Guideline of nitrous oxide-oxygen inhalation sedation technique in dental outpatient / 中华口腔医学杂志

The use of nitrous oxide-oxygen inhalation sedation to relieve anxiety and pain in dental outpatient treatment has been a very mature and safe technique in the world. This technology has been introduced into China for nearly 20 years, and many clinical cases have proved its safety, practicability and effectiveness, which can meet the clinical needs of patients. To further standardize and popularize this technique, the Society of Sedation and Analgesia, Chinese Stomatological Association formed the recommended application guidelines after many discussions and revisions on the basis of widely soliciting opinions and referring to relevant literatures. It covers indications, contraindications, standardized operation procedures, occupational protection, identification and treatment of adverse reactions, training and other aspects. This guideline can be used as a reference for the use of nitrous oxide-oxygen inhalation sedation techniques in the outpatient setting of dentistry.

¿Anestesia halogenada o anestesia total endovenosa en neurocirugía? / Volatile or total intravenous anesthesia for neurosurgery?

Total intravenous anesthesia (TIVA) with propofol/remifentanil appears in the literatura as a good option for neurosurgical patients who have increased intracranial pressure (ICP),risk of postoperative nausea and vomiting (PONV), need for neuromonitoring, and in those with impaired brain self-regulation. On the other hand, in patients with normal neurological status, normal ICP, a technique with volatile (halogenated) agents plus an opiiid can be used. This review describes two anesthetic techniques available for use in neurosurgery, highlighting the neurophysiological changes, advantages and disadvantages of each technique. MATERIAL AND METHOD: PubMed search engine was used for bibliographic search. DISCUSSION: The search for an ideal anesthetic in neurosurgery is still a matter of debate. There are numerous investigations aimed at finding an optimal agent that ensure the coupling between cerebral flow (CBF) and metabolism, keeping self-regulation intact without increasing the CBF and intracerebral pressure (ICP). CONCLUSIONS: Both anesthetic techniques, TIVA and volatile agents (halogenated), can be used in neurosurgical procedures and should provide neuroprotection, brain relaxation and a rapid awakening.

La anestesia total endovenosa (TIVA) con propofol/remifentanilo aparece en la literatura como una buena opción para pacientes neuroquirúrgicos que tienen aumento de la presión intracraneana (PIC), riesgo de náuseas y vómitos posoperatorios (NVPO), necesidad de neuromonitoreo, y en aquellos con alteración de la autorregulación cerebral. Por otra parte, en pacientes con estado neurológico normal, PIC normal puede usarse una técnica con agentes volátiles (halogenados) más un opioide. Esta revisión describe dos técnicas anestésicas disponibles para su uso en neurocirugía, destaca los cambios neurofisiológicos, ventajas y desventajas de cada técnica. MATERIAL Y MÉTODO: Para búsqueda bibliográfica se usó buscador PubMed. DISCUSIÓN: La búsqueda de un anestésico ideal en neurocirugía sigue siendo tema de debate. Existen numerosas investigaciones destinadas a buscar un agente óptimo que asegure el acoplamiento entre flujo sanguíneo cerebral (FSC) y metabolismo, manteniendo la autorregulación intacta sin aumentar el FSC y presión intracerebral (PIC). CONCLUSIONES: Ambas técnicas anestésicas, TIVA y agentes volátiles (halogenados), pueden ser usadas en procedimientos neuroquirúrgicos y deben brindar neuroprotección, relajación cerebral y un despertar rápido.

Caso de hipertermia maligna en paciente intervenida de apendicectomía laparoscópica / Malignant Hyperthermia after a laparoscopic appendicectomy: Case report

Malignant hyperthermia is an hypermetabolic syndrome in which the intracellular calcium receptors are altered. Patients who present compatible symptoms with this symdrome are genetically predisposed. Many of the cases have been described in the surgical area, due to the use of anesthesic drugs and neuromuscular blockers. However, there are some cases with an unknown trigger. The prevalence of the syndrome is very difficult to estimate. The diagnosis and early treatment are pronostic factors predicting the evolution of the syndrome.

