Rodrigo Machado Saldanha

Analgesia pós-operatória para cesariana: a adição de clonidina à morfina subaracnóidea melhora a qualidade da analgesia?

JUSTIFICATIVA E OBJETIVOS: O mecanismo de acao analgesica a2-adrenergico tem sido explorado ha mais de 100 anos. A clonidina aumenta de maneira dose-dependente a duracao dos bloqueios sensitivo e motor e tem propriedades antinociceptivas. O objetivo desse estudo foi avaliar se a adicao de clonidina na dose de 15 e 30 µg a raquianestesia, para cesariana, com bupivacaina hiperbarica a 0,5% (12,5 mg) e morfina (100 µg), melhora a qualidade da analgesia pos-operatoria. METODO: Foi realizado um estudo prospectivo e aleatorio com 60 pacientes divididas em tres grupos: BM - bupivacaina hiperbarica a 0,5% (12,5 mg) e morfina (100 µg), BM15 - bupivacaina hiperbarica a 0,5% (12,5 mg), morfina (100 µg) e clonidina (15 µg) e BM30 - bupivacaina hiperbarica a 0,5% (12,5 mg), morfina (100 µg) e clonidina (30 µg), administradas separadamente. No peri-operatorio, foram anotados o consumo de efedrina e a avaliacao do recem-nascido pelo indice de Apgar. No pos-operatorio, a dor foi avaliada na 12a h pela Escala Analogica Visual, o tempo para solicitacao de analgesicos e efeitos colaterais pos-operatorios, como prurido, nauseas, vomitos, bradicardia, hipotensao arterial e sedacao. Os valores foram considerados significativos quando p < 0,05. RESULTADOS: Os grupos foram homogeneos. O consumo de efedrina e a avaliacao pelo indice de Apgar nao exibiram diferenca estatistica significativa entre os grupos. Os escores de dor e o tempo medio de analgesia mostraram diferenca entre os grupos BM e BM15/BM30 e nao houve diferenca com relacao a incidencia de efeitos colaterais pos-operatorios. CONCLUSOES: A adicao de clonidina na raquianestesia com bupivacaina hiperbarica a 0,5% (12,5 mg) e morfina (100 µg) para cesariana, melhorou a qualidade da analgesia pos-operatoria, sem aumentar a incidencia de efeitos colaterais, sendo 15 µg de clonidina a dose sugerida.BACKGROUND AND OBJECTIVES The mechanism of action of alpha2-adrenergic analgesia has been explored for more than one hundred years. The increased duration of the sensitive and motor blockades caused by clonidine is dose-dependent and has antinociceptive properties. The objective of this study was to evaluate whether the addition of 15 to 30 microg of clonidine to spinal anesthesia for cesarean sections with 0.5% hyperbaric bupivacaine (12.5 mg) and morphine (100 microg) improves the quality of postoperative analgesia. METHODS We realized a prospective, randomized study that included 60 patients divided in 3 groups: BM - 0.5% hyperbaric bupivacaine (12.5 mg) and morphine (100 microg), BM15 - 0.5% hyperbaric bupivacaine (12.5 mg), morphine (100 microg), and clonidine (15 mg), and BM30 - 0.5% hyperbaric bupivacaine (12.5 mg), morphine (100 microg), and clonidine (30 microg), administered separately. In the perioperative period the use of ephedrine and the newborns Apgar score were recorded. In the postoperative period, the pain was evaluated in the 12th h by the VAS, the length of time it took the patient to ask for analgesics, and the postoperative side effects, such as pruritus, nausea, vomiting, bradycardia, hypotension, and sedation. The values were considered significant when p < 0.05. RESULTS The groups were homogenous. The use of ephedrine and the evaluation by the Apgar score did not show statistically significant differences among the different groups. The pain scores and the average time to start analgesia showed differences among the groups BM and BM15/BM30, and there were no differences regarding the incidence of postoperative side effects. CONCLUSIONS The addition of clonidine to spinal anesthesia with 0.5% hyperbaric bupivacaine (12.5 mg) and morphine (100 microg) for cesarean section improved the quality of the postoperative analgesia without increasing the incidence of side effects. We suggest that the dose of 15 microg of clonidine should be used.

[Hydrocortisone treatment and prevent post-dural puncture headache: case reports].

