Renato Mestriner Stocche

Effects of intrathecal sufentanil on plasma oxytocin and cortisol concentrations in women during the first stage of labor.

Background and Objectives Intrathecal sufentanil provides analgesia comparable to epidural bupivacaine for the first stage of labor. Both epidural local anesthetics and intrathecal opioid reduce some parameters of the neuroendocrine response to labor pain and the reflex release of oxytocin in animals. In humans, epidural local anesthetics only reduce the spurt release of oxytocin. This study compared the effect of intrathecal sufentanil and epidural bupivacaine administration on the plasma concentration of oxytocin and cortisol in women with labor pain during the first stage of labor. Methods Thirty healthy parturients requesting analgesia were enrolled in this randomized and open-label study. Each patient was in spontaneous labor at greater than 5 cm cervical dilatation. Using a combined spinal and epidural technique, patients received either intrathecal sufentanil 10 μg (SUF = intrathecal sufentanil group) or epidural plain bupivacaine 0.25%, 12 mL (BUPIV = epidural bupivacaine group). Analgesia was assessed using a visual analog scale, and blood samples for oxytocin and cortisol plasma concentration measurements were collected immediately before analgesia and 15, 30, 60, and 90 minutes after induction of the analgesia. Plasma cortisol and oxytocin concentrations were determined by specific radioimmunoassay. The values were expressed as mean ± SEM. Results Intrathecal sufentanil provided faster and more complete analgesia within 15 and 30 minutes of its administration, compared with epidural bupivacaine. Plasma oxytocin concentrations were similar in the 2 groups before analgesia (7.24 ± 2.1 and 6.6 ± 3.1 pg/mL SUF and BUPIV, respectively). It decreased significantly in the SUF and increased in the BUPIV after analgesic administration. Cortisol concentrations were elevated in both groups before analgesia (51.6 ± 5.3 and 54.2 ± 4.8 μg/dL SUF and BUPIV, respectively). Both analgesic treatments significantly decreased the plasma cortisol levels. Conclusions Intrathecal sufentanil analgesia decreases plasma concentrations of oxytocin and cortisol in women with labor pain during the first stage of labor, but epidural bupivacaine only reduced the cortisol concentration.

Labor analgesia in a patient with paroxysmal nocturnal hemoglobinuria with thrombocytopenia

Background and Objectives Paroxysmal nocturnal hemoglobinuria (PNH) is a form of acquired hemolytic anemia in which a defect of glycophosphoinositol anchor proteins in the cell membrane of bone marrow stem cells leads to activation of the complement system and consequent destruction of defective cells. The characteristics of this disease are an increased frequency of thrombotic events, anemia, and thrombocytopenia. Methods We report a case of a pregnant patient with PNH with thrombocytopenia who delivered vaginally after receiving epidural labor analgesia. Prophylaxis of thromboembolism was performed with heparin 1 hour after the removal of the epidural catheter, and repeated at 12-hour intervals. Sensory changes or motor changes and pain were monitored every 10 minutes for 8 hours after delivery. Results During analgesia, the patient reported complete pain relief. Delivery and the immediate postpartum period were without any untoward events. Conclusions Four major factors influenced the anesthetic conduct used for the present patient: (1) the risk of an acute hemolytic crisis, (2) the need to perform prophylaxis for thromboembolism, (3) the need to reduce labor stress, and (4) minimizing the risk of missing an epidural hematoma. We also present a survey of the literature about PNH and discuss the anesthetic conduct in this patient.

Uso do azul de metileno no tratamento de choque anafilático durante anestesia: relato de caso

