Articaine and mepivacaine efficacy in postoperative analgesia for lower third molar removal: a double-blind, randomized, crossover study

Objective: Comparison of the clinical efficacy of 4% articaine in relation to 2% mepivacaine, both with 1:100,000 epinephrine, in the prevention of postoperative pain after lower third molar removal. Study design: Twenty patients underwent removal of bilateral lower third molars under local anesthesia (articaine or mepivacaine) in 2 separate appointments, in a double-blind, randomized, and crossed manner. Objective and subjective parameters were recorded for paired comparison of postoperative courses. Results: Duration of analgesia provided by articaine and mepivacaine was 198.00 ± 25.86, and 125.40 ± 13.96 min, respectively (P = .02), whereas the duration of anesthesia was 273.80 ± 15.94 and 216.85 ± 20.15 min, respectively (P = .06). Both solutions exerted no important effects upon arterial pressure, heart rate, or oxygen saturation (P > .05). Conclusions: Articaine provides a longer period of analgesic effect and a tendency for a longer period of anesthesia as compared to mepivacaine. The presence of a vasoconstrictor agent in local anesthetic solutions does not seem to influence hemodynamic parameters during lower third molar removal in healthy subjects. © 2006 Mosby, Inc. All rights reserved.

Pneumoencéfalo intraventricular após perfuração acidental de dura-máter. Relato de caso

BACKGROUND AND OBJECTIVES: The loss of resistance to air to identify the epidural space is widely used. However, the accidental perforation of the dura mater is one of the possible complications of this procedure, with an estimated incidence between 1% and 2%. The objective of this report was to describe the case of a patient with intraventricular pneumocephalus after the accidental perforation of the dura mater using the loss of resistance with air technique. CASE REPORT: Female patient, 26 years old, 75 kg, 1.67 m, physical status ASA I, with a 38-week pregnancy, was referred to the obstetric service for a cesarean section. Venipuncture was performed after placement of the monitoring. The patient was placed in a sitting position for administration of the epidural anesthesia. During the identification of the epidural space with the loss of resistance with air technique, an accidental perforation of the dura mater was diagnosed by observing free flow of CSF through the needle. The technique was modified to epidural anesthesia and anesthetics were administered by the needle placed in the subarachnoid space. In the first 24 hours, the patient developed headache and she was treated with caffeine, dypirone, hydration, hydrocortisone, and bed rest; despite those measures, the patient's symptoms worsened and evolved to headache in decubitus. A CT scan of the head showed the presence of pneumocephalus. After evaluation by a specialist, the patient remained under observation, with progressive improvement of the symptoms and was discharged from the hospital in the fifth day, without complications. CONCLUSIONS: Pneumocephalus after accidental perforation of the dura mater presented headache with the characteristics of headache secondary to loss of CSF, but with spontaneous resolution after the air was absorbed. Invasive measures, such as epidural blood patch, were not necessary. © Sociedade Brasileira de Anestesiologia, 2006.

The effect of alcohol consumption on periodontal bone support in experimental periodontitis in rats

Objective: The aim of this study was to evaluate the effect of the alcohol consumption on the periodontal bone support (PBS) in experimental periodontitis in rats. Materials and Methods: Sixty-three male rats were divided into seven groups: G1 (control); G2 (10% ethanol); G3 (nutritional control of G2); G4 (20% ethanol); G5 (nutritional control of G4); G6 (30% ethanol) and G7 (nutritional control of G6). The groups G3, G5 and G7 received controlled diets with equivalent caloric amounts to those consumed in G2, G4 and G6 respectively, with the ethanol replaced by sucrose. After anesthesia, ligatures were installed around the mandibular first molar, leaving the contralateral teeth unligated. After 8 weeks, the rats were killed and their mandibles were radiographed to measure the percentage of PBS on the distal aspect. Results: The intragroup analyses showed that presence of ligatures induced periodontitis (p<0.05). Unligated groups did not show significant differences among the percentages of PBS (p=0.1969). However, in ligated groups the rats that received alcohol (G2:48.71%±3.88; G4:47.66%±2.54; G6:47.32%±3.24) and the nutritional control group associated with a high concentration of ethanol (G7:47.40%±3.24) presented a significantly lower percentage of PBS than the other groups (G1:52.40%±2.75; G3:52.83%±2.41; G5:50.85%±4.14). Conclusions: These results demonstrated that alcohol consumption in rats may result in a direct effect on alveolar bone loss and increased development of periodontitis. In addition, they suggest that heavy caloric consumption of ethanol may also present an indirect effect on periodontal tissue as a consequence of malnutrition.

