Tempo de latencia e duracao do efeito do brometo de rocuronio no paciente submetido ao transplante renal

Background and Objectives - Successful cadaver kidney transplantation relies on a fast procedure. Patients with chronic renal failure may present with a delayed gastric emptying making it critical a fast tracheal intubation and airway maintenance. Rocuronium a recently introduced nondepolarizing neuromuscular blocker with a fast onset. The aim of this study was to evaluate onset time and duration of rocuronium effects in patients undergoing renal transplantation. Methods - Sixty patients were allocated into two groups of 30: Group R (GR) = patients undergoing renal transplantation and Group N (GN) = patients with normal renal function. All patients were premedicated with oral midazolam (15 mg) and anesthesia was induced with 30 μg.kg-1 alfentanil, 0.3 mg.kg-1 etomidate and 0.6 mg.kg-1 rocuronium injected through a central venous catheter. neuromuscular block was monitored by acceleromyography in the ulnar nerve pathway. The following parameters were evaluated: time between administration of rocuronium and first twitch reduction to 5% after supra-maximal stimulation (T1) (onset time = OT); time for first twitch to return to 25% (clinical duration = R25); time elapsed between 25% and 75% recovery of first twitch (relaxation recovery time = R25-75). Heart rate (HR) and mean blood pressure (MBP) were recorded in 6 moments. Results - Median OT was 31 sec. in GR and 47 sec. in GN. Median R25 was 51.5 min in GR and 33.5 min in GN. Median R25-75 was 28 min in GR and 20 min in GN. MBP and HR were higher in GR. Tracheal intubation conditions were excellent for most patients in both groups. Conclusions - These results open the possibility of 0.6 mg.kg-1 rocuronium being injected through a central venous catheter when a faster onset is needed. Due to wide differences in individual responses, monitoring of neuromuscular block is recommended.

Identificação de Enterobacter spp. através de técnicas convencionais e do sistema semi-automatizado Microscan (Autoscan-4)

A hundred and ninety-five (195) strains of Enterobacter spp., isolated from diverse clinical specimens - urine, feces, cateter, blood, wound, tracheal aspirate, vaginal fluid - were submitted to the conventional identification by biochemical tests, and were also submitted to the identification by panels NegCombo 20 of the system automated MicroScan - AutoScan- 4 (Dade Behring Inc., West Sacramento, CA, USA). The samples were from patients of the Clinical Laboratory from the School of Pharmacy and Biochemistry of UNOESTE, Presidente Prudente, SP, and from patients hospitalized at the University Hospital Domingos Leonardo Cerávolo, UNOESTE. Of the total of strains tested, 191 (97.9%) presented agreement between the two approaches utilized and 4 strains (2.1%) presented identification disagreement, that is, the genus identified was different in each approach. By this study, the conclusion is that both the approaches utilized for the identification presented advantages and disadvantages related to the cost, facility of execution, quickness, reliability and some other characteristics. Even so, our results showed that conventional methods represent a reliable tool for Enterobacter identification.

The frequency of pharmacological pain relief in university neonatal intensive care units

Objective: To evaluate the use of drugs to relieve the pain of invasive procedures newborn infants cared for at a university hospital NICU. Methods: A prospective cohort study of all newborn infants hospitalized in four NICU during October 2001. The following data were collected: demographic data of the hospitalized newborn infants; clinical morbidity; number of potentially painful procedures and frequency of analgesic administration. Factors associated with the use of analgesia in this cohort of patients were studied by multiple linear regression using SPSS 8.0. Results: Ninety-one newborn infants were admitted to the NICU during the study period (1,025 patient-days). Only 25% of the 1,025 patient-days received systemic analgesia. No specific drugs were administered to relieve acute pain during any of the following painful events: arterial punctures, venous, capillary and lumbar punctures or intubations. For chest tube insertion, 100% of newborn infants received specific analgesia. For the insertion of central catheters 8% of the newborn infants received painkillers. Only nine of the 17 newborn infants that underwent surgical procedures received any analgesic dosage during the postoperative period. For 93% of patients under analgesia the drug of choice was fentanyl. The presence of mechanical ventilation increased the chance of newborn infants receiving painkillers by 6.9 times and the presence of chest tube increased this chance by five times. Conclusion: It is necessary to train health professionals in order to bridge the gap between scientific knowledge regarding newborn infant pain and clinical practice. Copyright © 2005 by Sociedade Brasileira de Pediatria.

