Uso da máscara laríngea descartável em adenotonsilectomias

JUSTIFICATIVA E OBJETIVOS: A intubação traqueal associada a operações das vias aéreas faz com que complicações como laringoespasmo, broncoespasmo e períodos de redução da saturação de oxigênio sejam frequentemente relatados em adenotonsilectomias, procedimento que, por sua natureza, eleva a incidência de tais complicações. O objetivo deste estudo foi analisar a ocorrência de problemas respiratórios comparando-se o uso da máscara laríngea (ML) descartável com a intubação orotraqueal em adenotonsilectomias. MÉTODOS: Foram avaliados 204 pacientes pediátricos submetidos a anestesia geral para adenotonsilectomias e alocados em dois grupos, aleatoriamente: grupo Cânula Traqueal (CT, n = 100) e grupo Máscara Laríngea (ML, n = 104). Foram observados os níveis de saturação de pulso de oxigênio (SpO2) após a indução anestésica (SpO2-1), após o estabelecimento de campo operatório (SpO2-2), ao término do procedimento cirúrgico (SpO2-3), três minutos após a retirada do dispositivo respiratório (SpO2-4) e na admissão da sala de recuperação anestésica (SpO2-5). As complicações respiratórias foram relatadas. RESULTADOS: Os valores médios e os desvios padrão de SpO2 nos grupos CT e ML foram, respectivamente: SpO2-1: 98,9 ± 1,0 e 98,7 ± 0,8 (p > 0,25); SpO2-2: 97,4 ± 1,0 e 94,9 ± 4,3 (p < 0,001); SpO2-3: 96,9 ± 1,1 e 97,2 ± 1,1 (p = 0,037); SpO2-4: 91,7 ± 9,0 e 95,2 ± 2,2 (p < 0,001); SpO2-5: 94,0 ± 2,1 e 95,8 ± 2,6 (p < 0,001). No grupo ML, em 12 pacientes, foi necessária alguma manobra para ajuste do dispositivo e correção de vazamento durante o ato operatório. A ML foi substituída pela CT em quatro pacientes. As complicações respiratórias foram similares entre os grupos. CONCLUSÕES: Adenotonsilectomias em pacientes pediátricos com o emprego da ML, em comparação com a CT, resulta em menores valores de SpO2 intraoperatórios e, eventualmente, necessidade de substituição da ML pela CT. Apesar de a ML viabilizar a cirurgia, pela segurança, o uso da CT é preferível.

Influence of fresh frozen plasma as a trigger factor for kidney dysfunction in cardiovascular surgery

OBJETIVO: A disfunção renal é uma complicação importante no cenário de pós-operatório de cirurgia cardiovascular. Como fatores de risco conhecidos no intraoperatório para o seu desenvolvimento destacam-se a circulação extracorpórea, a hemodiluição, drogas antifibrinolíticos e a transfusão sanguínea. O objetivo deste estudo é identificar os fatores de risco na transfusão de sangue e derivados para o desenvolvimento de disfunção renal em pacientes submetidos à cirurgia cardiovascular. MÉTODOS: Noventa e sete pacientes foram estudados e 84 foram analisados. A amostra foi estratificada em dois grupos, sendo que o incremento de 30% na creatinina sérica no pós-operatório foi considerado para o grupo com disfunção renal (n = 9; 10,71%). O grupo não disfunção renal foi caracterizado pela creatinina sérica, que permaneceu inferior a aumento de 30% no pós-operatório (n = 75; 89,28%). RESULTADOS: Foi observado que a transfusão de plasma fresco congelado no grupo não disfunção renal foi de 2,05 ± 0,78 unidades e 3,80 ± 2,16 unidades no grupo disfunção renal com P= 0,032. CONCLUSÃO: Foi possível associar, nesta série de pacientes, que a transfusão de plasma fresco congelado foi um fator de risco para disfunção renal pós-operatório de cirurgia cardiovascular.

