THE USE OF NEAR INFRARED SPECTROSCOPY IN ALKAPTONURIA - THE MISLEADING OCHRONOSIS - A CASE REPORT AND LITERATURE REVIEW.

INTRODUCTION: Near infrared spectroscopy is a non-invasive method to assess regional oxygenation and is being used in transcatheter aortic valve implantation to document periods of cerebral hypoperfusion, where cerebrovascular events are one of the most feared complications. Alkaptonuria is a rare metabolic disease characterized by accumulation of homogentisic acid in tissues and body fluids. The accumulation of pigment might interfere with the absorption of near infrared light, used in near infrared spectroscopy monitoring. We present a case of near infrared spectroscopy failing to accurately monitor cerebral oximetry in a woman, with alkaptonuria, undergoing a transcatheter aortic valve implantation.

Analgesia Management for Mitral Valve Repair Via Minithoracotomy - A Case Report.

INTRODUCTION: Minimally invasive cardiac surgery (MICS), via minithoracotomy, is thought to be a fast track to extubation and recovery after surgery. Chronic pain, due to intercostal nerve injury, develops in up to 50% of postthoracotomy patients.A number of regional anaesthesia and analgesia techniques may be employed, and the anaesthesiologists play a key role in facilitating optimal outcomes after surgery. METHODS: We report a case of postoperative pain management with a local anesthetic infiltration for MICS. RESULTS: A 63-year-old woman, 80kg, American Society Anaesthesiology (ASA) physical status 3 [arterial hypertension, atrial fibrillation (AF), rheumatic mitral stenosis and class II NYHA heart failure] was presented for an elective minimally invasive mitral valve repair through a minithoracotomy and cryoablation of AF. No relevant facts were found on pre-operative evaluation. Calculated EuroScore II was 1.55%. After premedication with intravenous (IV) midazolam 1.5mg, radial arterial and jugular central venous catether were placed. General anaesthesia was induced with IV remifentanil 1mcg/kg/h, propofol 50mg, rocuronium 1mg/ kg. A transesophageal echocardiography probe was inserted atraumatically, which revealed thickened mitral valve leaflets. ASA standard, invasive blood pressure, central venous pressure, depth of anaesthesia and cerebral oximetry monitoring were used. Urine output and arterial blood gas were measured periodically. A right lateral minithoracotomy was performed. After cardiopulmonary bypass (CPB) by femoral cannulation, cryoablation was performed followed by placement of the mechanical prosthesis. Total bypass time was 186min including 139min aortic cross-clamping time. At the ending of CPB, there was no need for inotropic support. Analgesia with paracetamol 1g, tramadol 100mg and morphine 10mg was performed after protamine reversion. Immediately before closure of skin, catheter was placed nearly to intercostal space (figures 1, 2) and ropivacaine 0,75% 75mg was administered. Anaesthesia and surgery were uneventful. Patient was shifted to intensive care unit (ICU), being extubated 3 hours after surgery. There was no need for additional bolus of ropivacaine during 2 days of ICU stay. She was discharged home on the 4th postoperative day, without complications. In a telephone interview 3 weeks after surgery, the patient referred no pain and good satisfaction with analgesia management. CONCLUSION: Thoracotomy incisions are associated with severe pain, leading to a decrease in pulmonary function, an increase in metabolic and hormonal activity and increased cardiac morbidity. Regional analgesia techniques have an opioid-sparing effect, reducing stress response and pain chronification. The local infiltration through catheter with local anaesthetics allows excellent analgesia for 8-12 hours, providing a route of additional analgesia according to pain control.

[Influence of processed EEG monitoring in the anesthetic management and its cost in off-pump coronary surgery: a research protocol]. / Influência da Monitorização com EEG processado na Conduta Anestésica e seu Custo em Cirurgia Coronária Off-PuMP: Protocolo de Investigação.

BACKGROUD: Although in some studies intraoperative processed EEG monitoring has shown advantages such as less use of hypnotic drugs and decrease duration of both anesthetic emergency and recovery times, there is controversy on the incidence of awareness. It has not been demonstrated that this type of monitoring interferes with length of hospital stay, morbidity and mortality. Processed EEG monitoring, such as the bispectral index (BIS) has been widely accepted in assessing anesthetic depth, yet its usage is not part of the standard monitoring of the American Society of Anesthesiologiy (ASA). Other forms of monitoring anesthetic depth widely used are clinical monitoring associated with monitoring expiratory fraction of halogenated anesthetic agents. METHODOLOGY: Prospective randomized study comparing two groups of patients undergoing coronary artery bypass surgery without cardiopulmonary bypass (CPB): group A - BIS visible (BIS value is shown throughout the procedure) and group B - BIS not visible (BIS is hidden and monitoring of anesthetic depth is based on clinical signs associated with the monitoring of expiratory fraction of halogenated anesthetic agent). The aim of this study is to verify the existence of differences in anesthetic depth and associated costs in the two group study's and also to add evidence to anesthetic depth monitoring in an area where few studies have been done - cardiac surgery.