Opioid-free general anesthesia and induced recovery from anesthesia in a patient with myotonic dystrophy type-1: a case report / Anestesia geral sem opioide e recuperação induzida da anestesia em paciente com distrofia miotônica tipo-1: relato de caso

Abstract Myotonic dystrophy type-1 (Steinert disease) is an autosomal dominant, progressive multisystem disease in which myotonic crisis can be triggered by several factors including pain, emotional stress, hypothermia, shivering, and mechanical or electrical stimulation. In this report, dexmedetomidine-based general anesthesia, in combination with a thoracic epidural for laparoscopic cholecystectomy in a patient with Steinert disease, is presented. An Aintree intubation catheter with the guidance of a fiberoptic bronchoscope was used for intubation to avoid laryngoscopy. Prolonged anesthetic effects of propofol were reversed, and recovery from anesthesia was accelerated using an intravenous infusion of theophylline.

Resumo A Distrofia Miotônica (DM) tipo-1 (Doença de Steinert) é uma doença multissistêmica progressiva autossômica dominante em que a crise miotônica pode ser desencadeada por vários fatores, incluindo dor, estresse emocional, hipotermia, tremores e estímulo mecânico ou elétrico. O presente relato descreve anestesia geral realizada com dexmedetomidina em combinação com peridural torácica para colecistectomia laparoscópica em paciente com Doença de Steinert. Para evitar laringoscopia, a intubação traqueal foi realizada utilizando cateter de intubação Aintree guiado por broncofibroscopia óptica. Os efeitos anestésicos prolongados do propofol foram revertidos e a recuperação anestésica foi acelerada pelo uso de infusão intravenosa de teofilina.

[Opioid-free general anesthesia and induced recovery from anesthesia in a patient with myotonic dystrophy type-1: a case report]. / Anestesia geral sem opioide e recuperação induzida da anestesia em paciente com distrofia miotônica tipo­1: relato de caso.

Myotonic dystrophy type-1 (Steinert disease) is an autosomal dominant, progressive multisystem disease in which myotonic crisis can be triggered by several factors including pain, emotional stress, hypothermia, shivering, and mechanical or electrical stimulation. In this report, dexmedetomidine-based general anesthesia, in combination with a thoracic epidural for laparoscopic cholecystectomy in a patient with Steinert disease, is presented. An Aintree intubation catheter with the guidance of a fiberoptic bronchoscope was used for intubation to avoid laryngoscopy. Prolonged anesthetic effects of propofol were reversed, and recovery from anesthesia was accelerated using an intravenous infusion of theophylline.

Relajación residual posoperatoria en la unidad de cuidados postanestésicos de un hospital universitario: Estudio de corte transversal / Postoperative residual curarization at the post-anesthetic care unit of a university hospital: A cross-sectional study

Abstract Introduction: Postoperative residual curarization has been related to postoperative complications. Objective: To determine the prevalence of postoperative residual curarization in a university hospital and its association with perioperative conditions. Method: A prospective registry of 102 patients in a period of 4 months was designed to include ASA I-II patients who intraoperatively received nondepolarizing neuromuscular blockers. Abductor pollicis response to a train-of-four stimuli based on accelleromyography and thenar eminence temperature (TOF-Watch SX®. Organon, Ireland) was measured immediately upon arrival at the postanesthetic care unit and 30 s later. Uni-bivariate analysis was planned to determine possible associations with residual curarization, defined as two repeated values of T4/T1 ratio <0.90 in response to train-of-four stimuli. Results: Postoperative residual curarization was detected in 42.2% of the subjects. Pancuronium was associated with a high risk for train-of-four response <0.9 at the arrive at postoperative care unit [RR:2.56 (IC95% 1.99-3.30); p = 0.034]. A significant difference in thenar temperature (°C) was found in subjects with train-of-four <0.9 when compared to those who reach adequate neuromuscular function (29.9 ± 1.6 vs. 31.1 ± 2.2; respectively. p = 0.003). However, we were unable to demonstrate a direct attribution of findings in train-of-four response to temperature (R² determination coefficient = 0.08%). Conclusions: A high prevalence of postoperative residual curarization persists in university hospitals, despite a reduced use of "long-lasting" neuromuscular blockers. Strategies to assure neuromuscular monitoring practice and access to therapeutic alternatives in this setting must be considered. Intraoperative neuromuscular blockers using algorithms and continued education in this field must be priorities within anesthesia services.

