Paulo de Oliveira Vasconcelos Filho

Peculiaridades no pós-operatório de cirurgia cardíaca no paciente idoso

JUSTIFICATIVA E OBJETIVOS: O paciente idoso tem caracteristicas fisiologicas proprias e, muitas vezes, pode apresentar deficiencias orgânicas ou afeccoes graves, que por si, ja tornam o pos-operatorio complicado. O objetivo deste artigo e apresentar uma revisao das condutas pos-operatorias de cirurgia cardiaca no idoso, apresentando as alteracoes mais frequentes nesse tipo de paciente. CONTEUDO: As condutas no periodo intra-operatorio do paciente idoso devem ser tomadas tendo em vista a diminuicao da morbidade pos-operatoria. Na chegada do paciente idoso a UTI, devem ser cumpridos os mesmos criterios utilizados na internacao de outros pacientes adultos de cirurgia cardiaca, para o servico ter sempre um padrao, que nao leve a uma alteracao na rotina e que nao provoque equivocos. Estabelecer um plano de cuidados intensivos para o pos-operatorio de cirurgia cardiaca ira resultar em uma otima utilizacao de recursos da unidade, em efetividade de atencao e em diminuicao do tempo nos cuidados em relacao ao paciente idoso. Os exames auxiliares solicitados tambem devem seguir um padrao, estabelecido pelo servico, a nao ser que alteracoes sejam identificadas. Complicacoes neurologicas, pulmonares, circulatorias, insuficiencia renal, infeccao e hipotireoidismo sao frequentes, com particularidades no idoso. Elas estao delineadas neste artigo e devem ser bem compreendidas pelo intensivista que cuida desse tipo de paciente. CONCLUSOES: As complicacoes apresentadas neste artigo sao as que trazem maior preocupacao ao intensivista, quando ha um paciente idoso em pos-operatorio de cirurgia cardiaca na UTI. Este paciente necessita de cuidados especiais, mesmo quando a cirurgia transcorre em perfeita normalidade, pois o estresse cirurgico e muito grande e o idoso tem reserva funcional diminuida.BACKGROUND AND OBJECTIVES Elderly patients have their own physiologic characteristics, and sometimes may have organic deficits or severe diseases, which by themselves may complicate the postoperative period. This article is aimed at reviewing post-cardiac surgery procedures in the elderly, describing their most frequent problems. CONTENTS Elderly patients intraoperative approaches should be decided taking into account lower postoperative morbidity. At ICU arrival, the same criteria for other adult patients of cardiac surgeries should be adopted to maintain service standardization and routine, thus preventing mistakes. Establishing an intensive care plan for the post-cardiac surgery period may result in optimal use of resources, effective attention and decreased time of care. Subsidiary exams should also follow the standards of the service, unless any problem be identified. Neurological, pulmonary and circulatory complications, renal failure, infections and hypothyroidism outlined in this article are frequent and unique in the elderly, and should be fully understood by the ICU physician. CONCLUSIONS Complications outlined in this article are those of greatest concern for the ICU physician when there are elderly patients in the post-cardiac surgery period. These patients need special care, even when surgery is perfectly normal, because there is major surgical stress and the elderly have decreased functional reserves.

Diaphragmatic pacing stimulation in spinal cord injury: anesthetic and perioperative management

OBJECTIVE: The standard therapy for patients with high-level spinal cord injury is long-term mechanical ventilation through a tracheostomy. However, in some cases, this approach results in death or disability. The aim of this study is to highlight the anesthetics and perioperative aspects of patients undergoing insertion of a diaphragmatic pacemaker. METHODS: Five patients with quadriplegia following high cervical traumatic spinal cord injury and ventilator-dependent chronic respiratory failure were implanted with a laparoscopic diaphragmatic pacemaker after preoperative assessments of their phrenic nerve function and diaphragm contractility through transcutaneous nerve stimulation. ClinicalTrials.gov: NCT01385384. RESULTS: The diaphragmatic pacemaker placement was successful in all of the patients. Two patients presented with capnothorax during the perioperative period, which resolved without consequences. After six months, three patients achieved continuous use of the diaphragm pacing system, and one patient could be removed from mechanical ventilation for more than 4 hours per day. CONCLUSIONS: The implantation of a diaphragmatic phrenic system is a new and safe technique with potential to improve the quality of life of patients who are dependent on mechanical ventilation because of spinal cord injuries. Appropriate indication and adequate perioperative care are fundamental to achieving better results.

