Identification of Sleep Medicine and Anesthesia Core Topics for Anesthesia Residency: A Modified Delphi Technique Survey.

BACKGROUND: Sleep disorders affect up to 25% of the general population and are associated with increased risk of adverse perioperative events. The key sleep medicine topics that are most important for the practice of anesthesiology have not been well-defined. The objective of this study was to determine the high-priority sleep medicine topics that should be included in the education of anesthesia residents based on the insight of experts in the fields of anesthesia and sleep medicine. METHODS: We conducted a prospective cross-sectional survey of experts in the fields of sleep medicine and anesthesia based on the Delphi technique to establish consensus on the sleep medicine topics that should be incorporated into anesthesia residency curricula. Consensus for inclusion of a topic was defined as >80% of all experts selecting "agree" or "strongly agree" on a 5-point Likert scale. Responses to the survey questions were analyzed with descriptive statistical methods and presented as percentages or weighted mean values with standard deviations (SD) for Likert scale data. RESULTS: The topics that were found to have 100% agreement among experts were the influence of opioids and anesthetics on control of breathing and upper airway obstruction; potential interactions of wake-promoting/hypnotic medications with anesthetic agents; effects of sleep and anesthesia on upper airway patency; and anesthetic management of sleep apnea. Less than 80% agreement was found for topics on the anesthetic implications of other sleep disorders and future pathways in sleep medicine and anesthesia. CONCLUSIONS: We identify key topics of sleep medicine that can be included in the future design of anesthesia residency training curricula.

Determining the amount of training needed for competency of anesthesia trainees in ultrasonographic identification of the cricothyroid membrane.

BACKGROUND: Airway guidelines recommend the use of ultrasound to localize the cricothyroid membrane prior to airway manipulation in difficult airways. In this study, we aimed to determine the amount of training anesthesia trainees would need to achieve competence in bedside ultrasound to identify the cricothyroid membrane. METHODS: This is a prospective non-randomized cohort study in the Department of Anesthesia at Mount Sinai Hospital (Toronto, Ontario, Canada). Following institutional ethics approval, six anesthesia trainees consisting of four residents and two fellows underwent a 2-h training session on neck ultrasound to identify neck landmarks and the cricothyroid membrane. The trainees had no previous airway ultrasound experience. One-two weeks later, each trainee performed consecutive neck ultrasound scans on 20 healthy volunteers to identify the cricothyroid membrane. Cumulative sum (CUSUM) learning curves were constructed for each trainee. Primary outcome was the number of ultrasound examinations required to achieve competence, defined as 90% success rate in a series of 20 ultrasound scans. Secondary outcomes were the overall success rate, the time (sec.) required to perform the task, and 3-month skills assessment. RESULTS: CUSUM analysis showed four trainees achieved competence with a mean [range] success rate of 94.0% [90-100%] and a median [range] number of attempts of 14 [9-18]. Two trainees did not achieve competence, but obtained a success rate of 75.0 and 80.0% each. Overall (number of attempts) success rate was 88.3% (106/120) with a mean (SD) time of 36.9 (9.0) sec. Three months after training, ultrasound of five consecutive neck scans showed a mean success rate of 86.7% (26/30) and mean (SD) time of 47.7 (16.0) sec. CONCLUSIONS: After a short 2-h training session, most anesthesia trainees (n = 4/6) achieved competence in ultrasound-identification of the cricothyroid membrane with less than 20 scans in a mean time less than 60 s., and that they remain reasonably competent 3 months later. The learning curve for ultrasound identification of the cricothyroid membrane seems to be short even without prior airway ultrasound experience.

Quality of labour neuraxial analgesia and maternal satisfaction at a tertiary care teaching hospital: a prospective observational study.

PURPOSE: Current labour analgesia practices are evidence-based; however, such evidence often originates in controlled trials, the results of which may not be readily applicable in the context of day-to-day clinical practice. The objective of this study was to evaluate the effectiveness of and maternal satisfaction with the neuraxial labour analgesia regimen provided at a tertiary care teaching hospital. METHODS: All women with a viable pregnancy who requested neuraxial analgesia for labour during November 2011 at our institution were approached to participate in this prospective study. Patients were managed as per departmental routine based on a patient-controlled epidural analgesia regimen with a maintenance solution of 0.0625% bupivacaine and fentanyl 2 µg·mL(-1). Demographic and obstetric data, characteristics of the neuraxial analgesia, pain scores, side effects, and complications were recorded. After delivery, patients completed a satisfaction questionnaire. RESULTS: All 332 eligible women were approached, and 294 completed the study. Most women received epidural analgesia and considered its placement comfortable. A large number of women reported having experienced pain during the first or second stages of labour (38% and 26%, respectively). Although 24.4% of women required top-ups both by nurses and physicians, adjustment in the local anesthetic maintenance concentration was made in only 7.8% of the cases. Most women (92%) were satisfied with the quality of analgesia. Unintentional dural puncture occurred in three (1%) cases, and there were no cases of intravascular catheter insertion or systemic local anesthetic toxicity. Overweight women (body mass index 25-30 kg·m(-2)) (adjusted odds ratio [AOR] = 2.56; 95% confidence interval [CI]: 1.1 to 5.97), those undergoing induced labour (AOR = 2.4; 95% CI: 1.2 to 5.2), and those requiring top-ups by the anesthesiologist (AOR = 5.08; 95% CI: 2.31 to 11.11) were associated with more dissatisfaction with pain control during the first stage of labour. CONCLUSION: Although our technique with dilute local anesthetic-opioid infusion was considered effective in previous randomized clinical trials, it did not provide sufficient labour analgesia for a large proportion of women. Nevertheless, most women were satisfied with their pain management and childbirth experience. Strategies to individualize care for labour and delivery should be readily available while providing labour analgesia.

