Susana Abe Miyahira

Injuries caused by Veress needle insertion for creation of pneumoperitoneum: a systematic literature review.

BackgroundThe aim of this study was to assess the prevalence, risks, and outcomes of injuries caused by the Veress needle described in the literature.Methods Iatrogenic injuries caused by Veress needle insertion during diagnostic or therapeutic laparoscopies in humans were researched, with no language restriction, in the Medline, Lilacs, Embase, Scielo, and Cochrane Library databases. The following words were combined: “Veress” or “insufflation needle” or “pneumoperitoneum needle,” and “complications” or “injuries” or “lesions.” The bibliographic references of the selected articles were also analyzed. We considered the following: (1) number of injuries described in the literature, (2) relationship between number of injuries and number of patients who underwent Veress needle insertion in the studies that reported Veress needle injury, (3) organs and structures injured (retroperitoneal vessels, digestive tract, and self-limited, minor injuries), and (4) outcome (death, conversion to laparotomy, laparoscopic repair, spontaneous resolution).ResultsThirty-eight selected articles included 696,502 laparoscopies, with 1,575 injuries (0.23%), 126 (8%) of which involved blood vessels or hollow viscera (0.018% of all laparoscopies). Of the 98 vascular injuries, 8 (8.1%) were injuries to major retroperitoneal vessels. There were 34 other reported retroperitoneal injuries, but the authors were not specific as to which vessel was injured. Of the 28 injuries to hollow viscera, 17 were considered major injuries, i.e., 60.7% (0.0024% of the total cases assessed).ConclusionThe insertion of the Veress needle in the abdominal midline, at the umbilicus, poses serious risk to the life of patients. Therefore, further studies should be conducted to investigate alternative sites for Veress needle insertion.

Tridimensional fuzzy pain assessment

A tridimensional fuzzy pain assessment for representing professional, social, and sexual aspects concerned to the fifth vital sign of medical condition is proposed in this paper. According to the 3D fuzzy pain assessment herein, pain is not only caused by activity in nociceptive information in the brain. The proposed approach embodies such sensorial information simultaneously that contextualize it within cultural aspects that permeate the human life. This paper extends both previous unidimensional fuzzy pain intensity scale and the accepted professional-social-sexual pain assessment to fuzzy inference systems. The fuzzy professional-social-sexual pain assessment is able to represent the inherent physiological, psychological characteristics by taking into account the emotional, complex perceptual, subjective, and personal phenomenon involving all domains of an individual meanwhile can deal with cultural mechanisms within individual life experience. According to the proposed approach, not only fuzzy set theory but fuzzy systems can also direct and immediately improve medicine and healthcare in general, and pain assessment, in particular, in a subjective and multi-dimensional model.

Intraperitoneal pressure and volume of gas injected as effective parameters of the correct position of the Veress needle during creation of pneumoperitoneum.

OBJECTIVE The aim of this work was to establish reliable parameters of the correct position of the Veress needle in the peritoneal cavity during creation of pneumoperitoneum. METHODS The Veress needle was inserted into the peritoneal cavity of 100 selected patients, and a carbon-dioxide flow rate of 1.2 L/min and a maximum pressure of 12 mm Hg were established. Intraperitoneal pressure (IP) and the volume of gas injected (VG) were recorded at the beginning of insufflation and at every 20 seconds. Correlations were established for pressure and volume in function of time. Values of IP and VG were predicted at 1, 2, 3, and 4 minutes of insufflation, by applying the following formulas: IP = 2.3083 + 0.0266 x time +8.3 x 10(-5) x time(2) - 2.44 x 10(-7) x time(3); and VG = 0.813 + 0.0157 x time. RESULTS A strong correlation was observed between IP and preestablished time points during creation of the pneumoperitoneum, as well as between VG and preestablished time points during creation of the pneumoperitoneum, with a coefficient of determination of 0.8011 for IP and of 0.9604 for VG. The predicted values were as follows: 1 minute = 4.15; 2 minutes = 6.27; 3 minutes = 8.36; and 4 minutes = 10.10 for IP (mm Hg); and 1 minute = 1.12; 2 minutes = 2.07; 3 minutes = 3.01; and 4 minutes = 3.95 for VG (L). CONCLUSIONS Values of IP and VG at given time points during insufflation for creation of the pneumoperitoneum, using the Veress needle, can be effective parameters to determine whether the needle is correctly positioned in the peritoneal cavity.

Fuzzy Obesity Index for obesity treatment and surgical indication

A Fuzzy Obesity Index for being used as an alternative in obesity treatment and bariatric surgery indication (BSI) is presented in this paper. Obesity is nowadays understood as universal epidemy and became an important source of death and co-morbidities. The search for a more accurate method to evaluate obesity and to indicate a better treatment is important in the world health context. In this paper the Body Mass Index (BMI) is first modified and treated as fuzzy sets. BMI is characterized by its capacity of weight excess and considered the main criteria for obesity treatment and BSI. Nevertheless, the fat excess related to the Body Fat (BF) is actually the principal harmful factor in obesity disease, that is usually neglected. Due to that this paper also presents a new fuzzy mechanism for evaluating obesity by associating BMI with Body Fat (BF) that yields a fuzzy obesity index for obesity evaluation and treatment and allows to build up a Fuzzy Decision Support System (FDSS) for BSI. Different values of BMI and BF (in terms of %BF) used for validating the proposed method classify individuals in distinct categories with degrees of compatibility more realistic than those accomplished by Boolean classification, as usually occur. The proposed method may assume an important whole in medicine as an index for obesity evaluation and surgery treatment by using the advantages of BMI and BF in synergy.