Evaluation of obstructive sleep apnea in obese patients scheduled for bariactric surgery

PURPOSE: To evaluate the frequency of obstructive sleep apnea (OSA) in obese patients scheduled for bariatric surgery and their identification for risk of OSA by Berlin Questionnaire (BQ) and excessive daytime sleepiness by Epworth Sleepiness Scale (ESS). METHODS: Fifty nine patients were evaluated by BQ and ESS. Out of these individuals, 35 performed a full-night sleep study using a type 3 portable monitoring (PM). The questionnaire results were compared for gender and BMI. The presence and severity of OSA was correlated with gender and both questionnaires. RESULTS: 94.75% of the respondents presented high risk for OSA by BQ and 59.65% presented positivity by ESS. Taking into account the AHI> 5 per hour for OSA diagnosis, all of them presented OSA, average AHI of 45.31±26.3 per hour and 68.6% have severe OSA (AHI>30). The male patients had a higher AHI (p<0.05). There was a positive correlation between the positivity in both questionnaires as well as the severity of OSA measured by AHI (p<0.05). CONCLUSION: The frequency and severe obstructive sleep apnea in the studied group is high. The Berlin Questionnaire and Epworth Sleepiness Scale had a positive correlation with the diagnosis of OSA in the group studied.

Poliuretana de mamona (Ricinus communis) para desvio da crista tibial no cão

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Pure-transvaginal natural orifice transluminal endoscopic surgery (NOTES) ovariohysterectomy in bitches: a preliminary feasibility study

Cirurgia endoscópica por orifícios naturais (NOTES) constitui um acesso cirúrgico relativamente novo para abordagem minimamente invasiva, a qual vem sendo amplamente estudada na medicina humana. Porém, poucos estudos envolvendo sua aplicação na prática cirúrgica de pequenos animais foram realizados até o momento. O objetivo do presente estudo foi avaliar a factibilidade da ovário-histerectomia transvaginal por NOTES pura em cadelas. Cinco cadelas foram avaliadas. A cavidade abdominal foi acessada por um trocarte de 11mm introduzido por uma incisão vaginal. Empregando-se um endoscópio rígido com canal de trabalho, os pedículos ovarianos foram coagulados e seccionados usando-se diatermia bipolar. O corno uterino foi tracionado para o interior do trocarte e exteriorizado juntamente com a cânula. O corpo e vasos uterinos foram coagulados ou ligados com sutura. O coto uterino foi reposicionado na cavidade abdominal e o pneumoperitônio, drenado. O procedimento foi realizado com sucesso em quatro das cinco cadelas. Na primeira tentativa, houve conversão para uma técnica de NOTES-híbrida, devido à quebra de uma pinça de coagulação. O tempo cirúrgico médio foi 52,1 (DP±11,5 minutos) para a técnica de NOTES pura. A OHE por NOTES pura é factível em cadelas, sem resultar em complicações maiores e proporcionando excelente recuperação pós-operatória.

Efeito da implementação de diretriz para profilaxia de tromboembolismo venoso em pacientes cirúrgicos

INTRODUÇÃO: Estratégias efetivas para profilaxia do tromboembolismo venoso (TEV) são amplamente disponíveis, mas são ainda subutilizadas, principalmente no nosso meio. OBJETIVO: Avaliar o efeito da implementação de diretriz para profilaxia do TEV, em pacientes cirúrgicos, sobre a conduta da equipe de saúde na prescrição dessa profilaxia. Método. Estudo retrospectivo pré-intervenção - pós-intervenção. Prontuários de 150 pacientes antes e 150 depois da implementação de uma diretriz para a profilaxia (AID e DID) foram sorteados dentre pacientes de mais de 40 anos internados para cirurgia maior abdominal ou ortopédica. Foram registrados dados demográficos, referência a risco de TEV no prontuário, prescrição de profilaxia para TEV e diagnóstico de TEV durante a internação. RESULTADOS: Não houve diferença entre os dois grupos, AID e DID, quanto aos dados demográficos e ao tempo de profilaxia (5,6 x 6,6 dias). A frequência de profilaxia AID x DID antes da cirurgia foi: profilaxia farmacológica (PF), 6% x 9%; meias de compressão graduada (MCG), 4% x 3%; compressão pneumática intermitente (CPI), 2% x 3%. Após cirurgia: PF 53% x 53%; MCG, 23% x 40% (P<0,05); CPI, 26% x 32% . No total, AP, foi prescrita profilaxia para 60,5% dos pacientes AID e para 66,5% DID, mas a profilaxia foi considerada adequada em 34% dos pacientes AID e em 32% DID. Conclusão. A adoção do protocolo, embora com maior a preocupação com a profilaxia, traduzida pelo aumento na prescrição de MCG, melhorou minimamente sua qualidade, indicando a necessidade de outras intervenções ativas e contínuas para aumentar a aderência ao mesmo.