Incidência de cirurgia cardíaca em octogenários: estudo retrospectivo

JUSTIFICATIVA Y OBJETIVOS: El aumento de la expectativa de vida hace con que pacientes cada vez mas edosos tengan indicacion de tratamiento quirurgico de cardiopatias. Este estudio tiene como objetivo evaluar la incidencia de pacientes con mas de 80 anos sometidos a cirugia cardiaca en el Instituto del Corazon del Hospital de Clinicas de la FMUSP, en los ultimos 16 anos. METODO: Fueron analizados, en el periodo de 1986 a 2001, el numero de cirugias de revascularizacion del miocardio (RM) y cirugia valvar (CV) y, en cada grupo, el numero de cirugias en pacientes con mas de 80 anos. Los datos fueron analizados descriptivamente. RESULTADOS: Los datos revelan aumento progresivo del numero de octogenarios sometidos a cirugia cardiaca. Las cirugias de revascularizacion del miocardio tuvieron aumento de 0,13% en 1986 para 3,5% en 2001. Las cirugias valvares aumentaron de 0% en 1986 para 1,44% en 2001, registrando el mayor valor de 3,02% en 1999. CONCLUSIONES: Los conocimientos de la fisiopatologia, de la senilidad y los avanzos en el manoseo del trauma quirurgico estan permitiendo extender los recursos de la cirugia cardiaca en el grupo de pacientes mas edosos. La eleccion de la tecnica anestesica debe tener criterio, bien como la hidratacion, la asistencia ventilatoria y la analgesia pos-operatoria, permitiendo reduccion de la morbimortalidad en este grupo de mayor riesgo quirurgico.BACKGROUND AND OBJECTIVES Increased life expectancy makes increasingly older patients to be submitted to cardiac surgeries. This study aimed at evaluating the incidence of octogenarian patients submitted to cardiac surgeries in the Heart Institute, Hospital das Clínicas, FMUSP, in the last 16 years. METHODS The number of myocardial revascularization (MR) and valvar surgeries (VS) was analyzed for the period 1986 to 2001 and, within each group, the number of surgeries in octogenarian patients. Data were descriptively analyzed. RESULTS Data have shown a progressive increase in the number of octogenarian patients submitted to cardiac surgeries. Myocardial revascularization surgeries have increased from 0.13% in 1986 to 3.5% in 2001. Valvar surgeries have increased from 0% in 1986 to 1.44% in 2001, with the highest rate of 3.02% in 1999. CONCLUSIONS The understanding of pathophysiology and senility, and the advances in surgical trauma handling are allowing cardiac surgery resources to be expanded to elderly patients. Anesthetic technique should be carefully chosen, as well as hydration, ventilatory assistance and postoperative analgesia, to provide decreased morbidity and mortality in this higher surgical risk group.

Comparação das alterações histológicas da medula espinal e neurológicas de cobaias após anestesia subaracnóidea com grandes volumes de bupivacaína racêmica, de mistura com excesso enantiomérico de 50% de bupivacaína (S75-R25) e de levobupivacaína

