Resumo em Inglês:

Abstract Background Recent data suggest the regime of fluid therapy intraoperatively in patients undergoing major surgeries may interfere in patient outcomes. The development of postoperative Acute Kidney Injury (AKI) has been associated with both Restrictive Fluid Balance (RFB) and Liberal Fluid Balance (LFB) during non-cardiac surgery. In patients undergoing cardiac surgery, this influence remains unclear. The study objective was to evaluate the relationship between intraoperative RFB vs. LFB and the incidence of Cardiac-Surgery-Associated AKI (CSA-AKI) and major postoperative outcomes in patients undergoing on-pump Coronary Artery Bypass Grafting (CABG). Methods This prospective, multicenter, observational cohort study was set at two high-complexity university hospitals in Brazil. Adult patients who required postoperative intensive care after undergoing elective on-pump CABG were allocated to two groups according to their intraoperative fluid strategy (RFB or LFB) with no intervention. Results The primary endpoint was CSA-AKI. The secondary outcomes were in-hospital mortality, cardiovascular complications, ICU Length of Stay (ICU-LOS), and Hospital LOS (H-LOS). After propensity score matching, 180 patients remained in each group. There was no difference in risk of CSA-AKI between the two groups (RR = 1.15; 95% CI, 0.85-1.56, p= 0.36). The in-hospital mortality, H-LOS and cardiovascular complications were higher in the LFB group. ICU-LOS was not significantly different between the two groups. ROCcurve analysis determined a fluid balance above 2500 mL to accurately predict in-hospital mortality. Conclusion Patients undergoing on-pump CABG with LFB when compared with patients with RFB present similar CSA-AKI rates and ICU-LOS, but higher in-hospital mortality, cardiovascular complications, and H-LOS.

Resumo em Inglês:

Abstract Introduction Intraoperative fluid therapy in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy plays an important role in postoperative morbidity. Studies have found an association between overload fluid therapy and increased postoperative complications, advising restrictive intraoperative fluid therapy. Our objective in this study was to compare the morbidity associated with restrictive versus non-restrictive intraoperative fluid therapy. Methods Retrospective analysis of a database collected prospectively in the Anesthesiology Service of Virgen del Rocío Hospital, from December 2016 to April 2019. One hundred and six patients who underwent complete cytoreductive surgery and hyperthermic intraperitoneal chemotherapy were divided into two cohorts according to Fluid Therapy received 1. Restrictive ≤ 9 mL.kg-1.h-1 (34 patients), 2. Non-restrictive ≥ 9 mL.kg-1.h-1 (72 patients). Percentage of major complications (Clavien-Dindo grade III-IV) and length hospital stay were the main outcomes variables. Results Of the 106 enrolled patients, 68.9% were women; 46.2% had ovarian cancer, 35.84% colorectal cancer, and 7.5% peritoneal cancer. The average fluid administration rate was 11 ± 3.58 mL.kg-1.h-1. The restrictive group suffered a significantly higher percentage of Clavien-Dindo grade III-IV complications (35.29%) compared with the non-restrictive group (15.27%) (p= 0.02). The relative risk associated with restrictive therapy was 1.968 (95% confidence interval: 1.158-3.346). We also found a significant difference for hospital length of stay, 20.91 days in the restrictive group vs 16.19 days in the non-restrictive group (p= 0.038). Conclusions Intraoperative fluid therapy restriction below 9 mL.kg-1.h-1 in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy was associated with a higher percentage of major postoperative complications.

Resumo em Inglês:

Abstract Background and objectives The Beach Chair Position (BCP) has many advantages such as less neurovascular injury and better intra-articular visualization, but it has also negative consequences, including hemodynamic instability. Although maintaining normal Mean Arterial Pressure (MAP) is important, fluid management is also a crucial concept for hemodynamic stability. The main objective of this study is whether preloading before positioning would be effective for less hemodynamic instability. Methods This randomized, controlled study was conducted in a single center in the Istanbul University, Istanbul Faculty of Medicine. Forty-nine patients undergoing elective arthroscopic surgery in the BCP were recruited. In the study group, crystalloid fluid at 10 mL.kg-1 of ideal body weight was administered intravenously 30 min before the BCP for preloading. The primary outcome measures were differences of hemodynamic variables as MAP, Stroke Volume (SV), Heart Rate (HR), and Cardiac Output (CO). The secondary outcome measures were Postoperative Nausea and Vomiting (PONV) rates in postoperative first day, surgical satisfaction scale, total ephedrine dose used during surgery, and total amount of fluid. Results The MAP, CO, and SV measurements of the study group were higher than those of the control group in the 5th minute after the BCP (respectively, p= 0.001, p= 0.016, p= 0.01). The total amount of crystalloid and surgical satisfaction scales were higher in the study group (respectively, p= 0.016, p= 0.001). Total amount of colloid and ephedrine dose used in the intraoperative period, and PONV rates were lower in the study group (p= 0.003, p= 0.018, p= 0.019, respectively). Conclusion Consequently, preloading can be favorable approach to preserve hemodynamic stability.

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Abstract Background The influence of different crystalloid solutions infused during deceased-donor kidney transplant on the incidence of delayed graft function remains unclear. We investigated the influence of Plasma-Lyte® vs. 0.9% saline on the incidence of delayed graft function in deceased-donor kidney transplant recipients. Methods We conducted a single-blind randomized controlled trial of 104 patients aged 18 to 65 years who underwent deceased-donor kidney transplant under general anesthesia. Patients were randomly assigned to receive either Plasma-Lyte® (n = 52) or 0.9% saline (n = 52), at the same infusion volume, for intraoperative fluid replacement. The primary outcome was the occurrence of delayed graft function. Secondary outcomes included metabolic and electrolytic changes at the end of surgery. Results Two patients in the Plasma-Lyte® group and one in the 0.9% saline group died postoperatively and were not included for analysis. The incidence of delayed graft function in Plasma-Lyte® and 0.9% saline groups were 60.0% (95% Confidence Interval [95% CI 46.2-72.4]) and 74.5% (95% CI 61.1-84.4), respectively (p= 0.140). Mean (standard deviation) values of immediate postoperative pH and serum chloride levels in Plasma-Lyte® and 0.9% saline groups were 7.306 (0.071) and 7.273 (0.061) (p= 0.013), and 99.6 (4.2) mEq.L-1 and 103.3 (5.6) mEq.L-1, respectively (p< 0.001). All other postoperative metabolic and electrolyte variables were not statistically different at the immediate postoperative period (p> 0.05). Conclusion In deceased-donor kidney transplant recipients, the incidence of delayed graft function is not influenced by Plasma-Lyte® or 0.9% saline used for intraoperative fluid replacement.

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Abstract Background Hydroxyethyl starches are colloids used in fluid therapy that may reduce volume infusion compared with crystalloids, but they can affect renal function in critical care patients. This study aims to assess renal effects of starches using renal biomarkers in the perioperative setting. Methods This prospective, controlled, randomized study compared Hydroxyethyl starch 6% (HES) with Ringer's lactate (RL) in hysterectomy. Each episode of mean arterial pressure (MAP) below 60 mmHg guided the fluid replacement protocol. The RL group received 300 mL bolus of RL solution while the HES group received 150 mL of HES solution. All patients received RL (2 mL.kg−1.h−1) intraoperatively to replace insensible losses. Blood and urine samples were collected at three time points (preoperatively, 24 hours, and 40 days postoperatively) to assess urinary NGAL and KIM-1, as primary outcome, and other markers of renal function. Results Seventy patients were randomized and 60 completed the study. The RL group received a higher crystalloid volume (1,277 ± 812.7 mL vs. 630.4 ± 310.2 mL; p= 0.0002) with a higher fluid balance (780 ± 720 mL vs. 430 ± 440 mL; p= 0.03) and fluid overload (11.7% ± 10.4% vs. 7.0% ± 6.3%; p= 0.04) compared to the HES group. NGAL and KIM-1 did not differ between groups at each time point, however both biomarkers increased 24 hours postoperatively and returned to preoperative levels after 40 days in both groups. Conclusion HES did not increase renal biomarkers following open hysterectomy compared to RL. Moreover, HES provided better hemodynamic parameters using less volume, and reduced postoperative fluid balance and fluid overload.