Cardiac output monitoring during Cesarean delivery in a patient with palliated tetralogy of Fallot.

PURPOSE: Tetralogy of Fallot (TOF) is one of the most common causes of cyanotic congenital heart disease. The anesthetic management of parturients with uncorrected TOF is challenging and controversial, especially for Cesarean delivery (CD). We describe the use of noninvasive cardiac output (CO) monitoring to assist the management of CD for a woman with palliated TOF under general anesthesia. CLINICAL FEATURES: A 34-yr-old woman presented for elective CD at 38 weeks gestation. Having been born with TOF, she underwent a modified Blalock-Taussig shunt at six years of age, followed nine years later by creation of an aortopulmonary connection. The patient's functional status was New York Heart Association class I despite evident central cyanosis. A CD was performed under general anesthesia. Fentanyl, etomidate, and succinylcholine were utilized for induction, and intrathecal morphine was administered for postoperative pain control. The baseline CO (7.2 L·min(-1)), blood pressure (156/74 mmHg), heart rate (74 beats·min(-1)), and total peripheral resistance (1,059 dynes·sec(-1)·cm(-5)) remained stable throughout the procedure. Maintenance anesthesia consisted of rocuronium, sevoflurane, and an oxygen/nitrous oxide mixture. Upon delivery, an infusion of oxytocin combined with ergometrine was administered. Hemodynamic parameters remained stable and no vasopressor was required. CONCLUSION: Balanced general anesthesia and careful titration of uterotonic agents provided stable hemodynamic conditions during CD in a patient with a palliated TOF, as assessed by a continuous noninvasive CO monitor. Noninvasive CO monitoring may improve our understanding of the hemodynamic implications of various anesthetic techniques for CD in cardiac patients.

Anesthesia for ex utero intrapartum treatment (EXIT procedure) in fetus with prenatal diagnosis of oral and cervical malformations: case reports.

BACKGROUND AND OBJECTIVES: Fetus prenatally diagnosed with neck tumors, or with any other disease that obstructs the airways, should not be treated conventionally, as the assistant physician has to face two challenges right after the infant's delivery: the limited time to establish the access to the potentially difficult airways and the lack of anesthesia of the neonate in case of instrumentation of the airways. The ex utero intrapartum treatment, i.e., the EXIT procedure consists of maintaining the fetoplacental circulation during the cesarean section, until the airways of the fetus be secured. CASE REPORTS: Female patient, 37 years old, G3P2, 38 weeks pregnant, having polyhydramnios and fetus diagnosed with large cervical masses by prenatal ultrasound. A cesarean section was performed using the EXIT procedure to enable safe access to the infant's airways. After hysterotomy, the fetus was intubated by direct laryngoscopy. The neonate was immediately transferred to another operating room, where cervical tumor resection of the neck tumor and tracheostomy were successfully performed. Female patient, 27 years old, G3P1A1, 32 weeks pregnant, whose fetus was prenatally diagnosed with a large oral tumor. As the tumor obstructed the fetus' airways, a tracheostomy was performed when the fetus underwent EXIT procedure. It was then possible to use direct laryngoscopy for neonate intubation. The fetus underwent tumor resection and was sent to the Neonatal Intensive Care Unit. CONCLUSIONS: Reports describe the successful use of general anesthesia with isoflurane for cesarean delivery followed by the EXIT procedure in fetus diagnosed with tumors obstructing the airways.

Anestesia para tratamento intraparto extraútero (EXIT) em fetos com diagnóstico pré-natal de malformações cervical e oral: relato de casos / Anesthesia for ex utero intrapartum treatment (EXIT procedure) in fetus with prenatal diagnosis of oral and cervical malformations: case reports / Anestesia para el tratamiento intraparto extraútero (EXIT) en fetos con diagnóstico prenatal de malformaciones cervical y oral: relato de casos

JUSTIFICATIVA E OBJETIVOS: O feto com diagnóstico pré-natal de massa cervical, ou qualquer outra doença que obstrua as vias aéreas, não deve ser abordado de forma convencional por apresentar dois desafios ao médico assistente logo após o parto: o tempo limitado para se estabelecer o acesso a vias aéreas potencialmente difíceis e a ausência de anestesia do neonato caso seja necessária instrumentação das vias aéreas. O procedimento EXIT (ex utero intrapartum treatment - EXIT procedure) consiste em manter a circulação fetoplacentária durante a cesariana até que as vias aéreas do feto estejam asseguradas. RELATO DOS CASOS: Mulher de 37 anos, G3P2, 38 semanas de gestação, apresentando polidrâmnio e feto com grande massa cervical diagnosticada por ultrassonografia pré-natal. A cesariana foi realizada com procedimento EXIT para possibilitar o acesso seguro das vias aéreas. Após a histerotomia, o feto foi intubado sob laringoscopia direta. O concepto foi transferido imediatamente para outra sala de cirurgia, onde foi realizada a ressecção do tumor cervical e a traqueostomia, ambos com sucesso. Mulher de 27 anos, G3P1A1, idade gestacional de 32 semanas, cujo feto tinha diagnóstico pré-natal de grande tumor em região oral. O tumor obstruía as vias aéreas do feto e foi programada traqueostomia com técnica EXIT, no entanto, foi possível intubar o recém-nascido sob laringoscopia direta, sendo então submetido à ressecção do tumor e encaminhado à UTI neonatal. CONCLUSÕES: Os relatos descrevem o uso bem sucedido de anestesia geral com isoflurano para a realização de cesariana seguida de procedimento EXIT em fetos com tumores obstruindo as vias aéreas.

