Minimal fresh gas flow sevoflurane anesthesia and postoperative acute kidney injury in on-pump cardiac surgery: a randomized comparative trial

Abstract Background Compound A is generated by sevoflurane when it reacts with carbon dioxide absorbers with strong bases at minimal fresh gas flow (FGF) and is nephrotoxic in animals. No conclusive data has shown increased risk in humans. The aim of this study was to investigate if minimal FGF promotes an increase in the incidence of acute kidney injury (AKI) when compared to high FGF in patients undergoing on-pump cardiac surgery under sevoflurane anesthesia. Methods Two hundred and four adult patients scheduled for on-pump cardiac surgery under sevoflurane anesthesia were randomly allocated to two groups differentiated by FGF: minimal FGF (0.5 L.min−1) or high FGF (2.0 L.min−1). Baseline creatinine measured before surgery was compared daily to values assayed on the first five postoperative days, and 24-hour urinary output was monitored, according to the KDIGO (Kidney Disease Improving Global Outcomes) guideline to define postoperative cardiac surgery-associated acute kidney injury (CSA-AKI). Creatinine measurements were also obtained 20 and 120 days after hospital discharge. Results Postoperative AKI occurred in 55 patients, 26 patients (29.5%) in the minimal FGF group and 29 patients (31.5%) in the high FGF group (p= 0.774). Twenty days after discharge, 11 patients (6.1%) still had CSA-AKI and 120 days after discharge only 2 patients (1.6%) still had CSA-AKI. Conclusions When compared to high FGF, minimal FGF sevoflurane anesthesia during on-pump cardiac surgery is not associated with increased risk of postoperative AKI in this population at high risk for renal injury.

Pain management & opioid dose reduction with topical sevoflurane instillations in intractable venous ulcers: a case report

Abstract Vascular ulcers (VU) constitute a major cause of pain and disability, and significantly compromise quality of life. VU have a natural tendency to become chronic and in many cases exhibit anunsatisfactoryresponse to many of the standard therapeutic options.The case of a 73 year-old Caucasian female with severe pain and poorly-controlled pain (Visual Analogic Scale-VAS- of 8-9) due to three lower leg long-standing VUs is reported and discussed herein. The patient was treated with topical instillations of undiluted sevoflurane as per institutional off-label protocol (starting doses of 1mL/cm2 twice a day, and up-titrated according to response to a maximum of 7 mL twice daily). The VAS score dropped to 0-1 shortly after initiation of therapy and remained stable throughout treatment up until the closure of the observations. Subsequently, opioid therapy was gradually tapered down and ultimately abandoned.Sevoflurane application resulted on adequate and sustained pain management of refractory VU, with no significant side effects. On account of its beneficial effectivity and safety profiles, topical sevoflurane emerges as an add-on alternative for the long-term management of VU, and potentially other painful conditions.

Estrogen Receptor-A in Medial Preoptic Area Contributes to Sex Difference of Mice in Response to Sevoflurane Anesthesia / 神经科学通报·英文版

A growing number of studies have identified sex differences in response to general anesthesia; however, the underlying neural mechanisms are unclear. The medial preoptic area (MPA), an important sexually dimorphic structure and a critical hub for regulating consciousness transition, is enriched with estrogen receptor alpha (ERα), particularly in neuronal clusters that participate in regulating sleep. We found that male mice were more sensitive to sevoflurane. Pharmacological inhibition of ERα in the MPA abolished the sex differences in sevoflurane anesthesia, in particular by extending the induction time and facilitating emergence in males but not in females. Suppression of ERα in vitro inhibited GABAergic and glutamatergic neurons of the MPA in males but not in females. Furthermore, ERα knockdown in GABAergic neurons of the male MPA was sufficient to eliminate sex differences during sevoflurane anesthesia. Collectively, MPA ERα positively regulates the activity of MPA GABAergic neurons in males but not in females, which contributes to the sex difference of mice in sevoflurane anesthesia.

