Relación entre el tiempo de circulación extracorpórea y el pinzamiento aórtico con diferentes variables de evolución postquirúrgicas / Relationship between cardiopulmonary bypass time and aortic cross clamping time with different variables of post-surgical evolution

Resumen Justificación: La mayor cantidad de cirugías cardiacas realizadas a nivel mundial se efectúa con circulación extracorpórea y pinzamiento de la aorta, lo que conlleva una serie de alteraciones fisiopatológicas que deben ser reconocidas por el personal de salud que participa en la atención de estos pacientes. Objetivo: Describir el perfil y los factores de riesgo presentes en los pacientes sometidos a cirugía cardiaca con circulación extracorpórea, y analizar la existencia de una potencial relación entre el tiempo de circulación extracorpórea y el pinzamiento aórtico, con la aplicación de desfibrilaciones tras al pinzado de la aorta, la necesidad de soporte cardiovascular farmacológico, el comportamiento del nivel de lactato plasmático y la mortalidad. Métodos: Se desarrolló un estudio observacional y descriptivo con una muestra de 104 pacientes electivos, sometidos a intervención quirúrgica y circulación extracorpórea, en el Hospital México, desde octubre de 2016 a noviembre de 2017. Se caracterizó la población en estudio, se analizaron los factores de riesgo incluido el EuroSCORE I y II, el tiempo de circulación extracorpórea, el tiempo de pinzamiento aórtico, las desfibrilaciones posteriores al pinzamiento aórtico, e lactato inmediatamente postcirculación extracorpórea, y a las 2, 6, 24 h postquirúrgicas, el uso de soporte cardiovascular farmacológico en infusión continua posterior a la circulación extracorpórea y mortalidad a los 30 días. Resultados: La edad media fue 56,4 años, predominó el sexo masculino (69 %) y la hipertensión arterial fue el factor de riesgo más frecuente (76,07 %). Se registró un tiempo de pinzado aórtico menor a 100 min en 61 pacientes (58,65 %) y superior a ese tiempo en 43 pacientes (41,35 %). El EuroSCORE I promedio fue del 4,21 % (DE: 4,80), mientras que el EuroSCORE II fue del 2,37 % (DE: 2,41). El tiempo promedio de circulación extracorpórea fue de 129 minutos (DE: 36,88) y el de pinzado aórtico, de 94 minutos (DE:32,04). Hubo un pico de lactato a las 6 horas postquirúrgicas (5,13 mmol/L, DE:2,89); un 8,65 % de los pacientes fueron desfibrilados después del retiro de la pinza en la aorta; se utilizó soporte cardiovascular en el 16,35 % y la mortalidad quirúrgica fue del 1,92 %. Conclusiones: En el estudio, el tiempo de circulación extracorpórea y el pinzado aórtico junto con el uso de inotrópicos, vasoconstrictores, hiperlactatemia y mortalidad quirúrgica, no alcanzó una relación significativa.

Abstract Justification: Currently, the largest number of cardiac surgeries performed worldwide are performed with cardiopulmonary bypass and aortic cross clamp, which leads to a series of pathophysiological alterations that are important for health personnel involved in the care of these patients. Objective: To describe the profile and risk factors present in patients undergoing cardiac surgery with cardiopulmonary bypass and the existence of a potential relationship between the cardiopulmonary bypass time and aortic cross clamping time, with the use of post clamp defibrillations, pharmacological cardiovascular support, plasma lactate behavior and mortality. Methods: An observational and descriptive study was carried out with a sample of 104 elective patients, undergoing surgical intervention and cardiopulmonary bypass at Hospital México, from October 2016 to November 2017. The study population was characterized, risk factors were analyzed including EuroSCORE I and II, CPB time, aortic cross clamping time, post-aortic clamping defibrillation, lactate immediately after extracorporeal circulation and at 2, 6, 24 hours postoperatively, use of pharmacological cardiovascular support in continuous infusion after extracorporeal circulation and mortality at 30 days. Results: The mean age was 56.4 years, the male sex predominated (69%) and arterial hypertension was the most frequent risk factor (76.07%). Aortic cross clamp time of less than 100 min was recorded in 61 patients (58.65%) and greater than that time in 43 patients (41.35%). The average EuroSCORE I was 4.21% (SD: 4.80), while the EuroSCORE II was 2.37% (SD: 2.41). The average cardiopulmonary bypass time was 129 minutes (SD: 36.88) and aortic cross clamp time was 94 minutes (SD: 32.04). There was a lactate peak at 6 postoperative hours (5.13 mmol/L, SD: 2.89); 8.65% of patients were defibrillated after removal the clamp in the aorta; pharmacological cardiovascular support was used in 16.35% and surgical mortality was 1.92%. Conclusions: In this study, cardiopulmonary bypass time and aortic cross clamp time together with the use of inotropics, vasoconstrictors, hyperlactatemia and surgical mortality did not reach a significant relationship.

Síndrome vasopléjico en cirugía cardíaca / Vasoplegia syndrome in cardiac surgery / Síndrome de vasoplegia em cirurgia cardíaca

Resumen: El síndrome de respuesta inflamatoria sistémica constituye un conjunto de situaciones clínicas de diferente gravedad, que se presenta con una incidencia de hasta el 25% durante las primeras horas del posoperatorio de cirugía cardíaca. En esta revisión, se analizan sus aspectos fisiopatológicos y los factores de riesgo que favorecen su desarrollo. Se plantea un enfoque diagnóstico, con la presentación final de una propuesta terapéutica.

