RMMG - Revista Médica de Minas Gerais

Volume: 24. (Suppl.3)

 

Editorial

1 - Mensagem dos Coordenadores Revista Mineira de Anestesiologia

Luciana Laurentys; Marcel Andrade Souki

Rev Med Minas Gerais; 24.(Suppl.3):1-3, Jan/Jun, 2014

Artigos de Revisão

2 - Anestesia na gestante cardiopata

Anesthesia on cardiac pregnant patients

Eliane Cristina de Souza Soares; Carlos Othon Bastos; Maria Cecília Lessa Beloni

Rev Med Minas Gerais; 24.(Suppl.3):4-8, Jan/Jun, 2014

As cardiopatias representam a primeira causa não obstétrica de morte materna no ciclo gravídico puerperal. Este artigo tem como objetivo apresentar os principais fatores envolvidos na predição do risco de morbimortalidade cardiovascular em gestantes cardiopatas. Os avanços obtidos ao longo dos anos no diagnóstico, tratamento e correção cirúrgica de cardiopatias permitiram significativo aumento no número de mulheres portadoras dessas doenças que alcançam a idade fértil e engravidam. Esse grupo de pacientes representa um grande desafio pelas complicações potenciais e pelo fato de que a otimização das condições maternas deve ser cuidadosamente pensada para assegurar a sobrevivência e bem-estar fetais. O cuidado dessas pacientes deve envolver uma equipe multidisciplinar com a participação do anestesiologista. E assim como ocorre em diversas outras situações em anestesia obstétrica, o trabalho em equipe e a comunicação precoce são elementos-chave para garantir a redução da morbimortalidade materna e fetal.

Palavras-chave Anestesia obstétrica; Preditores de risco; Morte materna.

Cardiopathies represent the first non-obstetric cause of maternal death during the pregnancy-puerperal cycle. This article aims to present the main factors involved in the prediction of cardiovascular morbidity and mortality risks in pregnant women with heart disease. The progress achieved over the years in the diagnosis, treatment, and surgical correction of cardiopathies allowed for a significant increase in the number of these women who reach child-bearing age and become pregnant. This group of patients represents a major challenge because of potential complications and the optimization of maternal conditions that must be carefully designed to ensure fetal survival and well-being. The care of these patients should involve a multidisciplinary team with the participation of an anesthesiologist. Similarly to several other situations involving obstetric anesthesia, teamwork and early communication are key elements to ensure the reduction of maternal and fetal morbidity and mortality.

Keywords Anesthesia, Obstetrical; Risk Factors; Maternal Mortality.

3 - Anestesia na gestante portadora de estenose mitral

Anesthesia in pregnant women with mitral stenosis

Eliane Cristina de Souza Soares; Carlos Othon Bastos; Rachel de Andrade Ivo

Rev Med Minas Gerais; 24.(Suppl.3):9-13, Jan/Jun, 2014

A doença cardíaca é a principal causa não obstétrica de morte materna e sua incidência varia entre 0,1 e 4% das gestações.1 No Brasil, 55% dos casos de cardiopatias em gestantes têm como etiologia a doença reumática, com 70 a 80% dos casos representados pela estenose mitral. A evolução da estenose mitral na gravidez envolve complicações tanto maternas quanto fetais, com incidência diretamente relacionada à gravidade da lesão. O objetivo deste artigo é revisar a fisiopatologia, quadro clínico e condução anestésica em gestantes portadoras de estenose mitral.

Palavras-chave Anestesia Obstétrica; Febre Reumática; Estenose da Valva Mitral.

Heart disease is the leading non-obstetric cause of maternal death and its incidence varies between 0.1 and 4% of pregnancies.1 In Brazil, the etiology for 55% of cardiopathy cases in pregnant women is rheumatic disease with 70 to 80% of cases represented by mitral stenosis. The evolution of mitral stenosis during pregnancy involves both maternal and fetal complications with incidences directly related to the severity of the injury. The purpose of this article is to review the pathophysiology, clinical presentation, and anesthetic approach in pregnant women with mitral stenosis.

Keywords Anesthesia, Obstetrical; Rheumatic Fever; Mitral Valve Stenosis.

