Study of the potential toxicity of adrenaline to neurons, using the SH-SY5Y human cellular model

Abstract Prolonged overexposure to catecholamines causes toxicity, usually credited to continuous adrenoceptor stimulation, autoxidation, and the formation of reactive pro-oxidant species. Non-differentiated SH-SY5Y cells were used to study the possible contribution of oxidative stress in adrenaline (ADR)-induced neurotoxicity, as a model to predict the toxicity of this catecholamine to peripheral nerves. Cells were exposed to several concentrations of ADR (0.1, 0.25, 0.5 and 1mM) and two cytotoxicity assays [lactate dehydrogenase (LDH) release and 3-(4,5-dimethylthiazol-2yl)-2,5-diphenyl tetrazolium bromide (MTT) reduction] were performed at several time-points (24, 48, and 96h). The cytotoxicity of ADR was concentration- and time-dependent in both assays, since the lowest concentration tested (0.1mM) also caused significant cytotoxicity at 96h. N-acetyl-cysteine (1mM), a precursor of glutathione synthesis, prevented ADR-induced toxicity elicited by 0.5mM and 0.25mM ADR following a 96-h exposure, while the antioxidant Tiron (100µM) was non-protective. In conclusion, ADR led to mitochondrial distress and ultimately cell death in non-differentiated SH-SY5Y cells, possibly because of ADR oxidation products. The involvement of such processes in the catecholamine-induced peripheral neuropathy requires further analysis.

Guia prático de urticária aguda / Practical guide to acute urticaria

A urticária aguda é uma causa frequente de consulta com alergistas, caracterizada por urticas e/ou angioedema. Embora autolimitada e benigna, pode causar desconforto significativo e raramente representar uma doença sistêmica grave ou reação alérgica com risco de vida. Nesta revisão, elaborada pelo Departamento Científico de Urticária da Associação Brasileira de Alergia e Imunologia, foram abordadas as principais questões referentes ao tema para auxiliar o médico especialista e generalista.

Acute urticaria is a frequent cause of consultations with allergists, being characterized by wheals and/or angioedema. Although self-limited and benign, it may cause significant discomfort and uncommonly represent a serious systemic disease or life-threatening allergic reaction. In this review prepared by the Urticaria Scientific Department of the Brazilian Association of Allergy and Immunology, the main questions about this topic are addressed to help specialists and general practitioners.

El auge y la caída del mito de la epinefrina en la mano / The Rise and Fall of the Epinephrine Myth in the Hand

La posibilidad de operar a los pacientes con afecciones de la mano bajo anestesia local con la lidocaína y la epinefrina usando la técnica WALANT provocó una revolución en la cirugía de la mano, que facilitó la vida de los pacientes y disminuyó los costos de los servicios hospitalarios. Es necesario que los cirujanos conozcan la técnica y la historia de esta técnica. El objetivo fue identificar los orígenes del auge y la caída del mito y del dogma de la prohibición de la adrenalina en los bloqueos anestésicos de los dedos. Se realizó un análisis crítico de los principales textos de los artículos y los libros sobre el uso de la epinefrina en la anestesia de los dedos. La creación del mito de prohibir el uso de la epinefrina en los bloqueos anestésicos de los dedos se produjo debido a la mala interpretación de los informes de los casos de necrosis ocurridos que, en realidad, no fueron causados por la epinefrina. Ese mito influyó en la aparición de un dogma. La historia del uso de la epinefrina en los bloqueos de los dedos anestésicos demuestra que las interpretaciones superficiales y erróneas de las complicaciones clínicas publicadas como informes de casos pueden generar mitos y dogmas. Solo la ciencia puede prevenir y destruir tales mitos y dogmas médicos(AU)

The possibility of operating patients with hand conditions under local anesthesia, with lidocaine and epinephrine, using WALANT technique caused a revolution in hand surgery, which made life easier for patients and lowered the costs of hospital services. Surgeons need to be aware of the possibilities and history of WALANT technique. The objective was to identify the origins of the rise and fall of the myth and dogma of the prohibition of adrenaline in anesthetic finger blocks. A critical analysis of the main texts of the articles and books on the use of epinephrine in finger anesthesia was carried out. The conception of the myth of banning the use of epinephrine in anesthetic finger blocks occurred due to misinterpretation of reports of necrosis occurring, which were not actually caused by epinephrine. That myth influenced the appearance of a dogma. The history of the use of epinephrine in anesthetic finger blocks demonstrates that superficial and misleading interpretations of clinical complications published as case reports can breed myth and dogma. Only science can prevent and destroy such medical myths and dogmas(AU)

Assessment of The Addition of Epinephrine to Intra-articular Bupivacaine for the Control of Acute Pain in Patients underwent to Anterior Cruciate Ligament Reconstruction / Avaliação da adição da epinefrina à bupivacaína intra-articular no controle da dor aguda em pacientes submetidos a reconstrução do ligamento cruzado anterior

Abstract Objective To evaluate postoperative pain, using the visual analog scale (VAS), in patients undergoing anterior cruciate ligament reconstruction (ACLR) and receiving intra-articular anesthetic solutions. Methods The present is a randomized clinical trial with a sample of 48 patients divided into 4 groups: Group I (n » 12) - 20 mL of saline solution (control); Group II (n » 12) - 20 mL of 0.5% bupivacaine; Group III (n » 12) - 20 mL of 0.5% bupivacaine þ 0.1 mg of epinephrine; and Group IV (n » 12) - 20 mL of saline solution þ 0.1 mg of epinephrine. These solutions were injected into the knee at the end of the surgery. Pain was assessed using the VAS immediately and 6, 12, 24 and 48 hours after the procedure. Results The VAS scores were highly variable among the groups. A Kruskal-Wallis analysis of variance (ANOVA), considering a level of significance of 5%, revealed that all intra-articular anesthetic solutions influenced the assessment of pain (p » 0.003), and that Group-III subjects presented less postoperative pain. There was no evidence of a higher or lower use of supplemental analgesic agents, or of adverse effects resulting from these anesthetic solutions. Conclusion Bupivacaine combined with epinephrine was the most effective solution for pain control in patients undergoing ACLR, but with no statistically significant differences when compared to Group II (p » 0.547). There was no decrease or increase in the use of supplemental analgesics or in the occurrence of adverse systemic effects (p > 0.05).