Summary: The systemic inflammatory response syndrome constitutes a set of clinical situations of different severity, which presents with an incidence of up to 25% during the first hours after cardiac surgery. In this review, the pathophysiological aspects and the risk factors that favor its development are analyzed. A diagnostic approach is proposed, with the final presentation of a therapeutic proposal.

Resumo: A síndrome da resposta inflamatória sistêmica constitui um conjunto de situações clínicas de gravidade diversa, que se apresenta com incidência de até 25% nas primeiras horas de pós-operatório de cirurgia cardíaca. Nesta revisão, são analisados os aspectos fisiopatológicos e os fatores de risco que favorecem o seu desenvolvimento. É proposta uma abordagem diagnóstica, com a apresentação final de uma proposta terapêutica.

Conceptos actuales de interpretación de los signos vitales en odontología y su aplicación clínica / Current concepts of interpretation of vital signs in dentistry and its clinical application

La medición de los signos vitales es de gran importancia en el consultorio dental, de esta forma podemos obtener una visión objetiva y anticipada del estado funcional del paciente. Según la información obtenida, se tomarán decisiones terapéuticas. El odontólogo debe saber que el seguimiento clínico y el uso de la técnica adecuada para sus mediciones representan un aspecto muy relevante para prevenir emergencias en el consultorio dental. El odontólogo debe medir los signos vitales antes, durante y después del procedimiento dental y, del mismo modo, debe estar involucrado en la situación individual de cada paciente y proporcionar medidas higiénicodietéticas para mejorar su calidad de vida. La evaluación continua de los signos vitales durante el procedimiento quirúrgico dental, en el que se usan anestésicos locales, es particularmente relevante en este caso, ya que puede ayudarnos a prevenir complicaciones como arritmias cardiacas, crisis hipertensivas o angina de pecho. El objetivo de este artículo es promover en toda la profesión odontológica, el monitoreo de los signos vitales, su técnica de medición correcta y su correlación con otros datos de un historial completo médico y dental (AU)

The measurement of vital signs is of great importance in the dental office, this way we can obtain an objective and anticipated vision of the functional state of the patient. According to the information obtained, therapeutic decisions will be made. The dentist must know that monitoring and using the appropriate technique for its measurements, represents a very relevant aspect for the emergency in the dental office. The dentist must measure the vital signs before, during and after the dental procedure, likewise, they must be involved in the individual situation of each patient and provide hygienic-dietetic measures to improve their quality of life. The continuous assessment of vital signs during the dental surgical procedure, in which local anesthetics are used, is particularly relevant in this case since it can help us prevent complications such as cardiac arrhythmias, hypertensive crisis or angor pectoris. The objective of this article is to promote throughout the dental profession, the monitoring of vital signs, their correct measurement technique and their correlation with other data from a complete medical and dental history (AU)

Influencia de los vasoconstrictores añadidos a la anestesia dental en la frecuencia cardiaca y la tensión arterial / Influence of vasoconstrictors added to dental anesthetics on blood pressure and heart rate

Introduction: vasoconstrictors are substances added to local anesthetics to lengthen their time of action, reduce their toxicity and enhance their local hemostatic effect. There is controversy about whether the use of vasoconstrictors in dental anesthetics has a negative effect on blood pressure and heart rate. Objective: determine the influence of vasoconstrictors added to dental anesthetics on blood pressure and heart rate. Methods: an experimental study was conducted with 120 patients divided in two groups of 60. These patients attended clinics in the Dental Academic Unit of the Autonomous University of Guerrero from July to December 2015. Group A was given just 3 percent mepivacaine, whereas Group B was given mepivacaine with epinephrine at a concentration of 1:100 000. Measurements were taken of the patients' heart rate, systolic blood pressure and diastolic blood pressure at two moments: at baseline before infiltration and 5 minutes after infiltration. Statistical analysis was based on Student's t-test for independent samples. Results: heart rate and systolic blood pressure did not yield any statistically significant value. Diastolic blood pressure was the only hemodynamic parameter showing a statistically significant difference (t= 2.3; p= 0.02). Conclusions: the results obtained coincide with those reported by similar studies. At the doses recommended, epinephrine is safe for healthy patients as well as for those with controlled cardiovascular conditions(AU)

Introducción: los vasoconstrictores son substancias que han sido añadidas a los anestésicos locales con la finalidad de aumentar su tiempo de acción, disminuir su toxicidad y aprovechar su efecto hemostático local. Existe controversia sobre si el uso de vasoconstrictores en los anestésicos dentales produce efectos negativos en la tensión arterial y la frecuencia cardiaca. Objetivo: determinar la influencia de los vasoconstrictores añadidos a la anestesia dental en la frecuencia cardiaca y la tensión arterial. Métodos: se realizó un estudio experimental en 120 pacientes divididos en dos grupos de 60, que acudieron a las clínicas de la Unidad Académica de Odontología de la Universidad Autónoma de Guerrero en el periodo julio-diciembre de 2015. Al grupo A se le administró mepivacaína simple al 3 por ciento, y al grupo B se le administró mepivacaína con epinefrina a una concentración de 1:100 000. Se realizaron tomas de frecuencia cardiaca, tensión arterial sistólica y tensión arterial diastólica en dos momentos. Se realizó una toma basal de frecuencia cardiaca, tensión arterial sistólica y diastólica antes de la infiltración, y una segunda toma 5 min posteriores a la infiltración. Se realizó la prueba estadística t de Student para grupos independientes. Resultados: la frecuencia cardiaca y la tensión arterial sistólica no obtuvieron significancia estadística. El único parámetro hemodinámico que tuvo una diferencia estadísticamente significativa fue la tensión arterial diastólica (t= 2,3; p= 0,02). Conclusiones : los resultados obtenidos en esta investigación, coinciden con los reportados en otros estudios similares. La epinefrina puede ser utilizada de manera segura a las dosis recomendadas tanto en pacientes sin enfermedad cardiovascular, como en pacientes con compromiso cardiovascular en control(AU)

