Parada cardíaca inesperada durante colecistectomia: relato de caso

JUSTIFICATIVA E OBJETIVOS: A parada cardíaca per-operatória é um evento grave, e sua incidência em nosso serviço é de 31:10.000 anestesias. O objetivo deste relato é apresentar um caso de parada cardíaca durante anestesia geral em uma paciente submetida a colecistectomia. RELATO do CASO: Paciente feminina, 16 anos, 62 kg, estado físico ASA I, submetida à colecistectomia por via aberta. Midazolam (15 mg) por via oral foi a medicação pré-anestésica. Foi realizadas indução anestésica com sufentanil (50 µg), propofol (150 mg) e atracúrio (30 mg). A anestesia foi mantida com isoflurano e N2O. Após trinta minutos de cirurgia ocorreu bradicardia sinusal revertida com atropina (0,5 mg). Vinte minutos depois, ocorreu outra bradicardia com bloqueio átrio-ventricular de 3º grau evoluindo rapidamente para parada cardíaca (PCR) em assistolia, apesar da administração de atropina (1 mg). As manobras de reanimação foram iniciadas imediatamente, juntamente com a administração de adrenalina (1 mg), com retorno dos batimentos cardíacos espontâneos após aproximadamente cinco minutos da PCR. A cirurgia foi concluída e a paciente manteve-se estável hemodinami- camente. A paciente foi extubada duas horas após o término da cirurgia apresentando-se sonolenta, não contactante, com bom padrão ventilatório e hemodinâmico. Após doze horas de observação na unidade de terapia intensiva (UTI) a paciente apresentava-se agitada e desconexa. Vinte e quatro horas após a PCR a paciente recebeu alta da UTI consciente, orientada, sem queixas e sem déficit neurológico. Recebeu alta hospitalar no 4º dia do pós-operatório. CONCLUSÕES: Diversos fatores podem contribuir para a ocorrência de disritmias e parada cardíaca no per-operatório, destacando-se a estimulação vagal secundária às manobras cirúrgicas. O diagnóstico precoce e o rápido início das manobras de reanimação são de fundamental importância para a boa evolução neurológica desses pacientes

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.

Disfunção arterial como possível mecanismo de agressão cardíaca em pacientes com diabetes mellitus tipo II. Estudo Doppler-ecocardiográfico

OBJETIVO: Avaliar a estrutura e função do ventrículo esquerdo (VE) e a rigidez arterial em portadores de diabetes mellitus tipo II. MÉTODOS: Foram estudados 13 doentes diabéticos de ambos os sexos (55±8 anos) sem outras doenças. A estrutura e função do VE foram avaliadas por meio de ecodopplercardiografia associada à monitorização não invasiva da pressão arterial (PA). Os resultados foram comparados aos obtidos em grupo de indivíduos normais de mesma idade (n=12). RESULTADOS: Não houve diferenças entre os grupos quanto a PA diastólica, dimensões das câmaras esquerdas e índices de função sistólica e diastólica. Os pacientes diabéticos apresentaram índice de massa do VE (101±10 vs 80±14g/m²; p<0,001) e índice de rigidez arterial sistêmica (0,86±0,26 vs 0,69±0,19mmHg/mL; p<0,05) significantemente maiores que os controles. CONCLUSÃO: O diabetes mellitus está associado a aumento da rigidez arterial sistêmica e esse fator poderia contribuir para seus efeitos adversos sobre o VE.

Estudo Comparativo de Juntas Soldadas a TIG e Laser Empregando-se Ti com Pureza Comercial Utilizado em Prótese sobre Implantes

Welding in the dentistry has been used for great part of the specialized dentist-surgeons in the implants area to solve prosthesis supported by implant adaptation problems. The development of new equipments Laser and TIG allowed a larger use of these processes in the prosthesis production. In this work, it was studied welded joints made by Laser and TIG, using commercial purity titanium, cpTi, applied in prosthesis supported by implants. The weld characterizations were carried out by light microscopy, EDS_elementary mapping, microhardness and tensile test. Through metallographic characterization, the weld bead presented a martensitic microstructure in the Laser welding process, originated from shear provoked by deformations in the lattice. This caused structural changes of the transformed area, which determines a fine plate-like morphology. In the weld bead from TIG, besides presenting higher hardness, was observed formation of Widmansttaten structure, which is characteristic of a geometric model, resulted of new phase formation along of the crystallographic plans. The martensitic structure is more refined than Widmansttaten structure, due to the high-speed cooling (10(3)degrees C/s) imposed by the Laser process.

