Comparação do C‐MAC convencional e C‐MAC D‐blade com laringoscópios diretos em simulação de lesão da coluna cervical–estudo em modelo

Background

CMAC videolaryngoscope has recently been introduced for videoscope guided intubation. The aim of our study was to compare and evaluate the efficacy of the conventional blade and the angulated D blade of the CMAC videolaryngoscope with the direct laryngoscopes in simulated cervical spine injury patients on the airway manikin.

Materials and methods

Following power analysis, 33 resident doctors were enrolled to perform endotracheal intubation using all the 4 different laryngoscopes namely the Macintosh laryngoscope, McCoy laryngoscope, conventional CMAC videolaryngoscope and the D blade of the CMAC videolaryngoscopes on the airway manikin in simulated cervical spine injury. The demographic variables of the resident doctors were recorded. The outcomes measured included vocal cord visualization (Cormack–Lehane grading), time taken to intubate, number of attempts for successful intubation and optimizing maneuvers required.

Results

The use of indirect videolaryngoscopes resulted in better glottic visualization in comparison to the direct laryngoscopes (CL‐I) in 20/33 (60.6%) in the Macintosh group, 24/33 (72.7%) in McCoy group, 30/33 in (90.9%) in Vlc group and 32/33 (96.9%) in Vld group. The time taken to intubate averaged to 15.54 ± 2.6 in Macintosh group, 18.90 ± 4.47 in McCoy group, 20.21 ± 7.9 in Vlc group and 27.42 ± 9.09 in Vld group. The 1st attempt intubation success rate was 84.8% (Macintosh), 72.7% (McCoy), 90.9% (Vlc) and, 78.7% (Vld).

Conclusions

The overall performance of the conventional CMAC blade proved to be the best when compared with the D‐blade CMAC, Macintosh blade and the McCoy blade for intubation in simulated cervical spine patients by anesthesia residents.     

Infusão intraoperatória de esmolol reduz o consumo pós‐operatório de analgésicos e o uso de anestésico durante a septorrinoplastia: estudo randômico

Background and objectives

Esmolol is known to have no analgesic activity and no anaesthetic properties; however, it could potentiate the reduction in anaesthetic requirements and reduce postoperative analgesic use. The objective of this study is to evaluate the effect of intravenous esmolol infusion on intraoperative and postoperative analgesic consumptions as well as its effect on depth of anaesthesia.

Method

This randomized‐controlled double blind study was conducted in a tertiary care hospital between March and June 2010. Sixty patients undergoing septorhinoplasty were randomized into two groups. History of allergy to drugs used in the study, ischaemic heart disease, heart block, bronchial asthma, hepatic or renal dysfunction, obesity and a history of chronic use of analgesic or β‐blockers were considered cause for exclusion from the study. Thirty patients received esmolol and remifentanil (esmolol group) and 30 patients received normal saline and remifentanil (control group) as an intravenous infusion during the procedure. Mean arterial pressure, heart rate, and bispectral index values were recorded every 10 min. Total remifentanil consumption, visual analogue scale scores, time to first analgesia and total postoperative morphine consumption were recorded.

Results

The total remifentanil consumption, visual analogue scale scores at 0, 20 and 60 min, total morphine consumption, time to first analgesia and the number of patients who needed an intravenous morphine were lower in the esmolol group.

Conclusions

Intravenous infusion of esmolol reduced the intraoperative and postoperative analgesic consumption, reduced visual analogue scale scores in the early postoperative period and prolonged the time to first analgesia; however it did not influence the depth of anaesthesia.     

Solicitud de sangre preoperatoria en cirugía programada de colon: ¿necesidad o rutina?

Background

Preoperative blood ordering is frequently in elective colon surgery, even for procedures that rarely require blood transfusion. Most often this procedure is performed without proper analysis of the real needs. The aim of this study was to evaluate the patients who receive transfusion and determining their associated factors.

Methods

Retrospective study of all consecutive patients scheduled for elective colon surgery was carried out at 2007-2012. Several clinico-pathological and surgical variables were analyzed and predictive blood transfusion indices such as the cross-matched/transfusion ratio (C/T ratio), transfusion index and transfusion probability were calculated. Patients were divided in 2 groups according have received perioperative surgical transfusion or not.

Results

There were 457 surgery patients. A total of 171 blood units, in a 74 patients were perioperative transfused. Overall cross-matched transfused ratio was 5.34, the transfusion probability 162%, and the transfusion index 0.18. Variables that were significantly associated with receiving blood transfusion in a multivariable analysis were a preoperative haemoglobin level less than 10 g/dl (OR: 309.8; 95% CI: 52.7-985.2), chronic pulmonary obstructive disease (OR: 3.7; 95% CI: 1.3-10.7), oral anticoagulant therapy (OR: 5.7; 95% CI: 1.7-19.4) and surgical time over 120 min (OR: 10.7; 95% CI: 4.7-24.1).

