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Brazilian Journal of Anesthesiology, Volume: 71, Issue: 6, Published: 2021
  • Brazilian Journal of Anesthesiology: seventy years fostering research in anesthesiology Editorial

    Carmona, Maria José Carvalho
  • Comprehensive perioperative eye protection Editorial

    Carmona, Maria José Carvalho; Quintão, Vinícius Caldeira
  • Incidence and risk factors of postoperative visual function impairment in elderly patients undergoing nonocular surgery: a prospective cohort study Clinical Research

    Badessa, Guinther G.; Almeida, Juliano Pinheiro; Fukushima, Julia Tizue; Badessa, Marianne; Colella, Felipe; Torres, Marcelo L.; Alves, Milton Ruiz; Falcão, Luiz Fernando R.; Silveira, Cirilo Haddad; Alfano, Adeli Mariane Vieira Lino; Amaral Neto, Mauricio; Nakashima, Aloísio Fumio; Carmona, Maria José C.

    Abstract in English:

    Abstract Background: Elderly patients may present with visual function impairment after surgery, which may increase the incidence of postoperative delirium and falls and decrease their quality of life. The aim of this study was to assess visual function in elderly patients after long-duration nonocular surgery to determine the incidence and risk factors for visual function impairment after surgery. Methods: This prospective and observational study included patients aged between 60 and 80 years who had been scheduled for elective non-ocular surgery expected to last longer than 120 minutes under general anaesthesia. Ocular examinations were performed before surgery, on post-operative day 3 and on post-operative day 21 and consisted of a LogMAR-Snellen chart test, a Jager chart test, biomicroscopy, optical tonometry, ocular motility assessment and fundoscopy. Baseline characteristics of all patients as well as intraoperative and postoperative data were collected. Results: A total of 107 patients were included in the final analysis. Visual function impairment was diagnosed in 21 patients (19.6%) at POD 3. Of those, 7 patients (6.5%) still presented with visual changes at POD 21. On POD 3, compared with that at baseline, visual acuity assessed by the Snellen chart test had decreased in these patients. Significant differences regarding refraction tests and intraocular pressure measures were also found. Multivariable analysis identified diabetes mellitus, duration of surgery, hypotension during anaesthesia induction, lower peripheral oxygen saturation at the end of the procedure and body mass index as independent risk factors for postoperative visual impairment. Conclusion: In elderly patients undergoing long-duration non-ocular procedures under general anaesthesia, the incidence of visual function impairment was considerably high. Most patients recovered to baseline visual function, but clinically significant visual changes may still be present 3 weeks after surgery. Obesity, diabetes mellitus, and the duration of surgical and anaesthetic techniques appear to increase the risk of visual impairment after surgery.
  • The effect of robotic surgery on intraocular pressure and optic nerve sheath diameter: a prospective study Clinical Research

    Balkan, Bedih; Emir, Nalan Saygı; Demirayak, Bengi; Çetingök, Halil; Bayrak, Başak

    Abstract in English:

    Abstract Background and objectives To investigate the effect of the steep Trendelenburg position (35° to 45°) and carbon dioxide (CO2) insufflation on optic nerve sheath diameter (ONSD), intraocular pressure (IOP), and hemodynamic parameters in patients undergoing robot-assisted laparoscopic prostatectomy (RALP), and to evaluate possible correlations between these parameters. Methods A total of 34 patients were included in this study. ONSD was measured using ultrasonography and IOP was measured using a tonometer at four time points: T1 (5 minutes after intubation in the supine position); T2 (30 minutes after CO2 insufflation); T3 (120 minutes in steep Trendelenburg position); and T4 (in the supine position, after abdominal exsufflation). Systolic and diastolic arterial pressure, heart rate, and end-tidal CO2 (etCO2) were also evaluated. Results The mean IOP was 12.4 mmHg at T1, 20 mmHg at T2, 21.8 mmHg at T3, and 15.6 mmHg at T4. The mean ONSD was 4.87 mm at T1, 5.21 mm at T2, 5.30 mm at T3, and 5.08 at T4. There was a statistically significant increase and decrease in IOP and ONSD between measurements at T1 and T4, respectively. However, no significant correlation was found between IOP and ONSD. A significant positive correlation was found only between ONSD and diastolic arterial pressure. Mean arterial pressure, heart rate, and etCO2 were not correlated with IOP or ONSD. Conclusions A significant increase in IOP and ONSD were evident during RALP; however, there was no significant correlation between the two parameters.
  • Changes in intraocular pressure during coronary artery bypass graft surgery: an observational study Clinical Research