Resumo Objetivo Avaliar primariamente a dor pós-operatória, por meio da escala visual analógica (EVA), nos pacientes submetidos a reconstrução do ligamento cruzado anterior (RLCA) que receberam soluções anestésicas intra-articulares (IAs). Métodos Ensaio clínico randomizado com uma amostra de 48 pacientes, divididos em 4 grupos: Grupo I (n » 12) - 20 ml de solução fisiológica (controle); Grupo II (n » 12) - 20 ml de bupivacaína a 0,5%; Grupo III (n » 12) - 20 ml de bupivacaína a 0,5% þ 0,1 mg de epinefrina; e Grupo IV (n » 12) - 20 ml de solução fisiológica þ 0,1 mg de epinefrina, injetados no joelho ao término da cirurgia. A dor foi avaliada pela EVA imediatamente e 6, 12, 24 e 48 horas após o procedimento. Resultados Observou-se grande variabilidade nos resultados da EVA entre os pacientes avaliados em cada grupo. Verificou-se, pela análise de variância (analysis of variance, ANOVA) de Kruskal-Wallis, considerando um nível de 5% de significância, que as soluções anestésicas IAs de cada grupo influenciaram na avaliação da dor desses pacientes (p » 0,003), sendo os do Grupo III os que apresentaram menor dor pósoperatória. Não se evidenciou um maior ou menor consumo de drogas analgésicas suplementares, ou efeitos adversos das decorrentes das soluções empregadas. Conclusão A solução combinada de bupivacaína e epinefrina foi a mais eficaz no controle da dor nos pacientes submetidos a RLCA, mas sem diferenças estatisticamente significativas com relação ao grupo II (p » 0,547). Não se observou diminuição ou aumento no consumo de analgésicos suplementares, ou o aparecimento de efeitos sistêmicos adversos (p > 0,05).

Aplicación de la técnica WALANT en las cirugías de mano / Use of WALANT Technique in Hand Surgeries

Introducción: En los últimos años la anestesia local sin torniquete y con el paciente despierto, técnica conocida por WALANT (por sus siglas en inglés), ha ganado mucha popularidad en las cirugías de la mano y la muñeca. Objetivo: Reportar nuestra experiencia con el uso de la técnica WALANT, a fin de prescindir del uso del torniquete en las cirugías de la mano. Métodos: En noviembre del 2020 fueron intervenidos 30 pacientes por diversas enfermedades ortopédicas, entre las que figuraron: dedos en resorte, síndrome del túnel carpiano, tenovaginitis estenosante del pulgar, gangliones del carpo y amputación del tercer radio por rigidez en extensión postraumática, entre otras. Para la evaluación de la técnica tuvimos en cuenta: tiempo quirúrgico, magnitud del sangrado, dolor durante la infiltración anestésica, la intervención, y en las primeras 24 horas del postoperatorio, la necesidad de refuerzo anestésico, uso de isquemia, complicaciones y nivel de satisfacción del paciente. Resultados: Los resultados obtenidos con esta técnica anestésica son semejantes a otras, con las ventajas que el sangrado es leve, no hay que utilizar isquemia, el tiempo quirúrgico es menor y el efecto anestésico duró entre 10 y 12 horas en todos los pacientes. En ninguno de los pacientes hubo necesidad de refuerzo anestésico. Conclusiones: Se demuestra la efectividad de la técnica WALANT en las cirugías de mano. Con ella se disminuye el gasto de materiales para el acto quirúrgico, así como de personal, es de fácil aplicación y disminuyen las sensaciones desagradables y los peligros del uso de isquemia en los pacientes(AU)

Introduction: Currently, the use of local anaesthetic with no tourniquet and wide awake patient (Wide Awake Local Anaesthetic No Tourniquet - WALANT) has gained popularity in surgeries of the hand and wrist. Objective: To report our experience in the use of WALANT technique in order to discard the use of tourniquet in hand surgeries. Method: In November 2020, thirty patients underwent surgery due to different orthopaedic conditions, among them trigger fingers, carpal tunnel syndrome, stenosing tenovaginitis of the thumb, carpal ganglion and amputation of the third radius due to post trauma stiffness, among others. In order to assess this technique, we considered surgical time, volume of bleeding, pain during anesthetic infiltration, intervention and the need for additional anesthetic during the first 24 hours after surgery; we considered also ischemia, complications and level patient´s satisfaction. Results: This technique had similar results to others; however, the bleeding is mild, there is no need for ischemia, the surgical time is lesser and the anesthetic effect lasted 10 to 12 hours in all patients. None of them required additional anesthetic. All subjects felt the initial infiltration but none complained of pain during the rest of the anesthetic injection or during the surgical act. There were no complications. Conclusions: The effectiveness of WALANT technique in hand surgeries is shown. The cost of materials for the surgical act is reduced with it, as well as the surgical staff, it is easy to use and unpleasant sensations and dangers of the use of ischemia in patients are reduced(AU)