BACKGROUND AND OBJECTIVES The risk of perioperative anaphylaxis should always be considered. The incidence of anesthetic allergic reactions is controversial, varying from 1/3,000 to 1/20,000, with mortality range between 3 and 9%. This report describes the use of methylene blue as coadjuvant drug to treat anaphylaxis refractory to conventional therapy. CASE REPORT A 53-year-old male patient was submitted to inguinal hernia correction under spinal anesthesia. After receiving 1.5 g intravenous dipirone at surgery completion, he immediately developed bronchospasm, cyanosis, decreased SpO2 and SBP, culminating with cardiac arrest. Resuscitation was started with external cardiac massage followed by tracheal intubation, as well as 1 mg epinephrine and 1 mg atropine injections. Heart rate returned (150 bpm) with no palpable pulse though. Additional 1 mg epinephrine and 1 g hydrocortisone were administered with central pulse recovery (8 minutes). Although receiving dopamine (20 microg.kg-1.min-1), patient remained hypotensive (60 mmHg) until 80 minutes. Intravenous 100 mg methylene blue was then administered with increased SBP to 85 and 105 mmHg after the second dose. Dopamine dose was tapered from 10 to 7, 5 and finally 2 microg.kg-1.min-1. CONCLUSIONS Histamine is the major anaphylaxis mediator. Inducing nitric oxide (NO) production, it consequently increases guanylate cyclase, which promotes arteriolar vasodilation by increasing cyclic GMP. Methylene blue may be helpful in such situations because it inhibits guanylate cyclase and consequently vasodilation, resulting in hemodynamic improvement.

Anesthesia for cesarean section in a patient with familiar hypertrophic cardiomyopathy: case report

BACKGROUND AND OBJECTIVES Familiar Hypertrophic cardiomyopathy (FHC) is a rare hereditary cardiac disorder characterized by hypertrophy of the ventricular septum and variable degrees of subvalvular aortic stenosis. In this disease, the increase in myocardial contractility and reduction in peripheral vascular resistance can aggravate left ventricular outlet obstruction, leading to arrhythmias and cardiac ischemia. The objective of this report was to discuss the anesthetic management of cesarean section in a patient with FHC. CASE REPORT A patient in the 33rd week of pregnancy and prior diagnosis of FHC presented, on the 24-hour Holter monitor, 22 episodes of non-sustained ventricular tachycardia (NSVT) and 2 episodes of sustained ventricular tachycardia (SVT). She complained of episodes of palpitation, dyspnea, and chest pain of short duration. The patient was medicated with atenolol, with control of symptoms and cardiac arrhythmias. Within 38 weeks and 5 days of gestation, the patient underwent elective cesarean section. Besides the usual monitoring, analysis of the ST segment and invasive blood pressure were also instituted. Anesthesia consisted of combined spinal-epidural technique with subarachnoidal administration of 5 microg of sufentanil followed by the administration of increasing doses of 0.375% bupivacaine until it reached the level of T6 (total of 16 mL). Metaraminol was used as a vasopressor. Perioperative maternal hypotension or other complications were not observed. CONCLUSIONS General anesthesia is often used for cesarean sections in patients with FHC. Spinal-epidural anesthesia with slow installation of the blockade was a safe alternative. In those patients, one should avoid an increase in myocardial contractility and, if necessary, a a-agonist should be used to treat maternal hypotension.

Comparação entre nifedipina por via sublingual e clonidina por via venosa no controle de hipertensão arterial peri-operatória em cirurgias de catarata