La hipertermia maligna es conocida como un síndrome de estimulación masiva del metabolismo, debido a la alteración en la liberación de calcio intracelular. Muchos pacientes que presentan clínica compatible con este síndrome están genéticamente predispuestos. La mayoría de los casos se describen en el ámbito quirúrgico, con el empleo de fármacos anestésicos y determinados relajantes neuromusculares, aunque también existen casos en los que no se halla desencadenante. De prevalencia difícil de estimar, la sospecha diagnóstica y el tratamiento precoz marcan el pronóstico evolutivo de estos pacientes.

Research Progress of Pharmacological Intervention of Sevoflurane-induced Nerve Injury in the Developing Brain / 中国医学科学院学报

Sevoflurane is one of the most commonly used inhaled anesthetics in obstetric and pediatric general anesthesia.According to related literature,this article reviews major possible mechanisms including myelin formation damage,nerve inflammation,cell apoptosis,oxidative stress,inhibition of histone acetylation,synapsis and receptor changes of sevoflurane-induced neurotoxicity in animal experiments.Furthermore,we summarize the neuroprotection effects and functioning mechanisms of anti-anemia medicine,plant-based drugs,alpha 2 adrenoceptor agonists and others,aiming to provide a basis for the brain protection of fetuses and infants during the perioperative period.

Síndrome de hipertermia maligna: una patología infrecuente / Malignant hyperthermia syndrome: A rare entity

Resumen Introducción: El síndrome de hipertermia maligna es un trastorno farmacogenético del músculo esquelético de carácter hereditario, que se caracteriza por un estado hipermetabólico relacionado con la exposición a anestésicos inhalatorios o relajantes musculares despolarizantes. Se trata de una afección infrecuente en individuos genéticamente predispuestos, con una incidencia muy baja en pediatría (1 de cada 10,000-15,000 procedimientos anestésicos). Caso clínico: Se presenta un caso de hipertermia maligna relacionado con la exposición a sevoflurano durante una cirugía de adenoidectomía en un paciente de sexo femenino de 6 años de edad. La paciente presentó taquicardia, hipercapnia e hipertermia, que precisaron la administración de dos dosis sucesivas de dantroleno sódico. La evolución posterior fue buena. Conclusiones: El síndrome de hipertermia maligna es un cuadro poco frecuente en la edad pediátrica. Se debe sospechar de forma precoz, ya que es fundamental su detección temprana para iniciar el tratamiento.

Abstract Background: Malignant hyperthermia syndrome is a hereditary pharmacogenetic disorder of skeletal muscle characterized by hypermetabolic state related to the exposure of volatile anesthetic gases or depolarizing muscle relaxants. It is an infrequent entity that occurs in genetically predisposed individuals, with a very low incidence in pediatrics (1 in 10,000-15,000 anesthetic procedures). Case report: We report a case of malignant hyperthermia related to exposure to sevoflurane during adenoidectomy surgery in a 6-year-old female. The patient presented with tachycardia, hypercapnia, and hyperthermia, requiring two successive doses of dantrolene sodium administration, with an adequate response to the treatment. Conclusions: Malignant hyperthermia syndrome is a rare condition in pediatric patients that should be detected in early stages since it is essential to initiate the treatment as soon as possible.

Comparison of post-operative nausea and vomiting with intravenous versus inhalational anesthesia in laparotomic abdominal surgery: a randomized clinical trial / Comparação entre anestesia intravenosa e inalatória na náusea e vômito pós-operatórios em laparotomia: estudo clínico randomizado