Injeção epidural de cetamina ou cetamina levógira no controle da dor pós-incisional, em eqüinos

The aim of this study was to evaluate the pre-emptive effect of epidural ketamine S (+) (SK) or racemic ketamine (RK) administration, in post-incisional pain in horses. Were used in a blinded, randomized experimental study, sixteen mixed breed mares, 6±2 years old, weighting 273.2±42.0 kg. An epidural catheter was inserted 24 hours before the trials. The thigh region was shaved bilaterally, and mechanical cutaneous sensibility was measured using von Frey filaments (T-30). Using the left side as the control one, local anesthesia was performed at the right side. Twenty-five minutes later, SK was injected in G1 or RK in G2 through the epidural catheter. Five minutes after the ketamine injection, a 10 cm skin incision was made on the right side, and then sutured. Mechanical post-incisional pain was measured using von Frey filaments, at 1, 3 and 5 cm around the incision at 15 minutes intervals, for 2 hours, then 4, 6 and 8 hours after suturing. No changes were observed in the heart and respiratory rate and rectal temperature among groups or times of each group. Hind limb ataxia was observed in 62.5% and 12.5% of G1 and G2 respectively. SK and RK reduced cutaneous sensibility in the right and the left sides to mechanical postincisional pain during all time of experiment. Epidural SK and RK produce similar post-incisional analgesic effects, did not interfere in the cardio-respiratory parameters. The SK induces more intense ataxia in mares and presents a larger analgesic potency in the first 60 minutes after the administration.

Abscesso do músculo psoas em paciente submetida à analgesia por via peridural. Relato de caso

BACKGROUND AND OBJECTIVES: Psoas muscle abscess is a rare complication of epidural analgesia. The adequate approach to this complication is fundamental for a good resolution. The objective of this report was to discuss the diagnosis and treatment of psoas muscle abscess. CASE REPORT: A female patient, 65 years old, with neuropathic pain in the lower limbs, difficult to control with systemic drugs. The patient was treated with epidural opioid and local anesthetic as an alternate treatment. Twenty days after the continuous epidural administration, the patient complained of lumbar pain, headache, and fever. A CT scan of the pelvis showed an abscess of the psoas muscle, thus, closed drainage and antibiotics were indicated. CONCLUSIONS: An adequate, continuous supervision of the patient is necessary when an epidural catheter is placed, and it should continue after its removal. © Sociedade Brasileira de Anestesiologia, 2007.

Botucatu, Brazil: A Regional Community Palliative Care Model

The Pain Management and Palliative Care Service in the Department of Anesthesia at Botucatu Medical School, UNESP is a pioneer in Brazil. Based on an interdisciplinary team that provides specialized inpatient, ambulatory outpatient, and home care to patients in Botucatu and the surrounding region, the service is also able to provide extensive educational opportunities in pain management and palliative care for medical students, anesthesia residents, practicing anesthetists, and nurses. © 2007 U.S. Cancer Pain Relief Committee.

Disfunção temporária do nervo lingual após uso de máscara laríngea. Relato de caso

BACKGROUND AND OBJECTIVES: The laryngeal mask has been frequently used in Anesthesiology. Although the rate of complications with this technique is smaller than that of the endotracheal tube, it is not devoid of risks, especially in cases of difficult airways. The objective of this study was to report a case of unilateral lingual nerve damage after the use of the laryngeal mask airway. CASE REPORT: A female patient underwent a surgical procedure for removal of bilateral breast prosthesis under general, balanced anesthesia, with a size three laryngeal mask. The balloon was inflated with 30 mL of air. After the first postoperative hour, she developed decreased sensation and pain in the oropharynx and posterior two thirds of the tongue, which evolved for loss of taste in the next 24 hours. A tentative diagnosis of lingual nerve neuropraxis secondary to the use of the laryngeal mask was made. After three weeks, her symptoms subsided. CONCLUSION: Although complications after the use of the laryngeal mask airway are rare, they do occur, and neuropraxis of the lingual nerve is one of them. The diagnosis is clinical and it has a good outcome, with resolution of the symptoms within a few weeks or months. © Sociedade Brasileira de Anestesiologia, 2007.

