Roberto Cardoso Bessa Júnior

Síndrome de Tako-Tsubo em decorrência de bloqueio neuromuscular residual: relato de caso

JUSTIFICATIVA Y OBJETIVOS: El Sindrome de Tako-Tsubo es una complicacion postoperatoria rara con una mortalidad en torno de un 5%. El objetivo de este relato es presentar el bloqueo neuromuscular residual como factor desencadenante del referido sindrome, discutir sobre el y alertar sobre el bloqueo neuromuscular residual. RELATO DEL CASO: Paciente del sexo femenino, 61 anos, estado fisico ASA I, sometida a la anestesia general asociada al bloqueo paravertebral cervical para la reparacion artroscopica de lesion de manguito de los rotadores. Despues de la extubacion, quedo demostrado el bloqueo neuromuscular residual a traves del examen clinico. En la sala de recuperacion postanestesica, evoluciono con somnolencia, taquicardia, hipertension arterial y acidosis respiratoria grave. Despues de la reintubacion evoluciono con parada cardiaca en actividad electrica sin pulso, revertida con adrenalina y masaje cardiaco externo. En el postoperatorio presento una elevacion de segmento ST, aumento de troponina y acinesia de segmento medio-apical del ventriculo izquierdo, con fraccion de eyeccion estimada en un 30%. La cineangiocoronariografia mostro coronarias exentas de ateromatosis significativa y un grave comprometimiento de la funcion sistolica con acinesia inferior y antero-septo-apical, con hipercontratilidad compensatoria de sus porciones basales. Con el tratamiento iniciado, hubo una recuperacion funcional completa. CONCLUSIONES: El bloqueo neuromuscular residual asociado a la paralisis diafragmatica y la posible atelectasia pulmonar, que conlleva a la insuficiencia respiratoria, hipercapnia y descarga adrenergica, fueron los factores desencadenantes del sindrome de Tako-Tsubo con su grave repercusion clinica.BACKGROUND AND OBJECTIVES Tako-Tsubo syndrome is a rare postoperative complication with a 5% mortality rate. The objective of this report was to present residual neuromuscular blockade as a trigger for this syndrome, discuss this disorder, and call attention to the risks of residual neuromuscular blockade. CASE REPORT A 61-year old female, physical status ASA I, who underwent general anesthesia associated with paravertebral cervical block for arthroscopic repair of a rotator cuff lesion. Physical exam after extubation detected residual neuromuscular blockade. In the post-anesthetic care unit the patient developed somnolence, tachycardia, hypertension, and severe respiratory acidosis. After reintubation the patient evolved for cardiac arrest with electrical activity without a pulse, which was reverted with the administration of adrenaline and external cardiac massage. In the postoperative period the patient presented elevation of the ST segment, increased troponin, and left ventricular medial-apical akinesia with an estimated ejection fraction of 30%. Cardiac catheterization showed absence of significant atheromatous lesions in the coronary vessels, and severe disruption of the systolic function with inferior and antero-septo-apical akinesia and compensatory basal hypercontractility. The patient had complete functional recovery with the treatment instituted. CONCLUSIONS Residual neuromuscular blockade associated with diaphragmatic paralysis and possible pulmonary atelectasis leading to respiratory failure, hypercapnia, and adrenergic discharge triggered the Tako-Tsubo syndrome with severe clinical repercussion.