Anestesia local con epinefrina, sin manguito hemostático, para la liberación del túnel carpiano. Estudio comparativo de dos variantes técnicas en 89 casos / WALANT in carpal tunnel release. Comparative study of two technical variants in 89 cases

Objetivo: Evaluar la eficacia intra- y posoperatoria, y la comodidad para el paciente de dos variantes de la anestesia en dos grupos con síndrome del túnel carpiano. Materiales y Métodos: Estudio descriptivo, comparativo, retrospectivo, observacional mediante un cuestionario telefónico de 12 ítems sobre la anestesia local sin manguito. Se incorporó a pacientes con síndrome del túnel car-piano operados entre 2008 y 2019, mediante un miniabordaje abierto, y se los dividió en: grupo 1: lidocaína al 2% más bupivacaína al 0,5% más epinefrina 1:200.000 más sedación ligera (n = 32) y grupo 2: lidocaína al 2% más epinefrina 1:200.000 (n = 57). Resultados: Se evaluó a 89 pacientes (media de edad 66.9 años). Todos se mostraron satisfechos y confirmaron que volverían a elegir este procedimiento. No hubo diferencias significativas en la comodidad o el posible desarrollo de síntomas intra- o posoperatorios entre ambos grupos. La permanencia posoperatoria fue de 1-3 h, sin hospitalización. El sangrado fue mínimo. Conclusiones: La liberación del túnel carpiano bajo anestesia local más epinefrina, sin manguito hemostático, resultó segura y sin complicaciones. Los pacientes no refirieron dolor local intraoperatorio ni posoperatorio inmediato, ni en el sitio del torniquete. La permanencia en el centro asistencial fue breve. La estancia corta y la menor cantidad de elementos empleados (anestésicos, manguito) implican una reducción de los costos del procedimiento. Si bien es recomendable la presencia de un anestesiólogo, puede llegar a realizarse en ámbitos adecuados sin él. No se recomienda su empleo sin estudios prequirúrgicos ni fuera del quirófano. Nivel de Evidencia: III

Objective: To evaluate the intraoperative and postoperative efficacy and comfort of two variants of anesthesia in two groups with carpal tunnel syndrome (CTS). Materials and Methods: Descriptive, comparative, retrospective, observational study using a 12-item telephone questionnaire on local anesthesia without a tourniquet. We included patients with CTS who underwent surgery between 2008 and 2019 with a mini-open approach and divided them into two groups: 1) 2% lidocaine plus 0.5% bupivacaine plus 1:200,000 epinephrine plus light sedation (n = 32) and 2) 2% lidocaine plus epinephrine 1:200,000 (n = 57). Results: 89 patients were evaluated (mean age 66.9 years). All patients were satisfied and confirmed they would choose this procedure again. There were no significant differences in comfort or the possible development of intra- or postoperative symptoms between the two groups. The postoperative stay was 1-3 hours; hospitalization was not required. The bleeding was minimal. Conclusion: Carpal tunnel release under local anesthesia with lidocaine + epinephrine, without a tourniquet, has proven to be a safe procedure with no complications. The patients did not complain of local immediate intraoperative or postoperative pain or pain at the site of the tourniquet. The stay in the healthcare facility was shorter. The short stay and the fewer elements used (anesthetics, tourniquet) imply a reduction in the costs of the procedure. Though the presence of an anaesthesiologist is recommended, the procedure can be performed in appropriate settings without one. We do not recommend its use without preoperative studies or outside the operating room. Level of Evidence: III

Trends of vasopressor use in intensive care units in Colombia / Tendencias de consumo de vasopresores en unidades de cuidados intensivos de Colombia

Abstract Introduction Vasopressors are essential in the management of various types of shock. Objective To establish the trend of vasopressors use in the intensive care units (ICU) in a population of patients affiliated with the Colombian Health System, 2010-2017. Methods Observational trial using a population database of patients hospitalized in eleven ICUs in various cities in Colombia. The drugs dispensed to hospitalized patients over 18 years old, from January 2010 until December 2017 were considered. A review and analysis of the vasopressors dispensed per month was conducted, taking into account sociodemographic and pharmacological variables (vasopressor used and daily doses defined per 100/beds/day (DBD). Results 81,348 dispensations of vasopressors, equivalent to 26,414 treatments in 19,186 patients receiving care in 11 hospitals from 7 cities were reviewed. The mean age of patients was 66.3±18.1 years and 52.6 % were males. Of the total number of treatments recorded, 17,658 (66.8 %) were with just one vasopressor. Norepinephrine was the most frequently prescribed drug (75.9 % of the prescriptions dispensed; 60.5 DBD), followed by adrenaline (26.6 %; 41.6 DBD), dopamine (19.4%), dobutamine (16.0 %), vasopressin (8.5 %) and phenylephrine (0.9 %). The use of norepinephrine increased from 2010 to 2017 (+6.19 DBD), whilst the use of other drugs decreased, particularly the use of adrenaline (-60.6 DBD) and dopamine (-10.8 DBD). Conclusions Norepinephrine is the most widely used vasopressor showing a growing trend in terms of its use during the study period, which is supported by evidence in favor of its effectiveness and safety in patients with shock.