Evaluation of blood glucose in type II diabetic patients submitted to local anesthesia with different vasoconstrictors / Avaliação da glicemia de pacientes diabéticos submetidos à anestesia local com diferentes vasoconstritores

ABSTRACT Objective: In the dental clinic, the use of local anesthetics containing vasoconstrictors in diabetic patients are still controversial raising some doubts. Thus, the objective of this randomized crossover clinical trial was to evaluate blood glucose, pulse oximetry and heart rate of type 2 diabetic patients when submitted to local anesthesia using prilocaine 3% associated to felypressin 0,03UI / ml (G1) and 2% lidocaine associated to epinephrine 1: 100,000 (G2). Methods: The sample consisted of 20 compensated type 2 diabetic patients (both genders) who were taking oral hypoglycemic drugs. The volunteers underwent two periodontal sessions (scaling) and one of the solutions tested was used in each visit. The cited parameters were evaluated at three different times: before the procedure (T1), 10 minutes after anesthesia (T2) and after 20 minutes (T3). Results: Regarding the blood glucose levels, no statistically significant difference was found in different times between G1 and G2 (p> 0.05). Similarly, regarding pulse oximetry and heart rate, no statistically significant differences were observed in intervals assessed between groups (p> 0.05), presenting values within normal limits. Conclusion: Considering the vasoconstrictors and the volume of anesthetic solution used, the results suggest that the evaluated vasoconstrictors do not alter significantly blood glucose, pulse oximetry and heart rate in compensated type 2 diabetic patients.

RESUMO Objetivo: Na clínica odontológica, o uso de soluções anestésicas locais contendo vasoconstritores em pacientes diabéticos ainda sucita algumas dúvidas. Desta forma, o objetivo deste ensaio clínico cruzado e randomizado foi avaliar de forma comparativa a glicemia, oximetria de pulso e frequência cardíaca de pacientes portadores de diabetes tipo II quando submetidos à anestesia local com prilocaína 3% com felipressina 0,03UI/ml (G1) e lidocaína a 2% com epinefrina 1:100.000 (G2). Métodos: Foram selecionados 20 indivíduos diabéticos do tipo II, compensados, sem distinção de gênero, que faziam uso de hipoglicemiantes orais. Os voluntários foram submetidos a duas sessões de instrumentação periodontal, sendo administrada uma das soluções testadas em cada consulta. Os parâmetros citados foram avaliados em três momentos distintos: antes do procedimento (T1), 10 minutos após a anestesia (T2) e após 20 minutos (T3). Resultados: Para os valores de glicemia não houve diferença estatisticamente significante nos diferentes tempos entre G1 e G2 (p>0,05). Da mesma forma, em relação à oximetria de pulso e frequência cardíaca, não foram observadas diferenças estatisticamente significativas nos intervalos avaliados entre os grupos (p>0,05), com valores dentro da normalidade. Conclusão: Considerando a concentração dos vasoconstritores e o volume das soluções anestésicas empregadas, os resultados sugerem que os vasoconstritores avaliados não alteram de forma significativa a glicemia, oximetria de pulso e frequência cardíca de adultos portadores de diabetes tipo II compensados.

Patogenia, diagnóstico y tratamiento de la disfunción renal en cirrosis / Pathogenesis, Diagnosis and Treatment of Renal Dysfunction in Cirrhosis

Los pacientes con cirrosis hepática son susceptibles a presentar un deterioro de la función renal que puede ser de naturaleza funcional y/o estructural. La insuficiencia renal aguda (IRA) prerrenal representa la forma más frecuente en el 68% de los casos, e incluye un tipo especial de insuficiencia renal funcional conocida como síndrome hepatorrenal (SHR). La creatinina sérica permanece como el mejor biomarcador de IRA en cirrosis a pesar de sus reconocidas limitaciones. La diferenciación entre necrosis tubular aguda (NTA) y SHR se puede establecer con el uso de biomarcadores urinarios como la uNGAL. Los factores de riesgo de IRA en cirrosis incluyen las infecciones bacterianas, la hemorragia digestiva, las pérdidas de líquidos gastrointestinales y renales, la paracentesis sin albúmina y los agentes nefrotóxicos, entre otros. Los nuevos criterios por estadios de la AKI-IAC para el diagnóstico de IRA en cirrosis, que inician por un aumento de la creatinina sérica ≥0,3 mg/dL en menos de 48 horas, mejoran el pronóstico de los pacientes al permitir una intervención más temprana. El diagnóstico del SHR se establece al excluir las causas de azoemia prerrenal, NTA y expandir el volumen con albúmina. El uso de vasoconstrictores esplácnicos, como la terlipresina junto con la albúmina, permite revertir hasta el 40% de los casos de SHR. El trasplante hepático representa el tratamiento definitivo en pacientes con SHR.

