Perioperative Glycemia Management in Patients Undergoing Craniotomy for Brain Tumor Resection: A Global Survey of Neuroanesthesiologists' Perceptions and Practices.

OBJECTIVE: There is a paucity of clinical evidence that guides perioperative glycemia management in patients undergoing craniotomy for brain tumor resection. The purpose of this study was to better understand global perceptions and practices related to glycemia management in these patients. METHODS: Neuroanesthesiologists throughout North America, South America, Europe, and Asia filled out a brief online questionnaire related to their perceptions and practices regarding glycemia management in patients undergoing craniotomy for brain tumor resection. RESULTS: Over 4 weeks, 435 participants practicing in 34 countries across 6 continents participated in this survey. Although responders in North America were found to perceive a higher risk hyperglycemia compared with those practicing in European (P = 0.024) and South Asian (P = 0.007) countries, responders practicing in South Asian countries (P = 0.030), Middle Eastern countries (P = 0.029), and South American (P = 0.005) countries were more likely than those from North America to remeasure glucose after an initial normal glucose measurement at incision. Responders from North America reported that a higher blood glucose threshold was necessary for them to delay or cancel the surgery compared with responders in Slavic (P < 0.001), European (P = 0.002), South American (P = 0.002), and Asian and Pacific (P < 0.001) countries. Responders from North America were more likely to report that they would delay or cancel the surgery because of a higher blood glucose threshold. CONCLUSIONS: Our survey results suggest that perceptions and practices related to blood glucose management in patients undergoing brain tumor resection are variable. This study highlights the need for stronger clinical evidence and guidelines to help guide decisions for when and how to manage blood glucose derangements in these patients.

Anesthetic protocol for right ventricular dysfunction management in heart transplantation: systematic review, development and validation.

BACKGROUND: Right Ventricular Dysfunction (RVD) is the most frequent intraoperative hemodynamic complication in Heart Transplantation (HTx). RVD occurs in 0.04-1.0% of cardiac surgeries with cardiotomy and in 20-50% of HTx, with mortality up to 75%. No consensus has been established for how anesthesiologists should manage RVD, with management methods many times remaining unvalidated. METHODS: We conducted a systematic review, following PRISMA guidelines, to create an anesthetic protocol to manage RVD in HTx, using databases that include PubMed and Embase, until September 2018 based on inclusion and exclusion criteria. The articles screening for the systematic review were done two independent reviewers, in case of discrepancy, we consulted a third independent reviewer. Based on the systematic review, the anesthetic protocol was developed. The instrument selected to perform the validation of the protocol was AGREE II, for this purpose expert anesthetists were recruited to do this process. The minimum arbitration score for domains validation cutoff of AGREE II is arbitered to 70%. This study was registered at PROSPERO (115600). RESULTS: In the systematic review, 152 articles were included. We present the protocol in a flowchart with six steps based on goal-directed therapy, invasive monitoring, and transesophageal echocardiogram. Six experts judged the protocol and validated it. CONCLUSION: The protocol has been validated by experts and new studies are needed to assess its applicability and potential benefits on major endpoints.

[Update on perioperative hypersensitivity reactions: joint document from the Brazilian Society of Anesthesiology (SBA) and Brazilian Association of Allergy and Immunology (ASBAI) - Part II: etiology and diagnosis]. / Atualização sobre reações de hipersensibilidade perioperatória: documento conjunto da Sociedade Brasileira de Anestesiologia (SBA) e Associação Brasileira de Alergia e Imunologia (ASBAI) ­ Parte II: etiologia e diagnóstico.

This second joint document, written by experts from the Brazilian Association of Allergy and Immunology (ASBAI) and Brazilian Society of Anesthesiology (SBA) concerned with perioperative anaphylaxis, aims to review the pathophysiological reaction mechanisms, triggering agents (in adults and children), and the approach for diagnosis during and after an episode of anaphylaxis. As anaphylaxis assessment is extensive, the identification of medications, antiseptics and other substances used at each setting, the comprehensive data documentation, and the use of standardized nomenclature are key points for obtaining more consistent epidemiological information on perioperative anaphylaxis.