JUSTIFICATIVA Y OBJETIVOS: Estudio reciente muestra que la clonidina por via venosa se presenta eficaz y segura en el tratamiento de crisis hipertensivas durante cirugia de catarata. Este estudio visa comparar el uso de nifedipina, droga ampliamente utilizada por via sub-lingual, y clonidina por via venosa en el control de la hipertension en cirugias de catarata. METODO: Setenta e cinco pacientes sometidos a facectomia fueron distribuidos de forma aleatoria y encubierta en: Grupo A, que recibio nifedipina y Grupos C2 y C3, que recibieron, respectivamente, 2 y 3 µg.kg-1 de clonidina por via venosa. Todos los pacientes presentaban hipertension arterial (PAS > 170 mmHg o PAD > 110 mmHg). Las PAS, PAD y frecuencia cardiaca (FC) fueron medidas y comparadas en los momentos: 0 (antes del tratamiento) y de 2 en 2 minutos hasta el final del procedimiento. Los eventos adversos fueron anotados. RESULTADOS: Despues del tratamiento ocurrieron diminuciones de la PAS y PAD en los 3 grupos (p < 0,001). Hubo control de la presion arterial (<160 mmHg) en 32%, 64% y 72% de los pacientes en los grupos A, C2 y C3, respectivamente (p < 0,05). En el grupo C3 ocurrio mayor incidencia de efectos colaterales que en los grupos C2 y A (p < 0,05). CONCLUSIONES: La clonidina por via venosa es mas eficaz que la nifedipina, por via sub-lingual, en el control de crisis hipertensivas en el peri-operatorio de cirugias de catarata. Sin embargo, la dosis de 3 µg.kg-1 puede estar relacionada a efectos colaterales, debiendose iniciar el tratamiento con 2 µg.kg-1.BACKGROUND AND OBJECTIVES A recent study has shown that intravenous clonidine is effective and safe in treating perioperative arterial hypertension during cataract procedures. This study aimed at comparing sublingual nifedipine and intravenous clonidine to control arterial hypertension during cataract procedures. METHODS Participated in this randomized double-blind study 75 patients submitted to facectomy, who were distributed in: Group A, receiving nifedipine and Groups C2 and C3, receiving 2 and 3 microg.kg-1 intravenous clonidine, respectively. All patients had arterial hypertension (SBP > 170 mmHg or DBP > 110 mmHg). SBP, DBP and HR were monitored and compared in moments 0 (before treatment), and at 2-minute intervals until the end of the procedure. Adverse events were recorded. RESULTS There has been SBP and DBP decrease in all groups after treatment (p < 0.001). There has been blood pressure control (< 160 mmHg) in 32%, 64% and 72% of groups A, C2 and C3 patients, respectively (p < 0.05). Group C3 presented a higher incidence of side-effects, as compared to groups C2 and A (p < 0.05). CONCLUSIONS Intravenous clonidine is more effective than sublingual nifedipine to control perioperative arterial hypertension during cataract extraction. However, the dose of 3 microg.kg-1 may be related to side-effects and treatment should be started with 2 microg.kg-1.

Influência da clonidina por via venosa no custo de anestesia com sevoflurano em cirurgias de ouvido médio em regime ambulatorial

BACKGROUND AND OBJECTIVES Clonidine is an a2-agonist which decreases intravenous and inhalational anesthetics consumption. This study aimed at evaluating the cost-benefit ratio of preanesthetic medication with intravenous clonidine for general anesthesia with sevoflurane in outpatient procedures. METHODS Forty five patients aged 15 to 52 years were included in this double-blind, randomized and placebo controlled study, and were distributed in 3 groups of 15: Group S (placebo), Group C3 (3 microg kg(-) clonidine) and Group C5 (5 microg kg(-1) clonidine). Anesthesia was induced with sevoflurane, alfentanil (30 microg kg(-1)) and pancuronium (0.08 mg kg(-1)). The following parameters were recorded: incidence of complications, halogenate consumption and anesthesia duration, as well as phase I and II recovery time. Cost analysis has considered direct and indirect costs. RESULTS There were no differences among groups in demographics data, incidence of complications and phase I anesthetic recovery. Phase II anesthetic recovery was prolonged in Group C5 (p < 0.05). Sevoflurane consumption per minute of surgery was 0.54 +/- 0.14, 0.33 +/- 0.09 and 0.34 +/- 0.13 in Groups S, C3 and C5 respectively (p < 0.05). Costs were approximately 35% lower in the clonidine groups. CONCLUSIONS Intravenous clonidine (3 microg kg(-1)) decreases sevoflurane consumption without prolonging phase I recovery. Although decreasing sevoflurane consumption, 5 microg kg(-1) clonidine prolongs phase II recovery, thus being inadequate for outpatient procedures.BACKGROUND AND OBJECTIVES: Clonidine is an a2-agonist which decreases intravenous and inhalational anesthetics consumption. This study aimed at evaluating the cost-benefit ratio of preanesthetic medication with intravenous clonidine for general anesthesia with sevoflurane in outpatient procedures. METHODS: Forty five patients aged 15 to 52 years were included in this double-blind, randomized and placebo controlled study, and were distributed in 3 groups of 15: Group S (placebo), Group C3 (3 µg.kg-1 clonidine) and Group C5 (5 µg.kg-1 clonidine). Anesthesia was induced with sevoflurane, alfentanil (30 µg.kg-1) and pancuronium (0.08 mg.kg-1). The following parameters were recorded: incidence of complications, halogenate consumption and anesthesia duration, as well as phase I and II recovery time. Cost analysis has considered direct and indirect costs. RESULTS: There were no differences among groups in demographics data, incidence of complications and phase I anesthetic recovery. Phase II anesthetic recovery was prolonged in Group C5 (p < 0.05). Sevoflurane consumption per minute of surgery was 0.54 ± 0.14, 0.33 ± 0.09 and 0.34 ± 0.13 in Groups S, C3 and C5 respectively (p < 0.05). Costs were approximately 35% lower in the clonidine groups. CONCLUSIONS: Intravenous clonidine (3 µg.kg-1) decreases sevoflurane consumption without prolonging phase I recovery. Although decreasing sevoflurane consumption, 5 µg.kg-1 clonidine prolongs phase II recovery, thus being inadequate for outpatient procedures.

