Amputação interescapulotorácica sob anestesia locorregional

Forequarter amputations are an uncommon option for the treatment of upper limb and shoulder girdle tumors nowadays. This procedure can be done by different approaches and general anesthesia is commonly used. The authors report a case of forequarter amputation by the posterior approach performed for treatment of a soft-tissue sarcoma under a brachial plexus block associated with venous sedation and local anesthesia.

Does a previous surgical experience interfere on psychic stress in patients submitted to major surgery?

OBJECTIVE: to evaluate the impact of stress in patients undergoing major surgeries under general anesthesia, relating their physical and psychic reactions to the different stages of stress. METHODS: we studied 100 adult patients of both genders, who were divided into two groups: Group 1 - 22 patients without experience with surgery; Group 2 - 78 patients previously submitted to medium and major surgery. To investigate the stress, we used the Inventory of Stress Symptoms for Adults, developed by Lipp, the day before the procedure and two days and seven days after the operation. The comparison of groups with respect to gender, pain, and percentage of stress were performed using the Chi-square test, and for the age variable the Student's t test was used. Differences were considered significant at p<0.05. RESULTS: the groups were not homogeneous as for the overall percentage of stress on the three measurements. G1 had decreased postoperative stress, whilst in G2 it increased. Psychological symptoms of stress prevailed in both groups. CONCLUSION: previous surgery reduced preoperative stress but did not affect postoperative emotional disorders.

Management of stab wounds to the anterior abdominal wall

The meeting of the Publication "Evidence Based Telemedicine - Trauma and Emergency Surgery" (TBE-CiTE), through literature review, selected three recent articles on the treatment of victims stab wounds to the abdominal wall. The first study looked at the role of computed tomography (CT) in the treatment of patients with stab wounds to the abdominal wall. The second examined the use of laparoscopy over serial physical examinations to evaluate patients in need of laparotomy. The third did a review of surgical exploration of the abdominal wound, use of diagnostic peritoneal lavage and CT for the early identification of significant lesions and the best time for intervention. There was consensus to laparotomy in the presence of hemodynamic instability or signs of peritonitis, or evisceration. The wound should be explored under local anesthesia and if there is no injury to the aponeurosis the patient can be discharged. In the presence of penetration into the abdominal cavity, serial abdominal examinations are safe without CT. Laparoscopy is well indicated when there is doubt about any intracavitary lesion, in centers experienced in this method.

Implementation of a perioperative management protocol for patients undergoing orthopedic surgery

OBJECTIVE: To evaluate the initial results after the implementation of perioperative protocol in patients over 60 years of age undergoing surgical treatment for femur fractures.METHODS: We conducted a prospective study of patients older than 60 years who were hospitalized with femur fracture. They were operated under spinal anesthesia and analgesia by lumbar plexus blockade. Data evaluation was performed before arrival in the operating room during surgery, in the post-anesthesia recovery room and in the ward the next morning of the operation.RESULTS: 105 patients underwent various types of surgical corrections of the femur. The hospital stay ranged from three to 86 days. Fasting ranged from 9h15min to 19h30mn. Hypotension occurred in 5.7%. The duration of motor blockade ranged from 1h45min to 5h30imn. Maltodextrin feeding ranged from 50min to 3h45min and the time spent in the post-anesthetic care unit ranged from 50 minutes to 4 hours. Onset of oral intake in the ward ranged from 4hto 8h15min. The duration of anesthesia ranged from 14 to 33 hours. No patient required a urinary catheter, nor was transferred to the ICU. All patients were able to be discharged on the first postoperative day.CONCLUSION: The use of a protocol to accelerate the postoperative period may reduce the fasting time, length of hospital stay and provide faster i discharge n elderly patients with femur fractures.