Update on perioperative hypersensitivity reactions: joint document from the Brazilian Society of Anesthesiology (SBA) and Brazilian Association of Allergy and Immunology (ASBAI) - Part II: etiology and diagnosis / Atualização sobre reações de hipersensibilidade perioperatória: documento conjunto da Sociedade Brasileira de Anestesiologia (SBA) e Associação Brasileira de Alergia e Imunologia (ASBAI) - Parte II: etiologia e diagnóstico

Abstract This second joint document, written by experts from the Brazilian Association of Allergy and Immunology (ASBAI) and Brazilian Society of Anesthesiology (SBA) concerned with perioperative anaphylaxis, aims to review the pathophysiological reaction mechanisms, triggering agents (in adults and children), and the approach for diagnosis during and after an episode of anaphylaxis. As anaphylaxis assessment is extensive, the identification of medications, antiseptics and other substances used at each setting, the comprehensive data documentation, and the use of standardized nomenclature are key points for obtaining more consistent epidemiological information on perioperative anaphylaxis.

Resumo Este segundo documento, escrito por especialistas da Associação Brasileira de Alergia e Imunologia (ASBAI) e da Sociedade Brasileira de Anestesiologia (SBA) interessados no tema anafilaxia perioperatória, tem por objetivo revisar os mecanismos fisiopatológicos, agentes desencadeantes (em adultos e crianças), assim como a abordagem diagnóstica durante e após o episódio. Por se tratar de uma avaliação abrangente, a identificação das medicações, antissépticos e outras substâncias usadas em cada região, registros detalhados, e nomenclatura padronizada são pontos fundamentais para a obtenção de dados epidemiológicos mais fidedignos sobre a anafilaxia perioperatória.

[Update on perioperative hypersensitivity reactions: joint document of the Brazilian Society of Anesthesiology (SBA) and Brazilian Association of Allergy and Immunology (ASBAI) - Part I: post-crisis guidelines and treatment]. / Atualização sobre reações de hipersensibilidade perioperatória: documento conjunto da Sociedade Brasileira de Anestesiologia (SBA) e Associação Brasileira de Alergia e Imunologia (ASBAI) ­ Parte I: tratamento e orientação pós­crise.

Experts from the Brazilian Association of Allergy and Immunology (ASBAI) and the Brazilian Society of Anesthesiology (SBA) interested in the issue of perioperative anaphylaxis, and aiming to strengthen the collaboration between the two societies, combined efforts to study the topic and to prepare a joint document to guide specialists in both areas. The purpose of the present series of two articles was to report the most recent evidence based on the collaborative assessment between both societies. This first article will consider the updated definitions, treatment and guidelines after a perioperative crisis. The following article will discuss the major etiologic agents, how to proceed with the investigation, and the appropriate tests.

Update on perioperative hypersensitivity reactions: joint document of the Brazilian Society of Anesthesiology (SBA) and Brazilian Association of Allergy and Immunology (ASBAI) - Part I: post-crisis guidelines and treatment / Atualização sobre reações de hipersensibilidade perioperatória: documento conjunto da Sociedade Brasileira de Anestesiologia (SBA) e Associação Brasileira de Alergia e Imunologia (ASBAI) - Parte I: tratamento e orientação pós-crise

Abstract Experts from the Brazilian Association of Allergy and Immunology (ASBAI) and the Brazilian Society of Anesthesiology (SBA) interested in the issue of perioperative anaphylaxis, and aiming to strengthen the collaboration between the two societies, combined efforts to study the topic and to prepare a joint document to guide specialists in both areas. The purpose of the present series of two articles was to report the most recent evidence based on the collaborative assessment between both societies. This first article will consider the updated definitions, treatment and guidelines after a perioperative crisis. The following article will discuss the major etiologic agents, how to proceed with the investigation, and the appropriate tests.

