Efecto del óxido nítrico inhalado en la mecánica ventilatoria y oxigenación de pacientes con hipoxemia grave refractaria a prono prolongado y bloqueo neuromuscular secundario a infección por SARS-CoV-2 / Effect of inhaled nitric oxide on ventilatory mechanics and oxygenation of patients with severe hypoxemia refractory to prolonged prone and neuromuscular blockade secondary to SARS-CoV-2 / Efeito do óxido nítrico inalado na mecânica ventilatória e oxigenação de pacientes com hipoxemia grave refratária a pronação prolongada e bloqueio neuromuscular secundário à infecção por SARS-CoV-2

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Abstract: Introduction: Among the patients infected with SARS-CoV-2, 14.6% were admitted to intensive care unit. this 29 to 75% required invasive mechanical ventilation with an associated mortality of 12 to 81%. Acute respiratory distress syndrome (ARDS) is the most serious form of presentation. The pathophysiology of ARDS secondary to SARS-CoV-2 differs from conventional causes. It presents dysregulation in hypoxic pulmonary vasoconstriction, secondary acute pulmonary hypertension and microthrombotic phenomena. The development of refractory severe hypoxemia (PaO2 < 60 mmHg or PaO2/FiO2 < 100 mmHg, with FiO2 80 to 100%, with PEEP > 10 to 20 cmH2O for at least 10 to 12 hours) constitutes the scenario of maximum severity with an associated mortality of 71 to 94%. The use of rescue strategies that impact on the specific pathophysiology of this entity such as the use of inhaled nitric oxide, neuromuscular blockade and prone ventilation have emerged as therapeutic targets of interest. Protective mechanical ventilation (plateau pressure [Pplat] < 27 cmH2O and driving pressure [DP] < 15 cmH2O) continues to be the cornerstone of the management. Objectives: To determine whether there is an association between the use of inhaled nitric oxide and prone ventilation with ventilatory mechanics in patients with severe refractory hypoxemia secondary to SARS-CoV-2 infection. Material and methods: A historical, retrospective, descriptive, comparative and retrolective cohort study was carried out. Data from the records of patients admitted to the Respiratory ICU of the ABC Medical Center with a diagnosis of ARDS secondary to SARS-CoV-2 infection who required iNO and mechanical ventilation in prone from April 1 to December 31, 2020 were analyzed. A univariate analysis was performed, the statistical analysis was performed in SPSS v 21, measures of trend, dispersion were analyzed as well as the analysis of risk factors with Student's t test and χ2. Results: A total of 108 patients were analyzed, of which 54 received iNO, neuromuscular blockade and prone and 54 only neuromuscular blockade and prone ventilation. 81.5% (n = 88) were men. The most common comorbidity was diabetes mellitus in 51.9% (n = 56). The increase in oxygenation (delta PaO2/FiO2) was with a median of 31.9 ± 15.2 mmHg in the iNO group and 52.9 ± 16.74 mmHg in the control group (p = 0.001). The postintervention Pplat in the iNO group was 26.3 ± 3 and 34.5 ± 1.9 cmH2O in the control group (p = 0.792). The preintervention DP in the iNO group was 17.2 ± 3.9 and 13.4 ± 2.8 cmH2O in control group vs 13.1 ± 1.29 and 12 ± 1.92 cmH2O after the intervention (p = 0.001). Conclusions: The use of iNO in patients with severe hypoxemia refractory to prone ventilation and neuromuscular blockade did not produce a statistically significant improvement in oxygenation, however it allowed to reprogram the ventilatory support to keep the patient in goals of alveolar protection.

Resumo: Introdução: 14.6% dos pacientes infectados com SARS-CoV-2 são internados em terapia intensiva. Destes, 29 a 75% necessitam de ventilação mecânica invasiva com mortalidade associada de 12 a 81%. A síndrome do desconforto respiratório agudo (SDRA) é a forma mais grave de apresentação. A fisiopatologia da SDRA secundária ao SARS-CoV-2 difere das causas convencionais. Apresenta desregulação na vasoconstrição pulmonar hipóxica, hipertensão pulmonar aguda secundária e fenômenos microtrombóticos. O desenvolvimento de hipoxemia grave refratária (PaO2 < 60 mmHg ou PaO2/FiO2 < 100 mmHg, com FiO2 de 80 a 100%, PEEP > 10 a 20 cmH2O por pelo menos 10 a 12 horas) constitui o cenário mais grave com mortalidade associada de 71 a 94%. O uso de estratégias de resgate que impactam na fisiopatologia específica dessa entidade, como o uso de óxido nítrico inalatório (NOi), bloqueio neuromuscular e ventilação prona, surgiram como alvos terapêuticos de interesse. A ventilação mecânica protetora (Pressão de Platô [PPLAT] < 27 cmH2O e Pressão de Condução [CP] < 15 cmH2O) continua sendo a base de seu manejo. Objetivo: Determinar se existe associação entre o uso de óxido nítrico inalatório e ventilação prona prolongada com mecânica ventilatória em pacientes com hipoxemia refratária grave secundária à infecção por SARS-CoV-2. Material e métodos: Realizou-se um estudo de coorte histórico, retrospectivo, descritivo, comparativo e retroletivo. Analisaram-se dados dos prontuários de pacientes internados na UTI Respiratória do Centro Médico ABC com diagnóstico de SDRA secundária à infecção por SARS-CoV-2 que necessitaram de óxido nítrico inalatório e ventilação mecânica prona no período de 1o de abril a 31 de dezembro de 2020. Realizou-se uma análise univariada , a análise estatística foi realizada no SPSS v 21, foram analisadas as medidas de tendência e dispersão, assim como a análise dos fatores de risco com teste t de Student e χ2. Resultados: Analisaram-se 108 pacientes, dos quais 54 receberam NOi, bloqueio neuromuscular e prono e 54 apenas bloqueio neuromuscular e ventilação prona. 81.5% (n = 88) eram homens. A comorbidade mais comum foi diabetes mellitus em 51.9% (n = 56). O aumento da oxigenação (Delta PaO2/FiO2) foi com mediana de 31.9 ± 15.2 mmHg no grupo NOi e 52.9 ± 16.74 mmHg no grupo controle (p = 0.001). A PPLAT após a intervenção no grupo NOi foi de 26.3 ± 3 e 34.5 ± 1.9 cmH2O no grupo controle (p = 0.792). A PC antes da intervenção no grupo NOi foi de 17.2 ± 3.9 e 13.4 ± 2.8 cmH2O no grupo controle vs 13.1 ± 1.29 e 12 ± 1.92 cmH2O após a intervenção (p = 0.001). Conclusões: O uso de NOi em pacientes com hipoxemia grave refratária à ventilação em pronação e bloqueio neuromuscular não produziu melhora estatisticamente significativa na oxigenação, porém permitiu que o suporte ventilatório fosse reprogramado para manter as metas de proteção alveolar do paciente.