Conclusions

Likelihood of receiving perioperative transfusion in elective colon surgery is very low. Among their associated factors, the haemoglobin level less than 10 g/dl is the one with strongest association. Those patients with such low preoperative haemoglobin level should not be scheduled for elective colon surgery until they received specific treatment.     

Atividade simpática de cetamina S‐(+) em doses baixas no espaço epidural

Background and objectives

S‐(+)‐ketamine is an intravenous anaesthetic and sympathomimetic with properties of local anaesthetic. It has an effect of an analgetic and local anaesthetic when administered epidurally, but there are no data whether low doses of S‐(+)‐ketamine have sympathomimetic effects. The aim of this study was to determine whether low doses of S‐(+)‐ketamine, given epidurally together with local anaesthetic, have any effect on sympathetic nervous system, both systemic and below the level of anaesthetic block.

Methods

The study was conducted on two groups of patients to whom epidural anaesthesia was administered to. Local anaesthesia (0.5% bupivacaine) was given to one group (control group) while local anaesthesia and S‐(+)‐ketamine were given to other group. Age, height, weight, systolic, diastolic and mean arterial blood pressure were measured. Non‐competitive enzyme immunochemistry method (Cat Combi ELISA) was used to determine the concentrations of catecholamines (adrenaline and noradrenaline). Immunoenzymometric determination with luminescent substrate on a machine called Vitros Eci was used to determine the concentration of cortisol. Pulse transit time was measured using photoplethysmography. Mann–Whitney U‐test, Wilcoxon test and Friedman ANOVA were the statistical tests. Blood pressure, pulse, adrenaline, noradrenaline and cortisol concentrations were measured in order to estimate systemic sympathetic effects.

Results

40 patients in the control group were given 0.5% bupivacaine and 40 patients in the test group were given 0.5% bupivacaine with S‐(+)‐ketamine. Value p < 0.05 has been taken as a limit of statistical significance.

Conclusions

Low dose of S‐(+)‐ketamine administered epidurally had no sympathomimetic effects; it did not change blood pressure, pulse, serum hormones or pulse transit time. Low dose of S‐(+)‐ketamine administered epidurally did not deepen sympathetic block. Adding 25 mg of S‐(+)‐ketamine to 0.5% bupivacaine does not deprive sympathetic tonus below the level of epidural block at the moment of most expressed sympathetic block and has no effect on sympathetic tonus above the block level.     

Adquirir habilidades no manejo de crises de hipertermia maligna: comparação de simulação de alta‐fidelidade versus estudo de caso em computador

Introduction

The primary purpose of this study was to compare the effect of high fidelity simulation versus a computer‐based case solving self‐study, in skills acquisition about malignant hyperthermia on first year anesthesiology residents.

Estudo randômico e duplo‐cego de profilaxia com fibrinogênio para reduzir o sangramento em cirurgia cardíaca

Background and objectives

Postoperative bleeding has a great clinical importance and can contribute to increased mortality and morbidity in patients undergoing coronary artery bypass graft surgery. In this prospective, randomized, double‐blind study, we evaluated the effect of prophylactic administration of fibrinogen concentrate on post‐coronary artery bypass graft surgery bleeding.

Methods

A total of 60 patients undergoing coronary artery bypass surgery were randomly divided into two groups. Patients in the fibrinogen group received 1 g of fibrinogen concentrate 30 min prior to the operation, while patients in the control group received placebo. Post‐operative bleeding volumes, prothrombin time, partial thromboplastin time, INR, hemoglobin and transfused blood products in both groups were recorded. A strict red blood cell transfusion protocol was used in all patients.

Results

There were no significant differences between intra‐operative packed red blood cells infusion in the studied groups (1.0 ± 1.4 in fibrinogen group, and 1.3 ± 1.1 in control group). Less postoperative bleeding was observed in the fibrinogen group (477 ± 143 versus 703 ± 179, p = 0.0001). Fifteen patients in the fibrinogen group and 21 in the control group required post‐op packed red blood cells infusion (p = 0.094). No thrombotic event was observed through 72 h after surgery.

Conclusion

Prophylactic fibrinogen reduces post‐operative bleeding in patients undergoing coronary artery bypass graft.     