Implantation sites after embryo transfer into the central area of the uterine cavity

A total of 63 pregnancies (47 singleton, 15 twin, 1 triplet) from intracytoplasmic sperm injection cycles were analysed. In all embryo transfers, the catheter was introduced into the endometrial cavity guided by abdominal ultrasound, with the catheter tip placed at the middle point of the endometrial cavity. Gestational sacs (GS) were located 21-24 days after transfer (gestational age = 5 weeks) by two-dimensional and three-dimensional transvaginal ultrasound. The uterine cavity was divided into three parts: upper, middle and lower. Furthermore, the upper region was subdivided into right, middle and left areas, and the middle region was subdivided into right and left areas. The frequency of gestational sacs in each area was evaluated. In singleton pregnancies 66.0% (31/47) of the GS were detected in the upper region, 29.8% (14/47) in the middle region and 4.2% (2/47) in the lower region. In multiple pregnancies (twins and triplet) 45.5% (15/33) of the GS were detected in the upper region, 51.5% (17/33) in the middle region and 3.0% (1/33) in the lower region. In conclusion, the results demonstrate that when embryos are transferred to the central area of the uterine cavity there is an increase in implantation rate in the middle region compared with the rate expected in naturally conceived pregnancies (9-15%).

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.

Risk-assessment algorithm and recommendations for venous thromboembolism prophylaxis in medical patients

The risk for venous thromboembolism (VTE) in medical patients is high, but risk assessment is rarely performed because there is not yet a good method to identify candidates for prophylaxis. Purpose: To perform a systematic review about VTE risk factors (RFs) in hospitalized medical patients and generate recommendations (RECs) for prophylaxis that can be implemented into practice. Data sources: A multidisciplinary group of experts from 12 Brazilian Medical Societies searched MEDLINE, Cochrane, and LILACS. Study selection: Two experts independently classified the evidence for each RF by its scientific quality in a standardized manner. A risk-assessment algorithm was created based on the results of the review. Data synthesis: Several VTE RFs have enough evidence to support RECs for prophylaxis in hospitalized medical patients (eg, increasing age, heart failure, and stroke). Other factors are considered adjuncts of risk (eg, varices, obesity, and infections). According to the algorithm, hospitalized medical patients ≥40 years-old with decreased mobility, and ≥1 RFs should receive chemoprophylaxis with heparin, provided they don't have contraindications. High prophylactic doses of unfractionated heparin or low-molecular-weight-heparin must be administered and maintained for 6-14 days. Conclusions: A multidisciplinary group generated evidence-based RECs and an easy-to-use algorithm to facilitate VTE prophylaxis in medical patients. © 2007 Rocha et al, publisher and licensee Dove Medical Press Ltd.

Ocorrência de infecção urinária em pacientes de um hospital universitário

Infection in hospitals is a serious problem for the Public Health System. It is responsible for the increasing number of hospital deaths, as well as the longer time patients may have to stay in hospital, raising the costs of confinement more and more. The most common hospital infection is urinary tract infections (UTI), the use of the urinary catheter being the main risk factor. The aim of this study was to evaluate the profile of UTI among hospitalized patients in a University Hospital in Brazil, from October to December 2003. Out of 271 samples of urine checked, 51 were positive, 27 of these from patients having community-acquired UTI and 24 whose infection originated in the hospital. The community-acquired UTIs were more frequent in female patients (63%). The highest incidence of infection was caused by Escherichia coli (74%), especially in patients aged from 0 to 15 (37%). The episodes of hospital-acquired infection happened, in the main, in male patients aged above 50 (68%) who were using a lasting vesical catheter; in this group of patients the infection was frequently caused by E. coli (29.1%) and Klebsiella spp. (29.1%). E. coli and Klebsiella pneumoniae exhibited strong resistance (62.5%) to trimethoprim-sulfamethoxazole, as well as to ampicillin, showing that these drugs should not be used to cure UTIs in this institution.