Resumen Introducción Los fármacos vasopresores son fundamentales en el manejo de los diferentes tipos de choque. Objetivo Determinar la tendencia de utilización de fármacos vasopresores en unidades de cuidados intensivos (UCI) en una población de pacientes afiliados al Sistema de Salud de Colombia, 2010-2017. Métodos Estudio observacional, a partir de una base de datos poblacional con pacientes hospitalizados en once UCI de diferentes ciudades de Colombia. Se obtuvieron las dispensaciones de pacientes mayores de 18 años hospitalizados desde enero de 2010 hasta diciembre de 2017. Se hizo revisión y análisis de la dispensación mensual de vasopresores. Se consideraron variables sociodemográficas y farmacológicas (medicamento vasopresor usado y dosis diarias definidas por 100 camas/día [DCD]). Resultados Se revisaron 81.348 dispensaciones de vasopresores, equivalentes a 26.414 terapias en 19.186 pacientes atendidos en 11 hospitales de 7 ciudades, cuya edad promedio fue 66,3±18,1 años y el 52,6 % eran hombres. Del total de terapias registradas, 17.658 (66,8 %) fueron con un solo vasopresor. La norepinefrina fue el más comúnmente prescrito (75,9 % de las dispensaciones; 60,5 DCD), seguido por adrenalina (26,6 %; 41,6 DCD), dopamina (19,4 %), dobutamina (16,0 %), vasopresina (8,5 %) y fenilefrina (0,9 %). El uso de norepinefrina se incrementó de 2010 a 2017 (+6,19 DCD), mientras que el de otros fármacos disminuyó, especialmente adrenalina (-60,6 DCD) y dopamina (-10,8 DCD). Conclusiones La norepinefrina es el fármaco vasopresor más utilizado y el que ha demostrado una tendencia de uso incremental durante el periodo de estudio, lo cual está respaldado por evidencia a favor de su efectividad y seguridad en pacientes con choque.

Cirugía de mano con anestesia local con técnica WALANT. Experiencia con una serie de casos / Hand surgery with local anesthesia with WALANT technique. Experience with a cases series

Resumen Introducción: Los procedimientos en cirugía de mano requieren el uso de torniquete para evitar el sangrado y, generalmente, utilizan sedación por anestesiología para controlar el dolor e incomodidad del torniquete. Hace una década se viene usando en cirugía de mano anestesia local sin torniquete ni sedación, como una opción segura y eficiente para las intervenciones quirúrgicas; esta técnica es conocida como WALANT (en inglés). El objetivo del trabajo es evaluar una serie prospectiva de pacientes intervenidos con técnica de WALANT en cirugía de mano. Métodos: Es una serie de casos que caracteriza el desempeño de una técnica anestésica local para procedimientos en cirugía de mano sin sedación y sin torniquete. Se evaluaron tiempo de cirugía, dolor intra- y posoperatorio y nivel de satisfacción. Este trabajo es aceptado por el comité de ética. Resultados: Se operaron 96 pacientes, 73 fueron cirugías de partes blandas y 23 de partes óseas. 92 pacientes (96 %) refirieron estar satisfechos y sin dolor posoperatorio. En 4 casos fue necesaria sedación intraoperatoria. Ningún paciente requirió torniquete. No fue necesario usar volúmenes mayores a 40 ml, sin embargo, estos varían según el tipo de intervención. Conclusiones: Este estudio muestra que la técnica funciona muy bien, y es de gran utilidad en cirugías de tendones, donde se requiere que el paciente esté despierto para evaluar el funcionamiento intraoperatorio. Los costos de cirugía son más baratos y es una técnica reproducible, con un desempeño satisfactorio.

Abstract Introduction: Procedures in hand surgery require tourniquet use to control bleeding and generally sedation by anesthesiology to manage the pain and discomfort of the tourniquet. A decade ago, local anesthesia without tourniquet or sedation was used in hand surgery as a safe and efficient option for surgical interventions, known as WALANT (Wide Awake Local Anesthesia with No Tournique) technique. The aim of the study is to evaluate a prospective series of patients who have undergone surgery with the WALANT technique in hand surgery. Methods: Consecutive series of cases that show the performance of a local anesthetic technique for procedures in hand surgery without sedation and without tourniquet. Surgery time, intra and postoperative pain and satisfaction level were evaluated. This study was accepted by the ethics committee. Results: Ninety-six patients underwent surgery, seventy-three were soft tissue surgery and twenty-three bone surgery. Ninety-two patients (96%) reported being satisfied and without postoperative pain. In four cases, intraoperative sedation was necessary. No patient required a tourniquet. It was not necessary to use volumes greater than 40 ml; however, these vary according to the type of intervention. Conclusions: This study shows that the technique works very well and is very useful in tendon surgeries, where the patient is required to be awake to evaluate intraoperative functioning. Surgery costs are cheaper, and it is a reproducible technique with satisfactory performance.

Guia Prático de Atualização no tratamento da exacerbação de asma na criança e no adolescente ­ Posicionamento conjunto da Associação Brasileira de Alergia e Imunologia e Sociedade Brasileira de Pediatria / Practical Update Guide on the treatment of asthma exacerbation in children and adolescents ­ Joint position of the Brazilian Association of Allergy and Immunology and the Brazilian Society of Pediatrics

Exacerbação aguda de asma é uma condição frequente na criança e no adolescente e uma das causas mais comuns de procura aos pronto atendimentos e de internações. Pode ocorrer em pacientes que ainda não foram diagnosticados como asmáticos, e mesmo naqueles cujo controle da doença não se encontre adequado. Reconhecer a exacerbação e iniciar seu tratamento desde o domicílio até o adequado manejo inicial em ambiente hospitalar é fundamental para evitar sua evolução para complicações que coloquem o paciente em risco de vida. O tratamento compreende o reconhecimento e tratamento da hipoxemia, da obstrução e do processo inflamatório, além de fornecer orientações na alta hospitalar e encaminhamentos para continuidade do tratamento.