4 - Anestesia no paciente usuário de crack e cocaína

Anesthesia in patients who are users of crack and cocaine

Cláudio Henrique Corrêa; Leonardo Saraiva Guimarães de Oliveira; José Eduardo Alves de Assis; Rafael Teixeira Corrêa de Barros

Rev Med Minas Gerais; 24.(Suppl.3):14-19, Jan/Jun, 2014

A incidência de pacientes dependentes de drogas está aumentando. As substâncias ilícitas de consumo mais comuns são cocaína, maconha, álcool e heroína, embora o uso do crack tenha se tornado cada vez mais frequente, tornando-se um problema comum nos hospitais que atendem emergências. O efeito agudo e a longo prazo do abuso de drogas pode complicar o manejo anestésico. Muitas vezes esses pacientes não são identificados no pré-operatório, por tratar-se de cirurgia de emergência ou omissão de informação. Esses pacientes demandam vigilância contínua e perspicácia do anestesiologista para evitar sérias complicações perioperatórias. Neste artigo são apresentados os principais problemas relacionados ao uso da cocaína e do crack, bem como a melhor abordagem perioperatória. Durante o procedimento anestésico são utilizados vários medicamentos de ação central que interagem com outras substâncias como a cocaína, tornando predizer o tipo de resposta apresentado pelos pacientes que fazem uso desse tipo de droga. Isso torna a anestesia nesses pacientes um verdadeiro desafio para o anestesiologista que, portanto, deve conhecer as alterações fisiopatológicas para melhor abordar esses pacientes e diminuir a morbimortalidade.

Palavras-chave Anestesia; Cocaína; Cocaina Crack; Usuários de Drogas.

The incidence of drug dependent patients is increasing. The most common consumption among illicit substances includes cocaine, marijuana, alcohol, and heroin, however, the use of crack has become increasingly frequent and a common problem in hospitals that tend to emergencies. The acute and long-term effects of drug abuse can complicate the anesthetic management. These patients are often not identified preoperatively because they are in need of emergency surgery or due to information omission. These patients require continuous vigilance and insight from the anesthesiologist to avoid serious perioperative complications. This article presents the main problems related to the use of cocaine and crack, as well as the best perioperative approach. During the anesthetic procedure, several centrally acting medications that interact with other substances like cocaine is used making it difficult to predict the type of responses from the patients who make use of these drugs. Thus, anesthesia in these patients is a real challenge to the anesthesiologist who must therefore be aware of the pathophysiological alterations to best address these patients and decrease morbidity and mortality.

Keywords Anestheia; Cocaine; Crack Cocaine; Drug Users.

5 - Monitorização da coagulação sanguínea perioperatória

Perioperative blood coagulation monitoring

Walkíria Wingester Vilas Boas; Gustavo Henrique Silva de Oliveira

Rev Med Minas Gerais; 24.(Suppl.3):20-29, Jan/Jun, 2014

A monitorização perioperatória da coagulação sanguínea é crítica para entender melhor as causas de hemorragia, guiar terapias hemostáticas e prever o risco de sangramento durante procedimento cirúrgico. Nosso entendimento de coagulopatia perioperatória, ferramentas diagnósticas e abordagens terapêuticas têm evoluído nos últimos anos. O recentemente desenvolvido modelo celular da coagulação somado aos novos testes hemostáticos viscoelásticos (TEG e ROTEM) e testes de função plaquetária realizados à beira do leito facilita o entendimento e mede a formação e resolução do coágulo no sangue total, possibilitando rápido diagnóstico e tratamento da coagulopatia perioperatória.

Palavras-chave Coagulação Sanguínea; Monitoramento; Assistência Perioperatória, Substâncias Viscoelásticas; Tromboelastografia; Cirurgia Geral.

The perioperative blood coagulation monitoring is critical to better understand the causes of bleeding, guide hemostatic therapies, and predict the risk of bleeding during surgery. Our understandings of perioperative coagulopathy, diagnostic tools, and therapeutic approaches have evolved in recent years. The newly developed cell coagulation model combined with new hemostatic viscoelastic tests (TEG or ROTEM) and platelet function tests, carried out by the bedside, facilitates the understanding and measure of the formation and resolution of the clot in whole blood, enabling rapid diagnosis and treatment of perioperative coagulopathy.

Keywords Blood Coagulation; Monitoring; Perioperative Care; Viscoelastic Substances; Thrombelastography; General Surgery.