Efeitos de diferentes frações inspiradas de oxigênio sobre a dinâmica respiratória em cães submetidos à infusão contínua de propofol e mantidos em ventilação espontânea

The effects of several inspired oxygen fractions (FiO 2) on the respiratory dynamics in spontaneously breathing dogs submitted to continuous infusion of propofol were evaluated. Eight adult mongrel dogs were used. Each animal underwent five anesthesias, in each procedure the patient was allowed to breath a different FiO 2, thereby resulting in five groups, namely: G100 (FiO 2 = 1), G80 (FiO 2 = 0.8), G60 (FiO 2 =0.6), G40 (FiO 2 = 0.4), and G20 (FiO 2 = 0.21). To induce anesthesia, propofol was given until the animals allowed orotracheal intubation, followed by immediate continuous infusion of drug. The initial measurement (M0) was recorded thirty minutes after the infusion of propofol has begun. Additional recordings were performed at 15 minute intervals for 60 minutes (M15, M30, M45 and M60). Numeric data were submitted to Analysis of Variance followed by Tukey Test (p<0.05). We recorded significantly lower values of SpO 2 and SaO 2 at G20, whereas PaO 2 varied according to the changes in oxygen. Regarding PaCO 2, the mean of G100 was greater than G20 at M30. However, spontaneously breathing dogs anesthetized with propofol at the rate of 0.7mg/kg/min should not be provided with 100%, 80%, and 21% oxygen owing to the significant compromise of respiratory system.

Edema agudo pulmonar associado à obstrução das vias aéreas. Relato de caso

BAKGROUND AND OBJECTIVES: Negative pressure pulmonary edema has been defined as non-cardiogenic edema, with transudation of fluid to the interstitial space of the lungs due to an increase in negative intrathoracic pressure secondary to obstruction of the upper airways. This is the case of a healthy patient who underwent general anesthesia and developed acute pulmonary edema after extubation. CASE REPORT: A 23-year old female patient, physical status ASA II, underwent gynecologic videolaparoscopy under general anesthesia. The procedure lasted 3 hours without intercurrence. After extubation the patient developed laryngeal spasm and reduction in oxygen saturation. The patient improved after placement of an oral cannula and administration of oxygen under positive pressure with a face mask. Once the patient was stable she was transferred to the recovery room where, shortly after her arrival, she developed acute pulmonary edema with elimination of bloody serous secretion. Treatment consisted of elevation of the head, administration of oxygen via a face mask, furosemide and fluid restriction. Chest X-ray was compatible with acute pulmonary edema and normal cardiac area. Electrocardiogram (ECG), echocardiogram and cardiac enzymes were normal. The condition of the patient improved and she was discharged from the hospital the following day, asymptomatic. CONCLUSIONS: Acute pulmonary edema associated with obstruction of the upper airways can aggravate surgical procedures with low morbidity, affecting mainly young patients. Early treatment should be instituted because it has a fast evolution and, in most cases, resolves without lasting damages. © Sociedade Brasileira de Anestesiologia, 2008.

