Associacao de opioides lipofilicos a bupivacaina na anestesia peridural. Ha vantagem no aumento da dose do opioide?

Background and Objectives: - The effects of associating lipophilic opioids to local anesthetics in epidural anesthesia are not well defined. There are still questions and controversies about opioid doses to be used and their major effects in the epidural block. This study aimed at evaluating the epidural block effects in humans of the association of different fentanyl and sufentanil doses to bupivacaine with 1:200.000 epinephrine. Methods: - A double-blind randomized study was performed in 94 patients of both genders, physical status ASA I, aged between 18 and 60 years, submitted to lower abdomen, perineal or lower limb surgery. Patients without preanesthetic medication were epidurally injected with 100 mg (20 ml) 0.5% bupivacaine, 0.1 mg (0.1 ml) 1%o epinephrine plus a combination of the following drugs: BUPI Group (15 patients): 2 ml of 0.9% saline solution (SS); FENT50 Group (19 patients): 50 μg (1 ml) fentanyl + 1 ml SS; FENT100 Group (20 patients): 100 μg (2 ml) fentanyl; SUF30 Group (20 patients): 30 μg (0.6 ml) sufentanil + SS (1.4 ml); SUF100 Group (20 patients): 50 μg (1 ml) sufentanil + SS (1 ml). The following parameters were studied: onset of sensory block, analgesic block (onset time) in T12, T10 and T8, analgesic block duration in T10 and T12, motor block degree, consciousness degree, need for supplemental perioperative sedation and analgesia, hypotension, bradycardia and peri and post operative side-effects, analgesia duration, proportion of patients needing supplemental analgesia and evaluation of postoperative pain (pain analog visual scale). Results: Groups were demographically uniform. The addition of fentanyl or sufentanil did not alter major characteristics of perioperative epidural block and has not significantly increased postoperative analgesia duration as compared to the use of bupivacaine only. However, the addition of lipophilic opioids has increased the quality of perioperative anesthetic block, translated into a lesser need for supplemental analgesia (p < 0.02). The increased dose of fentanyl and especially of sufentanil has increased the incidence of perioperative drowsiness (p < 0.001) without significant increase in other side effects. Conclusions: In the conditions and doses used, the addition of lipophilic opioids to bupivacaine and the increased dose of lipophilic opioids have improved anesthetic block quality without changes in the epidural block characteristics or a significant increase in side effects, with the exception of drowsiness mainly caused by sufentanil. However, they were not able to provide a significant increase in postoperative analgesia duration.

Comparacao da recuperacao de anestesia venosa com propofol e anestesia inalatoria com sevoflurano para laparoscopia ginecologica

Backgrounds and Objectives: Both continuous venous anesthesia with propofol and inhalational anesthesia with sevoflurane propitiate fast arousal with few side effects. The aim of this study was to compare the arousal and post anesthestic recovery times in patients submitted to these two agents. Methods: Forty three patient aged 18 to 50 years, physical status I or II, submitted to gynecological laparoscopy were distributed in two groups: G1 - propofol in continuous infusion of 115 μg.kg -1.min -1 and G2 sevoflurane. All the patients were pre-medicated with 7.5 mg midazolam, sufentanil 0.5 μg.kg -1, propofol 2 mg.kg -1, atracurium 0.5 mg.kg -1, N 2O in 50% of oxygen in a no-rebreathing system. The depth of the anesthesia and arousal time were assessed by the Bispectral index (BIS). The time between end of anesthesia and eye opening, time for command response and time for orientation were also evaluated. Results: The times recorded in minutes were: G1 - eye opening 8.2 ± 2.9, command response 8.6 ± 3.1, orientation 9.8 ± 3.4, recovery 31.6 ± 3.8; G2 - eye opening 4.5 ± 3, command response 4.9 ± 3.4, orientation 6.2 ± 3.4, recovery 66 ± 8. Except the recovery time, all the values were larger in G1. Conclusions: Both intravenous propofol or inhalational sevoflurane were considered excellent anesthetic techniques as to recovery time and recovery room discharge. Sevoflurane provided an earlier arousal with a longer recovery room stay as compared to propofol.

Titulacao do sevoflurano utilizando o indice bispectral em anestesia pediatrica. Influencia da medicacao pre-anestesica no tempo de despertar e no consumo de anestesico inalatorio