Abstract Background: Postoperative Nausea and Vomiting (PONV) is a multifactorial surgical complication with an unclear underlying cause. Anesthetic methods, patients' characteristics and the type of surgery are considered as factors affecting PONV. This study was designed to compare the effect of inhalational and intravenous anesthesia in abdominal surgery on the incidence and severity of PONV. Methods: A single-blinded prospective randomized clinical trial on 105 patients aged 18 − 65 years was carried out. Patients were divided into two groups of Total Intravenous Anesthesia (TIVA) and inhalational anesthesia. The incidence and the severity of PONV were examined at 0, 2, 6, 12 and 24 hours after the surgery. The use of a rescue antiemetic was also evaluated. Results: 50.9% of the patients in the inhalation group and 17.3% of the patients in the intravenous group developed PONV (p < 0.001). The incidence of vomiting was reported in 11.3% of the inhalational group and 3.8% of the TIVA group (p = 0.15). 24.5% of patients in the inhalation group and 9.6% of patients in the intravenous group needed an antiemetic medication (p = 0.043). Conclusion: The incidence of postoperative nausea and vomiting and the need for administration of an antiemetic rescue drug and the severity of nausea in patients were significantly lower in the TIVA group.

Resumo Justificativa: Náusea e Vômito no Pós-Operatório (NVPO) é uma complicação multifatorial com etiologia não esclarecida. A técnica anestésica, as características dos pacientes e o tipo de cirurgia são considerados fatores que afetam a NVPO. O presente estudo foi desenhado para comparar o efeito da anestesia inalatória com anestesia intravenosa na incidência e gravidade de NVPO na cirurgia abdominal. Método: Foi realizado estudo clínico mono-cego prospectivo randomizado com 105 pacientes com idades de 18 − 65 anos. Os pacientes foram divididos em dois grupos, Anestesia Total Intravenosa (TIVA) e anestesia inalatória. A incidência e gravidade de NVPO foram avaliadas em cinco momentos: 0, 2, 6, 12 e 24 horas pós-cirurgia. O uso de antiemético de resgate também foi avaliado. Resultados: NVPO ocorreu em 50,9% dos pacientes no grupo inalatória e 17,3% dos pacientes no grupo TIVA (p< 0,001). A incidência de vômitos relatados foi 11,3% no grupo Inalatória e 3,8% no grupo TIVA (p = 0,15). Necessitaram de medicação antiemética 24,5% dos pacientes no grupo Inalatória e 9,6% dos pacientes no grupo TIVA (p = 0.043). Conclusão: A incidência de náusea e vômito no pós-operatório, a necessidade de administração de droga antiemética de resgate e a gravidade da náusea foram significantemente mais baixas no grupo TIVA.

Malignant hyperthermia in a child after magnetic resonance imaging: a case report / Hipertermia maligna em criança após exame de ressonância magnética: relato de caso

ABSTRACT Objective: To report on a case of malignant hyperthermia in a child after a magnetic resonance imaging of the skull was performed using sevoflurane anesthesia. Case description: A 3-year-old boy admitted to the pediatric intensive care unit after presenting clinical and laboratory findings consistent with unspecified viral meningoencephalitis. While the patient was sedated, a magnetic resonance imaging of the skul was performed using propofol followed by the administration of sevoflurane through a laryngeal mask in order to continue anesthesia. Approximately three hours after the start of the procedure, the patient presented persistent tachycardia, tachypnea, generalized muscular stiffness and hyperthermia. With a diagnostic hypothesis of malignant hyperthermia, dantrolene was then administered, which immediately induced muscle stiffness, tachycardia, tachypnea and reduced body temperature. Comments: Malignant hyperthermia is a rare pharmacogenetic syndrome characterized by a severe hypermetabolic reaction after the administration of halogenated inhalational anesthetics or depolarizing muscle relaxants such as succinylcholine, or both. Although it is a potentially fatal disease, the rapid administration of continued doses dantrolene has drastically reduced the morbidity and mortality of the disease.

RESUMO Objetivo: Relatar um caso de hipertermia maligna em criança após exame de ressonância magnética de crânio realizada sob efeito anestésico de sevoflurano. Descrição do caso: Menino de três anos de idade, admitido na Unidade de Terapia Intensiva Pediátrica (UTIP) após apresentar quadros clínico e laboratorial compatíveis com meningoencefalite viral não especificada. Foi realizado um exame de ressonância magnética de crânio com sedação utilizando, na indução anestésica, o propofol seguido pela administração de sevoflurano por meio de máscara laríngea para manutenção anestésica. Aproximadamente três horas após o início do procedimento, o paciente apresentou taquicardia, taquipneia, rigidez muscular generalizada e hipertermia persistentes. Com hipótese diagnóstica de hipertermia maligna, foi então administrado dantrolene, que fez ceder de forma imediata a rigidez muscular, a taquicardia, a taquipneia e reduziu a temperatura corporal. Comentários: A hipertermia maligna é uma síndrome farmacogenética rara, que se caracteriza por reação hipermetabólica grave após administração de anestésicos inalatórios halogenados e/ou relaxantes musculares despolarizantes, como a succinilcolina. Apesar de ser uma doença potencialmente fatal, a rápida administração de dantrolene, junto às doses de manutenção, tem reduzido drasticamente a morbimortalidade da doença.