JUSTIFICATIVA E OBJETIVOS: A levobupivacaina apresenta menos efeitos colaterais sobre o sistema nervoso central do que os induzidos pela bupivacaina racemica; entretanto, o efeito anestesico e menos intenso. Foi realizado estudo experimental para comparar efeitos adversos de grandes volumes de bupivacaina, de bupivacaina S75-R25 e de levobupivacaina quando injetados no espaco subaracnoideo de cobaias. METODO: Quarenta cobaias foram divididas em quatro grupos. Anestesiadas com O2 a 100% e isoflurano a 2%, com posterior puncao no espaco intervertebral L6-S1. Nos animais do Grupo I foram administrados 2 mL de solucao fisiologica a 0,9%; no Grupo II, 2 mL de bupivacaina 0,5%; no Grupo III, 2 mL de bupivacaina S75-R25 0,5% e no Grupo IV, 2 mL de levobupivacaina 0,5%. Apos o despertar, nos momentos 0, 60, 120 e 180 minutos, foi realizado exame neurologico, diariamente, por uma semana. Os animais foram sacrificados e submetidos a perfusao com paraformaldeido a 4%. Apos a fixacao, a medula espinal foi isolada por disseccao e analisada histologicamente para avaliacao do grau de lesao medular. RESULTADOS: As cobaias do grupo-controle nao apresentaram bloqueio nervoso. As do Grupo II apresentaram bloqueio sensitivo e motor por mais de 180 minutos. Nos Grupos III (S75-R25) e IV (levobupivacaina) houve bloqueios motor e sensitivo no momento 0 minuto; contudo, no momento 60 minutos o bloqueio motor era minimo. Ao exame histologico, o Grupo I nao apresentou alteracoes. No Grupo II foram encontradas alteracoes medulares intensas. Nos Grupos III e IV as alteracoes medulares foram pouco intensas. CONCLUSOES: A levobupivacaina em grandes volumes causou pouco dano ao sistema nervoso, comparada com a bupivacaina. Entre levobupivacaina e bupivacaina S75-R25, nao houve diferenca estatistica significativa.

Physicians’ job satisfaction and motivation in a public academic hospital

BackgroundPhysician shortage is a global issue that concerns Brazil’s authorities. The organizational structure and the environment of a medical institution can hide a low-quality life of a physician. This study examines the relationship between the hospital work environment and physicians’ job satisfaction and motivation when working in a large public academic hospital.MethodsThe study was restricted to one large, multispecialty Brazil’s hospital. Six hundred hospital physicians were invited to participate by e-mail. A short version of the Physician Worklife Survey (PWS) was used to measure working satisfaction. Physicians were also asked for socio-demographic information, medical specialty, and the intention to continue working in the hospital.ResultsData from 141 questionnaires were included in the analyses. Forty-five physicians graduated from the hospital’s university, and they did not intend to leave the hospital under any circumstance (affective bond). The motivating factor for beginning the career at the hospital and to continue working there were the connection to the medical school and the hospital status as a “prestigious academic hospital”; the physicians were more satisfied with the career than the specialty. Only 30% completely agreed with the statement “If I had to start my career over again, I would choose my current specialty,” while 45% completely agreed with the statement “I am not well compensated given my training and experience.” The greater point of satisfaction was the relationship with physician colleagues. They are annoyed about the amount of calls they are requested to take and about how work encroaches on their personal time. No significant differences between medical specialties were found in the analysis.ConclusionsThe participants were satisfied with their profession. The fact that they remained at the hospital was related to the academic environment, the relationship with colleagues, and the high prestige in which society holds the institution. The points of dissatisfaction were inadequate remuneration and the fact that work invaded personal time. Routinely, there is a need for organizations to examine the impact of their structures, policies, and procedures on the stress and quality of life of physicians.

Tratamento alternativo para neuralgia pós-herpética após transplante pulmonar. Relato de caso

BACKGROUND AND OBJECTIVES: Post-herpetic neuralgia (PHN) is the pain remaining after the resolution of acute herpes zoster episode. This study aimed at reporting a case of PHN pain treatment in lung transplantated patient. CASE REPORT: Male patient, 73 years old, submitted to lung transplantation three years ago and under immunosuppressants. He developed herpes zoster one year ago with vesicles in the eighth intercostal space of the right hemithorax (RHT). Treatment was effective with ganciclovir, however the patient evolved with severe, constant burning pain worsened one month ago with intensity 9 according to the numeric visual scale (NVS), even with 600 mg/day gabapentin. At physical evaluation he presented a hyperesthesic reddish lesion in the RHT. Patient was treated with gabapentin (900 mg), amitriptyline (25 mg), dipirone (8 g) and oxycodone (20 mg) per day. Low intensity laser (LIL) was applied daily for one week, followed by treatment with 4% topic amitriptyline. Pain intensity decreased to 5. LIL frequency was decreased to once every two days with significant NVS improvement to 1 and 2. He was discharged with 25 mg/day oral amitriptyline and 4% topic amitriptyline. CONCLUSION: LIL and topic amitriptyline were effective for pain remission.

