Safety and effectiveness of adding fentanyl or sufentanil to spinal anesthesia: systematic review and meta-analysis of randomized controlled trials

Abstract Introduction Spinal infusions of either fentanyl or sufentanil have been reported in international reports, articles, and scientific events worldwide. This study aimed to determine whether intrathecal fentanyl or sufentanil offers safety in mortality and perioperative adverse events. Methods MEDLINE (via PubMed), EMBASE, CENTRAL (Cochrane library databases), gray literature, hand-searching, and clinicaltrials.gov were systematically searched. Randomized controlled trials with no language, data, or status restrictions were included, comparing the effectiveness and safety of adding spinal lipophilic opioid to local anesthetics (LAs). Data were pooled using the random-effects models or fixed-effect models based on heterogeneity. Results The initial search retrieved 4469 records; 3241 records were eligible, and 3152 articles were excluded after reading titles and abstracts, with a high agreement rate (98.6%). After reading the full texts, 76 articles remained. Spinal fentanyl and sufentanil significantly reduced postoperative pain and opioid consumption, increased analgesia and pruritus. Fentanyl, but not sufentanil, significantly reduced both postoperative nausea and vomiting, and postoperative shivering; compared to LAs alone. The analyzed studies did not report any case of in-hospital mortality related to spinal lipophilic opioids. The rate of respiratory depression was 0.7% and 0.8% when spinal fentanyl or sufentanil was added and when it was not, respectively. Episodes of respiratory depression were rare, uneventful, occurred intraoperatively, and were easily manageable. Conclusion There is moderate to high quality certainty that there is evidence regarding the safety and effectiveness of adding lipophilic opioids to LAs in spinal anesthesia.

Safety and effectiveness of adding fentanyl or sufentanil to spinal anesthesia: systematic review and meta-analysis of randomized controlled trials.

INTRODUCTION: Spinal infusions of either fentanyl or sufentanil have been reported in international reports, articles, and scientific events worldwide. This study aimed to determine whether intrathecal fentanyl or sufentanil offers safety in mortality and perioperative adverse events. METHODS: MEDLINE (via PubMed), EMBASE, CENTRAL (Cochrane library databases), gray literature, hand-searching, and clinicaltrials.gov were systematically searched. Randomized controlled trials with no language, data, or status restrictions were included, comparing the effectiveness and safety of adding spinal lipophilic opioid to local anesthetics (LAs). Data were pooled using the random-effects models or fixed-effect models based on heterogeneity. RESULTS: The initial search retrieved 4469 records; 3241 records were eligible, and 3152 articles were excluded after reading titles and abstracts, with a high agreement rate (98.6%). After reading the full texts, 76 articles remained. Spinal fentanyl and sufentanil significantly reduced postoperative pain and opioid consumption, increased analgesia and pruritus. Fentanyl, but not sufentanil, significantly reduced both postoperative nausea and vomiting, and postoperative shivering; compared to LAs alone. The analyzed studies did not report any case of in-hospital mortality related to spinal lipophilic opioids. The rate of respiratory depression was 0.7% and 0.8% when spinal fentanyl or sufentanil was added and when it was not, respectively. Episodes of respiratory depression were rare, uneventful, occurred intraoperatively, and were easily manageable. CONCLUSION: There is moderate to high quality certainty that there is evidence regarding the safety and effectiveness of adding lipophilic opioids to LAs in spinal anesthesia.

[Effect of palonosetron, ondansetron and dexamethasone in the prevention of postoperative nausea and vomiting in video cholecystectomy with total venous anesthesia with propofol-remifentanil - randomized clinical trial]. / Efeito da palonosetrona, ondansetrona e dexametasona na prevenção de náusea e vômito pós­operatório em videocolecistectomia com anestesia venosa total com propofol­remifentanil ­ ensaio clínico randomizado duplo cego.