Dopaminergic Neurons in the Ventral Tegmental-Prelimbic Pathway Promote the Emergence of Rats from Sevoflurane Anesthesia / 神经科学通报·英文版

Dopaminergic neurons in the ventral tegmental area (VTA) play an important role in cognition, emergence from anesthesia, reward, and aversion, and their projection to the cortex is a crucial part of the "bottom-up" ascending activating system. The prelimbic cortex (PrL) is one of the important projection regions of the VTA. However, the roles of dopaminergic neurons in the VTA and the VTADA-PrL pathway under sevoflurane anesthesia in rats remain unclear. In this study, we found that intraperitoneal injection and local microinjection of a dopamine D1 receptor agonist (Chloro-APB) into the PrL had an emergence-promoting effect on sevoflurane anesthesia in rats, while injection of a dopamine D1 receptor antagonist (SCH23390) deepened anesthesia. The results of chemogenetics combined with microinjection and optogenetics showed that activating the VTADA-PrL pathway prolonged the induction time and shortened the emergence time of anesthesia. These results demonstrate that the dopaminergic system in the VTA has an emergence-promoting effect and that the bottom-up VTADA-PrL pathway facilitates emergence from sevoflurane anesthesia.

Efecto epitelizante y analgésico del sevoflurano tópico en el tratamiento de las úlceras por presión grado I-III no infectadas Hospital Obrero N°1 de La Paz Bolivia / Epithelializing and analgesic effect of topical sevoflurane in the treatment by pressure of uninfected grade I-III ulcers Hospital Obrero (workers´ Hospital) N°1 of La Paz Bolivia

INTRODUCCIÓN: las úlceras por presión constituyen un importante problema de salud por su frecuencia, carácter crónico, costes económicos y una merma en la calidad de vida en pacientes internados en las unidades de cuidados especiales. MATERIAL Y MÉTODOS: el objetivo del estudio fue evaluar el efecto epitelizante y analgésico del sevoflurano aplicado tópicamente en úlceras por presión grado I-III no infectadas de pacientes internados. El tipo de estudio fue Ensayo clínico aleatorizado. Un total de 16 pacientes fueron incluidos en el estudio y fueron divididos aleatoriamente en 2 grupos: grupo A (8 pacientes), en los que se realizó la curación con sevoflurano tópico más povidona yodada y, grupo B (8 pacientes) curación solo con yodopovidona. La valoración de la evolución de la úlcera se realizó mediante la Escala PUSH, que valora superficie, cantidad de exudado y tipo de tejido del lecho. RESULTADOS: durante la realización de la curación, el dolor manifestado por los integrantes del Grupo A (1.6 ± 0.7), fue mucho menor que el observado el Grupo B (7.2 ± 1). No se encontró diferencias significativas en la superficie de la úlcera y en la cantidad de exudado; si se encontró una diferencia significativa en el tipo de tejido existente en el lecho ulceroso, en los pacientes del Grupo A se evidenció la presencia de tejido de granulación y epitelial a partir de la tercera semana de tratamiento, lo cual, en los pacientes del Grupo B, se observó a partir de la cuarta semana.

INTRODUCTION: pressure ulcers constitute an important health problem due to their frequency, chronic nature, economic costs and a reduction in the quality of life in patients hospitalized in special care units. MATERIAL AND METHODS: the aim of the study was to evaluate the epithelializing and analgesic effect of sevoflurane applied topically in uninfected grade I-III pressure ulcers of hospitalized patients. The type of study was Randomized Clinical Trial. A total of 16 patients were included in the study and were randomly divided into 2 groups: group A (8 patients), in which the cure was performed with topical sevoflurane plus povidone iodine, and group B (8 patients) only with povidone iodine. The evaluation of the evolution of the ulcer was performed using the PUSH Scale, which assesses surface area, amount of exudate and type of bed tissue. RESULTS: during the healing, the pain manifested by the members of Group A (1.6 ± 0.7), was much lower than that observed in Group B (7.2 ± 1). No significant differences were found on the surface of the ulcer and in the amount of exudate; If a significant difference was found in the type of tissue existing in the ulcer bed, in Group A patients the presence of epithelial and granulation tissue was evidenced starting the third week of treatment, which, in Group A patients B, was observed starting the fourth week.

