Pedro Paulo Kimachi

Simulation of ultrasound-guided peripheral nerve block: learning curve of CET-SMA/HSL anesthesiology residents

JUSTIFICATIVA Y OBJETIVOS: La tecnica de ultrasonido ha sido cada vez mas utilizada para la realizacion de bloqueos de nervios perifericos. Existen pocos relatos en la literatura que analizan la curva de aprendizaje de la tecnica de ultrasonido. El objetivo del estudio fue evaluar la curva de aprendizaje de los residentes de Anestesiologia del CET-SMA/HSL en bloqueos perifericos guiados por ultrasonido a traves de modelo experimental de gelatina. METODO: Fue desarrollado un modelo experimental con un recipiente lleno de gelatina y aceituna sumergida. Nueve residentes se distribuyeron aleatoriamente en tres grupos (G1, G2, G3) compuestos cada uno, por un R1, un R2 y un R3. Los tres grupos recibieron una explicacion teorica. El G1 recibio dos horas de entrenamiento practico, el G2 una hora y el G3 no fue entrenado. Acto seguido, se les solicito a los participantes que pusiesen la aguja en el punto medio de la pared de la aceituna, cerca del transductor y reposicionar la aguja entre la aceituna y el fondo del recipiente, simulando la inyeccion perineural del anestesico. Se evaluaron la velocidad y la eficacia de las tareas, ademas de las fallas tecnicas. RESULTADOS: El G1 presento un promedio de tiempo para la realizacion de las tareas de 37,63 segundos, sin fallas tecnicas; en el G2 se observo un promedio de 64,40 segundos, ocurriendo dos fallas tecnicas y el G3 presento un promedio de 93,83 segundos, con doce fallas tecnicas. CONCLUSIONES: El estudio permite concluir que el mayor tiempo de entrenamiento en un modelo experimental de bloqueos perifericos guiados por ultrasonido mejoro la curva de aprendizaje en el simulacro de la tecnica.BACKGROUND AND OBJECTIVES The use of ultrasound imaging in peripheral nerve block has been increasing. However, there are few reports in the literature on the learning curve of the ultrasound technique. The objective of this report was to evaluate the learning curve of CET-SMA/HSL Anesthesiology residents of ultrasound-guided peripheral block using an experimental agar model. METHODS An experimental model was developed by filling a bowl with agar and olives. Nine residents were randomly divided in three groups (G1, G2, and G3), each one with a R1, a R2, and a R3. All three groups received theoretical explanation. G1 also had two hours of practical training, G2 had one hour, and G3 had no training. Residents were then asked to place a needle at the middle of the olive wall, near the transducer and then reposition the needle between the olive and the bottom of the bowl, simulating the epidural injection of anesthetic. The speed and efficacy of the tasks, as well as technical flaws, were evaluated. RESULTS The mean length of time to perform the tasks was 37.63 seconds for G1, without technical flaws; 64.40 seconds for G2, with two technical flaws; and 93.83 seconds for G3, with 12 technical flaws. CONCLUSIONS This study allows us to conclude that the longer training of ultrasound-guided peripheral nerve block in an experimental model improved the learning curve of the technique.

Simulação de bloqueios periféricos guiados por ultra-som: curva de aprendizado dos residentes de anestesiologia do CET-SMA/HSL