INTRODUCTION AND OBJECTIVES: The incidence of Postoperative Nausea and Vomiting (PONV) after video cholecystectomy is high. Progress in pharmacological PONV prophylaxis includes a new generation of 5-HT3 antagonists. This study aims to assess the effect of the 5-HT3 antagonist in postanesthetic antiemetic management of patients submitted to laparoscopic cholecystectomy with total intravenous anesthesia. METHODS: Sixty individuals who underwent video cholecystectomy were randomized into three groups of 20 individuals according to the treatment administered: 0.125 mg of palonosetron (Group 1); 4 mg of ondansetron associated with 4 mg of dexamethasone (Group 2); 4 mg of dexamethasone (Group 3). General intravenous anesthesia was performed with propofol, remifentanil and rocuronium. The group to which the participant belonged was concealed from the investigator who assessed drug effect. PONV was assessed using the Rhodes Scale at 12 and 24 hours after surgery. Rescue medication was 0.655 to 1.5 mg of droperidol. RESULTS: Group 1 presented a lower incidence of PONV and required less rescue medication in the first postoperative hour. There was no significant difference among the three groups regarding PONV incidence in the first 12 postoperative hours. Groups 1 and 2 were superior to Group 3 regarding the control of PONV from 12 to 24 hours, and after rescue medication from 12 to 24 hours. Group 1 showed significantly superior nausea control in the first 12 postoperative hours. CONCLUSIONS: The present study showed evidence that palonosetron is superior to the drugs compared regarding a protracted antiemetic effect and less requirement of rescue drugs, mainly related to its ability to completely inhibit the uncomfortable symptom of nausea.

Effect of palonosetron, ondansetron and dexamethasone in the prevention of postoperative nausea and vomiting in video cholecystectomy with total venous anesthesia with propofol-remifentanil - randomized clinical trial / Efeito da palonosetrona, ondansetrona e dexametasona na prevenção de náusea e vômito pós-operatório em videocolecistectomia com anestesia venosa total com propofol-remifentanil - ensaio clínico randomizado duplo cego

Abstract Introduction and objectives: The incidence of Postoperative Nausea and Vomiting (PONV) after video cholecystectomy is high. Progress in pharmacological PONV prophylaxis includes a new generation of 5-HT3 antagonists. This study aims to assess the effect of the 5-HT3 antagonist in postanesthetic antiemetic management of patients submitted to laparoscopic cholecystectomy with total intravenous anesthesia. Methods: Sixty individuals who underwent video cholecystectomy were randomized into three groups of 20 individuals according to the treatment administered: 0.125 mg of palonosetron (Group 1); 4 mg of ondansetron associated with 4 mg of dexamethasone (Group 2); 4 mg of dexamethasone (Group 3). General intravenous anesthesia was performed with propofol, remifentanil and rocuronium. The group to which the participant belonged was concealed from the investigator who assessed drug effect. PONV was assessed using the Rhodes Scale at 12 and 24 hours after surgery. Rescue medication was 0.655 to 1.5 mg of droperidol. Results: Group 1 presented a lower incidence of PONV and required less rescue medication in the first postoperative hour. There was no significant difference among the three groups regarding PONV incidence in the first 12 postoperative hours. Groups 1 and 2 were superior to Group 3 regarding the control of PONV from 12 to 24 hours, and after rescue medication from 12 to 24 hours. Group 1 showed significantly superior nausea control in the first 12 postoperative hours. Conclusions: The present study showed evidence that palonosetron is superior to the drugs compared regarding a protracted antiemetic effect and less requirement of rescue drugs, mainly related to its ability to completely inhibit the uncomfortable symptom of nausea.

Resumo Justificativa e objetivo: Náuseas e Vômitos no Pós-Operatório (NVPO) têm alta incidência após videocolecistectomia. Avanços na profilaxia farmacológica de NVPO incluem a nova geração de antagonista 5-HT3. O objetivo deste estudo foi avaliar o efeito do antagonista 5-HT3 no controle antiemético pós-anestésico em videocolecistectomia com anestesia venosa total. Método: Estudo realizado no HC-UFU (Hospital Terciário). Sessenta indivíduos submetidos a videocolecistectomia foram randomizados em três grupos de igual número, sendo administrados 0,125 mg de palonosetrona (Grupo 1); 4 mg de ondasetrona e 4 mg de dexametasona (Grupo 2); ou 4 mg de dexametasona (Grupo 3). A anestesia geral venosa foi realizada com propofol, remifentanil e rocurônio. O avaliador do efeito da droga desconhecia o grupo ao qual o indivíduo pertencia. NVPO foi avaliada aplicando a Escala de Rhodes após 12 e 24 horas do término da cirurgia. Para resgate terapêutico, foi estabelecido 0,655−1,5 mg de droperidol. Resultado: Observou-se no Grupo 1 menor incidência de NVPO e de resgate terapêutico na primeira hora de PO. Não foi observada diferença significativa entre os três grupos com relação a ocorrência de NVPO nas primeiras 12 horas de pós-operatório. Os grupos 1 e 2 foram superiores ao Grupo 3 no que se refere ao controle de NVPO de 12 a 24 horas e após o resgate de 12−24 horas. Observou-se que o controle de náuseas nas primeiras 12 horas de pós-operatório do Grupo 1 foi significantemente superior. Conclusão: O presente estudo mostrou evidências da superioridade da palonosetrona às demais drogas empregadas no que se refere ao efeito antiemético prolongado e menor necessidade de resgate, principalmente na capacidade de inibir completamente o desconfortável sintoma de náusea.