BACKGROUND AND OBJECTIVES: Fetus prenatally diagnosed with neck tumors, or with any other disease that obstructs the airways, should not be treated conventionally, as the assistant physician has to face two challenges right after the infant's delivery: the limited time to establish the access to the potentially difficult airways and the lack of anesthesia of the neonate in case of instrumentation of the airways. The ex utero intrapartum treatment, i.e., the EXIT procedure consists of maintaining the fetoplacental circulation during the cesarean section, until the airways of the fetus be secured. CASE REPORTS: Female patient, 37 years old, G3P2, 38 weeks pregnant, having polyhydramnios and fetus diagnosed with large cervical masses by prenatal ultrasound. A cesarean section was performed using the EXIT procedure to enable safe access to the infant's airways. After hysterotomy, the fetus was intubated by direct laryngoscopy. The neonate was immediately transferred to another operating room, where cervical tumor resection of the neck tumor and tracheostomy were successfully performed. Female patient, 27 years old, G3P1A1, 32 weeks pregnant, whose fetus was prenatally diagnosed with a large oral tumor. As the tumor obstructed the fetus' airways, a tracheostomy was performed when the fetus underwent EXIT procedure. It was then possible to use direct laryngoscopy for neonate intubation. The fetus underwent tumor resection and was sent to the Neonatal Intensive Care Unit. CONCLUSIONS: Reports describe the successful use of general anesthesia with isoflurane for cesarean delivery followed by the EXIT procedure in fetus diagnosed with tumors obstructing the airways.

JUSTIFICATIVA Y OBJETIVOS: El feto con diagnóstico prenatal de masa cervical, o cualquier otra enfermedad que obstruya las vías aéreas, no debe ser abordado de forma convencional por presentar dos retos para el médico asistente inmediatamente después del parto: a) el tiempo limitado para establecer el acceso a las vías aéreas potencialmente difíciles y b) la ausencia de anestesia del neonato en el caso de que sea necesaria la instrumentación de las vías aéreas. El procedimiento EXIT (ex utero intrapartum treatment - EXIT procedure), consiste en mantener la circulación feto-placentaria durante la cesárea hasta que las vías aéreas del feto estén aseguradas. RELATO DE LOS CASOS: Mujer de 37 años, G3P2, 38 semanas de embarazo, presentando un polihidramnios y feto con gran masa cervical diagnosticada por ultrasonido prenatal. La cesárea fue realizada con el procedimiento EXIT para posibilitar el acceso seguro a las vías aéreas. Después de la histerotomía, el feto fue intubado bajo laringoscopia directa. Fue transferido inmediatamente a otra sala de cirugía, donde se le hizo la resección del tumor cervical y la traqueostomía, ambos con éxito. Mujer de 27 años, G3P1A1, edad gestacional de 32 semanas, cuyo feto tenía un diagnostico prenatal de gran tumor en la región oral. El tumor obstruía las vías aéreas del feto y fue programada la traqueostomía con técnica EXIT. Sin embargo, se pudo intubar al recién nacido bajo laringoscopia directa, siendo entonces sometido a la resección del tumor y derivado a la UCI neonatal. CONCLUSIONES: Los relatos describen el uso exitoso de la anestesia general con el isoflurano para la realización de la cesárea seguida de procedimiento EXIT en fetos con tumores obstruyendo las vías aéreas.

O que o paciente sabe sobre o trabalho do anestesiologista? / What do patients know about the work of anesthesiologists?

JUSTIFICATIVA E OBJETIVOS: Estudos internacionais modernos retratam a falta de conhecimento dos pacientes em relação à formação e ao papel do anestesiologista. Não existem dados atuais sobre esse tema que revelem o panorama nacional. O objetivo deste trabalho é avaliar o nível de conhecimento dos pacientes sobre a formação e as áreas de atuação desses especialistas. MÉTODO: Estudo prospectivo em hospital universitário terciário de São Paulo. Pacientes no pré-operatório foram entrevistados por um período de 18 meses. Os dados foram analisados com o uso do teste exato de Fisher, teste do qui-quadrado e teste de Mann-Whitney, conforme o tipo de variável estudada. Foi considerado, para todo o estudo, risco α< 0,05 de se cometer erro tipo I. RESULTADOS: Foram incluídos 400 pacientes no estudo, sendo 203 (50,75 por cento) homens e 197 (49,25 por cento) mulheres entre 18 e 89 anos. Um total de 207 (51,75 por cento) pacientes reconheceu o anestesiologista como médico. Duzentos e oitenta e nove (72,25 por cento) entrevistados responderam que o anestesiologista cuida do paciente durante a cirurgia, enquanto 256 (64 por cento) pacientes não sabiam que o anestesiologista determina se o paciente está apto a ser submetido à cirurgia. Houve correlação estatística entre o nível de escolaridade e a presença de experiência prévia de procedimentos anestésico-cirúrgicos com a resposta correta em relação à formação médica do anestesiologista. Não houve diferença significativa entre os grupos - submetido e não submetido - à avaliação pré-anestésica em relação ao conhecimento da formação médica do anestesiologista. CONCLUSÕES: Uma grande proporção dos pacientes tem conhecimento limitado sobre a formação e as atribuições do anestesiologista. A avaliação pré-anestésica não aumentou a proporção de respostas de que o anestesiologista tem formação médica.