Acute exacerbation of asthma is a frequent condition in children and adolescents and one of the most common causes of seeking emergency care and hospitalization. It can occur in patients who have not yet been diagnosed with asthma, and even in those whose disease control is not adequate. Recognizing the exacerbation and starting its treatment from home until proper initial management in a hospital environment is essential to avoid its evolution to complications that put the patient at risk of life. Treatment comprises the recognition and treatment of hypoxemia, obstruction, and the inflammatory process, in addition to providing guidance at hospital discharge and referrals for continued treatment.

Anafilaxia no primeiro ano de vida: como diagnosticar / Anaphylaxis in the first year of life: how to diagnose

A anafilaxia é uma reação alérgica mais grave e potencialmente fatal. Apresenta-se quase sempre com manifestações cutâneas, acompanhadas por acometimento dos sistemas respiratório, gastrointestinal, nervoso e cardiovascular. Indivíduos de todas as faixas etárias podem manifestar anafilaxia, e seu diagnóstico no primeiro ano de vida é difícil por ser o lactente incapaz de expressar de modo claro as sensações vividas durante o episódio agudo. Nessa faixa etária os alimentos são os agentes desencadeantes mais envolvidos, embora medicamentos e veneno de himenópteros também o sejam. Em pacientes submetidos a várias cirurgias e procedimentos médicos a alergia ao látex pode ocorrer. A adrenalina intramuscular é a primeira linha de tratamento da anafilaxia na fase inicial, mas continua sendo subutilizada. Além disso, medidas de suporte, tais como decúbito supino, reposição de fluidos, vias aéreas pérvias e oxigenação, devem ser instituídas. Após a alta, o paciente deve ser encaminhado à avaliação e seguimento por especialista visando à identificação do agente desencadeante, assim como educar responsáveis/cuidadores destes pacientes sobre a prevenção de novos episódios. É importante que esse paciente tenha consigo algum tipo de identificação que o aponte como tendo tido episódio de anafilaxia, sobretudo se tiver sido recorrente. A oferta de um plano escrito de como proceder diante de um novo episódio é fundamental.

Anaphylaxis is a serious and potentially fatal allergic reaction. Most frequently, it features cutaneous manifestations accompanied by involvement of the respiratory, gastrointestinal, nervous, and/or cardiovascular systems. Individuals of all age groups may present with anaphylaxis, and its diagnosis in the first year of life is difficult because the infant is unable to clearly express the sensations experienced during the acute episode. In this age group, foods are the most common triggering agents, together with medications and Hymenoptera venom. In patients undergoing multiple surgeries and medical procedures, latex allergy may occur. Intramuscular epinephrine is the first line of treatment for early anaphylaxis, but it remains underutilized. In addition, supportive measures such as supine decubitus, fluid replacement, patent airways, and oxygenation should be instituted. After discharge, the patient should be referred for evaluation and follow-up by a specialist, with the purpose of identifying the triggering agent as well as educating the caregivers of these patients about the prevention of new episodes. This patient should always carry some type of identification that indicates that he/she has had any episode of anaphylaxis, especially if it has been recurrent. Providing a written plan of how to proceed in the face of a new episode is essential.

Evolución clínica de niños con shock séptico refractario a fluidos tratados con dopamina o adrenalina. Estudio retrospectivo en un servicio de emergencias pediátrico de Argentina / Clinical outcome of children with fluid-refractory septic shock treated with dopamine or epinephrine. A retrospective study at a pediatric emergency department in Argentina

RESUMEN Objetivo: Analizar la evolución clínica de niños con shock séptico refractario a volumen tratados inicialmente con dopamina o adrenalina. Métodos: Estudio de cohorte retrospectivo con ámbito en un servicio de urgencias pediátrico de un hospital de tercer nivel. Población: niños ingresados con shock séptico refractario a volumen. Se comparó la evolución clínica entre 2 grupos: Grupo Dopamina y Grupo Adrenalina. Las variables de interés fueron: uso de ventilación mecánica invasiva, días de inotrópicos, estancia hospitalaria, estancia en cuidados intensivos y mortalidad. Para variables numéricas y categóricas utilizamos medidas de tendencia central y para comparación las pruebas de U Mann Whitney y χ2 test. Resultados: Incluimos 118 pacientes. El 58,5% recibió dopamina y 41,5% adrenalina. El uso de ventilación mecánica invasiva fue 38,8% para adrenalina versus 40,6% para dopamina (p = 0,84) con una mediana de 4 días para adrenalina y 5,5 para dopamina (p = 0,104). La mediana para días de inotrópicos fue de 2 días para ambos grupos (p = 0,714). La mediana de estancia hospitalaria fue de 11 para adrenalina y 13 para dopamina (p = 0,554) y de estancia en cuidados intensivos se registró una mediana de 4 días (0 - 81 días) siendo igual en ambos grupos (p = 0,748). La mortalidad fue de 5% para el Grupo Adrenalina versus 9% para el Grupo Dopamina (p = 0,64). Conclusiones: En nuestro centro, no observamos diferencias en uso de ventilación mecánica invasiva y tiempo de inotrópicos, estancia hospitalaria y cuidados intensivos y mortalidad entre niños ingresados al servicio de urgencias pediátrico con diagnóstico de shock séptico refractario a volumen tratados inicialmente con dopamina o adrenalina.

