function after IRI. Ketamine affords significant benefits against IRI-induced acute kidney injury (AKI). The present study investigated the effects of IP and IP associated with subanesthetic S(+)-ketamine in ischemia-reperfusion-induced AKI. Methods. Forty-one Wistar rats were randomized into four groups: CG (10), control; KG (10), S(+)-ketamine infusion; IPG (10), IP; and KIPG (11), S(+)-ketamine infusion + IP. All rats underwent right nephrectomy. IRI and IP were induced only in IPG and KIPG by left kidney arterial occlusion for 30 min followed by reperfusion for 24 h. Complete reperfusion was preceded by three cycles of 2 min of reocclusion followed by 2 min of reperfusion. Renal function was assessed by measuring serum neutrophil gelatinase-associated lipocalin (NGAL), creatinine, and blood urea nitrogen (BUN). Tubular damage was evaluated by renal histology. Results. Creatinine and BUN were significantly increased. Severe tubular injury was only observed in the groups with IRI (IPG and KIPG), whereas no injury was observed in CG or KG. No significant differences were detected between IPG and KIPG. Conclusions. No synergic effect of the use of subanesthetic S(+)-ketamine and IP on AKI was observed in this rat model.

Anestesia em Paciente com Saturnismo: Relato de Caso

JUSTIFICATIVA Y OBJETIVOS: El saturnismo proviene de la intoxicacion cronica por el plomo comun despues de la exposicion ocupacional. Los proyectiles que el cuerpo retiene pueden traer como resultado elevados niveles plasmaticos de plomo con innumerables repercusiones clinicas, principalmente neurologicas. Presentamos aqui un caso de paciente sintomatico, sin diagnostico, y que fue detectado durante la visita preanestesica. RELATO DEL CASO: Paciente que se presento para la retirada de una bala que se habia alojado en la rodilla izquierda hacia 14 anos, con polineuropatia sin investigacion. Durante la visita preanestesica se penso en saturnismo, lo que fue confirmado por los altos niveles plasmaticos de plomo (129 µg.dL-1). La cirugia fue realizada bajo anestesia general antes del inicio de la quelacion del plomo. Durante la induccion anestesica, el paciente evoluciono con apnea sin rigidez toracica despues de 50 µg de fentanilo. CONCLUSIONES: La intoxicacion por plomo interfiere con la funcion de diversos organos y sistemas, altera el metabolismo oxidativo y los mecanismos intracelulares de senalizacion. El compromiso neurologico, con la reduccion de la conduccion neural, merece una especial atencion por parte del anestesiologo.

Anestesia venosa total (AVT) em lactente com doença de Werdnig-Hoffmann: relato de caso

SUMMARY Resende MAC, Silva EV, Nascimento OJM, Gemal AE, Quintanilha G, Vasconcelos EM – Total Intravenous Anesthesia (TIVA) in an In-fant with Werdnig-Hoffmann Disease. Case Report. BACKGROUND AND OBJECTIVES: Werdnig-Hoffmann disease is the most common cause of hypotonia in infants and its prognosis is worse if it is present shortly after delivery. Symmetrical muscular weakness, areflexia, and fasciculations of the tongue are character-istic. The majority of the infants die before two years of age as a con-sequence of respiratory failure. The present report presents a case in which total intravenous anesthesia was used. CASE REPORT: This is a 1 year old white female weighing 10 kg, physical status ASA III, with Werdnig-Hoffmann disease diagnosed at two months of age. The patient was a candidate for open gas-trostomy, fundus gastroplication, and tracheostomy. After venoclysis, the patient was monitored with cardioscope, non-invasive blood pres-sure, pulse oximeter, precordial stethoscope, and rectal temperature. She was oxygenated and, after bolus administration of atropine (0.3 mg), boluses of remifentanil (20 µg) and propofol (30 mg) were ad-ministered for anesthetic induction. After tracheal intubation, she was ventilated with manual controlled system without CO

Total intravenous anesthesia (TIVA) in an infant with Werdnig-Hoffmann disease. Case report.