The Pediatric Rheumatology International Trials Organization American-College-of-Rheumatology provisional criteria for the evaluation of response to therapy in juvenile systemic lupus erythematosus: Prospective validation of the definition of improvement

Objective. To use the Pediatric Rheumatology International Trials Organization (PRINTO) core set of outcome measures to develop a validated definition of improvement for the evaluation of response to therapy in juvenile systemic lupus erythematosus (SLE).Methods. Thirty-seven experienced pediatric rheumatologists from 27 countries, each of whom had specific experience in the assessment of juvenile SLE patients, achieved consensus on 128 patient profiles as being clinically improved or not improved. Using the physicians' consensus ratings as the gold standard measure, the chi-square, sensitivity, specificity, false-positive and false-negative rates, area under the receiver operating characteristic curve, and kappa level of agreement for 597 candidate definitions of improvement were calculated. Only definitions with a kappa value greater than 0.7 were retained. The top definitions were selected based on the product of the content validity score multiplied by its kappa statistic.Results. The definition of improvement with the highest final score was at least 50% improvement from baseline in any 2 of the 5 core set measures, with no more than 1 of the remaining worsening by more than 30%.Conclusion. PRINTO proposes a valid and reproducible definition of improvement that reflects well the consensus rating of experienced clinicians and that incorporates clinically meaningful change in core set measures in a composite end point for the evaluation of global response to therapy in patients with juvenile SLE. The definition is now proposed for use in juvenile SLE clinical trials and may help physicians to decide whether a child with SLE responded adequately to therapy.

The Brazilian pediatric myelodysplastic cooperative group strategies: are they relevant to improve educational approach and correct diagnosis?

Brazil is a wide country with huge contrasts. Its peculiarities can highlight environmental factors that could influence the frequencies of different cancers. The standard treatment and results achieved from several different areas of the country may not be found in others. The establishment of a national cooperative group has the potential to improve outcomes. The The Brazilian Cooperative Group on Pediatric Patients with Myelodysplastic Syndrome (BCG-MDS-PED) was first organized in January 1997 as a working group of hematologists, pediatric oncologists, pediatric-hematologists, molecular biologists and other professionals in order to study pediatric (age < 18 years) MDS. Six distinct subcommittees constituted with members from several universities: cytology, histopathology, clinical, cytogenetics, molecular biology and epidemiology. The goals of the BCG-MDS-PED were: (i) to offer support for diagnosis and orientation for treatment; (ii) educational Support for the colleagues all over the country and (iii) research on pathogenesis and new approaches for pediatric MDS patients. There are socio-economical differences among the five regions of the country. The BCG-MDS-PED believes that it is absolutely necessary to Study the clinical, cellular, molecular and epidemiological aspects of MDS, taking in account these peculiar differences among populations and regions. Since 1997, 114 pediatric cases were referred to the BCG-MDS-PED from 21 centres. Seven Brazilian states have sent cases to the group, 31 patients were referred from universities, 73 patients from pediatric oncology units (foundations) and 10 patients came from private clinics. Some of these patients have been followed up and/or treated by the physician who referred them to the BCG-MDS-PED for confirmation of the initial diagnosis. The majority of these physicians have required orientation on diagnostic and treatment issues, as well as to complete cytogenetic and molecular studies. From these 114 patients, 64 patients were confirmed as MDS. We believe that, the more numerous the MDS-studied cases, the more experienced will be the referee group on clinical and laboratory features on childhood MDS in Brazil. (C) 2002 Published by Elsevier B.V. Ltd.

A single intraoperative sub-Tenon's capsule triamcinolone acetonide injection for the treatment of post-cataract surgery inflammation