JUSTIFICATIVA Y OBJETIVOS: La tecnica de ultrasonido ha sido cada vez mas utilizada para la realizacion de bloqueos de nervios perifericos. Existen pocos relatos en la literatura que analizan la curva de aprendizaje de la tecnica de ultrasonido. El objetivo del estudio fue evaluar la curva de aprendizaje de los residentes de Anestesiologia del CET-SMA/HSL en bloqueos perifericos guiados por ultrasonido a traves de modelo experimental de gelatina. METODO: Fue desarrollado un modelo experimental con un recipiente lleno de gelatina y aceituna sumergida. Nueve residentes se distribuyeron aleatoriamente en tres grupos (G1, G2, G3) compuestos cada uno, por un R1, un R2 y un R3. Los tres grupos recibieron una explicacion teorica. El G1 recibio dos horas de entrenamiento practico, el G2 una hora y el G3 no fue entrenado. Acto seguido, se les solicito a los participantes que pusiesen la aguja en el punto medio de la pared de la aceituna, cerca del transductor y reposicionar la aguja entre la aceituna y el fondo del recipiente, simulando la inyeccion perineural del anestesico. Se evaluaron la velocidad y la eficacia de las tareas, ademas de las fallas tecnicas. RESULTADOS: El G1 presento un promedio de tiempo para la realizacion de las tareas de 37,63 segundos, sin fallas tecnicas; en el G2 se observo un promedio de 64,40 segundos, ocurriendo dos fallas tecnicas y el G3 presento un promedio de 93,83 segundos, con doce fallas tecnicas. CONCLUSIONES: El estudio permite concluir que el mayor tiempo de entrenamiento en un modelo experimental de bloqueos perifericos guiados por ultrasonido mejoro la curva de aprendizaje en el simulacro de la tecnica.BACKGROUND AND OBJECTIVES The use of ultrasound imaging in peripheral nerve block has been increasing. However, there are few reports in the literature on the learning curve of the ultrasound technique. The objective of this report was to evaluate the learning curve of CET-SMA/HSL Anesthesiology residents of ultrasound-guided peripheral block using an experimental agar model. METHODS An experimental model was developed by filling a bowl with agar and olives. Nine residents were randomly divided in three groups (G1, G2, and G3), each one with a R1, a R2, and a R3. All three groups received theoretical explanation. G1 also had two hours of practical training, G2 had one hour, and G3 had no training. Residents were then asked to place a needle at the middle of the olive wall, near the transducer and then reposition the needle between the olive and the bottom of the bowl, simulating the epidural injection of anesthetic. The speed and efficacy of the tasks, as well as technical flaws, were evaluated. RESULTS The mean length of time to perform the tasks was 37.63 seconds for G1, without technical flaws; 64.40 seconds for G2, with two technical flaws; and 93.83 seconds for G3, with 12 technical flaws. CONCLUSIONS This study allows us to conclude that the longer training of ultrasound-guided peripheral nerve block in an experimental model improved the learning curve of the technique.

Caudal epidural anesthesia: an anesthetic technique exclusive for pediatric use? Is it possible to use it in adults? What is the role of the ultrasound in this context?

BACKGROUND AND OBJECTIVES Caudal epidural anesthesia is the most popular regional anesthesia technique used in children. With advanced age, only the relative difficulty in localizing the sacral hiatus limits its use. However, in adults this technique has been widely used to control chronic pain by adjuvant use of fluoroscopy. Thus, the ability to locate the hiatus and define anatomical variations is the main determinant of the success and safety of caudal epidural anesthesia. In this context, the use of the ultrasound in caudal epidural anesthesia has been increasing. The objective of this review was to determine the role of the ultrasound in caudal epidural anesthesia and to demonstrate that this technique, widely used in children, is also useful and can be used in adults. CONTENT A review of the literature on sacral anatomy and the anesthetic technique necessary to perform caudal epidural anesthesia was undertaken. Recent studies in ultrasound-guided caudal epidural anesthesia both in children and adults were also included. CONCLUSIONS Despite its limitations, the ultrasound can be a useful tool to position the needle in the caudal space. It allows prompt identification of the sacral anatomy and real-time visualization of the injection. Considering it is portable, non-invasive, and free of radiation exposure, it is an attractive technique in the operating room especially in difficult cases. However, since its use in neuroaxis anesthesia is very primitive, more studies are necessary to make it a routine technique in anesthetic practice.

Transesophageal Echocardiography in Anesthesiology: Characterization of Use Profile in a Tertiary Hospital

