Postoperative analgesia for the surgical correction of congenital clubfoot: comparison between peripheral nerve block and caudal epidural block.

BACKGROUND AND OBJECTIVES: Correction of congenital clubfoot (CCF) is associated with severe postoperative pain. Caudal epidural block associated with general anesthesia is the anesthetic technique used more often in children, but it is limited by the short duration of the postoperative analgesia. Peripheral nerve blocks are associated with a low incidence of complications and prolonged analgesia. The objective of this study was to compare the duration of analgesia in peripheral nerve blocks and caudal block, as well as morphine consumption in the first 24 hours after correction of CCF in children. METHODS: This is a randomized, double-blind study with children undergoing surgeries for posteromedial release of CCF, who were divided in four groups according to the anesthetic technique: caudal (ACa), sciatic and femoral block (IF), sciatic and saphenous block (IS), and sciatic block and local anesthesia (IL), associated with general anesthesia. In the first 24 hours, patients received oral dypirone and acetaminophen, and they were evaluated by anesthesiologists who were unaware of the technique used. Oral morphine (0.19 mg x kg(1) per day) was administered according to the scores of the CHIPPS (Children's and infants' postoperative pain scale) scale. RESULTS: One hundred and eighteen children separated into four groups: ACa (30), IF (32), IS (28), and IL (28) participated in this study. The mean time between the blockade and the first dose of morphine was 6.16 hours in group ACa, 7.05 hours in group IF, 7.58 in IS, and 8.18 hours in IL. Morphine consumption was 0.3 mg.kg-1 per day in all four groups. Significant differences were not observed among the groups. CONCLUSIONS: peripheral nerve blocks did not promote longer lasting analgesia or a decrease in morphine consumption in the first 24 hours in children undergoing CCF correction when compared to caudal epidural block.

Influence of angiotensin-converting enzyme inhibitors on hypotension after anesthetic induction: is the preoperative discontinuation of this drug necessary?

BACKGROUND AND OBJECTIVES: The discontinuation of drugs such as angiotensin-converting enzyme inhibitors (ACE inhibitors) has been suggested based on reports of hypotension during anesthesia. This may imply on a higher risk of intraoperative hypertensive peaks with deleterious consequences for the patient. The objective of the present study was to evaluate the influence of the preoperative use of ACE inhibitors on the development of hypotension during anesthesia. METHODS: This is a case-controlled study of patients who developed hypotension after anesthetic induction. The control group was composed of patients of the same age and gender who underwent surgeries during the same period and who did not develop hypotension. Parameters of interest included: age, gender, size of the surgery, prior diagnosis of hypertension, use of ACE inhibitors, physical status (ASA), intraoperative bleeding, anesthetic technique, and duration of the surgery. RESULTS: In 2,179 surgeries, 40 patients developed hypotension. Twenty of those patients used ACEIs on the day of the surgery. The control group was composed by 171 patients, 11 of which used ACE inhibitors. Univariate analysis showed an association between hypertension and advanced age (p < 0.001), prior diagnosis of hypertension (p < 0.001), use of ACEIs (p = 0.006), physical status (ASA) (p = 0.006), and size of the surgery (p = 0.028). Stratified analysis did not show an association between hypotension and use of ACE inhibitors. On logistic regression, the association between the size of the surgery and the age of the patient and the development of hypotension remained. CONCLUSIONS: We did not observe an association between the use of ACE inhibitors and hypotension during anesthesia. The authors considered that the recommendation to discontinue ACE inhibitors on the day before the surgery should be reviewed. Other studies are necessary to confirm those results.

