Roberto Araújo Ruzi

Analgesia pós-operatória em cirurgia ortopédica: estudo comparativo entre o bloqueio do plexo lombar por via perivascular inguinal (3 em 1) com ropivacaína e a analgesia subaracnóidea com morfina

JUSTIFICATIVA E OBJETIVOS: O bloqueio do plexo lombar pelo acesso perivascular inguinal, chamado de bloqueio 3 em 1, tem sido utilizado para analgesia pos-operatoria. O objetivo deste estudo foi comparar a analgesia pos-operatoria do bloqueio 3 em 1 a da morfina subaracnoidea em pacientes submetidos a cirurgias ortopedicas em membro inferior (MI). METODO: Foram estudados 40 pacientes escalados para cirurgia ortopedica de MI, de ambos os sexos, estado fisico ASA I e II, com idades entre 15 e 75 anos, distribuidos em 2 grupos (M e BPL). Foi realizada anestesia subaracnoidea em todos os pacientes, em L3-L4 ou L4-L5, com 20 mg de bupivacaina isobarica a 0,5%. No grupo M (n = 20) foi associado 50 µg de morfina ao anestesico local. No grupo BPL (n = 20) foi realizado o bloqueio 3 em 1 ao termino da cirurgia, utilizando 200 mg de ropivacaina a 0,5%. Avaliou-se a analgesia e a intensidade da dor as 4, 8, 12, 14, 16, 20 e 24 horas apos o termino da cirurgia, o nivel do bloqueio subaracnoideo, o tempo cirurgico e as complicacoes. RESULTADOS: A duracao da analgesia no grupo BPL foi de 13,1 ± 2,47, enquanto no grupo M todos os pacientes referiam dor e ausencia de bloqueio motor no primeiro instante avaliado (4 horas). Houve falha do bloqueio de um dos 3 nervos em 3 pacientes. A incidencia de nausea e prurido foi significativamente maior no grupo M. Quanto a retencao urinaria, nao houve diferenca significante entre os grupos. Nao houve depressao respiratoria, hipotensao arterial ou bradicardia. A analgesia pos-operatoria foi mais efetiva no grupo BPL, comparada ao grupo M as 4, 8, 12,14 e 16 horas. As 20 e 24 horas nao houve diferenca significante entre os grupos. CONCLUSOES: A analgesia pos-operatoria proporcionada pelo bloqueio 3 em 1 apresentou efeitos colaterais inferiores a morfina subaracnoidea com tempo de analgesia semelhante.

Anesthesia in a patient with Marshall-Smith syndrome: case report

BACKGROUND AND OBJECTIVESnThe Marshall-Smith Syndrome is a rare disease characterized by facial dysmorphism, accelerated osseous maturation, retarded neuropsychomotor development, and abnormalities of the airways. Patients with this syndrome have a high risk of developing anesthetic complications, especially concerning the maintenance of the airways. There are very few data in the anesthetic literature regarding this syndrome. The objective of this report was to show the difficulties and anesthetic management in a 28-day old child with this syndrome, who underwent surgery for correction of choanal atresia under general anesthesia.nnnCASE REPORTnA male child, 28 days old, weighing 2.8 kg, undergoing general anesthesia for surgical correction of choanal atresia. The child presented the typical manifestations of the Marshall-Smith syndrome, with a narrow thorax, pectus excavatum, large hands and feet, long neck, facial dysmorphism, high and arched palate, and accelerated osseous maturation. Anesthetic induction was done with a mask with 100% O2 associated with sevoflurane. Due to the possibility of a difficult intubation, tracheal intubation with a fibrobronchoscope was scheduled. After tracheal intubation and assisted manual ventilation, 1.5 mg of rocuronium were administered and, after ten minutes, the patient developed bradycardia (80 bpm), severe hypoxemia (O2 saturation of 30%), and manual ventilation through the tracheal tube became impossible. An urgent tracheostomy was done and the surgical procedure was cancelled.nnnCONCLUSIONnIn cases of anesthetic-surgical emergencies, in which the child does not ventilate and tracheal intubation is not possible, there is desaturation and bradycardia, requiring fast and appropriate decision making to guarantee adequate pulmonary ventilation. These patients need careful evaluation of the airways to identify upper and lower airways obstruction. During anesthesia, spontaneous ventilation should be maintained during induction until control of the airways is possible, avoiding the use of neuromuscular blockers.

