Dexmedetomidina e sufentanil como analgésicos per-operatórios: estudo comparativo

JUSTIFICATIVA E OBJETIVOS: A utilização das drogas agonistas dos alfa2-adrenoceptores para controlar a pressão arterial e freqüência cardíaca, propiciar menores respostas hemodinâmicas à intubação e extubação traqueal e poupar anestésicos já está difundida na literatura desde a introdução da clonidina. O desenvolvimento de agentes providos de maior seletividade alfa2-adrenoceptora que, por isso, determinam menos efeitos adversos, como a dexmedetomidina, recentemente liberada para utilização clínica, possibilitou que ocorressem maior sedação e analgesia com o seu uso. Despertou-se, então, o interesse em sua utilização como substitutos dos opióides, conhecidos por determinarem potente analgesia e sedação. O objetivo deste trabalho foi comparar a analgesia promovida pela dexmedetomidina e pelo sufentanil, utilizados em infusões contínuas durante anestesias de procedimentos otorrinolaringológicos e de cabeça e pescoço. MÉTODO: Os 60 pacientes estudados foram divididos em dois grupos de 30: G1, recebendo sufentanil e G2, dexmedeto- midina, na indução e manutenção anestésicas. Para a manutenção da anestesia utilizaram-se, também, o óxido nitroso e o propofol, em infusão contínua alvo-controlada. Foram avaliados os parâmetros hemodinâmicos (pressões arteriais sistólica e diastólica e freqüência cardíaca), tempos de despertar e de extubação após interrupção do propofol, locais onde foram extubados os pacientes, sala de operação (SO) ou sala de recuperação pós-anestésica (SRPA), tempo de permanência na SRPA, índice de Aldrete e Kroulik e as complicações apresentadas na SO e SRPA. RESULTADOS: G1 apresentou menores valores de pressões arteriais sistólica, diastólica e freqüência cardíaca, tempos de despertar e extubação maiores, maior número de extubações na SRPA, maior tempo de permanência na SRPA, valores mais baixos para Aldrete e Kroulik na alta da SRPA e mais complicações per e pós-operatórias. CONCLUSÕES: A utilização de dexmedetomidina como analgésico per-operatório apresentou melhores resultados que a de sufentanil, nos procedimentos selecionados neste trabalho, com relação à estabilidade hemodinâmica e às condições de despertar e de recuperação anestésica.

Fisioterapia respiratória e sua aplicabilidade no período pré-operatório de cirurgia cardíaca

Procedimentos cirúrgicos torácicos podem alterar a mecânica respiratória, repercutindo na função pulmonar. A presença de profissionais fisioterapeutas é fundamental no preparo e na reabilitação dos indivíduos que são submetidos à cirurgia cardíaca, visto que dispõem de um grande arsenal de técnicas. O objetivo foi verificar a efetividade de exercícios respiratórios, com e sem a utilização de dispositivos, e o treinamento muscular respiratório pré-cirurgia cardíaca na redução das complicações pulmonares pós-operatórias. Mesmo existindo controvérsias a respeito de qual técnica utilizar, estudos demonstram a eficácia da fisioterapia respiratória pré-cirúrgica na prevenção e na redução de complicações pulmonares pós-operatórias.

Removal of epulis fissuratum associated to vestibuloplasty with carbon dioxide laser

There have been numerous surgical techniques developed for removing the epulis fissuratum lesions in order to improve alveolar ridge contour and improving adaptation of full prostheses. Most of these techniques can cause postoperative complications, such as oedema, pain, difficulty in swallowing and jaw movements, haemorrhage, infections and slow placement of final prostheses. The use of carbon dioxide (CO2) laser for the surgical removal of epulis lesions has resulted in many significant improvements including convenient mucosa removal, no bleeding or need for sutures, and minimal postoperative pain and oedema. This study is of 15 cases of removal of extensive epulis with vestibuloplasty in the maxilla and mandible that was carried out with CO2 laser, with no postoperative complications, rapid healing, and excellent aesthetic and functional outcome, all of which allowed for more rapid placement of final prosthesis.

Arteriovenous fistula between the right internal mammary artery and the subclavian vein: percutaneous closure with detachable ballooncatheter embolization

A case of iatrogenic fistula from the right internal mammary artery to the subclavian vein following subclavian vein catheterization is reported. The patient had undergone percutaneous Intracath catheterization of the subclavian vein to treat hypovolemic shock during the surgical treatment of ectopic pregnancy. She had remained symptom-free for 7 years and then started to complain of effort dyspnea. The patient was found to have a thrill and a bruit at the subclavian region, and arteriography demonstrated a fistula between the right internal mammary artery and the subclavian vein. The fistula was successfully closed by embolization with a percutaneous detachable balloon catheter. © 1993.

Topical effect of propolis in the repair of sulcoplasties by the modified Kazanjian technique. Cytological and clinical evaluation.