Analgesic effectiveness and improvement in quality of life after using topical sevoflurane for an extremely painful anal fissure / Eficácia analgésica e melhoria da qualidade de vida com o uso tópico de sevoflurano em fissura anal extremamente dolorosa

Painful anal fissures could be distressing conditions that severely impair the patients' quality of life. The analgesic effectiveness of topical drugs, such as calcium-antagonists and nitrates is quite variable. The inhalational anesthetic sevoflurane is being repurposed as a topical analgesic for painful chronic wounds.We report a pioneer experience treating a painful chronic anal fissure with topical sevoflurane. A young adult male was suffering from an extremely painful chronic anal fissure, which severely affected his quality of life. The topical treatment with nitroglycerine and diltiazem gels failed. The patient agreed to the treatement with topical sevoflurane as an off-label medication, and it produced an immediate, intense, and long-lasting analgesic effect. An intense but rapidly transient burning sensation, as well as persistent but well-tolerated flatulence were the only adverse effects. The quality of life was greatly improved, and the cost of the treatment was affordable. Therefore, the off-label use of topical sevoflurane appears to be an effective alternative for the symptomatic treatment of painful anal fissures (AU)

As fissuras anais dolorosas podem ser condições angustiantes que prejudicam gravemente a qualidade de vida dos pacientes. A eficácia analgésica de medicamentos tópicos, como antagonistas de cálcio e nitratos, é bastante variável. O anestésico inalatório sevoflurano está sendo reaproveitado como analgésico tópico para feridas crônicas dolorosas. Relatamos uma experiência pioneira de tratamento com sevoflurano tópico em fissura anal crônica dolorosa. Umjovemadulto do sexomasculino sofria de uma fissura anal crônica extremamente dolorosa, que afetava gravemente sua qualidade de vida. O tratamento tópico com nitroglicerina e géis de diltiazem foi ineficaz. O paciente concordou com o tratamento com sevoflurano tópico como medicamento off-label, ou seja, com uso diferente do aprovado embula. O sevoflurano tópico produziu um efeito analgésico imediato, intenso e duradouro. Uma sensação de ardência intensa, mas transitória, e flatulência persistente, embora bem tolerada, foram os únicos efeitos adversos. A qualidade de vidamelhorou significativamente, e o custo do tratamento revelou-se acessível. Portanto, o uso off-label de sevoflurano tópico pode ser uma alternativa analgésica eficaz em casos de fissuras anais dolorosas. (AU)

lncRNA KCNQ1OT1 reverses the effect of sevoflurane on hepatocellular carcinoma progression via regulating the miR-29a-3p/CBX3 axis

Sevoflurane (SEVO) is widely applied as an anesthetic, which exerts antitumor capacity in various cancers, including hepatocellular carcinoma (HCC). Previous studies indicated that long non-coding RNA KCNQ1 opposite strand/antisense transcript 1 (KCNQ1OT1) was upregulated, while microRNA-29a-3p (miR-29a-3p) was downregulated in HCC. Thus, we aimed to explore the roles of KCNQ1OT1 and miR-29a-3p in HCC cells exposed to SEVO. Cell proliferation, apoptosis, migration, and invasion were assessed by the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay, flow cytometry, and transwell assays, respectively. The levels of genes were determined by quantitative real-time polymerase chain reaction (qRT-PCR) or western blot. Furthermore, the interaction between miR-29a-3p and KCNQ1OT1 or chromebox protein homolog 3 (CBX3) was predicted by Starbase or Targetscan, and then confirmed by dual-luciferase reporter assay. We found that the levels of KCNQ1OT1 and CBX3 were decreased, while miR-29a-3p was increased in SEVO-treated HCC cells. KCNQ1OT1 overexpression weakened the inhibitory effects of SEVO on HCC cell proliferation, apoptosis, migration, and invasion. Interestingly, KCNQ1OT1 bound to miR-29a-3p, and miR-29a-3p targeted CBX3. KCNQ1OT1 upregulated CBX3 level by repressing miR-29a-3p expression. Furthermore, KCNQ1OT1 exerted tumor promotion in HCC cells via suppressing miR-29a-3p to regulate CBX3 expression. Collectively, our findings demonstrated that KCNQ1OT1 regulated the antitumor effects of SEVO on HCC cells through modulating the miR-29a-3p/CBX3 axis, providing a theoretical basis for the treatment of HCC.

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.