Abstract Objective: To analyze the clinical outcome of children with fluid-refractory septic shock initially treated with dopamine or epinephrine. Methods: A retrospective cohort study was conducted at a pediatric emergency department of a tertiary hospital. Population: children admitted because of fluid-refractory septic shock. Clinical outcome was compared between two groups: Dopamine and Epinephrine. Variables evaluated were use of invasive mechanical ventilation, days of inotropic therapy, length of hospital stay, intensive care stay, and mortality. For numerical and categorical variables, we used measures of central tendency. They were compared by the Mann-Whitney U-test and the (2 test. Results: We included 118 patients. A total of 58.5% received dopamine and 41.5% received epinephrine. The rate of invasive mechanical ventilation was 38.8% for epinephrine versus 40.6% for dopamine (p = 0.84), with a median of 4 days for the Epinephrine Group and 5.5 for the Dopamine Group (p = 0.104). Median time of inotropic therapy was 2 days for both groups (p = 0.714). Median hospital stay was 11 and 13 days for the Epinephrine and Dopamine groups, respectively (p = 0.554), and median stay in intensive care was 4 days (0 - 81 days) in both groups (p = 0.748). Mortality was 5% for the Epinephrine Group versus 9% for the Dopamine Group (p = 0.64). Conclusions: At our center, no differences in use of invasive mechanical ventilation, time of inotropic therapy, length of hospital stay, length of intensive care unit stay, or mortality were observed in children admitted to the pediatric emergency department with a diagnosis of fluid-refractory septic shock initially treated with dopamine versus epinephrine.

Acidente com autoinjetor de adrenalina / Accidental use of an adrenaline autoinjector

A anafilaxia é uma reação alérgica potencialmente fatal. Autoinjetor pode ser prescrito para tratamento precoce nesses casos. Relatamos o caso de uma criança que fez uso acidental de adrenalina autoinjetora que ao exame de imagem evidenciou falange distal com fratura. Objetivamos alertar a importância de orientar o paciente e seus familiares acerca do uso correto desse dispositivo.

Anaphylaxis is a potentially fatal allergic reaction. Autoinjection can be prescribed for early treatment in these cases. We report the case of a child who accidentally used an adrenaline autoinjector and then had a distal phalanx fracture on imaging examination. We aim to draw attention to the importance of carefully guiding patients and their families about the correct use of this device.

Abordagem das reações de hipersensibilidade perioperatória: Orientações da Sociedade Brasileira de Anestesiologia e da Associação Brasileira de Alergia e Imunologia - Parte II: etiologia e diagnóstico / Approach to perioperative hypersensitivity reactions: Guidelines from the Brazilian Society of Anesthesiology and the Brazilian Association of Allergy and Immunology - Part II: etiology and diagnosis

A anafilaxia perioperatória é manifestação importante no contexto de eventos adversos relacionados à cirurgia. Embora frequentemente relacionada à indução anestésica, pode ocorrer por outros agentes administrados por outras vias. A anafilaxia pode se apresentar como colapso cardiovascular, obstrução da via aérea e/ou insuficiência respiratória com ou sem manifestação cutânea, com consequências fatais em muito casos. Apesar de considerada inevitável em alguns casos, a sua incidência poderia (e deveria) ser reduzida através da busca por fármacos mais seguros. A avaliação abrangente de um episódio é um dos elementos primordiais para tornar a exposição subsequente mais segura, com orientações derivadas dessa investigação. Entretanto, representa um desafio estatístico por ser reação rara, randômica e muitas vezes independente de exposições sucessivas dos pacientes a procedimentos de baixo risco. Neste documento são revisados os mecanismos fisiopatológicos, agentes desencadeantes (adultos e crianças), assim como a abordagem diagnóstica durante a crise e após o episódio. Uma avaliação abrangente, a identificação das medicações, antissépticos e outras substâncias usadas em cada região, registros detalhados e nomenclatura padronizada são pontos fundamentais para a obtenção de dados epidemiológicos mais fidedignos sobre a anafilaxia perioperatória.

Perioperative anaphylaxis is an important manifestation in the context of surgery-related adverse events. Although often related to anesthetic induction, it may be caused by other agents administered by other routes. Anaphylaxis may manifest as cardiovascular collapse, airway obstruction and/or respiratory failure with or without skin manifestation, resulting often in death. Although this reaction is considered inevitable in some cases, its incidence could (and should) be reduced by the search for safer drugs. Comprehensive assessment of an allergic reaction is a key element to make subsequent exposure safer, with guidance derived from this investigation. However, surveillance of perioperative anaphylaxis represents a statistical challenge because this is a rare, random reaction and often independent of successive patient exposures to low-risk procedures. This paper reviews pathophysiological mechanisms, triggering agents (adults and children), as well as therapeutic and diagnostic approach during and after an allergic reaction. Comprehensive assessment, identification of medications/antiseptics used in each region and detailed records with standardized terminology are key points for obtaining more reliable epidemiological data on perioperative anaphylaxis.