Resumo Especialistas da Associação Brasileira de Alergia e Imunologia (ASBAI) e da Sociedade Brasileira de Anestesiologia (SBA) interessados no tema anafilaxia perioperatória reuniram-se com o objetivo de intensificar a colaboração entre as duas sociedades no estudo desse tema e elaborar um documento conjunto que possa guiar os especialistas de ambas as áreas. O objetivo desta série de dois artigos foi mostrar as evidências mais recentes alicerçadas na visão colaborativa entre as sociedades. Este primeiro artigo versará sobre as definições mais atuais, formas de tratamento e as orientações após a crise no perioperatório. No próximo artigo serão discutidos os principais agentes causais e a condução da investigação com testes apropriados.

[Efficacy and safety of antifibrinolytics in oncological surgery: a systematic review and meta-analysis]. / Eficácia e segurança de antifibrinolíticos em cirurgia oncológica: uma revisão sistemática e metanálise.

BACKGROUND AND OBJECTIVES: The administration of antifibrinolytics has been shown to be effective in reducing blood loss and the need for transfusions in surgeries. However, few studies have evaluated these drugs in cancer surgery. The objective was to review the efficacy and safety of the treatment with antifibrinolytics in patients who underwent oncologic surgeries. CONTENTS: An electronic bibliographic research was conducted in PubMed, OVID, MEDLINE, EMBASE, EBSCO and in the Cochrane Library data basis in order to identify randomized clinical trials performed in any type of oncologic surgery. The data evaluated were blood loss, need for transfusion and incidence of arteriovenous thromboembolism. Five randomized controlled trials evaluating 838 patients met the inclusion requirements. In the analysis of the incidence of thromboembolic events in the five RCTs, there was no statistically significant difference between the administration of tranexamic acid when compared with the placebo (OR=0.36, 95% IC: 0.11-1.19, p=0.09, I2=0%). However, when total estimated blood loss and need for blood transfusion are analyzed, the use of tranexamic acid was associated with a significant reduction over placebo (MD=-135.79, 95% CI: -179.50 to -92.08, p<0.00001, I2=68%) and (OR=0.45, 95% CI: 0.32-0.65, p<0.00001, I2=60%), respectively. CONCLUSIONS: This meta-analysis found no evidence that the administration of antifibrinolytics increases the risk of thromboembolic complications in patients submitted to oncologic surgery, and has shown evidence that it is effective in reducing total perioperative blood loss and the need for blood transfusion.

Efficacy and safety of antifibrinolytics in oncological surgery: a systematic review and meta-analysis / Eficácia e segurança de antifibrinolíticos em cirurgia oncológica: uma revisão sistemática e metanálise

Abstract Background and objectives: The administration of antifibrinolytics has been shown to be effective in reducing blood loss and the need for transfusions in surgeries. However, few studies have evaluated these drugs in cancer surgery. The objective was to review the efficacy and safety of the treatment with antifibrinolytics in patients who underwent oncologic surgeries. Contents: An electronic bibliographic research was conducted in PubMed, OVID, MEDLINE, EMBASE, EBSCO and in the Cochrane Library data basis in order to identify randomized clinical trials performed in any type of oncologic surgery. The data evaluated were blood loss, need for transfusion and incidence of arteriovenous thromboembolism. Five randomized controlled trials evaluating 838 patients met the inclusion requirements. In the analysis of the incidence of thromboembolic events in the five RCTs, there was no statistically significant difference between the administration of tranexamic acid when compared with the placebo (OR = 0.36, 95% IC: 0.11‒1.19, p= 0.09, I2 = 0%). However, when total estimated blood loss and need for blood transfusion are analyzed, the use of tranexamic acid was associated with a significant reduction over placebo (MD = −135.79, 95% CI: −179.50 to −92.08, p< 0.00001, I2= 68%) and (OR = 0.45, 95% CI: 0.32‒0.65, p< 0.00001, I2= 60%), respectively. Conclusions: This meta-analysis found no evidence that the administration of antifibrinolytics increases the risk of thromboembolic complications in patients submitted to oncologic surgery, and has shown evidence that it is effective in reducing total perioperative blood loss and the need for blood transfusion.