Analgesia pós-operatória em correção cirúrgica de pé torto congênito: comparação entre bloqueio nervoso periférico e bloqueio peridural caudal / Analgesia postoperatoria en corrección quirúrgica de pie jorobado congénito: comparación entre bloqueo nervioso periférico y bloqueo epidural caudal / Postoperative analgesia for the surgical correction of congenital clubfoot: comparison between peripheral nerve block and caudal epidural block

Justificativa e objetivos: O procedimento de correção de pé torto congênito (PTC) cursa com dor pós-operatória intensa. A técnica mais utilizada em crianças é a peridural caudal associada à anestesia geral. Tem como limitação a curta duração da analgesia pós-operatória. Os bloqueios de nervos periféricos têm sido apontados como procedimentos com baixa incidência de complicações e tempo prolongado de analgesia. O objetivo do estudo foi comparar o tempo de analgesia dos bloqueios nervosos periféricos e bloqueio caudal e o consumo de morfina nas primeiras 24 horas após a correção de PTC em crianças...

Background and objetives: Correction of congenital clubfoot (CCF) is associated with severe postoperative pain. Caudal epidural block associated with general anesthesia is the anesthetic technique used more often in children, but it is limited by the short duration of the postoperative analgesia. Peripheral nerve blocks are associated with a low incidence of complications and prolonged analgesia. The objective of this study was to compare the duration of analgesia in peripheral nerve blocks and caudal block, as well as morphine consumption in the first 24 hours after correction of CCF in children...

Justificativa y objetivos: El procedimiento de corrección depie jorobado congénito (PJC), debuta con dolor postoperatorio intenso. La técnica más utilizada en niños es la epidural caudal asociada a la anestesia general. Posee la limitante de una corta duración de la analgesia postoperatoria. Los bloqueos de nervios periféricos han sido indicados como procedimientos con una baja incidencia de complicaciones y un tiempo prolongado de analgesia. El objetivo del estudio actual, fue comparar el tiempo de analgesia de los bloqueos nerviosos periféricos y del bloqueo caudal y el consumo de morfina, en las primeras 24 horas después de la corrección...

Influência do uso crônico dos inibidores da enzima conversora da angiotensina na hipotensão arterial após indução anestésica: é necessário suspender esse fármaco no pré-operatório? / Influencia del uso crónico de los inhibidores de la enzima conversora de la angiotensina en la hipotensión arterial después de la inducción anestésica: ¿es necesario suspender ese fármaco en el preoperatorio? / Influence of angiotensin-converting enzyme inhibitors on hypotension after anesthetic induction: is the preoperative discontinuation of this drug necessary?

Justificativa e objetivos: Tem sido sugerida a suspensão de medicamentos como os inibidores da enzima conversora de angiotensina (IECA) com base em relatos de hipotensão arterial durante a anestesia. Isso pode implicar em maior risco de picos hipertensivos no intraoperatório, com efeitos deletérios para o paciente. O objetivo deste estudo foi avaliar a influência dos IECA utilizados no pré-operatório na ocorrência de hipotensão arterial...

Background and objetives: The discontinuation of drugs such as angiotensin-converting enzyme inhibitors (ACE inhibitors) has been suggested based on reports of hypotension during anesthesia. This may imply on a higher risk of intraoperative hypertensive peaks with deleterious consequences for the patient. The objective of the present study was to evaluate the influence of the preoperative use of ACE inhibitors on the development of hypotension...

Justificativa y objetivos: En base a relatos de hipotensión arterial durante la anestesia, se ha sugerido la suspensión de medicamentos como los inhibidores de la enzima conversora de angiotensina (IECA). Eso puede redundar en un riesgo más elevado de picos hipertensivos en el intraoperatorio y con efectos perjudiciales para el paciente. El objetivo de este estudio, fue evaluar la influencia de los IECA utilizados en el preoperatorio si surge la hipotensión arterial...

Markov decision process applied to the control of hospital elective admissions.

OBJECTIVE: To present a decision model for elective (non-emergency) patient admissions control for distinct specialties on a periodic basis. The purpose of controlling patient admissions is to promote a more efficient utilization of hospital resources, thereby preventing idleness or excessive use of these resources, while considering their relative importance. METHODS: The patient admission control is modeled as a Markov decision process. A hypothetical prototype is implemented, applying the value iteration algorithm. RESULTS: The model is able to generate an optimal admission control policy that maintains resource consumption close to the desired levels of utilization, while optimizing the established deviation costs. CONCLUSION: This is a complex model due to its stochastic dynamic and dimensionality. The model has great potential for application, and requires the development of customized solution methods.