Patients with cirrhosis of the liver are susceptible to deterioration of renal function which may be functional or structural. Prerenal acute renal failure which occurs in 68% of these cases is the most common form. It includes a special type of functional renal failure known as hepatorenal syndrome (HRS). Serum creatinine remains the best biomarker for acute renal failure in cirrhosis despite its recognized limitations. Acute tubular necrosis and HRS can be differentiated by using urinary biomarkers such as urinary neutrophil gelatinase-associated lipocalin (uNGAL). Risk factors for acute renal failure in cirrhosis include bacterial infections, gastrointestinal bleeding, loss of gastrointestinal and renal fluids, paracentesis without albumin, and nephrotoxic agents. The new criteria for staging acute kidney injury (AKI) in cirrhosis have improved patient outcomes by enabling earlier interventions by starting when serum creatinine increases above 0.3 mg/dl in less than 48 hours. The diagnosis of HRS is established by excluding causes of pre-renal azotemia, acute tubular necrosis and volume expansion with albumin. The use of splanchnic vasoconstrictors such as terlipressin together with albumin can reverse up to 40% of cases of SHR. Liver transplantation is the definitive treatment for patients with hepatorenal syndrome.

Clinical evaluation of different epinephrine concentrations for local dental anesthesia / Avaliação clínica da epinefrina em diferentes concentrações para anestesia local odontológica

BACKGROUND AND OBJECTIVES: Clinical trials comparing lidocaine associated to different epinephrine concentrations are scarce. This study aimed at comparing cardiovascular parameters, anesthetic efficacy and level of discomfort during the injection of two 2% lidocaine solutions associated to 1:100,000 or 1:200,000 epinephrine. METHODS: Participated in this cross-sectional double blind study 30 patients (24.3±4.7 years) who were submitted to anamnesis, vital signs evaluation and baseline threshold measurement of right upper canine tooth. In each clinical session, with 15 days interval, 1.8mL of one of the anesthetic solutions were administered. Anesthetic efficacy was measured with electric stimulation and vital parameters were evaluated in three periods: 5 minutes before, during and soon after anesthesia. At the end of each session, the visual analog scale was applied to evaluate injection pain sensitivity, which was repeated 24h later. RESULTS: All volunteers had satisfactory pressure levels to carry out the trial. There has been no statistically significant differences in systolic blood pressure (p=0.33), diastolic blood pressure (p=0.1505), heart rate (p=0.9464) and oxygen saturation (p=0.9297) considering each local anesthetic solution in each moment (during and after anesthesia). Formulations of 2% lidocaine with 1:100,000 and 1:200,000 epinephrine have shown no statistical differences for all anesthetic parameters (p>0.05). CONCLUSION: Considering the volume used in this study, decreased epinephrine concentration on lidocaine solution has not affected its clinical efficacy and has not influenced cardiovascular parameters. .

JUSTIFICATIVA E OBJETIVOS: Estudos clínicos comparando o uso da lidocaína associada a diferentes concentrações de epinefrina na odontologia são escassos. O objetivo deste estudo foi comparar parâmetros cardiovasculares, eficácia anestésica e grau de desconforto durante a injeção de 2 soluções de lidocaína a 2% associadas a epinefrina 1:100.000 ou 1:200.000. MÉTODOS: Trinta pacientes (24,3±4,7 anos) foram incluídos (estudo cruzado e duplamente encoberto) e submetidos a anamnese, avaliação de sinais vitais e mensuração do limiar basal do dente canino superior direito. Em cada sessão clínica, com intervalo de 15 dias, foram administrados 1,8mL de uma das soluções anestésicas. A eficácia anestésica foi mensurada com estímulo elétrico, e os parâmetros vitais foram avaliados em 3 períodos: 5 minutos antes, durante e logo após a anestesia. Ao final de cada sessão foi aplicada a escala analógica visual para avaliação da sensibilidade dolorosa da injeção, e repetida após 24h. RESULTADOS: Todos os voluntários apresentaram níveis pressóricos satisfatórios para realização do estudo. Não houve diferenças estatisticamente significativas entre os valores de pressão arterial sistólica (p=0,33), pressão arterial diastólica (p=0,1505), frequência cardíaca (p=0,9464) e saturação de oxigênio (p=0,9297) considerando cada anestésico local em cada momento (durante e após a anestesia). As formulações de lidocaína a 2% com epinefrina a 1:100.000 e 1:200.000 não apresentaram diferença estatística para todos os parâmetros anestésicos (p>0,05). CONCLUSÃO: Considerando o volume utilizado no presente estudo, a redução da concentração da epinefrina na solução de lidocaína não afetou sua eficácia clínica e não influenciou os parâmetros cardiovasculares. .