SBA 2020: Regional anesthesia safety recommendations update / SBA 2020: Atualização das recomendações para segurança em anestesia regional

Abstract The purpose of the Brazilian Society of Anesthesiology (SBA)'s Regional Anesthesia Safety Recommendations Update is to provide new guidelines based on the current relevant clinical aspects related to safety in regional anesthesia and analgesia. The goal of the present article is to provide a broad overview of the current knowledge regarding pre-procedure asepsis and antisepsis, risk factors, diagnosis and treatment of infectious complications resulting from anesthetic techniques. It also aims to shed light on the use of reprocessed materials in regional anesthesia practice to establish the effects of aseptic handling of vials and ampoules, and to show cost-effectiveness in the preparation of solutions to be administered continuously in regional blockades. Electronic databases were searched between January 2011 (final date of the literature search for the past SBA recommendations for safety in regional anesthesia) and September 2019. A total of 712 publications were found, 201 of which were included for further analysis, and 82 new publications were added into the review. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the quality of each study and to classify the strength of evidence. The present review was prepared by members of the SBA Technical Standards Committee.

Resumo O propósito desta atualização das Recomendações da Sociedade Brasileira de Anestesiologia (SBA) para Segurança em Anestesia Regional foi apresentar novas diretrizes com base na relevância e atualidade clínica nos aspectos de segurança relacionados a analgesia e anestesia regional. Este artigo visa prover uma visão ampla sobre o conhecimento atual no tocante a assepsia e antissepsia pré-procedimento, fatores de risco, diagnóstico e tratamento das complicações infecciosas decorrentes das técnicas anestésicas. Também visa esclarecer sobre o uso de materiais reprocessados na prática da anestesia regional, estabelecer as implicações no manejo asséptico de frascos e ampolas e elucidar sobre a relação custo-efetividade no preparo de soluções a serem administradas continuamente em bloqueios regionais. As bases de dados eletrônicas foram pesquisadas entre Janeiro de 2011 (final da pesquisa de literatura das diretrizes anteriores da SBA sobre segurança em anestesia regional) e Setembro de 2019. Um total de 712 artigos foram encontrados, dos quais 201 foram incluídos para análise posterior e 82 novos estudos foram acrescentados nesta revisão. O sistema de Avaliação, Desenvolvimento e Avaliação da Classificação das Recomendações (GRADE) foi utilizado para avaliar a qualidade do estudo individual e classificar a força da evidência. Esta revisão foi elaborada por membros da Comissão de Normas Técnicas da SBA.

SBA 2020: Regional anesthesia guideline for using anticoagulants update / SBA 2020: Atualização na diretriz da anestesia regional em uso de anticoagulantes

Abstract The development of protocols to prevent perioperative Venous Thromboembolism (VTE) and the introduction of increasingly potent antithrombotic drugs have resulted in concerns of increased risk of neuraxial bleeding. Since the Brazilian Society of Anesthesiology 2014 guideline, new oral anticoagulant drugs were approved by international regulating agencies, and by ANVISA. Societies and organizations that try to approach concerns through guidelines have presented conflicting perioperative management recommendations. As a response to these issues and to the need for a more rational approach, managements were updated in the present narrative review, and guideline statements made. They were projected to encourage safe and quality patient care, but cannot assure specific results. Like any clinical guide recommendation, they are subject to review as knowledge grows, on specific complications, for example. The objective was to assess safety aspects of regional analgesia and anesthesia in patients using antithrombotic drugs, such as: possible technique-associated complications; spinal hematoma-associated risk factors, prevention strategies, diagnosis and treatment; safe interval for discontinuing and reinitiating medication after regional blockade.