Emergence delirium following sevoflurane anesthesia in adults: prospective observational study / Delirium do despertar após anestesia com sevoflurano em adultos: estudo observacional prospectivo

Abstract Background and objectives: Emergence delirium after general anesthesia with sevoflurane has not been frequently reported in adults compared to children. This study aimed to determine the incidence of emergence delirium in adult patients who had anesthesia with sevoflurane as the volatile agent and the probable risk factors associated with its occurrence. Design & methods: A prospective observational study was conducted in adult patients who had non-neurological procedures and no existing neurological or psychiatric conditions, under general anesthesia. Demographic data such as age, gender, ethnicity and clinical data including ASA physical status, surgical status, intubation attempts, duration of surgery, intraoperative hypotension, drugs used, postoperative pain, rescue analgesia and presence of catheters were recorded. Emergence delirium intensity was measured using the Nursing Delirium Scale (NuDESC). Results: The incidence of emergence delirium was 11.8%. The factors significantly associated with emergence delirium included elderly age (>65) (p = 0.04), emergency surgery (p = 0.04), African ethnicity (p = 0.01), longer duration of surgery (p = 0.007) and number of intubation attempts (p = 0.001). Factors such as gender, alcohol and illicit drug use, and surgical specialty did not influence the occurrence of emergence delirium. Conclusions: The incidence of emergence delirium in adults after general anesthesia using sevoflurane is significant and has not been adequately reported. Modifiable risk factors need to be addressed to further reduce its incidence.

Resumo Justificativa e objetivos: O delirium do despertar após a anestesia geral com sevoflurano não tem sido relatado com frequência em adultos como nas crianças. Este estudo teve como objetivo determinar a incidência de delirium do despertar em pacientes adultos submetidos à anestesia com sevoflurano como agente volátil e os prováveis fatores de risco associados à sua ocorrência. Desenho e métodos: Um estudo observacional prospectivo foi conduzido com pacientes adultos sem distúrbios neurológicos ou psiquiátricos submetidos à anestesia geral para procedimentos não neurológicos. Dados demográficos como idade, sexo, etnia e dados clínicos, inclusive estado físico ASA, estado cirúrgico, tentativas de intubação, tempo de cirurgia, hipotensão intraoperatória, drogas usadas, dor pós-operatória, analgesia de resgate e presença de cateteres, foram registrados. A intensidade do delirium do despertar foi medida com a Escala de Triagem de Delirium em Enfermagem (Nursing Delirium Scale - NuDESC). Resultados: A incidência de delirium do despertar foi de 11,8%. Os fatores significativamente associados ao delirium do despertar incluíram idade avançada (> 65) (p = 0,04), cirurgia de emergência (p = 0,04), descendência africana (p = 0,01), tempo maior de cirurgia (p = 0,007) e número de tentativas de intubação (p = 0,001). Fatores como sexo, uso de álcool e drogas ilícitas e especialidade cirúrgica não influenciaram a ocorrência de delirium do despertar. Conclusões: A incidência de delirium do despertar em adultos após a anestesia geral com sevoflurano é significativa e não tem sido relatada adequadamente. Fatores de risco modificáveis precisam ser abordados para reduzir ainda mais sua incidência.