JUSTIFICATIVA E OBJETIVOS: A cefaleia pos-puncao da dura-mater e a complicacao mais frequente apos a raquianestesia ou a sua perfuracao acidental durante tentativa de bloqueio peridural. O objetivo deste relato e descrever o uso da hidrocortisona no tratamento e na prevencao da cefaleia pos-puncao da dura-mater (CPPD). RELATO DOS CASOS: Sao relatados tres casos em que a hidrocortisona foi utilizada no tratamento e na prevencao da cefaleia pos-puncao da dura-mater. O primeiro foi de uma paciente obstetrica submetida a cesariana, que apresentou cefaleia no pos-operatorio, nao responsiva a medicacao convencional e ao tratamento com tampao sanguineo peridural (TSP), mas que apresentou remissao completa do quadro com hidrocortisona por via venosa. Outras duas pacientes, em quem ocorreu perfuracao acidental da dura-mater durante a tentativa de localizacao do espaco peridural e que tratadas com hidrocortisona, por via venosa, com fins preventivos, nao desenvolveram quadro de cefaleia. CONCLUSOES: Nos casos observados a hidrocortisona mostrou eficacia no tratamento da CPPD apos falha das medidas conservadoras e do TSP. A utilizacao da hidrocortisona em pacientes com perfuracao acidental da dura-mater pode ser util, pois nao e tecnica invasiva e a incidencia e a gravidade das CPPD nesse grupo de pacientes e elevada. Sao necessarios estudos controlados para estabelecer o real papel da hidrocortisona na prevencao e tratamento da CPPD.BACKGROUND AND OBJECTIVES Post-dural puncture headache is the most frequent complication after spinal anesthesia or accidental dural perforation during attempted epidural block. This report aimed at describing the use of hydrocortisone to treat and prevent post-dural puncture headache (PDPH). CASE REPORTS Three cases in which hydrocortisone was used to treat and prevent post-dural puncture headache are reported. The first is an obstetric patient submitted to Cesarean section with postoperative headache not responding to conventional medication and epidural blood patch (EBP), however with total remission after intravenous hydrocortisone. The other two patients, who suffered accidental dural perforation during attempted epidural space location, were preventively treated with intravenous hydrocortisone and have not developed headache. CONCLUSIONS In our cases, hydrocortisone was effective to treat PDPH after failed conservative measures and EBP. Hydrocortisone for accidental dural perforation patients may be useful since it is a noninvasive technique and the incidence of PDPH in this group of patients is high. Controlled studies are needed to determine the actual role of hydrocortisone in preventing and treating PDPH.

Uso da hidrocortisona no tratamento e na prevenção da cefaléia pós-punção da dura-máter: relato de casos

JUSTIFICATIVA E OBJETIVOS: A cefaleia pos-puncao da dura-mater e a complicacao mais frequente apos a raquianestesia ou a sua perfuracao acidental durante tentativa de bloqueio peridural. O objetivo deste relato e descrever o uso da hidrocortisona no tratamento e na prevencao da cefaleia pos-puncao da dura-mater (CPPD). RELATO DOS CASOS: Sao relatados tres casos em que a hidrocortisona foi utilizada no tratamento e na prevencao da cefaleia pos-puncao da dura-mater. O primeiro foi de uma paciente obstetrica submetida a cesariana, que apresentou cefaleia no pos-operatorio, nao responsiva a medicacao convencional e ao tratamento com tampao sanguineo peridural (TSP), mas que apresentou remissao completa do quadro com hidrocortisona por via venosa. Outras duas pacientes, em quem ocorreu perfuracao acidental da dura-mater durante a tentativa de localizacao do espaco peridural e que tratadas com hidrocortisona, por via venosa, com fins preventivos, nao desenvolveram quadro de cefaleia. CONCLUSOES: Nos casos observados a hidrocortisona mostrou eficacia no tratamento da CPPD apos falha das medidas conservadoras e do TSP. A utilizacao da hidrocortisona em pacientes com perfuracao acidental da dura-mater pode ser util, pois nao e tecnica invasiva e a incidencia e a gravidade das CPPD nesse grupo de pacientes e elevada. Sao necessarios estudos controlados para estabelecer o real papel da hidrocortisona na prevencao e tratamento da CPPD.BACKGROUND AND OBJECTIVES Post-dural puncture headache is the most frequent complication after spinal anesthesia or accidental dural perforation during attempted epidural block. This report aimed at describing the use of hydrocortisone to treat and prevent post-dural puncture headache (PDPH). CASE REPORTS Three cases in which hydrocortisone was used to treat and prevent post-dural puncture headache are reported. The first is an obstetric patient submitted to Cesarean section with postoperative headache not responding to conventional medication and epidural blood patch (EBP), however with total remission after intravenous hydrocortisone. The other two patients, who suffered accidental dural perforation during attempted epidural space location, were preventively treated with intravenous hydrocortisone and have not developed headache. CONCLUSIONS In our cases, hydrocortisone was effective to treat PDPH after failed conservative measures and EBP. Hydrocortisone for accidental dural perforation patients may be useful since it is a noninvasive technique and the incidence of PDPH in this group of patients is high. Controlled studies are needed to determine the actual role of hydrocortisone in preventing and treating PDPH.