Dexmedetomidine-mediated Wnt Pathway Inhibits Sevoflurane-induced Cognitive Impairment in Neonatal Rats / 中国医学科学院学报

Objective To explore the effect of dexmedetomidine(Dex)on sevoflurane-induced cognitive impairment in neonatal rats through Wnt signaling pathway. Methods Sixty 7-day-old SD rats were assigned into five groups:control group(without any intervention),Dex group(intraperitoneal injection of 25 μg/kg Dex),sevoflurane group(3% sevoflurane treatment for 4 hours),sevoflurane+Dex group(inhalation of 3% sevoflurane after injection of 25 μg/kg Dex for 4 hours),and sevoflurane+Dex+Wnt inhibitor group(Wnt inhibitor XAV393 and 25 μg/kg Dex were injected and 3% sevoflurane was inhaled for 4 hours).Three weeks later,Morris water maze was used to detect the cognitive function;TdT-mediated dUTP nick end labeling(TUNEL)staining was performed to detect the apoptosis of hippocampal neurons;neuronal nuclei (NeuN) staining was conducted to detect the survival of hippocampal neurons;Western blot was carried out to detect the expression of apoptosis-related proteins.The expression of the factors involved in Wnt/GSK-3β/β-catenin signaling pathway was detected by fluorescence quantitative polymerase chain reaction,and Western blot. Results Compared with the control group,there was no significant difference in the escape latency of Dex group(t=0.304,P=0.768);the escape latency in sevoflurane group(t=5.823,P=0.002),sevoflurane+Dex group(t=3.188,P=0.010),and sevoflurane+Dex+Wnt inhibitor group(t=5.784,P=0.002)was significantly prolonged.Compared with that in the sevoflurane group,the escape latency in sevoflurane+Dex group(t=3.646,P=0.005)was significantly shortened.Compared with that in sevoflurane+Dex group,the escape latency in sevoflurane+Dex+Wnt inhibitor group(t=3.296,P=0.008)was prolonged.Compared with that in the control group,the times of crossing platform in sevoflurane group(t=5.179, P=0.004),sevoflurane+Dex group(t=2.309,P=0.043),and sevoflurane+Dex+Wnt inhibitor group(t=3.871, P=0.003)decreased.Compared with that in sevoflurane group,the times of crossing platform in sevoflurane+Dex group(t=3.296,P=0.008)significantly increased.Compared with that in sevoflurane+Dex group,the times of crossing platform in sevoflurane+Dex+Wnt inhibitor group(t=2.361, P=0.041)reduced.Compared with the control group,there was no significant difference in the number of apoptotic cells in Dex group(t=1.920,P=0.127),and the number of apoptotic cells in sevoflurane group,sevoflurane+Dex group,and sevoflurane+Dex+Wnt inhibitor group increased by 16%(t=13.436,P=0.002),5%(t=7.752, P=0.001),and 11.5%(t=12.612,P=0.002),respectively.Compared with that in the sevoflurane group,the number of apoptotic cells in sevoflurane+Dex group and sevoflurane+Dex+Wnt inhibitor group decreased by 11%(t=8.521,P=0.002)and 5.5%(t=3.123,P=0.036),respectively.Compared with that in the sevoflurane+Dex group,the number of apoptotic cells in sevoflurane+Dex+Wnt inhibitor group increased by 6.5%(t=6.250,P=0.003).Compared with that in the control group,the number of positive cells in 0.15 mm

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.

Sufentanil reduces emergence delirium in children undergoing transthoracic device closure of vsd after sevoflurane-based cardiac anesthesia

Abstract Objective: The aim of this study was to evaluate whether sufentanil can reduce emergence delirium in children undergoing transthoracic device closure of ventricular septal defect (VSD) after sevoflurane-based cardiac anesthesia. Methods: From February 2019 to May 2019, 68 children who underwent transthoracic device closure of VSD at our center were retrospectively analyzed. All patients were divided into two groups: 36 patients in group S, who were given sufentanil and sevoflurane-based cardiac anesthesia, and 32 patients in group F, who were given fentanyl and sevoflurane-based cardiac anesthesia. The following clinical data were recorded: age, sex, body weight, operation time, and bispectral index (BIS). After the children were sent to the intensive care unit (ICU), pediatric anesthesia emergence delirium (PAED) and face, legs, activity, cry, consolability (FLACC) scale scores were also assessed. The incidence of adverse reactions, such as nausea, vomiting, drowsiness and dizziness, was recorded. Results: There was no significant difference in age, sex, body weight, operation time or BIS value between the two groups. Extubation time (min), PEAD score and FLACC scale score in group S were significantly better than those in group F (P<0.05). No serious anesthesia or drug-related side effects occurred. Conclusions: Sufentanil can be safely used in sevoflurane-based fast-track cardiac anesthesia for transthoracic device closure of VSD in children. Compared to fentanyl, sufentanil is more effective in reducing postoperative emergence delirium, with lower analgesia scores and greater comfort.