Resumo Os padrões evolutivos para a prevenção do tromboembolismo venoso perioperatório e a introdução de medicações antitrombóticas cada vez mais potentes resultaram em preocupações com o aumento do risco de sangramento neuroaxial. Após o consenso da Sociedade Brasileira de Anestesiologia em 2014, novos medicamentos anticoagulantes orais foram aprovados pelas instituições reguladoras internacionais, assim como pela ANVISA. As sociedades que buscam abordar o manejo perioperatório desses fármacos apresentam recomendações conflitantes. Em resposta a essas questões e à necessidade de uma abordagem mais racional, as condutas foram atualizadas nesta revisão narrativa e feitas declarações de consenso. Elas foram projetadas para encorajar a assistência ao paciente de forma segura e de qualidade, mas não podem garantir um resultado específico. Tal como acontece com qualquer recomendação de orientação clínica, estas estão sujeitas a revisão com o conhecimento de avanços específicos de complicações. O objetivo foi avaliar aspectos da segurança em anestesia e analgesia regional em pacientes em uso de medicações antitrombóticas, tais como: possíveis complicações decorrentes da técnica; fatores de risco associados ao hematoma espinhal, estratégias de prevenção, diagnóstico e tratamento; intervalo seguro para suspensão e reinício da medicação após o bloqueio regional.

[SBA 2020: Regional anesthesia guideline for using anticoagulants update]. / SBA 2020: Atualização na diretriz da anestesia regional em uso de anticoagulantes.

The development of protocols to prevent perioperative Venous Thromboembolism (VTE) and the introduction of increasingly potent antithrombotic drugs have resulted in concerns of increased risk of neuraxial bleeding. Since the Brazilian Society of Anesthesiology (SBA) 2014 guideline, new oral anticoagulant drugs were approved by international regulating agencies, and by ANVISA. Societies and organizations that try to approach concerns through guidelines have presented conflicting perioperative management recommendations. As a response to these issues and to the need for a more rational approach, managements were updated in the present narrative revision, and guideline statements made. They were projected to encourage safe and quality patient care, but cannot assure specific results. Like any clinical guide recommendation, they are subject to review as knowledge grows, on specific complications, for example. The objective was to assess safety aspects of regional analgesia and anesthesia in patients using antithrombotic drugs, such as: possible technique-associated complications; spinal hematoma-associated risk factors, prevention strategies, diagnosis and treatment; safe interval for discontinuing and reinitiating medication after regional blockade.

[SBA 2020: Regional anesthesia safety recommendations update]. / SBA 2020: Atualização das recomendações para segurança em anestesia regional.

The purpose of the Brazilian Society of Anesthesiology's (SBA) Regional Anesthesia Safety Recommendations Update is to provide new guidelines based on the current relevant clinical aspects related to safety in regional anesthesia and analgesia. The goal of the present article is to provide a broad overview of the current knowledge regarding pre-procedure asepsis and antisepsis, risk factors, diagnosis and treatment of infectious complications resulting from anesthetic techniques. It also aims to shed light on the use of reprocessed materials in regional anesthesia practice to establish the effects of aseptic handling of vials and ampoules, and to show cost-effectiveness in the preparation of solutions to be administered continuously in regional blockades. Electronic databases were searched between January 2011 (final date of the literature search for the past SBA recommendations for safety in regional anesthesia) and September 2019. A total of 712 publications were found, 201 of which were included for further analysis, and 82 new publications were added into the review. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the quality of each study and to classify the strength of evidence. The present review was prepared by members of the SBA Technical Standards Committee.

Ventilação mecânica protetora, utilizar para todos? / Lung protective ventilation (PPV): can we use for all patient?