Atualização sobre reações de hipersensibilidade perioperatória: Documento conjunto da Sociedade Brasileira de Anestesiologia e Associação Brasileira de Alergia e Imunologia ­ Parte II: etiologia e diagnóstico / Update on perioperative hypersensitivity reactions: Joint document from the Brazilian Society of Anesthesiology and Brazilian Association of Allergy and Immunology ­ Part II: Etiology and diagnosis

A anafilaxia perioperatória é manifestação importante no contexto de eventos adversos relacionados à cirurgia. Embora frequentemente relacionada à indução anestésica, pode ocorrer por outros agentes administrados por outras vias. A anafilaxia pode se apresentar como colapso cardiovascular, obstrução da via aérea e/ou insuficiência respiratória com ou sem manifestação cutânea, com consequências fatais em muito casos. Apesar de considerada inevitável em alguns casos, a sua incidência poderia (e deveria) ser reduzida através da busca por fármacos mais seguros. A avaliação abrangente de um episódio é um dos elementos primordiais para tornar a exposição subsequente mais segura, com orientações derivadas dessa investigação. Entretanto, representa um desafio estatístico por ser reação rara, randômica e muitas vezes independente de exposições sucessivas dos pacientes a procedimentos de baixo risco. Neste documento são revisados os mecanismos fisiopatológicos, agentes desencadeantes (adultos e crianças), assim como a abordagem diagnóstica durante a crise e após o episódio. Uma avaliação abrangente, a identificação das medicações, antissépticos e outras substâncias usadas em cada região, registros detalhados e nomenclatura padronizada são pontos fundamentais para a obtenção de dados epidemiológicos mais fidedignos sobre a anafilaxia perioperatória.

Perioperative anaphylaxis is an important manifestation in the context of surgery-related adverse events. Although often related to anesthetic induction, it may be caused by other agents administered by other routes. Anaphylaxis may manifest as cardiovascular collapse, airway obstruction and/or respiratory failure with or without skin manifestation, resulting often in death. Although this reaction is considered inevitable in some cases, its incidence could (and should) be reduced by the search for safer drugs. Comprehensive assessment of an allergic reaction is a key element to make subsequent exposure safer, with guidance derived from this investigation. However, surveillance of perioperative anaphylaxis represents a statistical challenge because this is a rare, random reaction and often independent of successive patient exposures to low-risk procedures. This paper reviews pathophysiological mechanisms, triggering agents (adults and children), as well as therapeutic and diagnostic approach during and after an allergic reaction. Comprehensive assessment, identification of medications/antiseptics used in each region and detailed records with standardized terminology are key points for obtaining more reliable epidemiological data on perioperative anaphylaxis.

Safety of local anesthetics

Abstract Local anesthetics are essential medications for the conduction of dermatological procedures. They stop the depolarization of nerve fibers and are divided into two main categories, the amide and ester types. Systemic toxicity with reflex on the central nervous and cardiovascular systems is their most feared adverse reactions, and the anaphylactic reaction is the most concerning one. Although potentially fatal, these events are extremely rare, so local anesthetics are considered safe for use in in-office procedures.

Passive Cigarette Smoking Impact on Blood Pressure Response to Epinephrine and Felypressin in 1K1C Hypertensive Rats Treated or not with Atenolol / Impacto do Tabagismo Passivo na Resposta Pressórica à Epinefrina e Felipressina em Ratos Hipertensos 1K1C Tratados ou não com Atenolol

Abstract Background: Cigarette smoking is usually associated with hypertension and may modify vasoconstrictor response. Objective: The present study aimed to analyze and compare the interaction of passive cigarette smoking and hypertension on epinephrine and felypressin blood pressure effects after intravascular injection. Method: 45-day male Wistar rats had the main left renal artery partially constricted and the right kidney removed (1K1C model). Rats were placed in the chamber for exposition to passive cigarette smoking (10 cigarettes) during 10 min (6 days a week). Hypertensive rats received atenolol (90 mg/kg/day) by gavage for two weeks. Hypotensive and hypertensive response, response duration and heart rate were recorded from direct blood pressure values. The significance level was 5%. Results: Passive cigarette smoking increased maximal hypertensive response to epinephrine in normotensive and 1K1C-atenolol treated rats and to felypressin only in 1K1C-atenolol treated rats; it also reduced epinephrine hypotensive response. Epinephrine increased heart rate in normotensive and hypertensive passive smokers or non-smoker rats. Comparing the two vasoconstrictors, epinephrine showed greater hypertensive response in normotensive smokers, 1K1C-atenolol treated smokers and non-smokers. However, in normotensive-nonsmoker rats, felypressin showed a greater and longer hypertensive effect. Conclusions: Our results suggest that passive cigarette smoking may reduce epinephrine vasodilation and increase hypertensive response when compared to felypressin. Therefore, felypressin may be safe for hypertensive patients to avoid tachycardia and atenolol interaction, but for normotensive and non-smoker patients, epinephrine may be safer than felypressin.

Resumo Fundamento: O tabagismo geralmente está associado à hipertensão e pode modificar a resposta vasoconstritora. Objetivo: O presente estudo teve como objetivo analisar e comparar a interação do tabagismo passivo e hipertensão sobre os efeitos da epinefrina e felipressina na pressão arterial após injeção intravascular. Métodos: Ratos Wistar machos de 45 dias tiveram a artéria renal principal esquerda parcialmente obstruída e o rim direito removido (modelo 1K1C). Os ratos foram colocados na câmara para exposição ao tabagismo passivo (10 cigarros) durante 10 minutos (6 dias por semana). Ratos hipertensos receberam atenolol (90 mg/kg/dia) por gavagem durante duas semanas. A resposta hipotensora e hipertensiva, a duração da resposta e a frequência cardíaca foram registradas a partir da medida dos valores diretos da pressão arterial. O nível de significância foi de 5%. Resultados: O tabagismo passivo aumentou a resposta hipertensiva máxima à epinefrina em ratos normotensos e ratos 1K1C tratados com atenolol e à felipressina apenas em ratos 1K1C tratados com atenolol; também reduziu a resposta hipotensiva à epinefrina. A epinefrina aumentou a frequência cardíaca em ratos fumantes passivos ou não-fumantes, normotensos e hipertensos. Comparando os dois vasoconstritores, a epinefrina apresentou maior resposta hipertensiva em fumantes normotensos, ratos 1K1C fumantes e não fumantes tratados com atenolol. No entanto, em ratos normotensos e não fumantes, a felipressina apresentou um efeito hipertensivo maior e mais prolongado. Conclusões: Nossos resultados sugerem que o tabagismo passivo pode reduzir a vasodilatação da epinefrina e aumentar a resposta hipertensiva quando comparado à felipressina. Portanto, a felipressina pode ser segura para pacientes hipertensos, com o objetivo de evitar a interação entre taquicardia e atenolol, mas para pacientes normotensos e não-fumantes, a epinefrina pode ser mais segura que a felipressina.