Variability of anesthetic depth in total intravenous anesthesia vs balanced anesthesia using entropy indices: a randomized, crossover, controlled clinical trial / Variabilidad de la profundidad anestésica en anestesia total intravenosa vs. anestesia general balanceada usando índices de entropía. Un ensayo clínico aleatorizado, cruzado y controlado

Abstract Introduction: Total intravenous anesthesia (TIVA) and balanced anesthesia (BA) are the most commonly used anesthetic techniques. The differences are the variability of the depth of anesthesia between these techniques that might predict which one is safer for patients and presents a lower risk of intraoperative awakening. Objective: To determine whether a difference exists in the variability of depth of anesthesia obtained by response entropy (RE). Methods: A crossover clinical trial was conducted on 20 healthy patients receiving upper or lower limb ambulatory orthopedic surgery. Patients were randomly assigned to (a) target-controlled infusion of propofol using the Schnider model at a target concentration of 2.5 µg/mL for 15 minutes and a 10-minute washout, followed by sevoflurane administration at 0.8 minimal alveolar concentration (MAC) for the reminder of the surgery, or (b) the reverse sequence. Differences in the variability of the depth of anesthesia using RE were evaluated using paired t-test. Results: The treatment effect showed no significant difference in the average values of RE, during TIVA = 97.23 vs BA 97.04 (P = 0.39). Carry Over (-4.98 vs 4.08) and Period (100.3 vs 94.68) effects were not significantly different. Conclusion: The present study suggests that both anesthetic techniques are equivalent in terms of the stability of the depth of anesthesia. It is important to keep testing the determinants of the efficacy of different populations because the individual behaviors of patients might ultimately tip the scale.

Resumen Introducción: La anestesia total intravenosa (TIVA, por sus siglas en inglés) y la anestesia balanceada (AB) son las técnicas anestésicas más comúnmente utilizadas. La diferencia está en la variabilidad de la profundidad de la anestesia entre estas dos técnicas, lo cual pudiera predecir cuál es más segura para los pacientes y representar un menor riesgo de despertar intraoperatorio. Objetivo: Determinar si existe alguna diferencia en la variabilidad de la profundidad de la anestesia obtenida según los índices de entropía de respuesta (ER). Métodos: Se llevó a cabo un estudio clínico cruzado en 20 pacientes sanos que se sometieron a cirugía ortopédica ambulatoria de miembros superiores o inferiores. Los pacientes se asignaron aleatoriamente así: a) infusión controlada por objetivo (TCI, por sus siglas en inglés) de propofol, utilizando el modelo Schnider a una concentración objetivo de 2,5 µg/mL durante 15 min y un período de lavado de 10 minutos, seguido de la administración de sevoflurano a 0,8 de concentración alveolar mínima (CAM) durante el tiempo restante de la cirugía; o b) la secuencia inversa. Las diferencias en la variabilidad de la profundidad de la anestesia utilizando entropía de respuesta se evaluaron utilizando la prueba t pareada. Resultados: El efecto del tratamiento no mostró ninguna diferencia significativa en los valores promedio de entropía de respuesta (ER) durante TIVA = 97,23 vs. AB 97,04 (P = 0,39). Los efectos de arrastre (-4,98 vs. 4,08) y período (100,3 vs. 94,68) no fueron significativamente diferentes. Conclusiones: El presente estudio sugiere que ambas técnicas anestésicas son equivalentes en términos de estabilidad de la profundidad de la anestesia. Es importante continuar probando los factores determinantes de eficacia en las distintas poblaciones, ya que el comportamiento individual de cada paciente pudiera finalmente inclinar la balanza.

Short term olfactory memory and olfactory function after inhalation anesthetic agents: a randomized clinical trial / Memória olfativa de curta duração e função olfativa após anestésicos inalatórios: estudo clínico randomizado