Efeito sinérgico entre a dexmedetomidina e a ropivacaína 0,75% na anestesia peridural

BACKGROUND. This study aimed to evaluate clinical characteristics of epidural anesthesia performed with 0.75% ropivacaine associated with dexmedetomidine. METHODS. Forty patients scheduled for hernia repair or varicose vein surgeries under epidural anesthesia participated in this study. They were assigned to: Control Group (n = 20), 0.75% ropivacaine, 20 ml (150 mg); and Dexmedetomidine Group (n = 20), 0.75% ropivacaine, 20 ml (150 mg), plus dexmedetomidine, 1 μg.kg -1. The following variables were studied: total analgesic block onset time, upper level of analgesia, analgesic and motor block duration time, intensity of motor block, state of consciousness, hemodynamics, postoperative analgesia and incidence of side-effects. RESULTS. Epidural dexmedetomidine did not affect onset time or upper level of anesthesia (p > 0.05) however it prolonged sensory and motor block duration time (p < 0.05) and postoperative analgesia (p < 0.05), and also resulted in a more intense motor block, 1 (p < 0.05). Values of bispectral index were lower in Dexmedetomidine Group (p < 0.05). There was no difference in incidence of hypotension and bradycardia (p > 0.05). Occurrence of side-effects (shivering, vomiting and SpO 2 < 90%) was low and similar between groups (p > 0.05). CONCLUSION. There is clear synergism between epidural dexmedetomidine and ropivacaine, further this drug association does not bring about additional morbidity.

Excision of an atypical case of palatal bone exostosis: a case report.

Bone exostosis has long been described in the literature, appearing in most cases as a torus palatinus or mandibularis. These two variations are relatively common and affect approximately 30% of the world's population. Incidence is even higher when human skulls are examined post mortem, indicating that in some cases the exostosis is small and cannot be seen under the soft tissue. Removal of an exostosis is usually associated with the construction of a prothesis, but in rare cases such as the present, the lesion enlarges enough to affect speech and feeding. Few studies have reported the removal of such a large exostosis, and all were conducted in a hospital environment. In this case, complete removal was successfully conducted in an ambulatory clinic under local anesthesia.

Determinação de cetamina em plasma por HPLC: Aplicação em um estudo de farmacocinética de associação medicamentosa em cães

A S(+) cetamina é um fármaco amplamente utilizado na medicina para induzir anestesia e a associação com midazolam é empregada para minimizar seus efeitos adversos. Associações medicamentosas podem resultar em interações farmacocinéticas e a disponibilidade de métodos bioanalíticos para a determinação da cetamina em plasma constitui ferramenta útil para a avaliação do perfil cinético do fármaco administrado isoladamente ou em associação. O presente estudo teve como objetivo o desenvolvimento e validação de um método analítico para determinação da cetamina em plasma por cromatografia líquida de alta eficiência (HPLC) e a investigação do perfil farmacocinético da cetamina em quatro cães hígidos da raça Beagle. A S(+) cetamina (10mg/kg) foi administrada pela veia cefálica em dose única isoladamente (protocolo I) ou associada ao midazolam (0.2mg/kg) (protocolo II) em estudo cruzado com intervalo de uma semana para washout. Amostras seriadas de sangue foram coletadas no intervalo de oito horas e analisadas por HPLC para a avaliação do perfil farmacocinético utilizando modelo bicompartimental. O método bioanalítico apresentou limites de confiança aceitáveis para sua aplicação em estudos de farmacocinética e os parâmetros área sob a curva (ASC0-8), volume de distribuição (Vd), clearance total (Clt), meia vida de eliminação (t/12 ß), constante de eliminação (ß), meia vida de distribuição (t1/2α) e constante de distribuição (α) não mostraram diferenças estatísticas significativas entre os grupos (p < 0.05, Wilcoxon). Os resultados obtidos sugerem que a redução dos efeitos colaterais da cetamina decorrente do uso da associação cetamina-midazolam não está relacionada a alterações no perfil farmacocinético da cetamina.

Estudo retrospectivo dos procedimentos anestésicos realizados em cães e gatos submetidos a neurocirurgias