    Erol, Gokhan; Doganci, Suat; Tumer, Naim Boran; Kunt, Atike Tekeli; Yildirim, Vedat

    Abstract in English:

    Abstract Background In this study, the effects of pulsatile and non-pulsatile on-pump Coronary Artery Bypass Graft surgery (CABG) and off-pump CABG techniques on the intraocular pressure were investigated. Methods Forty-five patients who planned to elective coronary artery bypass surgery with on-pump pulsatile (n = 15), non-pulsatile (n = 15), or off-pump (n = 15) were included. Intraocular Pressure (IOP) measurements were performed on both eyes at nine time-points: 1) Before the operation, 2) After anesthesia induction, 3) 3 minutes after heparin administration Left Internal Mammary Artery (LIMA) harvesting, 4) End of the first anastomosis, 5) End of LIMA anastomosis, 6) 3 minutes after protamine administration, 7) End of the operation, and 8) Second hour in Intensive Care Unit (ICU), 9) Fifth hour in ICU. Mean Arterial Pressure (MAP) and Central Venous Pressure (CVP) were also recorded at the same time points as IOP. Results In Cardiopulmonary Bypass (CPB) groups (pulsatile or non-pulsatile CPB) with the beginning of CPB, there were significant decreases in IOP values when compared to baseline (p = 0.012). This decrease was more prominent in the non-pulsatile group when compared to the pulsatile group (T4 IOP values: pulsatile, 9.7 ± 2.6; non-pulsatile, 6.8 ± 1.9; p = 0.002; T5 IOP values: pulsatile, 9.5 ± 1.9; non-pulsatile, 6.7 ± 2.1; p = 0.004). At the end of the surgery (T7), IOP values returned to the baseline and stayed stable at the remaining time-points. In-off pump group, IOP values significantly increased with a head-down position (T4 IOP values: off-pump surgery, 19.7 ± 5.2; p = 0.015). IOP values remained high until the normalization of head-down position (T6) and stayed stable through the rest of all remaining time-points. Conclusion During cardiac surgery regardless of the technique (on-pump CABG, off-pump CABG), intraocular pressures remain in the normal ranges. It should be kept in mind that patients should be avoided from long and extreme Trendelenburg position, low CVP, and MAP levels during cardiac surgery to prevent eye-related complications.
  • Intraocular pressure during robotic-assisted laparoscopic prostatectomy: a prospective observational study Clinical Research

    Kondo, Yuriko; Echigo, Noriyuki; Mihara, Takahiro; Koyama, Yukihide; Takahashi, Kosuke; Okamura, Kenta; Goto, Takahisa

    Abstract in English:

    Abstract Background and objectives Although previous reports have shown intraocular pressure changes during robotic-assisted laparoscopic prostatectomy, they did not discuss the time course of changes or the timing of the largest change. We conducted this study to quantify pressure changes over time in patients assuming the steep Trendelenburg position during robotic-assisted laparoscopic prostatectomy. Methods Twenty-one men were enrolled. Intraocular pressure was measured before anesthesia induction in the supine position (T0); 30 (T1), 90 (T2), and 150 minutes after assuming the Trendelenburg position (T3); and 30 minutes after reassuming the supine position (T4). End-tidal carbon dioxide and blood pressure were also recorded. To compare intraocular pressure between the time points, we performed repeated-measures analysis of variance. A mixed-effects multivariate regression analysis was conducted to adjust for confounding factors. Results The mean (standard deviation) intraocular pressure was 18.3 (2.4), 23.6 (3.0), 25.1 (3.1), 25.3 (2.2), and 18.1 (5.0) mmHg at T0, T1, T2, T3, and T4, respectively. The mean intraocular pressure was higher at T1, T2, and T3 than at T0 (p < 0.0001 for all). There was no significant difference between T0 and T4, and between T3 and T2 (p > 0.99 for both). Conclusions The Trendelenburg position during robotic-assisted laparoscopic prostatectomy increased intraocular pressure. The increase was moderate at 90 minutes after the position was assumed, with the value being approximately 7 mmHg higher than the baseline value. The baseline intraocular pressure was restored at 30 minutes after the supine position was reassumed. Trial registration UMIN ID 000014973 Date of registration August 27, 2014
  • The association between surgical technique and oculocardiac reflex in pediatric strabismus surgery: an observational study Clinical Research