Tako-Tsubo syndrome secondary to residual neuromuscular blockade: case report

JUSTIFICATIVA Y OBJETIVOS: El Sindrome de Tako-Tsubo es una complicacion postoperatoria rara con una mortalidad en torno de un 5%. El objetivo de este relato es presentar el bloqueo neuromuscular residual como factor desencadenante del referido sindrome, discutir sobre el y alertar sobre el bloqueo neuromuscular residual. RELATO DEL CASO: Paciente del sexo femenino, 61 anos, estado fisico ASA I, sometida a la anestesia general asociada al bloqueo paravertebral cervical para la reparacion artroscopica de lesion de manguito de los rotadores. Despues de la extubacion, quedo demostrado el bloqueo neuromuscular residual a traves del examen clinico. En la sala de recuperacion postanestesica, evoluciono con somnolencia, taquicardia, hipertension arterial y acidosis respiratoria grave. Despues de la reintubacion evoluciono con parada cardiaca en actividad electrica sin pulso, revertida con adrenalina y masaje cardiaco externo. En el postoperatorio presento una elevacion de segmento ST, aumento de troponina y acinesia de segmento medio-apical del ventriculo izquierdo, con fraccion de eyeccion estimada en un 30%. La cineangiocoronariografia mostro coronarias exentas de ateromatosis significativa y un grave comprometimiento de la funcion sistolica con acinesia inferior y antero-septo-apical, con hipercontratilidad compensatoria de sus porciones basales. Con el tratamiento iniciado, hubo una recuperacion funcional completa. CONCLUSIONES: El bloqueo neuromuscular residual asociado a la paralisis diafragmatica y la posible atelectasia pulmonar, que conlleva a la insuficiencia respiratoria, hipercapnia y descarga adrenergica, fueron los factores desencadenantes del sindrome de Tako-Tsubo con su grave repercusion clinica.BACKGROUND AND OBJECTIVES Tako-Tsubo syndrome is a rare postoperative complication with a 5% mortality rate. The objective of this report was to present residual neuromuscular blockade as a trigger for this syndrome, discuss this disorder, and call attention to the risks of residual neuromuscular blockade. CASE REPORT A 61-year old female, physical status ASA I, who underwent general anesthesia associated with paravertebral cervical block for arthroscopic repair of a rotator cuff lesion. Physical exam after extubation detected residual neuromuscular blockade. In the post-anesthetic care unit the patient developed somnolence, tachycardia, hypertension, and severe respiratory acidosis. After reintubation the patient evolved for cardiac arrest with electrical activity without a pulse, which was reverted with the administration of adrenaline and external cardiac massage. In the postoperative period the patient presented elevation of the ST segment, increased troponin, and left ventricular medial-apical akinesia with an estimated ejection fraction of 30%. Cardiac catheterization showed absence of significant atheromatous lesions in the coronary vessels, and severe disruption of the systolic function with inferior and antero-septo-apical akinesia and compensatory basal hypercontractility. The patient had complete functional recovery with the treatment instituted. CONCLUSIONS Residual neuromuscular blockade associated with diaphragmatic paralysis and possible pulmonary atelectasis leading to respiratory failure, hypercapnia, and adrenergic discharge triggered the Tako-Tsubo syndrome with severe clinical repercussion.

Ruptura brônquica após intubação com tubo de duplo lúmen: relato de caso

BACKGROUND AND OBJECTIVES Tracheobronchial tree injuries are uncommon however severe complications after intubation or bronchoscopy. This report aimed at calling the attention to the difficult selective intubation, which has led to bronchial rupture associated to pneumomediastinum and hypertensive pneumothorax, with airway deformation and death by systemic inflammatory response. CASE REPORT Male patient, 50 years old, with bronchopleural fistula secondary to bulla rupture in right lung upper lobe. After anesthetic induction it was difficult to intubate left bronchus. At the third attempt, patient developed hypoxemia, hypotension and extensive subcutaneous emphysema, being submitted to thoracic drainage for hypertensive pneumothorax. Fibrobronchoscopy has revealed left bronchus laceration. Patient evolved with hemoptysis, and left thoracotomy was necessary to suture bronchial laceration. Patient developed postoperative multiple organs dysfunction and evolved to death. CONCLUSIONS Selective intubation is a procedure to be carefully performed, being necessary the understanding of some risk factors and the early diagnosis of complications.JUSTIFICATIVA Y OBJETIVOS: Las lesiones del arbol traqueobronquico son complicaciones raras, sin embargo despues de intubacion o broncoscopia pasan a ser graves. El objetivo de ese relato fue llamar la atencion sobre la dificultad de intubacion selectiva que ocasiono rotura bronquica asociada a pneumomediastino y neumotorax hipertensivo, con deformaciones de las vias aereas y fallecimiento por la respuesta inflamatoria sistemica. RELATO DEL CASO: Paciente del sexo masculino, 50 anos, portador de fistula broncopleural secundaria a la rotura de ampolla en el lobo superior de pulmon derecho. Despues de la induccion anestesica, hubo dificultad en la intubacion endobronquica izquierda. En la tercera tentativa, se desarrollo un cuadro de hipoxemia, hipotension y enfisema subcutaneo extenso, siendo sometido a drenaje toracico por neumotorax hipertensivo. La fibrobroncoscopia mostro laceracion del bronquio izquierdo. Evoluciono con hemoptisis, siendo necesaria toracotomia izquierda para sutura de la laceracion bronquica. En el postoperatorio, el paciente desarrollo cuadro de disfuncion de multiples organos, evolucionando en fallecimiento. CONCLUSIONES: La intubacion selectiva es un procedimiento que debe ser realizado con cautela, siendo necesario el reconocimiento de algunos factores de riesgo y el diagnostico precoz de las complicaciones.