A study was conducted to analyze the effects of propolis mouth rinse on the repair of surgical wounds after sulcoplasty by the modified Kazanjian technique. Twenty-seven patients who underwent sulcoplasty were divided into three groups: C1--patients who did not use the mouth rinse C2--patients who used a mouth rinse containing 5% aqueous alcohol T--patients who used a mouth rinse containing 5% propolis in aqueous alcohol solution. The patients returned 7, 14, 30, and 45 days after surgery for cytological and clinical evaluation. It was concluded that: 1) the mouth rinse containing propolis in aqueous alcohol solution aids repair of intra-buccal surgical wounds and exerts a small pain-killing and anti-inflammatory effect; 2) the vehicle employed has a minor irritant effect on intra-buccal surgical wounds; 3) exfoliative cytology allows epithelization of intrabuccal surgical wounds.

Transplante pancreato-duodenal em ratos com microcirurgia. A téchnica e os resultados após 12 anos de experimentação

In this study we present the technical details, adaptations and modifications of the original procedure of pancreaticoduodenal transplantation in rats described by Lee et al. in 1972. We also present the results and technical failures observed in a follow-up of 12 years. From March, 1982 to December, 1994, we performed in the Laboratory of Surgical Technique and Experimental Surgery of Faculty of Medicine, Botucatu - UNESP, Brazil, 665 duodenopancreatectomies in donor rats and 592 surgeries for revascularization of the pancreatic graft in recipient animals. The observed percentage of technical failures in donor rats was 11% due to bleeding and/or vascular complications, irregular flushing of the graft with saline and respiratory insufficiency. In recipients of grafts, we observed a percentage of technical failures of 22,5% due to porto-caval thrombosis, vascular bleeding, pancreatitis and graft ischemia. In both surgeries, the successful results are directly related to the technical performance of the surgeon and the cares in the postoperative period.

Preoperative combined with intraoperative skin-surface warming avoids hypothermia caused by general anesthesia and surgery

Study Objectives: To evaluate the effects of intraoperative skin-surface warming with and without 1 hour of preoperative warming, in preventing intraoperative hypothermia, and postoperative hypothermia, and shivering, and in offering good conditions to early tracheal extubation. Design: Prospective, randomized, blind study. Setting: Teaching hospital. Patients: 30 ASA physical status I and II female patients scheduled for elective abdominal surgery. Interventions: Patients received standard general anesthesia. In 10 patients, no special precautions were taken to avoid hypothermia. Ten patients were submitted to preoperative and intraoperative active warming. Ten patients were only warmed intraoperatively. Measurements and Main Results: Temperatures were recorded at 15-minute intervals. The patients who were warmed preoperatively and intraoperatively had core temperatures significantly more elevated than the other patients during the first two hours of anesthesia. All patients warmed intraoperatively were normothermic only at the end of the surgery. The majority of the patients warmed preoperatively and intraoperatively or intraoperatively only were extubated early, and none had shivering. In contrast, five unwarmed patients shivered. Conclusions: One hour of preoperative warning combined with intraoperative skin-surface warming, not simply intraoperative warming alone, avoided hypothermia caused by general anesthesia during the first two hours of surgery. Both methods prevented postoperative hypothermia and shivering and offered good conditions for early tracheal extubation. © 2003 by Elsevier B.V.

Azul de metileno no tratamento da síndrome vasoplégica em cirurgia cardíaca. quinze anos de perguntas, respostas, dúvidas e certezas

Objective: There is strong evidence that methylene blue (MB), an inhibitor of guanylate cyclase, is an excellent therapeutic option for vasoplegic syndrome (VS) treatment in heart surgery. The aim of this article is to review the MB's therapeutic function in the vasoplegic syndrome treatment. Methods: Fifteen years of literature review. Results: 1) Heparin and ACE inhibitors are risk factors; 2) In the recommended doses it is safe (the lethal dose is 40 mg/ kg); 3) The use of MB does not cause endothelial dysfunction; 4) The MB effect appears in cases of nitric oxide (NO) up-regulation; 5) MB is not a vasoconstrictor, by blocking of the GMPc system it releases the AMPc system, facilitating the norepinephrine vasoconstrictor effect; 6) The most used dosage is 2 mg/kg as IV bolus followed by the same continuous infusion because plasmatic concentrations strongly decays in the first 40 minutes; 7) There is a possible window of opportunity for the MB's effectiveness. Conclusions: Although there are no definitive multicentric studies, the MB used to treat heart surgery VS, at the present time, is the best, safest and cheapest option, being a Brazilian contribution for the heart surgery.

Orbitoethmoidal impacted injury by kitchen knife causing abducens nerve palsy

Introduction: Impacted knife injuries in the maxillofacial region are rare and infrequently reported. In cases of injury involving orbit or eye, these reports are even rarer. Discussion: Damage to the orbital contents may result in a rupture of the globe, extraocular muscle injury, lacrimal gland damage, and others. Orbital foreign bodies are not only difficult to detect, and clinical features vary according to its size, characteristics, shape, penetrating method, and site. In this report, a case of abducens nerve palsy after orbitoethmoidal knife injury is presented. © 2010 Springer-Verlag.