Peculiarities of post-cardiac surgery care in elderly patients

JUSTIFICATIVA E OBJETIVOS: O paciente idoso tem caracteristicas fisiologicas proprias e, muitas vezes, pode apresentar deficiencias orgânicas ou afeccoes graves, que por si, ja tornam o pos-operatorio complicado. O objetivo deste artigo e apresentar uma revisao das condutas pos-operatorias de cirurgia cardiaca no idoso, apresentando as alteracoes mais frequentes nesse tipo de paciente. CONTEUDO: As condutas no periodo intra-operatorio do paciente idoso devem ser tomadas tendo em vista a diminuicao da morbidade pos-operatoria. Na chegada do paciente idoso a UTI, devem ser cumpridos os mesmos criterios utilizados na internacao de outros pacientes adultos de cirurgia cardiaca, para o servico ter sempre um padrao, que nao leve a uma alteracao na rotina e que nao provoque equivocos. Estabelecer um plano de cuidados intensivos para o pos-operatorio de cirurgia cardiaca ira resultar em uma otima utilizacao de recursos da unidade, em efetividade de atencao e em diminuicao do tempo nos cuidados em relacao ao paciente idoso. Os exames auxiliares solicitados tambem devem seguir um padrao, estabelecido pelo servico, a nao ser que alteracoes sejam identificadas. Complicacoes neurologicas, pulmonares, circulatorias, insuficiencia renal, infeccao e hipotireoidismo sao frequentes, com particularidades no idoso. Elas estao delineadas neste artigo e devem ser bem compreendidas pelo intensivista que cuida desse tipo de paciente. CONCLUSOES: As complicacoes apresentadas neste artigo sao as que trazem maior preocupacao ao intensivista, quando ha um paciente idoso em pos-operatorio de cirurgia cardiaca na UTI. Este paciente necessita de cuidados especiais, mesmo quando a cirurgia transcorre em perfeita normalidade, pois o estresse cirurgico e muito grande e o idoso tem reserva funcional diminuida.BACKGROUND AND OBJECTIVES Elderly patients have their own physiologic characteristics, and sometimes may have organic deficits or severe diseases, which by themselves may complicate the postoperative period. This article is aimed at reviewing post-cardiac surgery procedures in the elderly, describing their most frequent problems. CONTENTS Elderly patients intraoperative approaches should be decided taking into account lower postoperative morbidity. At ICU arrival, the same criteria for other adult patients of cardiac surgeries should be adopted to maintain service standardization and routine, thus preventing mistakes. Establishing an intensive care plan for the post-cardiac surgery period may result in optimal use of resources, effective attention and decreased time of care. Subsidiary exams should also follow the standards of the service, unless any problem be identified. Neurological, pulmonary and circulatory complications, renal failure, infections and hypothyroidism outlined in this article are frequent and unique in the elderly, and should be fully understood by the ICU physician. CONCLUSIONS Complications outlined in this article are those of greatest concern for the ICU physician when there are elderly patients in the post-cardiac surgery period. These patients need special care, even when surgery is perfectly normal, because there is major surgical stress and the elderly have decreased functional reserves.