Anestesia venosa total em paciente portador de Osteogênesis imperfecta: relato de caso

JUSTIFICATIVA Y OBJETIVOS: La Osteogenesis Imperfecta es una rara enfermedad genetica del tejido conjuntivo, con prevalencia de 1/10000, que primariamente envuelve la osificacion endocondral, resultando en huesos fragiles, multiplas fracturas e deformidades esqueleticas. El objetivo de ese articulo fue relatar un caso de paciente portador de Osteogenesis Imperfecta, sometido a anestesia venosa total para tratamiento quirurgico de fractura de femur. RELATO DEL CASO: Paciente del sexo masculino, 15 anos, 41 kg, 140 cm, con historia de Osteogenesis Imperfecta y cardiopatia, programado para tratamiento quirurgico de fractura del femur. En la sala de operacion fue monitorizado con ECG, FC, PANI y SpO2 y sometido a anestesia general venosa total con propofol, alfentanil y cisatracurio. Despues de IOT, fue acrecentada monitorizacion de la PETCO2 y de la temperatura esofagica. En el periodo intra-operatorio y en la sala de recuperacion pos-anestesica no presento complicaciones. Tuvo alta hospitalar en el 5o dia de post operatorio. CONCLUSIONES: El presente relato mostro una buena evolucion intra y post operatoria de paciente con Osteogenesis Imperfecta sometido a anestesia general venosa total. La complexidad de la enfermedad mostro la necesidad de evaluacion y monitorizacion adecuada por el anestesiologista.BACKGROUND AND OBJECTIVES Osteogenesis Imperfecta is an uncommon genetic connective tissue disease with prevalence of 1/10000, primarily involving endochondral ossification, resulting in brittle bones, multiple fractures and skeletal deformities. This article aimed at reporting a case of Osteogenesis Imperfecta patient submitted to total intravenous anesthesia for fractured femur surgical repair. CASE REPORT Male patient, 15 years old, 41 kg, 140 cm, with history of Osteogenesis Imperfecta and cardiopathy, scheduled for fractured femur surgical repair. In the operating room patient was monitored with ECG, HR, NIBP and SpO2 and was submitted to total intravenous anesthesia with propofol, alfentanil and cisatracurium. Monitoring of P ET CO2 and esophageal temperature was introduced after TI. There have been no complications both in the intraoperative period and in the post-anesthetic care unit. Patient was discharged 5 days later. CONCLUSIONS This report has shown satisfactory intra and postoperative evolution of Osteogenesis Imperfecta patient submitted to total intravenous general anesthesia. Disease complexity has shown the need for anesthesiologists adequate evaluation and monitoring.