BACKGROUND AND OBJECTIVES: Modern international studies portray the lack of knowledge of patients regarding the education and role of anesthesiologists. There are no current data on this subject in the national scenario. The objective of this study was to assess the level of knowledge of patients about the education and areas of performance of these specialists. METHODS: This is a prospective study undertaken at a tertiary university hospital in São Paulo. During an 18-month period preoperative patients were interviewed. The data were analyzed by the Fisher's exact test, Chi-square test, and Mann-Whitney test according to the variable investigated. In the study, an α risk < 0.05 of making a type I error was considered. RESULTS: Four hundred patients, 203 (50.75 percent) males and 197 (49.25 percent) females, aged between 18 and 89 years were included in this study. A total of 207 patients (51.75 percent) recognized anesthesiologists as physicians. Two hundred and eighty-nine (72.25 percent) patients answered that anesthesiologists care for patients during surgeries, while 256 (64 percent) did not know that anesthesiologists determine whether patients are fit to undergo surgery. A statistical correlation was observed between the level of schooling and the presence of prior experience with anesthetic-surgical procedures and the correct response to the medical education of anesthesiologists. A significant difference was not observed between the group of patients who underwent pre-anesthetic evaluation and those that did not undergo the evaluation regarding the knowledge of the medical education of anesthesiologists. CONCLUSIONS: A large proportion of patients have a limited knowledge about the education and role of anesthesiologists. Pre-anesthetic evaluation did not increase the proportion of answers that anesthesiologists have medical education.

JUSTIFICATIVA Y OBJETIVOS: Modernos estudios internacionales reflejan la falta de conocimiento de los pacientes con relación a la formación y al papel del anestesiólogo. No existen datos actuales sobre ese tema que revelen el panorama nacional. El objetivo de este trabajo, es evaluar el nivel de conocimiento de los pacientes sobre la formación y las áreas de actuación de esos expertos. MÉTODO: Estudio prospectivo realizado en un hospital universitario terciario de São Paulo. Los pacientes en el preoperatorio fueron entrevistados durante 18 meses. Los datos se analizaron con el uso del test exacto de Fisher, test del Xi-Cuadrado (Xi²), y el test de Mann-Whitney, conforme al tipo de variable estudiada. Durante todo el estudio, se tuvo en cuenta, el riesgo α< 0,05 de cometerse un error tipo I. RESULTADOS: Se incluyeron 400 pacientes en el estudio, siendo 203 (50,75 por ciento) hombres y 197 (49,25 por ciento) mujeres entre los 18 y los 89 años. Un total de 207 (51,75 por ciento) pacientes reconoció al anestesiólogo como médico. Doscientos ochenta y nueve (72,25 por ciento) de los entrevistados respondieron que el anestesiólogo cuida al paciente durante la cirugía, mientras que 256 (un 64 por ciento) pacientes no sabían que el anestesiólogo determina si el paciente está apto para ser sometido a la cirugía. Hubo una correlación estadística entre el nivel de escolaridad y la presencia de experiencia previa de procedimientos anestésicoquirúrgicos, con la respuesta correcta con relación a la formación médica del anestesiólogo. No hubo diferencia significativa entre los grupos (sometido y no sometido), a la evaluación preanestésica con relación al conocimiento de la formación médica del anestesiólogo. CONCLUSIONES: Una gran proporción de los pacientes tienen un conocimiento limitado sobre la formación y las funciones del anestesiólogo. La evaluación preanestésica no aumentó la proporción de las respuestas sobre si el anestesiólogo posee una formación médica.

What do patients know about the work of anesthesiologists?

BACKGROUND AND OBJECTIVES: Modern international studies portray the lack of knowledge of patients regarding the education and role of anesthesiologists. There are no current data on this subject in the national scenario. The objective of this study was to assess the level of knowledge of patients about the education and areas of performance of these specialists. METHODS: This is a prospective study undertaken at a tertiary university hospital in São Paulo. During an 18-month period preoperative patients were interviewed. The data were analyzed by the Fisher's exact test, Chi-square test, and Mann-Whitney test according to the variable investigated. In the study, an α risk≤0.05 of making a type I error was considered. RESULTS: Four hundred patients, 203 (50.75%) males and 197 (49.25%) females, aged between 18 and 89 years were included in this study. A total of 207 patients (51.75%) recognized anesthesiologists as physicians. Two hundred and eighty-nine (72.25%) patients answered that anesthesiologists care for patients during surgeries, while 256 (64%) did not know that anesthesiologists determine whether patients are fit to undergo surgery. A statistical correlation was observed between the level of schooling and the presence of prior experience with anesthetic-surgical procedures and the correct response to the medical education of anesthesiologists. A significant difference was not observed between the group of patients who underwent pre-anesthetic evaluation and those that did not undergo the evaluation regarding the knowledge of the medical education of anesthesiologists. CONCLUSIONS: A large proportion of patients have a limited knowledge about the education and role of anesthesiologists. Pre-anesthetic evaluation did not increase the proportion of answers that anesthesiologists have medical education.