Safety and tolerability of controlled-release oxycodone on postoperative pain in patients submitted to the oncologic head and neck surgery

Objective: To evaluate the safety and tolerability of controlled-release oxycodone in the treatment of postoperative pain of head and neck oncologic resections.Methods: We conducted a prospective, observational and open study, with 83 patients with moderate to severe pain after head and neck oncological operations. All patients received general anesthesia with propofol, fentanyl and sevoflurane. Postoperatively, should they have moderate or severe pain, we began controlled-release oxycodone 20 mg 12/12 b.i.d on the first day and 10 mg b.i.d. on the second. We assessed the frequency and intensity of adverse effects, the intensity of postoperative pain by a verbal numeric scale and the use of rescue analgesia from 12 hours after administration of the drug and between 7 and 13 days after the last oxycodone dose.Results: The most common adverse events were nausea, vomiting, dizziness, pruritus, insomnia, constipation and urinary retention, most mild. No serious adverse events occurred. In less than 12 hours after the use of oxycodone, there was a significant decrease in the intensity of postoperative pain, which remained until the end of the study. The rescue medication was requested at a higher frequency when the opioid dose was reduced, or after its suspension.Conclusion: Controlled release oxycodone showed to be safe and well tolerated and caused a significant decrease in post-operative pain.

Temporary abdominal closure with zipper-mesh device for management of intra-abdominal sepsis

OBJECTIVE: to present our experience with scheduled reoperations in 15 patients with intra-abdominal sepsis. METHODS: we have applied a more effective technique consisting of temporary abdominal closure with a nylon mesh sheet containing a zipper. We performed reoperations in the operating room under general anesthesia at an average interval of 84 hours. The revision consisted of debridement of necrotic material and vigorous lavage of the involved peritoneal area. The mean age of patients was 38.7 years (range, 15 to 72 years); 11 patients were male, and four were female. RESULTS: forty percent of infections were due to necrotizing pancreatitis. Sixty percent were due to perforation of the intestinal viscus secondary to inflammation, vascular occlusion or trauma. We performed a total of 48 reoperations, an average of 3.2 surgeries per patient. The mesh-zipper device was left in place for an average of 13 days. An intestinal ostomy was present adjacent to the zipper in four patients and did not present a problem for patient management. Mortality was 26.6%. No fistulas resulted from this technique. When intra-abdominal disease was under control, the mesh-zipper device was removed, and the fascia was closed in all patients. In three patients, the wound was closed primarily, and in 12 it was allowed to close by secondary intent. Two patients developed hernia; one was incisional and one was in the drain incision. CONCLUSION: the planned reoperation for manual lavage and debridement of the abdomen through a nylon mesh-zipper combination was rapid, simple, and well-tolerated. It permitted effective management of severe septic peritonitis, easy wound care and primary closure of the abdominal wall.

Comparative analysis of the frequency and the severity of diagnosed lesions between pedestrians struck by motor vehicles and other blunt trauma mechanisms victims

ABSTRACTObjective:to compare the frequency and the severity of diagnosed injuries between pedestrians struck by motor vehicles and victims of other blunt trauma mechanisms.Methods:retrospective analysis of data from the Trauma Registry, including adult blunt trauma patients admitted from 2008 to 2010. We reviewed the mechanism of trauma, vital signs on admission and the injuries identified. Severity stratification was carried using RTS, AIS-90, ISS e TRISS. Patients were assigned into group A (pedestrians struck by motor vehicle) or B (victims of other mechanisms of blunt trauma). Variables were compared between groups. We considered p<0.05 as significant.Results:a total of 5785 cases were included, and 1217 (21,0%) of which were in group A. Pedestrians struck by vehicles presented (p<0.05) higher mean age, mean heart rate upon admission, mean ISS and mean AIS in head, thorax, abdomen and extremities, as well as lower mean Glasgow coma scale, arterial blood pressure upon admission, RTS and TRISS. They also had a higher frequency of epidural hematomas, subdural hematomas, subarachnoid hemorrhage, brain swelling, cerebral contusions, costal fractures, pneumothorax, flail chest, pulmonary contusions, as well as pelvic, superior limbs and inferior limbs fractures.Conclusion:pedestrian struck by vehicles sustained intracranial, thoracic, abdominal and extremity injuries more frequently than victims of other blunt trauma mechanism as a group. They also presented worse physiologic and anatomic severity of the trauma.