BACKGROUND AND OBJECTIVES Werdnig-Hoffmann disease is the most common cause of hypotonia in infants and its prognosis is worse if it is present shortly after delivery. Symmetrical muscular weakness, areflexia, and fasciculations of the tongue are characteristic. The majority of the infants die before two years of age as a consequence of respiratory failure. The present report presents a case in which total intravenous anesthesia was used. CASE REPORT This is a 1 year old white female weighing 10 kg, physical status ASA III, with Werdnig-Hoffmann disease diagnosed at two months of age. The patient was a candidate for open gastrostomy, fundus gastroplication, and tracheostomy. After venoclysis, the patient was monitored with cardioscope, non-invasive blood pressure, pulse oximeter, precordial stethoscope, and rectal temperature. She was oxygenated and, after bolus administration of atropine (0.3 mg), boluses of remifentanil (20 microg) and propofol (30 mg) were administered for anesthetic induction. After tracheal intubation, she was ventilated with manual controlled system without CO(2) absorber, Baraka (Mapleson D system), FGF of 4 L.min(-1), and FiO(2) 0.5 (O(2)/N(2)O). Anesthesia was maintained with continuous manual infusion of propofol, 250 microg x kg(-1) x min(-1), and remifentanil, 0.3 microg x kg(-1) x min(-1). The surgery lasted 150 minutes. The patient regained consciousness 8 minutes after the end of the infusion, ventilating spontaneously. Two hours later, she was transferred to the pediatric unit, being discharged from the hospital on the fourth postoperative day. CONCLUSIONS The choice of anesthetic technique gives priority to the safety associated with the familiarity of handling available drugs. In children with neuromuscular diseases, due to the extremely short duration, total intravenous anesthesia with remifentanil and propofol in infusion systems can have a favorable influence on disease evolution.

Neuropathic pain profile: the basic neurological exam of 33 patients

BACKGROUND AND OBJECTIVES Very few texts in the literature approach the neurologic exam of patients with neuropathic pain (NP). The objective of this study was to evaluate the profile of patients with NP through the neurological exam. METHODS This is an observational study that followed-up patients with NP for one year. The neurologic exam was evaluated at the outpatient clinic and through prospective analysis. Patients whose pain severity was equal or greater than six on the Visual Analogue Scale were included in this study. RESULTS Burning pain predominated, affecting 54.5% of the patients. Unlike multifocal neuropathy (15.15%), distal and symmetrical polyneuropathy was the predominant clinical-topographic pattern (48%). The thermoalgic and tactile modalities of the sensorial exam were affected the most, followed by changes in motor function and deep tendon reflexes, and proprioception. Although NP does not have specific signs and symptoms, burning pain is attributed to the involvement of thin nerve fibers and thermoalgic pain is typical of those changes. CONCLUSIONS History and physical exam findings are key factors in the diagnosis of NP. The log of changes in the physical exam should emphasize the involvement observed, guiding the diagnostic and therapeutic approach, curative or palliative.

[Lumbar plexopathy after abdominal hysterectomy: case report.].