BACKGROUND AND OBJECTIVE Since its introduction in the 80s, transesophageal echocardiography (TEE) not only gained popularity but also experienced great advances in technology and currently it is an extremely valuable tool in the intraoperative period. In Brazil, there are no published data on the profile of its use in the intraoperative period by anesthesiologists. The objective of this study was to describe the use of intraoperative TEE in an Anesthesiology Service in a tertiary private hospital. PATIENTS AND METHODS Retrospective study from completed medical charts in all cases where the patient was monitored with TEE. Monitoring was applied in patients classified as I-II according to the American Society of Echocardiography and presenting no contraindication to the examination. At the end of procedure, after examination, a note on the chart classified monitoring according to its usefulness in the intraoperative period into three groups: group 1, no interference of TEE in anesthetic or surgical approach; group 2, TEE prompted change in anesthetic approach regarding the administration of volume, introduction and/or modification of vasoactive drugs (here, TEE generated change of anesthetic approach in conjunction with other monitors, but it was the deciding factor); group 3, TEE led to a change in approach or review of surgical procedure performed. RESULTS From January 2009 to January 2011, 164 intraoperative TEE were performed in our service, with 41 pediatric and 123 adult patients. In all patients, the test was successful and there were no problems regarding the introduction of transesophageal tube. In pediatric sample, group I had 10 patients (24.4%), group II had 27 patients (65.8%), and group III had 4 patients (9.8%). Among adults, group I had 38 patients (30.9%), group II had 81 patients (65.9%), and group III had 4 patients (3.2%). CONCLUSION Despite this small sample size compared to the literature, and the limitations of this study, there was agreement with other reports related to changes in anesthetic-surgical approach based on intraoperative TEE. Our data also strongly suggest that transesophageal echocardiography is an extremely useful tool for monitoring patients at high cardiovascular risk, even when undergoing noncardiac surgery. Larger studies conducted in our country are needed, as there are no other studies in literature defining the use profile of TEE or even clearly setting out how it has been used in our field.

Bloqueio peridural caudal: técnica anestésica de uso exclusivo em crianças? É possível sua realização em adultos? Qual o papel do ultrassom nesse contexto?

JUSTIFICATIVA Y OBJETIVOS: El bloqueo epidural caudal es la mas popular entre todas las tecnicas de anestesia regional en ninos. Cuando la edad avanza, apenas la relativa dificultad en localizar el hiato sacral limita su uso. Sin embargo, en los adultos, la tecnica ha venido siendo ampliamente utilizada para el control del dolor cronico, con la ayuda de la fluoroscopia. Por lo tanto, la habilidad en poder ubicar el hiato y definir las variaciones anatomicas es el principal factor determinante del exito y de la seguridad en la ejecucion del bloqueo epidural por la via caudal. En ese contexto, el ultrasonido ha venido ganando espacio como guia para la realizacion del bloqueo caudal. El objetivo de esta revision fue elucidar el papel del ultrasonido en la anestesia caudal, ademas de demostrar que el bloqueo caudal, muy utilizado en ninos, tambien es util y puede ser usado en adultos. CONTENIDO: Se hizo una revision literaria sobre la anatomia de la region sacral y de la tecnica anestesica necesaria para la adecuada realizacion del bloqueo caudal. Ademas, tambien se incluyeron articulos recientes sobre estudios realizados con bloqueos epidurales caudales guiados por ultrasonido tanto en ninos como en adultos. CONCLUSIONES: El ultrasonido, a pesar de sus limitaciones, puede ser util como una herramienta coadyuvante en el posicionamiento de la aguja en el espacio caudal. Permite la facil identificacion de la anatomia sacral, ademas de la visualizacion de la inyeccion en tiempo real. Su naturaleza portatil, no invasiva y libre de exposicion a la radiacion, lo convierte en una tecnologia atractiva en quirofano, principalmente en las situaciones de emergencia de casos complicados. Sin embargo, como su uso en bloqueos centrales del neuro eje todavia es muy primitivo, se hacen necesarias mas investigaciones para que se consagre como una tecnica de rutina en la practica anestesica.

Mudança de conduta cirúrgica motivada pela ecocardiografia transesofágica intraoperatória