Abstract Background and objectives: This clinical trial aimed to evaluate the effects of two different inhalation anesthetic agents on postoperative olfactory memory and olfactory function in patients who underwent micro laryngeal surgery. Methods: This randomized prospective controlled study consisted of 102 consecutive patients with a voice disorder. The patients underwent micro laryngeal surgery for voice disorders under general anesthesia. Patients who did not meet inclusion criteria and/or declined to participate (n = 34) were excluded from the study. Patients were divided into two groups. Four patients from Group 1 and four patients from Group 2 were lost to follow-up. Group 1 (n = 30) received sevoflurane, and Group 2 (n = 30) received desflurane during anesthesia. We compared the results by performing the pre-op and post-op Connecticut Chemosensory Clinical Research Center Olfactory test. Results: Thirty-three patients (55%) were male and 27 (45%) were female. The mean age was 48.18 ± 13.88 years (range: 19‒70 years). Preoperative and postoperative olfactory functions did not show a significant difference within the groups postoperatively (p > 0.05). Preoperative and postoperative olfactory memory showed a significant decrease 3 hours after the surgery (p < 0.05). Conclusions: Olfactory functions and memory were not affected by desflurane in the early postoperative period. Although sevoflurane did not affect olfactory functions, it had a temporary negative effect on olfactory memory in the early postoperative period.

Resumo Introdução e objetivos: O estudo avaliou o efeito pós-operatório de dois agentes anestésicos inalatórios distintos na memória olfativa de curta duração e na função olfativa em pacientes submetidos à microcirurgia de laringe. Método: O estudo prospectivo controlado randomizado avaliou, consecutivamente, 102 pacientes com alteração vocal submetidos à microcirurgia de laringe sob anestesia geral. Trinta e quatro pacientes não obedeceram aos critérios de inclusão e/ou não aceitaram participar do estudo e foram excluídos. Os pacientes foram divididos em dois grupos. Quatro pacientes do Grupo 1 e quatro do Grupo 2 foram perdidos durante o seguimento. O Grupo 1 (n = 30) recebeu sevoflurano durante a anestesia e o Grupo 2 (n = 30), desflurano. Comparamos resultados pré e pós-operatórios de memória olfativa e funções olfativas, realizando o Connecticut Chemosensory Clinical Research Center Olfactory test. Resultados: Foram incluídos um total de 33 (55%) homens e 27 (45%) mulheres. A idade média foi 48,18 ± 13,88 anos (variação: 19-70 anos). As funções olfativas pré e pós-operatórias não apresentaram diferença estatisticamente significante dentro dos grupos no pós-operatório (p > 0,05). A memória olfativa pré e pós-operatória não mostrou diminuição estatisticamente significante quando avaliada três horas após a cirurgia (p< 0,05). Conclusões: Memória e funções olfativas não foram alteradas pelo desflurano no pós-operatório imediato. Embora o sevoflurano não tenha alterado as funções olfativas, causou efeito temporário negativo na memória olfativa no pós-operatório imediato.

Sevoflurano tópico como tratamiento analgésico y antimicrobiano de tenosinovitis piógena de los flexores de la mano. Caso clínico / Topical sevoflurane as analgesic and antimicrobial treatment of pyogenic flexor tenosynovitis of the hand. Case report

Presentamos el caso de un paciente con una tenosinovitis piógena del 5° dedo de la mano, tratado inicialmente con desbridamiento quirúrgico y antibioterapia empírica. La evolución fue desfavorable, pues el dedo presentaba un defecto de cobertura con signos infecciosos en la herida y las curas resultaban muy dolorosas. Al paciente se le ofertaron varias opciones quirúrgicas y, mientras se decidía por alguna, aceptó por escrito iniciar curas con sevoflurano líquido tópico (según protocolo vigente para uso de fármacos fuera de indicación). El efecto analgésico del sevoflurano apareció rápidamente, y la evolución posterior de la herida fue muy favorable, pues los signos infecciosos desaparecieron y el defecto de cobertura se había cerrado tras tres semanas de empleo de sevoflurano tópico, sin necesidad de nuevas cirugías. Este caso ejemplifica que el uso fuera de indicación de sevoflurano tópico para tratar heridas complejas puede evitar actuaciones quirúrgicas, mucho más agresivas para los pacientes.

The clinical case is presented on a patient suffering from pyogenic tenosynovitis affecting the 5th finger of the hand, which was initially treated with surgical debridement and empirical antibiotic treatment. The clinical outcome was unfavourable, since the finger presented with a coverage defect, and the wound seemed to be infected. Wound cleaning and dressings were very painful. The patient was asked to choose between several surgical therapeutic alternatives, but he gave written informed consent to be treated with topical sevoflurane, following an approved protocol for the off-label use of this drug. Pain was accurately controlled after sevoflurane application, and the wound exhibited a very good outcome with disappearance of the clinical signs of infection and complete closure of the defect coverage after three weeks of sevoflurane, with no new surgical procedures. The present clinical case illustrates how the off-label use of topical sevoflurane for the treatment of complicated wounds could be useful to avoid surgical procedures that are more aggressive for patients.

