Cardiopulmonary effects of prolonged surgical abdominal retractors application during general anesthesia: a prospective observational comparative study

Abstract Introduction: Increasing abdominal pressures could affect pulmonary compliance and cardiac performance, a fact based on which the aim of the present study to detect the cardiopulmonary burden of multiple retractors application during supine versus lateral abdominal surgeries. We hypothesized that surgical ring multiple retractors application would affect the pulmonary and cardiac functions during both lateral and supine abdominal surgeries. Methods: Prospective observational comparative study on forty surgical patients subdivided into two groups twenty each, comparing pulmonary compliance and cardiac performance before, during and after retractors application, group (S) supine position cystectomy surgery, and group (L) lateral position nephrectomy surgery under general anesthesia, Composite 1ry outcome; dynamic compliance C-dyn and cardiac index CI and Other outcome variables ICON cardio-meter were also recorded. Results: C-dyn and C-stat were significantly decreased late during retractor application in lateral compared to supine surgery with significant decrease compared to basal values all over the surgical time. CI was significantly increased after retractor removal in both of the study groups compared to basal values. PAW P was significantly increased in -lateral compared to supine surgery -with significant increase compared to basal value all over the surgical time in both of the study groups. significant increase in DO2I compared to basal value during both supine and lateral positions. Conclusion: Surgical retraction results in a short-lived significant decreases in lung compliance and cardiac output particularly during the lateral-kidney position than the supine position compliance.

Manejo anestésico de una gestante con síndrome de Morquio / Anesthetic Management for a pregnant woman with Morquio syndrome Sobre los autores:

Introducción: El síndrome de Morquio es una enfermedad hereditaria autosómica recesiva con distintos grados de afectación al metabolismo de los glúcidos, lo que genera incapacidad para romper los enlaces de las cadenas largas de glucosamiglicanos, esto provoca acumulación de mucopolisacáridos en distintos tejidos del cuerpo humano. Objetivo: Describir el manejo anestésico de una gestante con síndrome de Morquio. Presentación del caso: Gestante primigesta de 30 años de edad, de raza negra, de 103 cm de estatura y 33 Kg de peso. Acude a consulta preoperatoria por presentar embarazo a término, baja talla y se realizó interrupción del embarazo por vía alta. Se procede a la valoración preanestésica donde se recoge antecedentes de enfermedad genética e ingreso previo por presentar cifras elevadas de tensión arterial. La paciente padecía de alergia a la dipirona. Conclusiones: Los pacientes con mucopolisacaridosis tienen una alta incidencia de dificultad para la ventilación y la intubación endotraqueal asociada con insuficiencia cardiopulmonar. La afectación de la columna presenta dificultades adicionales para los anestesiólogos. Cualquier cirugía electiva requiere una evaluación preoperatoria de los factores de riesgo anestesiológicos y la disponibilidad de un espectro de equipos para el manejo de las vías respiratorias. La anestesia debe ser realizada por un equipo con experiencia en el manejo de la vía aérea(AU)

Introduction: Morquio syndrome is an autosomal recessive hereditary disease that affects, to different extents, carbohydrate metabolism, which obstructs the ability to break bonds of long chains of glycosaminoglycans, causing mucopolysaccharides accumulation in different tissues of the human body. Objective: To describe the anesthetic management of a pregnant woman with Morquio syndrome. Case presentation: This is the case of a 30-year-old primigravid pregnant woman, of black skin, 103 cm of height and 33 kg of weight. She came for preoperative consultation because she was pregnant at term and had low body size; the pregnancy was terminated through the abdominal route. A preanesthetic assessment was performed, which permitted to observe a history of genetic disease and previous admission for high blood pressure. The patient was allergic to dipyrone. Conclusions: Among patients with mucopolysaccharidosis, there is a high incidence of difficulty for ventilation and endotracheal intubation associated with cardiopulmonary insufficiency. Spinal involvement represents additional difficulties for anesthesiologists. Any elective surgery requires preoperative assessment of anesthesiologic risk factors and the availability of a spectrum of airway management equipment. Anesthetic managment should be performed by a team experienced in airway management(AU)

Anestesia general durante la atención odontológica a niños y personas con discapacidad / General anesthesia for the dental care of children and people with disabilities

Introducción: La anestesia general es considerada como una herramienta farmacológica que forma parte de las técnicas avanzadas en odontología para el manejo de la conducta de pacientes poco colaboradores o con alguna discapacidad física y/o mental, sirviendo como mecanismo de soporte en la ejecución de tratamientos odontológicos. Objetivo: Evaluar el uso de la anestesia general durante la atención odontológica a niños y personas con discapacidad. Métodos: Revisión sistemática de la literatura en la que se analizaron 17 estudios publicados entre el 2009 y el 2019, seleccionados de seis bases de datos (MedLine-PubMed, LILACS, SciELO, Clinical Key, IBECS y Cuiden). Para el estudio se tuvieron en cuenta las recomendaciones del Preferred Reporting Items for Systematic Reviews and Meta-Analyes (PRISMA) y se mantuvo el rigor ético y metodológico correspondiente. Resultados: Los resultados de la búsqueda permitieron caracterizar los estudios por año, país y abordaje metodológico. La evidencia muestra que el uso de la anestesia general como técnica odontológica es útil y eficaz para el manejo de conducta en pacientes pediátricos y discapacitados. Conclusiones: La anestesia general es una excelente alternativa como técnica odontológica para la resolución de problemas bucodentales en niños y personas con discapacidades físicas y/o mentales y en el mejoramiento de su calidad de vida(AU)

Introduction: General anesthesia is considered to be a pharmacological tool included among the advanced dental techniques used to manage uncooperative and physically and/or mentally disabled patients, as well as a support mechanism in the performance of dental treatments. Objective: Evaluate the use of general anesthesia for the dental care of children and people with disabilities. Methods: A systematic bibliographic review was conducted of 17 studies published from 2009 to 2019 in six databases: MedLine-PubMed, LILACS, SciELO, Clinical Key, IBECS and Cuiden. The study followed the recommendations contained in Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and maintained the corresponding ethical and methodological rigor. Results: Search results made it possible to characterize the studies by year, country and methodological approach. The evidence obtained shows that general anesthesia is useful and effective as a technique to control the behavior of children and people with disabilities during dental care. Conclusions: General anesthesia is an excellent alternative as a technique to solve the oral problems of children and people with physical and/or mental disabilities, thus improving their quality of life(AU)