Unusually rapid growth of brown tumour in the mandible after parathyroidectomy associated with the presence of a supernumerary parathyroid gland

The aim of this study is to report the case of a quick growing brown tumour in the jaw after a parathyroidectomy due to the presence of a rare fifth parathyroid gland. The patient had chronic renal disease and the diagnosis was tertiary hyperparathyroidism. Thirty days after the parathyroidectomy, the patient returned with a significant increase in the tumour size. The suspicion of a supernumerary gland was confirmed by parathyroid scintigraphy. The treatment of brown tumour is dependent on the treatment of the hyperparathyroidism. However, curettage should be considered if a large lesion is disturbing mastication. In conclusion, this case should attract the attention of general practitioner dentists, since they may be the first professionals who have contact with the patient with a brown tumour in the jaws. Likewise, this case emphasises the importance of knowing the type of hyperparathyroidism involved to allow for effective treatment planning. © 2011 European Association for Cranio-Maxillo-Facial Surgery.

Combined therapy with mineral trioxide aggregate, and guided tissue regeneration for a large radicular cyst: A 13-year follow-up

Biomaterials such as membrane barriers and/or bone grafts are often used to enhance periapical new bone formation. A combination of apical surgery and these biomaterials is one of the latest treatment options for avoiding tooth extraction. In case of periapical lesions, guided tissue regeneration (GTR) is attempted to improve the self-regenerative healing process by excluding undesired proliferation of the gingival connective tissue or migration of the oral epithelial cells into osseous defects. In many cases, GTR is necessary for achieving periodontal tissue healing. This report describes the healing process after surgery in a challenging case with a long-term followup. In this case report, endodontic surgery was followed by retrograde sealing with mineral trioxide aggregate (MTA) in the maxillary right central incisor and left lateral incisor. Apicectomy was performed in the maxillary left central incisor and a 1-mm filling was removed. The bone defect was filled with an anorganic bone graft and covered with a decalcified cortical osseous membrane. No intraoperative or postoperative complications were observed. After 13 years of follow-up, the patient showed no clinical signs or symptoms associated with the lesion and radiographic examination showed progressive resolution of radiolucency. In conclusion, the combination of apical surgery and regenerative techniques can successfully help the treatment of periapical lesions of endodontic origin and is suitable for the management of challenging cases.

Anterior pericranial flap for frontal sinus duct obliteration: Is it a valuable resource?

Inappropriate treatments of frontal sinus fractures may lead to serious complications, such as mucopyocele, meningitis, and brain abscess. Assessment of nasofrontal duct injury is crucial, and nasofrontal duct injury requires sinus obliteration, which is often accomplished by autogenous grafts such as fat, muscle, or bone. These avascular grafts have an increased risk of resorption and infection and donor site morbidity. For these reasons, pericranial flap, which is vascular, should be used for frontal sinus obliteration. The pericranial flap presented with less morbidity procedure and has decreased infection rates, which justifies its use in frontal sinus obliteration. This study aimed to report a case of a comminuted frontal sinus fracture with a brief literature review, regarding the use of pericranial flap. The authors report a case of a 23-year-old male subject with a severely comminuted fracture of the anterior and posterior walls of the frontal sinus. The patient was successfully treated by cranialization with frontal sinus duct obliteration, using anterior pericranial flap. The patient was followed up for 16 months with no postoperative complication, such as infection. Pericranial flap is a good resource for frontal sinus duct obliteration because it is a durable and well-vascularized flap, which determines low rates of postoperative complications. Copyright © 2013 by Mutaz B. Habal, MD.

Modified radical mastectomy: A pilot clinical trial comparing the use of conventional electric scalpel and harmonic scalpel

Background: The aim of this study was to compare the rates of local postoperative complications among women undergoing modified radical mastectomy with an electric scalpel (ES) or a harmonic scalpel (HS). It is thought that HS use has less postoperative complications, mainly seroma formation. Methods: This study was a prospective non-randomised clinical trial (NCT01391988) among consecutive patients, performed in parallel. Patients underwent modified radical mastectomy using an HS or ES. We analysed the following operative variables: time, blood loss and seroma volume drainage. Postoperative complications, including seroma, flap necrosis, haematoma and infection were evaluated on the 7th and 14th days. Results: Forty-six patients underwent a MRM with ES and 49 with HS; no differences were observed between the groups. The rate of local complications was 29% in the HS group and 52% in the ES group (p=0.024). The rates of seroma (16.3% versus 28.3%; p=0.161), necrosis (4.1% vs. 21.7%; p=0.013; OR=0.15), haematoma (2.0% vs. 8.7%; p=0.195) and infection (2.0% vs. 6.5%; p=0.351) were lower in the HS group. Adding the findings of all comparative studies using HSs in MRM to the seroma rates in the current study, the seroma rate, expressed as a categorical variable, did not decrease with HS. Seroma was present in 60/219 cases using an HS and in 69/239 cases utilising an ES (p=0.72). Based on a multivariate analysis, HS decreased the risk of skin necrosis (p=0.015). Conclusions: HSs do not decrease the seroma rate. However, this method may be useful in skin sparing mastectomy because it decreases skin flap necrosis. © 2013 Surgical Associates Ltd.