Abordagem simplificada do nervo ciático por via posterior, no ponto médio do sulco glúteo-femoral, com uso de neuroestimulador

BACKGROUND AND OBJECTIVESnThe sciatic nerve may be blocked by several routes, all of them with advantages and disadvantages. It is the largest human nerve in diameter and length, being the prolongation of the upper sacral plexus fascicle (L4, L5, S2 and S3). It leaves the pelvis through the foramen ischiadicum majus, passing below the piriform muscle and going down between the greater trochanter and the ischial tuberosity, continuing along the femoral dorsum, anterior to biceps femoris and semitendinous muscles, to the lower femoral third, where it is divided in two major branches called tibial and common fibular nerves. It becomes superficial at the lower border of the gluteus maximus muscle. Based on this anatomic description, we developed a posterior approach with the following advantages: easy identification of the surface anatomy, superficial level of the nerve at this location; and less discomfort to patients since a 5 cm needle may be used.nnnMETHODSnSeventeen ASA I - III patients aged 21 to 79 years, weighing 55 to 90 kg, undergoing leg or foot surgery were studied. After monitoring, patients were placed in the prone position and blockade was performed at the middle point of the sulcus gluteus (skin fold between nates and posterior thigh), with the aid of a neurostimulator, using 1% plain lidocaine (300 mg). Onset time, blockade performing time, and tibial, common fibular and cutaneous femoris posterior nerves anesthesia were evaluated. Saphenous nerve was also blocked with 5 ml of 1% lidocaine whenever needed.nnnRESULTSnAdequate anesthesia was obtained in all cases. There was no patient with cutaneous femoris posterior nerve anesthesia. Blockade performing time was 8.58 +/- 5.71 min. Onset time was 5.88 +/- 1.6 min. Sensory and motor block duration was 4.05 +/- 1.1 and 2.9 +/- 0.8 hours, respectively.nnnCONCLUSIONSnThis new approach is effective and easy. However, it is not indicated when the cutaneous femoris posterior nerve anesthesia is necessary.BACKGROUND AND OBJECTIVES: The sciatic nerve may be blocked by several routes, all of them with advantages and disadvantages. It is the largest human nerve in diameter and length, being the prolongation of the upper sacral plexus fascicle (L4, L5, S2 and S3). It leaves the pelvis through the foramen ischiadicum majus, passing below the piriform muscle and going down between the greater trochanter and the ischial tuberosity, continuing along the femoral dorsum, anterior to biceps femoris and semitendinous muscles, to the lower femoral third, where it is divided in two major branches called tibial and common fibular nerves. It becomes superficial at the lower border of the gluteus maximus muscle. Based on this anatomic description, we developed a posterior approach with the following advantages: easy identification of the surface anatomy, superficial level of the nerve at this location; and less discomfort to patients since a 5 cm needle may be used. METHODS: Seventeen ASA I - III patients aged 21 to 79 years, weighing 55 to 90 kg, undergoing leg or foot surgery were studied. After monitoring, patients were placed in the prone position and blockade was performed at the middle point of the sulcus gluteus (skin fold between nates and posterior thigh), with the aid of a neurostimulator, using 1% plain lidocaine (300 mg). Onset time, blockade performing time, and tibial, common fibular and cutaneous femoris posterior nerves anesthesia were evaluated. Saphenous nerve was also blocked with 5 ml of 1% lidocaine whenever needed. RESULTS: Adequate anesthesia was obtained in all cases. There was no patient with cutaneous femoris posterior nerve anesthesia. Blockade performing time was 8.58 ± 5.71 min. Onset time was 5.88 ± 1.6 min. Sensory and motor block duration was 4.05 ± 1.1 and 2.9 ± 0.8 hours, respectively. CONCLUSIONS: This new approach is effective and easy. However, it is not indicated when the cutaneous femoris posterior nerve anesthesia is necessary.