Acupuntura en la recuperación de la anestesia general en pacientes intervenidas quirúrgicamente de nódulo de mama / Acupuncture in the recovery from general anesthesia in patients who underwent a breast nodule surgery

RESUMEN Introducción: en el período de recuperación de la anestesia general se deben metabolizar los medicamentos empleados y restablecer las alteraciones fisiológicas. La acupuntura es un método de tratamiento que ha sido estudiado en el período perioperatorio con diferentes fines; sin embargo, es menos conocido su efecto en la recuperación de la anestesia general. Objetivo: describir el efecto de la estimulación con Acupuntura en la recuperación de la anestesia general balanceada en pacientes intervenidas quirúrgicamente por nódulo de mama. Materiales y métodos: se realizó un estudio observacional prospectivo, en 60 pacientes intervenidas quirúrgicamente de nódulo de mama con anestesia general endotraqueal balanceada, de enero de 2014 a enero de 2016, en el Hospital Provincial Docente José Ramón López Tabrane, de Matanzas. Se conformaron dos grupos: grupo I, al que al finalizar la cirugía se le colocaron agujas de acupuntura en los puntos R1, Du26 y P9; y grupo II, al que no se le realizó acupuntura. El efecto de la acupuntura en la recuperación anestésica se midió a través de la Escala de Aldrete. Resultados: la edad de mayor incidencia fue de 40 a 49 años. El estado físico de las pacientes, según la Sociedad Americana de Anestesiología, es I. Prevaleció un tiempo anestésico de 61 a 90 minutos. Más del 75 % de las féminas tuvieron un tiempo de recuperación anestésica entre 31 y 60 minutos. Se presentaron dos complicaciones leves atribuibles a la acupuntura. Conclusiones: la aplicación de la acupuntura acortó el tiempo de recuperación anestésica en las pacientes estudiadas (AU).

ABSTRACT Introduction: in the recovery period from general anesthesia the used drugs should be metabolized and the physiological alterations restored. Acupuncture is a treatment method that has been studied in the perioperative period with different aims; nevertheless its effect on the recovery from general anesthesia is less well known. Objective: to describe the acupuncture stimulation effect on the recovery from general balanced anesthesia in patients who underwent a breast nodule surgery. Materials and methods: a prospective, observational study was performed in 60 patients who underwent a surgery of breast nodule with balanced endotracheal general anesthesia, from January 2014 to January 2016, at the Provincial Teaching Hospital "Jose Ramon Lopez Tabrane" of Matanzas. Two groups were formed: group I included patients to whom acupuncture needles were placed in R1, Du 26 and P9 acupoints after surgery, and Group II patients to whom acupuncture was not performed. The acupuncture effect on anesthetic recovery was assessed using the Aldrete Scale. Two groups were formed: group I, whose members at the end of the surgery were placed acupuncture needles to in the points R1, Du26 and P9; and group II, whose members did not receive acupuncture. The effect of acupuncture on anesthetic recovery was measured through the Aldrete Scale. Results: the highest incidence age was 40 to 49 years. The physical condition of the patients, according to the American Society of Anesthesiology, was I. An anesthetic time of 61 to 90 minutes prevailed. More than 75% of the women had an anesthetic recovery time between 31 and 60 minutes. There were two minor complications attributable to acupuncture. Conclusions: acupuncture application shortened the anesthetic recovery time in the studied patients (AU).

Conducción anestésica perioperatoria en gestante a término con hipertensión pulmonar idiopática / Perioperative anesthetic management in term pregnant women with idiopathic pulmonary hypertension

Introducción: La hipertensión arterial pulmonar es una enfermedad con una baja incidencia en la gestante, aunque trae consigo una alta mortalidad una vez presentada. Un diagnóstico oportuno y un manejo perioperatorio adecuado minimizan el riesgo de desenlace fatal tanto para la madre como el feto. Objetivo: Describir el comportamiento de la hipertensión arterial pulmonar en la gestante a término y su conducción anestésica. Presentación del caso: Paciente de 23 años, antecedentes de salud, edad gestacional de 35.2 semanas. Luego de presentar dolor de espalda y ardor en el pecho relacionado con el esfuerzo, palpitaciones, disnea y bloqueo de rama derecha en electrocardiograma, se ingresa en UTI con sospecha de tromboembolismo pulmonar, el cual queda descartado tras diagnóstico confirmatorio de hipertensión pulmonar después de realizar angio TAC y ecocardiografía. Se decide realizar cesárea programada bajo técnica regional peridural, sin complicaciones tanto para la madre como el niño. Después de 2 días bajo vigilancia intensiva se traslada a su centro hospitalario de cabecera. Conclusiones: La vía del parto, así como una elección adecuada de la técnica anestésica, puede ser la diferencia entre el éxito y la fatalidad. Las técnicas regionales suelen recomendarse por encima de la técnica de anestesia general siempre que no se presenten contraindicaciones(AU)

Introduction: Pulmonary arterial hypertension is a disease with low incidence in the pregnant woman, although it brings about high mortality once presented. Timely diagnosis and adequate perioeprative management minimize the risk of fatal outcome for both mother and fetus. Objective: To describe pulmonary arterial hypertension and its anesthetic management in the term pregnant woman. Case presentation: 23-year-old female patient, with health history and gestational age of 35.2 weeks. After presenting back pain and chest burning associated with exertion, palpitations, dyspnea and right bundle branch block in the electrocardiogram, the patient was admitted to the intensive care unit with suspected pulmonary thromboembolism, which was ruled out due to the confirmatory diagnosis of pulmonary hypertension after performing computerized tomography angiography and echocardiography. Scheduled cesarean section was decided to be perform using the regional peridural technique, without complications for both the mother and the child. After two days under intensive surveillance, she was transferred to her primary hospital. Conclusions: The route of delivery, as well as an adequate choice of the anesthetic technique, can be the difference between success and fatality. Regional techniques are usually recommended over the general anesthesia technique, as long as there are no contraindications(AU)

Avaliação do Escore de Wilson e do Teste de Mallampati modificado como preditores de difícil intubação orotraqueal: Estudo transversal / Evaluation of the Wilson risk-sum and the modified Mallampati Test as predictors of difficult orotracheal intubation: Cross-sectional study