6 - Anticoagulantes e bloqueios do neuroeixo

Anticoagulants and neuraxial blockade

Estefânia Furtado Rocha; Gabriela Ferreira Duarte; Marcela Morais Afonso Cruz; Gisela Magnus

Rev Med Minas Gerais; 24.(Suppl.3):30-36, Jan/Jun, 2014

O número de pacientes em uso de fármacos anticoagulantes ou que alteram a hemostasia tem aumentado em virtude da maior expectativa de vida da população, do advento de medicamentos mais seguros e do aumento na prevalência de doenças cardiovasculares. A anestesia por bloqueio do neuroeixo quando realizada nesses pacientes traz o risco de sangramento e hematoma espinhal. Apesar da incidência estimada de complicações hemorrágicas associadas a bloqueios neuroaxiais ser baixa, além de imprecisa, a gravidade de suas consequências torna imperativo o desenvolvimento de estratégias que aumentem a segurança no procedimento anestésico desses pacientes. Entretanto, as recomendações baseadas em evidências são fracas, pois se baseiam principalmente em relatos de casos, pequenos estudos e farmacocinética das drogas. Neste artigo, revisamos a literatura sobre técnicas neuroaxiais realizadas em pacientes em uso de drogas anticoagulantes e/ou que alteram a hemostasia, com o objetivo de auxiliar o anestesiologista no manejo mais seguro e de qualidade para os pacientes.

Palavras-chave Anestesia por Condução; Raqueanestesia; Anticoagulantes, Inibidores da Agregação de Plaquetas; Hematoma Epidural Espinal.

The number of patients using anticoagulants or drugs that alter hemostasis has increased because of increased life expectancy, advent of safer medicines, and increased prevalence of cardiovascular diseases. In these patients, anesthesia by neuraxial blockade brings the risk of bleeding and spinal hematoma. Despite the estimated incidence of hemorrhagic complications associated with neuraxial blockade being low and inaccurate, the gravity of its consequences makes the development of strategies that increase the safety in the anesthetic procedures in these patients imperative. However, evidence-based recommendations are weak because they are based primarily on case reports, small studies, and drugs pharmacokinetics. In this article, we reviewed the literature on neuraxial techniques performed in patients using anticoagulant drugs, and/or those that alter hemostasis, with the objective of assisting the anesthesiologist to improve the quality and safety in these patients' management.

Keywords Anesthesia, Conduction; Anesthesia, Spinal; Anesthesia, Epidural; Anticoagulants; Platelet Aggregation Inhibitors; Hematoma, Epidural, Spinal.

7 - O Concentrado de Complexo Protrombínico e suas aplicações na sala de cirurgia

Prothrombin Complex Concentrate and its applications in the operating room

Erick Martins Faria de Abreu; Leonardo Saraiva Guimarães de Oliveira; Pablo Martins Biagioni de Menezes; Jaci Custódio Jorge

Rev Med Minas Gerais; 24.(Suppl.3):37-48, Jan/Jun, 2014

Os concentrados de complexo protrombínico (CCPs) contêm fatores de coagulação dependentes da vitamina K em uma concentração 25 vezes maior que a do plasma e são classificados em compostos de três ou quatro fatores, de acordo com a presença do fator VII (FVII). Quando comparados ao plasma fresco congelado (PFC), são mais eficazes, podendo ser administrados rapidamente e com baixa dose para atingir o efeito desejado. O perfil de segurança dos CCPs ainda é incerto, já que eventos adversos, principalmente tromboembólicos, foram relatados com o seu uso. Os CCPs foram desenvolvidos, inicialmente, para o tratamento da hemofilia B. Hoje, sua indicação principal é a reversão emergencial da anticoagulação induzida por antagonistas da vitamina K. Após a criação dos concentrados de fatores específicos, os CCPs têm sido utilizados em hemofílicos, na sua forma ativada, para profilaxia de sangramento no peroperatório de pacientes portadores de anticorpos inibidores. Diversos trabalhos demonstram bons resultados com o uso de CCPs na coagulopatia dilucional induzida pelo trauma e cirurgia cardíaca. Redução do sangramento e diminuição da necessidade de hemotransfusão foram verificadas quando administrados em associação ao concentrado de fibrinogênio, porém estudos de maior impacto ainda são necessários para comprovar tais benefícios. Novos anticoagulantes orais (NACs) foram introduzidos como substitutos de cumarínicos. Mesmo com mais previsibilidade, estes não possuem antídotos conhecidos. Os CCPs ainda não são indicados de rotina no peroperatório de usuários de NACs, exceto em casos de sangramento importante ou em órgãos críticos. Em hepatopatas, CCPs são promissores, porém poucos trabalhos avaliam sua segurança e eficácia nesse perfil de paciente.

Palavras-chave Protrombina; Cuidados Intraoperatórios; Anticoagulantes.

