Deambulación precoz e incidencia de cefalea pospunción dural en paciente obstétrica propuesta para cesárea electiva / Early ambulation and incidence of postdural puncture headache in an obstetric patient proposed for elective cesarean section

Introducción: La cefalea pospunción dural es la complicación más habitual tras la anestesia neuroaxial, y es especialmente frecuente en obstetricia, un hallazgo común en el período posparto. Suele ser una complicación benigna y autolimitada, pero sin tratamiento puede conducir a otras complicaciones más graves. Objetivo: Describir la incidencia de cefalea pospunción dural en las pacientes obstétricas programadas para cesárea electiva con anestesia espinal y su relación con la deambulación precoz. Métodos: Se realizó un estudio observacional descriptivo en una serie de casos (50), todas las pacientes propuestas para cesárea electiva bajo el método anestésico espinal subaracnoideo con trocar calibre 25 en el período comprendido entre mayo a diciembre del 2018. Resultados: De un total de 50 pacientes estudiadas con edades entre 18 y 35 años de edad, al 96 por ciento se le realizó punción única de la duramadre, en todas se utilizó trócar 25, atraumático y ninguna presentó cefalea pospunción dural. Conclusiones: Se concluye que la incidencia de cefalea pospunción dural puede disminuir cuando se utilizan agujas espinales atraumáticas, de pequeño calibre; lo cual facilita también la deambulación temprana de la paciente(AU)

Introduction: Postdural puncture headache is the most common complication following neuraxial anesthesia, and is especially common in obstetrics, a common finding in the postpartum period. It is usually a benign and self-limited complication, but if not treated, it can lead to further serious complications. Objective: To describe the incidence of postdural puncture headache in obstetric patients scheduled for elective cesarean section with spinal anesthesia and its relationship with early ambulation. Methods: A descriptive observational study was carried out in a case series (50) of patients proposed for elective cesarean section under the subarachnoid spinal anesthesia method with 25-gauge trocar in the period from May to December 2018. Results: Out of a total of 50 patients aged 18-35 years who participated in the study, 96 percent underwent single dura mater puncture. In all cases, a 25-gauge trocar was used and none presented postdural puncture headache. Conclusions: The incidence of postdural puncture headache may be concluded to decrease when atraumatic spinal needles of small caliber are used, which also facilitates early ambulation of the patient(AU)

Diretrizes Brasileiras de Mobilização Precoce em Unidade de Terapia Intensiva / Brazilian Guidelines for Early Mobilization in Intensive Care Unit

RESUMO A imobilidade pode causar várias complicações que influenciam na recuperação de doentes críticos, incluindo atrofia e fraqueza muscular esquelética. Esse efeito pode ser amenizado com a realização de mobilização precoce. Seis questões primordiais nortearam essa pesquisa: É segura? Quem é o candidato à mobilização precoce? Quais são as contraindicações? Qual a dose adequada e como defini-la? Quais os resultados obtidos? Quais os indicadores prognósticos em sua utilização? O objetivo desta diretriz foi elaborar um documento que reunisse recomendações e sugestões baseadas em níveis de evidência sobre a mobilização precoce do paciente crítico adulto, visando melhorar o entendimento sobre o tema, com impacto positivo no atendimento aos pacientes. Esta diretriz foi desenvolvida com base em uma revisão sistemática de artigos, utilizando a estratégia de busca no modelo PICO, conforme recomendado pelo Projeto de Diretrizes da Associação Médica Brasileira. Foram selecionados ensaios clínicos randomizados, estudos de coortes prognósticos, revisões sistemáticas com ou sem metanálise, sendo as evidências classificadas segundo Oxford Centre for Evidence-based Medicine - Levels of Evidence. Em todas as questões abordadas, foram encontradas evidências suficientes para a realização da mobilização precoce de forma segura e bem definida, com indicadores prognósticos que evidenciam e recomendam a técnica. A mobilização precoce está associada a melhores resultados funcionais, devendo ser realizada sempre que indicada. É segura e deve ser meta de toda equipe multidisciplinar.

ABSTRACT Immobility can cause several complications, including skeletal muscle atrophy and weakness, that influence the recovery of critically ill patients. This effect can be mitigated by early mobilization. Six key questions guided this research: Is early mobilization safe? Which patients are candidates for early mobilization? What are the contraindications? What is the appropriate dose, and how should it be defined? What results are obtained? What are the prognostic indicators for the use of early mobilization? The objective of this guideline was to produce a document that would provide evidence-based recommendations and suggestions regarding the early mobilization of critically ill adult patients, with the aim of improving understanding of the topic and making a positive impact on patient care. This guideline was based on a systematic review of articles conducted using the PICO search strategy, as recommended by the Guidelines Project of the Associação Médica Brasileira. Randomized clinical trials, prognostic cohort studies, and systematic reviews with or without meta-analysis were selected, and the evidence was classified according to the Oxford Center for Evidence-based Medicine Levels of Evidence. For all the questions addressed, enough evidence was found to support safe and well-defined early mobilization, with prognostic indicators that support and recommend the technique. Early mobilization is associated with better functional outcomes and should be performed whenever indicated. Early mobilization is safe and should be the goal of the entire multidisciplinary team.