INTRODUÇÃO: A consulta pré-anestésica é de extrema importância para o médico anestesiologista no planejamento do manejo das vias aéreas de pacientes sob o efeito de anestesia geral com intubação orotraqueal (IOT). OBJETIVO: Avaliar a sensibilidade, especificidade, valor preditivo positivo/negativo (VPP/VPN) de testes de predição de IOT difícil (Escore de Wilson - EW, e Teste de Mallampati modificado - TMM), em pacientes submetidos à anestesia geral, em hospital filantrópico do interior de Minas Gerais. MATERIAIS E MÉTODOS: Estudo descritivo transversal, por meio de fichas pré-anestésicas e transoperatórias, de pacientes submetidos à anestesia geral com IOT, entre os meses de janeiro (2019) e março (2020). RESULTADOS: Dos 440 pacientes, 56,1% necessitaram de IOT: média de idade de 49,9 anos (desvio padrão 18,6). A maioria foi classificada: TMM classe I e II; pontuação 0 a 2 no EW; distância esternomentoniana >12,5 cm, sugerindo IOT fácil. Apenas o TMM apresentou correlação com IOT difícil (p=0,045). Sensibilidade e especificidade dos testes respectivamente: TMM (54,6%;75,9%); EW (36,4% e 79,7%); baixo VPP (TMM: 9,5%; EW: 7,7%) e alto VPN (TMM: 97,3%; EW: 96,4%). Curva ROC: área sob a curva foi de TMM = 0,68; EW = 0,60. CONCLUSÃO: Apesar do TMM apresentar correlação significativa com a IOT difícil, não foi possível definir o melhor teste preditor. Ressaltamos que a sensibilidade e o VPP, de ambas as avaliações, ficaram abaixo daquilo que seria considerado adequado para um teste de rastreio e predição.

Introduction: A pre-anesthetic appointment is extremely important for the anesthesiologist when planning the management of the airways of patients under the effect of general anesthesia with orotracheal intubation (OTI). Objective: To evaluate the sensitivity, specificity, positive/ negative predictive value (PPV/NPV) of difficult OTI prediction tests (Wilson risk-sum ­ WRS, and Modified Mallampati Test - MMT) in patients undergoing general anesthesia in a philanthropic hospital in the countryside of the state of Minas Gerais. Materials and methods: Descriptive cross-sectional study using pre-anesthetic and transoperative records of patients submitted to general anesthesia with OTI between the months of January (2019) and March (2020). Results: Of the 440 patients, 56.1% required OTI: average age of 49.9 years (standard deviation 18.6). Most classified: MMT class I and II; score 0 to 2 on the WRS; sternomental distance greater than 12.5 cm, suggesting easy OTI. Only MMT showed statistical significance with difficult OTI (p=0.045). Sensitivity and specificity of the tests respectively: MMT (54.6%; 75.9%) WRS (36.4% and 79.7%) low PPV (MMT: 9.5%; WRS: 7.7%) and high NPV (MMT: 97.3%; WRS: 96.4%). ROC Curve: area under the curve was MMT = 0,68; WRS = 0,60. Conclusion: Although the MMT has a significant correlation with the difficult OTI, it was not possible to define the best predictor test. We emphasize that the sensitivity and PPV of both evaluations were below what would be considered adequate for a screening and prediction test.

Bloqueo caudal más anestesia general balanceada en un paciente con pentalogía de Cantrell, presentación de un caso clínico / Caudal block plus inhaled general anesthesia in a patient with pentalogy of Cantrell, presentation of a clinical case

The pentalogy of Cantrell is a disorder characterized by congenital abnormalities in the abdominal wall, lower sternum, anterior diaphragm, diaphragmatic pericardium, and cardiac anomalies. It is a rare disease with 250 cases registered around the world. The anesthetic implications will require a specialized management given the ventilatory mechanics and cardiac function which are compromised by the disease in the newborn. We present the case of a female patient with pentalogy of Cantrell without prenatal diagnosis, who had an operative procedure to correct patent ductus arteriosus and abdominal mesh placement under balanced general anesthesia with sevoflurane and fentanyl plus caudal block. This case is reported to provide our experience in the anesthetic management of this type of patients.

La pentalogía de Cantrell es una enfermedad caracterizada por anormalidades congénitas de la pared abdominal supraumbilical, esternón inferior, diafragma, pericardio diafragmático y anomalías cardiacas. Se trata de una enfermedad rara con 250 casos registrados alrededor del mundo. Las implicaciones anestésicas requieren de un manejo especializado debido a la mecánica ventilatoria y función cardíaca que se encuentran comprometidas en el recién nacido. Se presenta el caso de una recién nacida portadora de pentalogía de Cantrell, no diagnosticada prenatalmente, quien fue sometida a corrección de ductus arterioso persistente y colocación de malla abdominal bajo anestesia general balanceada con sevofluorano y fentanilo más bloqueo caudal. Se reporta el presente caso para brindar nuestra experiencia en el manejo anestésico de este tipo de pacientes.

Opioid-free general anesthesia and induced recovery from anesthesia in a patient with myotonic dystrophy type-1: a case report / Anestesia geral sem opioide e recuperação induzida da anestesia em paciente com distrofia miotônica tipo-1: relato de caso

Abstract Myotonic dystrophy type-1 (Steinert disease) is an autosomal dominant, progressive multisystem disease in which myotonic crisis can be triggered by several factors including pain, emotional stress, hypothermia, shivering, and mechanical or electrical stimulation. In this report, dexmedetomidine-based general anesthesia, in combination with a thoracic epidural for laparoscopic cholecystectomy in a patient with Steinert disease, is presented. An Aintree intubation catheter with the guidance of a fiberoptic bronchoscope was used for intubation to avoid laryngoscopy. Prolonged anesthetic effects of propofol were reversed, and recovery from anesthesia was accelerated using an intravenous infusion of theophylline.

Resumo A Distrofia Miotônica (DM) tipo-1 (Doença de Steinert) é uma doença multissistêmica progressiva autossômica dominante em que a crise miotônica pode ser desencadeada por vários fatores, incluindo dor, estresse emocional, hipotermia, tremores e estímulo mecânico ou elétrico. O presente relato descreve anestesia geral realizada com dexmedetomidina em combinação com peridural torácica para colecistectomia laparoscópica em paciente com Doença de Steinert. Para evitar laringoscopia, a intubação traqueal foi realizada utilizando cateter de intubação Aintree guiado por broncofibroscopia óptica. Os efeitos anestésicos prolongados do propofol foram revertidos e a recuperação anestésica foi acelerada pelo uso de infusão intravenosa de teofilina.