Prothrombin Complex Concentrates (PCCs) contain clotting factors that are vitamin K-dependent at a concentration 25 times greater than the plasma and are classified into compounds of three or four factors according to the presence of factor VII (FVII). When compared to frozen fresh plasma (FFPs), those are more effective, and can be administered quickly and at low doses to achieve the desired effect. The safety profile of PCCs is still uncertain because its adverse events, especially thromboembolic ones, have been reported with its use. PCCs were developed initially for the treatment of hemophilia B. Today, its main indication is the emergency reversal of anticoagulation induced by vitamin K antagonists. After the creation of specific concentrate factors, PCCs have been used in hemophiliacs, in its activated form, for the prophylaxis of bleeding in the peri-operative period of patients who are carriers of antibody inhibitors. Several studies demonstrate good results with the use of PCCs in dilutional coagulopathy induced by trauma and cardiac surgery. Reduced bleeding and decreased need for blood transfusions were observed when administered in association with fibrinogen concentrate; however, high-impact studies are still needed to prove such benefits. New oral anticoagulants (NACs) were introduced as coumarin replacements, which even with more predictability there are no known antidotes. The PCCs are still not routinely indicated in the per-operative period for NACs users, except in cases of major bleeding or in critical organs. PCCs are promising options for patients with liver disease; however, few studies assess its safety and efficacy in these patients.

Keywords Prothrombin; Intraoperative Care; Anticoagulants.

8 - Reversão de urgência da anticoagulação

Urgent reversal of anticoagulation

Igor Neves Afonso Castro; Rafael Coelho Tibúrcio; Marcel Andrade Souki

Rev Med Minas Gerais; 24.(Suppl.3):49-59, Jan/Jun, 2014

Com o envelhecimento da população e as consequentes comorbidades associadas, o uso de anticoagulantes tem se tornado cada vez mais prevalente. Os anestesiologistas devem estar preparados para o manejo do sangramento e dos riscos associados a esses medicamentos. Esta revisão tem o intuito de nortear a reversão de urgência da anticoagulação e estabelecer as opções disponíveis para este fim.

Palavras-chave Anticoagulantes; Antifibrinolíticos; Anestesiologia; Emergências.

The use of anticoagulants has become increasingly prevalent with the aging of the populations and the consequent comorbidities associated with it. Anesthesiologists should be prepared for the management of bleeding and the risks associated with these medications. This review is intended to guide the urgent reversion of anticoagulation and establish options available for this purpose.

Keywords Anticoagulants; Antifibrinolytic Agents; Anesthesiology; Emergencies.

Relato de Caso

9 - Ambiente látex seguro: relato de dois casos

Latex safe environment: report of two cases

Renato Machado Coelho Filho; Cláudia Helena Ribeiro Silva; Wirleyde Mattos Leão; Núbia Campos Faria Isoni; Marcelle Mafra de Queiroz; Magna Adaci de Quadros Coelho

Rev Med Minas Gerais; 24.(Suppl.3):60-67, Jan/Jun, 2014

INTRODUÇÃO: a anafilaxia é a forma mais grave de manifestação alérgica e constitui verdadeira emergência médica. A alergia ao látex aumentou muito nos últimos 30 anos, paralelamente ao emprego de produtos derivados no ambiente da saúde, com especial destaque para as luvas. Simultaneamente, medidas preventivas e terapêuticas surgiram no âmbito da Anestesiologia para o adequado manejo de pacientes suscetíveis à alergia ao látex, desde a avaliação pré-anestésica, até a alta hospitalar. A magnitude das reações ao látex varia desde inofensivas placas cutâneas, até o dramático colapso cardiovascular.1
OBJETIVO: descrever a abordagem pré-operatória de dois pacientes alérgicos ao látex, com ênfase no preparo da sala de cirurgia látex seguro ("latex free") na Santa Casa de Belo Horizonte e fazer breve revisão bibliográfica sobre a alergia ao látex e suas implicações para o anestesiologista.
MÉTODOS: foram selecionados dois casos recentes, abordados em março e abril de 2012, e solicitada autorização por escrito dos pacientes. Para a revisão bibliográfica, foram procuradas publicações indexadas nacionais e estrangeiras sobre o tema.
CONCLUSÃO: a alergia ao látex representa um problema real, de incidência de 0,2% na população geral, sem considerar os indivíduos com fatores de risco. Assim, medidas preventivas e terapêuticas devem ser do conhecimento do anestesiologista, para o adequado manejo de pacientes susceptíveis. Nesse contexto, merece especial destaque o ambiente látex seguro como principal alternativa preventiva.

Palavras-chave Anafilaxia; Hipersensibilidade ao Látex; Hipersensibilidade ao Látex; Complicações Intraoperatórias; Anestesiologia.

