Sheila Braga Machado

Levobupivacaína versus bupivacaína em anestesia peridural para cesarianas: estudo comparativo

JUSTIFICATIVA Y OBJETIVOS: El anestesico local bupivacaina es encontrado en la forma de dos enantiomeros: levobupivacaina - S (-) y dextrobupivacaina - R (+). Basado en estudios que demuestran que la cardiotoxicidad es menor con el enantiomero S(-), fue difundido el uso de este agente en la practica clinica. El objetivo de este estudio es comparar la eficacia y la efectividad del uso de bupivacaina racemica con levobupivacaina en anestesia peridural de pacientes sometidas a cesarea electiva. METODO: Ensayo clinico eventual, doblemente encubierto, con gestantes estado fisico ASA I y II. Las pacientes fueron distribuidas para recibir 20 mL de bupivacaina a 0,5% racemica o 20 mL de levobupivacaina a 0,5%, ambas con 10 µg de sufentanil y vasoconstrictor. RESULTADOS: Participaron del estudio 47 pacientes, 24 en el grupo de la levobupivacaina y 23 en el grupo de la bupivacaina. Los grupos eran comparables entre si en lo que se refiere a las caracteristicas materno-fetales. Transcurridos 15 minutos despues del termino de la puncion peridural, 62,5% de las pacientes del grupo de la levobupivacaina tenian Bromage 2 o 3 contra 72,7% en el grupo de la bupivacaina (p = 0,83). Transcurridos veinte minutos, 66,7% de las pacientes del grupo de la levobupivacaina tenian Bromage 2 o 3 contra 86,3% del grupo de la bupivacaina (p = 0,21). La complicacion mas frecuente fue la hipotension arterial, encontrada en 16 (66,7%) pacientes del grupo de la levobupivacaina y en 10 (43,5%) pacientes del grupo de la bupivacaina (p = 0,11). CONCLUSIONES: La levobupivacaina y la bupivacaina fueron igualmente efectivas en el bloqueo peridural de pacientes sometidas a cesarea.BACKGROUND AND OBJECTIVES Local anesthetic bupivacaine is found in two different enantiomers: levobupivacaine - S (-) and dextrobupivacaine - R (+). Based on studies showing that S(-) enantiomers are less cardiotoxic, their use has been increasing in clinical practice. This study aimed at comparing racemic bupivacaine and levobupivacaine in epidural anesthesia for elective cesarean section. METHODS Randomized, double blind clinical trial enrolling physical status ASA I and II parturients. Patients were assigned to receive either 20 mL of 0.5% racemic bupivacaine or 20 mL of 0.5% levobupivacaine, both with 10 microg sufentanil and epinephrine 1:200,000. RESULTS Participated in this study 47 patients being 24 in the levobupivacaine group and 23 in the bupivacaine group. Both groups were comparable regarding maternal-fetal characteristics. Fifteen minutes after epidural anesthesia, 62.5% of levobupivacaine group patients experienced Bromage 2 or 3 motor block, whereas the same event was documented in 72.7% of bupivacaine group patients (p = 0.83). After 20 minutes, 66.7% of levobupivacaine group patients experienced Bromage 2 or 3 motor block versus 86.3% of bupivacaine group patients (p = 0.21). Most common complication was hypotension, detected in 16 (66.7%) levobupivacaine group patients and in 10 (43.5%) bupivacaine group patients (p = 0.11). CONCLUSIONS Levobupivacaine and bupivacaine were equally effective for epidural block in patients undergoing cesarean section.

Comparison between 0.125% and 0.25% bupivacaine associated to fentanyl for epidural labor analgesia