[Perioperative challenges and neuromuscular blockade concerns in robotic thymectomy for myasthenia gravis]. / Desafios perioperatórios e pontos de atenção no bloqueio neuromuscular durante timectomia robótica para miastenia gravis.

Myasthenia Gravis (MG) is an autoimmune disease characterized by weakness and fatigability of skeletal muscles, with improvement following rest. It is a disease of great significance to the anesthesiologist because it affects the neuromuscular junction. Robotic thymectomy has come up in recent times due to the minimally invasive nature and its advantages. This presents a new set of challenges for the anesthesia team, and here we present the various anesthesia considerations and perioperative management in a series of 20 patients who underwent robotic thymectomy. As it is a recent upcoming procedure, there is a paucity of literature on this topic, and most of the available literature talks about One-Lung Ventilation (OLV) and thoracic epidurals. To our notice, this is the first literature without the use of OLV and thoracic epidural for the management of robotic thymectomy.

Perioperative challenges and neuromuscular blockade concerns in robotic thymectomy for myasthenia gravis / Desafios perioperatórios e pontos de atenção no bloqueio neuromuscular durante timectomia robótica para miastenia gravis

Abstract Myasthenia Gravis (MG) is an autoimmune disease characterized by weakness and fatigability of skeletal muscles, with improvement following rest. It is a disease of great significance to the anesthesiologist because it affects the neuromuscular junction. Robotic thymectomy has come up in recent times due to the minimally invasive nature and its advantages. This presents a new set of challenges for the anesthesia team, and here we present the various anesthesia considerations and perioperative management in a series of 20 patients who underwent robotic thymectomy. As it is a recent upcoming procedure, there is a paucity of literature on this topic, and most of the available literature talks about One-Lung Ventilation (OLV) and thoracic epidurals. To our notice, this is the first literature without the use of OLV and thoracic epidural for the management of robotic thymectomy.

Resumo Miastenia Gravis (MG) é uma doença autoimune que se caracteriza por fraqueza e fadiga da musculatura esquelética, com melhora após o repouso. É uma doença de grande interesse para o anestesiologista, pois compromete a junção neuromuscular. Recentemente, a timectomia robótica tem sido empregada por apresentar as vantagens da abordagem minimamente invasiva. O procedimento introduz uma série de novos desafios para a equipe de anestesia. Relatamos aqui as várias considerações anestésicas e o cuidado perioperatório em uma série de 20 pacientes submetidos a timectomia robótica. Sendo um procedimento recente, há limitada literatura discutindo esse tópico e, além disso, a maior parte da literatura disponível concentra a atenção na Ventilação Monopulmonar (VMP) e na peridural torácica. A nosso ver, este é a primeiro relato na literatura sem o emprego de VMP e peridural torácica para o manejo da timectomia robótica.

Bloqueio neuromuscular e manuseio das vias aéreas na intubação endotraqueal em unidades de terapia intensiva brasileiras: um levantamento nacional / Neuromuscular blockade and airway management during endotracheal intubation in Brazilian intensive care units: a national survey

RESUMO Objetivo: Descrever o uso do bloqueio neuromuscular e de outras práticas entre os médicos brasileiros atuantes em unidades de terapia intensiva para pacientes adultos. Métodos: Um levantamento nacional on-line foi aplicado a intensivistas brasileiros. As questões foram selecionadas utilizando o método Delphi e avaliavam os dados demográficos dos médicos, as características da unidade de terapia intensiva, as práticas relativas ao manuseio das vias aéreas e o uso de bloqueio neuromuscular e sedação durante a intubação endotraqueal na unidade de terapia intensiva. Como desfecho secundário, aplicamos uma análise multivariada para avaliar fatores associados com o uso do bloqueio neuromuscular. Resultados: Responderam ao questionário 565 intensivistas de todas as regiões do país. A maioria dos que responderam era homens (65%), com média de idade de 38 ± 8,4 anos, e 58,5% dos participantes tinham título de especialista em terapia intensiva. Apenas 40,7% dos intensivistas relataram o uso de bloqueio neuromuscular durante todas ou em mais de 75% das intubações endotraqueais. Na análise multivariada, o número de intubações realizadas por mês e a especialização do médico em anestesiologia se associaram diretamente com o uso frequente de bloqueio neuromuscular. Etomidato e cetamina foram utilizados mais comumente na situação clínica de hipotensão e choque, enquanto propofol e midazolam foram mais comumente prescritos em situações de estabilidade hemodinâmica. Conclusão: O relato de uso de bloqueio neuromuscular foi baixo entre intensivistas, e os fármacos sedativos foram escolhidos segundo a estabilidade hemodinâmica do paciente. Estes resultados podem ajudar no delineamento de futuros estudos relativos ao manuseio das vias aéreas no Brasil.

