ABSTRACT
JUSTIFICATIVA E OBJETIVOS: A amigdalectomia é considerada um procedimento relativamente seguro. O objetivo deste relato foi mostrar uma complicação rara desta cirurgia, o enfisema subcutâneo. RELATO DO CASO: Paciente do sexo masculino, 25 anos, com amigdalite recorrente e hipertrofia de cornetos. Foi submetido a amigdalectomia e turbinectomia sob anestesia geral com intubação orotraqueal. A operação transcorreu sem intercorrências. Na sala de recuperação pós-anestésica (SRPA) o paciente agitou-se, apresentando grande esforço físico. Quatro horas após a cirurgia, notou-se edema crepitante e depressível no pescoço e na região parotídea esquerda, característico de enfisema subcutâneo. A tomografia computadorizada mostrou a existência de ar nas regiões malar e cervical (principalmente à esquerda), atingindo até o mediastino superior. Não houve obstrução das vias aéreas e o estado geral do paciente permaneceu estável. Teve alta hospitalar no dia seguinte e foi acompanhado no ambulatório. O enfisema regrediu totalmente após 10 dias. CONCLUSÕES: O enfisema subcutâneo é uma complicação rara da amigdalectomia, ocorrendo quase sempre após dissecções profundas da mucosa faríngea, quando se cria interface porosa que proporciona a entrada do ar. O aumento da pressão nas vias aéreas superiores pode contribuir para o problema.
Subject(s)
Male , Adult , Humans , Subcutaneous Emphysema/diagnosis , Subcutaneous Emphysema/etiology , Postoperative Complications , Tonsillectomy/adverse effectsABSTRACT
Backgoruind and oblectives - Nitrous oxide is less iritating than carbon dioxide when injected into the abdominal cavity, besides inducing less hemodynamic and respiratory changes. The objective of this study was to demonstrate that: a) N2O used as pneumoperitoneum gas is little absorbed by the splancnic circulation; b) Intraperitoneal N2), associated or not with inhaled N2O, does not change PETCO2, and cannot be responsible for postoperative vomiting; c) the association of inhaled and intraperitoneal N2O reduces alfentanil requirement as compared to ventilation with 100 per cent oxygen. Methods - After Institutional approval, thirty two patientes of both sexes, ASA physical status 1 or 2, submmited to laparoscopic cholecystectomy, gave their informed consent to participate. Patients were premedicated with intramuscular midazolan (0.1mg.Kg-1). Monitoring included blood presure, ECG, gas analyser, pulse oximeter, oxygen analyser and peripheral nerve stimulator. Anhestesia was included with droperidol (0.15 mg.Kg-1), alfentanil (40ug.Kg-1), propofol (0.5 mg.Kg-1) in continuous infusion, atracurium (0.5 mg.Kg-1) and 100 per cent oxygen by mask, followed by tracheal intubation. Ventilation was controlled with 7 ml.Kg-1 tidal voleme and the ventilatory rate was adjusted to maintain PETCO2 at 32-36 mmHg, 97-98 per cent HbO2 saturation, 33-35 per cent FlO2 and intratracheal pressure of 10-12 cmH2O. Metropolol, 0.05-1 mgKg-1, was injested after tracheal intubation. The patients were allocated into two groups: Group O, ventilated with 100 per cent O2; Group N, ventilated with N2O 66-67 per cent in O2. Maintenance of anesthesia was done with propofol infusion (35 ug.Kg-1) and intermitent doses of alfentanil in both groups. Alfentanil doses systolic and diastolic arterial pressures and heart rate were registered. The PETCO2 was adjusted to 32-36 mmHg with constant tidal volume and changes in ventilatory rate if necessary. The N2O was insuflated into the abdominal cavity up to obtaining 10-12 mmHg pressure and the initial volume was registered. Samples were colected from the gastric cavity and the N2O concentration was measured in the abdominal cavity at the end of the procedure. In Group O, the expired N2O was monitored to detect absorption by splacnin circulation. In Group N, the time after discontinuation of N2O required for the expires concentration to reach 15 per cent and zero, were registered. Data were statisticaly analyzed with Student's "t" test, ANOVA and chi square test. Results - In Group O, alfentanil doses were higher than in Group N (p<0.001). Initial intraperitoneal insuflation volume of N2O were 1.76 +- 0.47 Land l.92 +- 0.59 L respectively in Groups O and N. In both groups, the N2O concentration in the desinsuflation gas was near 100 per cent and N2O was not detected in the gastric cavity gas. In Group O, N2O was not detected in the expiratory gases. In 3.38 +- 1.09 min the N2o concentration was reduced to 15 per cent and 8.38 +- 3.36 min it was zero in Group N. Conclusions - The authors concluded that: 1- N2O used by peritoneal route is not absorbed by splancnic circulation; 2- the association of inhalation and intraperitoneal N2O does not induce significant hemodynamic or respiratory changes; 3- because it is little absrbed and unlikely to produce explosive mixtures, the authors recommend N2O to be used as pneumoperitoneum gas in laparoscopic cholecistectony
Subject(s)
Humans , Alfentanil , Anesthesia, Inhalation , Anesthesia, Intravenous , Nitrous Oxide , Pneumoperitoneum/complications , Propofol , Cholecystectomy, LaparoscopicABSTRACT