BACKGROUND AND OBJECTIVES: Epidural analgesia aims at decreasing or even abolishing maternal suffering during labor. It is considered a safe and effective method for pain relief. This study aimed at comparing two bupivacaine concentrations (0.25% and 0.125%) associated to fentanyl in epidural labor analgesia to determine its efficacy on pain relief and its effect on motor block. We have also observed the influence of these two concentrations on labor duration, fetal outcome and maternal satisfaction. METHODS: Participated in this prospective and double blind study 51 primiparous women who were randomized to receive one out of two bupivacaine concentrations for epidural labor analgesia (0.25% [n = 23] or 0.125% [n = 28]). Analgesia was measured using a numeric pain scale, and motor block was verified using Bromage scale. Means were compared using Students t test, while proportions were compared using Qui-square test, with p < 0.05. RESULTS: There has been no statistical difference in pain, degree of motor block and fetal outcome between groups. Cesarean delivery rate was statistically higher in the group receiving 0.25% bupivacaine (p < 0.05). Lower concentration group patients were more satisfied with the procedure (p < 0.01). CONCLUSIONS: The association of fentanyl and 0.125% bupivacaine proved to be more beneficial as compared to 0.25% concentration. With this dose, there has been a lower incidence of adverse effects without compromising analgesia, and yet a higher rate of maternal satisfaction.

Changes in purines concentration in the cerebrospinal fluid of patients experiencing pain: A case-control study

This study analyzes the relationship between extracellular purines and pain perception in humans. Cerebrospinal fluid (CSF) levels of purines and their metabolites were compared between patients displaying acute and/or chronic pain syndromes and control subjects. The CSF levels of IMP, inosine, guanosine and uric acid were significantly increased in the chronic pain group and correlated with pain severity (P<0.05). Patients displaying both chronic and acute pain presented similar changes in the CSF purines concentration (P<0.05). However, in the acute pain group, only CSF inosine and uric acid levels were significantly increased (P<0.05). These findings suggest that purines, in special inosine, guanosine and uric acid, are associated with the spinal mechanisms underlying nociception.

Levobupivacaine versus bupivacaine in epidural anesthesia for cesarean section: comparative study

JUSTIFICATIVA Y OBJETIVOS: El anestesico local bupivacaina es encontrado en la forma de dos enantiomeros: levobupivacaina - S (-) y dextrobupivacaina - R (+). Basado en estudios que demuestran que la cardiotoxicidad es menor con el enantiomero S(-), fue difundido el uso de este agente en la practica clinica. El objetivo de este estudio es comparar la eficacia y la efectividad del uso de bupivacaina racemica con levobupivacaina en anestesia peridural de pacientes sometidas a cesarea electiva. METODO: Ensayo clinico eventual, doblemente encubierto, con gestantes estado fisico ASA I y II. Las pacientes fueron distribuidas para recibir 20 mL de bupivacaina a 0,5% racemica o 20 mL de levobupivacaina a 0,5%, ambas con 10 µg de sufentanil y vasoconstrictor. RESULTADOS: Participaron del estudio 47 pacientes, 24 en el grupo de la levobupivacaina y 23 en el grupo de la bupivacaina. Los grupos eran comparables entre si en lo que se refiere a las caracteristicas materno-fetales. Transcurridos 15 minutos despues del termino de la puncion peridural, 62,5% de las pacientes del grupo de la levobupivacaina tenian Bromage 2 o 3 contra 72,7% en el grupo de la bupivacaina (p = 0,83). Transcurridos veinte minutos, 66,7% de las pacientes del grupo de la levobupivacaina tenian Bromage 2 o 3 contra 86,3% del grupo de la bupivacaina (p = 0,21). La complicacion mas frecuente fue la hipotension arterial, encontrada en 16 (66,7%) pacientes del grupo de la levobupivacaina y en 10 (43,5%) pacientes del grupo de la bupivacaina (p = 0,11). CONCLUSIONES: La levobupivacaina y la bupivacaina fueron igualmente efectivas en el bloqueo peridural de pacientes sometidas a cesarea.BACKGROUND AND OBJECTIVES Local anesthetic bupivacaine is found in two different enantiomers: levobupivacaine - S (-) and dextrobupivacaine - R (+). Based on studies showing that S(-) enantiomers are less cardiotoxic, their use has been increasing in clinical practice. This study aimed at comparing racemic bupivacaine and levobupivacaine in epidural anesthesia for elective cesarean section. METHODS Randomized, double blind clinical trial enrolling physical status ASA I and II parturients. Patients were assigned to receive either 20 mL of 0.5% racemic bupivacaine or 20 mL of 0.5% levobupivacaine, both with 10 microg sufentanil and epinephrine 1:200,000. RESULTS Participated in this study 47 patients being 24 in the levobupivacaine group and 23 in the bupivacaine group. Both groups were comparable regarding maternal-fetal characteristics. Fifteen minutes after epidural anesthesia, 62.5% of levobupivacaine group patients experienced Bromage 2 or 3 motor block, whereas the same event was documented in 72.7% of bupivacaine group patients (p = 0.83). After 20 minutes, 66.7% of levobupivacaine group patients experienced Bromage 2 or 3 motor block versus 86.3% of bupivacaine group patients (p = 0.21). Most common complication was hypotension, detected in 16 (66.7%) levobupivacaine group patients and in 10 (43.5%) bupivacaine group patients (p = 0.11). CONCLUSIONS Levobupivacaine and bupivacaine were equally effective for epidural block in patients undergoing cesarean section.