Avaliação e prevenção da hipertensão arterial por vasos constritores em Implantodontia – estudo clínico prospectivo / Evaluation and preventive measures against arterial hypertension (AHT) provoked by vasoconstrictors in dental implant practice – a clinical prospective study

Objetivo: alertar os profissionais da Implantologia sobre a alta incidência de hipertensão arterial (HTA) nos pacientes da terceira idade que se submeterão ao procedimento cirúrgico, considerando-se também os protocolos de carga imediata. Material e métodos: foram realizados 113 procedimentos com anestesia parenteral com a finalidade de reabilitação oral por meio de protocolos de carga imediata entre os anos de 2010 e 2014. A idade dos pacientes variou entre 65 e 75 anos, salientando que todos eles eram portadores de hipertensão arterial de grau leve, moderado e grave. Destes pacientes, 90 eram hipertensos sintomáticos que usavam medicamentos hipotensores, e 23 eram hipertensos assintomáticos. No caso dos pacientes que optaram pelas cargas imediatas de dupla arcada, por escolha própria, os procedimentos foram efetuados em hospitais, já que poderiam ser realizados em clínicas odontológicas, desde que gozassem de boa saúde. Os pacientes com avaliação física A.S.A. III somente podem passar por procedimentos realizados em hospitais. Todos os procedimentos foram catalogados em fichas de anestesia, que consistem em um documento de responsabilidade do anestesiologista e que contém os dados clínicos do paciente, orientando os procedimentos da futura anestesia. Resultados: nos pacientes de carga imediata, foram identificados 90 portadores de HTA de grau leve, moderado e grave. Ainda, dois casos demonstraram níveis críticos de pressão arterial elevada (180 e 200 mmHg) logo no começo da infiltração, e providências imediatas foram realizadas, como o uso de um hipotensor de ação rápida via sublingual de Adalat de 10 mg. Conclusão: é importante aferir a pressão arterial, em curtos intervalos de tempo, em procedimentos odontológicos nos pacientes da terceira idade, com história pregressa de HTA. A prevenção da HTA na fase pré-cirúrgica consiste em diminuir a ansiedade com o uso de medicamento com finalidade ansiolítica...

Objective: to alert implant dental practitioners on the high incidence of arterial hypertension (AHT) on third age patients undergoing surgical procedures, also considering the immediate loading protocols. Material and methods: between the years of 2010 to 2014, 113 procedures were performed with parenteral anesthesia for oral rehabilitation treatment. The patient´s age ranged from 65 to 75 years, all demonstrating mild, moderate, and severe AHT. From these, 90 were hypertensive under appropriate medication, while 23 were asymptomatic. For patients preferring immediate loading in both jaws, all procedures were performed in a hospital setting. Patients under A.S.A. III category cannot be operated at dental clinics. All procedures were recording in appropriate anesthesiology files with all clinical data for further anesthetic administration. Results: 90 patients were considered with mild, moderate, and severe AHT levels. Also, two cases demonstrated critical levels of arterial pressure (180 and 200 mmHg) at the beginning of infi ltration, and immediate maneuvers were provided with a fast hypotensive sublingual agent (Adalat 10 mg). Conclusion: it is important to check arterial pressure at short periods of time during dental procedures for third age patients with a reported history of AHT. Prevention of ATH at the pre-surgical moment can reduce the anxiety by use of appropriate medication. ATH levels can be diminished with an hypotensive agent and a boosting dose also reducing epinephrine doses relative to ATH classification.

Síndrome hepatorrenal: diagnóstico y tratamiento / Hepatorenal syndrome: diagnosis and treatment

El síndrome hepatorrenal es potencialmente reversible, se presenta en pacientes con cirrosis, ascitis, insuficiencia hepática aguda o hepatitis alcohólica y se caracteriza por deterioro de la función renal, alteraciones de la función cardiovascular e hiperactividad de sistemas como el nervioso simpático y el renina-angiotensina. Han sido innumerables las investigaciones realizadas sobre la coexistencia de la disfunción hepática y renal y su impacto en la morbilidad y mortalidad en las unidades de atención al paciente en estado crítico. El objetivo del presente artículo es proporcionar una revisión bibliográfica actualizada acerca del tema y facilitar la actuación médica ante los afectados con el mencionado síndrome.

The hepatorenal syndrome is potentially reversible, it is presented in patients with cirrhosis, ascites, acute hepatic failure or alcoholic hepatitis and it is characterized by deterioration of the renal function, changes of the cardiovascular function and hyperactivity of systems as the sympathetic nervous one and the renin-angiotensin system. The investigations carried out on the coexistence of the hepatic and renal disorders and their impact in the mobility and mortality in the institutions for critically ill patient have been countless. The objective of the present work is to provide an updated literature review about the topic and to facilitate the medical performance in those cases with the mentioned syndrome.

Antidepressivos e anestésicos locais: interaçõesmedicamentosas de interesse odontológico / Antidepressants and local anesthetics: druginteractions of interest to dentistry

Introdução: Em virtude da ampla variedade de tratamentosfarmacológicos de transtornos mentais, é cada vez mais comumpacientes que procuram tratamento odontológico fazerem uso contínuode psicofármacos. O número de pessoas que utilizam antidepressivostem crescido, e isso exige dos cirurgiões-dentistas atualização a respeitoda interação entre essa classe de medicamentos e os fármacos usadosna clínica odontológica, como anestésicos locais e vasoconstritores.Objetivo: Efetuar uma revisão de literatura sobre o tema. Revisãode literatura e conclusão: Os dados sugerem que vasoconstritoressimpatomiméticos (adrenalina, noradrenalina e fenilefrina) associadosa anestésicos locais podem potencializar os efeitos colaterais dosantidepressivos, principalmente tricíclicos e inibidores da MAO, sobreo sistema cardiovascular. Porém poucos são os estudos clínicos epré-clínicos sobre o assunto; na sua maioria foram realizados entre as décadas de 1960 e 1980. Pesquisas atuais são necessárias, já quemuitas drogas antidepressivas novas, com diferentes mecanismos deação, foram lançadas no mercado e estão sendo usadas atualmente.