Anesthesia for Duchenne muscular dystrophy patients: case reports

JUSTIFICATIVA E OBJETIVOS: Este estudo objetiva relatar dois casos de anestesia em pacientes portadores de Distrofia Muscular de Duchenne (DMD), uma doenca rara, progressiva e incapacitante, e discutir sobre a conduta anestesica. O comprometimento das funcoes pulmonar e cardiaca, a possibilidade de ocorrencia de hipertermia maligna, a maior sensibilidade aos bloqueadores neuromusculares e o aumento da morbidade pos-operatoria sao alguns dos desafios enfrentados pelo anestesiologista. RELATO DOS CASOS: O primeiro caso foi o de um paciente pediatrico com diagnostico de DMD e rabdomiossarcoma, agendado para exerese da lesao e esvaziamento cervical ampliado. Na avaliacao pre-anestesica (anamnese, exame clinico e exames complementares) nao foram detectadas alteracoes, exceto pela tumoracao cervical. Optou-se pela tecnica venosa total, com remifentanil em infusao continua e propofol em infusao alvo-controlada, sem a utilizacao de bloqueadores neuromusculares. O procedimento cirurgico teve duracao de 180 minutos, sem intercorrencias. O segundo caso foi de um paciente do sexo masculino, 24 anos, com diagnostico de DMD e colelitiase com indicacao cirurgica, cuja avaliacao pre-operatoria revelou pneumopatia restritiva grave, com diminuicoes da capacidade e da reserva respiratorias, sendo necessario o uso de BIPAP nasal noturno. Neste paciente, optou-se pela intubacao traqueal com sedacao minima e anestesia topica, seguida pela tecnica venosa total com remifentanil em infusao continua e propofol em infusao alvo-controlada, sem a utilizacao de bloqueadores neuromusculares. Ao termino, o paciente foi extubado ainda na sala de operacoes e imediatamente colocado no BIPAP nasal. Encaminhado a UTI, com alta no 2o PO e alta hospitalar no 3o PO. CONCLUSOES: A anestesia venosa total com infusao continua de propofol e remifentanil sem bloqueadores neuromusculares constitui-se em opcao segura e eficiente nos portadores de DMD.BACKGROUND AND OBJECTIVES Reporting two cases of anesthesia in Duchenne Muscular Dystrophy (DMD) patients, which is an uncommon, progressive and disabling disease, and discussing anesthetic approaches, impairment of pulmonary and cardiac functions, the possibility of malignant hyperthermia, increased sensitivity to neuromuscular blockers and increased postoperative morbidity are some challenges faced by anesthesiologists. CASE REPORTS First case was a pediatric patient with DMD and rhabdomyosarcoma, scheduled for tumor excision and cervical emptying. During preanesthetic evaluation, history, clinical and additional exams, no changes were detected except for the cervical tumor. We decided for total intravenous anesthesia with remifentanil administered by continuous infusion and propofol by target-controlled infusion without neuromuscular blockers. Surgery lasted 180 minutes without intercurrences. The second case was a male patient, 24 years old, with DMD and cholelithiasis with surgical indication who, during preoperative evaluation, has revealed severe restrictive pneumopathy with decreased capacity and respiratory reserves and the need for nasal BIPAP at night. For this patient we decided for tracheal intubation with minimum sedation and topic anesthesia, followed by total intravenous anesthesia with remifentanil administered by continuous infusion and propofol by target-controlled infusion without neuromuscular blockers. At the end, patient was extubated still in to operating room and nasal BIPAP was immediately placed, being patient referred to the ICU. Patient was discharged from ICU in the 2nd PO day and from hospital in the 3rd PO day. CONCLUSIONS Total intravenous anesthesia with propofol and remifentanil administered by continuous infusion without neuromuscular blockers is a safe and effective option for DMD patients.

Anestesia em paciente portador de distrofia muscular de Duchenne: relato de casos