Músculo esquelético, insuficiência cardíaca crônica e o papel do exercício

Patients with chronic heart failure (CHF) show metabolic, hemodynamic and skeletal muscle alterations, which decrease the life expectancy. These alterations are attributed to several factors. The focus of this review was to approach the questions related to physiological, metabolic, morphological and molecular alterations which affect the muscular system of these patients. Later, it was discussed the benefits of physical exercise to this syndrome as well as the pharmacological interventions, which are in investigation aiming the treatment of the same. Some muscle alterations are already described on the literature. For example, the more predominance of type II fibers, lower oxidative enzymatic activity, muscle atrophy and elevated concentration of cytokines that affect the muscle integrity. Thus, further studies involving cellular and molecular mechanisms of skeletal muscle in order to create strategies for prevention and treatment for patients with CHF are required

Fadiga de grampos de retenção em prótese parcial removível. Efeito de ligas, espessuras e técnicas de fusão. Parte I.

The authors looked for the verification of the fatigue of retentive clasps utilized on the removable partial denture. According to this, it was idealized and built on assay machine, that through movements, simulate the insertion and removal of the clasp for a pattern tooth, manufactured on cobalt-chromium which has all the preparation normally utilized to the correct confection of this type of prosthesis. It was utilized three different commercial alloys based on cobalt-chromium: L1-Biosil; L2-Steldent; L3-Duracron. It was utilized the T clasp of Roach, with was tested upon three different proportions among width and thickness: E1-1.7;E2-2.0 and E3-2.3 and was casted through two casting techniques: F1-oxygen-gas and F2-oxygen-acetylene. The clasps were tested on the machine, which allowed the reading of the number of insertion and removal cycles made until fatigue appeared. The obtained results were submitted to the statistic analysis and the authors concluded that: a) L3 (Duracrom) obtained the best results followed by L1 (Biosil) and finally L3 (Steldent); b) among the analyzed thickness, the best results were obtained by E3, followed by E2 and after this E1; c) form the casting techniques, F2 gave us the best results.

Fadiga de grampos de retenção em prótese parcial removível. Efeito de ligas, espessuras e técnicas de fusão. Parte II.

The authors tested the T clasp of Roach in three differents proportions among width and thickness: E1-1.7; E2-2.0 and E3-2.3, with a constant length of 15 mm. These clasps were casted with three cobalt-chromium alloys (L1-Biosil; L2-Steldent and L3-Duracrom), through two casting techniques (F1-oxygen-gas and F2-oxygen-acetylene). The fatigue of the clasps were verified by using and assay machine, that through movements, simulate the insertion and removal of the clasps for a pattern which were obtained from a premolar, prepared in a surveyor. This machine detect the fatigue of the clasps and count the number of cycles of insertion and removal realized. The obtained results of the interaction between the analysed factors, were submitted to the statistic analysis and the authors concluded that: a) the interaction of factors, Alloy x Thickness, Alloy x Casting Technique and Thickness x Casting Technique did not change the order of effects that the factors showed separately but gave rise to effects of different magnitude for any observed sense; b) the simultaneous interaction of the factors Alloy x Thickness x Casting Technique confirmed the superiority of the L3 alloy, the thickness E3 and the F2 casting technique.

A influência da perfusão cardíaca nas relações pressão/volume do ventrículo esquerdo.

PURPOSE--To analyze the influence of the myocardial engorgement due to coronary perfusion on the left ventricular diastolic pressure/volume (P/V) relations. METHODS--The study was undertaken in the isovolumic blood-perfused dog heart preparation (n = 7). The P/V relations were determined promoting ventricular volumes variations by steps of 2ml, in two conditions: during coronary perfusion pressure of 100mmHg and after occlusion of the perfusion line. RESULTS--It was verified that the P/V relations obtained without myocardial perfusion shifted to the down right in respect to the perfused heart. A exponential fitting of the P/V relations allows to conclude that there was no difference among the slopes of the curves obtained with and without perfusion. CONCLUSION--Our results indicated that coronary perfusion restrain the capacity of the left ventricle to receive blood, but there is no influence on the passive elastic stiffness of the chamber. This effect was taught to be consequence of the myocardial erectile property.