Video assisted resections. Increasing access to minimally invasive liver surgery?

Objective: To evaluate perioperative outcomes, safety and feasibility of video-assisted resection for primary and secondary liver lesions. Methods : From a prospective database, we analyzed the perioperative results (up to 90 days) of 25 consecutive patients undergoing video-assisted resections in the period between June 2007 and June 2013. Results : The mean age was 53.4 years (23-73) and 16 (64%) patients were female. Of the total, 84% were suffering from malignant diseases. We performed 33 resections (1 to 4 nodules per patient). The procedures performed were non-anatomical resections (n = 26), segmentectomy (n = 1), 2/3 bisegmentectomy (n = 1), 6/7 bisegmentectomy (n = 1), left hepatectomy (n = 2) and right hepatectomy (n = 2). The procedures contemplated postero-superior segments in 66.7%, requiring multiple or larger resections. The average operating time was 226 minutes (80-420), and anesthesia time, 360 minutes (200-630). The average size of resected nodes was 3.2 cm (0.8 to 10) and the surgical margins were free in all the analyzed specimens. Eight percent of patients needed blood transfusion and no case was converted to open surgery. The length of stay was 6.5 days (3-16). Postoperative complications occurred in 20% of patients, with no perioperative mortality. Conclusion : The video-assisted liver resection is feasible and safe and should be part of the liver surgeon armamentarium for resection of primary and secondary liver lesions.

Resultados neonatais no parto vaginal espontâneo comparados aos dos partos com fórcipe de Simpson-Braun em primíparas

OBJETIVO: comparar os resultados neonatais dos partos vaginais espontâneos ou assistidos com fórcipe de Simpson-Braun em nulíparas. MÉTODO: em estudo de corte retrospectivo foram avaliados dois grupos de primíparas atendidas no Centro Obstétrico do CAISM/UNICAMP, que tiveram parto vaginal sob analgesia epidural. O grupo fórcipe foi formado por 119 pacientes que tiveram parto a fórcipe de Simpson-Braun, e o grupo normal por 114 casos de parto vaginal espontâneo. Foram estudadas as variáveis neonatais imediatas como o estado do líquido amniótico e os índices de Apgar, assim como a evolução neonatal nos primeiros dias de vida. Para análise estatística foram utilizados os testes c², exato de Fisher e t de Student para comparação de médias e considerada significativa a diferença correspondente a p<0,05. RESULTADOS: as indicações para uso do fórcipe Simpson-Braun foram: alívio materno-fetal (90 casos) e abreviação de período expulsivo (29 casos). Nas pacientes atendidas com fórcipe Simpson-Braun houve 8 casos de laceração de canal de parto (6,7%), valor semelhante ao observado no grupo de parto vaginal espontâneo. As médias de dias de internação das puérperas e neonatos foram idênticas (2,4). Os dois grupos foram semelhantes quanto aos índices de Apgar menores que 7 no primeiro (7,5 e 4,3%) e quinto minuto (1,6 e 1,7%) e quanto ao peso dos recém-nascidos (3.146 e 3.016 g). A evolução neonatal foi semelhante nos dois grupos. CONCLUSÃO: o uso do fórcipe de Simpson-Braun mostrou-se seguro, quando comparado ao parto vaginal espontâneo.