A ventilação mecânica (VM) tem como objetivo permitir trocas gasosas e, assim, manter níveis adequados de O2 e CO2 sanguíneos. Várias estratégias vêm sendo desenvolvidas ao longo dos anos com o objetivo de permitir, cada vez mais, a ventilação mais próximo da fisiológica e, dessa forma, diminuir efeitos deletérios que podem ser causados ou agravados pela VM. Diversas propostas foram desenvolvidas buscando encontrar estratégias mais adequadas ao paciente em relação ao volume corrente, pressão positiva no final da expiração (PEEP), FiO2 . Atualmente, uma das principais modificações adotadas é o uso da ventilação protetora pulmonar (VPP), adotando volumes correntes menores (que são mais próximos do fisiológico), nível apropriado de PEEP e baixas concentrações inspiradas de oxigênio (FiO2). Essa técnica evita lesões ou reações pulmonares inflamatórias, redução da morbimortalidade e do tempo de permanência hospitalar. Os evidentes benefícios da VPP é importante fator como estratégia na rotina anestesiologica em relação ao cuidado ventilatório intra e pós-operatório.

Mechanical ventilation (MV) is a mechanism to allow gas exchange and maintain adequate blood levels of O2 and CO2 .Various strategies have being developed over the years with the goal of allowing increasingly a ventilation closer to the physiological and thus decrease the deleterious effects that can be caused or aggravated by the MV. There are numerous attempts to get the most beneficial tidal volume, PEEP, FiO2 .One of the main changes adopted is the use of lung protective ventilation (PPV) that is based on the use smaller tidal volumes (which are more physiologic), appropriate level of positive end-expiratory pressure (PEEP) and lower oxygen concentrations. Those actions may possible avoid pulmonary lesions or may not aggravate existing ones. Studies have shown that this technique allows a reduction in morbidity and mortality and length of hospital stay. Given the obvious benefits to patients, the PPV have been a key element in respiratory care intra operative and post-operative.

Bloqueio dos nervos tibial e fibular comum em fossa poplítea com punção única utilizando o estimulador percutâneo de nervos: considerações anatômicas e descrição ultrassonográfica / Tibial and common fibular nerve block in the popliteal fossa with single puncture using percutaneous nerve stimulator: anatomical considerations and ultrasound description

JUSTIFICATIVA E OBJETIVOS: As técnicas de bloqueios de nervos periféricos têm ganhado popularidade nas últimas duas décadas, tornando-se crescente opção anestésica para a cirurgia de membros. Este estudo propõe uma técnica de abordagem dos nervos tibial e fibular comum na fossa poplítea por punção única e utilizando o estimulador percutâneo de nervos, considerando a correlação com estudo anatômico e ultrassonográfico. MÉTODO: Estudo prospectivo, observacional e aleatório realizado com 28 pacientes escalados para cirurgias no pé. Após localização dos nervos tibial e fibular comum por meio de estimulação percutânea, realizou-se punção no ponto de estímulo do nervo tibial com agulha de 5 cm (B.Braun, Stimuplex 50) e foram injetados 10 mL de levobupivacaína. A agulha foi recuada e redirecionada para o ponto de estímulo do nervo fibular comum em busca da resposta motora correspondente, injetando-se 10 mL do anestésico. Realizado estudo fotográfico da região poplítea por ultrassonografia para correlação da anatomia com a técnica utilizada. RESULTADOS: Obteve-se anestesia adequada em todos os casos. O tempo médio para a localização dos nervos tibial e fibular comum, utilizando o estimulador percutâneo de nervos, foi de 57,1 e 32,8 segundos, respectivamente, e com o estimulador de nervos foi de 2,22 e 1,79 minutos. A profundidade média da agulha para o nervo tibial foi de 10,7 mm. CONCLUSÕES: A abordagem dos nervos tibial e fibular comum com punção única na fossa poplítea utilizando o estimulador percutâneo de nervos é uma boa opção para anestesia e analgesia para cirurgias do pé.

BACKGROUND AND OBJECTIVES: Techniques of peripheral nerve block have gained popularity over the last two decades becoming a growing anesthetic option for limb surgeries. This study proposes a technical approach of the tibial and common fibular nerves in the popliteal fossa with single puncture using percutaneous nerve stimulator, considering the correlation with an anatomical and ultrasound study. METHODS: This prospective, observational, randomized study was performed with 28 patients scheduled for foot surgeries. After localizing the tibial and common fibular nerves through percutaneous stimulation, the puncture was performed at the point of tibial nerve stimulation with a 5-cm needle (B.Braun, Stimuplex 50), and 10 mL of levobupivacaine were injected. The needle was pulled back and redirected to the point of common fibular nerve stimulation looking for the corresponding motor response, and 10 mL of the local anesthetic were injected. Imaging study of the popliteal region was performed by ultrasound to correlate the anatomy with the technique used. RESULTS: Adequate anesthesia was obtained in all cases. The mean time to localize the tibial and common fibular nerves suing the percutaneous stimulator was 57.1 and 32.8 seconds, respectively, and with the nerve stimulator it was 2.22 and 1.79 minutes, respectively. The mean depth of the needle into the tibial nerve was 10.7 mm. CONCLUSIONS: The approach for tibial and common fibular nerves with single puncture in the popliteal fossa using peripheral nerve stimulator is a good option for anesthesia and analgesia for foot surgeries.