Introduction: Since there is a vast variety of pharmacologicaltreatments for mental conditions, it has been increasingly morecommon that patients seeking dentistry treatment are continuallyusing psychoactive drugs as antidepressants. The number of peopletaking antidepressants is increasing; consequently, dentists shouldupdate their knowledge on the interaction between this drug classand those used in dental daily practice, such as local anesthetics andvasoconstrictors. Objective: To conduct a literature review on thissubject. Literature review and conclusion: Literature data suggestthat sympathomimetic vasoconstrictors (epinephrine, norepinephrine,and phenylephrine) associated with local anesthetics may potentiatethe side effects of antidepressants, particularly tricyclics and MAOinhibitors, on the cardiovascular system. There are few clinical trialsand preclinical studies on this subject, and most of them were carriedout between the 60s and 80s. Current studies are needed, since manynew antidepressant drugs with different

Síndrome hepatorenal: patogénesis y tratamiento / Hepatorenal syndrome: pathogenesis and treatment

El Síndrome Hepatorenal (SHR) es una insuficiencia renal aguda funcional y reversible, que se desarrolla en pacientes con cirrosis hepática descompensada o en insuficiencia hepática aguda severa. La característica principal del SHR es la intensa vasoconstricción renal causada por la interacción entre alteraciones hemodinámicas a nivel sistémico y portal. El aumento del volumen intravascular y un prolongado tratamiento con fármacos vasoconstrictores pueden revertir la falla renal en un porcentaje significativo de pacientes. El SHR Tipo 2, el más frecuente, generalmente presenta una evolución lenta y un mejor pronóstico que el SHR Tipo 1. La terapia vasoconstrictora con terlipresina asociado a albúmina es el tratamiento de elección en pacientes con SHR. Apesar del avance en las diferentes estrategias terapéuticas, el pronóstico a largo plazo es aún pobre y depende generalmente del grado de reversibilidad de la enfermedad hepática asociada o del acceso al trasplante hepático. En la presente revisión se discutirán los avances más recientes en el diagnóstico, patogénesis y tratamiento del SHR.

The Hepatorenal Syndrome (HRS) is a functional and reversible form of acute renal failure, which develops in decompensated cirrhosis or acute liver failure. The distinctive hallmark feature of HRS is the intense renal vasoconstriction caused by interactions between systemic and portal hemodynamics. Increasing intravascular volume and prolonged treatment with vasoconstrictors drugs reverses renal failure in a significant proportion of patients. Type 2 HRS, the most frequent, generally follows a slower course and has a better prognosis than Type 1 HRS. Vasopressor therapy with terlipressin plus intravenous albumin is the medical treatment of choice for patients with HRS. Despite improvements in the therapeutic strategies, long term prognosis is still poor and generally depends on the degree of reversibility of the underlying liver disease or access to liver transplantation. In the present review, the most recent advances in diagnosis, pathophysiology, and treatment of HRS are discussed.

Pacientes hipertensos e a anestesia na Odontologia: devemos utilizar anestésicos locais associados ou não com vasoconstritores? / Hypertensive patients and anesthesia in Dentistry: we should use local anesthetics associates or not with vasoconstrictors agents?

Anestésicos locais associados a alguns vasoconstritores podem ser utilizados em pacientes hipertensos na odontologia. A felipressina ou a epinefrina são os mais indicados no atendimento a pacientes com hipertensão controlada no estágio I ou II. Quando utilizada em doses terapêuticas e, evitando-se a administração intravascular, as alterações pressóricas que podem ocorrer com os vasoconstritores adrenérgicos como a elevação na pressão sistólica, são compensadas por uma diminuição na resistência vascular periférica e, consequentemente,uma diminuição da pressão diastólica. Portanto, a preocupação deve ser com o aumento na concentração sanguínea de catecolaminas, em função de uma sobredosagem e/ou administração intravascular inadvertida,principalmente, se associados a um elevado grau de estresse e de ansiedade. A potencialização dos seus efeitos sistêmicos pode ainda estar relacionada a interações medicamentosas em pacientes que fazem uso de antihipertensivos do tipo beta-bloqueadores não-seletivos ou diuréticos não caliuréticos, que poderiam estar mais susceptíveis a possíveis precipitações de episódios hipertensivos motivados por estes vasoconstritores. Uma anamnese bem detalhada, uma anestesia mais eficaz com a associação de um vasoconstritor, bem como o controle da ansiedade e do medo frente a um tratamento odontológico são benéficos no atendimento aos hipertensos.