Epinephrine in pediatric cardiorespiratory arrest: when and how much? / Epinefrina na parada cardiorrespiratória pediátrica: quando e quanto?

ABSTRACT The objective of the present study was to assess the efficacy of different doses, times for infusion of the first dose, intervals of administration of subsequent doses, and number of epinephrine doses in the survival of children and adolescents who went into cardiorespiratory arrest. It is a review study with data from the PubMedⓇ/MEDLINEⓇdatabase. The search was for articles published from January 1st, 2000 to February 10, 2019, with a sample of patients aged under 18 years, published in English, Portuguese and Spanish. We found 222 articles, of which 16 met the inclusion criteria of the study. The first dose should be given as soon as possible. The standard dose (0.01mg/kg) has a better outcome when compared to the higher dose (0.1mg/kg). There is an iⓇverse relation between the number of epinephrine doses and survival. The interval currently recommended between doses has lower survival when compared to larger intervals. The dosage recommended by the American Heart Association presents a better outcome for survival, but the interval between doses and the maximum number of doses should be better assessed.

RESUMO O objetivo deste estudo foi avaliar a eficácia de diferentes doses, tempos para infusão da primeira dose, intervalos de administração de doses subsequentes e número de doses de epinefrina na sobrevida de crianças e adolescentes que sofreram parada cardiorrespiratória. Trata-se de estudo de revisão, cujas buscas foram feitas na base de dados PubMedⓇ /MEDLINEⓇ. Foram selecionados artigos publicados de 1° de janeiro de 2000 até 10 de fevereiro de 2019, realizados em menores de 18 anos de idade, publicados em inglês, português e espanhol. Foram encontrados 222 artigos, dos quais 16 atenderam os critérios de inclusão no estudo. A primeira dose deve ser aplicada o mais rápido possível. A dose padrão (0,01mg/kg) apresenta melhor desfecho quando comparada à dose alta (0,1mg/kg). Houve relação inversa entre número de doses de epinefrina e sobrevida. O intervalo entre doses recomendado atualmente apresenta menor sobrevida quando comparado a intervalos maiores. A dose recomendada pela American Heart Association apresenta melhor desfecho para sobrevida, porém o intervalo entre doses e o número máximo de doses devem ser melhor avaliados.

Infiltración periarticular y ácido tranexámico tópico para control de pérdida sanguínea en artroplastia total de rodilla / Periarticular injection and topical tranexamic acid for blood loss control in total knee arthroplasty

Introducción La pérdida sanguínea durante el remplazo total de rodilla es una de las principales variables que influyen en los resultados de esta cirugía para lo cual se han implementado varios métodos para reducirla. Objetivo Cuantificar el cambio en el hematocrito y hemoglobina a las 24 horas postoperatorias en pacientes a quienes se les realizó reemplazo total de rodilla primario entre marzo del 2016 y agosto del 2017. Metodología Se realizó un estudio observacional a partir de una cohorte retrospectiva. Los criterios de inclusión fueron aquellos pacientes a quienes se les realizó reemplazo total de rodilla primaria con infiltración periarticular con bupivacaina con epinefrina, ketorolaco y morfina e intrarticular con ácido tranexámico. Se midieron hemoglobina y hematocrito pre y post operatorio, cálculo de pérdida sanguínea y transfusiones. Resultados Se analizaron un total de 159 reemplazos totales de rodilla (75 prótesis convencionales, 84 prótesis navegadas). El porcentaje de transfusión fue de 0,69% (1 paciente). La disminución del hematocrito promedio fue de 7,36% y la disminución de la hemoglobina de 2,49 gr/dl para una pérdida sanguínea calculada de 780ml. Se usó torniquete en 147 pacientes. Discusión La combinación de uso de torniquete, infiltración periarticular e intra articular de ácido tranexamico reduce la pérdida sanguínea y la necesidad de tranfusiones.

Background The blood loss during the total knee replacement is one of the main variables that influence the outcomes of this surgery, and several methods have been implemented to reduce it. The aim of the study is to quantify the change in haematocrit and haemoglobin at 24hours post-surgery in patients subjected to a total primary knee replacement at the Clinica Colombia between March 2016 and August 2017. Methods An observational study was conducted on a retrospective cohort. The inclusion criteria were those patients who had a total primary knee replacement with periarticular infiltration with bupivacaine, with adrenaline, ketorolac, and morphine, and intra-articular with tranexamic acid. Haemoglobin and pre- and post-operative haematocrit, blood loss calculation, and transfusions were measured. Results The analysis included a total of 159 total knee replacements (75 conventional prostheses, 84 navigated prostheses). The percentage of transfusion was 0.69% (1 patient). The decrease in mean haematocrit was 7.36%, and the mean decrease in haemoglobin was 2.49g / dl for a calculated blood loss of 780ml. A tourniquet was used in 147 patients. Discussion The combination of tourniquet use, periarticular, and intra-articular injection of tranexamic acid reduces blood loss and the need for tranfusions.