Hand skill assessment with a reduced version of the Peg Moving Task (PMT-5) in children: normative data and application in children with cerebral palsy.

This paper proposes a simple method of hand skill assessment in children that can be useful in clinical practice. A reduced 5-hole version of Annett's Peg Moving Task was used to quantify hand skill bilaterally in 435 normally developing preschool and school-children, and adolescents aged 3-18 years from Brazil. The cross-cultural validity of the normative data obtained in Brazil was verified in 157 school-children aged 6-11 years from France. An application in 76 children with cerebral palsy (hemiplegia 21, diplegia 34, triplegia 6, mixed type 15) showed very important variability of the deficits in hand function within each subtype of cerebral palsy (CP). Hand deficits were more severe in children in special schools than in children in regular schools within each CP subtype. A qualitative analysis showed which difficulties during the execution of the task were specific to children with CP and which were also observed in normally developing children.

Monitorizaçäo eletroneurofisiológica da anestesia: estudo clínico com a utilizaçäo de sevoflurano e óxido nitroso no paciente pediátrico / Electrical neurophysiological monitoring of anesthesia: clinical study with sevoflurane and nitrous oxide in pediatric patients

Justificativa e objetivos: o potencial evocado somatossensitivo (PESS) é uma técnica eletrofisiológica para monitorizaçäo da funçäo cerebral através de ondas reprodutíveis. Este estudo tem como objetivo avaliar os efeitos do sevoflurano como agente único e associado ao óxido nitroso (N2O) sobre o PESS em pacientes pediátricos. Método: foram estudados 51 pacientes, de ambos os sexos, com idade entre 6 meses e 6 anos, estado físico ASA I ou II, submetidos a correçäo cirúrgica de pé torto congênito sob anestesia geral inalatória associada a bloqueio peridural lombar ou caudal com bupivacaína, e medicaçäo pré-anestésica com midazolam (0,7 mg.kg(elevado a menos um)) por via oral. Os pacientes foram divididos em dois grupos (S e SN). No grupo S (n=26) foi administrado sevoflurano em oxigênio a 100 por cento e no grupo SN (n=25) foi administrado sevoflurano em oxigênio (O2) a 40 por cento e óxido nitroso (N2O) a 60 por cento. Foram monitorizadas pressäo arterial (PA); frequência cardíaca (FC); a spO2; PetCO2, temperatura esofágica; e fraçöes expiradas de sevoflurano e os registros das ondas do PESS foram obtidos em concentraçöes decrescentes até que o paciente acordasse. Resultados: houve diminuiçäo da amplitude e aumento da latência das ondas do PESS. As alteraçöes foram mais acentuadas quanto maior a concentraçäo alveolar (FA) do anestésico. Em FA próximas a 1,0 CAM houve tendência ao desaparecimento dos traçados. Em FA <- 0,02 CAM os pacientes apresentaram sinais de despertar e ondas do PESS com forma, amplitude e tendência de padräo normal. Conclusöes: o sevoflurano causa inibiçäo dose-dependente do PESS em crianças no SNC, e a inibiçäo é maior quando associado ao N2O. Os resultados mostraram ser possíveis obter inibiçäo do PESS com menores concentraçöes de sevoflurano quando associado ao óxido nitroso

Qualidade nos serviços de saúde: amplitude e perspectivas / Quality in health services: scope and perspectives

Estabelecer um julgamento sobre a Qualidade no que tange aos serviços de saúde não é algo simples, pois a condução de tratamento é tarefa complexa que envolve diversas equipes e cada caso deve ser conduzido individualmente. Custos crescentes, usuários mais exigentes, pressão da comunidade, dos profissionais de saúde e do governo são fatores que impulsionam o setor de saúde a adequar-se qualitativamente às exigências do final do século e de tempos futuros. Este trabalho aborda aspectos do movimento em favor de uma sistematização da qualidade nos serviços de saúde