Arterite de Takayasu na gestação: relato de caso e revisão de literatura / Takayasus's arteritis in pregnancy: case report and literature review / Arteritis de Takayasu en el embarazo: relato de caso y revisión de la literatura

JUSTIFICATIVA E OBJETIVOS: A Arterite de Takayasu (AT) é uma doença idiopática, crônica, inflamatória e progressiva que causa estreitamento, oclusão e aneurismas das artérias sistêmicas e pulmonares, afetando principalmente a aorta e seus ramos. Durante a gestação deve-se estar atento à condução dessas pacientes. O objetivo foi relatar um caso de condução anestésica periparto de uma paciente com AT e fazer uma revisão da literatura. RELATO DE CASO: Gestante de 31 anos com troca de arco aórtico e prótese metálica em válvula aórtica por AT há 4 anos. A gestação prosseguiu sem complicações e a paciente foi internada com 34 semanas para adequação da anticoagulação. Realizou-se cesariana eletiva com 39 semanas de gestação com anestesia peridural contínua. Doses fracionadas de anestésico local foram administradas para garantir a instalação lenta do bloqueio. Paciente permaneceu estável hemodinamicamente e foi encaminhada para pós-operatório na UTI. CONCLUSÕES: Muitas complicações podem ocorrer na gestante com AT. Avaliação cuidadosa da paciente, tratamento das complicações da AT e planejamento anestésico cirúrgico são fundamentais. Manutenção da perfusão orgânica é a principal preocupação nessas pacientes e bloqueios neuroaxiais podem ser utilizados sem prejuízo para mãe ou recém-nato. Na paciente com as complicações da AT compensadas, a monitoração não difere da utilizada rotineiramente em cesarianas. Anestesia peridural contínua de instalação lenta mantém a estabilidade hemodinâmica e permite monitorar a perfusão cerebral através do nível de consciência da gestante. Para evitar hipoperfusão orgânica ou complicações hipertensivas no pós-operatório, a paciente deve permanecer monitorada em unidade intensiva ou semi-intensiva por 24 horas.

BACKGROUND AND OBJECTIVES: Takayasus's Arteritis (TA) is a chronic, inflammatory, progressive, idiopathic disease that causes narrowing, occlusion, and aneurysms of systemic and pulmonary arteries affecting especially the aorta and its branches. During pregnancy, one should pay special attention to these patients. The objective of this report was to present the peripartum anesthetic care of a patient with TA and a review of the literature. CASE REPORT: This is a 31-year old gravida who underwent exchange of the aortic arch and placement of a metallic aortic valve for TA four years ago. She had no complications during pregnancy, and she was admitted at 34 weeks of pregnancy for anticoagulation management. Elective cesarean section was performed at 39 weeks with continuous epidural anesthesia. Fractionated doses of local anesthetic were administered to guarantee slow installation of the blockade. The patient remained hemodynamically stable and was transferred to the ICU in the postoperative period. CONCLUSIONS: Several complications can affect gravidas with TA. Careful patient evaluation, treatment of TA complications, and anesthetic-surgical planning are fundamental. Maintenance of perfusion is the main concern in these patients, and neuraxial blocks may be used without harming the mother and fetus. In patients with compensated TA complications, monitoring does not differ from that routinely used in cesarean sections. Continuous epidural anesthesia with slow installation maintains hemodynamic stability and allows monitoring cerebral perfusion through the level of consciousness. To avoid postoperative hypoperfusion or hypertensive complications patients should be monitored in an intensive or semi-intensive care unit for 24 hours.

JUSTIFICATIVA Y OBJETIVOS: La Artritis de Takayasu (AT), es una enfermedad idiopática, crónica, inflamatoria y progresiva, que causa el estrechamiento, la oclusión y los aneurismas de las arterias sistémicas y pulmonares, afectando principalmente a la aorta y a sus ramas. Durante el embarazo, debemos estar atentos al seguimiento de esas pacientes. El objetivo fue relatar un caso de seguimiento anestésico periparto de una paciente con AT y hacer una revisión de la literatura. RELATO DE CASO: Embarazada de 31 años con cambio del arco aórtico y prótesis metálica en válvula aórtica por AT hacía 4 años. El embarazo continuó sin complicaciones y la paciente fue ingresada con 34 semanas para la adecuación de la anticoagulación. Se realizó la cesárea electiva con 39 semanas de embarazo con anestesia epidural continua. Se administraron dosis fraccionadas de anestésico local para garantizar la instalación lenta del bloqueo. La paciente permaneció estable hemodinámicamente y fue derivada al postoperatorio en la UCI. CONCLUSIONES: Muchas complicaciones pueden sobrevenir en la embarazada con AT. La evaluación cuidadosa de la paciente, el tratamiento de las complicaciones de la AT y la planificación anestésica quirúrgica son fundamentales. El mantenimiento de la perfusión orgánica es la principal preocupación en esas pacientes, y los bloqueos neuroaxiales pueden ser utilizados sin miedo de perjudicar a la madre o al recién nacido. En la paciente con las complicaciones de la AT compensadas, la monitorización no es diferente de la utilizada como rutina en cesáreas. La anestesia epidural continua de instalación lenta, mantiene la estabilidad hemodinámica y permite monitorizar la perfusión cerebral a través del nivel de conciencia de la embarazada. Para evitar la hipoperfusión orgánica o las complicaciones hipertensivas en el postoperatorio, la paciente debe permanecer monitorizada en una unidad de cuidados intensivos o semi-intensivos durante 24 horas.