JUSTIFICATIVA E OBJETIVOS: A utilizacao da ecocardiografia transesofagica (ETE) e de valor indiscutivel em procedimentos cirurgicos como valvoplastias, cirurgias da aorta toracica e correcoes de cardiopatias congenitas. Entre as grandes vantagens da utilizacao da ETE destacam-se a pouca invasividade do metodo e a capacidade de agregar informacoes que podem alterar o curso da cirurgia. O objetivo deste relato foi apresentar um caso onde a conducao cirurgica da paciente foi alterada em decorrencia de novos diagnosticos feitos pela ecocardiografia transesofagica no intraoperatorio e ressaltar a importância da utilizacao do eco transesofagico em cirurgias para correcao de cardiopatia congenita. RELATO DO CASO: Paciente do sexo feminino, 28 anos, ASA II, com historia de dispneia progressiva aos medios e depois pequenos esforcos, veio encaminhada de outro servico para correcao cirurgica eletiva de estenose da valva pulmonar diagnosticada pela ecocardiografia transtoracica. A ecocardiografia transesofagica intraoperatoria evidenciou presenca do forâmen oval patente, estenose infundibular da via de saida do ventriculo direito e comunicacao interventricular (CIV) perimembranosa subaortica medindo 0,4 cm com fluxo da esquerda para direita. Apos a entrada da paciente em circulacao extracorporea foram confirmados os diagnosticos mencionados acima, e a cirurgia realizada incluiu o fechamento do forâmen oval e da CIV e a resseccao da estenose do infundibulo. Nao houve intercorrencias cirurgicas, e a paciente foi encaminhada intubada para a unidade de terapia intensiva. CONCLUSOES: A ecocardiografia transesofagica em pacientes submetidos a correcao de cardiopatia congenita e de extrema utilidade, pois, alem de ajudar no manejo hemodinâmico do paciente, pode trazer novas informacoes, capazes de melhorar o resultado final da cirurgia.

Transesophageal echocardiography and intraoperative diagnosis of persistent left superior vena cava

BACKGROUND AND OBJECTIVES Isolated persistent left superior vena cava has an incidence of 0.5% in the normal population, but in patients with congenital cardiopathy its incidence ranges from 3% to 10%. The objective of this report was to present a case of intraoperative diagnosis with transesophageal echocardiography and to emphasize the importance of its routine use in surgical procedures for correction of congenital cardiopathies. CASE REPORT This is a 16-year old male patient, ASA II, with a diagnosis of superior sinus venosus interatrial communication (IAC) with partial anomalous drainage of the pulmonary veins scheduled for the surgical correction of the cardiopathy. After induction of general anesthesia, transesophageal echocardiography (TEE) showed initially a dilation of the right cardiac chambers, a 17-mm superior sinus venosus IAC, anomalous drainage of the right superior pulmonary vein draining into the right superior vena cava (SVC), and dilation of the coronary sinus raising the possibility of persistent left superior vena cava. To confirm this suspicion, 10 mL of NS (works as a contrast in echocardiography) were injected in the venous access of the left arm, and microbubbles crossing the coronary sinus were observed immediately afterwards confirming the diagnosis of persistent left superior vena cava. CONCLUSIONS Routine intraoperative transesophageal echocardiography in patients with congenital cardiopathy is a fundamental auxiliary method, not only for the surgeon, often having direct influence on the surgical technique used, but also for the anesthesiologist, who can get useful information for the hemodynamic management of the patient.

Changes in surgical conduct due to the results of intraoperative transesophageal echocardiography

BACKGROUND AND OBJECTIVES Transesophageal echocardiography (TEE) is extremely useful in surgeries like valvuloplasty, of the thoracic aorta, and correction of congenital cardiopathies. The low degree of invasiveness and the capacity to aggregate information that can change the course of the surgery are among the advantages of TEE. The objective of this report was to present a case in which the surgical conduct was changed due to a new diagnosis provided by intraoperative transesophageal echocardiography, and to emphasize the importance of using the transesophageal echo in surgeries to correct congenital cardiopathies. CASE REPORT A 28-year old female, ASA II, with a history of dyspnea progressing from medium to small efforts was referred by another department for elective surgical correction of stenosis of the pulmonary valve diagnosed by transthoracic echocardiography. Intraoperative transesophageal echocardiography showed patent foramen ovale, infundibular stenosis of the right ventricular outlet, and perimembranous subaortic interventricular communication (IVC) of 0.4 cm with left to right shunt. After beginning ECC, the above mentioned diagnoses were confirmed and the surgery included closure of the foramen ovale and IVC, and resection of the infundibular stenosis. Intraoperative intercurrences were not observed and the patient was intubated when she was transferred to the intensive care unit. CONCLUSIONS Transesophageal echocardiography is extremely useful in patients undergoing surgical correction of congenital cardiopathies because, besides helping the hemodynamic management, it can provide new information capable of improving the final result of the surgery.