Background and Objectives - Sevoflurane is an inhalational anesthetic drug with low blood/gas solubility providing fast anesthesia induction and emergence. Its ability to maintain cardiovascular stability makes it ideal for pediatric anesthesia. The aim of this study was to evaluate hemodynamic stability, consumption of inhalational anesthetics and emergence time in children with and without premedication (midazolam or clonidine) anesthetized with sevoflurane titrated according to BIS monitoring. Methods - Participated in this study 30 patients aged 2 to 12 years, physical status ASA I, undergoing elective surgeries who were divided into 3 groups: G1 - without premedication, G2 - 0.5 mg.kg-1 oral midazolam, G3 - 4 μg.kg-1 oral clonidine 60 minutes before surgery. All patients received 30 μg.kg-1 alfentanil, 3 mg.kg-1 propofol, 0.5 mg.kg-1 atracurium, sevoflurane in different concentrations monitored by BIS (values close to 60) and N2O in a non rebreathing system. Systolic and diastolic blood pressure, heart rate, expired sevoflurane concentration (EC), sevoflurane consumption (ml.min-1) and emergence time were evaluated. Emergence time was defined as time elapsed between the end of anesthesia and patients' spontaneous movements trying to extubate themselves, crying and opening eyes and mouth. Results - There were no differences among groups as to systolic and diastolic blood pressure, EC, sevoflurane consumption and emergence time. Heart rate was lower in G3 group. Conclusions - Sevoflurane has provided hemodynamic stability. Premedication with clonidine and midazolam did not influence emergence time, inhaled anesthetic consumption or maintenance of anesthesia with sevoflurane. Anesthesia duration has also not influenced emergence time. Hypnosis monitoring was important for balancing anesthetic levels and this might have been responsible for the similarity of emergence times for all studied groups.

Bupivacaína, Ropivacaína e Levobupivacaína em Analgesia e Anestesia de Parto. Repercussões Materno-Fetais

Background and Objectives - Bupivacaine has been a very useful local anesthetic in Obstetrics in spite of its potential cardiotoxicity. In obstetric analgesia, ropivacaine is preferred to bupivacaine, and levobupivacaine is less cardiotoxic than the racemic mixture. The aim of this study was to compare the maternal-fetal effects of bupivacaine, ropivacaine and levobupivacaine in obstetric analgesia and anesthesia. Methods - Participated in this study 33 term pregnant women, physical status ASA I and II submitted to epidural anesthesia who received 18.75 mg (in 15 ml completed with 9% saline) of: GI - bupivacaine, GII - ropivacaine, and GIII - levobupivacaine. Pain intensity, sensory block level, onset time, quality of analgesia, motor block intensity, analgesia duration and time for labor resolution were evaluated. For vaginal delivery, 40 mg (in 8 ml of saline) of the same local anesthetic were used; for cesarean delivery, the dose has been mg in 20 ml solution. Newborns of these mothers were evaluated through the Apgar score in minutes 1, 5 and 10, and through the Amiel-Tison method (neurologic and adaptative capacity score - NACS) at 30 min, 2 h, and 24 h. Results - There were no significant statistical differences among groups as to sensory block level, onset time, quality of analgesia, labor analgesia duration, time for labor resolution, and Apgar scores at minute 1. Ast to motor block, GIII > GII and GI was intermediary. In relation to pain intensity, there was a trend for GI > GIII. For Apgar scores in minute 5, GII > (GI = GIII), and in minute 10 (GI = GII) < GIII. NACS at 2 h showed, GII > GI > GIII, and at 24 h, GII > GIII > GI. Conclusions - Ropivacaine has relieved maternal pain with less motor block. Newborns of GII mothers (ropivacaine) showed the best Apgar and NACS scores.

Complicacoes respiratorias em criancas submetidas a anestesia geral

Background and Objectives - The decision to perform anesthetic and surgical procedures in children with upper airway infeccious disease, due to the possibility of intraoperative respiratory morbidity, has been a dilemma for anesthesiologists. This study aimed at evaluating the incidence of respiratory complications in children submitted to general anesthesia and correlate them to preoperative signs and symptoms related to the respiratory tract, thus determining anesthetic-surgical morbidity. Methods - Participated in this study 284 children, physical status ASA I or II, submitted to general anesthesia. During preoperative evaluation, respiratory signs and symptoms were recorded, as well as types of diseases and corresponding diagnoses. Respiratory complications during anesthesia and in the recovery room were also recorded and analyzed taking into account age, elective or urgent procedure, airway management and presence or absence of signs, symptoms or history of respiratory tract diseases. Results - We found 38% of patients with preoperative respiratory disease history. The most common respiratory disease was upper airway infection. Intraoperative respiratory complications were present in 26.4% of patients. Children under 12 months of age and those with preoperative respiratory disease history had more intraoperative and PACU complications. Conclusions - We concluded that children, specially younger, with respiratory system involvement, like upper airway infections, are at a higher risk of intra and postoperative respiratory complications, thus with an increased incidence of anesthetic-surgical morbidity.