INTRODUCTION: Anaphylaxis is the most severe form of allergic manifestation and constitutes a true medical emergency. Allergy to latex has increased a lot in the last 30 years parallel to the use of derivative products in healthcare environments with particular emphasis on gloves. At the same time, preventive measures and therapies have emerged within the Anesthesiology field for the appropriate management of patients with allergy to latex, from the pre-anesthetic assessment to hospital discharge. The magnitude of the reactions to latex range from harmless skin plates to dramatic cardiovascular collapse.1
OBJECTIVE: to describe the preoperative approach in two patients allergic to latex, with emphasis on the preparation of an operating room as latex safe ("latex free") at the Santa Casa de Belo Horizonte and to present a brief bibliographical review about latex allergy and its implications for the anesthesiologist.
METHODS: we selected two recent cases, in March and April of 2012, and requested written consent from these patients. The literature review included a search of indexed domestic and foreign publications on the topic.
CONCLUSION: latex allergy represents a real problem with 0.2% incidence in the general population, without considering individuals with risk factors. Thus, preventive and therapeutic measures should be known to the anesthesiologist for the appropriate management of susceptible patients. Therefore, latex safe environments deserve special mention as the main preventive alternative.

Keywords Anaphylaxis; Latex Hypersensitivity; Intraoperative Complications; Anesthesiology.

10 - Analgesia para toracotomia com cateter multiperfurado e bomba elastomérica: relato de caso

Analgesia for thoracotomy with multi-perforated catheters and elastomeric pump: case report

Flávia Aparecida Resende; Maria Beatriz Assumpção Mourão; Bárbara Sanches Cardoso Allevato; Bráulio Antônio Maciel de Faria Mota Oliveira; Celso Homero Santos Oliveira; Sérgio Ricardo Botrel e Silva

Rev Med Minas Gerais; 24.(Suppl.3):68-72, Jan/Jun, 2014

A toracotomia é um procedimento que provoca intensa dor no pós-operatório. Para amenizá-la, várias técnicas de analgesia são descritas, sem, contudo, mostrar superioridade comprovada uma sobre as outras. Apresenta-se um caso de analgesia para toracotomia com cateteres multiperfurados e bomba elastomérica.
RELATO DO CASO: paciente com proposta de toracotomia exploradora devido à fratura brônquica por trauma torácico compressivo. Planejada a realização de anestesia geral e peridural torácica para analgesia, porém o paciente apresentava múltiplas lesões dermatológicas difusas pelo dorso. Realizadas então anestesia geral e analgesia com implantação de cateteres multiperfurados e infusão contínua de anestésico local por bomba elastomérica. Concluiu-se que as opções para realização de uma boa analgesia pós-operatória para toracotomia são muitas e novas técnicas vêm surgindo e ganhando espaço. A utilização de cateteres multiperfurados pode ser considerada uma opção para pacientes que tenham contraindicação à peridural torácica.

Palavras-chave Anestesia por Condução; Toracotomia; Traumatismos Torácicos/terapia; Cateteres.

Thoracotomy is a procedure that causes intense pain in the postoperative period. Several analgesia techniques are described to ease this pain, however, without showing a proven superiority of one over the other. A case of analgesia for thoracotomy with multi-perforated catheters and elastomeric pump is presented.
CASE REPORT: a patient with proposed exploratory thoracotomy due to bronchial fracture by compressive chest trauma. The general anesthesia and thoracic epidural for analgesia were planned, however, the patient presented multiple diffuse dorsal skin lesions. General anesthesia and analgesia were then performed with the implantation of multi-perforated catheters and continuous infusion of local anesthetic through an elastomeric pump. It was concluded that the options for performing a good postoperative analgesia for thoracotomy are many and that new techniques are emerging and gaining space. The use of multi-perforated catheters can be considered an option for patients who have a contraindication to thoracic epidural.

Keywords Anesthesia, Conduction; Thoracotomy; Thoracic Injuries/therapy; Catheters.