JUSTIFICATIVA Y OBJETIVOS: Las lesiones neurologicas diagnosticadas en el periodo postoperatorio muchas veces se atribuyen al acto anestesico, aunque puedan tambien decorrer del acto quirurgico. El objetivo de este relato fue presentar el caso de una paciente sometida a la intervencion quirurgica pelvica que evoluciono con un cuadro de plexopatia lumbar y discutir las posibles causas. RELATO DEL CASO: Paciente del sexo femenino, 38 anos, 58 kg, 1,63 m de altura, estado fisico ASA I, internada para tratamiento de leiomiomatosis uterina, con indicacion de histerectomia total abdominal. La monitorizacion inicial incluyo oximetro de pulso, presion arterial no invasiva, electrocardioscopio y diuresis. Despues de la puncion venosa en el miembro superior izquierdo con cateter 18G, fueron administrados, por via venosa, cefazolina (2 g), dipirona (2 g), dexametasona (10 mg) y metoclopramida (10 mg). La anestesia peridural fue realizada con aguja Tuohy 16G, en el espacio L3-L4, en la linea mediana con la paciente en decubito lateral izquierdo. Fueron administrados 15 mL de ropivacaina a 0,75% y 2 mg de morfina, a continuacion posicionado cateter para analgesia postoperatoria. La intervencion quirurgica no tuvo intercurrencia, manteniendo a la paciente estable bajo el punto de vista cardiovascular. En la visita posanestesica, 8 horas despues del procedimiento, la paciente no deambulaba y presentaba monoparesia en el miembro inferior izquierdo. Despues de las investigaciones clinicas y radiologicas fue descartada la hipotesis diagnostica de sindrome radicular. Al no haber regresion del cuadro, 30 dias despues fue realizada una electroneuromiografia que quedo compatible con plexopatia lumbar de posible origen traumatica. CONCLUSIONES: El anestesiologo debe estar atento a las complicaciones neurologicas que puedan surgir en el postoperatorio, participando de la elucidacion de las causas, del tratamiento y de su evolucion.BACKGROUND AND OBJECTIVES Very often, neurological injuries diagnosed postoperatively are attributed to the anesthesia, but they can also be secondary to the surgery itself. The aim of this report was to present the case of a patient who underwent a pelvic surgery and developed lumbar plexopathy, and to discuss the possible causes. CASE REPORT A woman patient, 38 years old, 58 kg, 1.63 m, physical status ASA I, was admitted to undergo a total abdominal hysterectomy for treatment of uterine leiomyomatosis. Initial monitoring included pulse oxymetry, non-invasive blood pressure, electrocardioscope, and urine output. After venous cannulation in the left upper limb with an 18G catheter, cefazoline (2 g), dypirone (2 g), dexamethasone (10 mg), and metochlopramide (10 mg) were administered. With the patient in left lateral decubitus, a 16G Tuohy needle was inserted in the L3-L4 space, in the median line, for the epidural block. Fifteen milliliters of 0.75% ropivacaine and 2 mg of morphine were administered, followed by placement of the catheter for postoperative analgesia. The surgery was uneventful, and the patients cardiovascular parameters were stable. Eight hours after the procedure, at the postanesthetic follow-up, the patient could not walk and presented monoparesis in the left lower limb. The hypothesis of radicular syndrome was ruled out after clinical and radiological evaluation. Since symptoms did not resolve, an electroneuromyography was done 30 days later, and was compatible with lumbar plexopathy, which was possibly caused by trauma. CONCLUSIONS The anesthesiologist must be aware of the postoperative neurological complications and should be part of the efforts to diagnose their causes, of the treatment, and its evolution.

The Anaesthesiologist and Palliative Care in a Newborn with the Adam “Sequence”

Reports focusing on biomedical principlism and the role of anaesthesiologists in palliative care are rare. We present the case of a newborn with multiple craniofacial anomalies and a diagnosis of ADAM “sequence,” in which surgical removal of placental adhesions to the dura mater and the correction of meningocele was not indicated due to the very short life expectancy. After 48 hours, the odor from the placenta indicted a necrotic process, which prevented the parents from being close to the child and increased his isolation. Urgent surgery was performed, after which the newborn was transported to the ICU and intubated under controlled mechanical ventilation. The patient died a week later. The principles of beneficence, nonmaleficence, justice, and respect for autonomy are simultaneously an inspiratory and regulatory framework for clinical practice. Although only necessary procedures are defended, which suggests a position contrary to invasive interventions at the end of life, sometimes they are the best palliative measures that can be taken in cases like the one described here.

Double Invasive Blood Pressure Monitoring for Cesarean Delivery in a Pregnant Woman With Aortic Coarctation.

Aortic coarctation is a discrete narrowing of the proximal thoracic aorta. It is poorly tolerated during pregnancy because of its association with hypertension, cerebrovascular accident, and aortic rupture. We report a case of severe uncorrected congenital aortic coarctation in a 31-year-old symptomatic pregnant woman at 29 weeks of gestation who underwent successful cesarean delivery with an epidural anesthetic technique. Transthoracic echocardiography showed a gradient of 75 mm Hg. To avoid undiagnosed arterial hypotension and inadequate uteroplacental flow distal to the coarctation, double (radial and femoral) invasive arterial blood pressure measurement was used to monitor both pre- and postcoarctation arterial blood pressure.