Comparison between sublingual nifedipine and intravenous clonidine to control perioperative arterial hypertension in cataract procedures.

JUSTIFICATIVA Y OBJETIVOS: Estudio reciente muestra que la clonidina por via venosa se presenta eficaz y segura en el tratamiento de crisis hipertensivas durante cirugia de catarata. Este estudio visa comparar el uso de nifedipina, droga ampliamente utilizada por via sub-lingual, y clonidina por via venosa en el control de la hipertension en cirugias de catarata. METODO: Setenta e cinco pacientes sometidos a facectomia fueron distribuidos de forma aleatoria y encubierta en: Grupo A, que recibio nifedipina y Grupos C2 y C3, que recibieron, respectivamente, 2 y 3 µg.kg-1 de clonidina por via venosa. Todos los pacientes presentaban hipertension arterial (PAS > 170 mmHg o PAD > 110 mmHg). Las PAS, PAD y frecuencia cardiaca (FC) fueron medidas y comparadas en los momentos: 0 (antes del tratamiento) y de 2 en 2 minutos hasta el final del procedimiento. Los eventos adversos fueron anotados. RESULTADOS: Despues del tratamiento ocurrieron diminuciones de la PAS y PAD en los 3 grupos (p < 0,001). Hubo control de la presion arterial (<160 mmHg) en 32%, 64% y 72% de los pacientes en los grupos A, C2 y C3, respectivamente (p < 0,05). En el grupo C3 ocurrio mayor incidencia de efectos colaterales que en los grupos C2 y A (p < 0,05). CONCLUSIONES: La clonidina por via venosa es mas eficaz que la nifedipina, por via sub-lingual, en el control de crisis hipertensivas en el peri-operatorio de cirugias de catarata. Sin embargo, la dosis de 3 µg.kg-1 puede estar relacionada a efectos colaterales, debiendose iniciar el tratamiento con 2 µg.kg-1.BACKGROUND AND OBJECTIVES A recent study has shown that intravenous clonidine is effective and safe in treating perioperative arterial hypertension during cataract procedures. This study aimed at comparing sublingual nifedipine and intravenous clonidine to control arterial hypertension during cataract procedures. METHODS Participated in this randomized double-blind study 75 patients submitted to facectomy, who were distributed in: Group A, receiving nifedipine and Groups C2 and C3, receiving 2 and 3 microg.kg-1 intravenous clonidine, respectively. All patients had arterial hypertension (SBP > 170 mmHg or DBP > 110 mmHg). SBP, DBP and HR were monitored and compared in moments 0 (before treatment), and at 2-minute intervals until the end of the procedure. Adverse events were recorded. RESULTS There has been SBP and DBP decrease in all groups after treatment (p < 0.001). There has been blood pressure control (< 160 mmHg) in 32%, 64% and 72% of groups A, C2 and C3 patients, respectively (p < 0.05). Group C3 presented a higher incidence of side-effects, as compared to groups C2 and A (p < 0.05). CONCLUSIONS Intravenous clonidine is more effective than sublingual nifedipine to control perioperative arterial hypertension during cataract extraction. However, the dose of 3 microg.kg-1 may be related to side-effects and treatment should be started with 2 microg.kg-1.