Neurosurgeries are frequent in the routine of veterinary hospitals and, therefore, knowledge of the different anesthetic protocols to be used for each patient is necessary to prevent the morbity and mortality in the after and trans-surgical period. The objectives of this study were to evaluate the anesthetic protocols used in patients undergoing neurosurgeries; the results of those protocols; the rate of complications, and if those complications are related to the duration of the anesthesia time. We studied the anesthetical data of 52 dogs and two cats submitted to neurosurgery between January of 2003 and December of 2006, in the Veterinary Hospital of UEL. Findings showed that the main protocols used were propofol for induction and halothane or isofluorane for maintenance of the anesthesia. These protocols induced adequate anesthesia for the surgical procedure and did not occur complications during the anesthetic period in 37/54 (68,5%) of the cases. 7/19 (36.8%) of the complications observed occurred in patients submitted to anesthesia with halothane and 8/32 (25.2%) in patients with isofluorane. The complication most observed in this study was bradicardy, which occurred in 15/54 (27.8%) of the patients. Two deaths occurred in patients submitted to slot cervical. Good knowledge of the neurological disease and of surgical and anesthetic techniques are essential to prevent alterations in the central nervous system caused by the drugs, disease or association of these factors.

Effect of remifentanil hydrochloride administered via constant rate infusion on the minimum alveolar concentration of isoflurane in cats

Objective - To evaluate the effects of increasing doses of remifentanil hydrochloride administered via constant rate infusion (CRI) on the minimum alveolar concentration (MAC) of isoflurane in cats. Animals - 6 healthy adult cats. Procedures - For each cat, 2 experiments were performed (2-week interval). On each study day, anesthesia was induced and maintained with isoflurane; a catheter was placed in a cephalic vein for the administration of lactated Ringer's solution or remifentanil CRIs, and a catheter was placed in the jugular vein for collection of blood samples for blood gas analyses. On the first study day, individual basal MAC (MAC Basal) was determined for each cat. On the second study day, 3 remifentanil CRIs (0.25, 0.5, and 1.0 μg/kg/min) were administered (in ascending order); for each infusion, at least 30 minutes elapsed before determination of MAC (designated as MAC R0.25, MAC R0.5, and MAC R1.0, respectively). A 15-minute washout period was allowed between CRIs. A control MAC (MAC Control) was determined after the last remifentanil infusion. Results - Mean ± SD MAC Basal and MAC Control values at sea level did not differ significantly (1.66 ± 0.08% and 1.52 ± 0.21%, respectively). The MAC values determined for each remifentanil CRI did not differ significantly. However, MAC R0.25, MAC R0.5, and MAC R1.0, were significantly decreased, compared with MAC Basal, by 23.4 ± 79%, 29.8 ± 8.3%, and 26.0 ± 9.4%, respectively. Conclusions and Clinical Relevance - The 3 doses of remifentanil administered via CRI resulted in a similar degree of isoflurane MAC reduction in adult cats, indicating that a ceiling effect was achieved following administration of the lowest dose.

Raquianestesia contínua em paciente submetido à gastrectomia parcial. Relato de caso

BACKGROUND AND OBJECTIVES: Due to the high incidence of technical and neurological complications, continuous spinal blocks were not performed for several years. With the advent of intermediate catheters the technique has been used more often and gaining acceptance among anesthesiologists. The objective of this report was to demonstrate the usefulness of the technique as a viable alternative for medium and major size surgeries. CASE REPORT: This is a 58 years old female patient, weighing 62 kg, physical status ASA I, with a history of migraines, low back pain, and prior surgeries under spinal block without intercurrence. The patient was scheduled for exploratory laparotomy for a probable pelvic tumor. After venoclysis with an 18G catheter, monitoring with cardioscope, non-invasive blood pressure and pulse oximetry was instituted; she was sedated with 2 mg of midazolam and 100 μg of fentanyl, and placed in left lateral decubitus. The patient underwent continuous spinal block through the median approach in L 3-L 4; 9 mg of 0.5% hyperbaric bupivacaine and 120 μ g of morphine sulfate were administered. Inspection of the abdominal cavity revealed a gastric stromal tumor that required an increase in the incision for a partial gastrectomy. A small dose of hyperbaric solution was required for the entire procedure, which was associated with complete hemodynamic stability. Postoperative admission to the ICU was not necessary; the patient presented a good evolution without complaints and with a high degree of satisfaction. She was discharged from the hospital after 72 hours without intercurrence. CONCLUSIONS: Intermediate catheters used in continuous spinal blocks have shown the potential to turn it an attractive and useful technique in medium and large size surgeries and it can even be an effective alternative in the management of critical patients to whom hemodynamic repercussions can be harmful.