Profile of malignant hyperthermia susceptibility reports confirmed with muscular contracture test in Brazil / Perfil dos relatos de suscetibilidade à hipertermia maligna confirmados com teste de contratura muscular no Brasil

Abstract Background and objectives: Malignant hyperthermia is an autosomal dominant hypermetabolic pharmacogenetic syndrome, with a mortality rate of 10%-20%, which is triggered by the use of halogenated inhaled anesthetics or muscle relaxant succinylcholine. The gold standard for suspected susceptibility to malignant hyperthermia is the in vitro muscle contracture test in response to halothane and caffeine. The determination of susceptibility in suspected families allows the planning of safe anesthesia without triggering agents for patients with known susceptibility to malignant hyperthermia by positive in vitro muscle contracture test. Moreover, the patient whose suspicion of malignant hyperthermia was excluded by the in vitro negative muscle contracture test may undergo standard anesthesia. Susceptibility to malignant hyperthermia has a variable manifestation ranging from an asymptomatic subject presenting a crisis of malignant hyperthermia during anesthesia with triggering agents to a patient with atrophy and muscle weakness due to central core myopathy. The aim of this study is to analyze the profile of reports of susceptibility to malignant hyperthermia confirmed with in vitro muscle contracture test. Method: Analysis of the medical records of patients with personal/family suspicion of malignant hyperthermia investigated with in vitro muscle contracture test, after given written informed consent, between 1997 and 2010. Results: Of the 50 events that motivated the suspicion of malignant hyperthermia and family investigation (sample aged 27 ± 18 years, 52% men, 76% white), 64% were investigated for an anesthetic malignant hyperthermia crisis, with mortality rate of 25%. The most common signs of a malignant hyperthermia crisis were hyperthermia, tachycardia, and muscle stiffness. Susceptibility to malignant hyperthermia was confirmed in 79.4% of the 92 relatives investigated with the in vitro muscle contracture test. Conclusion: The crises of malignant hyperthermia resembled those described in other countries, but with frequency lower than that estimated in the country.

Resumo Justificativa e objetivo: Hipertermia maligna é uma síndrome farmacogenética hipermetabólica, autossômica dominante, com mortalidade entre 10%-20%, desencadeada por uso de anestésico inalatório halogenado ou relaxante muscular succinilcolina. O padrão-ouro para pesquisa de suscetibilidade à hipertermia maligna é o teste de contratura muscular in vitro em resposta ao halotano e à cafeína. A determinação da suscetibilidade nas famílias suspeitas permite planejar anestesias seguras sem agentes desencadeantes para os pacientes confirmados como suscetíveis à hipertermia maligna pelo teste de contratura muscular in vitro positivo. Além disso, o paciente no qual a suspeita de hipertermia maligna foi excluída pelo teste de contratura muscular in vitro negativo pode ser anestesiado de forma convencional. Suscetibilidade à hipertermia maligna tem manifestação variável, desde indivíduo assintomático que apresenta crise de hipertermia maligna durante anestesia com agentes desencadeantes, até paciente com atrofia e fraqueza muscular por miopatia central core disease. O objetivo deste trabalho é analisar o perfil dos relatos de suscetibilidade à hipertermia maligna confirmados com teste de contratura muscular in vitro. Método: Análise das fichas de notificação dos pacientes com suspeita pessoal/familiar de hipertermia maligna investigados com teste de contratura muscular in vitro, após assinatura do termo de consentimento, entre 1997-2010. Resultados: Dos 50 eventos que motivaram a suspeita de hipertermia maligna e a investigação familiar (amostra com 27 ± 18 anos, 52% homens, 76% brancos), 64% foram investigados por crise de hipertermia maligna anestésica, com mortalidade de 25%. Sinais mais comuns da crise de hipertermia maligna foram hipertermia, taquicardia e rigidez muscular. Suscetibilidade à hipertermia maligna foi confirmada em 79,4% dos 92 parentes investigados com teste de contratura muscular in vitro. Conclusão: Crises de hipertermia maligna assemelharam-se às descritas em outros países, porém com frequência inferior à estimada no país.