Participação do Estado Contrátil e do Relaxamento Miocárdico na Disfunção Ventricular durante a Transição Hipertrofia-Falência Cardíaca

Purpose - To investigate the participation of contractile state and relaxation in cardiac muscle dysfunction during the transition from stable hypertrophy to cardiac decompensation in aging spontaneously hypertensive rats (SHR). Methods - isolated left ventricular papillary muscle function was studied in SHR with heart failure (SHR-F), in age-matched SHR without evidence of heart failure (SHR-NF), and in nonhypertensive controls Wistar-Kyoto rats (WKY). Muscles were analised in isometric and isotonic contractions in Krebs-Henseleit solution with calcium concentration of 1.25mM at 28°C. Results - Papillary muscles from SHR-F and SHR-NF demonstrated decreased active tension development and shortening velocity relative to normotensive WKY (p<0.05). SHR-F and SHR-NF did not differ. Compared with SHR-NF and WKY, muscle passive stiffness was increased in the failing SHR (p<0.05 versus WKY and SHR-NF). This parameter did not differ between SHR-NF and WKY (p> 0.05). Conclusion - These data suggest that the progression from stable hypertrophy to heart failure is associated with changes in the passive stiffness and is not related to depression of myocardial contractile function.

Formulário do perfil psicossocial do paciente anoftálmico com indicação de prótese ocular

The patient with anophthalmia may present feelings of inferiority and rejection. Knowing his/her needs and expectations contribute to a better technical intervention. Purpose: To elaborate a questionnaire of the psychosocial profile of the patient with anophthalmia with indication of ocular prosthesis. Methods: An exploratory research was used to elaborate the questionnaire, by means of a guided interview followed by writing down what was said by the interviewees, who were adult patients of the Bucco-Maxillo-Facial Prosthesis Center of FOSJC - UNESP. The guided interview was made up of 14 items directly related to the future outline of the profile. Each item of the interview resulted in questions of the questionnaire, which was pretested twice before reaching its final version. Results: The patients reported, in the exploratory research, unpleasant feelings with the loss of the eye; relationship shyness; expectations regarding surgery and prosthesis use; a wish to receive explanations and to hold their opinion about the treatment. The questionnaire of the psychosocial profile of the patient with anophthalmia with indication of ocular prosthesis is, therefore, made of 43 questions divided into 5 blocks in order to aid the comprehension of the inquired aspects and to facilitate both the computation of data and discussion, and also to improve the selection of questions according to the objective of the researcher or professional. Conclusions: It was concluded that the questionnaire was viable, can be used in full or by selecting blocks and provide a panorama of the patient's history related to the problem he/she faces, from the loss of the ocular globe to the confection of the prosthesis.

Remodelação cardíaca induzida pelo tabagismo (tabaquismo)

Previous studies accomplished by our group suggest that tobacco smoke exposure results in cardiac remodeling, with progressive ventricular dysfunction. However, the mechanisms involved in this process are not known. Therefore, our laboratory has been trying to identify the potentials responsible mechanisms for cardiac remodeling induced by tobacco. The blood pressure increase, the renin-angiotensin system and the oxidative stress can modulate this process. On the other hand, the activation of MMP-2 or MMP-9, as well as lipid peroxidation, don't seem to participate of the morphologic and functional alterations induced by tobacco smoke exposure.

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.

Avaliação das condutas de biossegurança em laboratórios de prótese dentária de João Pessoa, PB, Brasil

Objective: To evaluate the biosecurity measures adopted in dental prosthesis laboratories of the city of João Pessoa, PB, Brazil with respect to prosthetic works sent by dentists. Method: Twenty-five dental prosthesis technicians (DPT) of the city of João Pessoa, PB, filled out a questionnaire referring to their knowledge of the biosecurity principles, disinfection of impressions and other prosthetic items, and the use of individual protection equipment (IPE). Results: Although 92% of the interviewees believed in the possible occurrence of cross-infection between dental prosthesis laboratories and dental offices, 64% declared that the prosthetic works received in their laboratories do not undergo any disinfection procedure. It was also observed that, for disinfection of impressions and stone casts, the chemical substances are not used as recommended by the manufacturers or are innocuous to microorganisms. Regarding the use of IPE, 60% of the DPT used mask, but only 4% used gowns. With respect to the measures taken regarding the impressions received from dental offices, 56% of the interviewees only wash them in running tap water, and 56% of the stone casts that arrive at the laboratory are not disinfected in any way. Conclusion: There is a need for more motivation and instructions to DPT regarding the prevention of cross-contamination during sending and receiving of prosthetic works between dental prosthesis laboratories and dental offices because the DPT evaluated in this study were found negligent with respect to disinfection procedures.

Efeitos do treinamento resistido sobre a variabilidade da frequência cardíaca, capacidade funcional e força muscular periférica na DPOC

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)