Purpose: To compare a single intraoperative sub-Tenon's capsule triamcinolone acetonicle injection with steroid drops in the treatment of ocular inflammation after cataract surgery.Design: Randomized, double-masked controlled trial.Participants: A total of 100 patients were randomized prospectively into 2 groups: 50 patients treated with 1% prednisolone eyedrops (control group A) and 50 patients treated with sub-Tenon's capsule triamcinolone (treatment group B).Methods: All patients underwent phacoemulsification and intraocular posterior lens implantation. After surgery, patients were randomized to receive either (group B) an intraoperative 40 mg triamcinolone acetonicle sub-Tenon's capsule injection or (group A) 1% prednisolone acetate eyedrops, according to the following schedule: 1 drop 4 times daily (week 1), 3 times daily (week 2), 2 times daily (week 3), once daily (week 4). To mask the study, group B received vehicle drops administered on a similar schedule, and group A received an intraoperative sub-Tenon's capsule injection of a 1 ml balanced salt solution.Main Outcome Measures: the main outcome measures included inflammation (cell, flare, ciliary flush), intraocular pressure, and lack of response.Results: Triamcinolone was shown to have anti-inflammatory efficacy clinically equivalent to conventional 1% prednisolone eyedrops in reducing intraocular inflammation, as measured by clinical methods. Triamcinolone was found to be as safe as the prednisolone in terms of adverse effects, changes in visual acuity, intraocular pressure, and biomicroscopic and ophthalmoscopic variables. on the third, seventh, fourteenth, and twenty-eighth postoperative days, a significantly lower intraocular pressure (P<0.01) was noted in the triamcinolone group than in the prednisolone group.Conclusions: A single intraoperative 40-mg triamcinolone acetonide sub-Tenon's capsule injection demonstrated a clinically equivalent therapeutic response and ocular tolerance compared with 1% prednisolone drops in controlling postoperative inflammation after uncomplicated cataract surgery and merits further investigation. (C) 2004 by the American Academy of Ophthalmology.

Treatment of pediatric myelodysplastic syndromes and juvenile myelomonocytic leukemia: the Brazilian experience in the past decade

Background: Therapy strategies for myelodysplastic syndromes (MDS) and juvenile myelomonocytic leukemia (JMML) vary considerably. Objective: To review the treatment of Brazilian children who were diagnosed with MDS or JMML in the past decade and reported to the Brazilian Cooperative Group on Pediatric Myelodysplastic syndromes (BCG-MDS-PED). Results: of 173 children reported to the BCG-MDS-PED from January 1997 to January 2003 with a suspected diagnosis of MDS or JMML, 91 had the diagnosis confirmed after central review of the bone marrow aspirate and biopsy. Information on previous treatments was available for 78 MDS/JMML patients. Treatment varied from different schedules of low-dose (14%) and standard-dose chemotherapy (50%), granulocyte-colony-stimulating factor (G-CSF 7%), interferon (5%), steroids (2%) and erythropoietin (2%) to allogeneic stem-cell transplantation (SCT) (14%). No survival advantage could be demonstrated based on Hasle's classification or based on treatment. Conclusion: This report reflects the current practice in treating Brazilian children with MDS/JMML without specific Cooperative Group guidelines. Treatment modalities were very heterogeneous. The strategies for implementing a national protocol should consider international guidelines and focus on local experience and available resources. (C) 2004 Elsevier Ltd. All rights reserved.

Evaluation of the isoflurane-sparing effects of lidocaine and fentanyl during surgery in dogs

Objective-To evaluate the isoflurane-sparing effects of lidocaine and fentanyl administered by constant rate infusion (CRI) during surgery in dogs.Design-Randomized prospective study.Animals-24 female dogs undergoing unilateral mastectomy because of mammary neoplasia.Procedures-After premedication with acepromazine and morphine and anesthetic induction with ketamine and diazepam, anesthesia in dogs (n = 8/group) was maintained with isoflurane combined with either saline (0.9% NaCl) solution (control), liclocaine (1.5 mg/kg [0.68 mg/lb], IV bolus, followed by 250 mu g/kg/min [113 mu g/lb/min], CRI), or fentanyl (5 mu g/kg [2.27 mu g/lb], IV bolus, followed by 0.5 mu g/kg/min [0.23 mu g/lb/min], CRI). Positive-pressure ventilation was used to maintain eucapnia. An anesthetist unaware of treatment, endtidal isoflurane (ETiso) concentration, and vaporizer concentrations adjusted a nonprecision vaporizer to maintain surgical depth of anesthesia. Cardiopulmonary variables and ETiso values were monitored before and after beginning surgery.Results-Heart rate was lower in the fentanyl group. Mean arterial pressure did not differ among groups after surgery commenced. In the control group, mean +/- SD ETiso values ranged from 1.16 +/- 0.35% to 1.94 +/- 0.96%. Fentanyl significantly reduced isoflurane requirements during surgical stimulation by 54% to 66%, whereas the reduction in ETiso concentration (34% to 44%) observed in the lidocaine group was not significant.Conclusions and Clinical Relevance-Administration of fentanyl resulted in greater isoflurane sparing effect than did liclocaine. However, it appeared that the low heart rate induced by fentanyl may partially offset the improvement in mean arterial pressure that would be expected with reduced isoflurane requirements.