Prevalência de paralisia diafragmática após bloqueio de plexo braquial pela via posterior com ropivacaína a 0,2%

JUSTIFICATIVA Y OBJETIVOS: El bloqueo de plexo braquial por via interescalenica descrita por Winnie es una de las tecnicas mas eficaces para promover la analgesia postoperatoria de intervenciones quirurgicas en el hombro. Una de sus consecuencias es la paralisis diafragmatica. En pacientes con algun grado de disfuncion pulmonar previa, esa paralisis puede conllevar a la insuficiencia respiratoria. El abordaje del plexo braquial por via posterior ha conquistado espacio. El objetivo de este estudio fue el de determinar la prevalencia de paralisis diafragmatica, despues del bloqueo de plexo braquial interescalenico por via posterior con el uso de ropivacaina a 0,2%. METODO: Veinte y dos pacientes sometidos al bloqueo del plexo braquial interescalenico por via posterior con ropivacaina a 0,2% fueron evaluados en el postoperatorio con el objetivo de identificar senales radiologicas de elevacion de la cupula diafragmatica sugestivas de paralisis hemidiafragmatica. En 20 pacientes se utilizo 40 mL de ropivacaina a 0,2%, en ellos fue realizada la radiografia de torax en inspiracion. En dos fueron utilizados 20 mL de ropivacaina a 0,2%, con la siguiente evaluacion fluoroscopica. RESULTADOS: No hubo complicaciones relacionadas con la realizacion del bloqueo. En todos los pacientes, el bloqueo fue efectivo y proporciono una buena analgesia postoperatoria. Se observo una elevacion de la cupula diafragmatica compatible con la paralisis hemidiafragmatica en todos los casos estudiados. CONCLUSIONES: En las condiciones de este estudio se pudo observar que el bloqueo del plexo braquial por via posterior es una tecnica que esta asociada a la alta prevalencia de paralisis diafragmatica, incluso cuando se utilizan bajas concentraciones de anestesico local.BACKGROUND AND OBJECTIVES Brachial plexus blockade by the interscalene approach, described by Winnie, is one of the most effective techniques in promoting postoperative analgesia in surgeries of the shoulder. Diaphragmatic paralysis is one of the consequences of this technique. This paralysis can cause respiratory failure in patients with prior lung dysfunction. Brachial plexus blockade by the posterior approach has become increasingly more popular. The objective of this study was to determine the prevalence of diaphragmatic paralysis after interscalene brachial plexus blockade by the posterior approach with 0.2% ropivacaine. METHODS Twenty-two patients who underwent interscalene brachial plexus blockade by the posterior approach with 0.2% ropivacaine were evaluated in the postoperative period to identify radiological signs of elevation of the hemidiaphragm that could suggest hemidiaphragmatic paralysis. Forty mL of 0.2% ropivacaine were used in 20 patients; inspiratory chest X-rays were done in these patients. Twenty mL of 0.2% ropivacaine were used in two patients, with posterior fluoroscopic evaluation. RESULTS There were no complications related to the procedure. The anesthesia was effective in every patient, providing good postoperative analgesia. Every patient in this study presented elevation of the diaphragm compatible with hemidiaphragmatic paralysis. CONCLUSIONS We observed that brachial plexus blockade by the posterior approach is associated with a high prevalence of diaphragmatic paralysis, even with low concentrations of local anesthetics.