Resumo Justificativa e objetivos: A administração de agentes antifibrinolíticos mostrou ser eficaz para reduzir a perda sanguínea e a necessidade de transfusões em cirurgias. No entanto, poucos estudos avaliaram esses agentes em cirurgias oncológicas. O objetivo foi revisar a eficácia e segurança do tratamento com antifibrinolíticos em pacientes submetidos a cirurgias oncológicas. Conteúdo: Uma pesquisa bibliográfica foi conduzida nos bancos de dados eletrônicos PubMed, OVID, MEDLINE, EMBASE, EBSCO e na Biblioteca Cochrane para identificar ensaios clínicos randomizados feitos em qualquer tipo de cirurgia oncológica. Os dados analisados foram perda sanguínea, necessidade de transfusão e incidência de tromboembolismo arteriovenoso. Cinco ensaios clínicos randomizados que avaliaram 838 pacientes atenderam aos critérios de inclusão. Na análise da incidência de eventos tromboembólicos em cinco ECR, não houve diferença estatisticamente significativa entre a administração do ácido tranexâmico, comparado ao placebo (OR = 0,36, IC 95%: 0,11-1,19, p = 0,09; I2 = 0%). No entanto, quando a perda sanguínea total estimada e a necessidade de transfusão de sangue foram analisadas, o uso do ácido tranexâmico foi associado a uma redução significativa, comparado ao placebo. (DM: -135,79, IC 95%: -179,50 a -92,08, p < 0,00001, I2 = 68%) e (OR = 0,45, IC 95%: 0,32-0,65, p < 0,00001, I2 = 60%), respectivamente. Conclusões: Esta metanálise não encontrou evidências de que a administração de antifibrinolíticos aumente o risco de complicações tromboembólicas em pacientes submetidos à cirurgia oncológica e apresentou evidências de que é eficaz para reduzir a perda sanguínea total no perioperatório e a necessidade de transfusão de sangue.

Monitoring of coagulation by intraoperative thromboelastometry of liver transplantation in a patient using warfarin - case report / Monitoração da coagulação pela tromboelastometria no intraoperatório de transplante hepático em um paciente usando varfarina - relato de caso

Abstract Introduction: Advanced hepatic disease may - in addition to the widely recognized hemorrhagic complications - occur with thrombotic events. We describe the case of a cirrhotic patient taking warfarin and whose coagulation management during liver transplantation was guided by thromboelastometry (ROTEM®). Case report: A 56 year-old male patient diagnosed with alcohol cirrhosis using warfarin (2.5 mg.day−1) for partial portal vein thrombosis with the International Normalized Ratio (INR) of 2.14. At the beginning of surgery, the ROTEM® parameters were all normal. In the anhepatic phase, EXTEM and INTEM remained normal, but FIBTEM showed reduction of amplitude after 10 min and maximum clot firmness. Finally, in the neohepatic phase, there was a slight alteration in the hypocoagulability of most of the parameters of the EXTEM, INTEM and FIBTEM, besides a notable correction of the Coagulation Time (CT) in HEPTEM compared to the CT of the INTEM. Therefore, the patient did not receive any transfusion of blood products during surgery and in the postoperative period, being discharged on the 8th postoperative day. Discussion: Coagulation deficit resulting from cirrhosis distorts INR as a parameter of anticoagulation adequacy and as a determinant of the need for blood transfusion. Thus, thromboelastometry can provide important information for patient management.