Takayasus's arteritis in pregnancy. Case report and literature review.

BACKGROUND AND OBJECTIVES: Takayasus's Arteritis (TA) is a chronic, inflammatory, progressive, idiopathic disease that causes narrowing, occlusion, and aneurysms of systemic and pulmonary arteries affecting especially the aorta and its branches. During pregnancy, one should pay special attention to these patients. The objective of this report was to present the peripartum anesthetic care of a patient with TA and a review of the literature. CASE REPORT: This is a 31-year old gravida who underwent exchange of the aortic arch and placement of a metallic aortic valve for TA four years ago. She had no complications during pregnancy, and she was admitted at 34 weeks of pregnancy for anticoagulation management. Elective cesarean section was performed at 39 weeks with continuous epidural anesthesia. Fractionated doses of local anesthetic were administered to guarantee slow installation of the blockade. The patient remained hemodynamically stable and was transferred to the ICU in the postoperative period. CONCLUSIONS: Several complications can affect gravidas with TA. Careful patient evaluation, treatment of TA complications, and anestheticsurgical planning are fundamental. Maintenance of perfusion is the main concern in these patients, and neuraxial blocks may be used without harming the mother and fetus. In patients with compensated TA complications, monitoring does not differ from that routinely used in cesarean sections. Continuous epidural anesthesia with slow installation maintains hemodynamic stability and allows monitoring cerebral perfusion through the level of consciousness. To avoid postoperative hypoperfusion or hypertensive complications patients should be monitored in an intensive or semi-intensive care unit for 24 hours.

Dor crônica pós-operatória: fisiopatologia, fatores de risco e prevenção / Chronic postoperative pain: pathophysiology, risk factors and prevention

JUSTIFICATIVA E OBJETIVOS: A prevalência da dor crônica pós-operatória (DCPO) é grande, acometendo tanto cirurgias de pequeno porte como as de grande porte. Esse tema vem sendo estudado cada vez mais. O objetivo deste estudo foi descrever aspectos importantes sobre essa síndrome.CONTEÚDO: Descrevem-se os mecanismos da DCPO,os fatores de risco para seu desenvolvimento, a prevenção e o tratamento da dor.CONCLUSÃO: A DCPO afeta a qualidade de vida dos pacientes, é de difícil tratamento sendo a medida mais eficaz a sua prevenção. Com o melhor entendimento das bases fisiopatológicas da perpetuação da dor após um procedimento cirúrgico e dos fatores de risco, novas opções para o seu tratamento estão surgindo. Os reais benefícios da utilização de fármacos usados de forma preventiva estão sendo cada vez mais estudados. Na prevenção da dor as equipes cirúrgicas e os pacientes necessitam estar atentas nos riscos de cada procedimento, não somente no perioperatório imediato,mas também em longo prazo.

BACKGROUND AND OBJECTIVES: Chronic postoperative pain (CPOP) prevalence is high, and is manifested both after small and large size surgeries. This subject has been increasingly studied. This study aimed at describing major aspects of this syndrome.CONTENTS: CPOP mechanisms, risk factors for its development, prevention and pain treatments are described.CONCLUSION: CPOP impacts patients' quality of life is diffi cult to treat and the best approach is to prevent it. With a better understanding of pathophysiological bases for perpetuation of pain after a surgical procedure and of risk factors, new treatment options are appearing. The real benefits of preventive drugs are being increasingly studied. To prevent pain, surgical teams and patients have to be aware of the risks of each procedure, not only in the immediate postoperative period but also in the long run.

Opioid-induced hyperalgesia (OIH).

BACKGROUND AND OBJECTIVES: Opioids are commonly used for pain control; however, they can cause hyperalgesia. The reason why this can happen is not known. The objective of this review was to describe the mechanisms, factors implicated, and drug modulation. CONTENTS: The factors implicated in the development of opioid-induced hyperalgesia (OIH), such as duration of use, dose, and type of opioids are described. Mechanisms involved include the glutamatergic system and N-methyl-D-aspartate receptors (NMDA), spinal cyclooxygenase (COX) activation, excitatory amino acids, dynorphin, cytokines and chemokines; prostaglandins, and descending facilitation. Modulation of hyperalgesia could be done through: NMDA receptor antagonists, alpha2-adrenergic agonists, and COX inhibitors. CONCLUSIONS: This is a very complex subject, which involves a series of pathophysiological mechanisms that could contribute for OIH and patient discomfort, bringing disastrous consequences.