[Excessive sweating and hypothermia after spinal morphine: case report.].

BACKGROUND AND OBJECTIVES Anesthesia and surgery often promote significant temperature changes. Hypothermia during anesthesia is the most common perioperative thermal disorder. This report describes an unusual body heat balance change associated to spinal morphine. CASE REPORT Female patient, 44 years old, physical status ASA I, with no previous diseases, admitted for abdominal hysterectomy due to uterine myomatosis. Spinal anesthesia was performed with 20 mg hyperbaric bupivacaine and 100 mug morphine and surgical procedure was eventless. In the post-anesthetic recovery unit (PACU), 3h30 minutes after blockade, patient presented excessive sweating, even leading to detachment of electrodes and adhesive tapes, mild sleepiness and decreased tympanic temperature to 35.2 masculineC. Temperature was maintained below 36 masculineC for the next 60 minutes and 90 minutes later temperature was 36.2 masculineC with total remission of symptoms. CONCLUSIONS In addition to classic excessive heat loss mechanisms during neuraxial block, there may be direct disorders in the hypothalamic temperature control centers, in this case associated to spinal morphine.JUSTIFICATIVA E OBJETIVOS: A anestesia e a cirurgia frequentemente causam perturbacoes termicas significativas. A hipotermia durante a anestesia e o disturbio termico peri-operatorio mais comum. O presente relato evidenciou um mecanismo nao usual de alteracao do controle termico corporal, neste caso, associado a utilizacao da morfina no espaco subaracnoideo. O objetivo deste relato foi descrever este efeito incomum. RELATO DO CASO: Paciente do sexo feminino, 44 anos, estado fisico ASA I, sem doencas previas conhecidas, foi admitida para histerectomia abdominal por quadro de miomatose uterina. Foi realizada raquianestesia com 20 mg de bupivacaina hiperbarica e 100 µg de morfina. Durante o procedimento nao apresentou qualquer intercorrencia. Na sala de recuperacao pos-anestesica (SRPA), 3h30 minutos apos a realizacao do bloqueio, a paciente apresentou quadro de sudorese profusa do tronco levando, inclusive, ao descolamento de eletrodos e de fitas adesivas, leve sonolencia e diminuicao da temperatura timpânica para 35,2 oC. Nos 60 minutos subsequentes manteve temperatura abaixo de 36 oC e com 90 minutos apos o evento ja apresentava temperatura de 36,2 oC e remissao completa dos sintomas. CONCLUSOES: Alem dos classicos mecanismos de perda excessiva de calor durante o bloqueio do neuro-eixo, podem ocorrer perturbacoes diretas nos centros hipotalâmicos de controle da temperatura corporal, neste caso, associado ao uso de morfina por via subaracnoidea.

Anestesia em paciente com doença de Steinert: relato de caso

BACKGROUND AND OBJECTIVES Steinert disease is the most common muscular dystrophy of the adult. Due to its multisystem characteristic, the perioperative management of these patients is a challenge to the anesthesiologist. The aim of this report was to present a case of hemorrhoidectomy in a patient with muscular dystrophy and to discuss the several anesthetic implications involved. CASE REPORT A man patient, 58 years old, with Steinert disease, who underwent hemorrhoidectomy. Subaracnoid block with hyperbaric bupivacaine (saddle block with puncture at L3-L4 with 0.5% bupivacaine [5 mg]) associated with sedation with propofol (1 microg.mL-1 target using a target-controlled infusion pump). Dypirone (1.5 g) and local infiltration with 0.5% ropivacaine (150 mg) were used for the postoperative analgesia. Intraoperatively, the patient developed myotonic crisis (10 minutes after being placed on the litothomy position) that was controlled by sedation (the target concentration was increased to 1.5 microg.mL-1 and given a bolus of 40 mg). The patient remained stable and was discharged the following day. CONCLUSIONS The knowledge about the disease and the proper anesthetic planning are extremely important when managing patients with Steinert disease.JUSTIFICATIVA Y OBJETIVOS: La enfermedad de Steinert es la forma de distrofia muscular mas comun en el adulto. Debido a su caracter multisistemico el manoseo perioperatorio es un reto para el anestesiologo. El objetivo de este relato fue el de presentar un caso de hemorroidectomia en paciente portador de distrofia muscular y discutir las varias implicaciones anestesicas que involucra. RELATO DEL CASO: Paciente del sexo masculino, 58 anos, portador de enfermedad de Steinert, sometido la hemorroidectomia. La conducta anestesica fue raquianestesia con bupivacaina hiperbara (puncion L3-L4,con bupivacaina a 0,5% (5 mg) en silla de montar, asociada a la sedacion con propofol (blanco de 1 ig.mL-1 en bomba de infusion blanco controlada). La analgesia postoperatoria fue realizada con dipirona (1,5 g) e infiltracion local de ropivacaina a 0,5% (150 mg). El paciente desarrollo, en el intraoperatorio, crisis miotonica (10 minutos despues ser colocado en posicion de litotomia), que fue controlada con sedacion (aumento de la concentracion blanco para 1,5 ig.mL-1 y bolus de 40 mg). Permanecio estable y tuvo alta hospitalaria al dia siguiente. CONCLUSIONES: El conocimiento de la enfermedad y la planificacion anestesica son de fundamental importancia en el manoseo de pacientes portadores de la enfermedad de Steinert.