JUSTIFICATIVA E OBJETIVOS: Este estudo objetiva relatar dois casos de anestesia em pacientes portadores de Distrofia Muscular de Duchenne (DMD), uma doenca rara, progressiva e incapacitante, e discutir sobre a conduta anestesica. O comprometimento das funcoes pulmonar e cardiaca, a possibilidade de ocorrencia de hipertermia maligna, a maior sensibilidade aos bloqueadores neuromusculares e o aumento da morbidade pos-operatoria sao alguns dos desafios enfrentados pelo anestesiologista. RELATO DOS CASOS: O primeiro caso foi o de um paciente pediatrico com diagnostico de DMD e rabdomiossarcoma, agendado para exerese da lesao e esvaziamento cervical ampliado. Na avaliacao pre-anestesica (anamnese, exame clinico e exames complementares) nao foram detectadas alteracoes, exceto pela tumoracao cervical. Optou-se pela tecnica venosa total, com remifentanil em infusao continua e propofol em infusao alvo-controlada, sem a utilizacao de bloqueadores neuromusculares. O procedimento cirurgico teve duracao de 180 minutos, sem intercorrencias. O segundo caso foi de um paciente do sexo masculino, 24 anos, com diagnostico de DMD e colelitiase com indicacao cirurgica, cuja avaliacao pre-operatoria revelou pneumopatia restritiva grave, com diminuicoes da capacidade e da reserva respiratorias, sendo necessario o uso de BIPAP nasal noturno. Neste paciente, optou-se pela intubacao traqueal com sedacao minima e anestesia topica, seguida pela tecnica venosa total com remifentanil em infusao continua e propofol em infusao alvo-controlada, sem a utilizacao de bloqueadores neuromusculares. Ao termino, o paciente foi extubado ainda na sala de operacoes e imediatamente colocado no BIPAP nasal. Encaminhado a UTI, com alta no 2o PO e alta hospitalar no 3o PO. CONCLUSOES: A anestesia venosa total com infusao continua de propofol e remifentanil sem bloqueadores neuromusculares constitui-se em opcao segura e eficiente nos portadores de DMD.BACKGROUND AND OBJECTIVES Reporting two cases of anesthesia in Duchenne Muscular Dystrophy (DMD) patients, which is an uncommon, progressive and disabling disease, and discussing anesthetic approaches, impairment of pulmonary and cardiac functions, the possibility of malignant hyperthermia, increased sensitivity to neuromuscular blockers and increased postoperative morbidity are some challenges faced by anesthesiologists. CASE REPORTS First case was a pediatric patient with DMD and rhabdomyosarcoma, scheduled for tumor excision and cervical emptying. During preanesthetic evaluation, history, clinical and additional exams, no changes were detected except for the cervical tumor. We decided for total intravenous anesthesia with remifentanil administered by continuous infusion and propofol by target-controlled infusion without neuromuscular blockers. Surgery lasted 180 minutes without intercurrences. The second case was a male patient, 24 years old, with DMD and cholelithiasis with surgical indication who, during preoperative evaluation, has revealed severe restrictive pneumopathy with decreased capacity and respiratory reserves and the need for nasal BIPAP at night. For this patient we decided for tracheal intubation with minimum sedation and topic anesthesia, followed by total intravenous anesthesia with remifentanil administered by continuous infusion and propofol by target-controlled infusion without neuromuscular blockers. At the end, patient was extubated still in to operating room and nasal BIPAP was immediately placed, being patient referred to the ICU. Patient was discharged from ICU in the 2nd PO day and from hospital in the 3rd PO day. CONCLUSIONS Total intravenous anesthesia with propofol and remifentanil administered by continuous infusion without neuromuscular blockers is a safe and effective option for DMD patients.

Postoperative analgesia for cesarean section: does the addiction of clonidine to subarachnoid morphine improve the quality of the analgesia?