Neurokinin-1 receptor antagonists for postoperative nausea and vomiting: a systematic review and meta-analysis / Antagonistas do receptor da neurocinina-1 no tratamento de náusea e vômito no pós-operatório: Revisão sistemática e meta-análise

Abstract Background: Postoperative Nausea and Vomiting (PONV) is a common complication of general anesthesia. Several kinds of antiemetics, including 5-Hydroxytryptamine3 (5-HT3) receptor antagonists, and Neurokinin-1 (NK-1) receptor antagonists have been used to treat PONV. Objectives: To compare the antiemetic effect of NK-1 receptor antagonists, including fosaprepitant. Data sources: Online databases (PubMed, MEDLINE, Scopus, The Cochrane Library databases) were used. Study eligibility criteria, participants, and interventions: Randomized Controlled Trials (RCTs) performed in patients over 18 years with ASA-PS of I‒III, aimed to assess the efficacy of antiemetics including NK-1 receptor antagonists and 5-HT3 receptor antagonists, and compared the incidence of PONV were included. Study appraisal and synthesis methods: All statistical assessments were conducted by a random effect approach, and odds ratios and 95% Confidence Intervals were calculated. Results: Aprepitant 40 mg and 80 mg significantly reduced the incidence of vomiting 0‒24 hours postoperatively (Odds Ratio [OR = 0.40]; 95% Confidence Interval [95% CI 0.30‒0.54]; p < 0.001, and OR = 0.32; 95% CI 0.19‒0.56; p < 0.001). Fosaprepitant could also reduce the incidence of vomiting significantly both 0‒24 and 0‒48 hours postoperatively (OR = 0.07; 95% CI 0.02‒0.24; p < 0.001 and OR = 0.07; 95% CI 0.02‒0.23; p < 0.001). Limitations: Risk factors for PONV are not considered, RCTs using multiple antiemetics are included, RCTs for fosaprepitant is small, and some bias may be present. Conclusions and implications of key findings: Aprepitant and fosaprepitant can be effective prophylactic antiemetics for postoperative vomiting. However, more studies are required for higher-quality meta-analyses. Systematic review registration number: CRD42019120188.

Resumo Histórico: Náusea e Vômito no Pós-Operatório (NVPO) é um evento adverso frequente da anestesia geral. Várias classes de antieméticos, incluindo antagonistas do receptor 5-Hidroxitriptamina3 (5-HT3) e antagonistas do receptor da Neurocinina-1 (NK-1), têm sido utilizados para tratar a NVPO. Objetivo: Comparar o efeito antiemético dos antagonistas do receptor NK-1, incluindo o fosaprepitanto. Fontes de dados: Foram utilizadas bases de dados on-line (PubMed, MEDLINE, Scopus, The Cochrane Library). Critérios de elegibilidade do estudo, participantes e intervenções: Foram incluídos Estudos Clínicos Randomizados (ECR) realizados em pacientes acima de 18 anos classificação ASA I a III, com o objetivo de avaliar a eficácia de antieméticos que incluíssem antagonistas do receptor NK-1 e antagonistas do receptor 5-HT3, e que comparassem a incidência de NVPO. Métodos de avaliação e síntese do estudo: Todas as avaliações estatísticas foram realizadas por abordagem de efeito aleatório e foram calculadas razões de chances e Intervalos de Confiança de 95%. Resultados: As doses de 40 mg e 80 mg de aprepitanto reduziram significantemente a incidência de vômito no período de 0 a 24 horas pós-operatórias (razão de chances [OR = 0,40]; Intervalo de Confiança de 95% [95% IC] 0,30-0,54; p < 0,001 e OR = 0,32; 95% IC 0,19-0,56; p < 0,001). O fosaprepitanto pode também reduzir significantemente a incidência de vômito tanto de 0-24 horas como no período de 0-48 horas pós-operatórias (OR = 0,07; 95% IC 0,02-0,24; p < 0,001 e OR = 0,07; 95% IC 0,02-0,23; p < 0,001). Limitações: Os fatores de risco para NVPO não foram analisados, ECRs usando múltiplos antieméticos foram incluídos, ECRs para fosaprepitanto tinham amostras pequenas, podendo haver algum viés. Conclusões e implicações dos principais achados: Aprepitanto e fosaprepitanto podem ser drogas antieméticas profiláticas efetivas para vômito no pós-operatório. No entanto, são necessários mais estudos para elaboração de meta-análises de melhor qualidade. Número de registro da revisão sistemática: CRD42019120188.

Articular and cutaneous nerve block at elbow: two cases report / Bloqueio do nervo articular e cutâneo no cotovelo: relato de dois casos

Abstract Background and objectives: In patients with elbow fractures, when there is suspected injury to underlying nerves, it is imperative for surgeons to elicit the function in the immediate postoperative period. Brachial plexus blocks like interscalene, supraclavicular and infraclavicular approaches can be a hurdle in such situations. The block planned should allow assessment of integrity of the nerves immediately in the postoperative period. Case report: We describe two cases in which we administered a block not yet described in literature. We blocked the cutaneous and articular branches innervating the elbow under ultrasound guidance. General anesthesia was administered in both cases. The block provided stable intraoperative hemodynamics, good postoperative analgesia and also allowed surgeons to test the viability of the nerve. Conclusion: In situations where nerves are injured during elbow fractures, selective articular cutaneous block at elbow can be used as it provides good perioperative analgesia, besides allowing evaluation of motor and sensory components in the postoperative period.