Doença de Moyamoya e anestesia com sevoflurano fora do centro cirúrgico: relato de caso

BACKGROUND AND OBJECTIVES Moyamoya disease is a progressive cerebrovascular disorder implying anesthetic challenges due to patients poor brain perfusion, in addition to being a major cause for stroke in young people. This report aimed at describing a case of Moyamoyas disease in a patient submitted to general anesthesia with sevoflurane for a diagnostic procedure outside the surgery center. CASE REPORT Male child, 13 years old, physical status ASA IV, with Moyamoya disease and neurological sequelae after three previous strokes, chronic renal failure and systemic hypertension admitted for high digestive endoscopy. In the supine position and after monitoring, inhalational induction was attained through the tracheostomy canulla with sevoflurane (gradual inhaled concentration increase up to 6%) in a mixture of 50% oxygen/nitrous oxide. An intravenous catheter was inserted for 5% glucose solution infusion. Manual controlled ventilation was started and anesthesia was maintained with 4% sevoflurane in 50% oxygen/nitrous oxide. At the end of the procedure, all anesthetic agents were simultaneously withdrawn and 100% oxygen was administered. Anesthesia was satisfactory, with good hemodynamic stability, without complications and with early emergence. CONCLUSIONS Sevoflurane may open new perspectives for inhalational anesthesia in patients with neurological diseases to be submitted to outpatient procedures, since it provides hemodynamic stability and early emergence, while preserving brain physiology.

Cesariana em paciente com doença de von Willebrand associada à infecção pelo HIV: relato de caso

BACKGROUND AND OBJECTIVES Von Willebrands disease is the most common hereditary coagulation disorder in young women. The incidence of HIV infection among women has been progressively increasing, and vertical transmission may account for 25% of cases. This report aimed at describing the case of an HIV-positive patient with von Willebrands disease scheduled for cesarean section. CASE REPORT Female HIV-positive patient, 24 years old, with microcytic anemia and von Willebrands disease, admitted to the emergency room in early labor. She had no pre-natal care. Cesarean section was indicated to lower vertical transmission risks since HIV viral count was unknown. Patient had hematomas on both arms and legs and history of abdominal wall hematoma in previous cesarean section. Coagulation tests were mildly changed. General anesthesia was induced after factor VIII concentrate infusion. Both mother and newborn had satisfactory outcomes. CONCLUSIONS Clinical evaluation of patients with coagulopathies is critical for determining the anesthetic technique. Evaluation should be individualized, considering risks and benefits of the technique. Cesarean section for these patients should be avoided whenever possible and replaced by less invasive methods. Factor VIII concentrate therapy is the best treatment option for correcting specific deficiency and lowering viral transmission risks.BACKGROUND AND OBJECTIVES: Von Willebrands disease is the most common hereditary coagulation disorder in young women. The incidence of HIV infection among women has been progressively increasing, and vertical transmission may account for 25% of cases. This report aimed at describing the case of an HIV-positive patient with von Willebrands disease scheduled for cesarean section. CASE REPORT: Female HIV-positive patient, 24 years old, with microcytic anemia and von Willebrands disease, admitted to the emergency room in early labor. She had no pre-natal care. Cesarean section was indicated to lower vertical transmission risks since HIV viral count was unknown. Patient had hematomas on both arms and legs and history of abdominal wall hematoma in previous cesarean section. Coagulation tests were mildly changed. General anesthesia was induced after factor VIII concentrate infusion. Both mother and newborn had satisfactory outcomes. CONCLUSIONS: Clinical evaluation of patients with coagulopathies is critical for determining the anesthetic technique. Evaluation should be individualized, considering risks and benefits of the technique. Cesarean section for these patients should be avoided whenever possible and replaced by less invasive methods. Factor VIII concentrate therapy is the best treatment option for correcting specific deficiency and lowering viral transmission risks.