Peculiaridades en el post operatorio de cirugía cardíaca en el paciente de edad avanzada

JUSTIFICATIVA E OBJETIVOS: O paciente idoso tem caracteristicas fisiologicas proprias e, muitas vezes, pode apresentar deficiencias orgânicas ou afeccoes graves, que por si, ja tornam o pos-operatorio complicado. O objetivo deste artigo e apresentar uma revisao das condutas pos-operatorias de cirurgia cardiaca no idoso, apresentando as alteracoes mais frequentes nesse tipo de paciente. CONTEUDO: As condutas no periodo intra-operatorio do paciente idoso devem ser tomadas tendo em vista a diminuicao da morbidade pos-operatoria. Na chegada do paciente idoso a UTI, devem ser cumpridos os mesmos criterios utilizados na internacao de outros pacientes adultos de cirurgia cardiaca, para o servico ter sempre um padrao, que nao leve a uma alteracao na rotina e que nao provoque equivocos. Estabelecer um plano de cuidados intensivos para o pos-operatorio de cirurgia cardiaca ira resultar em uma otima utilizacao de recursos da unidade, em efetividade de atencao e em diminuicao do tempo nos cuidados em relacao ao paciente idoso. Os exames auxiliares solicitados tambem devem seguir um padrao, estabelecido pelo servico, a nao ser que alteracoes sejam identificadas. Complicacoes neurologicas, pulmonares, circulatorias, insuficiencia renal, infeccao e hipotireoidismo sao frequentes, com particularidades no idoso. Elas estao delineadas neste artigo e devem ser bem compreendidas pelo intensivista que cuida desse tipo de paciente. CONCLUSOES: As complicacoes apresentadas neste artigo sao as que trazem maior preocupacao ao intensivista, quando ha um paciente idoso em pos-operatorio de cirurgia cardiaca na UTI. Este paciente necessita de cuidados especiais, mesmo quando a cirurgia transcorre em perfeita normalidade, pois o estresse cirurgico e muito grande e o idoso tem reserva funcional diminuida.BACKGROUND AND OBJECTIVES Elderly patients have their own physiologic characteristics, and sometimes may have organic deficits or severe diseases, which by themselves may complicate the postoperative period. This article is aimed at reviewing post-cardiac surgery procedures in the elderly, describing their most frequent problems. CONTENTS Elderly patients intraoperative approaches should be decided taking into account lower postoperative morbidity. At ICU arrival, the same criteria for other adult patients of cardiac surgeries should be adopted to maintain service standardization and routine, thus preventing mistakes. Establishing an intensive care plan for the post-cardiac surgery period may result in optimal use of resources, effective attention and decreased time of care. Subsidiary exams should also follow the standards of the service, unless any problem be identified. Neurological, pulmonary and circulatory complications, renal failure, infections and hypothyroidism outlined in this article are frequent and unique in the elderly, and should be fully understood by the ICU physician. CONCLUSIONS Complications outlined in this article are those of greatest concern for the ICU physician when there are elderly patients in the post-cardiac surgery period. These patients need special care, even when surgery is perfectly normal, because there is major surgical stress and the elderly have decreased functional reserves.

Incidencia de cirugía cardíaca en octogenarios: estudio retrospectivo

JUSTIFICATIVA Y OBJETIVOS: El aumento de la expectativa de vida hace con que pacientes cada vez mas edosos tengan indicacion de tratamiento quirurgico de cardiopatias. Este estudio tiene como objetivo evaluar la incidencia de pacientes con mas de 80 anos sometidos a cirugia cardiaca en el Instituto del Corazon del Hospital de Clinicas de la FMUSP, en los ultimos 16 anos. METODO: Fueron analizados, en el periodo de 1986 a 2001, el numero de cirugias de revascularizacion del miocardio (RM) y cirugia valvar (CV) y, en cada grupo, el numero de cirugias en pacientes con mas de 80 anos. Los datos fueron analizados descriptivamente. RESULTADOS: Los datos revelan aumento progresivo del numero de octogenarios sometidos a cirugia cardiaca. Las cirugias de revascularizacion del miocardio tuvieron aumento de 0,13% en 1986 para 3,5% en 2001. Las cirugias valvares aumentaron de 0% en 1986 para 1,44% en 2001, registrando el mayor valor de 3,02% en 1999. CONCLUSIONES: Los conocimientos de la fisiopatologia, de la senilidad y los avanzos en el manoseo del trauma quirurgico estan permitiendo extender los recursos de la cirugia cardiaca en el grupo de pacientes mas edosos. La eleccion de la tecnica anestesica debe tener criterio, bien como la hidratacion, la asistencia ventilatoria y la analgesia pos-operatoria, permitiendo reduccion de la morbimortalidad en este grupo de mayor riesgo quirurgico.BACKGROUND AND OBJECTIVES Increased life expectancy makes increasingly older patients to be submitted to cardiac surgeries. This study aimed at evaluating the incidence of octogenarian patients submitted to cardiac surgeries in the Heart Institute, Hospital das Clínicas, FMUSP, in the last 16 years. METHODS The number of myocardial revascularization (MR) and valvar surgeries (VS) was analyzed for the period 1986 to 2001 and, within each group, the number of surgeries in octogenarian patients. Data were descriptively analyzed. RESULTS Data have shown a progressive increase in the number of octogenarian patients submitted to cardiac surgeries. Myocardial revascularization surgeries have increased from 0.13% in 1986 to 3.5% in 2001. Valvar surgeries have increased from 0% in 1986 to 1.44% in 2001, with the highest rate of 3.02% in 1999. CONCLUSIONS The understanding of pathophysiology and senility, and the advances in surgical trauma handling are allowing cardiac surgery resources to be expanded to elderly patients. Anesthetic technique should be carefully chosen, as well as hydration, ventilatory assistance and postoperative analgesia, to provide decreased morbidity and mortality in this higher surgical risk group.