Effects of elevated artificial pneumoperitoneum pressure on invasive blood pressure and levels of blood gases

BACKGROUND AND OBJECTIVE to evaluate the clinical, hemodynamic, gas analysis and metabolic repercussions of high transient pressures of pneumoperitoneum for a short period of time to ensure greater security for introduction of the first trocar. METHODS sixty-seven patients undergoing laparoscopic procedures were studied and randomly distributed in P12 group: n=30 (intraperitoneal pressure [IPP] 12mmHg) and P20 group: n=37 (IPP of 20mmHg). Mean arterial pressure (MAP) was evaluated by catheterization of the radial artery; and through gas analysis, pH, partial pressure of oxygen (PaO2), partial pressure of CO2 (PaCO2), bicarbonate (HCO3) and alkalinity (BE) were evaluated. These parameters were measured in both groups at time zero before pneumoperitoneum (TP0); at time 1 (TP1) when IPP reaches 12mmHg in both groups; at time 2 (TP2) after five min with IPP=12mmHg in P12 and after 5min with IPP=20mmHg at P20; and at time 3 (TP3) after 10min with IPP=12mmHg in P12 and with return of IPP from 20 to 12mmHg, starting 10min after TP1 in P20. Different values from those considered normal for all parameters assessed, or the appearance of atypical organic phenomena, were considered as clinical changes. RESULTS there were statistically significant differences in P20 group in MAP, pH, HCO3 and BE, but within normal limits. No clinical and pathological changes were observed. CONCLUSIONS high and transient intra-abdominal pressure causes changes in MAP, pH, HCO3 and BE, but without any clinical impact on the patient.

Unidimensional fuzzy pain intensity scale

A fuzzy pain scale for representing subjectivity and emotionality related to the fifth vital sign of medical condition is proposed in this paper. The classic intensity rating scales are inherently crisp sets. The medical and healthcare community does not realize that since the concept of fuzzy sets does not range all fields of knowledge yet. This paper extends the accepted international classic pain intensity rating scales to fuzzy set theory obtaining the fuzzy visual analog scale (FVAS), fuzzy numerical rating scale (FNRS), fuzzy qualitative pain scale (FQPS), and fuzzy face pain scale (FFPS). These fuzzy pain intensity scales take into account positive characteristics concerning classic pain intensity scales meanwhile represent the inherent imprecision, uncertainty and vagueness presented in the pain report and assessment. The proposed approach demonstrates how fuzzy set theory may push forwards the boundaries of medicine and healthcare by proposing a novel approach in order to improve the human quality level.

Punção com agulha de Veress no hipocôndrio esquerdo para a criação do pneumoperitônio: valor diagnóstico das provas de posicionamento da agulha em pacientes não selecionados

Objective: To assess the effectiveness of the Veress needle puncture in the left hypochondrium and the accuracy of the tests described for the intraperitoneal correct positioning of the tip of the Veress needle in an unselected population. Methods: Ninetyone patients consecutively scheduled for Videolaparoscopy had the abdominal wall punctured in the left hypochondrium. There were no exclusion criteria. The patients received general anesthesia and mechanical ventilation according to the protocol. After puncturing five tests were used to confirm the positioning of the needle tip within the peritoneal cavity: aspiration test - AT; resistance to infusion - Pres; recovery of the infused fluid - Prec, dripping test - DT, and test of initial intraperitoneal pressure - IIPP. The test results were compared with results from literature for groups with defined exclusion criteria. The results were used for calculating sensitivity (S) specificity (E), positive predictive value (PPV) and negative predictive value (NPV). Inferential statistical methods were used to analyze the findings. Results: There were 13 failures. AT had E = 100% and NPV 100%. Pres had S = 100%, E = 0; PPV = 85.71%; NPV does not apply. Prec: S = 100%, E = 53.84%, PPV = 92.85%, NPV = 100%. DT: S = 100%, E = 61.53%, PPV = 93.97% NPV 100%. In IIPP, S, E, PPV and NPV were 100%. Conclusion: The puncture in the left hypochondrium is effective and the performed tests guide the surgeon regardless of sex, BMI, or previous laparotomy.

Fuzzy obesity index (MAFOI) for obesity evaluation and bariatric surgery indication

BackgroundThe Miyahira-Araujo Fuzzy Obesity Index (MAFOI) for being used as an alternative in bariatric surgery indication (BSI) is validated in this paper. The search for a more accurate method to evaluate obesity and to indicate a better treatment is important in the world health context. Body mass index (BMI) is considered the main criteria for obesity treatment and BSI. Nevertheless, the fat excess related to the percentage of Body Fat (%BF) is actually the principal harmful factor in obesity disease that is usually neglected. The aim of this research is to validate a previous fuzzy mechanism by associating BMI with %BF that yields the Miyahira-Araujo Fuzzy Obesity Index (MAFOI) for obesity evaluation, classification, analysis, treatment, as well for better indication of surgical treatment.MethodsSeventy-two patients were evaluated for both BMI and %BF. The BMI and %BF classes are aggregated yielding a new index (MAFOI). The input linguistic variables are the BMI and %BF, and the output linguistic variable is employed an obesity classification with entirely new types of obesity in the fuzzy context, being used for BSI, as well.ResultsThere is gradual and smooth obesity classification and BSI criteria when using the Miyahira-Araujo Fuzzy Obesity Index (MAFOI), mainly if compared to BMI or %BF alone for dealing with obesity assessment, analysis, and treatment.ConclusionThe resulting fuzzy decision support system (MAFOI) becomes a feasible alternative for obesity classification and bariatric surgery indication.