Anesthesia for Non-Obstetrical Surgery during Pregnancy

The number of surgical procedures in gravid women unrelated to pregnancy itself has been increased over years. In such cases, one must keep in mind the responsibility for two patients, the optimization and maintenance of maternal homeostasis, avoiding alterations on uteroplacental perfusion that can bring harm to the fetus. This review focus on safety to performing these procedures during pregnancy, considering the advances in the prevention and treatment of obstetric and fetal morbidity related to anesthesia. Background and Objectives: Despite research advances, there is still much controversy in the anesthetic management of obstetric patients. Several studies have demonstrated the safety of anesthesia in this group of patients. In this review an analysis of anesthetics used in clinical practice is proposed as well as the technique to be chosen and its effects on the mother and fetus in non-obstetric surgery during pregnancy. Content: There was made a revision based on the main articles in the literature encompassing the epidemiology, physiological changes during pregnancy, anesthetic management, possible risks to the fetus due to the use of anesthetic drugs, fetal monitoring, and procedures such as fetal surgery and laparoscopic during pregnancy. Conclusion: Non-obstetric anesthesia in pregnant patients has proven to be safe in terms of maternal and fetal outcome, maternal morbidity and mortality, teratogenicity, premature birth and fetal loss.

Tibial and Common Fibular Nerve Block in the Popliteal Fossa with Single Puncture Using Percutaneous Nerve Stimulator: Anatomical Considerations and Ultrasound Description

BACKGROUND AND OBJECTIVESnTechniques of peripheral nerve block have gained popularity over the last two decades becoming a growing anesthetic option for limb surgeries. This study proposes a technical approach of the tibial and common fibular nerves in the popliteal fossa with single puncture using percutaneous nerve stimulator, considering the correlation with an anatomical and ultrasound study.nnnMETHODSnThis prospective, observational, randomized study was performed with 28 patients scheduled for foot surgeries. After localizing the tibial and common fibular nerves through percutaneous stimulation, the puncture was performed at the point of tibial nerve stimulation with a 5-cm needle (B.Braun, Stimuplex 50), and 10 mL of levobupivacaine were injected. The needle was pulled back and redirected to the point of common fibular nerve stimulation looking for the corresponding motor response, and 10 mL of the local anesthetic were injected. Imaging study of the popliteal region was performed by ultrasound to correlate the anatomy with the technique used.nnnRESULTSnAdequate anesthesia was obtained in all cases. The mean time to localize the tibial and common fibular nerves suing the percutaneous stimulator was 57.1 and 32.8 seconds, respectively, and with the nerve stimulator it was 2.22 and 1.79 minutes, respectively. The mean depth of the needle into the tibial nerve was 10.7 mm.nnnCONCLUSIONSnThe approach for tibial and common fibular nerves with single puncture in the popliteal fossa using peripheral nerve stimulator is a good option for anesthesia and analgesia for foot surgeries.

Prospective study of ultrasound-guided peri-plexus interscalene block with continuous infusion catheter for arthroscopic rotator cuff repair and postoperative pain control