Resumo Justificativa e objetivos: Quando há suspeita de lesão nos nervos subjacentes em pacientes com fratura de cotovelo, é imperativo que o cirurgião estimule a função dos nervos no pós-operatório imediato. Bloqueios do plexo braquial com as técnicas interescalênica, supraclavicular e infraclavicular pode ser um obstáculo nessas situações. O bloqueio deve ser planejado de modo a permitir a avaliação da integridade dos nervos no pós-operatório imediato. Relato de caso: Descrevemos dois casos em que realizamos uma técnica de bloqueio ainda não descrito na literatura. Realizamos o bloqueio dos ramos cutâneo e articular de nervos que inervam o cotovelo com auxílio de ultrassonografia. Anestesia geral foi realizada nos dois casos. O bloqueio proporcionou estabilidade hemodinâmica intraoperatória, boa analgesia pós-operatória e também permitiu que os cirurgiões testassem a viabilidade do nervo. Conclusão: Em fraturas do cotovelo associadas à lesão de nervos, o bloqueio seletivo articular cutâneo do cotovelo pode ser utilizado, pois proporciona boa analgesia perioperatória, além de permitir a avaliação dos componentes motores e sensoriais no pós-operatório.

Implicaciones del COVID-19 (SARS-CoV-2) para la práctica anestesiológica / Implications of COVID-19 (SARS-CoV-2) for the anesthesiological practice

El objetivo de este artículo es revisar las características del SARS-CoV-2, los aspectos clínico-epidemiológicos de COVID-19 y las implicaciones que tienen para los anestesiólogos al realizar procedimientos generadores de aerosoles. Se realizó una búsqueda en las bases de datos PubMed, Scopus, SciELO y Web of Science hasta el 9 de abril de 2020, utilizando las palabras: "COVID-19 or COVID19 or SARS-CoV-2 and anesthesiology or anesthesia". Se incluyeron 48 artículos con información sobre el manejo del paciente en el perioperatorio o en la unidad de cuidados intensivos ante la sospecha o confirmación de infección por SARS-CoV-2. En general, se recomienda el aplazamiento de las cirugías electivas por no más de seis a ocho semanas, de acuerdo a las condiciones clínicas de los pacientes. En el caso de cirugías de urgencia o emergencia, se revisan tópicos del sistema de protección personal así como las estrategias recomendadas para la realización de los procedimientos.

The purpose of this article is to review the characteristics of SARS-CoV-2, the clinical-epidemiological aspects of COVID-19, and the implications anesthesiologists when performing aerosol-generating procedures. A search of PubMed/MEDLINE, Scopus, SciELO, and Web of Science databases was performed until April 9, 2020, using the words: "COVID-19 or COVID19 or SARS-CoV-2 and anesthesiology or anesthesia". Forty-eight articles with information on the management of the patient in the perioperative period or the intensive care unit when suspected or confirmed SARS-CoV-2 infection were included. In general, the postponement of elective surgeries for no more than 6 to 8 weeks, depending on the clinical condition of the patients is recommended. In the case of urgent or emergency surgeries, we review the use of personal protection gear, as well as the recommended strategies for carrying out the procedure.

Anestesia general en infantes: consideraciones neurobiológicas y neuropsicológicas / General anesthesia in infants: neurobiological and neuropsychological concerns

Resumen La anestesia general es una herramienta imprescindible para el proceso quirúrgico, ya que disminuye el dolor, reduce la ansiedad y genera inconsciencia. Sin ella, las cirugías serían dolorosas, riesgosas y emocionalmente traumáticas. La reciente emisión de una alerta sobre el uso de fármacos anestésicos en niños menores de 3 años por parte de la Food and Drug Administration (FDA) de los Estados Unidos generó controversia en torno a sus posibles efectos negativos. En este artículo se abordan los principales hitos del desarrollo neurobiológico del niño y se revisan las posibles consecuencias neuropsicológicas del uso de anestesia general en esta población. La mayoría de los reportes que abordan este tema son de tipo retrospectivo y arrojan resultados controversiales por sus inherentes dificultades metodológicas. Sin embargo, el estudio prospectivo sobre seguridad del uso de anestesia general en niños de la Clínica Mayo (MASK, Mayo Anesthesia Safety in Kids), junto con otros estudios a gran escala, han confirmado algunos datos obtenidos en los estudios experimentales que dieron sustento a la alerta emitida por la FDA. Así, las evidencias hasta ahora publicadas sugieren que el uso de anestesia general es seguro para el desarrollo cognitivo general del niño, aunque evidencian también alteraciones focalizadas en procesos cognitivos específicos que deben ser consideradas por el médico y la familia ante un procedimiento quirúrgico-anestésico.

Abstract General anesthetics are crucial drugs for surgical interventions, which are indicated to induce analgesia, diminish pain, and reduce anxiety in order to facilitate invasive procedures. In pediatric patients, benefits of general anesthetics also include abolishment of motility. Besides their probed benefits on surgery, the recent warning of the Food and Drug Administration (FDA) on the use of general anesthetics in children yielded a controversy on their potential neurotoxic effects. In this review, the main facts of the cerebral development are studied, and the available evidence concerning the use of general anesthesia on the neuropsychological development of children is analyzed. Most of the studies found were uncontrolled retrospective cohorts for which conclusions are difficult to obtain. However, a few group of controlled studies, including the Mayo Anesthesia Safety in Kids study (MASK), have partially supported the FDA warning. Cumulated evidence appears to support the safety use of general anesthetics, but no conclusive data supporting that it may induce massive effects on the cognitive development of exposed children has been reported. Important evidence suggests that specific cognitive functions may result altered under long-term expositions. Such data must be considered for those involved in anesthetic procedures.

Perioperatorio y recurrencia oncológica: reto actual en la práctica anestésica / Perioperative and cancer relapse: a challenge in current anesthetic practice

Introducción: El cáncer es la segunda causa de muerte en el mundo y en Cuba. Su estrategia de tratamiento implica fármacos oncoespecíficos y cirugía; y diariamente aumentan los pacientes intervenidos quirúrgicamente lo que conlleva a un periodo perioperatorio y la administración de múltiples medicamentos anestésicos. Objetivo: Describir los principales factores relacionados con la anestesia que, durante el perioperatorio, influyen en la recurrencia oncológica. Desarrollo: El estrés quirúrgico y la anestesia general, con la subsecuente respuesta neuroendocrina e inflamatoria, por sí mismos, limitan la respuesta inmune y alteran el balance entre el potencial metastásico del tumor y antimetastásico de las defensas, lo cual representa un mecanismo plausible en el incremento de las metástasis y recurrencia oncológica. Conclusiones: La proliferación del cáncer y recidiva tumoral en el contexto quirúrgico asociado a la anestesia, es un tema relativamente nuevo y por tanto es necesario realizar estudios con mayor alcance que validen este fenómeno. No obstante, el efecto inmunosupresor que produce el estrés perioperatorio, fármacos anestésicos como opioides y halogenados pueden ser la clave para explicar este fenómeno. La anestesia general endovenosa total libre de opioides y adecuada analgesia regional contribuyen a disminuir este efecto(AU)