Local anesthetics associates with vasoconstrictors agents should be used in the hypertensive patients in Dentistry. Felypressin or epinephrine are the most indicated for the treatment of patients with controlledhypertension in stages I or II. When adrenergic vasoconstrictors agents are used in therapeutic doses and avoiding intravascular injection, the pressure alterations that may occur, such as an increase systolic pressure, are compensated by a reduction in peripheral vascular resistance and consequently, a reduced diastolic pressure. Therefore, attention must be paid to the decrease in blood catecholamine as a result of an overdose and/or unintentional intravascular injection, especially if associated with a high degree of stress and anxiety. The strengthening of its systemic effects may still be related to medical interactions in patients using non-specific beta-blocking anti-hypertension drugs or non-caliuretics diuretics, who might be more susceptible to possible occurrences of hypertension episodes motivated by vasoconstrictors agents. A detailed examination, a more effective anesthesia associated with vasoconstrictor, as well as anxiety and fear control when facing dental treatment are beneficial when treating hypertensive patients.

Efeito de anestésicos locais com e sem vasoconstritor em pacientes com arritmias ventriculares / Effect of local anesthetics with and without vasoconstrictor agent in patients with ventricular arrhythmias

FUNDAMENTO: A utilização de anestésicos locais associados a vasoconstritores para tratamento odontológico de rotina de pacientes cardiopatas ainda gera controvérsia, em razão do risco de efeitos cardiovasculares adversos. OBJETIVO: Avaliar e comparar os efeitos hemodinâmicos do uso de anestésico local com vasoconstritor não-adrenérgico em pacientes portadores de arritmias ventriculares, em relação ao uso de anestésico sem vasoconstritor. MÉTODOS: Um estudo prospectivo randomizado avaliou 33 pacientes com sorologia positiva para doença de Chagas' e 32 pacientes com doença arterial coronariana, portadores de arritmia ventricular complexa ao Holter (>10 EV/h e TVNS), 21 do sexo feminino, idade de 54,73 + 7,94 anos, submetidos a tratamento odontológico de rotina com anestesia pterigomandibular. Esses pacientes foram divididos em dois grupos: no grupo I, utilizou-se prilocaína a 3 por cento associada a felipressina 0,03 UI/ml, e no grupo II, lidocaína a 2 por cento sem vasoconstritor. Avaliaram-se o número e a complexidade de extra-sístoles, a freqüência cardíaca e a pressão arterial sistêmica dos pacientes no dia anterior, uma hora antes, durante o procedimento odontológico e uma hora após. RESULTADOS: Não foram observadas alterações hemodinâmicas, nem aumento do número e da complexidade da arritmia ventricular, relacionados ao anestésico utilizado, em ambos os grupos. CONCLUSÃO: Os resultados sugerem que prilocaína a 3 por cento associada a felipressina 0,03 UI/ml pode ser utilizada com segurança em pacientes chagásicos e coronarianos, com arritmia ventricular complexa.

BACKGROUND: The routine use of local anesthetics associated to vasoconstrictors for the dental treatment of patients with cardiopathies is still controversial, due to the risk of adverse cardiovascular effects. OBJECTIVE: To evaluate and compare the hemodynamic effects of the use of local anesthetics with a non-adrenergic vasoconstrictor in patients with ventricular arrhythmia, when compared to the use of anesthetics without vasoconstrictor. METHODS: A prospective randomized study evaluated 33 patients with positive serology for Chagas' disease and 32 patients with coronary artery disease that presented complex ventricular arrhythmia at Holter monitoring (>10 EV/h and NSVT), of which 21 were females, aged 54.73 + 7.94 years, submitted to routine dental treatment with pterygomandibular anesthesia. These patients were divided in two groups: group I received prilocaine 3 percent associated with felypressin 0.03 IU/ml and group II received lidocaine 2 percent without vasoconstrictor. The number and complexity of extrasystoles were analyzed, as well as the heart rate and systemic arterial pressure of the patients on the day before, one hour before, during the procedure and one hour after the dental procedure. RESULTS: No hemodynamic alterations or increase in the number and complexity of the ventricular arrhythmia related to the anesthetic used in the dental procedure were observed in either group. CONCLUSION: The results suggest that prilocaine 3 percent associated to a felypressin 0.03 IU/ml can be safely used in patients with Chagas' disease or coronariopathy with complex ventricular arrhythmia.

Como escolher um adequado anestésico local para as diferentes situações na clínica odontológica diária? / How to choose the adequate local anesthetics for different situations on everyday dentistry?

A anestesia local corresponde ao bloqueio reversível da condução nervosa e determina perda das sensações sem alteração do nível de consciência. A maioria dos profissionais de Odontologia elege somente uma solução anestésica local para todos os procedimentos que executa. A padronização de uma solução para uso geral nem sempre satisfaz às necessidades clínicas e ao bem-estar dos pacientes. Em razão disso, visando auxiliar o odontologista na escolha da solução anestésica ­ com base na revisão de literatura ­, foi proposta deste trabalho apresentar os anestésicos locais injetáveis adequados para os diferentes procedimentos operatórios e de acordo com as diversas condições sistêmicas dos pacientes. Sugere-se que o profissional tenha no consultório mais de um tipo de solução anestésica local com vasoconstritor e uma solução sem essa substância

The local anesthesia is the reversible blockade of the nervous impulse that induces the sensations' loss without changing the conscience level. Most of dentists choose only one local anesthetics for all clinic procedures. The standardization of the same solution anesthetics for all procedures does not always satisfy the clinical needs and the patients' well being. Because of this, based on the literature review, the aim of this study was to present the adequate local anesthetics for different clinical procedures and the several patients' systemic situations. Our suggestion for the dentist is to keep in his office more than one local anesthetics with vasoconstrictors and at least one solution without vasoconstrictors