Abstract Objective: To describe the use of neuromuscular blockade as well as other practices among Brazilian physicians in adult intensive care units. Methods: An online national survey was designed and administered to Brazilian intensivists. Questions were selected using the Delphi method and assessed physicians' demographic data, intensive care unit characteristics, practices regarding airway management, use of neuromuscular blockade and sedation during endotracheal intubation in the intensive care unit. As a secondary outcome, we applied a multivariate analysis to evaluate factors associated with the use of neuromuscular blockade. Results: Five hundred sixty-five intensivists from all Brazilian regions responded to the questionnaire. The majority of respondents were male (65%), with a mean age of 38 ( 8.4 years, and 58.5% had a board certification in critical care. Only 40.7% of the intensivists reported the use of neuromuscular blockade during all or in more than 75% of endotracheal intubations. In the multivariate analysis, the number of intubations performed monthly and physician specialization in anesthesiology were directly associated with frequent use of neuromuscular blockade. Etomidate and ketamine were more commonly used in the clinical situation of hypotension and shock, while propofol and midazolam were more commonly prescribed in the situation of clinical stability. Conclusion: The reported use of neuromuscular blockade was low among intensivists, and sedative drugs were chosen in accordance with patient hemodynamic stability. These results may help the design of future studies regarding airway management in Brazil.

Reversal of neuromuscular block with sugammadex in five heart transplant pediatric recipients / Reversão do bloqueio neuromuscular com sugamadex em cinco receptores pediátricos de transplante cardíaco

Abstract Heart transplantation is a frequent procedure in the treatment of end-stage cardiac dysfunction. Therefore, these patient populations will also be more frequent exposed to other more common surgical procedures after their transplantation. Anesthesiologist should be aware in their assessment of these patients, especially regarding some specific issues related to patients with a history of heart transplantation, like reversal of neuromuscular block. Several reports described that cholinesterase inhibitors drugs, like neostigmine, may produce a dose-dependent life-threatening bradycardia in heart transplant recipients while other publication described the safe use of neostigmine. Reversal of neuromuscular block with sugammadex is another possibility, but limited data exists in literature. We describe five cases in which successful reversal of neuromuscular block was performed with sugammadex in heart transplant pediatric recipients without sequale and discuss the reversal of neuromuscular block in this patient population.

Resumo O transplante cardíaco é um procedimento frequente no tratamento da disfunção cardíaca em estágio final. Portanto, essa população de pacientes também será exposta com mais frequência a outros procedimentos cirúrgicos mais comuns após o transplante. Em sua avaliação, o anestesiologista deve ter em mente algumas questões específicas relacionadas à história de transplante cardíaco desses pacientes, tais como a reversão do bloqueio neuromuscular. Vários estudos relataram que os inibidores da colinesterase, como a neostigmina, podem produzir uma bradicardia dose-dependente que ameaça a vida em receptores de transplante cardíaco, enquanto um estudo relatou o uso seguro de neostigmina. A reversão do bloqueio neuromuscular com sugamadex é outra possibilidade, mas os dados na literatura são escassos. Descrevemos cinco casos nos quais a reversão bem-sucedida do bloqueio neuromuscular foi realizada com sugamadex em receptores pediátricos de transplante cardíaco sem deixar sequelas e discutimos a reversão do bloqueio neuromuscular nessa população de pacientes.

Sugammadex by ideal body weight versus 20% and 40% corrected weight in bariatric surgery - double-blind randomized clinical trial / Uso de sugamadex pelo peso corporal ideal versus corrigido em 20% e 40% em cirurgia bariátrica - ensaio clínico randômico e duplo-cego

Abstract Background and objectives: The weight parameters for use of sugammadex in morbidly obese patients still need to be defined. Methods: A prospective clinical trial was conducted with sixty participants with body mass index ≥ 40 kg.m-2 during bariatric surgery, randomized into three groups: ideal weight (IW), 20% corrected body weight (CW20) and 40% corrected body weight (CW40). All patients received total intravenous anesthesia. Rocuronium was administered at dose of 0.6 mg.kg-1 of Ideal weight for tracheal intubation, followed by infusion of 0.3-0.6 mg.kg-1.h-1. Train of four (TOF) was used to monitor depth of blockade. After spontaneous recovery TOF-count 2 at the end of surgery, 2 mg.kg-1 of sugammadex was administered. Primary outcome was neuromuscular blockade reversal time to TOF ≥ 0.9. Secondary outcome was the occurrence of postoperative residual curarization in post-anesthesia recovery room, searching the patient's ability to pass from the surgical bed to the transport, adequacy of oxygenation, respiratory pattern, ability to swallow saliva and clarity of vision. Results: Groups were homogenous in gender, age, total body weight, ideal body weight, body mass index, type and time of surgery. The reversal times (s) were (mean ± standard deviation) 225.2 ± 81.2, 173.9 ± 86.8 and 174.1 ± 74.9 respectively, in the IW, CW20 and CW40 groups (p = 0.087). Conclusions: No differences were observed between groups with neuromuscular blockade reversal time and frequency of postoperative residual curarization. We concluded that ideal body weight can be used to calculate sugammadex dose to reverse moderate neuromuscular blockade in morbidly obese patients.

Resumo Justificativa e objetivos: Os parâmetros de peso para o uso de sugamadex em pacientes com obesidade mórbida ainda precisam ser definidos. Métodos: Um ensaio clínico prospectivo foi feito com 60 participantes com índice de massa corporal ≥ 40 kg.m-2, submetidos a cirurgia bariátrica, randomizados em três grupos: peso ideal (PI), peso corrigido em 20% (PC20) e peso corrigido em 40% (PC40). Todos os pacientes receberam anestesia intravenosa total. Rocurônio foi administrado em dose de 0,6 mg.kg-1 para intubação traqueal pelo peso ideal, seguido de infusão (0,3 a 0,6 mg.kg-1.h-1). A sequência de quatro estímulos (TOF) foi usada para monitorar a profundidade do bloqueio. Após recuperação espontânea da segunda resposta do TOF no fim da cirurgia, 2 mg.kg-1 de sugamadex foi administrado. O desfecho primário foi o tempo de reversão do bloqueio neuromuscular até obter TOF ≥ 0,9. O desfecho secundário foi a ocorrência de curarização residual pós-operatória na sala de recuperação pós-anestésica, avaliaram-se a capacidade do paciente de passar do leito cirúrgico para o de transporte, a adequação da oxigenação, o padrão respiratório, a habilidade para deglutir saliva e a clareza de visão. Resultados: Os grupos foram homogêneos quanto a gênero, idade, peso corporal total, peso corporal ideal, índice de massa corporal, tipo e tempo de cirurgia. Os tempos de reversão (segundos) foram (média ± desvio-padrão) 225,2 ± 81,2, 173,9 ± 86,8 e 174,1 ± 74,9, respectivamente, nos grupos PI, PC20 e PC40 (p = 0,087). Conclusões: Não foram observadas diferenças entre os grupos quanto ao tempo de reversão do bloqueio neuromuscular e frequência de curarização residual pós-operatória. Concluímos que o peso corporal ideal pode ser usado para calcular a dose de sugamadex para reverter o bloqueio neuromuscular moderado em pacientes com obesidade mórbida.