Electrocardiogram analysis by the anesthesiologist

BACKGROUND AND OBJECTIVES The primary goal of preoperative evaluation is to decrease morbidity/mortality related to surgical anesthetic procedures. All patients clinical surgical history must be obtained and only then the necessary exams may be determined. One of the most required exams is the electrocardiogram. This study aimed at comparing electrocar- diographic interpretation by cardiologists and different groups of anesthesiologists at Santa Casa de Porto Alegre. METHODS Fifty resting electrocardiograms of several patients undergoing non cardiac surgeries were selected. All ECGs were analyzed and interpreted by two cardiologists and their agreement was considered the golden standard for interpretation. Anesthesiologists were divided in three groups: I - Preoperative Evaluation anesthesiologists - POEA (n = 5); II - Surgical Center Sarmento Barata Anesthesiologists (n = 10) and III - Resident Anesthesiologists (n = 5). All participants were asked to perform an ECG analysis and scores were established for such evaluation: rhythm = 2 points, heart rate = 1 point, P and PR = 2 points, QRS = 2 points, ST and T = 2 points and primary diagnosis = 1 point. RESULTS Means obtained for each group were: group I - 7.35 +/- 0.86 points; group II - 5.44 +/- 1.69 points and group III - 6.34 +/- 0.89 points and the difference between groups I and II was statistically significant (p < 0.05). CONCLUSIONS Preoperative Evaluation Anesthesiologists achieved a higher score as compared to other groups. This was probably related to more training obtained by the constant ECG interpretation in the clinic.JUSTIFICATIVA E OBJETIVOS: O principal objetivo da avaliacao pre-operatoria e a diminuicao da morbimortalidade associada ao ato anestesico-cirurgico, devendo ser obtidos todos os dados relacionados a historia clinico-cirurgica do paciente e, a partir dai, determinar quais exames complementares sao necessarios. Dentre os exames mais solicitados esta o eletrocardiograma (ECG). O objetivo deste trabalho foi comparar a interpretacao de eletrocardiogramas feitas por cardiologistas, com a realizada por diferentes grupos de anestesiologistas do Servico de Anestesiologia da Santa Casa. METODO: Foram selecionados 50 ECG em repouso, de diferentes pacientes, que seriam submetidos a cirurgia nao cardiaca. Todos os ECG foram analisados e interpretados por dois cardiologistas, sendo a concordância entre ambos considerada padrao ouro de interpretacao. Os anestesiolo- gistas foram divididos em 3 grupos: I - Anestesiologistas do Ambulatorio de Avaliacao Pre-Operatoria - APOA (n = 5); II - Anestesiologistas do Centro Cirurgico Sarmento Barata (CCSB) (n = 10) e III - Medicos em Especializacao em Anestesiologia (ME) (n = 5). Foi solicitada uma analise do eletrocardiograma de todos os participantes. Para avaliacao dos mesmos foram elaborados criterios objetivos de pontuacao: ritmo = 2 pontos, frequencia cardiaca = 1 ponto, P e PR = 2 pontos, QRS = 2 pontos, ST e T = 2 pontos e diagnostico principal = 1 ponto. RESULTADOS: Foram obtidas as seguintes medias de pontuacao para cada grupo: I - 7,35 ± 0,86 pontos; II - 5,44 ± 1,69 pontos e III - 6,34 ± 0,89 pontos, sendo a diferenca entre os grupos I e II estatisticamente significativa (p < 0,05). CONCLUSOES: O grupo de Anestesiologistas do Ambulatorio de Avaliacao Pre-Operatoria alcancou uma pontuacao acima dos demais. Provavelmente isto se relaciona ao maior treinamento, pela constante interpretacao dos ECG no ambulatorio.