Detecção da produção de slime por estafilococos coagulase-negativa isolados de cateter venoso central

Slime production is an important virulence factor of coagulase-negative Staphylococcus spp., allowing them to attach to smooth surfaces of biomaterials, and it has been associated with infections of implanted medical devices. In the present study the production of slime capsules in 27 strains of coagulase-negative Staphylococcus was investigated by culture in Congo Red agar (77.7% positivity), spectrophotometric or microplate method (81.4% positivity) and scanning electron microscopy (88.9% positivity). The resistance of coagulase-negative strains of Staphylococcus to various antimicrobial agents was also determined by agar disk diffusion. The proportion of strains resistant to penicillin G, oxacillin, erythromycin, clindamycin and gentamicin among the slime-producing staphylococci was 88.9%, 70.4%, 81.5%, 66.7% and 59.2%, respectively; all of the coagulase-negative staphylococci were susceptible to vancomycin. The strains isolated from central venous catheters were identified by a conventional method and the API Staph system. The 27 coagulase-negative Staphylococcus strains were identified as: S. saprophyticus (3.7%), S. xylosus (7.4%), S. haemolyticus (14.8%), S. epidermidis (37.0%), S. warneri (14.8%), S. lugdunensis (7.4%), S. hominis (7.4%), S. schleiferi (3.7%) and S. chromogenes (3.7%). It can be concluded that in the most of the coagulase-negative Staphylococcus species there was an association between slime production, the nosocomial origin of the strains and reduced sensitivity to the antibiotics, suggesting a pathogenic potential in the hospital environment.

Aspirado traqueal de cavalos clinicamente sadios da raça quarto de milha após prova de três tambores

The aim of the present study was to evaluate through endoscopy the tracheal aspiration cytology in twenty seven Quarter Horses from Curitiba and surroundings, following the Three Barrel Competittion. Upper respiratory tract secretion was obtained by tracheal aspiration using a polyethylene catheter introduced through the endoscopic fiberoptic working channel, at the level of tracheal bifurcation. Cytologic slides were prepared by smear and stained by diff-quick technique and the differential was performed in 500 cells counting by 1,000X optic microscopy. None of the horses presented abnormality, including epixtasis, at the clinical examination. However, hemosiderophages were detected at cytology in three animals, suggesting that some may be suffering of subclinical pulmonary hemorrhage. Differential cell counting of tracheal aspiration results were, in average: 44.09 ± 35.68% of epithelial cells; 1.10 ± 2.18% of Globet cells; 23.10 ± 35.93% of neutrophils; 0.13 ± 0.37% of lymphocytes; 0.91 ± 2.81% of eosinophils; 30.57 ± 23.62% of macrophages and 0.13 + 0.93% of hemosiderophages. In conclusion, based in the present study, the evaluation of cellular populations with the tracheal aspiration may offer important additional information to the clinician, particularly about the inflammatory processes of lower respiratory tract and pulmonary bleeding.

Echocardiographic Doppler estimation of pulmonary artery pressure in critically ill patients with severe hypoxemia

BACKGROUND: In spontaneously breathing cardiac patients, pulmonary artery pressure (PAP) can be accurately estimated from the transthoracic Doppler study of pulmonary artery and tricuspid regurgitation blood flows. In critically ill patients on mechanical ventilation for acute lung injury, the interposition of gas between the probe and the heart renders the transthoracic approach problematic. This study was aimed at determining whether the transesophageal approach could offer an alternative. METHODS: Fifty-one consecutive sedated and ventilated patients with severe hypoxemia (arterial oxygen tension/fraction of inspired oxygen < 300) were prospectively studied. Mean PAP measured from the pulmonary artery catheter was compared with several indices characterizing pulmonary artery blood flow assessed using transesophageal echocardiography: preejection time, acceleration time, ejection duration, preejection time on ejection duration ratio, and acceleration time on ejection duration ratio. In a subgroup of 20 patients, systolic PAP measured from the pulmonary artery catheter immediately before withdrawal was compared with Doppler study of regurgitation tricuspid flow performed immediately after pulmonary artery catheter withdrawal using either the transthoracic or the transesophageal approach. RESULTS: Weak and clinically irrelevant correlations were found between mean PAP and indices of pulmonary artery flow. A statistically significant and clinically relevant correlation was found between systolic PAP and regurgitation tricuspid flow. In 3 patients (14%), pulmonary artery pressure could not be assessed echocardiographically. CONCLUSIONS: In hypoxemic patients on mechanical ventilation, mean PAP cannot be reliably estimated from indices characterizing pulmonary artery blood flow. Systolic PAP can be estimated from regurgitation tricuspid flow using either transthoracic or transesophageal approach. © 2008 American Society of Anesthesiologists, Inc.