Introduction: Cancer is the second cause of death worldwide and in Cuba. Its treatment strategy involves oncospecific drugs and surgery. Every day, the number of patients who undergo surgery increases, which leads to a perioperative period and the administration of multiple anesthetic medications. Objective: To describe the main factors related to anesthesia and that, during the perioperative period, influence oncological recurrence. Development: Surgical stress and general anesthesia, with the subsequent neuroendocrine and inflammatory response, by themselves, limit the immune response and alter the balance between the metastatic potential of the tumor and the antimetastatic defense, which represents a plausible mechanism for increased metastasis and oncological relapse. Conclusions: The proliferation of cancer and tumor relapse in the surgical context associated with anesthesia is a relatively new issue and it is therefore necessary to carry out studies with greater scope that validate this phenomenon. However, the immunosuppressive effect produced by perioperative stress, as well as anesthetic drugs such as opioids and halogenated drugs, can be the key to explaining this phenomenon. Total intravenous opioid-free general anesthesia and adequate regional analgesia contribute to diminish this effect(AU)

Feasibility of non-intubated anesthesia and regional block for thoracoscopic surgery under spontaneous respiration: a prospective cohort study

Data about the feasibility and safety of thoracoscopic surgery under non-intubated anesthesia and regional block are limited. In this prospective study, 57 consecutive patients scheduled for thoracoscopic surgery were enrolled. Patients were sedated with dexmedetomidine and anesthetized with propofol and remifentanil. Ropivacaine was used for intercostal nerve and paravertebral block. Lidocaine was used for vagal block. The primary outcomes were mean arterial pressure (MAP), heart rate (HR), oxygen saturation, and end-tidal carbon dioxide partial pressure (ETCO2) at T0 (pre-anesthesia), T1 (immediately after laryngeal mask/nasopharyngeal airway placement), T2 (immediately after skin incision), T3 (10 min after opening the chest), T4 (end of surgery), and T5 (immediately after laryngeal mask/nasopharyngeal airway removal). One patient required conversion to intubation, 15 developed intraoperative hypotension, and two had hypoxemia. MAP at T0 and T5 was higher than at T1-T4; MAP at T3 was lower (P<0.05 vs other time points). HR at T0 and T5 was higher (P<0.05 vs other time points). ETCO2 at T2 and T3 was higher (P<0.05 vs other time points). Arterial pH, PCO2, and lactic acid at T1 differed from values at T0 and T2 (P<0.05). The Quality of Recovery-15 (QoR-15) score at 24 h was lower (P<0.05). One patient experienced dysphoria during recovery. Thoracoscopic surgery with regional block under direct thoracoscopic vision is a feasible and safe alternative to conventional surgery under general anesthesia, intubation, and one-lung ventilation.

Anestesia para reparación antenatal de mielomeningocele: Presentación de un caso / Anesthesia for myelomenigocele antenatal repair: Case report

INTRODUCTION: The advance in the methods of prenatal diagnosis and surgical techniques have allowed the development of fetal surgery, achieving identification and early treatment of anomalies invalidating extrauterine life. Myelomeningocele (MMC) is the most frequent neural tube defect and its intrauterine correction has demonstrated benefits. OBJECTIVE: To publicize the anesthetic management of a prenatal correction of MMC performed in a public hospital in Chile. CASE REPORT: 31-year-old woman, pregnancy of 25 weeks of gestational age, fetus carrying MMC lumbosacral, who underwent open correction. Procedure performed with incidents under general anesthesia with remifentanil and sevoflorane MAC in 2 and tocolytic prophylaxis. At 48 hours post operative, he presented an acute pulmonary edema compatible (EPA), which was successfully resolved with depletive therapy for 24 hours in the Intensive Care Unit, without the need for mechanical ventilation or use of vasoactive drugs. Discharged one week later in good condition, with interruption of pregnancy by elective caesarean section at 37 weeks, with a newborn without stigmas of neurological sequelae. CONCLUSIONS: The mother-fetus binomial is a challenge for the anesthetist. In intrauterine surgery the need for knowledge about the pharmacology of tocolytics, placental uterine physiology and the complications of the procedure are added.

INTRODUCCIÓN: El avance en los métodos de diagnóstico prenatal y las técnicas quirúrgicas han permitido el desarrollo de la cirugía fetal, logrando identificación y tratamiento precoz de anomalías invalidantes para la vida extrauterina. El mielomeningocele (MMC) es el defecto del tubo neural más frecuente y su corrección intrauterina tiene beneficios demostrados. OBJETIVO: Dar a conocer el manejo anestésico de una corrección prenatal de MMC realizada en un hospital público de Chile. CASO CLÍNICO: Mujer de 31 años, embarazo de 25 semanas de edad gestacional, feto portador de MMC lumbosacro, que se sometió a una corrección por vía abierta. Procedimiento realizado con incidentes bajo anestesia general con remifentanilo y sevoflorano MAC en 2 y profilaxis tocolítica. A las 48 horas postoperatorias presentó cuadro compatible con edema pulmonar agudo (EPA), que se resolvió exitosamente con terapia depletiva por 24 horas en Unidad de Cuidados Intensivos, sin necesidad de ventilación mecánica ni uso de drogas vasoactivas. Dada de alta una semana después en buenas condiciones. El embarazo se interrumpió por cesárea electiva a las 37 semanas, con un recién nacido sin estigmas de secuela neurológica. CONCLUSIONES: El binomio madre-feto es un reto para el anestesista. En cirugía intraútero se suma la necesidad de conocimientos sobre la farmacología de los tocolíticos, fisiología útero placentaria y las complicaciones propias del procedimiento.