Transferência placentária de drogas

Grávidas podem depender do uso de medicações para minimizar os agravos da doença preexistente. A gravidez, por si só, pode causar situações que comprometem o bem-estar materno, como náuseas e vômitos, as quais necessitam de tratamento. O obstetra deve estar atento à transferência placentária de drogas e à exposição do feto a agentes teratogênicos ou tóxicos, que podem comprometer o seu desenvolvimento ou mesmo sua vida futura.O transporte através da placenta envolve o movimento de moléculas entre três compartimentos: sangue materno, citoplasma do sinciciotrofoblasto e sangue fetal. Esse movimento pode ocorrer pelos seguintes mecanismos: difusão simples, difusão facilitada, transporte ativo, bombas classe P, V, F e grande família ABC e endocitose. Com o uso de anticonvulsivantes a incidência de malformações maiores em recém-nascidos expostos é de 4 a 6%, comparado com 2 a 4% na população geral. A politerapia é mais lesiva, especialmente se o ácido valpróico e a hidantoína fazem parte da associação. Para as pacientes epilépticas clinicamente assintomáticas há dois anos recomenda-se a suspensão da drogas em uso, porém se apresentam crises, torna-se prudente consultar neurologista para discussão da terapia anticonvulsivante com melhores benefícios e menores efeitos colaterais. Os anestésicos locais e os opióides são largamente utilizados durante a resolução da gestação. A lidocaína utilizada como anestésico por via perineal para episiotomia, na dose fixa de 400 mg, apresenta alta concentração plasmática materna e alta taxa de transferência placentária no momento do nascimento, que vem alertar para o cuidado no uso de doses repetidas. A bupivacaína administrada por via epidural representa anestésico seguro, apresentando-se na forma racêmica e com transferência placentária em torno de 30%. A fentanila, anestésico opióide, utilizado por via epidural na resolução por cesariana, na dose fixa de 0,10 mg, apresenta alta taxa de transferência placentária, da ordem de 90%, o que vem alertar para cautela no uso de doses repetidas em analgesia durante o trabalho de parto.

Bloqueio combinado raquiperidural versus bloqueio peridural contínuo para analgesia de parto em primigestas: resultados maternos e perinatais

OBJETIVOS: comparar a evolução materna e perinatal após a utilização da analgesia peridural contínua versus analgesia combinada raqui-peridural em parturientes primigestas. MÉTODOS: foi realizado ensaio clínico aleatorizado com 128 gestantes primigestas em trabalho de parto, divididas em dois grupos: analgesia peridural (APC) com 65 mulheres e grupo analgesia combinada raqui-peridural (ACRP) com 63, admitidas no pré-parto de duas maternidades na cidade de Jundiaí - SP. Foram estudadas as variáveis: tempo de latência de instalação da analgesia, intensidade da dor e tempo total decorrido até a dilatação completa, índice de Apgar no primeiro e quinto minutos, tempo de resolução do parto, grau de bloqueio motor, efeitos adversos como náuseas, vômitos, prurido, hipotensão arterial, e grau de satisfação materna. Foram critérios de inclusão: primigestas, estado físico ASA 1 e 2, feto único, apresentação cefálica, de termo, dilatação cervical de 3 a 6 cm e solicitação de analgesia pelo obstetra. Foram excluídas mulheres com morbidades, ruptura de membranas, anormalidades fetais e uso de opioides até quatro horas antes. Para a análise estatística utilizou-se o teste de Mann-Whitney para as variáveis contínuas não paramétricas e os testes exato de Fisher e χ2 de Pearson, para variáveis categóricas. RESULTADOS: não houve diferença entre os grupos para velocidade de dilatação cervical, tempo para resolução do parto, parâmetros hemodinâmicos maternos, vitalidade do recém-nascido, complementações analgésicas durante o trabalho de parto e modo de parto. Houve maior rapidez de instalação da analgesia no grupo da ACRP e menor bloqueio motor no grupo de APC. Não foram observadas diferenças em relação aos efeitos adversos como náuseas, vômitos, prurido e hipotensão, sendo hipotensão mais frequente no grupo APC (16,9 versus 6,3%) e náusea no grupo ACRP (6,3 versus 3,1%). CONCLUSÕES: as duas técnicas mostraram-se seguras e eficientes, porém a ACRP ofereceu analgesia mais rápida, com alívio precoce da dor. O bloqueio motor menos intenso no grupo APC proporcionou movimentação mais ativa no leito e colaboração mais efetiva das gestantes durante o período expulsivo. A grande maioria das mulheres referiu satisfação com a analgesia recebida. As doses de anestésicos locais e opioides utilizadas em ambas as técnicas analgésicas e as doses complementares, iguais nos dois grupos, não produziram efeitos adversos maternos significativos ou alteraram a vitalidade dos recém-nascidos.