Influence of intravenous clonidine in the cost of sevoflurane anesthesia for outpatient middle ear procedures

BACKGROUND AND OBJECTIVES Clonidine is an a2-agonist which decreases intravenous and inhalational anesthetics consumption. This study aimed at evaluating the cost-benefit ratio of preanesthetic medication with intravenous clonidine for general anesthesia with sevoflurane in outpatient procedures. METHODS Forty five patients aged 15 to 52 years were included in this double-blind, randomized and placebo controlled study, and were distributed in 3 groups of 15: Group S (placebo), Group C3 (3 microg kg(-) clonidine) and Group C5 (5 microg kg(-1) clonidine). Anesthesia was induced with sevoflurane, alfentanil (30 microg kg(-1)) and pancuronium (0.08 mg kg(-1)). The following parameters were recorded: incidence of complications, halogenate consumption and anesthesia duration, as well as phase I and II recovery time. Cost analysis has considered direct and indirect costs. RESULTS There were no differences among groups in demographics data, incidence of complications and phase I anesthetic recovery. Phase II anesthetic recovery was prolonged in Group C5 (p < 0.05). Sevoflurane consumption per minute of surgery was 0.54 +/- 0.14, 0.33 +/- 0.09 and 0.34 +/- 0.13 in Groups S, C3 and C5 respectively (p < 0.05). Costs were approximately 35% lower in the clonidine groups. CONCLUSIONS Intravenous clonidine (3 microg kg(-1)) decreases sevoflurane consumption without prolonging phase I recovery. Although decreasing sevoflurane consumption, 5 microg kg(-1) clonidine prolongs phase II recovery, thus being inadequate for outpatient procedures.BACKGROUND AND OBJECTIVES: Clonidine is an a2-agonist which decreases intravenous and inhalational anesthetics consumption. This study aimed at evaluating the cost-benefit ratio of preanesthetic medication with intravenous clonidine for general anesthesia with sevoflurane in outpatient procedures. METHODS: Forty five patients aged 15 to 52 years were included in this double-blind, randomized and placebo controlled study, and were distributed in 3 groups of 15: Group S (placebo), Group C3 (3 µg.kg-1 clonidine) and Group C5 (5 µg.kg-1 clonidine). Anesthesia was induced with sevoflurane, alfentanil (30 µg.kg-1) and pancuronium (0.08 mg.kg-1). The following parameters were recorded: incidence of complications, halogenate consumption and anesthesia duration, as well as phase I and II recovery time. Cost analysis has considered direct and indirect costs. RESULTS: There were no differences among groups in demographics data, incidence of complications and phase I anesthetic recovery. Phase II anesthetic recovery was prolonged in Group C5 (p < 0.05). Sevoflurane consumption per minute of surgery was 0.54 ± 0.14, 0.33 ± 0.09 and 0.34 ± 0.13 in Groups S, C3 and C5 respectively (p < 0.05). Costs were approximately 35% lower in the clonidine groups. CONCLUSIONS: Intravenous clonidine (3 µg.kg-1) decreases sevoflurane consumption without prolonging phase I recovery. Although decreasing sevoflurane consumption, 5 µg.kg-1 clonidine prolongs phase II recovery, thus being inadequate for outpatient procedures.

Intravenous clonidine in the induced arterial hypotension technique for tympanoplasty