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.

Silvoflurano tópico en infección superficial por SARM tras artroplastia de rodilla: caso clínico / Topical sevoflurane for superficial MRSA infection after knee arthroplasty: case report

Intentar el tratamiento retentivo de material protésico ante heridas quirúrgicas infectadas por gérmenes resistentes es objeto de debate, especialmente cuando el agente causal es un Staphylococcus aureus resistente a meticilina (SARM). Una paciente diabética y con obesidad tipo I sufrió infección de la herida quirúrgica tras artroplastia de rodilla que no evolucionó bien con antibioterapia empírica y terapia hiperosmolar. Se planificó una reintervención que fue demorada por motivos extramédicos (falta de terapia de presión negativa para cubrir la herida postoperatoria, pues se preveía no poder realizar cierre primario). Mientras se conseguía este material, y tras obtener el consentimiento de la paciente, se iniciaron irrigaciones de la herida con sevoflurano tópico off-label, pues ese fármaco ha mostrado capacidad antimicrobiana. La evolución clínica fue excelente desde el inicio a pesar de que en el cultivo se aisló un SARM resistente a la antibioterapia empírica, por lo que se desestimó la reintervención y se continuó con sevoflurano tópico junto a la antibioterapia dirigida por antibiograma, lográndose la curación completa de la herida tras 6 semanas. Durante ese tiempo, la paciente no experimentó ningún efecto adverso atribuible al sevoflurano. El sevoflurano tópico aparece como una valiosa nueva opción terapéutica ante heridas postoperatorias infectadas, especialmente cuando los gérmenes causantes son resistentes a los antibióticos convencionales.

It is challenging to try a retentive treatment of prosthetic material superinfected by resistant microorganisms, especially when the causative agent is a methicillin-resistant Staphylococcus aureus (MRSA). A diabetic, obese female patient suffered from a postoperative wound infection after a knee arthroplasty. Initial treatment with antibiotics and hyperosmolar therapy failed and clinical evolution was no good. Surgery was scheduled, but it was delayed due to nonmedical reasons (lack of negative-pressure therapy to cover the wound since primary wound closure was anticipated to be very improbable to perform). While waiting for this therapy, off-label irrigations with topical sevoflurane were started after obtaining written consent, since this drug has exhibited antimicrobial properties. Clinical evolution turned out to be excellent since the very beginning, even though a MRSA resistant to the antibiotics empirically administered was isolated. Thus, surgery was discarded, and culture-guided antibiotic therapy was added to topical sevoflurane, which was followed by a complete healing of the wound after 6 weeks. Sevoflurane treatment was well tolerated as the patient reported no adverse effects. Therefore, treating postsurgical wounds with topical sevoflurane appears as a valuable new alternative, especially when infections are caused by microorganisms resistant to conventional antibiotics.

Enriched environment improves sevoflurane-induced cognitive impairment during late-pregnancy via hippocampal histone acetylation

Fetal exposure to sevoflurane induces long-term cognitive impairment. Histone acetylation regulates the transcription of genes involved in memory formation. We investigated whether sevoflurane exposure during late-pregnancy induces neurocognitive impairment in offspring, and if this is related to histone acetylation dysfunction. We determined whether the effects could be reversed by an enriched environment (EE). Pregnant rats were exposed to 2.5% sevoflurane or control for 1, 3, or 6 h on gestational day 18 (G18). Sevoflurane reduced brain-derived neurotrophic factor (BDNF), acetyl histone H3 (Ac-H3), and Ac-H4 levels and increased histone deacetylases-2 (HDAC2) and HDAC3 levels in the hippocampus of the offspring on postnatal day 1 (P1) and P35. Long-term potentiation was inhibited, and spatial learning and memory were impaired in the 6-h sevoflurane group at P35. EE alleviated sevoflurane-induced cognitive dysfunction and increased hippocampal BDNF, Ac-H3, and Ac-H4. Exposure to 2.5% sevoflurane for 3 h during late-pregnancy decreased hippocampal BDNF, Ac-H3, and Ac-H4 in the offspring but had no effect on cognitive function. However, when the exposure time was 6 h, impaired spatial learning and memory were linked to reduced BDNF, Ac-H3, and Ac-H4, which could be reversed by EE.

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.