Correlação de diferentes períodos de jejum com níveis séricos de cortisol, glicemia plasmática, estado clínico e equilíbrio ácido-base em case submetidos à anestesia geral inalatória

This study correlated the solid preoperative fasting periods with plasma glycemia, serum cortisol, condition clinic and acid-base balance in dogs submitted to inhalation of general anaesthesia. Eight adults, animals were distributed into three groups in accordance with solid preoperative fasting: group 1 (12 hours), group 2 (18 hours) and group 3 (24 hours). Gastric emptying was observed and following this animals were submitted to the same anesthetic procedure. Heart and respiratory rate, rectal temperature, capillary refill time, percent hydration and noninvasive arterial pressure determined before and after Acepromazine and every 10 minutes during anaesthesia, included ETCO 2; values blood gas (pH, PaCO 2, PaO 2, HCO 3, TCO 2, SaO 2, BE), glycemic and serum cortisol were analyzed before MPA and each 30 minutes during anaesthesia. In recovery anaesthetic, glycemia and serum cortisol were repeated. During anaesthesia there were little cardiovascular and respiratory alteration not having interference of the preoperative fasting periods. Animals with 12 hours of the preoperative fasting showed a higher rise in glycemia levels than others groups in recovery anaesthetic. Serum cortisol wasn't influenced by fasting. Solid preoperative fasting independent of the duration describe a discreet respiratory alkalosis. All animals showed good clinical condition in all three groups. Solid preoperative fasting of the 18 hours is recommended to ensure a complete absence of the solid food contents in stomach.

Efeito sinérgico entre a dexmedetomidina e a ropivacaína 0,75% na anestesia peridural

BACKGROUND. This study aimed to evaluate clinical characteristics of epidural anesthesia performed with 0.75% ropivacaine associated with dexmedetomidine. METHODS. Forty patients scheduled for hernia repair or varicose vein surgeries under epidural anesthesia participated in this study. They were assigned to: Control Group (n = 20), 0.75% ropivacaine, 20 ml (150 mg); and Dexmedetomidine Group (n = 20), 0.75% ropivacaine, 20 ml (150 mg), plus dexmedetomidine, 1 μg.kg -1. The following variables were studied: total analgesic block onset time, upper level of analgesia, analgesic and motor block duration time, intensity of motor block, state of consciousness, hemodynamics, postoperative analgesia and incidence of side-effects. RESULTS. Epidural dexmedetomidine did not affect onset time or upper level of anesthesia (p > 0.05) however it prolonged sensory and motor block duration time (p < 0.05) and postoperative analgesia (p < 0.05), and also resulted in a more intense motor block, 1 (p < 0.05). Values of bispectral index were lower in Dexmedetomidine Group (p < 0.05). There was no difference in incidence of hypotension and bradycardia (p > 0.05). Occurrence of side-effects (shivering, vomiting and SpO 2 < 90%) was low and similar between groups (p > 0.05). CONCLUSION. There is clear synergism between epidural dexmedetomidine and ropivacaine, further this drug association does not bring about additional morbidity.

Ensaio randomizado, duplo-cego e controlado de anestesia tópica induzida por iontoforese de lidocaína

Introduction: Needle infi ltration of local anesthetic is a painful procedure, thus, a topical anesthetic is a comfortable alternative; however, it is diffi cult to deliver transcutaneous polar drugs. Iontophoresis is a noninvasive technique that uses electrical current for releasing electrically charged drugs through biological membranes. Objective: To evaluate the anesthesia induced by iontophoresis of lidocaine for a standardized painful stimulus. Material and methods: Randomized, controlled, double-blind study, involving 10 volunteers under the anesthetic effects of topical application of lidocaine gel 2% and noradrenaline 1:50,000, with or without iontophoresis of 1.85 milliamps for 13 minutes. Pain sensitivity was evaluated by the prick of a 21G needle in the arms posterior region, using a visual numerical scale. Results: Patients mean age was 50.8 ± 11.4 years. Nine of them were women. All had previously received infi ltrative anesthesia. Iontophoresis was well tolerated by volunteers. The median pain scores were 0 and 3 for the arm that received the iontophoresis and for the one that did not receive, respectively (p < 0.01). Conclusion: The anesthetic effect in the region subjected to iontophoresis suggests an effi cient and comfortable method for promoting local anesthesia in the surgical approach of pediatric, hyperalgic, or needlephobic patients.

Anestesia para colecistectomía videolaparoscópica en paciente portador de enfermedad de Steinert. Relato de caso y revisiõn de la literatura

BACKGROUND AND OBJECTIVES: Myotonic dystrophies are autosomal dominant neuromuscular diseases. Among them, myotonic dystrophy type 1 (MD1), or Steinert disease, is the most common in adults, and besides muscular involvement it also has important systemic manifestations. Myotonic dystrophy type 1 poses a challenge to the anesthesiologist. Those patients are more sensitive to anesthetics and prone to cardiac and pulmonary complications. Besides, the possibility of developing malignant hyperthermia and myotonic episodes is also present. CASE REPORT: This is a 39-year old patient with DM1 who underwent general anesthesia for videolaparoscopic cholecystectomy. Total intravenous anesthesia with propofol, remifentanil, and rocuronium was the technique chosen. Intercurrences were not observed in the 90-minute surgical procedure, but after extubation, the patient developed respiratory failure and myotonia, which made tracheal intubation impossible. A laryngeal mask was used, allowing adequate oxygenation, and mechanical ventilation was maintained until full recovery of the respiratory function. The patient did not develop further complications. CONCLUSIONS: Myotonic dystrophy type 1 presents several particularities to the anesthesiologist. Detailed knowledge of its systemic involvement along with the differentiated action of anesthetic drugs in those patients will provide safer anesthetic-surgical procedure.