Resumo Introdução: A doença hepática avançada pode, além das complicações hemorrágicas amplamente reconhecidas, ocorrer com eventos trombóticos. Descrevemos o caso de um paciente cirrótico em uso de varfarina, cujo manejo da coagulação durante o transplante de fígado foi guiado por tromboelastometria (ROTEM®). Relato de caso: Paciente do sexo masculino, 56 anos, diagnosticado com cirrose alcoólica, recebendo varfarina (2,5 mg.dia−1) para trombose parcial da veia porta, com razão normalizada internacional (INR) de 2,14. No início da cirurgia, os parâmetros ROTEM® estavam todos normais. Na fase não hepática, EXTEM e INTEM permaneceram normais, mas FIBTEM mostrou redução da amplitude após 10 min e firmeza máxima do coágulo. Por fim, na fase neo-hepática houve uma ligeira alteração da hipocoagulabilidade na maioria dos parâmetros de EXTEM, INTEM e FIBTEM, além de uma correção notável do tempo de coagulação (CT) de HEPTEM em comparação com o CT de INTEM. Portanto, o paciente não recebeu transfusão de hemoderivados durante a cirurgia e no período pós-operatório, obteve alta no oitavo dia de pós-operatório. Discussão: O déficit de coagulação resultante da cirrose distorce o INR como um parâmetro da adequação da anticoagulação e como um determinante da necessidade de transfusão de sangue. Portanto, a tromboelastometria pode fornecer informações importantes para o manejo do paciente.

[Monitoring of coagulation by intraoperative thromboelastometry of liver transplantation in a patient using warfarin - case report]. / Monitoração da coagulação pela tromboelastometria no intraoperatório de transplante hepático em um paciente usando varfarina ­ relato de caso.

INTRODUCTION: Advanced hepatic disease may - in addition to the widely recognized hemorrhagic complications - occur with thrombotic events. We describe the case of a cirrhotic patient taking warfarin and whose coagulation management during liver transplantation was guided by thromboelastometry (ROTEM®). CASE REPORT: A 56 year-old male patient diagnosed with alcohol cirrhosis using warfarin (2.5mg.day-1) for partial portal vein thrombosis with the International Normalized Ratio (INR) of 2.14. At the beginning of surgery, the ROTEM® parameters were all normal. In the anhepatic phase, EXTEM and INTEM remained normal, but FIBTEM showed reduction of amplitude after 10min and maximum clot firmness. Finally, in the neohepatic phase, there was a slight alteration in the hypocoagulability of most of the parameters of the EXTEM, INTEM and FIBTEM, besides a notable correction of the Coagulation Time (CT) in HEPTEM compared to the CT of the INTEM. Therefore, the patient did not receive any transfusion of blood products during surgery and in the postoperative period, being discharged on the 8th postoperative day. DISCUSSION: Coagulation deficit resulting from cirrhosis distorts INR as a parameter of anticoagulation adequacy and as a determinant of the need for blood transfusion. Thus, thromboelastometry can provide important information for patient management.

Anesthetics, cerebral protection and preconditioning.

BACKGROUND AND OBJECTIVES: Several studies demonstrate that cerebral preconditioning is a protective mechanism against a stressful situation. Preconditioning determinants are described, as well as the neuroprotection provided by anesthetic and non-anesthetics agents. CONTENT: Review based on the main articles addressing the pathophysiology of ischemia-reperfusion and neuronal injury and pharmacological and non-pharmacological factors (inflammation, glycemia, and temperature) related to the change in response to ischemia-reperfusion, in addition to neuroprotection induced by anesthetic use. CONCLUSIONS: The brain has the ability to protect itself against ischemia when stimulated. The elucidation of this mechanism enables the application of preconditioning inducing substances (some anesthetics), other drugs, and non-pharmacological measures, such as hypothermia, aimed at inducing tolerance to ischemic lesions.