Influence of Vasoactive Substances on the Regulation of Cardiac ATP-Sensitive Potassium Channel Activity

BACKGROUND AND OBJECTIVES: It has been known that various vasoactive agents are involved in the regulation of cardiac function through the modification of the K+ channel activities, including the ATP-sensitive K+ channel (KATP). We examined the effects of several vasoactive agents on the cardiac KATP currents in isolated cardiac myocytes. MATERIALS AND METHODS: Ventricular myocytes were isolated from the hearts of ICR mice by enzymatic digestion. The channel currents were recorded by the excised inside-out and cell-attached patch clamp configurations. RESULTS: In the excised inside-out patches, bradykinin (BRK; 1-10 micrometer) and prostaglandin I2 (PGI; 10-50 micrometer) did not affect the channel activities, whereas the vasodilators increased the attenuated channel activities in the presence of 100 micrometer ATP. BRK and PGI in parallel shifted the dose-response curves of ATP (1-1,000 micrometer), and this inhibited the KATP currents to the right. Endothelin (ET-1; 0.1-1 nM) and leukotriene D4 (LTD; 3-10 micrometer) decreased the channel activities immediately after making the inside-out patches. However, the vasoconstrictors did not affect the attenuated channel activities by ATP. In the cell-attached patches, both BRK and PGI increased the channel activities and these effects were markedly attenuated by glibenclamide (50 micrometer). ET-1 and LTD did not affect the baseline channel activities in the cell-attached patches, but they markedly attenuated the dinitrophenol-induced activities. CONCLUSION: It was inferred that certain vasoactive substances are involved in the regulation of cardiac KATP channel activities, and that bradykinin and PGI2 enhance the channel activities, and ET-1 and LTD4 inhibit the channel activities.

Comparison of Two Titration Methods of Vasopressor Infusion to Correct Septic Shock

BACKGROUND: Administration of a vasopressor is frequently required in treating septic shock. The conventional method of vasopressor infusion, which includes incremental titration of a vasopressor to raise blood pressure, is sometimes a time-consuming process that might prolong the duration of the shock. PURPOSE: This study was to evaluate whether a method of vasopressor infusion that starts from an acceptable maximal dose has advantages over a method of vasopressor infusion that starts from a low dose in patients with septic shock. SUBJECTS AND METHODS: Twenty-five patients with septic shock, which was not corrected with fluid resuscitation of 20~30 ml/kg, were randomized into two groups. The patients in the low-to-high group (n=13) received a vasopressor in an incremental manner starting from a low dose. The patients in the high-to-low group (n=12) received a vasopressor in a decremental manner starting from an acceptable maximal dose. The shock durations (time from the beginning of vasopressor infusion to correction of the shock), and the hemodynamic and metabolic parameters, including blood pressure, pulse rate, arterial lactate concentration, anion gap, base excess, and central venous oxygen saturation, before vasopressor infusion, and 2, 4, 6, 12, and 24 hours after vasopressor infusion were compared for the two groups. The length of ICU stay, the length of total hospital stay, the type of discharge, and the survival rate were also compared. RESULTS: The shock duration was shorter in the high-to-low group than in the low-to-high group (14.7+/-21 min. vs 41.9 +/-41 min., p=0.01). There were no differences between the two groups as to hemodynamic and metabolic parameters. The ICU stay was shorter in the high-to-low group than in the low-to-high group (7+/-7 days vs 10+/-22 days); however, the difference did not reach statistical significance (p=0.934). CONCLUSION: The method of vasopressor infusion starting from acceptable maximal dose shortens the duration of shock compared to the conventional incremental titration method.

Effects of Flunarizine on Contractile Responses of Porcine Brain Arteries to Various Peripheral Vasoactive Agents

Effects of various peripheral vasoconstrictors on isolated porcine basilar and posterior communicating arteries(BA and PCA) were investingated and effected of flunarizine on the contractile responses were compared with those of a vasodilator, nitroglycerin. KCl elicited dose-dependent contractions in BA and PCA. 50mM KCl-induced contraction was not affected by nitroglycerin but dose-dependently inhibited by nimodipin and flunarizine in both rings. Epinephrine produced contractile response of BA and PCA in a dose-dependent fashion, but norepinephrine or phenylephrine did not cause obvious contraction by itself. Norepinephrine and phenylephrine elicited dose-dependent contractions in both rings treated with 10 -6M propranolol and the epinephrine-induced contractions were potentiated by pretreatment with propranolol, 5-hydroxytryptamine and histamine contracted BA and PCA in a dose-dependent manner and the contraction of PCA was more prominent than that of BA. In PCA rings, 10(-6)M 5-hydroxytryptamine and 10 -6M orepinephrine-induced contractions were not changed by nitroglycerin but inhibited by flunarizine in a dose-dependent manner. Small doses of flunarizine inhibited gradually both drug-induced contractions and large doses(3.5 x 10(-6) and 10(-6)M) steeply inhibit ed the contractions. Then the slopes of inhibitory curves in both cases were biphasic. Above results suggest that responsibility of catecholamine in porcine brain artery is more prominent in alpha-adrenoceptors than in beta-adrenoceptors, and inhibitory effect of flunarizine on brain artery results from inhibition of calcium influx through stimulated receptor-operated calcium channel(ROC) and potential-operated calcium channel(POC) .