[Anesthesia in a patient with Steinert disease: case report.].

BACKGROUND AND OBJECTIVES Steinert disease is the most common muscular dystrophy of the adult. Due to its multisystem characteristic, the perioperative management of these patients is a challenge to the anesthesiologist. The aim of this report was to present a case of hemorrhoidectomy in a patient with muscular dystrophy and to discuss the several anesthetic implications involved. CASE REPORT A man patient, 58 years old, with Steinert disease, who underwent hemorrhoidectomy. Subaracnoid block with hyperbaric bupivacaine (saddle block with puncture at L3-L4 with 0.5% bupivacaine [5 mg]) associated with sedation with propofol (1 microg.mL-1 target using a target-controlled infusion pump). Dypirone (1.5 g) and local infiltration with 0.5% ropivacaine (150 mg) were used for the postoperative analgesia. Intraoperatively, the patient developed myotonic crisis (10 minutes after being placed on the litothomy position) that was controlled by sedation (the target concentration was increased to 1.5 microg.mL-1 and given a bolus of 40 mg). The patient remained stable and was discharged the following day. CONCLUSIONS The knowledge about the disease and the proper anesthetic planning are extremely important when managing patients with Steinert disease.JUSTIFICATIVA Y OBJETIVOS: La enfermedad de Steinert es la forma de distrofia muscular mas comun en el adulto. Debido a su caracter multisistemico el manoseo perioperatorio es un reto para el anestesiologo. El objetivo de este relato fue el de presentar un caso de hemorroidectomia en paciente portador de distrofia muscular y discutir las varias implicaciones anestesicas que involucra. RELATO DEL CASO: Paciente del sexo masculino, 58 anos, portador de enfermedad de Steinert, sometido la hemorroidectomia. La conducta anestesica fue raquianestesia con bupivacaina hiperbara (puncion L3-L4,con bupivacaina a 0,5% (5 mg) en silla de montar, asociada a la sedacion con propofol (blanco de 1 ig.mL-1 en bomba de infusion blanco controlada). La analgesia postoperatoria fue realizada con dipirona (1,5 g) e infiltracion local de ropivacaina a 0,5% (150 mg). El paciente desarrollo, en el intraoperatorio, crisis miotonica (10 minutos despues ser colocado en posicion de litotomia), que fue controlada con sedacion (aumento de la concentracion blanco para 1,5 ig.mL-1 y bolus de 40 mg). Permanecio estable y tuvo alta hospitalaria al dia siguiente. CONCLUSIONES: El conocimiento de la enfermedad y la planificacion anestesica son de fundamental importancia en el manoseo de pacientes portadores de la enfermedad de Steinert.