Justificativa e objetivos - O oxido nitroso (N2O) tem sido utilizado como gas intracavitario no homem e considerado menos irritante ao peritinio, quando comparado com o CO2. O N2O intracavitario tem mostrado menores alteracoes hemodidinamicas que o CO2 o que nos levou a utiliza-lo. Os objetivos deste estudo sao: a) Comparar os efeitos hemodinamicos e respiratorios entre o pneumoperitinio realizado com N2O e com o CO2, b) Comprovar a existencia de absorcao de N2O da cavidade abdominal e que esta pode influenciar no plano anestesico, e c) se ha diferentas na recuperacao pos-anestesica. Metodo - Vinte e oito pacientes adultos de ambos os sexos, estado fisico ASA I ou II, foram submetidos a colecistectomia por via laparoscopica, sob anestesia geral venosa divididos em dois grupos de acordo com o gas utilizado na cavidade peritoneal: Grupo C em que o gas foi o CO2, e o grupo N, que foi o N2O. A medicacao pre-anestesica (MPA) foi o diazepam por via oral. A anestesia foi induzida com propofol, atracurium, droperidol e alfentanil e mantida com propofol, e doses adicionais de alfentanil e de atracurium de acordo com as necessidades. Os dados hemodinamicos e ventilatorios foram registrados em onze omomentos (M1 a M11) que abrangeram os tempos compreendidos desde a estabiliacao da ventilacao, insuflacao e desinsuflacao abdominal, ate a recuperacao pos-anestesica nas primeiras tres horas. Foram registradas as variacoes da freqnencia ventilatoria (FV), a fracao expirada de oxido nitroso (PETN2O) e de gas carb(nico (PETCO2), o consumo de alfentanil, a eliminacao de N2O pelas vias aereas, as intercorrencias na sala de recuperacao pos-anestesica e a necessidade do emprego de antagonista de opiaceos. Resultados - Houve variacao da FV. Quanto ao volume minuto, houve diferentas significativas entre os dois grupos durante a manutencao do pneumoperitoneo e apos a desinsuflacao, com aumento significativo da FV nos pacientes do Grupo C em relacao aos do Grupo N. Embora sob hiperventilacao, no Grupo C a PETCO2 manteve-se mais elevada que no Grupo N. Foi detectado tratos de N2O na fracao expirada durante o pneumoperitoneo no Grupo N. A PAM apresentou valores maiores no Grupo C a partir da insuflacao abdominal, com diferentas significativas no tempo de quinze minutos apos a insuflacao inicial. No grupo N houve diferenca significativa da PAD cinco minutos apos a desinsuflacao abdominal com valores superiores. O Grupo C exigiu doses significativamente maiores de alfentanil que...
Subject(s)
Humans , Male , Female , Adult , Anesthesia, General , Cholecystectomy, Laparoscopic , Nitrous Oxide , Pneumoperitoneum, Artificial , Anesthesia Recovery Period , Carbon Dioxide , Hemodynamics , Respiration, ArtificialABSTRACT
Twenty-four patients of both sexes, physical status ASA I and II, were submitted to laparoscopic cholecystectomy. Patients were premedicated with 10 mg of diazepam and the anesthesia was induced with droperidol (0,03 mg.kg(-1)), alfentanil (40 mg.kg(-1)), propofol (2 mg.kg(-1) ) and atracurium (0,5 mg.kg(-1)). After tracheal intubation, pulmonary ventilation was maintained with a Takaoka 676 ventilator with a tidal volume of 7 ml.kg(-1), FiO2 of 0.33-0.35, intracheal pressure of 10-12 cmH2 O and respiratory rate adjusted to maintain ETCO2 36-38 mmHg and Sp)2 97-98 por cent. The patients were allocated into two groups. Group air: ventilated eith room air enriched with oxygen to a FiO2 of 0.35 and group N20: ventilated with 67 por cent N2O in O2. Maintenance of anesthesia was done with 10 mg.kg(-1).h(-1) of propofol in the first 20 min and with 5 mg.kg(-1).h(-1) afterwards until the end of the surgical procedure, plus intermittent doses of alfentanil. Changes in pulmonary ventilation rate and in the intratracheal pressures were record at nine moments. Carbon dioxide was administered until intrabdominal pressure reached 12-14 mm Hg; the initial and final volumes administered were recorded. The intracavitary concentration of N2O was evoluated by an Ohmeda 5250 Gas Multianalyser at the end of the procedure. Systolic and dystolic blood pressure and heart rate were evaluated every 5 min, at the same moments as the pulmonary ventilation parameters. There was no difference in the minute volumes at moment 1, but they were significantly higher at the subsequent moments (p major then 0,05), in the group which was ventilated with air. There were significant differences in intratracheal pressures before and the after the insuflation of CO2 and after the deflation within each group, but not between the groups. Nitrous oxide was detected in the abdominal cavity in remarkable concentrations. There were significant differences between the groups regarding systolic arterial pressure after insuflation and deflation of CO2, during maintenance and after extubation. The authors conclued that N2O diffuses to the abdominal cavity in significant concentrations and that it is able to minimize the respiratory changes associated with high intrabdominal pressure and with CO2 absorption. There were no differences in CO2 volumes required during the laparoscopic procedure