Levobupivacaína versus bupivacaína en anestesia peridural para cesáreas: estudio comparativo

JUSTIFICATIVA Y OBJETIVOS: El anestesico local bupivacaina es encontrado en la forma de dos enantiomeros: levobupivacaina - S (-) y dextrobupivacaina - R (+). Basado en estudios que demuestran que la cardiotoxicidad es menor con el enantiomero S(-), fue difundido el uso de este agente en la practica clinica. El objetivo de este estudio es comparar la eficacia y la efectividad del uso de bupivacaina racemica con levobupivacaina en anestesia peridural de pacientes sometidas a cesarea electiva. METODO: Ensayo clinico eventual, doblemente encubierto, con gestantes estado fisico ASA I y II. Las pacientes fueron distribuidas para recibir 20 mL de bupivacaina a 0,5% racemica o 20 mL de levobupivacaina a 0,5%, ambas con 10 µg de sufentanil y vasoconstrictor. RESULTADOS: Participaron del estudio 47 pacientes, 24 en el grupo de la levobupivacaina y 23 en el grupo de la bupivacaina. Los grupos eran comparables entre si en lo que se refiere a las caracteristicas materno-fetales. Transcurridos 15 minutos despues del termino de la puncion peridural, 62,5% de las pacientes del grupo de la levobupivacaina tenian Bromage 2 o 3 contra 72,7% en el grupo de la bupivacaina (p = 0,83). Transcurridos veinte minutos, 66,7% de las pacientes del grupo de la levobupivacaina tenian Bromage 2 o 3 contra 86,3% del grupo de la bupivacaina (p = 0,21). La complicacion mas frecuente fue la hipotension arterial, encontrada en 16 (66,7%) pacientes del grupo de la levobupivacaina y en 10 (43,5%) pacientes del grupo de la bupivacaina (p = 0,11). CONCLUSIONES: La levobupivacaina y la bupivacaina fueron igualmente efectivas en el bloqueo peridural de pacientes sometidas a cesarea.BACKGROUND AND OBJECTIVES Local anesthetic bupivacaine is found in two different enantiomers: levobupivacaine - S (-) and dextrobupivacaine - R (+). Based on studies showing that S(-) enantiomers are less cardiotoxic, their use has been increasing in clinical practice. This study aimed at comparing racemic bupivacaine and levobupivacaine in epidural anesthesia for elective cesarean section. METHODS Randomized, double blind clinical trial enrolling physical status ASA I and II parturients. Patients were assigned to receive either 20 mL of 0.5% racemic bupivacaine or 20 mL of 0.5% levobupivacaine, both with 10 microg sufentanil and epinephrine 1:200,000. RESULTS Participated in this study 47 patients being 24 in the levobupivacaine group and 23 in the bupivacaine group. Both groups were comparable regarding maternal-fetal characteristics. Fifteen minutes after epidural anesthesia, 62.5% of levobupivacaine group patients experienced Bromage 2 or 3 motor block, whereas the same event was documented in 72.7% of bupivacaine group patients (p = 0.83). After 20 minutes, 66.7% of levobupivacaine group patients experienced Bromage 2 or 3 motor block versus 86.3% of bupivacaine group patients (p = 0.21). Most common complication was hypotension, detected in 16 (66.7%) levobupivacaine group patients and in 10 (43.5%) bupivacaine group patients (p = 0.11). CONCLUSIONS Levobupivacaine and bupivacaine were equally effective for epidural block in patients undergoing cesarean section.

Anesthesia for cesarean section in patient with von Willebrand's disease and HIV infection: case report