Effects of huperzine A on hippocampal inflammatory response and neurotrophic factors in aged rats after anesthesia

Abstract Purpose To investigate the effects of huperzine A (HupA) on hippocampal inflammatory response and neurotrophic factors in aged rats after anesthesia. Methods Thirty-six Sprague Dawley rats (20-22 months old) were randomly divided into control, isofluran, and isoflurane+HupA groups; 12 rats in each group. The isoflurane+HupA group was intraperitoneally injected with 0.2 mg/kg of HupA. After 30 min, isoflurane inhalation anesthesia was performed in the isoflurane and isoflurane+HupA groups. After 24 h from anesthesia, Morris water maze experiment and open-field test were performed. Hippocampal inflammatory and neurotrophic factors were determined. Results Compared with isoflurane group, in isofluran+HupA group the escape latency of rats was significantly decreased (P < 0.05), the original platform quadrant residence time and traversing times were significantly increased (P < 0.05), the central area residence time was significantly increased (P < 0.05), the hippocampal tumor necrosis factor α, interleukin 6 and interleukin 1β levels were significantly decreased (P < 0.05), and the hippocampal nerve growth factor, brain derived neurotrophic factor and neurotrophin-3 levels were significantly increased (P < 0.05). Conclusion HupA may alleviate the cognitive impairment in rats after isoflurane anesthesia by decreasing inflammatory factors and increasing hippocampal neurotrophic factors in hippocampus tissue.

Occupational hazards, DNA damage, and oxidative stress on exposure to waste anesthetic gases / Riscos ocupacionais, danos no material genético e estresse oxidativo frente à exposição aos resíduos de gases anestésicos

Abstract Background and objectives The waste anesthetic gases (WAGs) present in the ambient air of operating rooms (OR), are associated with various occupational hazards. This paper intends to discuss occupational exposure to WAGs and its impact on exposed professionals, with emphasis on genetic damage and oxidative stress. Content Despite the emergence of safer inhaled anesthetics, occupational exposure to WAGs remains a current concern. Factors related to anesthetic techniques and anesthesia workstations, in addition to the absence of a scavenging system in the OR, contribute to anesthetic pollution. In order to minimize the health risks of exposed professionals, several countries have recommended legislation with maximum exposure limits. However, developing countries still require measurement of WAGs and regulation for occupational exposure to WAGs. WAGs are capable of inducing damage to the genetic material, such as DNA damage assessed using the comet assay and increased frequency of micronucleus in professionals with long-term exposure. Oxidative stress is also associated with WAGs exposure, as it induces lipid peroxidation, oxidative damage in DNA, and impairment of the antioxidant defense system in exposed professionals. Conclusions The occupational hazards related to WAGs including genotoxicity, mutagenicity and oxidative stress, stand as a public health issue and must be acknowledged by exposed personnel and responsible authorities, especially in developing countries. Thus, it is urgent to stablish maximum safe limits of concentration of WAGs in ORs and educational practices and protocols for exposed professionals.

Resumo Justificativa e objetivos Os Resíduos de Gases Anestésicos (RGA) presentes no ar ambiente das Salas de Operação (SO) são associados a riscos ocupacionais diversos. O presente artigo propõe-se a discorrer sobre exposição ocupacional aos RGA e seu impacto em profissionais expostos, com ênfase em danos genéticos e estresse oxidativo. Conteúdo Apesar do surgimento de anestésicos inalatórios mais seguros, a exposição ocupacional aos RGA ainda é preocupação atual. Fatores relacionados às técnicas anestésicas e estação de anestesia, além da ausência de sistema de exaustão de gases em SO, contribuem para poluição anestésica. Para minimizar os riscos à saúde em profissionais expostos, recomendam-se limites máximos de exposição. Entretanto, em países em desenvolvimento, ainda carece a mensuração de RGA e de regulamentação frente à exposição ocupacional aos RGA. Os RGA são capazes de induzir danos no material genético, como danos no DNA avaliados pelo teste do cometa e aumento na frequência de micronúcleos em profissionais com exposição prolongada. O estresse oxidativo também é associado à exposição aos RGA por induzir lipoperoxidação, danos oxidativos no DNA e comprometimento do sistema antioxidante em profissionais expostos. Conclusões Por tratar-se de questão de saúde pública, é imprescindível reconhecer os riscos ocupacionais relacionados aos RGA, inclusive genotoxicidade, mutagenicidade e estresse oxidativo. Urge a necessidade de mensuração dos RGA para conhecimento desses valores nas SO, especialmente em países em desenvolvimento, de normatização das concentrações máximas seguras de RGA nas SO, além de se adotarem práticas de educação com conscientização dos profissionais expostos.