Objective This trial investigated postoperative analgesia in arthroscopic rotator cuff repair surgery patients under general anesthesia, associated with ultrasound-guided peri-plexus interscalene brachial plexus block (US-IBPB), and compared single injection to elastomeric pump continuous infusion of local anesthetics. Complications associated to both techniques are described. Methods In this prospective, quasi-randomized controlled clinical trial, 68 adults scheduled for elective arthroscopic rotator cuff repair were assigned to receive Group 1 (G1 = 41) US-IBPB with a 20 mL injection of 0.5% peri-plexus ropivacaine, introduction of catheter, injection of 20 mL of 0.5% ropivacaine through continuous catheter infusion of local anesthetic by elastomeric pump (ropivacaine 0.2%, infusion of 5 mL/h). In Group 2 (G2 = 27), US-IBPB, with a single peri-plexus injection of 40 mL ropivacaine 0.5%. In both groups oral analgesics were prescribed, paracetamol 500 mg associated to codeine 30 mg for patients with VAS between 3 and 5, and also oxycodone 20 mg for VAS ≥ 6. The anesthesiology team was available through contact telephones and the patients received a table to complete in order to report pain intensity according to VAS, use of oral medication, and complications related to the catheter and pump, until the third postoperative day. Results The intensity of pain was higher on second day after surgery than on days 1 and 3, in both groups confirmed by the ANOVA test (p = 0.00006) Among the groups, G1 patients had lower pain intensity than G2, (p = 0.000197). G2 patients presented greater pain intensity during all periods studied (days 1, 2, and 3) than G1 patients. Postoperatively, G2 patients had higher consumption of rescue analgesics, nausea, and vomiting (40.74%) vs. G1 (5%) and dizziness (25.92%). No patient with catheter and elastomeric pump (G1) had complications regarding its insertion and maintenance during postoperative period. Conclusion The quality of analgesia for arthroscopic rotator cuff repair with peri-plexus US-IBPB and continuous infusion with elastomeric pump presented superior postoperative analgesia quality to single puncture IBPB on postoperative days 2 and 3, with lower consumption of rescue opioids in this period.

Renal injury after anesthesia: what is in evidence

Perioperative acute kidney injury (AKI) is globally responsible for a large number of deaths each year, although being a well known disease, it does not have a precise diagnosis, which contributes to increase morbidity and mortality, since plasma creatinine (PCr) increases, hours or days after surgery, it is already associated with a considerable loss on glomerular function. Evaluation of urinary output during surgery, although widely used, does not guarantee its diagnosis, but allows to observe the dissociation between glomerular filtration and the elevation of PCr, which will occur later. As methods of early diagnosis, new stricter classifications, as well as laboratory tests using biomarkers such as C-cysteine have been used. Advanced age, emergency surgery, obesity, transoperative hypotension and hypovolemia are conditions associated with a higher risk of renal damage. Impaired renal function may occur both preand intraor post-renal, such as when there is tissue hypoperfusion, ischemia, nephrotoxins use or obstruction to the urinary flow, among other causes. The current review aims to address the issues related to AKI in the perioperative period, based on the latest scientific evidence to be applied in the anesthesiologist’s daily life.

Bloqueio dos nervos tibial e fibular comum em fossa poplítea com punção única utilizando o estimulador percutâneo de nervos: considerações anatômicas e descrição ultrassonográfica

JUSTIFICATIVA Y OBJETIVOS: Las tecnicas de bloqueos de nervios perifericos ha venido obteniendo popularidad en las ultimas de los decadas, y convirtiendose cada vez mas en una opcion anestesica para la cirugia de los miembros. Este estudio propone una tecnica de abordaje de los nervios tibial y fibular comun en la fosa poplitea por puncion unica y utilizando el estimulador percutaneo de nervios, considerando la correlacion con el estudio anatomico y ultrasonografico. METODO: Estudio prospectivo, observacional y aleatorio realizado con 28 pacientes selecionados para cirugias en el pie. Despues de la localizacion de los nervios tibial y fibular comun a traves de la estimulacion percutanea, se realizo una puncion en el punto de estimulo del nervio tibial con la aguja de 5 cm (B.Braun, Stimuplex 50), y fueron inyectados 10 mL de levobupivacaina. La aguja se echo hacia atras y fue redirigida hacia el punto de estimulo del nervio fibular comun en busca de la respuesta motora correspondiente, inyectando 10 mL del anestesico. Se realizo el estudio fotografico de la region poplitea por ultrasonografia para la correlacion de la anatomia con la tecnica utilizada. RESULTADOS: En todos los casos se obtuvo la anestesia adecuada. El tiempo promedio para la localizacion de los nervios tibial y fibular comun, utilizando el estimulador percutaneo de nervios, fue de 57,1 y 32,8 segundos respectivamente y con el estimulador de nervios fue de 2,22 y 1,79 minutos. La profundidad promedio de la aguja para el nervio tibial fue de 10,7 mm. CONCLUSIONES: El abordaje de los nervios tibial y fibular comun con puncion unica en la fosa poplitea utilizando el estimulador percutaneo de nervios, es una buena opcion para la anestesia y la analgesia en cirugias del pie.