Sudorese profusa e hipotermia após administração de morfina por via subaracnóidea: relato de caso

BACKGROUND AND OBJECTIVES Anesthesia and surgery often promote significant temperature changes. Hypothermia during anesthesia is the most common perioperative thermal disorder. This report describes an unusual body heat balance change associated to spinal morphine. CASE REPORT Female patient, 44 years old, physical status ASA I, with no previous diseases, admitted for abdominal hysterectomy due to uterine myomatosis. Spinal anesthesia was performed with 20 mg hyperbaric bupivacaine and 100 mug morphine and surgical procedure was eventless. In the post-anesthetic recovery unit (PACU), 3h30 minutes after blockade, patient presented excessive sweating, even leading to detachment of electrodes and adhesive tapes, mild sleepiness and decreased tympanic temperature to 35.2 masculineC. Temperature was maintained below 36 masculineC for the next 60 minutes and 90 minutes later temperature was 36.2 masculineC with total remission of symptoms. CONCLUSIONS In addition to classic excessive heat loss mechanisms during neuraxial block, there may be direct disorders in the hypothalamic temperature control centers, in this case associated to spinal morphine.JUSTIFICATIVA E OBJETIVOS: A anestesia e a cirurgia frequentemente causam perturbacoes termicas significativas. A hipotermia durante a anestesia e o disturbio termico peri-operatorio mais comum. O presente relato evidenciou um mecanismo nao usual de alteracao do controle termico corporal, neste caso, associado a utilizacao da morfina no espaco subaracnoideo. O objetivo deste relato foi descrever este efeito incomum. RELATO DO CASO: Paciente do sexo feminino, 44 anos, estado fisico ASA I, sem doencas previas conhecidas, foi admitida para histerectomia abdominal por quadro de miomatose uterina. Foi realizada raquianestesia com 20 mg de bupivacaina hiperbarica e 100 µg de morfina. Durante o procedimento nao apresentou qualquer intercorrencia. Na sala de recuperacao pos-anestesica (SRPA), 3h30 minutos apos a realizacao do bloqueio, a paciente apresentou quadro de sudorese profusa do tronco levando, inclusive, ao descolamento de eletrodos e de fitas adesivas, leve sonolencia e diminuicao da temperatura timpânica para 35,2 oC. Nos 60 minutos subsequentes manteve temperatura abaixo de 36 oC e com 90 minutos apos o evento ja apresentava temperatura de 36,2 oC e remissao completa dos sintomas. CONCLUSOES: Alem dos classicos mecanismos de perda excessiva de calor durante o bloqueio do neuro-eixo, podem ocorrer perturbacoes diretas nos centros hipotalâmicos de controle da temperatura corporal, neste caso, associado ao uso de morfina por via subaracnoidea.

Bronchial rupture after intubation with double lumen endotracheal tube. Case report.

BACKGROUND AND OBJECTIVES Tracheobronchial tree injuries are uncommon however severe complications after intubation or bronchoscopy. This report aimed at calling the attention to the difficult selective intubation, which has led to bronchial rupture associated to pneumomediastinum and hypertensive pneumothorax, with airway deformation and death by systemic inflammatory response. CASE REPORT Male patient, 50 years old, with bronchopleural fistula secondary to bulla rupture in right lung upper lobe. After anesthetic induction it was difficult to intubate left bronchus. At the third attempt, patient developed hypoxemia, hypotension and extensive subcutaneous emphysema, being submitted to thoracic drainage for hypertensive pneumothorax. Fibrobronchoscopy has revealed left bronchus laceration. Patient evolved with hemoptysis, and left thoracotomy was necessary to suture bronchial laceration. Patient developed postoperative multiple organs dysfunction and evolved to death. CONCLUSIONS Selective intubation is a procedure to be carefully performed, being necessary the understanding of some risk factors and the early diagnosis of complications.JUSTIFICATIVA Y OBJETIVOS: Las lesiones del arbol traqueobronquico son complicaciones raras, sin embargo despues de intubacion o broncoscopia pasan a ser graves. El objetivo de ese relato fue llamar la atencion sobre la dificultad de intubacion selectiva que ocasiono rotura bronquica asociada a pneumomediastino y neumotorax hipertensivo, con deformaciones de las vias aereas y fallecimiento por la respuesta inflamatoria sistemica. RELATO DEL CASO: Paciente del sexo masculino, 50 anos, portador de fistula broncopleural secundaria a la rotura de ampolla en el lobo superior de pulmon derecho. Despues de la induccion anestesica, hubo dificultad en la intubacion endobronquica izquierda. En la tercera tentativa, se desarrollo un cuadro de hipoxemia, hipotension y enfisema subcutaneo extenso, siendo sometido a drenaje toracico por neumotorax hipertensivo. La fibrobroncoscopia mostro laceracion del bronquio izquierdo. Evoluciono con hemoptisis, siendo necesaria toracotomia izquierda para sutura de la laceracion bronquica. En el postoperatorio, el paciente desarrollo cuadro de disfuncion de multiples organos, evolucionando en fallecimiento. CONCLUSIONES: La intubacion selectiva es un procedimiento que debe ser realizado con cautela, siendo necesario el reconocimiento de algunos factores de riesgo y el diagnostico precoz de las complicaciones.