Quantificação do interferon-tau durante o reconhecimento materno da gestação em fêmeas bovinas Bos taurus indicus

During the critical period of the maternal recognition, which occurs between days 15 and 19 of pregnancy, the conceptus must competently synthesize molecules capable of blocking the synthesis of prostaglandin F2α (PGF2α) and luteolysis. In cattle, the major macromolecule involved in suck blockage is the protein interferontau (IFN-τ). During the critical period, failures in the recognition of pregnancy determine embryonic mortality on up to 40% of inseminated cows. Data about IFN-τ in Bos taurus indicus are still scarce. Objective of this study was to quantitatively evaluate the presence of IFN-τ during the critical period for maternal recognition of pregnancy in uterine flushings obtained in vivo by Foley catheter (Days 14, 16 and 18 post estrus) or post-mortem (Day 18 post estrus). Multiparous, cyclic or pregnant zebu cows (Bos taurus indicus) on days 14, 16 and 18 post estrus were used for in vivo or post mortem uterine flushing collection. In both cases, a Ringer solution was used to wash the uterus of cows. Uterine flushings were concentrated by ultrafiltration and lyophilized. Proteins were separated by one-dimensional electrophoresis (SDS-PAGE) in a 15% polyacrilamide gel. Interferontau quantification in uterine flushings was performed by western blotting and densitometry. Non-specific protein bands were observed in both in vivo and post mortem uterine flushings. Interferon-tau was detected only in uterine flushings obtained from pregnant cows post-mortem (P<0.05). Optical density of protein bands was not affected by the day of the critical period, state (cyclic or pregnant) or interaction day x state. There was no effect of the conceptus weight or progesterone concentration on the day of uterine flushing collection in the optical density of the IFN-τ protein band. It was concluded that the detection and quantification of IFN-τ in the uterine environment of zebu cows, in these experimental?conditions, is only possible in uterine flushings obtained post-mortem.

O uso do pneumoperitônio progressivo no pré-operatório das hérnias volumosas da parede abdominal

Context - Correction of voluminous hernias and large abdominal wall defects is a big challenge in surgical practice due to technical difficulties and the high incidence of respiratory and cardiovascular complications. Objectives - To present the authors experience with inducing progressive pneumoperitoneum preoperative to surgical treatment of voluminous hernias of the abdominal wall. Methods - Retrospective study of six patients who presented voluminous hernias of the abdominal wall and were operated after installation of a pneumoperitoneum. The procedure was performed by placing a catheter in the abdominal cavity at the level of the left hypochondrium with ambient air insufflation for 10 to 15 days. Results - Four of the six patients were female and two male. Ages ranged from 42 to 62 years. Hernia duration varied from 5 to 40 years. Four patients had incisional, one umbilical, and one inguinal hernias. Mean pneumoperitoneum time was 11.6 days. There were no complications related to pneumoperitoneum installation and maintenance. All hernias were corrected without technical difficulties. The Lichtenstein technique was used to correct the inguinal hernia, peritoneal aponeurotic transposition for one of the incisional hernias, with the rest corrected using polypropylene mesh. One death and one wall infection were observed post operatively. No recurrences were reported until now, in 4 to 36 months of follow-up. Conclusion - Preoperative progressive pneumoperitoneum is a safe and easy executed procedure, which simplifies surgery and reduces post-operative respiratory and cardiovascular complications. It is indicated for patients with hernias that have lost the right of domain in the abdominal cavity.

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.