High frequency jet ventilator ‒ a new approach in the management of anesthesia for pediatric cardiac Magnetic Resonance Imaging: case series / Ventilação a jato de alta frequência - uma nova abordagem no manejo da anestesia para ressonância magnética em cardiologia pediátrica: série de casos

Abstract Background and objectives: Cardiac Magnetic Resonance Imaging (MRI) is a technique used for evaluation of children with congenital heart diseases. General anesthesia ensures immobility, particularly in uncooperative patients. However, chest wall movements can limit good quality scans. Prolonged apnea may be necessary to decrease respiratory motion artefacts, potentially leading to hypoxemia and other adverse events. The use of a high frequency jet ventilator may be a solution avoiding chest wall movements. Case report: We report four cases of pediatric patients, ASA II, aged between 4 and 15 years-old, scheduled for cardiac MRI. General anesthesia was proposed and parental informed consent was obtained. After general anesthesia was induced, an uncuffed endotracheal tube was inserted. Then, a 7Fr × 40 cm catheter was placed through the endotracheal tube. The proximal outlet of the catheter was attached through a connecting tube to a high frequency jet ventilator (Monsoon III®, Acutronic Medical Systems). Good quality MRI images were obtained. At the end of the procedures, we observed increased salivation and increased end-tidal CO2 (60-70 mmHg), in all patients. The patients were extubated after normocapnia was achieved and neuromuscular blockade reversed. Following appropriate recovery time, the four children were discharged home the same day. Conclusions: This case series demonstrates that the use of a high frequency jet ventilator for cardiac MRI was feasible, safe, providing good quality cardiac imaging and avoiding anesthesia personnel to be inside the hazardous environment of MRI room. Future studies are needed to confirm its safety and efficiency in pediatric patients.

Resumo Justificativa e objetivos: A ressonância magnética (RM) cardíaca é uma técnica usada na avaliação de crianças com cardiopatias congênitas. A anestesia geral garante imobilidade, especialmente em pacientes não cooperadores, porém os movimentos da parede torácica podem limitar a boa qualidade dos exames. A apneia prolongada pode ser necessária para diminuir os artefatos do movimento respiratório, potencialmente levando à hipoxemia e outros eventos adversos. O uso de ventilação a jato de alta frequência pode ser uma solução para evitar os movimentos da parede torácica. Relato de caso: Relatamos quatro casos de pacientes pediátricos, ASA II, entre 4-15 anos, programados para ressonância magnética cardíaca. Uma anestesia geral foi proposta e assinaturas em termo de consentimento livre e esclarecido foram obtidas dos pais. Após a indução da anestesia geral, um tubo endotraqueal sem balonete foi inserido. Em seguida, um cateter de 7Fr × 40 cm foi inserido através do tubo endotraqueal. A saída proximal do cateter foi conectada, mediante um tubo conector, a um sistema de ventilação a jato de alta frequência (Monsoon III®, Acutronic Medical Systems). Imagens de ressonância magnética de boa qualidade foram obtidas. No fim dos procedimentos, observamos aumento tanto de salivação quanto de CO2 expirado (60-70 mmHg) em todos os pacientes. Os pacientes foram extubados após a obtenção de normocapnia e reversão do bloqueio neuromuscular. Após o tempo de recuperação apropriado, as quatro crianças receberam alta no mesmo dia. Conclusões: Esta série de casos demonstra que o uso de um sistema de ventilação a jato de alta frequência para ressonância magnética cardíaca é viável e seguro, além de fornecer imagens cardíacas de boa qualidade e evitar a presença da equipe de anestesia dentro do ambiente de risco da sala de ressonância magnética. Estudos futuros são necessários para confirmar sua segurança e eficiência em pacientes pediátricos.

Síndrome de Boerhaave: uma complicação rara em pós-operatório de cirurgia estética / Boerhaave syndrome: a rare complication of cosmetic surgery

Introdução: Este estudo se trata de um relato de caso que tem por objetivo alertar os cirurgiões para uma possível complicação em pós-operatório de cirurgias estéticas longas sob anestesia geral. A Síndrome de Boerhaave é uma doença grave que ameaça a vida do paciente e merece um diagnóstico precoce até 12hs e um tratamento adequado. Relato de caso: A paciente no pós-operatório de cirurgia plástica abdominal e mastopexia apresentou, após anestesia geral, crises de vômito e náuseas. Resultados: Paciente com 58 anos do sexo feminino submetida à dermolipectomia abdominal e mastopexia pela a técnica de pedículo inferior sob raquianestesia, onde após um período de quatro horas do término da cirurgia apresentou vários episódios de vômitos. Após 10 horas do ato cirúrgico apresentou queixa de algia ao deglutir, seguida de algia intensa generalizada, dispneia intensa, sudorese, palidez, PA 90x50mmhg. Com a piora do quadro a paciente foi encaminhada para a unidade de terapia intensiva onde foi entubada. Foram realizados exames laboratoriais, toracocentese e exames radiológicos. Atualmente, a paciente encontra-se com prótese esofágica. Conclusões: Fazendo a correlação com a bibliografia, no caso em tela sugere-se evitar cirurgias prolongadas, principalmente sob anestesia geral onde pode ocorrer a retenção de gás carbônico, que pode levar a crise emética no pós-operatório em pacientes com antecedentes de doença esofagiana e estar atentos aos sintomas, não descartando a possibilidade da ocorrência da Síndrome Boerhaave.

Introduction: The objective of this case report is to alert surgeons to a possible postoperative complication of long cosmetic surgery under general anesthesia. Boerhaave syndrome is a serious life-threatening disease that requires diagnosis within 12 hours and proper treatment. Case report: A 58-year-old female patient presented with vomiting and nausea after abdominoplasty and mastopexy under general anesthesia. Results: The patient underwent dermolipectomy and mastopexy using the inferior pedicle technique under spinal anesthesia. Four hours after the operation, she presented several episodes of vomiting. Ten hours after the operation, she reported painful swallowing followed by generalized severe pain and presented severe dyspnea, sweating, pallor, and a 90/50 mmHg blood pressure. As the condition worsened, the patient was referred to the intensive care unit where she was intubated and underwent laboratory tests, thoracentesis, and radiological examinations. The patient currently uses an esophageal prosthesis. Conclusions: The literature suggests avoiding prolonged surgery, especially under general anesthesia, because of the risk of carbon dioxide retention, which may lead to postoperative emetic crisis in patients with a history of esophageal disease. It also suggests paying attention to symptoms, not excluding the possibility of Boerhaave syndrome.