Effect of dexmedetomidine in children undergoing general anesthesia with sevoflurane: a meta-analysis / Efeito da dexmedetomidina em crianças submetidas à anestesia geral com sevoflurano

Abstract Background and objectives: Sevoflurane is often used in pediatric anesthesia and is associated with high incidence of psychomotor agitation. In such cases, dexmedetomidine (DEX) has been used, but its benefit and implications remain uncertain. We assessed the effects of DEX on agitation in children undergoing general anesthesia with sevoflurane. Method: Meta-analysis of randomized clinical and double-blind studies, with children undergoing elective procedures under general anesthesia with sevoflurane, using DEX or placebo. We sought articles in English in PubMed database using the following terms: Dexmedetomidine, sevoflurane (Methyl Ethers/sevoflurante), and agitation (Psychomotor Agitation). Duplicate articles with children who received premedication and used active control were excluded. It was adopted random effects model with DerSimonian-Laird testing and odds ratio (OR) calculation for dichotomous variables, and standardized mean difference for continuous variables, with their respective 95% confidence interval (CI). Results: Of 146 studies identified, 10 were selected totaling 558 patients (282 in DEX group and 276 controls). The use of DEX was considered a protective factor for psychomotor agitation (OR = 0.17; 95% CI 0.13-0.23; p < 0.0001) and nausea and vomiting in PACU (OR = 0.49; 95% CI 0.35-0.68; p < 0.0001). Wake-up time and PACU discharge time were higher in the dexmedetomidine group. There was no difference between groups for extubation time and duration of anesthesia. Conclusion: Dexmedetomidine reduces psychomotor agitation during wake-up time of children undergoing general anesthesia with sevoflurane.

Resumo Justificativa e objetivos: Sevoflurano é frequentemente usado em anestesia pediátrica e está associado à alta incidência de agitação psicomotora ao despertar. Nesses casos a dexmedetomidina (dex) tem sido usada, porém permanecem incertos seus benefícios e suas implicações. Foram avaliados os efeitos da dex sobre a agitação no despertar de crianças submetidas à anestesia geral com sevoflurano. Método: Metanálise de ensaios clínicos randomizados e duplamente encobertos, com crianças submetidas a procedimentos eletivos sob anestesia geral com sevoflurano, que usaram dex ou placebo. Buscaram-se artigos em língua inglesa na base de dados Pubmed com termos como Dexmedetomidine, sevoflurane (Methyl Ethers/sevoflurane) e agitation (Psychomotor Agitation). Artigos duplicados, com crianças que receberam medicação pré-anestésica e que usaram controle ativo foram excluídos. Adotou-se modelo de efeitos aleatórios com testes de DerSimonian-Laird e cálculo de odds ratio (OR) para variáveis dicotômicas e diferença de média padronizada para variáveis contínuas, com seus respectivos intervalos de confiança de 95% (IC). Resultados: Dos 146 estudos identificados, 10 foram selecionados, com 558 pacientes (282 no grupo dex e 276 controles). O uso da dex foi considerado fator de proteção para agitação psicomotora (OR = 0,17; 95% IC 0,13-0,23; p < 0,0001) e para náuseas e vômitos na SRPA (OR = 0,49; 95% IC 0,35-0,68; p < 0,0001). Tempo para despertar e para alta da SRPA foram maiores no grupo dexmedetomidina. Não houve diferença entre os grupos para tempo de extubação e duração da anestesia. Conclusão: A dexmedetomidina reduz a agitação psicomotora no despertar de crianças submetidas à anestesia geral com sevoflurano.

Can thiamine pyrophosphate prevent desflurane induced hepatotoxicity in rats?