Benefits in radical mastectomy protocol: a randomized trial evaluating the use of regional anesthesia

Surgery is the first-line treatment for early, localized, or operable breast cancer. Regional anesthesia during mastectomy may offer the prevention of postoperative pain. One potential protocol is the combination of serratus anterior plane block (SAM block) with pectoral nerve block I (PECS I), but the results and potential benefits are limited. Our study compared general anesthesia with or without SAM block + PECS I during radical mastectomy with axillary node dissection and breast reconstruction using evaluations of pain, opioid consumption, side effects and serum levels of interleukin (IL)-1beta, IL-6 and IL-10. This is a prospective, randomized controlled trial. Fifty patients were randomized to general anesthesia only or general anesthesia associated with SAM block + PECS I (25 per group). The association of SAM block + PECS I with general anesthesia reduced intraoperative fentanyl consumption, morphine use and visual analog pain scale scores in the post-anesthetic care unit (PACU) and at 24 h after surgery. In addition, the anesthetic protocol decreased side effects and sedation 24 h after surgery compared to patients who underwent general anesthesia only. IL-6 levels increased after the surgery compared to baseline levels in both groups, and no differences in IL-10 and IL-1 beta levels were observed. Our protocol improved the outcomes of mastectomy, which highlight the importance of improving mastectomy protocols and focusing on the benefits of regional anesthesia.

Ecocardiografia transesofágica em anestesiologia: caracterização do perfil de uso em um hospital terciário

JUSTIFICATIVA Y OBJETIVOS: Desde su introduccion en la decada de 1980, la ecocardiografia transesofagica (ETE) no solo obtuvo popularidad, sino que tambien llego a alcanzar grandes avances tecnologicos y actualmente es una herramienta extremadamente valiosa en el periodo intraoperatorio. En Brasil todavia no existen datos publicados sobre el perfil de su uso en el periodo intraoperatorio por parte de los anestesiologos. El objetivo de este trabajo, fue describir el perfil de uso de la ETE en el intraoperatorio por nuestro Servicio de Anestesiologia en un hospital privado de nivel terciario. PACIENTES Y METODOS: Estudio retrospectivo hecho por medio de la recoleccion de datos de las fichas rellenadas en todos los casos en que el paciente estuvo monitorizado con la ETE. La monitorizacion fue aplicada a los pacientes encuadrados en las clases I y II de acuerdo con la Sociedad Norteamericana de Ecocardiografia y que no tenian ninguna contraindicacion para el examen. Al finalizar el procedimiento, y despues de la conclusion del examen, una anotacion en la ficha clasifico la monitorizacion en cuanto a su utilidad en el periodo intraoperatorio en tres grupos: grupo 1 - la ETE no interfirio en la conducta quirurgica o anestesica; grupo 2 - la ETE motivo un cambio en la conducta anestesica en cuanto a la administracion de volumen, introduccion y/o modificacion de farmacos vasoactivos (aqui la ETE genero el cambio de conducta anestesica en conjunto con los otros monitores, pero siendo ella el factor decisivo); grupo 3 - la ETE conllevo al cambio de conducta o revision del procedimiento quirurgico. RESULTADOS: De enero de 2009 a enero de 2011, 164 ETE intraoperatorias se realizaron en nuestro servicio, siendo 41 pacientes pediatricos y 123 adultos. En todos los pacientes el examen se hizo con exito y no hubo problemas con relacion a la introduccion de la sonda transesofagica. En el grupo de los pacientes pediatricos, 10 permanecieron en el grupo 1 (24,4%), 27 en el grupo 2 (65,8%) y cuatro en el grupo 3 (9,8%). Entre los adultos, el grupo 1 quedo con 38 pacientes (30,9%), el grupo 2 con 81 (65,9%) y el grupo 3 con 4 (3,2%). CONCLUSIONES: Pese a que nuestra pequena casuistica fue comparada con la literatura mundial y se vieron las limitaciones de este estudio, si que hubo una concordancia con otros relatos en la literatura con relacion a los cambios de conducta quirurgico-anestesica con base en la ETE intraoperatoria. Nuestros datos tambien sugieren firmemente que la ecocardiografia transesofagica es una herramienta extremadamente util para la monitorizacion de los pacientes de alto riesgo cardiovascular, incluso cuando estan sometidos a la cirugia no cardiaca. Mas estudios originados en nuestro pais se hacen necesarios, porque no hay en la literatura otros trabajos que definan el perfil de uso o incluso que establezcan claramente como ha venido siendo usada la ETE en nuestro medio.