Simplified posterior sciatic nerve block at mid gluteofemoral dulcus: comparison of different 1% lidocaine volumes

JUSTIFICATIVA Y OBJETIVOS: El bloqueo del nervio isquiatico por via subglutea fue descrito con exito en estudio anterior, siendo una opcion mas entre los varios abordajes posibles. El nervio isquiatico se hace superficial en el borde inferior del musculo gluteo maximo, permitiendo su acceso con facil ubicacion, poca incomodidad y bajo riesgo de puncion accidental de grandes vasos. El objetivo de este estudio fue el de evaluar el bloqueo del nervio isquiatico por este abordaje simplificado con diferentes volumenes de lidocaina a 1%. METODO: Se estudiaron 40 pacientes con intervenciones quirurgicas en la pierna o en el pie, distribuidos en dos grupos. Despues de la monitorizacion, fueron colocados en decubito ventral y realizado el bloqueo en el punto medio del surco gluteo-femoral, con auxilio de neuroestimulador y aguja de 5 cm, electricamente aislada, utilizando 300 mg (G1) o 200 mg (G2) de lidocaina a 1% sin adrenalina. RESULTADOS: Se obtuvo anestesia adecuada en todos los casos con el volumen y la concentracion utilizados. El tiempo de ejecucion del bloqueo fue de 8,6 ± 5,7 min (G1) y 5,6 ± 5,7 min (G2). La latencia fue de 5,98 ± 1,4 min (G1) y 6,7 ± 2,9 min (G2). La duracion sensitiva y motora del bloqueo fue de 243 ± 37 min y 152 ± 30 min (G1) y 235 ± 39 min y 149 ± 59 min (G2), respectivamente. No se observaron diferencias estadisticas significativas entre los grupos estudiados. CONCLUSIONES: Ese abordaje es eficaz y de facil ejecucion, pudiendo la dosis total de anestesico ser reducida sin el comprometimiento de la calidad.

Bloqueo del nervio isquiático por abordaje posterior simplificado en el punto medio del surco glúteo-femoral: estudio con diferentes volúmenes de lidocaína a 1%

JUSTIFICATIVA Y OBJETIVOS: El bloqueo del nervio isquiatico por via subglutea fue descrito con exito en estudio anterior, siendo una opcion mas entre los varios abordajes posibles. El nervio isquiatico se hace superficial en el borde inferior del musculo gluteo maximo, permitiendo su acceso con facil ubicacion, poca incomodidad y bajo riesgo de puncion accidental de grandes vasos. El objetivo de este estudio fue el de evaluar el bloqueo del nervio isquiatico por este abordaje simplificado con diferentes volumenes de lidocaina a 1%. METODO: Se estudiaron 40 pacientes con intervenciones quirurgicas en la pierna o en el pie, distribuidos en dos grupos. Despues de la monitorizacion, fueron colocados en decubito ventral y realizado el bloqueo en el punto medio del surco gluteo-femoral, con auxilio de neuroestimulador y aguja de 5 cm, electricamente aislada, utilizando 300 mg (G1) o 200 mg (G2) de lidocaina a 1% sin adrenalina. RESULTADOS: Se obtuvo anestesia adecuada en todos los casos con el volumen y la concentracion utilizados. El tiempo de ejecucion del bloqueo fue de 8,6 ± 5,7 min (G1) y 5,6 ± 5,7 min (G2). La latencia fue de 5,98 ± 1,4 min (G1) y 6,7 ± 2,9 min (G2). La duracion sensitiva y motora del bloqueo fue de 243 ± 37 min y 152 ± 30 min (G1) y 235 ± 39 min y 149 ± 59 min (G2), respectivamente. No se observaron diferencias estadisticas significativas entre los grupos estudiados. CONCLUSIONES: Ese abordaje es eficaz y de facil ejecucion, pudiendo la dosis total de anestesico ser reducida sin el comprometimiento de la calidad.