Embolização de mioma uterino em mulheres portadoras de miomas volumosos

OBJETIVO: avaliar a eficácia da embolização de mioma uterino (EMUT) em pacientes com miomas volumosos no que diz respeito tanto à evolução clínica quanto à redução do tamanho dos mesmos. MÉTODOS: vinte e seis pacientes com média etária de 36,5 anos, portadoras de miomas uterinos sintomáticos com volume acima de 1.000 cm³, foram submetidas à EMUT. Todas possuíam indicação para tratamento percutâneo. Os procedimentos foram realizados sob anestesia epidural e sedação, empregando-se protocolo institucional de analgesia. Após punção femoral unilateral, foi realizado o cateterismo seletivo das artérias uterinas e infusão de microesferas calibradas por meio de microcateter. A avaliação clínica pós-procedimento foi realizada em ambulatório de ginecologia segundo o protocolo de atendimento. Todas as pacientes tinham ressonância nuclear magnética (RNM) antes do procedimento e 15 pacientes RNM de controle após 6 meses. RESULTADOS: o sucesso técnico foi de 100%. Não houve complicação relacionada aos procedimentos. A média de volume uterino das 15 pacientes foi 1.401 cm³ antes da embolização (min. 1.045 cm³, max. 2.137 cm³) e, após 6 meses 799 cm³ (min. 525 cm³, max. 1.604 cm³), constituindo uma redução média de 42,9%. A melhora clínica foi constatada em 25 das 26 pacientes. Uma paciente com útero de 1.098 cm³ apresentou necrose e expulsão parcial do mioma, sendo submetida à miomectomia. Outra paciente foi submetida à miomectomia após seis meses devido ao desejo de gravidez, apesar da redução parcial do volume dos miomas. Uma paciente com volume uterino de 2.201 cm³ necessitou de segunda intervenção para alcançar um resultado adequado. Nenhuma paciente foi submetida à histerectomia. Foram utilizadas em média 9,2 seringas de microesferas por paciente. CONCLUSÃO: a embolização de miomas uterinos de grande volume é um procedimento factível, com aceitáveis resultados clínico e radiológico. Pode ser considerada uma opção para as pacientes que desejam a preservação uterina e também servir como terapêutica adjuvante à miomectomia de alto risco.

Análises histológica e morfométrica do uso de membrana biossintética de celulose em trocleoplastia experimental de cães

O objetivo deste trabalho foi avaliar a aplicação de membrana biossintética de celulose, de fabricação nacional, após a realização da trocleoplastia experimental, com intuito de verificar se o uso desta poderia favorecer a migração de células com potencial condrogênico. Foram utilizados 12 cães adultos, de ambos os sexos, sadios e sem alterações no aparelho locomotor. Os animais foram submetidos ao procedimento de trocleoplastia em ambos os membros pélvicos, após tranquilização e anestesia epidural. Na trocleoplastia do membro esquerdo foi aplicada membrana biossintética à base de celulose (grupo tratado, GT), fixada à cartilagem por meio de pontos simples separados com Poliglactina 910 6-0; no membro direito, foi realizada apenas a trocleoplastia, constituindo o grupo controle (GC). Os animais foram subdivididos em quatro subgrupos de acordo com o período final de avaliação aos 15, 30, 60 e 90 dias do pós-operatório. Após artrotomia exploratória nos momentos pré-estabelecidos, foi realizada biópsia da região da trocleoplastia para avaliação histológica e morfométrica do tecido de reparação. Aos 30 e 60 dias do pós-operatório, notou-se a presença de maior número de células semelhantes a condrócitos nas lesões tratadas com celulose em relação ao membro contra-lateral, apesar do aspecto imaturo. Aos 90 dias, o tecido de reparação era do tipo fibrocartilaginoso maduro, não havendo diferenças entre os dois grupos. No GC houve aumento progressivo do número de células até o período final de avaliação. Por outro lado no grupo tratado verificou-se que, em relação ao período inicial (15 dias), houve aumento do número de células até os 60 dias, com subseqüente retorno aos valores iniciais aos 90 dias. Dos 15 aos 60 dias o número de células foi maior no GT em relação ao GC. Inicialmente, o tecido de reparação neoformado foi mais espesso no grupo tratado. Dessa forma, conclui-se que a membrana de celulose acelerou o processo de reparação tecidual inicial da região da trocleoplastia, apresentando boa integração do tecido neoformado com a cartilagem adjacente.