11 - Choque neurogênico e posicionamento após trauma raquimedular

Neurogenic shock and positioning after spinal cord injury

Ana Paula Almada; Michelle Nacur Lorentz; Bruna Silviano Brandão Vianna

Rev Med Minas Gerais; 24.(Suppl.3):73-76, Jan/Jun, 2014

A lesão raquimedular constitui consequência importante no cenário do trauma no Brasil. Sua incidência é desconhecida, porém estima-se que ocorram a cada ano no país mais de 10.000 novos casos.1 É importante que o anestesiologista esteja atento a essa enfermidade, incluindo não só o manejo anestésico como também suas inúmeras complicações. Trata-se de paciente de 31 anos, sexo feminino, vítima de trauma raquimedular (TRM) após acidente automobilístico (fratura de T2-T4 e fratura-luxação de T6-T7), além de fratura de arcos costais e de esterno e hemotórax bilateral drenado no atendimento inicial, sem evidências de contusão pulmonar. Admitida no centro cirúrgico para realização de artrodese de coluna torácica via posterior no quarto dia pós-trauma. Após monitorização e indução anestésica, a paciente foi posicionada em decúbito ventral e apresentou queda brusca e acentuada da pressão arterial média (PAM), não responsiva a doses crescentes de vasopressornoradrenalina. Optou-se pelo retorno da paciente para decúbito dorsal, com normalizacão do quadro hipotensivo após poucos minutos. O procedimento foi então suspenso, a paciente encaminhada à UTI e posteriormente realizado sem intercorrências após três semanas. Conclui-se que o conhecimento da história natural e evolução do TRM é muito importante para o manejo perioperatório, devendo ser escolhido o melhor momento para a intervenção cirúrgica. O diagnóstico diferencial entre as várias possíveis etiologias de choque que podem se apresentar nesses casos é fundamental para a boa evolução.

Palavras-chave Choque; Choque Traumático; Traumatismos da Medula Espinal.

The rachis injury constitutes an important consequence in the scenario of trauma in Brazil. Its incidence is unknown, however, it is estimated that more than 10,000 new cases occur in the country each year.1 It is important that the anesthesiologist is aware of this disease not only for the anesthetic management but to prevent its numerous complications too. This was a 31-year-old patient, female, victim of spinal cord injury (SCI) after a car accident (T2-T4 fracture and fracture-dislocation of T6-T7), with ribs and sternum fracture, bilateral hemothorax drained in the initial attendance, and no evidence of pulmonary contusion. The patient was admitted to the surgical center for thoracic spine arthrodesis via posterior on the fourth day following the trauma. After monitoring and anesthetic induction, the patient was placed in ventral decubitus and presented sudden and sharp drop in the mean arterial pressure (MAP) becoming non-responsive to increasing doses of vasopressor noradrenaline. We opted for the return of the patient to the supine position, which normalized the hypotensive condition after a few minutes. The procedure was then suspended; the patient was transferred to the ICU, and the procedure was subsequently performed without complications after three weeks. It is concluded that the knowledge on the natural history and evolution of the TRM is very important for the perioperative management; the best time for the surgical intervention must be chosen. The differential diagnosis between the several possible etiologies of shock that can be presented in these cases is essential for a good case progression.

Keywords Shock; Shock, Traumatic; Spinal Cord Injuries.

12 - Manejo anestésico de paciente com trauma cranioencefálico em uso de clopidogrel: relato de caso e revisão de literatura

Anesthetic management of a patient with traumatic brain injury in use of clopidogrel: case report and literature review

Daniella Semino Tavares; Patrícia Rodrigues da Silva; Luciana de Souza Cota Carvalho Laurentys

Rev Med Minas Gerais; 24.(Suppl.3):77-82, Jan/Jun, 2014

Com o envelhecimento da população, os anestesiologistas têm se confrontado com um número crescente de pacientes do trauma que usam medicações antiplaquetárias e anticoagulantes. No caso do trauma cranioencefálico (TCE), o uso de agentes antiplaquetários pode estar associado ao aumento da extensão da lesão hemorrágica intracraniana (LHI) e da morbimortalidade. Além disso, a retirada desse medicamento expõe esses pacientes às complicações cardiovasculares.
RELATO DE CASO: paciente, sexo masculino, 74 anos, hipertenso e diabético, em uso de aspirina e clopidogrel devido à angioplastia coronariana, com stent farmacológico há seis meses. Sofreu queda da própria altura e foi diagnosticado hematoma subdural agudo volumoso, sendo indicada craniotomia de urgência. No perioperatório, recebeu duas plaquetaféreses, 12 UI de concentrado de plaquetas e desmopressina (0,3 mcg/kg) endovenosos, com o intuito de reduzir sangramento. Paciente recuperou sem sequelas neurológicas e sem complicações cardiovasculares no 13º dia de internação. Até o momento, a literatura é escassa de evidências sobre o manejo do paciente idoso com TCE em uso de agentes antiplaquetários, portanto, este relato de caso teve o objetivo de realizar a revisão de literatura e discutir opções terapêuticas em reverter a ação do clopidogrel.

Palavras-chave Anestesiologia; Traumatismos Craniocerebrais; Anticoagulantes; Fatores Etários; Idoso.