JUSTIFICATIVA E OBJETIVOS: O mecanismo de acao analgesica a2-adrenergico tem sido explorado ha mais de 100 anos. A clonidina aumenta de maneira dose-dependente a duracao dos bloqueios sensitivo e motor e tem propriedades antinociceptivas. O objetivo desse estudo foi avaliar se a adicao de clonidina na dose de 15 e 30 µg a raquianestesia, para cesariana, com bupivacaina hiperbarica a 0,5% (12,5 mg) e morfina (100 µg), melhora a qualidade da analgesia pos-operatoria. METODO: Foi realizado um estudo prospectivo e aleatorio com 60 pacientes divididas em tres grupos: BM - bupivacaina hiperbarica a 0,5% (12,5 mg) e morfina (100 µg), BM15 - bupivacaina hiperbarica a 0,5% (12,5 mg), morfina (100 µg) e clonidina (15 µg) e BM30 - bupivacaina hiperbarica a 0,5% (12,5 mg), morfina (100 µg) e clonidina (30 µg), administradas separadamente. No peri-operatorio, foram anotados o consumo de efedrina e a avaliacao do recem-nascido pelo indice de Apgar. No pos-operatorio, a dor foi avaliada na 12a h pela Escala Analogica Visual, o tempo para solicitacao de analgesicos e efeitos colaterais pos-operatorios, como prurido, nauseas, vomitos, bradicardia, hipotensao arterial e sedacao. Os valores foram considerados significativos quando p < 0,05. RESULTADOS: Os grupos foram homogeneos. O consumo de efedrina e a avaliacao pelo indice de Apgar nao exibiram diferenca estatistica significativa entre os grupos. Os escores de dor e o tempo medio de analgesia mostraram diferenca entre os grupos BM e BM15/BM30 e nao houve diferenca com relacao a incidencia de efeitos colaterais pos-operatorios. CONCLUSOES: A adicao de clonidina na raquianestesia com bupivacaina hiperbarica a 0,5% (12,5 mg) e morfina (100 µg) para cesariana, melhorou a qualidade da analgesia pos-operatoria, sem aumentar a incidencia de efeitos colaterais, sendo 15 µg de clonidina a dose sugerida.BACKGROUND AND OBJECTIVES The mechanism of action of alpha2-adrenergic analgesia has been explored for more than one hundred years. The increased duration of the sensitive and motor blockades caused by clonidine is dose-dependent and has antinociceptive properties. The objective of this study was to evaluate whether the addition of 15 to 30 microg of clonidine to spinal anesthesia for cesarean sections with 0.5% hyperbaric bupivacaine (12.5 mg) and morphine (100 microg) improves the quality of postoperative analgesia. METHODS We realized a prospective, randomized study that included 60 patients divided in 3 groups: BM - 0.5% hyperbaric bupivacaine (12.5 mg) and morphine (100 microg), BM15 - 0.5% hyperbaric bupivacaine (12.5 mg), morphine (100 microg), and clonidine (15 mg), and BM30 - 0.5% hyperbaric bupivacaine (12.5 mg), morphine (100 microg), and clonidine (30 microg), administered separately. In the perioperative period the use of ephedrine and the newborns Apgar score were recorded. In the postoperative period, the pain was evaluated in the 12th h by the VAS, the length of time it took the patient to ask for analgesics, and the postoperative side effects, such as pruritus, nausea, vomiting, bradycardia, hypotension, and sedation. The values were considered significant when p < 0.05. RESULTS The groups were homogenous. The use of ephedrine and the evaluation by the Apgar score did not show statistically significant differences among the different groups. The pain scores and the average time to start analgesia showed differences among the groups BM and BM15/BM30, and there were no differences regarding the incidence of postoperative side effects. CONCLUSIONS The addition of clonidine to spinal anesthesia with 0.5% hyperbaric bupivacaine (12.5 mg) and morphine (100 microg) for cesarean section improved the quality of the postoperative analgesia without increasing the incidence of side effects. We suggest that the dose of 15 microg of clonidine should be used.

[Total intravenous anesthesia in Osteogenesis imperfecta patient: case report.].

JUSTIFICATIVA Y OBJETIVOS: La Osteogenesis Imperfecta es una rara enfermedad genetica del tejido conjuntivo, con prevalencia de 1/10000, que primariamente envuelve la osificacion endocondral, resultando en huesos fragiles, multiplas fracturas e deformidades esqueleticas. El objetivo de ese articulo fue relatar un caso de paciente portador de Osteogenesis Imperfecta, sometido a anestesia venosa total para tratamiento quirurgico de fractura de femur. RELATO DEL CASO: Paciente del sexo masculino, 15 anos, 41 kg, 140 cm, con historia de Osteogenesis Imperfecta y cardiopatia, programado para tratamiento quirurgico de fractura del femur. En la sala de operacion fue monitorizado con ECG, FC, PANI y SpO2 y sometido a anestesia general venosa total con propofol, alfentanil y cisatracurio. Despues de IOT, fue acrecentada monitorizacion de la PETCO2 y de la temperatura esofagica. En el periodo intra-operatorio y en la sala de recuperacion pos-anestesica no presento complicaciones. Tuvo alta hospitalar en el 5o dia de post operatorio. CONCLUSIONES: El presente relato mostro una buena evolucion intra y post operatoria de paciente con Osteogenesis Imperfecta sometido a anestesia general venosa total. La complexidad de la enfermedad mostro la necesidad de evaluacion y monitorizacion adecuada por el anestesiologista.BACKGROUND AND OBJECTIVES Osteogenesis Imperfecta is an uncommon genetic connective tissue disease with prevalence of 1/10000, primarily involving endochondral ossification, resulting in brittle bones, multiple fractures and skeletal deformities. This article aimed at reporting a case of Osteogenesis Imperfecta patient submitted to total intravenous anesthesia for fractured femur surgical repair. CASE REPORT Male patient, 15 years old, 41 kg, 140 cm, with history of Osteogenesis Imperfecta and cardiopathy, scheduled for fractured femur surgical repair. In the operating room patient was monitored with ECG, HR, NIBP and SpO2 and was submitted to total intravenous anesthesia with propofol, alfentanil and cisatracurium. Monitoring of P ET CO2 and esophageal temperature was introduced after TI. There have been no complications both in the intraoperative period and in the post-anesthetic care unit. Patient was discharged 5 days later. CONCLUSIONS This report has shown satisfactory intra and postoperative evolution of Osteogenesis Imperfecta patient submitted to total intravenous general anesthesia. Disease complexity has shown the need for anesthesiologists adequate evaluation and monitoring.