Preemptive nebulized ketamine for pain control after tonsillectomy in children: randomized controlled trial / Uso preventivo de cetamina nebulizada para controle da dor após amigdalectomia em crianças: estudo randômico e controlado

Abstract Objectives The administration of ketamine as nebulized inhalation is relatively new and studies on nebulized ketamine are scarce. We aimed to investigate the analgesic efficacy of nebulized ketamine (1 and 2 mg.kg-1) administered 30 min before general anesthesia in children undergoing elective tonsillectomy in comparison with intravenous ketamine (0.5 mg.kg-1) and saline placebo. Methods One hundred children aged (7-12) years were randomly allocated in four groups (n = 25) receive; Saline Placebo (Group C), Intravenous Ketamine 0.5 mg.kg-1 (Group K-IV), Nebulized Ketamine 1 mg.kg-1 (Group K-N1) or 2 mg.kg-1 (Group K-N2). The primary endpoint was the total consumption of rescue analgesics in the first 24 h postoperative. Results The mean time to first request for rescue analgesics was prolonged in K-N1 (400.9 ± 60.5 min, 95% CI 375.9-425.87) and K-N2 (455.5 ± 44.6 min, 95% CI 437.1-473.9) groups compared with Group K-IV (318.5 ± 86.1 min, 95% CI 282.9-354.1) and Group C (68.3 ± 21.9 min, 95% CI 59.5-77.1; p < 0.001), with a significant difference between K-N1 and K-N2 Groups (p < 0.001). The total consumption of IV paracetamol in the first 24 h postoperative was reduced in Group K-IV (672.6 ± 272.8 mg, 95% CI 559.9-785.2), Group K-N1 (715.6 ± 103.2 mg, 95% CI 590.4-840.8) and Group K-N2 (696.6 ± 133.3 mg, 95% CI 558.8-834.4) compared with Control Group (1153.8 ± 312.4 mg, 95% CI 1024.8-1282.8; p < 0.001). With no difference between intravenous and Nebulized Ketamine Groups (p = 0.312). Patients in intravenous and Nebulized Ketamine Groups showed lower postoperative VRS scores compared with Group C (p < 0.001), no differences between K-IV, K-N1 or K-N2 group and without significant adverse effects. Conclusion Preemptive nebulized ketamine was effective for post-tonsillectomy pain relief. It can be considered as an effective alternative route to IV ketamine.

Resumo Objetivos A administração de cetamina por via inalatória através de nebulizador é relativamente nova e os estudos sobre este assunto são escassos. Nosso objetivo foi investigar a eficácia analgésica da cetamina nebulizada (1 e 2 mg.kg-1) administrada 30 minutos antes da anestesia geral em crianças submetidas à amigdalectomia eletiva, em comparação com cetamina intravenosa (0,5 mg.kg-1) e placebo (soro fisiológico). Métodos Cem crianças entre 7-12 anos foram randomicamente alocadas em quatro grupos (n = 25) e receberam: soro fisiológico para controle (Grupo C); 0,5 mg.kg-1 de cetamina intravenosa (Grupo C-IV); 1 mg.kg-1 de cetamina nebulizada (Grupo C-N1); 2 mg.kg-1 de cetamina nebulizada (Grupo C-N2). O desfecho primário foi o consumo total de analgésicos de resgate nas primeiras 24 horas de pós-operatório. Resultados O tempo médio para a primeira solicitação de analgésicos de resgate foi prolongado nos grupos C-N1 (400,9 ± 60,5 min, IC 95% 375,9-425,87) e C-N2 (455,5 ± 44,6 min, IC 95% 437,1-473,9) em comparação com o Grupo C-IV (318,5 ± 86,1 min, IC 95% 282,9-354,1) e o Grupo C (68,3 ± 21,9 min, IC 95% 59,5-77,1; p < 0,001), com uma diferença significativa entre os grupos C-N1 e C-N2 (p < 0,001). O consumo total de paracetamol IV nas primeiras 24 horas de pós-operatório foi reduzido no Grupo C-IV (672,6 ± 272,8 mg, IC 95% 559,9-785,2), Grupo C-N1 (715,6 ± 103,2 mg, IC 95% 590,4-840,8) e Grupo C-N2 (696,6 ± 133,3 mg, IC 95% 558,8-834,4) em comparação com o Grupo C (1153,8 ± 312,4 mg, IC 95% 1024,8-1282,8; p < 0,001). Não houve diferença entre os grupos de cetamina intravenosa e nebulizada (p = 0,312). Os pacientes dos grupos de cetamina intravenosa e nebulizada apresentaram escores VRS pós-operatórios menores, em comparação com o Grupo C (p < 0,001), sem diferenças entre os grupos C-IV, C-N1 ou C-N2 e sem efeitos adversos significativos. Conclusão A administração preventiva de cetamina nebulizada foi eficaz no alívio da dor pós-amigdalectomia. Cetamina nebulizada pode ser considerada como uma via alternativa eficaz à cetamina IV.

Evaluation of Bispectral Index time delay in response to anesthesia induction: an observational study / Avaliação do tempo de atraso do índice bispectral na resposta à indução da anestesia: estudo observacional

Abstract Background and objectives According to the manufacturer, the Bispectral Index (BIS) has a processing time delay of 5-10 s. Studies addressing this have suggested longer delays. We evaluated the time delay in the Bispectral Index response. Methods Based on clinical data from 45 patients, using the difference between the predicted and the real BIS, calculated during a fixed 3 minutes period after the moment the Bispectral Index dropped below 80 during the induction of general anesthesia with propofol and remifentanil. Results The difference between the predicted and the real BIS was in average 30.09 ± 18.73 s. Conclusion Our results may be another indication that the delay in BIS processing may be much longer than stated by the manufacture, a fact with clinical implications.

Resumo Justificativa e objetivos De acordo com o fabricante, o índice bispectral (BIS) tem um tempo de processamento de cinco a dez segundos. Estudos que avaliaram esse tempo de processamento sugeriram atrasos mais longos. Nós avaliamos o tempo de atraso na resposta do BIS. Métodos Com base em dados clínicos de 45 pacientes, calculamos a diferença entre o tempo de atraso previsto e real do índice bispectral durante um período fixo de três minutos após o momento em que o BIS caiu abaixo de 80 durante a indução da anestesia geral com propofol e remifentanil. Resultados A diferença entre o BIS previsto e real foi em média 30,09 ± 18,73 segundos. Conclusão Nossos resultados sugerem que o atraso no processamento do índice bispectral pode ser muito maior do que o declarado pelo fabricante, um fato com implicações clínicas.