Hiperalgesia induzida por opioides (HIO) / Opioid-induced hyperalgesia (OIH) / Hiperalgesia inducida por opioides (HIO)

JUSTIFICATIVA E OBJETIVOS: Opioides são medicamentos frequentemente usados para o controle da dor que, contudo, podem causar hiperalgesia. A circunstância pela qual esse fenômeno pode ocorrer não está inteiramente esclarecida. O objetivo desta revisão foi descrever os mecanismos, os fatores implicados e a modulação por medicamentos. CONTEÚDO: Foram descritos os fatores implicados no desenvolvimento da hiperalgesia induzida por opioides (HIO), como duração de uso, dose e tipo de opioide. Os mecanismos incluem o sistema glutamatérgico e receptores N-metil-D-aspartato (NMDA), ativação de ciclo-oxigenase (COX) espinal, aminoácidos excitatórios, dinorfina, citocinas e quimocinas; prostaglandinas e facilitação descendente. A modulação de hiperalgesia pode ser feita com antagonistas de receptores NMDA, agonistas adrenérgicos-alfa2 e inibidores de COX. CONCLUSÕES: O assunto é bastante complexo, envolvendo uma série de mecanismos fisiopatológicos que podem contribuir para a HIO e o desconforto do paciente, trazendo consequências que podem ser danosas.

BACKGROUND AND OBJECTIVES: Opioids are commonly used for pain control; however, they can cause hyperalgesia. The reason why this can happen is not known. The objective of this review was to describe the mechanisms, factors implicated, and drug modulation. CONTENTS: The factors implicated in the development of opioid-induced hyperalgesia (OIH), such as duration of use, dose, and type of opioids are described. Mechanisms involved include the glutamatergic system and N-methyl-D-aspartate receptors (NMDA), spinal cyclooxygenase (COX) activation, excitatory amino acids, dynorphin, cytokines and chemokines; prostaglandins, and descending facilitation. Modulation of hyperalgesia could be done through: NMDA receptor antagonists, alpha2-adrenergic agonists, and COX inhibitors. CONCLUSIONS: This is a very complex subject, which involves a series of pathophysiological mechanisms that could contribute for OIH and patient discomfort, bringing disastrous consequences.

JUSTIFICATIVA Y OBJETIVOS: Los opioides son medicamentos a menudo usados para el control del dolor y que sin embargo pueden causar hiperalgesia. La circunstancia por la cual ese fenómeno puede ocurrir no está totalmente aclarada. El objetivo de esta revisión es describir los mecanismos, los factores que están involucrados y la modulación por medicamentos. CONTENIDO: Fueron descritos los factores involucrados en el desarrollo de la hiperalgia inducida por opioides (HIO), como la duración en el uso, la dosis y el tipo de opioide. Los mecanismos incluyen los sistemas glutamatérgico y los receptores N-metil-D-aspartato (NMDA), activación de ciclo-oxigenasa (COX) espinal, aminoácidos excitatorios, dinorfina, citocinas y quimocinas; prostaglandinas y facilitación descendiente. La modulación de la hiperalgesia se puede lograr con los antagonistas de receptores NMDA, los agonistas adrenérgicosalfa2 y con los inhibidores de (COX). CONCLUSIONES: El tema es bastante complejo, e involucra una serie de mecanismos fisiopatológicos que pueden contribuir para la HIO y la incomodidad del paciente, con consecuencias dañinas para la salud.

Review of the use of gabapentin in the control of postoperative pain.

BACKGROUND AND OBJECTIVES: Gabapentin has been used as adjuvant in the treatment of postoperative pain with a neuropathic component. It is responsible for the inhibition of central sensitization, decreasing postoperative pain. CONTENTS: All clinical, randomized studies that evaluated the effects of gabapentin on postoperative pain in humans between 2002 and 2007 for a total of 26 studies were selected. In 17 studies, patients received a single preoperative dose, which ranged from 300 to 1,200 mg, 30 minutes to two hours before surgery in the remaining studies, the administration of the drug was initiated one to 24 hours before the procedure and continued for 10 days, in doses that ranged from 1,200 to 1,800 mg.day(-1). To measure pain severity, the Visual Analog or Numeric Rating Scale was used. In 75% of patients who received a single dose of gabapentin, scores were lower, and the same was seen in 55.6% of patients who received the drugs pre- and postoperatively. Opioid consumption was reduced in 82.4% of patients who received a single dose, and in 77.8% of patients who received pre- and postoperative gabapentin. Among the studies using a single dose of gabapentin, four did not describe adverse effects; 52.9% showed no differences, 11.8% detected more nausea or vomiting, 5.9% experienced more dizziness, 5.9% more sedation, less nausea or vomiting in one, and less urinary retention in one. Among the studies with pre- and postoperative administration of gabapentin, four did not describe adverse effects; 22.2% showed no differences, 11.1% had more nausea or vomiting, 22.2% more dizziness, and 11.1% more sedation. CONCLUSIONS: Gabapentin, used before as well as before and after surgery, decreased pain severity and the need of analgesic supplementation.