Analgesia postoperatória para cesárea: ¿la adición de clonidina a la morfina subaracnoidea mejora la calidad de la analgesia?

JUSTIFICATIVA E OBJETIVOS: O mecanismo de acao analgesica a2-adrenergico tem sido explorado ha mais de 100 anos. A clonidina aumenta de maneira dose-dependente a duracao dos bloqueios sensitivo e motor e tem propriedades antinociceptivas. O objetivo desse estudo foi avaliar se a adicao de clonidina na dose de 15 e 30 µg a raquianestesia, para cesariana, com bupivacaina hiperbarica a 0,5% (12,5 mg) e morfina (100 µg), melhora a qualidade da analgesia pos-operatoria. METODO: Foi realizado um estudo prospectivo e aleatorio com 60 pacientes divididas em tres grupos: BM - bupivacaina hiperbarica a 0,5% (12,5 mg) e morfina (100 µg), BM15 - bupivacaina hiperbarica a 0,5% (12,5 mg), morfina (100 µg) e clonidina (15 µg) e BM30 - bupivacaina hiperbarica a 0,5% (12,5 mg), morfina (100 µg) e clonidina (30 µg), administradas separadamente. No peri-operatorio, foram anotados o consumo de efedrina e a avaliacao do recem-nascido pelo indice de Apgar. No pos-operatorio, a dor foi avaliada na 12a h pela Escala Analogica Visual, o tempo para solicitacao de analgesicos e efeitos colaterais pos-operatorios, como prurido, nauseas, vomitos, bradicardia, hipotensao arterial e sedacao. Os valores foram considerados significativos quando p < 0,05. RESULTADOS: Os grupos foram homogeneos. O consumo de efedrina e a avaliacao pelo indice de Apgar nao exibiram diferenca estatistica significativa entre os grupos. Os escores de dor e o tempo medio de analgesia mostraram diferenca entre os grupos BM e BM15/BM30 e nao houve diferenca com relacao a incidencia de efeitos colaterais pos-operatorios. CONCLUSOES: A adicao de clonidina na raquianestesia com bupivacaina hiperbarica a 0,5% (12,5 mg) e morfina (100 µg) para cesariana, melhorou a qualidade da analgesia pos-operatoria, sem aumentar a incidencia de efeitos colaterais, sendo 15 µg de clonidina a dose sugerida.BACKGROUND AND OBJECTIVES The mechanism of action of alpha2-adrenergic analgesia has been explored for more than one hundred years. The increased duration of the sensitive and motor blockades caused by clonidine is dose-dependent and has antinociceptive properties. The objective of this study was to evaluate whether the addition of 15 to 30 microg of clonidine to spinal anesthesia for cesarean sections with 0.5% hyperbaric bupivacaine (12.5 mg) and morphine (100 microg) improves the quality of postoperative analgesia. METHODS We realized a prospective, randomized study that included 60 patients divided in 3 groups: BM - 0.5% hyperbaric bupivacaine (12.5 mg) and morphine (100 microg), BM15 - 0.5% hyperbaric bupivacaine (12.5 mg), morphine (100 microg), and clonidine (15 mg), and BM30 - 0.5% hyperbaric bupivacaine (12.5 mg), morphine (100 microg), and clonidine (30 microg), administered separately. In the perioperative period the use of ephedrine and the newborns Apgar score were recorded. In the postoperative period, the pain was evaluated in the 12th h by the VAS, the length of time it took the patient to ask for analgesics, and the postoperative side effects, such as pruritus, nausea, vomiting, bradycardia, hypotension, and sedation. The values were considered significant when p < 0.05. RESULTS The groups were homogenous. The use of ephedrine and the evaluation by the Apgar score did not show statistically significant differences among the different groups. The pain scores and the average time to start analgesia showed differences among the groups BM and BM15/BM30, and there were no differences regarding the incidence of postoperative side effects. CONCLUSIONS The addition of clonidine to spinal anesthesia with 0.5% hyperbaric bupivacaine (12.5 mg) and morphine (100 microg) for cesarean section improved the quality of the postoperative analgesia without increasing the incidence of side effects. We suggest that the dose of 15 microg of clonidine should be used.