[Reversal of neuromuscular block with sugammadex in five heart transplant pediatric recipients]. / Reversão do bloqueio neuromuscular com sugamadex em cinco receptores pediátricos de transplante cardíaco.

Heart transplantation is a frequent procedure in the treatment of end-stage cardiac dysfunction. Therefore, these patient populations will also be more frequent exposed to other more common surgical procedures after their transplantation. Anesthesiologist should be aware in their assessment of these patients, especially regarding some specific issues related to patients with a history of heart transplantation, like reversal of neuromuscular block. Several reports described that cholinesterase inhibitors drugs, like neostigmine, may produce a dose-dependent life-threatening bradycardia in heart transplant recipients while other publication described the safe use of neostigmine. Reversal of neuromuscular block with sugammadex is another possibility, but limited data exists in literature. We describe five cases in which successful reversal of neuromuscular block was performed with sugammadex in heart transplant pediatric recipients without sequelae and discuss the reversal of neuromuscular block in this patient population.

[Sugammadex by ideal body weight versus 20% and 40% corrected weight in bariatric surgery - double-blind randomized clinical trial]. / Uso de sugamadex pelo peso corporal ideal versus corrigido em 20% e 40% em cirurgia bariátrica ­ ensaio clínico randômico e duplo­cego.

BACKGROUND AND OBJECTIVES: The weight parameters for use of sugammadex in morbidly obese patients still need to be defined. METHODS: A prospective clinical trial was conducted with sixty participants with body mass index≥40kg.m-2 during bariatric surgery, randomized into three groups: ideal weight (IW), 20% corrected body weight (CW20) and 40% corrected body weight (CW40). All patients received total intravenous anesthesia. Rocuronium was administered at dose of 0.6mg.kg-1 of Ideal weight for tracheal intubation, followed by infusion of 0.3-0.6mg.kg-1.h-1. Train of four (TOF) was used to monitor depth of blockade. After spontaneous recovery TOF-count 2 at the end of surgery, 2mg.kg-1 of sugammadex was administered. Primary outcome was neuromuscular blockade reversal time to TOF≥0.9. Secondary outcome was the occurrence of postoperative residual curarization in post-anesthesia recovery room, searching the patient's ability to pass from the surgical bed to the transport, adequacy of oxygenation, respiratory pattern, ability to swallow saliva and clarity of vision. RESULTS: Groups were homogenous in gender, age, total body weight, ideal body weight, body mass index, type and time of surgery. The reversal times (s) were (mean±standard deviation) 225.2±81.2, 173.9±86.8 and 174.1±74.9 respectively, in the IW, CW20 and CW40 groups (p=0.087). CONCLUSIONS: No differences were observed between groups with neuromuscular blockade reversal time and frequency of postoperative residual curarization. We concluded that ideal body weight can be used to calculate sugammadex dose to reverse moderate neuromuscular blockade in morbidly obese patients.

Functional respiratory imaging after neostigmine- or sugammadex-enhanced recovery from neuromuscular blockade in the anesthetised rat: a randomised controlled pilot study / Imagem funcional da respiração após aceleração da recuperação do bloqueio neuromuscular com neostigmina ou sugamadex em ratos anestesiados: estudo piloto controlado e randomizado

Abstract Objectives Reductions in diaphragm activity are associated with the postoperative development of atelectasis. Neostigmine reversal is also associated with increased atelectasis. We assessed the effects of neostigmine, sugammadex, and spontaneous reversal on regional lung ventilation and airway flow. Methods Six Sprague-Dawley rats were paralysed with rocuronium and mechanically ventilated until recovery of the train-of-four ratio to 0.5. We administered neostigmine (0.06 mg.kg-1), sugammadex (15 mg.kg-1), or saline (n = 2 per group). Computed tomography scans were obtained during the breathing cycle. Three-dimensional models of lung lobes were generated using functional respiratory imaging technology, and lobar volumes were calculated during the breathing cycle. The diaphragmatic surface was segmented for the end-expiratory and end-inspiratory scans. The total change in volume was reported by the lung volume change from the end-expiratory scan to the end-inspiratory scan. Chest wall movement was defined as the lung volume change minus the volume change that resulted from diaphragm excursion. Results The two rats that received neostigmine exhibited a smaller relative contribution of diaphragm movement to the total change in lung volume compared with the two rats that received sugammadex or saline (chest wall contribution (%): 26.69 and 25.55 for neostigmine; -2.77 and 15.98 for sugammadex; 18.82 and 10.30 for saline). Conclusion This pilot study in rats demonstrated an increased relative contribution of chest wall expansion after neostigmine compared with sugammadex or saline. This smaller relative contribution of diaphragm movement may be explained by a neostigmine-induced decrease in phrenic nerve activity or by remaining occupied acetylcholine receptors after neostigmine.