JUSTIFICATIVA Y OBJETIVOS: Las técnicas de bloqueos de nervios periféricos ha venido obteniendo popularidad en las últimas de los décadas, y convirtiéndose cada vez más en una opción anestésica para la cirugía de los miembros. Este estudio propone una técnica de abordaje de los nervios tibial y fibular común en la fosa poplítea por punción única y utilizando el estimulador percutáneo de nervios, considerando la correlación con el estudio anatómico y ultrasonográfico. MÉTODO: Estudio prospectivo, observacional y aleatorio realizado con 28 pacientes selecionados para cirugías en el pie. Después de la localización de los nervios tibial y fibular común a través de la estimulación percutánea, se realizó una punción en el punto de estímulo del nervio tibial con la aguja de 5 cm (B.Braun, Stimuplex 50), y fueron inyectados 10 mL de levobupivacaína. La aguja se echó hacia atrás y fue redirigida hacia el punto de estímulo del nervio fibular común en busca de la respuesta motora correspondiente, inyectando 10 mL del anestésico. Se realizó el estudio fotográfico de la región poplítea por ultrasonografía para la correlación de la anatomía con la técnica utilizada. RESULTADOS: En todos los casos se obtuvo la anestesia adecuada. El tiempo promedio para la localización de los nervios tibial y fibular común, utilizando el estimulador percutáneo de nervios, fue de 57,1 y 32,8 segundos respectivamente y con el estimulador de nervios fue de 2,22 y 1,79 minutos. La profundidad promedio de la aguja para el nervio tibial fue de 10,7 mm. CONCLUSIONES: El abordaje de los nervios tibial y fibular común con punción única en la fosa poplítea utilizando el estimulador percutáneo de nervios, es una buena opción para la anestesia y la analgesia en cirugías del pie.

Tibial and common fibular nerve block in the popliteal fossa with single puncture using percutaneous nerve stimulator: anatomical considerations and ultrasound description.

BACKGROUND AND OBJECTIVES: Techniques of peripheral nerve block have gained popularity over the last two decades becoming a growing anesthetic option for limb surgeries. This study proposes a technical approach of the tibial and common fibular nerves in the popliteal fossa with single puncture using percutaneous nerve stimulator, considering the correlation with an anatomical and ultrasound study. METHODS: This prospective, observational, randomized study was performed with 28 patients scheduled for foot surgeries. After localizing the tibial and common fibular nerves through percutaneous stimulation, the puncture was performed at the point of tibial nerve stimulation with a 5-cm needle (B.Braun, Stimuplex 50), and 10 mL of levobupivacaine were injected. The needle was pulled back and redirected to the point of common fibular nerve stimulation looking for the corresponding motor response, and 10 mL of the local anesthetic were injected. Imaging study of the popliteal region was performed by ultrasound to correlate the anatomy with the technique used. RESULTS: Adequate anesthesia was obtained in all cases. The mean time to localize the tibial and common fibular nerves suing the percutaneous stimulator was 57.1 and 32.8 seconds, respectively, and with the nerve stimulator it was 2.22 and 1.79 minutes, respectively. The mean depth of the needle into the tibial nerve was 10.7 mm. CONCLUSIONS: The approach for tibial and common fibular nerves with single puncture in the popliteal fossa using peripheral nerve stimulator is a good option for anesthesia and analgesia for foot surgeries.