Anestesia en un paciente portador de distrofia muscular de Duchenne: relato de casos

JUSTIFICATIVA E OBJETIVOS: Este estudo objetiva relatar dois casos de anestesia em pacientes portadores de Distrofia Muscular de Duchenne (DMD), uma doenca rara, progressiva e incapacitante, e discutir sobre a conduta anestesica. O comprometimento das funcoes pulmonar e cardiaca, a possibilidade de ocorrencia de hipertermia maligna, a maior sensibilidade aos bloqueadores neuromusculares e o aumento da morbidade pos-operatoria sao alguns dos desafios enfrentados pelo anestesiologista. RELATO DOS CASOS: O primeiro caso foi o de um paciente pediatrico com diagnostico de DMD e rabdomiossarcoma, agendado para exerese da lesao e esvaziamento cervical ampliado. Na avaliacao pre-anestesica (anamnese, exame clinico e exames complementares) nao foram detectadas alteracoes, exceto pela tumoracao cervical. Optou-se pela tecnica venosa total, com remifentanil em infusao continua e propofol em infusao alvo-controlada, sem a utilizacao de bloqueadores neuromusculares. O procedimento cirurgico teve duracao de 180 minutos, sem intercorrencias. O segundo caso foi de um paciente do sexo masculino, 24 anos, com diagnostico de DMD e colelitiase com indicacao cirurgica, cuja avaliacao pre-operatoria revelou pneumopatia restritiva grave, com diminuicoes da capacidade e da reserva respiratorias, sendo necessario o uso de BIPAP nasal noturno. Neste paciente, optou-se pela intubacao traqueal com sedacao minima e anestesia topica, seguida pela tecnica venosa total com remifentanil em infusao continua e propofol em infusao alvo-controlada, sem a utilizacao de bloqueadores neuromusculares. Ao termino, o paciente foi extubado ainda na sala de operacoes e imediatamente colocado no BIPAP nasal. Encaminhado a UTI, com alta no 2o PO e alta hospitalar no 3o PO. CONCLUSOES: A anestesia venosa total com infusao continua de propofol e remifentanil sem bloqueadores neuromusculares constitui-se em opcao segura e eficiente nos portadores de DMD.BACKGROUND AND OBJECTIVES Reporting two cases of anesthesia in Duchenne Muscular Dystrophy (DMD) patients, which is an uncommon, progressive and disabling disease, and discussing anesthetic approaches, impairment of pulmonary and cardiac functions, the possibility of malignant hyperthermia, increased sensitivity to neuromuscular blockers and increased postoperative morbidity are some challenges faced by anesthesiologists. CASE REPORTS First case was a pediatric patient with DMD and rhabdomyosarcoma, scheduled for tumor excision and cervical emptying. During preanesthetic evaluation, history, clinical and additional exams, no changes were detected except for the cervical tumor. We decided for total intravenous anesthesia with remifentanil administered by continuous infusion and propofol by target-controlled infusion without neuromuscular blockers. Surgery lasted 180 minutes without intercurrences. The second case was a male patient, 24 years old, with DMD and cholelithiasis with surgical indication who, during preoperative evaluation, has revealed severe restrictive pneumopathy with decreased capacity and respiratory reserves and the need for nasal BIPAP at night. For this patient we decided for tracheal intubation with minimum sedation and topic anesthesia, followed by total intravenous anesthesia with remifentanil administered by continuous infusion and propofol by target-controlled infusion without neuromuscular blockers. At the end, patient was extubated still in to operating room and nasal BIPAP was immediately placed, being patient referred to the ICU. Patient was discharged from ICU in the 2nd PO day and from hospital in the 3rd PO day. CONCLUSIONS Total intravenous anesthesia with propofol and remifentanil administered by continuous infusion without neuromuscular blockers is a safe and effective option for DMD patients.