Resumo em Inglês:

Abstract Background Pancreaticoduodenectomy is associated with high morbidity. Many preoperative variables are risk factors for postoperative complications, but they are primarily non-modifiable. It is not clear whether an intraoperative goal-directed fluid regimen might be associated with fewer postoperative surgical complications compared to current conservative, non-goal-directed fluid practices. We hypothesize that the use of Systolic Volume Variation (SVV)-guided intraoperative fluid administration might be beneficial. Methods Data from 223 patients who underwent pancreaticoduodenectomy in our institution between 2015 and 2019 were reviewed. Patients were classified into two groups based on the use of intraoperative use of SVV to guide the administration of fluids. The decision to use SVV or not was made by the attending anesthesiologist. Subjects were classified into SVV-guided intraoperative fluid therapy (SVV group) and non-SVV-guided intraoperative fluid therapy (non-SVV group). Uni and multivariate regression analyses were conducted to determine if SVV-guided fluid therapy was significantly associated with a lower incidence of postoperative surgical complications, such as Postoperative Pancreatic Fistula (POPF), Delayed Gastric Emptying (DGE), among others, after adjusting for confounders. Results Baseline, demographic, and intraoperative characteristics were similar between SVV and non-SVV groups. In the multivariate analysis, the use of SVV guidance was significantly associated with fewer postoperative surgical complications (OR = 0.48; 95% CI 0.25-0.91; p= 0.025), even after adjusting for significant covariates, such as perioperative use of epidural, pancreatic gland parenchyma texture, and diameter of the pancreatic duct. Conclusions VV-guided intraoperative fluid administration might be associated with fewer postoperative surgical complications after pancreaticoduodenectomy.

Resumo em Inglês:

Abstract Background There is currently some discussion over the actual usefulness of performing preoperative upper airway assessment to predict difficult airways. In this field, modified Mallampati test (MMT) is a widespread tool used for prediction of difficult airways showing only a feeble predictive performance as a diagnostic test. We therefore aimed at evaluating if MMT test would perform better when used as a screening test rather than diagnostic. Methods An accuracy prospective study was conducted with 570 patients undergoing general anesthesia for surgical procedures. We collected preoperatively data on sex, age, weight, height, body mass index (BMI), ASA physical status, and MMT. The main outcome was difficult laryngoscopy defined as Cormack and Lahane classes 3 or 4. Bivariate analyses were performed to build three different predictive models with their ROC curves. Results Difficult laryngoscopy was reported in 36 patients (6.32%). Sex, ASA physical status, and MMT were associated with difficult laryngoscopy, while body mass index (BMI) was not. The MMT cut-off with the highest odds ratio was the class II, which also presented significantly higher sensitivity (94.44%). The balanced accuracy was 67.11% (95% CI: 62.78-71.44%) for the cut-off of class II and 71.68% (95% CI: 63.83-79.54) for the class III. Conclusion MMT seems to be more clinically useful when the class II is employed as the threshold for possible difficult laryngoscopies. At this cut-off, MMT shows the considerable highest sensitivity plus the highest odds ratio, prioritizing thus the anticipation of difficult laryngoscopies.

Resumo em Inglês:

Abstract Background and objectives Several anthropometric measurements have been suggested to identify a potentially difficult airway. We studied thyromental height (TMH) as a predictor of difficult laryngoscopy and difficult intubation. We also compared TMH, ratio of height to thyromental distance (RHTMD), and thyromental distance (TMD) as predictors of difficult airway. Methods This cross-sectional observational study was conducted in 300 adult surgical patients requiring tracheal intubation. Preoperatively airway characteristics were assessed. Standard anesthesia was administered. Degree of difficulty with mask ventilation, laryngoscopic view, duration of laryngoscopy, and difficulty in tracheal intubation (intubation difficulty scale score) were noted. Multivariate logistics regression analysis was performed to identify independent predictors for difficult laryngoscopy. Results Laryngoscopy was difficult in 46 of 300 (15.3%) patients; all 46 patients had Cormack-Lehane grade 3 view. Duration of laryngoscopy was 27 ± 11 s in patients with difficult laryngoscopy and 12.7 ± 3.9 s in easy laryngoscopy; p= 0.001. Multivariate analysis identified that TMH, presence of short neck, and history of snoring were independently associated with difficult laryngoscopy. Incidence of difficult intubation was 17.0%. A shorter TMH was associated with higher IDS scores; r = -0.16, p= 0.001. TMH and duration of laryngoscopy were found to be negatively correlated; a shorter TMH was associated with a longer duration of laryngoscopy; r = -0.13, p= 0.03. The cut-off threshold value for TMH in our study is 4.4 cm with a sensitivity of 66% and a specificity of 54%. Conclusion Thyromental height predicts difficult laryngoscopy and difficult intubation. TMD and RHTMD did not prove to be useful as predictors of difficult airway.

Resumo em Inglês:

Abstract Background Pulmonary aspiration is one of the most important complications in anesthesiology. Assessment of gastric content by ultrasound is a good method to quantify gastric volume and to determine the risk of intraoperative pulmonary aspiration. The aim of this study is to determine the accuracy of the gastric ultrasonography in the qualitative analysis of gastric content, mainly in the analysis of small amounts of liquid content. Methods Gastric ultrasound was performed to 36 patients before upper gastrointestinal endoscopy (UGI), making two longitudinal scans at the epigastric level, one in supine position and the other in right lateral decubitus position, measuring two diameters and the area of the gastric antrum and assessing the content characteristics determining whether it was an empty stomach or contained fluid or solid content. Subsequently, the ultrasound findings were compared with UGI findings. Results Gastric areas were analyzed by the trace and the lengths of the craniocaudal and anteroposterior axes concluding that there are no significant differences between the two methods. No statistically significant difference was found between UGI and US assessment technics. No statistically significant difference was found between the estimated volume by UGI and US. Conclusions Though our study has some limitations, qualitative analysis of gastric content using ultrasound followed by endoscopy enabled the conclusion that there are no differences in the qualitative assessment regarding these two techniques, supporting the important role of point-of-care gastric ultrasound (POCGUS) in the assessment of pulmonary aspiration risk by the anesthesiologist in the perioperative period.

Resumo em Inglês:

Abstract Background The traditional infusion of “yerba mate” is widely consumed in South America and exported to countries around the world. Although generally considered a “clear fluid”, there is no data to date on the gastric emptying time of yerba mate and safe preoperative fasting intervals. The objective of this study was to evaluate the gastric emptying time of a standardized infusion of yerba mate using bedside ultrasound and compare it with the time confirm of hot and cold tea. Methods This was a prospective, randomized crossover experimental study. Thirty healthy volunteers were evaluated after 8 hours of fasting for both fluids and solids. Gastric antral area and gastric volume were evaluated at baseline and every 20 minutes after drinking 300 mL of randomly assigned infusion of “yerba mate”, hot tea, or cold tea. Results The mean gastric emptying time was: 69.7 ± 22.1 min, 63.1 ± 14.5 min, and 64.3 ± 23.5 min for the mate, hot tea, and cold tea respectively. No significant differences were found in emptying time among the infusion groups (p-value = 0.043). When same time measures were compared, the only significant difference detected was between hot teas and mate infusion at 20 minutes (p-value = 0.012) Conclusion Yerba mate infusion has a similar gastric emptying time to that of tea. All subject's gastric volume returned to baseline values by 100 minutes. It is reasonable to recommend a similar fasting period of 2 hours for mate infusion prior to elective surgery.