Anestésicos, precondicionamento e proteção cerebral / Anesthetics, cerebral protection and preconditioning / Anestésicos, pre-condicionamiento y protección cerebral

JUSTIFICATIVA E OBJETIVOS: Diversos estudos têm demonstrado o precondicionamento cerebral como mecanismo protetor diante de uma situação de estresse. Fatores determinantes são descritos, bem como a neuroproteção proporcionada por agentes anestésicos e não anestésicos. CONTEÚDO: Fez-se revisão baseada nos principais artigos da literatura que englobam a fisiopatologia da isquemia-reperfusão e lesão neuronal e os fatores não farmacológicos (inflamação, glicemia e temperatura) e farmacológicos relacionados com a mudança da resposta à isquemia-reperfusão, além da neuroproteção induzida pelo uso dos anestésicos. CONCLUSÕES: O cérebro tem a capacidade de se proteger contra a isquemia quando estimulado. A elucidação desse mecanismo possibilita a aplicação de substâncias indutoras do precondicionamento, como alguns anestésicos, outros fármacos e medidas não farmacológicas, como a hipotermia, com o objetivo de induzir tolerância a lesões isquêmicas.

BACKGROUND AND OBJECTIVES: Several studies demonstrate that cerebral preconditioning is a protective mechanism against a stressful situation. Preconditioning determinants are described, as well as the neuroprotection provided by anesthetic and non-anesthetics agents. CONTENT: Review based on the main articles addressing the pathophysiology of ischemia-reperfusion and neuronal injury and pharmacological and non-pharmacological factors (inflammation, glycemia, and temperature) related to the change in response to ischemia-reperfusion, in addition to neuroprotection induced by anesthetic use. CONCLUSIONS: The brain has the ability to protect itself against ischemia when stimulated. The elucidation of this mechanism enables the application of preconditioning inducing substances (some anesthetics), other drugs, and non-pharmacological measures, such as hypothermia, aimed at inducing tolerance to ischemic lesions.

JUSTIFICATIVA Y OBJETIVOS: Diversos estudios han demostrado el pre-condicionamiento cerebral como un mecanismo protector frente a una situación de estrés. Están descritos algunos factores determinantes del PC, como también la neuroprotección proporcionada por los agentes anestésicos y no anestésicos. CONTENIDO: Se hizo la revisión con base en los principales artículos de la literatura que engloban la fisiopatología de la isquemia-reperfusión y la lesión neuronal, y los factores no farmacológicos (inflamación, glucemia y temperatura), y farmacológicos relacionados con el cambio de la respuesta a la isquemia-reperfusión, además de la neuroprotección inducida por el uso de los anestésicos. CONCLUSIONES: El cerebro tiene la capacidad de protegerse contra la isquemia cuando se le estimula. La elucidación de ese mecanismo posibilita la aplicación de sustancias inductoras del precondicionamiento cerebral, como algunos anestésicos, otros fármacos y medidas no farmacológicas, como la hipotermia, con el fin de inducir la tolerancia a las lesiones isquémicas.

Anesthetics, cerebral protection and preconditioning.

BACKGROUND AND OBJECTIVES: Several studies demonstrate that cerebral preconditioning is a protective mechanism against a stressful situation. Preconditioning determinants are described, as well as the neuroprotection provided by anesthetic and non-anesthetics agents. CONTENT: Review based on the main articles addressing the pathophysiology of ischemia-reperfusion and neuronal injury and pharmacological and non-pharmacological factors (inflammation, glycemia, and temperature) related to the change in response to ischemia-reperfusion, in addition to neuroprotection induced by anesthetic use. CONCLUSIONS: The brain has the ability to protect itself against ischemia when stimulated. The elucidation of this mechanism enables the application of preconditioning inducing substances (some anesthetics), other drugs, and non-pharmacological measures, such as hypothermia, aimed at inducing tolerance to ischemic lesions.