Resumo Objetivos As reduções da atividade do diafragma estão associadas ao desenvolvimento de atelectasia no período pós-operatório. A reversão com neostigmina também está associada ao aumento de atelectasia. Avaliamos os efeitos de neostigmina, sugamadex e da reversão espontânea sobre a ventilação pulmonar regional e o fluxo aéreo. Métodos Seis ratos Sprague-Dawley foram paralisados com rocurônio e mecanicamente ventilados até a recuperação da sequência de quatro estímulos atingir relação 0,5. Administramos neostigmina (0,06 mg.kg-1), sugamadex (15 mg.kg-1) ou solução salina (n = 2 por grupo). As tomografias foram feitas durante o ciclo respiratório. Modelos tridimensionais dos lobos pulmonares foram gerados com a tecnologia de imagem funcional respiratória e os volumes lobares foram calculados durante o ciclo respiratório. A superfície diafragmática foi segmentada para as varreduras expiratória final e inspiratória final. A alteração total no volume foi relatada pela alteração do volume pulmonar da varredura expiratória final para a varredura inspiratória final. O movimento da parede torácica foi definido como a variação do volume pulmonar menos a alteração no volume resultante da excursão do diafragma. Resultados Os dois ratos que receberam neostigmina apresentaram uma contribuição relativa menor do movimento do diafragma para a alteração total do volume pulmonar em comparação com os dois ratos que receberam sugamadex ou solução salina (contribuição da parede torácica (%): 26,69 e 25,55 para neostigmina; -2,77 e 15,98 para sugamadex; 18,82 e 10,30 para solução salina). Conclusão Este estudo piloto com ratos demonstrou uma contribuição relativa aumentada de expansão da parede torácica após neostigmina em comparação com sugamadex ou solução salina. Essa contribuição relativa menor de movimento do diafragma pode ser explicada por uma redução induzida por neostigmina na atividade do nervo frênico ou por receptores de acetilcolina permanecerem ocupados após a administração de neostigmina.

Deep versus moderate neuromuscular block during one-lung ventilation in lung resection surgery / Bloqueio neuromuscular profundo versus moderado durante a ventilação monopulmonar em cirurgia de ressecção pulmonar

Abstract Background and objectives: Neuromuscular relaxants are essential during general anesthesia for several procedures. Classical anesthesiology literature indicates that the use of neuromuscular blockade in thoracic surgery may be deleterious in patients in lateral decubitus position in one-lung ventilation. The primary objective of our study was to compare respiratory function according to the degree of patient neuromuscular relaxation. Secondary, we wanted to check that neuromuscular blockade during one-lung ventilation is not deleterious. Methods: A prospective, longitudinal observational study was made in which each patient served as both treated subject and control. 76 consecutive patients programmed for lung resection surgery in Gregorio Marañon Hospital along 2013 who required one-lung ventilation in lateral decubitus were included. Ventilator data, hemodynamic parameters were registered in different moments according to train-of-four response (intense, deep and moderate blockade) during one-lung ventilation. Results: Peak, plateau and mean pressures were significantly lower during the intense and deep blockade. Besides compliance and peripheral oxygen saturation were significantly higher in that moments. Heart rate was significantly higher during deep blockade. No mechanical ventilation parameters were modified during measurements. Conclusions: Deep neuromuscular blockade attenuates the poor lung mechanics observed during one-lung ventilation.

Resumo Justificativa e objetivos: Os relaxantes neuromusculares são essenciais durante a anestesia geral para vários procedimentos. A literatura clássica de anestesiologia indica que o uso de bloqueio neuromuscular em cirurgia torácica pode ser prejudicial em pacientes posicionados em decúbito lateral com ventilação seletiva. O objetivo primário deste estudo foi comparar a função respiratória de acordo com o grau de relaxamento neuromuscular do paciente. O objetivo secundário foi verificar que o bloqueio neuromuscular durante a ventilação seletiva não é prejudicial. Métodos: Estudo observacional, prospectivo e longitudinal no qual cada paciente serviu como próprio controle. Foram incluídos 76 pacientes consecutivos, agendados para cirurgia de ressecção do pulmão no Hospital Gregorio Marañon ao longo de 2013, submetidos à ventilação seletiva em decúbito lateral. Os dados do ventilador e os parâmetros hemodinâmicos foram registrados em diferentes momentos de acordo com a resposta por sequência de quatro estímulos (bloqueio intenso, profundo e moderado) durante a ventilação seletiva. Resultados: As pressões de pico, platô e média foram significativamente menores durante os bloqueios intenso e profundo. Além disso, complacência e saturação periférica de oxigênio foram significativamente maiores nesses momentos. A frequência cardíaca foi significativamente maior durante o bloqueio profundo. Não houve alteração dos parâmetros da ventilação mecânica durante as mensurações. Conclusões: O bloqueio neuromuscular profundo atenua a mecânica pulmonar deficiente observada durante a ventilação seletiva.

[Functional respiratory imaging after neostigmine- or sugammadex-enhanced recovery from neuromuscular blockade in the anesthetised rat: a randomised controlled pilot study]. / Imagem funcional da respiração após aceleração da recuperação do bloqueio neuromuscular com neostigmina ou sugamadex em ratos anestesiados: estudo piloto controlado e randomizado.

OBJECTIVES: Reductions in diaphragm activity are associated with the postoperative development of atelectasis. Neostigmine reversal is also associated with increased atelectasis. We assessed the effects of neostigmine, sugammadex, and spontaneous reversal on regional lung ventilation and airway flow. METHODS: Six Sprague-Dawley rats were paralysed with rocuronium and mechanically ventilated until recovery of the train-of-four ratio to 0.5. We administered neostigmine (0.06mg.kg-1), sugammadex (15mg.kg-1), or saline (n=2 per group). Computed tomography scans were obtained during the breathing cycle. Three-dimensional models of lung lobes were generated using functional respiratory imaging technology, and lobar volumes were calculated during the breathing cycle. The diaphragmatic surface was segmented for the end-expiratory and end-inspiratory scans. The total change in volume was reported by the lung volume change from the end-expiratory scan to the end-inspiratory scan. Chest wall movement was defined as the lung volume change minus the volume change that resulted from diaphragm excursion. RESULTS: The two rats that received neostigmine exhibited a smaller relative contribution of diaphragm movement to the total change in lung volume compared with the two rats that received sugammadex or saline (chest wall contribution (%): 26.69 and 25.55 for neostigmine; -2.77 and 15.98 for sugammadex; 18.82 and 10.30 for saline). CONCLUSION: This pilot study in rats demonstrated an increased relative contribution of chest wall expansion after neostigmine compared with sugammadex or saline. This smaller relative contribution of diaphragm movement may be explained by a neostigmine-induced decrease in phrenic nerve activity or by remaining occupied acetylcholine receptors after neostigmine.