    Kılıç, Yeliz; Güleç, Mehmet Sacit

    Abstract in English:

    Abstract Background and objectives The most common cause of oculocardiac reflex (OCR) is traction of the extraocular muscles. Therefore, strabismus surgery is highly risk for the development of this complication. This study aimed to investigate whether an association exists between the occurrence of OCR and the type of extraocular muscle manipulated during strabismus in a pediatric population. Methods A total of 53 pediatric patients who were operated for strabismus under sevoflurane anesthesia were enrolled in this prospective study. The association between surgical techniques and the occurrence of OCR was investigated. Results This study included 30 (56.6%) males and 23 (43.4%) females, with a mean age of 8.4 years. Overall, 83 eyes with 93 extraocular muscles were operated. Surgery was performed most frequently on the medial (44.6%) and lateral (36.1%) recti. OCR occurred in 33 (62.3%) patients. OCR was found to be significantly higher in the first operated muscle compared with the second muscle, regardless of muscle type, as identified in the statistical analysis based on the sequence of the operated muscles. Conclusions The manipulation of the first extraocular muscle has a higher risk of OCR in the pediatric population undergoing two-muscle surgery for strabismus.
  • Effect of adding clonidine to lidocaine on ocular hemodynamics during sub-Tenon’s anesthesia: randomized double-blind study Clinical Research

    Cabral, Sigmar Aurea; Carraretto, Antonio Roberto; Sousa, Angela Maria; Gomez, Renato Santiago

    Abstract in English:

    Abstract Introduction and objectives Different regional anesthesia techniques for ophthalmology can have hemodynamic effects on the eye. We assessed the effects of adding clonidine to lidocaine on Intraocular Pressure (IOP), Ocular Pulse Amplitude (OPA), and Ocular Perfusion Pressure (OPP) after the sub-Tenon’s technique for cataract surgery. Methods The study included 40 patients randomly allocated into two groups: sub-Tenon’s blockade with Lidocaine plus Saline Solution (LS) or Lidocaine plus Clonidine (LC). IOP, OPA and OPP were measured before anesthesia, and 1, 5 and 10 minutes after the injection of anesthetic solution. Results There was no difference between the groups in IOP, OPA, and OPP baseline values. After the injection of the anesthetic solution, the IOP increased in both groups at minute one, with a mean difference of +4.67 mmHg (p = 0.001) and +2.15 mmHg (p = 0.013) at 5 minutes. The increase was lower in the LC group when compared to LS (p = 0.027). OPA decreased in both groups, with a baseline difference, after 1 minute, of -0.85 mmHg (p = -0.85 mmHg (p = 0.001), and at 5 and 10 minutes with differences of -1.17 (p = 0.001) and -0.89 mmHg (p = 0.001), respectively. The highest decrease was observed in group LC in relation to group LS (p = 0.03). There was no difference in OPP in relation to baseline measurements. Conclusions Adding clonidine to lidocaine for sub-Tenon’s anesthesia reduced IOP and OPA without significant changes in OPP.
  • Minimum effective volume of local anesthetic in peribulbar block: does it differ with the eyeball axial length? Clinical Research

    Fawal, Sanaa M. El; Nofal, Walid H.; Sabek, Eman A.S.; Abdelaal, Wail Ahmed

    Abstract in English:

    Abstract Background: Peribulbar Anesthesia (PBA) is a relatively safe method for cataract surgery. The anesthetic volume should be adjusted according to the axial eyeball length. Thus, using Minimum Effective Volume (MEV) of local anesthetic helps avoiding unnecessary volumes, preventing increases in intra-ocular pressure, and producing satisfactory conditions for cataract surgery. This study aims to determine the MEV90 of local anesthetics in relation to eye globe axial length in peribulbar blocks for cataract surgery. Methods: Patients scheduled for cataract extraction under local anesthesia were divided according to their axial eyeball length; Group 1 included those with axial length from 22 to 24mm, Group 2 included patients with axial length from 24.1 to 26mm. The initial volume used was 7mL of a solution of bupivacaine 0.5% (3mL) + lidocaine 2% (3 mL) + hyaluronidase 150 IU (1 mL). The subsequent volumes were dependent on the response of the previous patient, by using a Bias Coin Design (BCD) and Up and Down Method (UDM) for MEV-90 determination. Results: The study was concluded with 119 patients. Sixteen patients needed supplemental volume of local anesthetic in Group 1 and thirteen in Group 2. The MEV90 for Group 1 was approximately 5.82 mL (95% CI 5.6 to 5.87mL) and 5.45 mL for Group 2 (95% CI 5.38 to 5.91 mL). No major complications were noted. There was a negative correlation between the effective volume of LA and eye globe axial length in both groups (p = 0.001). Conclusion: The MEV90 of local anesthetics for peribulbar block show a strong and inverse correlation with eye globe axial length. This may help achieving an effective block with minimum complications.
  • Spinal anesthesia for elective cesarean section. Bupivacaine associated with different doses of fentanyl: randomized clinical trial Clinical Research

    Ferrarezi, Wesla Packer Pfeifer; Braga, Angélica de Fátima de Assunção; Ferreira, Valdir Batista; Mendes, Sara Quinta; Brandão, Maria José Nascimento; Braga, Franklin Sarmento da Silva; Carvalho, Vanessa Henriques

    Abstract in English:

    Abstract Objective Assess patients submitted to elective cesarean section under spinal anesthesia, and the efficacy of different doses of fentanyl associated with bupivacaine. Methods The study included 124 pregnant women randomly distributed into 4 groups (n = 31) according to different doses of fentanyl (15 µg, 10 µg, 7.5 µg), Groups I, II, and III, respectively, and control group IV, associated with 0.5% hyperbaric bupivacaine (10 mg). An epidural catheter was inserted in case epidural top-up was required. We assessed the anesthetic blockage characteristics, negative maternal and neonatal outcomes, and maternal side effects. Statistical analysis was performed using Kruskal-Wallis, Fisher’s exact and chi-square tests. The level of significance was 5% (p < 0.05). Results The quality of analgesia, time for the first complaint of pain and motor block recovery time were significantly better for groups that received fentanyl in comparison to controls (p < 0.001). None of the groups had negative maternal-fetal outcomes. Nausea was significantly more frequent in patients in Groups II (10 µg) and III (7.5 µg) when compared to Groups I (15 µg) and IV (no fentanyl). Vomiting was more frequent in Group III than in Group I (p = 0.006). The incidence of pruritus was significantly higher in the groups receiving fentanyl (p = 0.012). Conclusions Among the solutions studied, the spinal anesthesia technique using 15 µg of fentanyl associated with 10 mg of hyperbaric bupivacaine provided satisfactory analgesia and very low incidence of adverse effects for patients submitted to cesarean section. Trial Registration Number UTN U1111-1199-0285. REBEC RBR-5XWT6T.
  • Chronic postoperative pain: ubiquitous and scarcely appraised – narrative review Narrative Review

    Lopes, Alexandre; Menezes, Miriam Seligman; Barros, Guilherme Antonio Moreira de

    Abstract in English:

    Abstract The International Association for the Study of Pain chose pain prevention as the theme for the 2020 Global Year. Chronic postoperative pain is one the many types of pain that can be potentially prevented. It develops or increases in severity after a surgery, persists for at least three months, even after ruling out all other possible causes of pain. To perform the present narrative review, the authors searched the PubMed database using the following keywords “postoperative pain” OR “postsurgical pain” AND “chronic” OR “persistent”. The present review focused on the incidence, pain development and chronification, and predisposing factors. It also discusses prevention, diagnosis, and treatment of chronic postoperative pain. Awareness of occurrence of chronic postoperative pain and recognizing risk factors is crucial for the day-to-day practice of the anesthesiologist. Hence, numerous surgical patients can have their outcome improved by preventing chronic postoperative pain, a condition scarcely identified and without a well-established treatment.
  • Noninvasive intracranial pressure real-time waveform analysis monitor during prostatectomy robotic surgery and Trendelenburg position: case report Case Reports

    Saba, Gabriela Tognini; Quintão, Vinicius Caldeira; Zeferino, Suely Pereira; Simões, Claudia Marquez; Coelho, Rafael Ferreira; Fazoli, Arnaldo; Nahas, William; Vilela, Gustavo Henrique Frigieri; Carmona, Maria José Carvalho

    Abstract in English:

    Abstract Both robotic surgery and head-down tilt increase intracranial pressure by impairing venous blood outflow. Prostatectomy is commonly performed in elderly patients, who are more likely to develop postoperative cognitive disorders. Therefore, increased intracranial pressure could play an essential role in cognitive decline after surgery. We describe a case of a 69-year-old male who underwent a robotic prostatectomy. Noninvasive Brain4care™ intraoperative monitoring showed normal intracranial compliance during anesthesia induction, but it rapidly decreased after head-down tilt despite normal vital signs, low lung pressure, and adequate anesthesia depth. We conclude that there is a need for intraoperative intracranial compliance monitoring since there are major changes in cerebral compliance during surgery, which could potentially allow early identification and treatment of impaired cerebral complacency.
  • Effects of allopurinol on pain and anxiety in fibromyalgia patients: a pilot study Case Reports

    Fagundes, Aécio C.; Souza, Diogo O.; Schmidt, André P.

    Abstract in English:

    Abstract Allopurinol is a potent inhibitor of the enzyme xanthine oxidase used in the treatment of hyperuricemia and gout. The aim of this pilot study was to investigate the effects of allopurinol on pain and anxiety in women displaying fibromyalgia refractory to conventional therapy. This prospective case series enrolled 12 women with previous diagnosis of fibromyalgia refractory to conventional therapy. Patients received an add-on therapy with oral allopurinol 300 mg twice daily for 30 days. Patients were submitted to evaluation for pain and anxiety scores before treatment, 15 and 30 days thereafter. This pilot study has demonstrated that oral administration of allopurinol 300 mg twice daily caused a significant reduction on pain scores up to 30 days of treatment in women with fibromyalgia. No effect was observed regarding anxiety scores. Randomized clinical trials are warranted and should further investigate allopurinol and more selective purine derivatives in the management of acute or chronic pain conditions.
  • Ultrasound block of first branch of the lateral plantar nerve (baxter nerve): case report of a promising and effective treatment for heel chronic pain Case Reports

    Rio Coles, Inês; Lima Vieira, Catarina; Barroco Gouveia, Isabel; Rebelo, Teresa; Agualusa, Luís

    Abstract in English:

    Abstract Chronic heel pain is a challenging diagnosis and although it is a common and disabling condition frequently mistreated. Baxter Nerve (BN) entrapment is responsible for 20% of heel pain and can be managed by an ultrasound guide nerve block, a simple, safe, and durable technique. A 67-year-old woman complained of paraesthesia on the left heel and a “stepping on glass” feeling. Various techniques were performed to manage her symptoms without any results. An ultrasound BN block was finally performed with an instant relief and satisfactory pain control for the follow-up period of six months. This clinical report highlights the success of the ultrasound BN block as an effective and lasting solution for chronic heel pain.
  • Sphenopalatine ganglion block for refractory COVID-19 headache: a descriptive case series Case Reports

    Machado, Felipe Chiodini; Carone Neto, Gilson; Carone, Rebeca Santiago Duarte

    Abstract in English:

    Abstract Coronavirus SARS-CoV-2 is responsible for the COVID-19 pandemic, and headache is reported in 6.5% to 34% of all cases. There is little published evidence on the pharmacological treatment of COVID-19 headache. This case series presents six COVID-19 infected patients with refractory headache in which intranasal bedside Sphenopalatine Ganglion Block was performed for analgesia. All patients had a reduction in headache intensity from severe to mild or no pain after the procedure with minor transient side effects. Proposed mechanisms of action include reduction of local autonomic stimuli, intracranial vasoconstriction, and reduction of vasoactive substances release in the pterygopalatine fossa.
  • Priming Insertion of the Laryngeal Mask at Induction: why should we dare to think about it? Letter To The Editor

    Almeida, Carlos Rodrigues
  • Inefficient humidification as the cause of noninvasive ventilation failure in COVID-19 patients Letter To The Editor

    Kumar, Amarjeet; Sinha, Chandni; Kumar, Abhyuday; Kumar, Neeraj; Kumar, Ajeet; Singh, Kunal; Singh, Prabhat Kumar
  • Videolaryngoscopes: not only for endotracheal intubation Letter To The Editor

    Araz, Coşkun; Kayhan, Zeynep
  • The quest for smooth extubation: I banned air from the ETT cuff for good… Letter To The Editor

    Ramos, Marcelo Sperandio
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