Early mobilization practices of mechanically ventilated patients: a 1-day point-prevalence study in southern Brazil

OBJECTIVES: To assess early mobilization practices of mechanically ventilated patients in southern Brazilian intensive care units (ICUs) and to identify barriers associated with early mobilization and possible complications. METHODS: A prospective, observational, multicenter, 1-day point-prevalence study was conducted across 11 ICUs and included all mechanically ventilated adult patients. Hospital and ICU characteristics and patients' demographic data, the highest level of mobilization achieved in the 24 hours prior to the survey and related barriers, and complications that occurred during mobilization were collected in the hospital and the ICU. RESULTS: A total of 140 patients were included with a mean age of 57±17 years. The median and interquartile range was 7 (3-17) days for the length of ICU stay to the day of the survey and 7 (3-16) days for the duration of mechanical ventilation (MV). The 8-level mobilization scale was classified into two categories: 126 patients (90%) remained in bed (level 1-3) and 14 (10%) were mobilized out of bed (level 4-8). Among patients with an endotracheal tube, tracheostomy, and noninvasive ventilation, 2%, 23%, and 50% were mobilized out of bed, respectively (p<0.001 for differences among the three groups). Weakness (20%), cardiovascular instability (19%), and sedation (18%) were the most commonly observed barriers to achieving a higher level of mobilization. No complications were reported. CONCLUSIONS: In southern Brazilian ICUs, the prevalence of patient mobilization was low, with only 10% of all mechanically ventilated patients and only 2% of patients with an endotracheal tube mobilized out of bed as part of routine care.

Influência da deambulação precoce no tempo de internação hospitalar no pós-operatório de cirurgia cardíaca / Influence of early ambulation in postoperative hospitalization following cardiac surgery

Fundamentos: Apesar do avanço tecnológico que visa a prolongar a qualidade de vida de pacientes submetidos acirurgia cardíaca, esse procedimento ainda é considerado de alta complexidade. A deambulação precoce é uma alternativa para melhorar a capacidade pulmonar, o condicionamento cardiovascular e o aumento do desempenho funcional. Objetivos: Avaliar o impacto da deambulação precoce sobre o tempo de internação na Unidade de Terapia Intensiva (UTI) e hospitalar em pacientes submetidos a cirurgia cardíaca. Métodos: Estudo transversal, realizado com 49 pacientes submetidos à cirurgia cardíaca e admitidos na UTI, no período de outubro de 2014 a abril de 2015. Os pacientes foram estratificados em dois grupos: com e semdeambulação precoce. Deambulação precoce definida como o ato de caminhar até o terceiro dia de internação na UTI. Análise estatística realizada para verificar a existência de modificações no tempo de permanência hospitalare UTI entre os dois grupos de deambulação.Resultados: Foram estudados 49 pacientes, dos quais 55,1% homens, média de idade 55,2±13,9 anos, internados na UTI em decorrência de cirurgia cardíaca no período do estudo. Não se observou correlação estatística entre o ato de deambular precocemente com o tempo de permanência na UTI cardíaca (3,0±1,5 dias vs. 2,8±1,1 dias, p=0,819) e hospitalar (5,4±3,3 dias vs. 5,3±2,6 dias, p=0,903).Conclusão: A deambulação precoce não se associou a um menor tempo de permanência na UTI ou hospitalar.

Background: Despite the technological advances aimed to extend the quality of life of patients undergoing cardiac surgery, such procedure is still deemed a highly complex intervention. Early ambulation is an alternative to improve lung capacity, cardiovascular fitness and increased functional performance. Objective: Assess the impact of early ambulation on the length of stay in intensive care unit (ICU) and in hospital, for patients undergoing cardiac surgery. Methods: Cross-sectional study of 49 patients undergoing cardiac surgery and admitted to the ICU from October 2014 to April 2015. Patients were stratified into two groups: with and without early ambulation. Early ambulation is the act of walking up to the third day of ICU admission. Statistical analysis performed to check for changes in the length of stay in ICU and in hospital between the two groups of ambulation. Results: The study observed 49 patients (55.1% men) with mean age of 55.2±13.9 years, admitted to the ICU due to cardiac surgery carried out during the study period. No statistical correlation was found between early ambulation and the length of stay in cardiac ICU (3.0±1.5 days vs. 2.8±1.1 days, p=0.819) and in hospital (5.4±3.3 days vs. 5.3±2.6 days, p=0.903).Conclusion: Early ambulation is not related to a shorter length of stay in ICU or in hospital.