[Deep versus moderate neuromuscular block during one-lung ventilation in lung resection surgery]. / Bloqueio neuromuscular profundo versus moderado durante a ventilação monopulmonar em cirurgia de ressecção pulmonar.

BACKGROUND AND OBJECTIVES: Neuromuscular relaxants are essential during general anesthesia for several procedures. Classical anesthesiology literature indicates that the use of neuromuscular blockade in thoracic surgery may be deleterious in patients in lateral decubitus position in one-lung ventilation. The primary objective of our study was to compare respiratory function according to the degree of patient neuromuscular relaxation. Secondary, we wanted to check that neuromuscular blockade during one-lung ventilation is not deleterious. METHODS: A prospective, longitudinal observational study was made in which each patient served as both treated subject and control. 76 consecutive patients programmed for lung resection surgery in Gregorio Marañon Hospital along the year of 2013 who required one-lung ventilation in lateral decubitus were included. Ventilator data, hemodynamic parameters were registered in different moments according to train-of-four response (intense, deep and moderate blockade) during one-lung ventilation. RESULTS: Peak, plateau and mean pressures were significantly lower during the intense and deep blockade. Besides, compliance and peripheral oxygen saturation were significantly higher in those moments. Heart rate was significantly higher during deep blockade. No mechanical ventilation parameters were modified during measurements. CONCLUSIONS: Deep neuromuscular blockade attenuates the poor lung mechanics observed during one-lung ventilation.

Práticas de bloqueios neuromusculares para o tratamento da espasticidade no Brasil / Neuromuscular block practice in the treatment of spasticity in Brazil

A toxina botulínica do tipo A (TBA) é um dos tratamentos mais efetivos e seguros para espasticidade. Para a avaliação algumas escalas podem ser utilizadas como a Escala Modificada de Ashworth (MAS). O sucesso terapêutico na aplicação depende da correta identificação do problema biomecânico e aplicação no músculo acometido, o que pode ser feito por técnicas de palpação de superfície ou métodos auxiliares como eletromiografia. Objetivo: Avaliar os métodos de aplicações da TBA e outros tipos de bloqueios como fenol para tratamento da espasticidade realizados na prática de médicos de reabilitação infantil e de adultos. Métodos: Estudo exploratório, transversal, com amostra dimensionada pela conveniência em eventos científicos nas cidades Rio de Janeiro, São Paulo, Goiânia, Belo Horizonte, Curitiba e Ribeirão Preto com questionários a respeito do tratamento da espasticidade que continham questões de múltipla escolha sobre grupos de pacientes e músculos tratados. As respostas foram analisadas quanto à frequência para cada questão. Não foi foram realizados testes de associação de variáveis ou de hipótese. Resultados: Foram analisados 49 questionários. 47% aplicam TBA há menos de 5 anos. A técnica mais utilizada para localização de pontos de aplicação foi a palpação muscular (80%). Para quantificação dos ganhos funcionais 78% utilizam a escala MAS. 57% faz aplicação em adultos e crianças. A faixa etária de tratamento mais comum entre as crianças foi 5 a 10 anos (83%) com o grupo muscular mais aplicado o tríceps sural (73,8%). Em relação ao uso do fenol, 16 utilizam com uma frequência de 1 a 5 pacientes por mês. 45% dos aplicadores sempre utilizam fenol em conjunto com TBA. Conclusão: A TBA é largamente utilizada no tratamento de espasticidade, porém não existe uma padronização na forma de aplicação, método de avaliação ou sobre necessidade de outro agente combinado

Botulinum toxin type A (TBA) is one of the most effective and safe treatments for spasticity. To evaluate some scales can be used, as the Modified Ashworth Scale (MAS). Therapeutic success in the application depends on the correct identification of the problem and biomechanical application of the affected muscle, which can be done by surface palpation techniques or auxiliary methods such as electromyography. Objective: To evaluate the methods of TBA applications for the treatment of spasticity performed in the practice of medical rehabilitation for children and adults. Methods: exploratory, cross-sectional study with a convenience sample size recruited in scientific events in Rio de Janeiro, São Paulo, Goiânia, Belo Horizonte, Curitiba and Ribeirão Preto (Brazil). Questionnaires regarding the treatment of spasticity containing multiple choice questions about groups of patients and treated muscles were applied. Responses were analyzed for frequency for each answer. No association test of variables or hypothesis were used. Results: 49 questionnaires were analyzed. 47% apply TBA for less than five years. The most used technique for locating points of application was muscular palpation (80%). To quantify the functional gains, 78% reported the use the MAS scale. 57% applies in adults and children. The most common children age group treated was 5-10 years (83%) and the most treated muscle group was the triceps surae (73.8%). Regarding the use of phenol, 16 used with a frequency of 1 to 5 patients per month. 45% of applicators used phenol associeted with TBA. Conclusion: The TBA is widely used in the treatment of spasticity, however there is no standardization in the form of application, method of analyzing the treatment success or the necessity of a combined agent

Survey of postoperative residual curarization, acute respiratory events and approach of anesthesiologists / Pesquisa de curarização residual no pós-operatório, eventos respiratórios agudos e abordagem de anestesiologistas