Revisão sobre o uso de gabapentina para controle da dor pós-operatória: [revisão] / Revisión sobre el uso de gabapentina para el control del dolor postoperatorio: [revisión] / Review of the use of gabapentin in the control of postoperative pain: [review]

JUSTIFICATIVA E OBJETIVOS: A gabapentina tem sido utilizada como adjuvante no tratamento da dor pós-operatória com componente neuropático. É responsável pela inibição da sensibilização central, diminuindo a dor pós-operatória. CONTEÚDO: Foram selecionados todos os estudos clínicos com distribuição aleatória que avaliaram o efeito da gabapentina na dor pós-operatória em humanos entre 2002 e 2007. Foram encontrados 26 artigos publicados. Em 17 estudos os pacientes receberam dose única pré-operatória que variou de 300 a 1.200 mg entre 30 min e duas horas antes dos procedimentos. Nos demais estudos a medicação foi iniciada entre uma e 24 horas antes dos procedimentos, foi continuada por dois a dez dias na dose de 1.200 a 1.800 mg.dia-1. Para medida de intensidade da dor foram utilizadas a Escala Analógica Visual ou Numérica. Em 75 por cento dos que receberam somente dose pré os escores foram menores com uso de gabapentina e também em 55,6 por cento dos que receberam dose pré e pós. O consumo de opióide foi menor em 82,4 por cento dos que receberam dose pré e em 77,8 por cento dos que receberam pré e pós. Em estudos que usaram pré, quatro não descreveram efeitos adversos; não houve diferença em 52,9 por cento, mais náusea ou vômito em 11,8 por cento, mais tontura em 5,9 por cento, mais sedação em 5,9 por cento, menos náusea ou vômito em um e menos retenção urinária em um. Em estudos que usaram pré e pós, quatro não descreveram efeitos adversos; não houve diferença em 22,2 por cento, mais náusea ou vômito em 11,1 por cento, mais tontura em 22,2 por cento e mais sedação em 11,1 por cento. CONCLUSÕES: A gabapentina usada tanto antes como antes e após a operação promove diminuição da intensidade da dor e da necessidade de complementação analgésica.

JUSTIFICATIVA Y OBJETIVOS: La gabapentina ha sido utilizada como adyuvante en el tratamiento del dolor postoperatorio con componente neuropático. Es responsable de la inhibición de la sensibilización central, disminuyendo el dolor postoperatorio. CONTENIDO: Fueron seleccionados todos los estudios clínicos con distribución aleatoria que evaluaron el efecto de la gabapentina en el dolor postoperatorio en humanos entre 2002 y 2007. Se encontraron 26 artículos publicados. En 17 estudios, los pacientes recibieron dosis única preoperatoria que varió entre 300 y 1200mg y entre 30min y dos horas antes de los procedimientos. En los demás estudios, la medicación fue iniciada entre una y 24 horas antes de los procedimientos, y continuada por dos a 10 días en la dosis de 1.200 a 1.800 mg.día-1. Para una medida de intensidad del dolor, fueron utilizadas la Escala Analógica Visual o Numérica. En un 75 por ciento entre los que recibieron solamente la dosis pre, los puntajes fueron menores con el uso de la gabapentina y también en un 55,6 por ciento entre los que recibieron dosis pre y pos. El consumo de opioide fue menor en un 82,4 por ciento de los que recibieron dosis pre y en un 77,8 por ciento en los que recibieron pre y pos. En estudios que usaron pre, cuatro no arrojaron efectos adversos; no hubo diferencia en un 52,9 por ciento, más náusea o vómito en un 11,8 por ciento, más mareos en un 5,9 por ciento, más sedación en un 5,9 por ciento, menos náusea o vómito en uno y menos retención urinaria en uno. En estudios que usaron pre y pos, cuatro no arrojaron efectos adversos; no hubo diferencia en un 22,2 por ciento, más náusea o vómito en 11,1 por ciento, más mareo en 22,2 por ciento y más sedación en un 11,1 por ciento. CONCLUSIONES: La gabapentina usada tanto antes, como antes y después de la operación, promueve la reducción de la intensidad del dolor y de la necesidad de complementación analgésica.

BACKGROUND AND OBJECTIVES: Gabapentin has been used as adjuvant in the treatment of postoperative pain with a neuropathic component. It is responsible for the inhibition of central sensitization, decreasing postoperative pain. CONTENTS: All clinical, randomized studies that evaluated the effects of gabapentin on postoperative pain in humans between 2002 and 2007 for a total of 26 studies were selected. In 17 studies, patients received a single preoperative dose, which ranged from 300 to 1,200 mg, 30 minutes to two hours before surgery. In the remaining studies, the administration of the drug was initiated one to 24 hours before the procedure and continued for 10 days, in doses that ranged from 1,200 to 1,800 mg.day-1. To measure pain severity, the Visual Analog or Numeric Rating Scale was used. In 75 percent of patients who received a single dose of gabapentin, scores were lower, and the same was seen in 55.6ù percent of patients who received the drugs pre- and postoperatively. Opioid consumption was reduced in 82.4 percent of patients who received a single dose, and in 77.8 percent of patients who received pre- and postoperative gabapentin. Among the studies using a single dose of gabapentin, four did not describe adverse effects; 52.9 percent showed no differences, 11.8 percent detected more nausea or vomiting, 5.9 percent experienced more dizziness, 5.9 percent more sedation, less nausea or vomiting in one, and less urinary retention in one. Among the studies with pre- and postoperative administration of gabapentin, four did not describe adverse effects; 22.2 percent showed no differences, 11.1 percent had more nausea or vomiting, 22.2 percent more dizziness, and 11.1 percent more sedation. CONCLUSIONS: Gabapentin, used before as well as before and after surgery, decreased pain severity and the need of analgesic supplementation.