Considering the aging of the population, anesthesiologists have been confronted with an increasing number of trauma patients using antiplatelet and anticoagulants medications. In the case of traumatic brain injury (TBI), the use of antiplatelet agents can be linked to increased extension of hemorrhagic intracranial lesion (LHI) and morbidity and mortality. In addition, the withdrawal of these drug exposes these patients to cardiovascular complications.
CASE REPORT: male patient, 74 years old, hypertensive and diabetic, in use of aspirin and clopidogrel due to coronary angioplasty with drug-eluting stent for six months. He fell down over his own height and was diagnosed with acute bulky subdural hematoma; an urgent craniotomy was indicated. In the perioperative period, he received two plateletpheresis and intravenous 12 IU of platelet concentrate and desmopressin (0.3 mcg/kg) to reduce bleeding. The patient recovered without neurological sequelae and without cardiovascular complications in 13th day of hospitalization. So far, the literature shows scarce evidences of management of elderly patients with TBI in use of antiplatelet agents, therefore, this case report aimed to carry out a literature review and discuss treatment options to revert the action of clopidogrel.

Keywords Anesthesiology; Traumatic brain injury; Anticoagulants; Age Factors; Aged.

Literatura Sugerida

13 - Management of bleeding and coagulopathy following major trauma: an updated European guideline

Spahn DR; Bouillon B; Cerny V; Coats TJ; Duranteau J; Fernández-Mondéjar E; Filipescu D; Hunt BJ; Komadina R; Nardi G; Neugebauer E; Ozier Y; Riddez L; Schultz A; Vincent JL; Rossaint R

Rev Med Minas Gerais; 24.(Suppl.3):83-84, Jan/Jun, 2014

INTRODUCTION: Evidence-based recommendations are needed to guide the acute management of the bleeding trauma patient. When these recommendations are implemented patient outcomes may be improved.
METHODS: The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with the aim of developing a guideline for the management of bleeding following severe injury. This document represents an updated version of the guideline published by the group in 2007 and updated in 2010. Recommendations were formulated using a nominal group process, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence and based on a systematic review of published literature.
RESULTS: Key changes encompassed in this version of the guideline include new recommendations on the appropriate use of vasopressors and inotropic agents, and reflect an awareness of the growing number of patients in the population at large treated with antiplatelet agents and/or oral anticoagulants. The current guideline also includes recommendations and a discussion of thromboprophylactic strategies for all patients following traumatic injury. The most significant addition is a new section that discusses the need for every institution to develop, implement and adhere to an evidence-based clinical protocol to manage traumatically injured patients. The remaining recommendations have been re-evaluated and graded based on literature published since the last edition of the guideline. Consideration was also given to changes in clinical practice that have taken place during this time period as a result of both new evidence and changes in the general availability of relevant agents and technologies.
CONCLUSIONS: A comprehensive, multidisciplinary approach to trauma care and mechanisms with which to ensure that established protocols are consistently implemented will ensure a uniform and high standard of care across Europe and beyond.

Available at: http://ec.europa.eu/health/ph_determinants/life_style/nutrition/documents/iotf_en.pdf

Acessed on: Jun 2014.

14 - Prophylactic phenylephrine for caesarean section under spinal anaesthesia: systematic review and meta-analysis

Heesen M; Klöhr S; Rossaint R; Straube S

Rev Med Minas Gerais; 24.(Suppl.3):83-84, Jan/Jun, 2014

We conducted a systematic review to determine the harm and benefit associated with prophylactic phenylephrine for caesarean section under spinal anaesthesia. We included 21 randomised controlled trials with 1504 women. The relative risk (95% CI) of hypotension with phenylephrine infusion - as defined by authors - before delivery was 0.36 (0.18-0.73) vs placebo, p = 0.004; 0.58 (0.39-0.88) vs an ephedrine infusion, p = 0.009; and 0.73 (0.55-0.96) when added to an ephedrine infusion, p = 0.02. After delivery, the relative risks of hypotension and nausea and vomiting with phenylephrine compared with placebo were 0.37 (0.19-0.71), p = 0.003, and 0.39 (0.17-0.91), p = 0.03, respectively. There was no evidence that hypertension, bradycardia or neonatal endpoints were affected. Phenylephrine reduced the risk for hypotension and nausea and vomiting after spinal doses of bupivacaine generally exceeding 8 mg, but there was no evidence that it reduced other maternal or neonatal morbidities.

Available at: http://onlinelibrary.wiley.com/doi/10.1111/anae.12445/abstract

Acessed on: Jun 2014.