BACKGROUND AND OBJECTIVES: residual paralysis following the use of neuromuscular blocking drugs (NMBDs) without neuromuscular monitoring remains a clinical problem, even when NMBDs are used. This study surveys postoperative residual curarization and critical respiratory events in the recovery room, as well as the clinical approach to PORC of anesthesiologists in our institution. METHODS: This observational study included 415 patients who received general anesthesia with intermediate-acting NMBDs. Anesthesia was maintained by non-participating anesthesiologists who were blinded to the study. Neuromuscular monitoring was performed upon arrival in the recovery room. A CRE was defined as requiring airway support, peripheral oxygen saturation <90% and 90-93% despite receiving 3 L/min nasal O2, respiratory rate >20 breaths/min, accessory muscle usage, difficulty with swallowing or speaking, and requiring reintubation. The clinical approach of our anesthesiologists toward reversal agents was examined using an 8-question mini-survey shortly after the study. RESULTS: The incidence of PORC was 43% (n = 179) for TOFR <0.9, and 15% (n = 61) for TOFR <0.7. The incidence of TOFR <0.9 was significantly higher in women, in those with ASA physical status 3, and with anesthesia of short duration (p < 0.05). In addition, 66% (n = 272) of the 415 patients arriving at the recovery room had received neostigmine. A TOFR <0.9 was found in 46% (n = 126) of the patients receiving neostigmine. CONCLUSIONS: When routine objective neuromuscular monitoring is not available, PORC remains a clinical problem despite the use of NMBDs. The timing and optimal antagonism of the neuromuscular blockade, and routine objective neuromuscular monitoring is recommended to enhance patient safety.

JUSTIFICATIVA E OBJETIVOS: A paralisia residual após o uso de bloqueadores neuromusculares (BNMs) sem monitoração neuromuscular continua sendo um problema clínico, mesmo quando BNMs são usados. Este estudo pesquisou a curarização residual pós-operatória e os eventos respiratórios críticos em sala de recuperação, bem como a abordagem clínica da CRPO feita pelos anestesiologistas em nossa instituição. MÉTODOS: Este estudo observacional incluiu 415 pacientes que receberam anestesia geral com BNMs de ação intermediária. A manutenção da anestesia foi feita por anestesiologistas não participantes, "cegos" para o estudo. A monitoração neuromuscular foi realizada no momento da chegada à sala de recuperação. Um ERC foi definido como necessidade de suporte ventilatório; saturação periférica de oxigênio <90% e 90-93%, a despeito de receber 3 L/min de O2 via cânula nasal; frequência respiratória >20 bpm; uso de musculatura acessória; dificuldade de engolir ou falar e necessidade de reintubação. A abordagem clínica de nossos anestesiologistas, em relação aos agentes de reversão, foi avaliada usando um miniquestionário de oito perguntas logo após o estudo. RESULTADOS: A incidência de CRPO foi de 43% (n = 179) para a SQE <0 e 15% (n = 61) para a SQE <0,7. A incidência de SQE <0,9 foi significativamente maior em mulheres, pacientes com estado físico ASA III e com anestesia de curta duração (p < 0,05). Além disso, 66% (n = 272) dos 415 pacientes que chegam à sala de recuperação haviam recebido neostigmina. Uma SQE <0,9 foi encontrada em 46% (n = 126) dos pacientes que receberam neostigmina. CONCLUSÃO: Quando a monitoração neuromuscular objetiva de rotina não está disponível, a CRPO continua sendo um problema clínico, a despeito do uso de BNMs. O momento e o antagonismo ideais do bloqueio neuromuscular e a monitoração neuromuscular objetiva de rotina são recomendados para aumentar a segurança do paciente.

Survey of postoperative residual curarization, acute respiratory events and approach of anesthesiologists.

BACKGROUND AND OBJECTIVES: residual paralysis following the use of neuromuscular blocking drugs (NMBDs) without neuromuscular monitoring remains a clinical problem, even when NMBDs are used. This study surveys postoperative residual curarization and critical respiratory events in the recovery room, as well as the clinical approach to PORC of anesthesiologists in our institution. METHODS: This observational study included 415 patients who received general anesthesia with intermediate-acting NMBDs. Anesthesia was maintained by non-participating anesthesiologists who were blinded to the study. Neuromuscular monitoring was performed upon arrival in the recovery room. A CRE was defined as requiring airway support, peripheral oxygen saturation <90% and 90-93% despite receiving 3 L/min nasal O2, respiratory rate > 20 breaths/min, accessory muscle usage, difficulty with swallowing or speaking, and requiring reintubation. The clinical approach of our anesthesiologists toward reversal agents was examined using an 8-question mini-survey shortly after the study. RESULTS: The incidence of PORC was 43% (n = 179) for TOFR < 0.9, and 15% (n = 61) for TOFR < 0.7. The incidence of TOFR < 0.9 was significantly higher in women, in those with ASA physical status 3, and with anesthesia of short duration (p < 0.05). In addition, 66% (n = 272) of the 415 patients arriving at the recovery room had received neostigmine. A TOFR < 0.9 was found in 46% (n = 126) of the patients receiving neostigmine. CONCLUSIONS: When routine objective neuromuscular monitoring is not available, PORC remains a clinical problem despite the use of NMBDs. The timing and optimal antagonism of the neuromuscular blockade, and routine objective neuromuscular monitoring is recommended to enhance patient safety.

Use of sugammadex on burn patients: descriptive study / Uso de sugamadex no paciente queimado: estudo descritivo / Utilización del sugammadex en el paciente quemado: estudio descriptivo

A burn patient is a challenge for any anesthesiologist, undergoing several surgeries during admission, and requiring general anesthesia and muscle relaxation most of the times. The victim may have respiratory system impairment and a response to muscle relaxants that differs from the healthy patient, thus proper monitoring and reversal is crucial. We analyzed sugammadex effectiveness and safety in this population.

O paciente queimado representa um desafio para o anestesiologista, pois se submete a várias intervenções cirúrgicas durante sua hospitalização e necessita de anestesia geral e relaxamento muscular na maior parte delas. Apresenta sistema respiratório comprometido e uma resposta aos relaxantes musculares que difere do paciente sadio; portanto, um monitoramento correto e reversão tornam-se imprescindíveis. Avaliamos a eficácia e segurança do sugamadex nessa população.