Incidence of cardiac surgery in octogenarian patients: retrospective study.

JUSTIFICATIVA Y OBJETIVOS: El aumento de la expectativa de vida hace con que pacientes cada vez mas edosos tengan indicacion de tratamiento quirurgico de cardiopatias. Este estudio tiene como objetivo evaluar la incidencia de pacientes con mas de 80 anos sometidos a cirugia cardiaca en el Instituto del Corazon del Hospital de Clinicas de la FMUSP, en los ultimos 16 anos. METODO: Fueron analizados, en el periodo de 1986 a 2001, el numero de cirugias de revascularizacion del miocardio (RM) y cirugia valvar (CV) y, en cada grupo, el numero de cirugias en pacientes con mas de 80 anos. Los datos fueron analizados descriptivamente. RESULTADOS: Los datos revelan aumento progresivo del numero de octogenarios sometidos a cirugia cardiaca. Las cirugias de revascularizacion del miocardio tuvieron aumento de 0,13% en 1986 para 3,5% en 2001. Las cirugias valvares aumentaron de 0% en 1986 para 1,44% en 2001, registrando el mayor valor de 3,02% en 1999. CONCLUSIONES: Los conocimientos de la fisiopatologia, de la senilidad y los avanzos en el manoseo del trauma quirurgico estan permitiendo extender los recursos de la cirugia cardiaca en el grupo de pacientes mas edosos. La eleccion de la tecnica anestesica debe tener criterio, bien como la hidratacion, la asistencia ventilatoria y la analgesia pos-operatoria, permitiendo reduccion de la morbimortalidad en este grupo de mayor riesgo quirurgico.BACKGROUND AND OBJECTIVES Increased life expectancy makes increasingly older patients to be submitted to cardiac surgeries. This study aimed at evaluating the incidence of octogenarian patients submitted to cardiac surgeries in the Heart Institute, Hospital das Clínicas, FMUSP, in the last 16 years. METHODS The number of myocardial revascularization (MR) and valvar surgeries (VS) was analyzed for the period 1986 to 2001 and, within each group, the number of surgeries in octogenarian patients. Data were descriptively analyzed. RESULTS Data have shown a progressive increase in the number of octogenarian patients submitted to cardiac surgeries. Myocardial revascularization surgeries have increased from 0.13% in 1986 to 3.5% in 2001. Valvar surgeries have increased from 0% in 1986 to 1.44% in 2001, with the highest rate of 3.02% in 1999. CONCLUSIONS The understanding of pathophysiology and senility, and the advances in surgical trauma handling are allowing cardiac surgery resources to be expanded to elderly patients. Anesthetic technique should be carefully chosen, as well as hydration, ventilatory assistance and postoperative analgesia, to provide decreased morbidity and mortality in this higher surgical risk group.