ABSTRACT PURPOSE : To investigate the effects of thiamine pyrophosphate (TPP) against desflurane induced hepatotoxicity. METHODS : Thirty experimental animals were divided into groups as healthy (HG), desflurane control (DCG) , TPP and desflurane group (TDG). 20 mg/kg TPP was injected to intraperitoneally TDG. After one hour of TPP administration, desflurane was applied for two hours. After 24 hours, liver tissues of the animals killed with decapitation were removed. The oxidant/antioxidant levels and ALT, AST and LDH activities were measured. The histopathological examinations were performed in the liver tissues for all rats. RESULTS : Notwithstanding the levels of oxidants and liver enzymes were significantly increased (p<0.0001), antioxidant levels were significantly decreased in DCG (p<0.0001). On contrary to the antioxidant parameters were increased (p<0.05) the oxidant parameters and liver enzymes were decreased in TDG (p<0.0001). Whereas multiple prominent, congestion, hemorrhage and dilatation were observed in sinusoids and lymphocyte-rich inflammation results in the centrilobular and portal areas of liver tissue in DCG, these findings were observed less frequently in TDG. CONCLUSİON : Thiamine pyrophosphate prevented liver oxidative damage induced with desflurane and may be useful in prophylaxis of desflurane induced hepatotoxicity.

Conservative treatment of Angle Class III malocclusion with anterior crossbite

Angle Class III malocclusion is characterized by anteroposterior dental discrepancy which might be associated or not with skeletal changes. Class III molar relationship is associated with vertical or lingually tipped mandibular incisors and a usually concave profile. These characteristics seriously affect facial esthetics and most frequently are the reason why patients seek orthodontic treatment. This case was presented to the committee of the Brazilian Board of Orthodontics and Facial Orthopedics (BBO) as part of the requisites to become a BBO Diplomate.

A má oclusão de Classe III de Angle é caracterizada por uma discrepância dentária anteroposterior, que pode ou não estar acompanhada por alterações esqueléticas. Observa-se uma relação molar de Classe III associada ao posicionamento vertical ou retroinclinado dos incisivos inferiores e, geralmente, perfil facial côncavo. Esse aspecto gera grande comprometimento estético na face, sendo justamente esse o fator que, na maioria das vezes, motiva o paciente a procurar pelo tratamento ortodôntico. O presente caso clínico foi apresentado à Diretoria do Board Brasileiro de Ortodontia e Ortopedia Facial (BBO) como parte dos requisitos para a obtenção do título de Diplomado pelo BBO.

Effect-Site Concentration of Remifentanil for Minimizing Cardiovascular Changes by Inhalation of Desflurane

PURPOSE: This study aims to investigate the most appropriate effect-site concentration of remifentanil to minimize cardiovascular changes during inhalation of high concentration desflurane. MATERIALS AND METHODS: Sixty-nine American Society of Anesthesiologists physical status class I patients aged 20-65 years were randomly allocated into one of three groups. Anesthesia was induced with etomidate and rocuronium. Remifentanil was infused at effect-site concentrations of 2, 4 and 6 ng/mL in groups R2, R4 and R6, respectively. After target concentrations of remifentanil were reached, desflurane was inhaled to maintain the end-tidal concentration of 1.7 minimum alveolar concentrations for 5 minutes (over-pressure paradigm). The systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate (HR) and end-tidal concentration of desflurane were measured for 5 minutes. RESULTS: The end-tidal concentration of desflurane increased similarly in all groups. The SBP, DBP, MAP and HR within group R4 were not significantly different as compared with baseline values. However, measured parameters within group R2 increased significantly 1-3 minutes after desflurane inhalation. The MAP within group R6 decreased significantly at 1, 2, 4, and 5 minutes (p<0.05). There were significant differences in SBP, DBP, MAP and HR among the three groups 1-3 minutes after inhalation (p<0.05). The incidence of side effects such as hyper- or hypo-tension, and tachy- or brady-cardia in group R4 was 4.8% compared with 21.8% in group R2 and 15.0% in group R6. CONCLUSION: The most appropriate effect-site concentration of remifentanil for blunting hemodynamic responses by inhalation of high concentration desflurane is 4 ng/mL.