BACKGROUND: Because etomidate impairs adrenal function and blunts the cortisol release associated with surgical stimulus, we hypothesized that patients induced with etomidate suffer greater mortality and morbidity than comparable patients induced with propofol.
METHODS: We evaluated the electronic records of 31,148 ASA physical status III and IV patients who had noncardiac surgery at the Cleveland Clinic. Among these, anesthesia was induced with etomidate and maintained with volatile anesthetics in 2616 patients whereas 28,532 were given propofol for induction and maintained with volatile anesthetics. Two thousand one hundred forty-four patients given etomidate were propensity matched with 5233 patients given propofol and the groups compared on 30-day postoperative mortality, length of hospital stay, cardiovascular and infectious morbidities, vasopressor requirement, and intraoperative hemodynamics.
RESULTS: Patients given etomidate had 2.5 (98% confidence interval [CI], 1.9-3.4) times the odds of dying than those given propofol. Etomidate patients also had significantly greater odds of having cardiovascular morbidity (odds ratio [OR] [98% CI]: 1.5 [1.2-2.0]), and significantly longer hospital stay (hazard ratio [95% CI]: 0.82 [0.78-0.87]). However, infectious morbidity (OR [98% CI]: 1.0 [0.8-1.2]) and intraoperative vasopressor use (OR [95% CI] 0.92: [0.82-1.0]) did not differ between the agents.
CONCLUSION: Etomidate was associated with a substantially increased risk for 30-day mortality, cardiovascular morbidity, and prolonged hospital stay. Our conclusions, especially on 30-day mortality, are robust to a strong unmeasured binary confounding variable. Although our study showed only an association between etomidate use and worse patients' outcomes but not causal relationship, clinicians should use etomidate judiciously, considering that improved hemodynamic stability at induction may be accompanied by substantially worse longer-term outcomes.

Available at: http://www.ncbi.nlm.nih.gov/pubmed/24257383

Acessed on: Jun 2014.

16 - Comparison of the effects of albumin 5%, hydroxyethyl starch 130/0.4 6%, and Ringer's lactate on blood loss and coagulation after cardiac surgery

Skhirtladze K; Base EM; Lassnigg A; Kaider A; Linke S; Dworschak M; Hiesmayr MJ

Rev Med Minas Gerais; 24.(Suppl.3):84-85, Jan/Jun, 2014

BACKGROUND: Infusion of 5% human albumin (HA) and 6% hydroxyethyl starch 130/0.4 (HES) during cardiac surgery expand circulating volume to a greater extent than crystalloids and would be suitable for a restrictive fluid therapy regimen. However, HA and HES may affect blood coagulation and could contribute to increased transfusion requirements.
METHODS: We randomly assigned 240 patients undergoing elective cardiac surgery to receive up to 50 ml kg(-1) day(-1) of either HA, HES, or Ringer's lactate (RL) as the main infusion fluid perioperatively. Study solutions were supplied in identical bottles dressed in opaque covers. The primary outcome was chest tube drainage over 24 h. Blood transfusions, thromboelastometry variables, perioperative fluid balance, renal function, mortality, intensive care unit, and hospital stay were also assessed.
RESULTS: The median cumulative blood loss was not different between the groups (HA: 835, HES: 700, and RL: 670 ml). However, 35% of RL patients required blood products, compared with 62% (HA) and 64% (HES group; P=0.0003). Significantly, more study solution had to be administered in the RL group compared with the colloid groups. Total perioperative fluid balance was least positive in the HA group [6.2 (2.5) litre] compared with the HES [7.4 (3.0) litre] and RL [8.3 (2.8) litre] groups (P<0.0001). Both colloids affected clot formation and clot strength and caused slight increases in serum creatinine.
CONCLUSIONS: Despite equal blood loss from chest drains, both colloids interfered with blood coagulation and produced greater haemodilution, which was associated with more transfusion of blood products compared with crystalloid use only.

Available at: http://www.ncbi.nlm.nih.gov/pubmed/24169821

Acessed on: Jun 2014.

17 - Clinical review: What are the best hemodynamic targets for noncardiac surgical patients?

Lobo SM; Oliveira NE

Rev Med Minas Gerais; 24.(Suppl.3):85, Jan/Jun, 2014

Perioperative hemodynamic optimization, or goal-directed therapy (GDT), has been show to significantly decrease complications and risk of death in high-risk patients undergoing noncardiac surgery. An important aim of GDT is to prevent an imbalance between oxygen delivery and oxygen consumption in order to avoid the development of multiple organ dysfunction. The utilization of cardiac output monitoring in the perioperative period has been shown to improve outcomes if integrated into a GDT strategy. GDT guided by dynamic predictors of fluid responsiveness or functional hemodynamics with minimally invasive cardiac output monitoring is suitable for the majority of patients undergoing major surgery with expected significant volume shifts due to bleeding or other significant intravascular volume losses. For patients at higher risk of complications and death, such as those with advanced age and limited cardiorespiratory reserve, the addition of dobutamine or dopexamine to the treatment algorithm, to maximize oxygen delivery, is associated with better outcomes.