BACKGROUND AND OBJECTIVES Induced arterial hypotension is an effective technique to decrease surgical bleeding. Clonidine is an a2-agonist with central action which was proven to be safe in anesthesia. This study aimed at evaluating the efficacy of intravenous clonidine as the primary drug for induced arterial hypotension. METHODS Participated in this prospective double-blind study 36 patients of both genders, physical status ASA I and II, who were randomly distributed in three groups of 12 patients receiving the following preanesthetic medication 15 minutes before anesthetic induction: 3 microg.kg-1 clonidine (C3), 5 microg.kg-1 clonidine (C5) or 0.9% saline solution (Control). Anesthesia was maintained with isoflurane in a maximum concentration of 2%. BP and HR were recorded before, 1 and 5 minutes after induction and at every 5 minutes of anesthesia. Patients receiving 2% isoflurane for more than 15 minutes and not presenting SBP below 80 mmHg were administered sodium nitroprusside to induce arterial hypotension. RESULTS Sodium nitroprusside was needed in three C3 group patients (25%), one C5 group patient (8%) and eight control group patients (66%). Total nitroprusside dose to induce arterial hypotension in the control group was higher as compared to groups C3 and C5 (p < 0.01). The incidence of complications was similar among groups. CONCLUSIONS Intravenous clonidine may lead to induced hypotension during tympanoplasties under balanced anesthesia with isoflurane concentration limited to 2%. In the conditions of this study, clonidine has not affected anesthetic quality and emergence time.JUSTIFICATIVA Y OBJETIVOS: A hipotension arterial inducida es una tecnica eficaz para diminuir el sangramiento durante actos quirurgicos. La clonidina es un a2-agonista de acion central que ya se mostro segura en anestesia. El objetivo de este estudio fue verificar la eficiencia de la clonidina por via venosa como droga principal en la hipotension arterial controlada. METODO: Participaron del estudio prospectivo y duplamente encubierto, 36 pacientes de ambos sexos, estado fisico ASA I y II, divididos aleatoriamente en tres grupos de 12 pacientes que recibieron medicacion pre-anestesica: clonidina 3 µg.kg-1 (C3), clonidina 5 µg.kg-1 (C5) o solucion fisiologica a 0,9% (Control) 15 minutos antes de la induccion anestesica. La manutencion anestesica fue hecha con isoflurano hasta la concentracion maxima de 2%. Fueron anotados la PA y la FC antes, con 1 y 5 minutos despues de la induccion y a cada 5 minutos de anestesia. Pacientes a mas de 15 minutos recibiendo isoflurano 2% y que no presentaron PAS menor que 80 mmHg recibieron nitroprusiato de sodio para induccion de la hipotension arterial. RESULTADOS: Tres pacientes (25%) y el grupo C3, un (8%) en el grupo C5 y ocho (66%) en el grupo control necesitaron de nitroprusiato de sodio. La dosis total de nitroprusiato para inducir hipotension arterial en el grupo control fue mayor de que en los grupos C3 y C5 (p < 0,01). La incidencia de complicaciones fue semejante en los tres grupos. CONCLUSIONES: La clonidina por via venosa puede llevar a hipotension arterial inducida en cirugias de timpanoplastia utilizandose tecnica de anestesia balanceada con concentracion de isoflurano limitada en 2%. En las condiciones de este estudio, la clonidina no influencio la calidad anestesica y el tiempo de despertar.

Anestesia peridural contínua com ropivacaína a 0,2% associada a anestesia geral para cirurgia do abdômen superior em crianças

BACKGROUND AND OBJECTIVES Several anesthetic techniques have been proposed for different pediatric surgeries to promote postoperative analgesia, among other advantages. This study aimed at evaluating propofol infusion rate and postanesthetic recovery of children submitted to upper abdominal surgeries under epidural anesthesia with 0.2% ropivacaine associated to general anesthesia with propofol or propofol plus sufentanil. METHODS Participated in this study 26 children physical status ASA I, II and III, aged 0 to 4 years, were scheduled to upper abdominal surgeries under thoracic epidural anesthesia (T7-T8) with 0.2% ropivacaine (1.5 ml.kg-1). They were randomly distributed in two groups: Propofol (propofol infusion) and Sufentanil (propofol infusion plus 1 microg.kg-1 sufentanil). Propofol infusion rates were 20 and 10 mg.kg-1.h-1 for the Propofol and Sufentanil groups, respectively, adjusted to maintain blood pressure in approximately 20% of baseline values and withdrawn 10 to 15 minutes before estimated surgery completion. Postanesthetic recovery was evaluated by a modified Aldrete-Kroulik scale and sedation was evaluated by a 5 grade score. RESULTS Techical difficulties excluded two children of each group. Infusion rate was significantly slower in the Sufentanil group as compared to the Propofol group during 100 minutes after beginning of surgery. Time for extubation and referral to post-anesthetic recovery unit (PACU) was significantly shorter for the Propofol group, however sedation intensity and duration were longer in this group as compared to Sufentanil group. Recovery scores were similar for both groups. Three hours after PACU admission all patients were meeting criteria to be transferred to the ward. Transient arterial hypotension was observed in 2 Sufentanil group patients. CONCLUSIONS Continuous thoracic epidural anesthesia with 0.2% ropivacaine (1.5 mg.kg-1) associated to propofol infusion provides effective and safe anesthesia for upper pediatric abdominal surgeries. Propofol infusion rate and sedation duration were decreased with the association of sufentanil.