BACKGROUND AND OBJECTIVES Von Willebrands disease is the most common hereditary coagulation disorder in young women. The incidence of HIV infection among women has been progressively increasing, and vertical transmission may account for 25% of cases. This report aimed at describing the case of an HIV-positive patient with von Willebrands disease scheduled for cesarean section. CASE REPORT Female HIV-positive patient, 24 years old, with microcytic anemia and von Willebrands disease, admitted to the emergency room in early labor. She had no pre-natal care. Cesarean section was indicated to lower vertical transmission risks since HIV viral count was unknown. Patient had hematomas on both arms and legs and history of abdominal wall hematoma in previous cesarean section. Coagulation tests were mildly changed. General anesthesia was induced after factor VIII concentrate infusion. Both mother and newborn had satisfactory outcomes. CONCLUSIONS Clinical evaluation of patients with coagulopathies is critical for determining the anesthetic technique. Evaluation should be individualized, considering risks and benefits of the technique. Cesarean section for these patients should be avoided whenever possible and replaced by less invasive methods. Factor VIII concentrate therapy is the best treatment option for correcting specific deficiency and lowering viral transmission risks.BACKGROUND AND OBJECTIVES: Von Willebrands disease is the most common hereditary coagulation disorder in young women. The incidence of HIV infection among women has been progressively increasing, and vertical transmission may account for 25% of cases. This report aimed at describing the case of an HIV-positive patient with von Willebrands disease scheduled for cesarean section. CASE REPORT: Female HIV-positive patient, 24 years old, with microcytic anemia and von Willebrands disease, admitted to the emergency room in early labor. She had no pre-natal care. Cesarean section was indicated to lower vertical transmission risks since HIV viral count was unknown. Patient had hematomas on both arms and legs and history of abdominal wall hematoma in previous cesarean section. Coagulation tests were mildly changed. General anesthesia was induced after factor VIII concentrate infusion. Both mother and newborn had satisfactory outcomes. CONCLUSIONS: Clinical evaluation of patients with coagulopathies is critical for determining the anesthetic technique. Evaluation should be individualized, considering risks and benefits of the technique. Cesarean section for these patients should be avoided whenever possible and replaced by less invasive methods. Factor VIII concentrate therapy is the best treatment option for correcting specific deficiency and lowering viral transmission risks.

Cesárea en paciente con enfermedad de von Willebrand asociada a la infección por el HIV: relato de caso

BACKGROUND AND OBJECTIVES Von Willebrands disease is the most common hereditary coagulation disorder in young women. The incidence of HIV infection among women has been progressively increasing, and vertical transmission may account for 25% of cases. This report aimed at describing the case of an HIV-positive patient with von Willebrands disease scheduled for cesarean section. CASE REPORT Female HIV-positive patient, 24 years old, with microcytic anemia and von Willebrands disease, admitted to the emergency room in early labor. She had no pre-natal care. Cesarean section was indicated to lower vertical transmission risks since HIV viral count was unknown. Patient had hematomas on both arms and legs and history of abdominal wall hematoma in previous cesarean section. Coagulation tests were mildly changed. General anesthesia was induced after factor VIII concentrate infusion. Both mother and newborn had satisfactory outcomes. CONCLUSIONS Clinical evaluation of patients with coagulopathies is critical for determining the anesthetic technique. Evaluation should be individualized, considering risks and benefits of the technique. Cesarean section for these patients should be avoided whenever possible and replaced by less invasive methods. Factor VIII concentrate therapy is the best treatment option for correcting specific deficiency and lowering viral transmission risks.BACKGROUND AND OBJECTIVES: Von Willebrands disease is the most common hereditary coagulation disorder in young women. The incidence of HIV infection among women has been progressively increasing, and vertical transmission may account for 25% of cases. This report aimed at describing the case of an HIV-positive patient with von Willebrands disease scheduled for cesarean section. CASE REPORT: Female HIV-positive patient, 24 years old, with microcytic anemia and von Willebrands disease, admitted to the emergency room in early labor. She had no pre-natal care. Cesarean section was indicated to lower vertical transmission risks since HIV viral count was unknown. Patient had hematomas on both arms and legs and history of abdominal wall hematoma in previous cesarean section. Coagulation tests were mildly changed. General anesthesia was induced after factor VIII concentrate infusion. Both mother and newborn had satisfactory outcomes. CONCLUSIONS: Clinical evaluation of patients with coagulopathies is critical for determining the anesthetic technique. Evaluation should be individualized, considering risks and benefits of the technique. Cesarean section for these patients should be avoided whenever possible and replaced by less invasive methods. Factor VIII concentrate therapy is the best treatment option for correcting specific deficiency and lowering viral transmission risks.