Early mobilization and reducing hospital stay in children with fracture femur treated by TENS fixation

We retrospectively reviewed 15 cases of diaphyseal femoral fractures treated with close reduction and intramedullary flexible titanium nails, in children aged 3-12 years. The mean follow-up time was 11.5 months [range 3-29]. No cases of nonunion or malunion were noted. We did not observe limb overgrowth of more than 1 cm in any of our patients. Two cases of postoperative angulation were noted, within the accepted limits for that age. In one case the lateral wire was long distally and bending on skin, this child underwent nail removal at 3 months after the initial surgery, without any complications. All the patients demonstrated callus formation on both x-ray views between 3-4 weeks and sound fracture healing between 7-8 weeks. All patients were capable of walking or supporting themselves with partial weight bearing on the injured leg at the end of the first month [range 2-4 weeks], and of walking with minimal support or unsupported at the end of the second month, or even earlier. In our opinion, not only should the final result be considered, but also the burden of the treatment process as a whole. When an alternative mode of treatment permits reduction of this burden without increasing the complication rate, and with similar final results, it is worth considering this option

Shoulder arthroscopy: part V post-arthroscopic immediate pain control, and then, early mobilization

Any evolution in surgical procedure must seek to improve established results, minimize previous complications, and maximize applicability to the general patient population. Arthroscopic examination and treatment of selected shoulder disorders have undoubtedly earned a permanent role in the practice of orthopaedic surgery, with an exciting and expanding future. The current study was designed to evaluate the clinical value of a post-arthroscopic local analgesic method using a single intra-articular injected dose of a mixture of 20mg [4 ml] tenoxicam, 20mg [0.5 ml] triamcinolone acetonide, 0.2% [10 ml] ropivacaine, and 0.5 ml of a 1: 1000 epinephrine solution, in an attempt to achieve a pain-free post-operative period to allow for early rehabilitation. The study was conducted in 76 patients, mostly were young active men, all underwent shoulder arthroscopic surgery for diagnostic and therapeutic purposes. Visual analogue scale [VAS] scores as regards pain intensity and relief were taken before surgery and then, at recovery, 1, 2, 4, 8, 24 hours postoperatively. In addition, patients were assessed for quality of sleep and for daily living. The physiotherapist's opinions about the analgesia provided were also recorded as indicated by the patient's ability to participate in the immediate post-operative mobilization programs. The results revealed a significant benefit as it offered an immediate post-operative pain relief, high therapist compliance, and good patient satisfaction. In addition, the incidence of adverse actions was negligible

External fixator in the management of trochanteric fractures in high risk geriatric patients--a friend to the elderly.

The best treatment option for trochanteric fracture in a geriatric high risk patient with all associated medical and surgical problems remains debatable. Conservative methods of treatment are associated with dangerous complications of prolonged recumbency while open reduction and internal fixation under anaesthesia significantly increases the mortality and morbidity rates. We treated 110 elderly patients who were unfit or high risk cases for anaesthesia and major surgery for internal fixation due to associated medical and surgical conditions, by external fixation under local anaesthesia. The average age was 65 years and mean follow up was 18 months. 83.3% were ambulatory with support and 97.2% were able to manage activities of daily living at the time of discharge. At 18 months post surgery, 74% were ambulatory with a stick or better. The fracture united in an average of 16.4 weeks. Overall satisfaction rate was 80% at end follow up. The mortality rates were comparable to series of open reduction and internal fixation. Pin tract infection and knee stiffness were the major complications. External fixation done under local anaesthesia offers advantages in the form of a quick, simple relatively inexpensive procedure with negligible blood loss, preserves fracture haematoma, can be easily removed as an out patient procedure, besides it provides earliest possible ambulation and day care to the elderly high risk patient.

Mobilizaçäo precoce da mäo pós-reimplantes ou revascularizaçöes / Early mobilization of the post-replantation hand or revascularizations

A alta frequência de complicaçöes pós-operatórias nos traumatismos das mäos e dedos por aderências cicatriciais, sugerem a aplicaçäo de técnicas de reabilitaçäo precoce, uma vez que a mobilizaçäo da mäo neste período fornece melhor aporte vascular à área lesada, promove melhor qualidade nutricional, mantém as superfícies de deslizamento e evita a täo rotineira aderência tendinosa, que impossibilita a integridade funcional da mäo e dedos comprometidos, além de evitar edemas e outros problemas pós-cirúrgicos. No entanto, há divergências em relaçäo ao início devido, talvez, à insegurança dos cirurgiöes na aplicaçäo da técnica de cinesioterapia pós-operatória imediata após uma cirurgia que normalmente teve muitas horas de duraçäo. Sugere-se neste estudo que a mobilizaçäo pós-reimplante ou revascularizaçäo dos dedos e/ou da mäo seja iniciada após 48 horas, conforme o protocolo utilizado nos 3 casos apresentados neste trabalho, justificando, dessa forma, a integridade funcional e a reabilitaçäo funcional da mäo e dedos traumatizados. Preconizou-se o ínico das atividades diárias a partir do 21§ dia após a cirurgia, sem qualquer incidente traumático em funçäo da precocidade e com integridade funcional da mäo.