Prevalence of diaphragmatic paralysis after brachial plexus blockade by the posterior approach with 0.2% ropivacaine

JUSTIFICATIVA Y OBJETIVOS: El bloqueo de plexo braquial por via interescalenica descrita por Winnie es una de las tecnicas mas eficaces para promover la analgesia postoperatoria de intervenciones quirurgicas en el hombro. Una de sus consecuencias es la paralisis diafragmatica. En pacientes con algun grado de disfuncion pulmonar previa, esa paralisis puede conllevar a la insuficiencia respiratoria. El abordaje del plexo braquial por via posterior ha conquistado espacio. El objetivo de este estudio fue el de determinar la prevalencia de paralisis diafragmatica, despues del bloqueo de plexo braquial interescalenico por via posterior con el uso de ropivacaina a 0,2%. METODO: Veinte y dos pacientes sometidos al bloqueo del plexo braquial interescalenico por via posterior con ropivacaina a 0,2% fueron evaluados en el postoperatorio con el objetivo de identificar senales radiologicas de elevacion de la cupula diafragmatica sugestivas de paralisis hemidiafragmatica. En 20 pacientes se utilizo 40 mL de ropivacaina a 0,2%, en ellos fue realizada la radiografia de torax en inspiracion. En dos fueron utilizados 20 mL de ropivacaina a 0,2%, con la siguiente evaluacion fluoroscopica. RESULTADOS: No hubo complicaciones relacionadas con la realizacion del bloqueo. En todos los pacientes, el bloqueo fue efectivo y proporciono una buena analgesia postoperatoria. Se observo una elevacion de la cupula diafragmatica compatible con la paralisis hemidiafragmatica en todos los casos estudiados. CONCLUSIONES: En las condiciones de este estudio se pudo observar que el bloqueo del plexo braquial por via posterior es una tecnica que esta asociada a la alta prevalencia de paralisis diafragmatica, incluso cuando se utilizan bajas concentraciones de anestesico local.BACKGROUND AND OBJECTIVES Brachial plexus blockade by the interscalene approach, described by Winnie, is one of the most effective techniques in promoting postoperative analgesia in surgeries of the shoulder. Diaphragmatic paralysis is one of the consequences of this technique. This paralysis can cause respiratory failure in patients with prior lung dysfunction. Brachial plexus blockade by the posterior approach has become increasingly more popular. The objective of this study was to determine the prevalence of diaphragmatic paralysis after interscalene brachial plexus blockade by the posterior approach with 0.2% ropivacaine. METHODS Twenty-two patients who underwent interscalene brachial plexus blockade by the posterior approach with 0.2% ropivacaine were evaluated in the postoperative period to identify radiological signs of elevation of the hemidiaphragm that could suggest hemidiaphragmatic paralysis. Forty mL of 0.2% ropivacaine were used in 20 patients; inspiratory chest X-rays were done in these patients. Twenty mL of 0.2% ropivacaine were used in two patients, with posterior fluoroscopic evaluation. RESULTS There were no complications related to the procedure. The anesthesia was effective in every patient, providing good postoperative analgesia. Every patient in this study presented elevation of the diaphragm compatible with hemidiaphragmatic paralysis. CONCLUSIONS We observed that brachial plexus blockade by the posterior approach is associated with a high prevalence of diaphragmatic paralysis, even with low concentrations of local anesthetics.