Uso correto do monitor de consciência / Proper use of the monitor of consciousness

O índice bispectral (BIS) é um parâmetro multifatorial que permite a monitorização da componente hipnótico da anestesia. O BIS provê medidas quantificáveis do efeito de anestésicos no cérebro que correlacionam com a profundidade da anestesia. A monito-rização da profundidade anestésica na indução e manutenção da anestesia geral previne consciência e despertar intraoperatório, permite titular a quantidade de anestésicos adequada para promover a rápida recuperação da anestesia e evitar efeitos adversos da superdosagem dos fármacos. Desde sua introdução, a monitorização com BIS vem se tornando comum na prática anestésica. Esta revisão tem o objetivo de elucidar o papel do BIS na monitorização da hipnose na anestesia geral. Foi realizada revisão sobre o conceito de anestesia geral e monitorização da profundidade anestésica com o uso do BIS, bem como atualizações dos benefícios de seu emprego para a qualidade da anestesia, interpretação dos artefatos e drogas que podem interferir na sua utilização...

The bispectral index (BIS) is a multifactorial parameter that allows monitoring of the hypnotic component of anesthesia. The BIS provides quantitiable measures of the effect of anesthetics in the brain that correia te with the depth of anesthesia. Monitoring anesthetic depth during induction and maintenance of general anesthesia prevents intraoperative awakening and conscience and allows to holder the amount of anesthetic agents appropriate to promote a speedy recovery of anesthesia and avoid adverse effects of an overdose of drugs. Since its introduction, the BIS monitoring is becoming acommonplace in anesthetic practice. This review has the objective of elucidating the role of BIS monitor- ing in hypnosis of general anesthesia. A Literature review was conducted on the concepts of general anesthesia and monitoring of anesthetic depth using the BIS Moreover, recent articles on studies of BIS and its benetits in the quality of general anesthesia as well as the presence of artifacts and drugs that may interfere in its utilization...

Anestesia regional e anticoagulação / Regional anesthesia e anticoagulation

O desenvolvimento de fármacos antitrombóticos mais potentes e seguros e a disseminação da profilaxia antitrombótica perioperatória levaram a discussões polêmicas sobre o risco de desenvolvimento de hematoma espinhal após bloqueios neuroaxiais. Esta revisão traz recomendações baseadas nas publicações mais recentes que devem ser observadas rigorosamente para evitar complicações anestésicas potencialmente graves.

The development of more potent and safe antithrombotic medications and the widespread of the perioperative thromboprophylaxis lead to great discussion regarding the risk of spinal hematoma after neuroaxial blocks in these patients. This review brings recommendations based on the newest publications that should be strictly observed to prevent serious anesthetic complications.

Bloqueios de nervos periféricos e punção venosa central guiados por ultrassom / Ultrasound-guided peripheral nerve blocks and central venous puncture

A anestesia regional sempre exigiu profundo conhecimento anatômico. A utilização da ultrassonografia para a realização de bloqueios regionais tornou possível a visualização de nervos, estruturas adjacentes e, principalmente, da exata localização da agulha e da deposição do anestésico local em tempo real. A manutenção de uma distância em que apenas o anestésico local entrará em contato direto com o nervo transforma o trauma pela agulha e a injeção intraneural em lesões evitáveis, revela uma conduta menos agressiva, previne sensações desconfortáveis ao paciente e agrega mais segurança ao procedimento anestésico. A ultrassonografia é aplicável também na inserção de cateter venoso central, pois auxilia na localização e na escolha do sítio de punção. A punção venosa central guiada por ultrassom reduz as taxas de insucesso na cateterização venosa, o número de tentativas e as complicações inerentes ao procedimento, pois garante a visualização precisa da veia e a progressão da agulha e do fio-guia. Por minimizar o risco de trauma, torna o procedimento factível mesmo nos pacientes com coagulopatias.

Regional anesthesia always demanded a deep anatomical knowledge. The use of ultrasonography for the accomplishment of regional blockades became the visualization of the nerves and adjacent structures possible and, mainly, shows the exact localization of the needle and the deposition of the local anesthetic in real time. The maintenance of a distance which only the local anesthetic will enter in direct contact with the nerve transforms the trauma for the needle and the intraneural injection in preventable injuries, reveals a less aggressive conduct, prevents discomfortable sensations to the patient and adds more security to the anesthetic procedure. Ultrasonography is also applicable in the insertion of central venous catheter, as it assists in the localization and choice of the puncture’s site. Ultrasound-guided central venous puncture reduces the failure taxes in venous catheterization, the number of attempts and the procedure inherent complications, therefore it guarantees the accurate visualization of the vein and the progression of the needle and the wire-guide. For minimizing the trauma risk, it becomes the procedure feasible even in patients with coagulopathies.