Comparação entre a posição de rampa e posição olfativa durante intubação traqueal: revisão sistemática e meta‐análise

ObjectivesPositioning during endotracheal intubation (ETI) is critical to ensure its success. We aimed to determine if the ramping position improved laryngeal exposure and first attempt success at intubation when compared to the sniffing position.MethodsPubMed, EMBASE, and Cochrane CENTRAL databases were searched systematically from inception until January 2020. Our primary outcomes included laryngeal exposure as measured by Cormack‐Lehane Grade 1 or 2 (CLG 1/2), CLG 3 or 4 (CLG 3/4), and first attempt success at intubation. Secondary outcomes were intubation time, use of airway adjuncts, ancillary maneuvers and complications during ETI.ResultsSeven studies met our inclusion criteria, of which 4 were RCTs and 3 were cohort studies. The meta‐analysis was conducted by pooling the effect estimates for all 4 included RCTs (n = 632). There were no differences found between ramping and sniffing positions for odds of CLG 1/2, CLG 3/4, first attempt success at intubation, intubation time, use of ancillary airway maneuvers and use of airway adjuncts, with evidence of high heterogeneity across studies. However, the ramping position in surgical patients is associated with increased likelihood of CLG 1/2 (OR = 2.05, 95% CI 1.26 to 3.32, p = 0.004) and lower likelihood of CLG 3/4 (OR = 0.49, 95% CI 0.30 to 0.79, p = 0.004), moderate quality of evidence.ConclusionOur meta‐analysis demonstrated that the ramping position may benefit surgical patients undergoing ETI by improving laryngeal exposure. Large‐scale well‐designed multicentre RCTs should be carried out to further elucidate the benefits of the ramping position in the surgical and intensive care unit patients.     

Níveis plasmáticos de interleucina‐10 e óxido nítrico em resposta a duas taxas de fluxo em anestesia com desflurano

Objective

This study investigated interleukin‐10 and nitric oxide plasma levels following surgery to determine whether there is a correlation between these two variables and if different desflurane anesthesia flow rates influence nitric oxide and interleukin‐10 concentrations in circulation.

Materials and methods

Forty patients between 18 and 70 years and ASA I–II physical status who were scheduled to undergo thyroidectomy were enrolled in the study.

Interventions

Patients were allocated into two groups to receive two different desflurane anesthesia flow rates: high flow (Group HF) and low flow (Group LF).

Measurements

Blood samples were drawn at the beginning (t₀) and end (t₁) of the operation and after 24 h (t₂). Plasma interleukin‐10 and nitric oxide levels were measured using an enzyme‐linked‐immunosorbent assay and a Griess reagents kit, respectively. Hemodynamic and respiratory parameters were assessed.

Results

There was no statistically significant difference between the two groups with regard to interleukin‐10 levels at the times of measurement. Interleukin‐10 levels were increased equally in both groups at times t₁ and t₂ compared with preoperative concentrations. For both groups, nitric oxide circulating concentrations were significantly reduced at times t₁ and t₂ compared with preoperative concentrations. However, the nitric oxide value was lower for Group HF compared to Group LF at t₂. No correlation was found between the IL‐10 and nitric oxide levels.

Conclusion

Clinical usage of two different flow anesthesia forms with desflurane may increase interleukin‐10 levels both in Group HF and Group LF; nitric oxide levels circulating concentrations were significantly reduced at times t₁ and t₂ compared with preoperative concentrations; however, at 24 h postoperatively they were higher in Group LF compared to Group HF. No correlation was detected between interleukin‐10 and nitric oxide levels.     

Efeitos de dexmedetomidina em conjunto com o pré‐condicionamento isquêmico remoto em lesão de isquemia‐reperfusão renal em ratos

Background and objectivesThe aim of this study was to evaluate the effects of remote ischemic preconditioning by brief ischemia of unilateral hind limb when combined with dexmedetomidine on renal ischemia–reperfusion injury by histopathology and active caspase‐3 immunoreactivity in rats.Methods28 Wistar albino male rats were divided into 4 groups. Group I (Sham, n = 7): Laparotomy and renal pedicle dissection were performed at 65th minute of anesthesia and the rats were observed under anesthesia for 130 min. Group II (ischemia–reperfusion, n = 7): At 65th minute of anesthesia bilateral renal pedicles were clamped. After 60 min ischemia 24 h of reperfusion was performed. Group III (ischemia–reperfusion + dexmedetomidine, n = 7): At the fifth minute of reperfusion (100 μg/kg intra‐peritoneal) dexmedetomidine was administered with ischemia–reperfusion group. Reperfusion lasted 24 h. Group IV (ischemia–reperfusion + remote ischemic preconditioning + dexmedetomidine, n = 7): After laparotomy, three cycles of ischemic preconditioning (10 min ischemia and 10 min reperfusion) were applied to the left hind limb and after 5 min with group III.ResultsHistopathological injury scores and active caspase‐3 immunoreactivity were significantly lower in the Sham group compared to the other groups. Histopathological injury scores in groups III and IV were significantly lower than group II (p = 0.03 and p = 0.05). Active caspase‐3 immunoreactivity was significantly lower in the group IV than group II (p = 0.01) and there was no significant difference between group II and group III (p = 0.06).ConclusionsPharmacologic conditioning with dexmedetomidine and remote ischemic preconditioning when combined with dexmedetomidine significantly decreases renal ischemia–reperfusion injury histomorphologically. Combined use of two methods prevents apoptosis via active caspase‐3.     