Effects of laparoscopy on the cardiorespiratory system of brown brocket deer (Mazama gouazoubira) anesthetized with ketamine/ xylazine/ midazolam combination and isoflurane

Laparoscopy is not widely used as a tool to perform assisted reproduction techniques in South American cervids; thus, scarce information in literature is available regarding its effects and appropriate anesthetic protocols to perform it. This study evaluated the effect of laparoscopy on heart rate (HR), respiration rate (RR), saturation of oxyhemoglobin (SpO2) and rectal temperature (RT) of six female brown brocket deer (Mazama gouazoubira) anesthetized with ketamine (5mg/kg), xylazine (0.3mg/kg), midazolam (0.5mg/kg) combination i.v. and isoflurane. Twelve laparoscopies were performed and each animal was used twice with a 40-day interval. After anesthetized, the animals were placed in dorsal recumbency to perform laparoscopy procedure using abdominal CO2 insufflations (14.2 ± 2.39mmHg; M ± SE). The main events of the laparoscopy procedure were divided into three periods: animal without (P1) and with abdominal insufflation (P2) and abdominal insufflation with the hips raised at 45º (P3). As a control, the animals were anesthetized again 40 days after the last laparoscopy, and were maintained in a dorsal recumbency for the same average duration of the previous anesthesia and no laparoscopy procedure was conducted. The period of anesthesia for the controls was also divided into P1, P2, and P3 considering the average duration of these periods in previous laparoscopies performed. Data were analyzed through the (ANOVA) variance analysis followed by Tukey test and values at P<0.05 were considered significant. No significant differences were observed in the parameters evaluated at P1, P2 and P3 between the animals submitted to laparoscopy and control. However, the RR mean between P1 (38.8 ± 4.42) and P3 (32.7 ± 4.81); and the RT mean between the P1 (38.2ºC ± 0.17), P2 (37.6ºC ± 0.19) and P3 (37.0ºC ± 0.21) varied significantly, independent of the laparoscopy. These data indicated that laparoscopy didn't cause any significant alterations in the cardiorespiratory parameters evaluated, even though the anesthetic protocol used can cause a reduction in the RT contributing to development of hypothermia during anesthesia.

Interference of age and repetition of the same noxious stimulus on hyperalgesia

Pain in animals has been recognized for less than one century. Several authors confirm that animals are capable to process, register and modulate nociceptive stimuli in a very similar way to human kind and there are several evidences registering the impact of pain sensation over vital systems interfering on disease outcome. Nevertheless, despite some evidences that animals, as human beings, can store information from past painful experiences less is known about how this so called pain memory works. The aims of this study were: to evaluate if the response to a painful stimuli differs during different stages of life and if repetition of a same acute stimuli in the same animal interferes with expression of hyperalgesia. Thus, 60 rats were selected and arranged in 3 equal groups: 3 months, 6 months, and 9 months of age. All animals were injected 5% formalin solution in the plantar face of hind paw under volatile general anesthesia. Von Frey filaments were applied at 1h, 24h and 48h after sensitization. Injection was repeated twice with a 30-day interval, each time in a different hind paw. Results showed that younger rats express lower hyperalgesia thresholds in the first stimulation compared to elder animals and that repetition of same stimulus diminishes hyperalgesia thresholds when it begins during infant period and augments hyperalgesia thresholds when it begins during elder ages.