El paciente quemado supone un reto para el anestesista, pues se somete a varias intervenciones quirúrgicas durante su ingreso, requiriendo anestesia general y relajación muscular en la mayor parte de ellas. Presentan un sistema respiratorio comprometido y una respuesta a los relajantes musculares que difiere de la del paciente sano, por lo que se hace imprescindible una correcta monitorización y reversión. Valoramos la efectividad y seguridad del sugammadex en esta población.

Use of sugammadex on burn patients: descriptive study.

OBJECTIVES: A burn patient is a challenge for any anesthesiologist, undergoing several surgeries during admission, and requiring general anesthesia and muscle relaxation most of the times. The victim may have respiratory system impairment and a response to muscle relaxants that differs from the healthy patient, thus proper monitoring and reversal is crucial. We analyzed sugammadex effectiveness and safety in this population. MATERIALS AND METHODS: It was a prospectively descriptive study, including 4 patients, and all of them were considered major burn patients, who underwent escharotomy with general anesthesia and neuromuscular relaxation. The main variable was the time for recovery of a TOF higher than 0.9 after the administration of sugammadex before extubation. RESULTS: Mean time of recovery from a TOF ratio higher than 0.9 following the administration of Sugammadex was of 4.95min 95% CI (3.25-6.64, p=.53). CONCLUSIONS: The reversion of neuromuscular relaxation with sugammadex appears to be effective and safe in the burn patient. More analytical, comparative studies of larger populations would be necessary to confirm these data.

[Use of sugammadex in burn patients: descriptive study]. / Uso de sugamadex no paciente queimado: estudo descritivo.

OBJECTIVES: The burn patient is a challenge for the anesthesiologist, undergoing several surgeries during admission, and requiring general anesthesia and muscle relaxation most of the times. They have respiratory system impairment and a response to muscle relaxants that differs from the healthy patient, thus proper monitoring and reversal is crucial. We analyzed sugammadex effectiveness and safety in this population. MATERIAL AND METHODS: Prospectively descriptive study including four patients, all of them considered major burn patients, who underwent escharotomy with general anesthesia and neuromuscular relaxation. The main variable was the time for recovery of a TOF higher than 0.9 after the administration of sugammadex before extubation. RESULTS: Mean time of recovery from a TOF ratio higher than 0.9 following the administration of Sugammadex was of 4.95minutes 95% CI (3.25-6.64, p=.53); CONCLUSIONS: The reversion of neuromuscular relaxation with sugammadex appears to be effective and safe in the burn patient. More analytical, comparative studies, of larger populations would be necessary to confirm this data.

[Comparison of the effects of remifentanil and remifentanil plus lidocaine on intubation conditions in intellectually disabled patients]. / Comparação dos efeitos de remifentanil e remifentanil + lidocaína em intubação de pacientes intelectualmente deficientes.

BACKGROUND AND OBJECTIVES: This is a prospective, randomized, single-blind study. We aimed to compare the tracheal intubation conditions and hemodynamic responses either remifentanil or a combination of remifentanil and lidocaine with sevoflurane induction in the absence of neuromuscular blocking agents. METHODS: Fifty intellectually disabled, American Society of Anesthesiologists I-II patients who underwent tooth extraction under outpatient general anesthesia were included in this study. Patients were randomized to receive either 2µg/kg remifentanil (Group 1, n=25) or a combination of 2µg/kg remifentanil and 1mg/kg lidocaine (Group 2, n=25). To evaluate intubation conditions, Helbo-Hansen scoring system was used. In patients who scored 2 points or less in all scorings, intubation conditions were considered acceptable, however if any of the scores was greater than 2, intubation conditions were regarded unacceptable. Mean arterial pressure, heart rate and peripheral oxygen saturation (SpO2) were recorded at baseline, after opioid administration, before intubation, and at 1, 3, and 5 min after intubation. RESULTS: Acceptable intubation parameters were achieved in 24 patients in Group 1 (96%) and in 23 patients in Group 2 (92%). In intra-group comparisons, the heart rate and mean arterial pressure values at all-time points in both groups showed a significant decrease compared to baseline values (p=0.000) CONCLUSION: By the addition of 2µg/kg remifentanil during sevoflurane induction, successful tracheal intubation can be accomplished without using muscle relaxants in intellectually disabled patients who undergo outpatient dental extraction. Also worth noting, the addition of 1mg/kg lidocaine to 2µg/kg remifentanil does not provide any additional improvement in the intubation parameters.

Comparison of the effects of remifentanil and remifentanil plus lidocaine on intubation conditions in intellectually disabled patients.

BACKGROUND AND OBJECTIVES: This is a prospective, randomized, single-blind study. We aimed to compare the tracheal intubation conditions and hemodynamic responses either remifentanil or a combination of remifentanil and lidocaine with sevoflurane induction in the absence of neuromuscular blocking agents. METHODS: Fifty intellectually disabled, American Society of Anesthesiologists I-II patients who underwent tooth extraction under outpatient general anesthesia were included in this study. Patients were randomized to receive either 2 µg kg(-1) remifentanil (Group 1, n=25) or a combination of 2 µg kg(-1) remifentanil and 1 mg kg(-1) lidocaine (Group 2, n=25). To evaluate intubation conditions, Helbo-Hansen scoring system was used. In patients who scored 2 points or less in all scorings, intubation conditions were considered acceptable, however if any of the scores was greater than 2, intubation conditions were regarded unacceptable. Mean arterial pressure, heart rate and peripheral oxygen saturation (SpO2) were recorded at baseline, after opioid administration, before intubation, and at 1, 3, and 5 min after intubation. RESULTS: Acceptable intubation parameters were achieved in 24 patients in Group 1 (96%) and in 23 patients in Group 2 (92%). In intra-group comparisons, the heart rate and mean arterial pressure values at all-time points in both groups showed a significant decrease compared to baseline values (p=0.000) CONCLUSION: By the addition of 2 µg/kg remifentanil during sevoflurane induction, successful tracheal intubation can be accomplished without using muscle relaxants in intellectually disabled patients who undergo outpatient dental extraction. Also worth noting, the addition of 1mg/kg lidocaine to 2 µg/kg remifentanil does not provide any additional improvement in the intubation parameters.