Avaliação da qualidade da recuperação e do estado de saúde no pós‐operatório de cirurgias eletivas

Purpose

Postoperative recovery is a complex process with physiologic, functional, and psychologic dimensions. Postoperative quality of recovery is considered as a crucial outcome following surgery and anesthesia. The objective of this study was to assess and compare the quality of postoperative recovery and health status before and after surgery, in patients undergoing elective surgery.

O valor preditivo do peptídeo natriurético tipo‐B em resultados de crianças com hipertensão pulmonar submetidas à cirurgia cardíaca congênita

Background and objectives

In children undergoing congenital heart surgery, plasma brain natriuretic peptide levels may have a role in development of low cardiac output syndrome that is defined as a combination of clinical findings and interventions to augment cardiac output in children with pulmonary hypertension.

Methods

In a prospective observational study, fifty‐one children undergoing congenital heart surgery with preoperative echocardiographic study showing pulmonary hypertension were enrolled. The plasma brain natriuretic peptide levels were collected before operation, 12, 24 and 48 h after operation. The patients enrolled into the study were divided into two groups depending on: (1) Development of LCOS which is defined as a combination of clinical findings or interventions to augment cardiac output postoperatively; (2) Determination of preoperative brain natriuretic peptide cut‐off value by receiver operating curve analysis for low cardiac output syndrome. The secondary end points were: (1) duration of mechanical ventilation ≥72 h, (2) intensive care unit stay >7days, and (3) mortality.

Results

The differences in preoperative and postoperative brain natriuretic peptide levels of patients with or without low cardiac output syndrome (n = 35, n = 16, respectively) showed significant differences in repeated measurement time points (p = 0.0001). The preoperative brain natriuretic peptide cut‐off value of 125.5 pg mL‐1 was found to have the highest sensitivity of 88.9% and specificity of 96.9% in predicting low cardiac output syndrome in patients with pulmonary hypertension. A good correlation was found between preoperative plasma brain natriuretic peptide level and duration of mechanical ventilation (r = 0.67, p = 0.0001).

Conclusions

In patients with pulmonary hypertension undergoing congenital heart surgery, 91% of patients with preoperative plasma brain natriuretic peptide levels above 125.5 pg mL‐1 are at risk of developing low cardiac output syndrome which is an important postoperative outcome.     

Tomografia por emissão de pósitrons com FDG‐18F na avaliação de pacientes com artrite reumatoide – revisão sistemática

IntroductionRheumatoid arthritis (RA) is a disease characterized by inflammation of the synovial membrane. Several authors have investigated the role of positron emission tomography (PET) with fluorine‐18 fluorodeoxyglucose (¹⁸F‐FDG) in RA.ObjectivesTo systematically review the current literature on the role of ¹⁸F‐FDG PET in the diagnosis, determination of disease activity and assessment of treatment response in patients with RA.MethodsSearches were conducted in Medline, Cochrane Library, Lilacs, Pubmed and Scopus in Portuguese, English and Spanish languages, using the keywords «rheumatoid arthritis», «synovitis», «FDG», «PET», «glycolytic metabolism» and «disease activity».Results142o articles were initially identified, of which only 40 were related directly to the subject. Twelve original articles and three case reports that met the inclusion criteria were selected.DiscussionThe presence of activated macrophages and fibroblasts in pannus are responsible for the intense periarticular uptake of ¹⁸F‐FDG. The uptake patterns do not allow the differential diagnosis with other arthritides. The uptake intensity and the number of joints involved are metabolic parameters of disease activity that correlate well with the composite indices. Longitudinal studies of PET have proven useful in assessing the response to treatment with anti‐TNF. When performed early, PET can predict the therapeutic response.ConclusionAlthough the actual role of this new technique for the investigation of RA is not yet established, ¹⁸F‐FDG PET is a promising tool in determining the activity and prediction of response to treatment of patients with RA.