Introducción: La relajación residual postoperatoria ha sido asociada con mayores complicaciones postoperatorias. Objetivo: determinar la prevalencia de relajación residual postoperatoria en un hospital universitario y su relación con condiciones perioperatorias. Métodos: Se diseñó un registro prospectivo de 4 meses de duración, que incluyó pacientes ASA I-II que intraoperatoriamente recibieran bloqueadores neuromusculares. Se registró la respuesta del abductor pollicis a un estímulo de tren de cuatro mediante aceleromiografía y se midió la temperatura de la eminencia tenar (TOF-Watch SX®.Organon, Ireland) inmediatamente al ingreso a recuperación y a los 30 segundos. Se realizó análisis uni y bivariado para determinar posibles asociaciones con relajación residual postoperatoria, definida como dos respuestas sucesivas al estímulo tren-de-cuatro con una relación T4/T1 <0.90. Resultados: Se reclutaron 102 pacientes, encontrando una prevalencia de relajación residual del 42.2%. Pancuronio fue asociado con un riesgo elevado de TOF < 0.9 al ingreso a recuperación [RR:2,56 (IC95% 1.99-3.30); p = 0.034]. Se evidenció una diferencia significativa en la temperatura tenar de los pacientes que presentaban relajación residual, al compararla con pacientes que recuperaron su función neuromuscular [Grupo evento = 29.9 ± 1.6 (n = 43); Grupo control = 31.1 ±2.2 (n = 59)]. Sin embargo no se logró determinar una atribución directa de relajación residual a esta medición (coeficiente de determinación = 0.08%). Conclusión: Persiste una alta prevalencia de relajación residual postoperatoria en los hospitales universitarios, a pesar del uso reducido de bloqueadores neuromusculares de larga duración. Se hace indispensable encaminar estrategias para incentivar la monitoria neuromuscular y establecer algoritmos que permitan un manejo eficiente de los bloqueadores neuromusculares.

Analysis of the level of consciousness related to the oxygen therapy in patients in anesthesia recovery period / Análise do estado de consciência relacionado à oxigenoterapia em pacientes em recuperação anestésica

Analyze the level of consciousness by means of the Aldrete-Kroulik scale associated with the use of oxygen therapy at the Post-Anesthesia Care Unit (PACU). It is a prospective and comparative study, with quantitative analysis. It was conducted in a big Federal Public Hospital, located in Belo Horizonte city. The sample was consisted of 60 subjects, separated between groups using and do not using oxygen therapy, aged between 18 and 64 years old, submitted to elective surgery, surgical site in upper torso, under general anesthesia, and with the American Society Anesthesiologists (ASA) status I or II. The most part of the patients were female, with 50 years old or older, classified as ASA II, under total intravenous anesthesia, and length of time of anesthesia over 240 minutes. In the analysis of the level of consciousness related to the use of oxygen therapy, it is noteworthy that the p-value (0.069) is significant at the 15 minutes of permanence in the PACU. A large number of patients from the group that received supplemental oxygen therapy showed improvement in the level of consciousness at the 15 minutes of permanence in the PACU. Team work is necessary to prevent patient's complications in anesthetic recovery period.

Analyze the level of consciousness by means of the Aldrete-Kroulik scale associated with the use of oxygen therapy at the Post-Anesthesia Care Unit (PACU). It is a prospective and comparative study, with quantitative analysis. It was conducted in a big Federal Public Hospital, located in Belo Horizonte city. The sample was consisted of 60 subjects, separated between groups using and do not using oxygen therapy, aged between 18 and 64 years old, submitted to elective surgery, surgical site in upper torso, under general anesthesia, and with the American Society Anesthesiologists (ASA) status I or II. The most part of the patients were female, with 50 years old or older, classified as ASA II, under total intravenous anesthesia, and length of time of anesthesia over 240 minutes. In the analysis of the level of consciousness related to the use of oxygen therapy, it is noteworthy that the p-value (0.069) is significant at the 15 minutes of permanence in the PACU. A large number of patients from the group that received supplemental oxygen therapy showed improvement in the level of consciousness at the 15 minutes of permanence in the PACU. Team work is necessary to prevent patient's complications in anesthetic recovery period.

Fast track em cirurgia cardíaca: quando e como fazer / Fast track in heart surgery: when and how to perform

Durante muito tempo, a anestesia em cirurgia cardíaca baseou-se em altas doses de opioides e outras drogas de meia-vida prolongada. Associada à circulação extracorpórea (CEC), heparinização e hipotermia, a recuperação anestésica mostrava-se extremamente prolongada, com uso de próteses ventilatórias e ventilação controlada por longo período após o término da cirurgia. Nos últimos anos, com a tendência à redução de custos e morbidade relacionada a essa recuperação prolongada e uso de agentes anestésicos de meia-vida mais curta, passou-se a considerar a possibilidade de despertar precoce, com extubação e retorno à ventilação espontânea em curto período de tempo após o término da cirurgia.

For a long time, cardiac anesthesia was based upon the use of high doses of opioids and long half-time drugs. Associated to the heart-lung by-pass, full heparinization and hypothermia, post-anesthetic recovery was extremely long, with the use of respiratory protesis and mechanical ventilation. During the last few years, the need to reduce intrahospitalarcosts and the morbidity related to those long recovery times, associated with the new coming of short half-time drugs, fast wake up times, with extubation and return to normal breathing are now being considered.