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Abstract Backgrounds Procedures for Postoperative Nausea and Vomiting (PONV) prevention are mostly based on identification of the risk factors before administering antiemetic drugs. The purpose of this study was to evaluate the impact of the extended use of antiemetic on the PONV in the Postanesthetic Care Unit (PACU). Methods Two separate 4-year periods (2007-2010, P1, and (2015-2018, P2) were evaluated. During P1, the protocol consisted of dexamethasone and droperidol for patients with a locally adapted high PONV score, followed by ondansetron for rescue in the PACU. For Period 2, dexamethasone (8 mg) and ondansetron (4 mg) were administered in patients under general or regional anesthesia, or sedation longer than 30 minutes, while droperidol (1.25 mg) in rescue was injected in cases of PONV in the PACU. An Anesthesia Information Management System was used to evaluate the intensity score of PONV (1 to 5), putative compliance, sedation, and perioperative opioid consumption upon arrival in the PACU. Results A total of 27,602 patients were assessed in P1 and 36,100 in P2. The administration of dexamethasone and ondansetron increased several fold (p < 0.0001). The high PONV scores were more improved in P2 than in P1, with scores (3+4+5) for P1 vs. P2, p < 0.0001. Overall, 99.7% of the patients in P2 were asymptomatic at discharge. Morphine consumption decreased from 6.9±1.5 mg in P1 to 3.5 ± 1.5 mg in P2 (p < 0.0001). Discussion The extension of pharmacological prevention of PONV was associated with a decrease in the intensity of severe PONV. However, uncertainty regarding confounding factors should not be ignored. IRB nº 92012/33465

Resumo em Inglês:

Abstract Background Dexmedetomidine (Dex) is widely used, and its most common side effect is bradycardia. The complete mechanism through which Dex induces bradycardia has not been elucidated. This research investigates the expression of gap junction proteins Connexin30.2 (Cx30.2) and Connexin40 (Cx40) within the sinoatrial node of rats with Dex-induced sinus bradycardia. Methods Eighty rats were randomly assigned to five groups. Saline was administered to rats in Group C. In the other four groups, the rats were administered Dex to induce bradycardia. In groups D1and D2, the rats were administered Dex at a loading dose of 30 μg.kg−1 and 100 μg.kg−1 for 10 min, then at 15 μg.kg−1.h−1 and 50 μg.kg−1.h−1 for 120 min separately. The rats in group D1A and D2A were administered Dex in the same way as in group D1and D2; however, immediately after the administration of the loading dose, 0.5 mg atropine was administered intravenously, and then at 0.5 mg.kg−1.h−1 for 120 min. The sinoatrial node was acquired after intravenous infusion was completed. Quantitative real-time polymerase chain reaction and western blot analyses were performed to measure mRNA and protein expression of Cx30.2 and Cx40, respectively. Results The expression of Cx30.2 increased, whereas the expression of Cx40 decreased within the sinoatrial node of rats with Dex-induced sinus bradycardia. Atropine reversed the effects of Dex on the expression of gap junction proteins. Conclusion Dex possibly altered the expression of gap junction proteins to slow down cardiac conduction velocity in the sinoatrial node.

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Abstract Background Interscalene brachial plexus block is associated with phrenic nerve paralysis. The objective of this study was to evaluate an alternative approach to interscalene brachial plexus blocks in terms of efficacy, grade of motor and sensory blockade, and phrenic nerve blockade. Methods The study was prospective and interventional. The ten living patients studied were 18 to 65 years old, ASA physical status I or II, and submitted to correction of rotator cuff injury. A superior trunk blockade was performed at the superior trunk below the omohyoid muscle, without blocking the phrenic nerve. The needle was advanced below the prevertebral layer until contacting the superior trunk. In order to guarantee the correct positioning of the needle tip, an intracluster pattern of the spread was visualized. The block was performed with 5 mL of 0.5% bupivacaine in ten patients. In the six cadavers, 5 mL of methylene blue was injected. Diaphragmatic excursion was assessed by ultrasonography of the ipsilateral hemidiaphragm. In three patients, pulmonary ventilation was evaluated with impedance tomography. Pain scores and analgesic consumption were assessed in the recovery room for 6 hours after the blockade. Results In the six cadavers, methylene blue didn’t reach the phrenic nerve. Ten patients underwent arthroscopic surgery, and no clinically phrenic nerve paralysis was observed. No patient reported pain during the first 6 hours. Conclusions This study suggests that this new superior trunk approach to block the superior trunk may be an alternative technique to promote analgesia for shoulder surgery in patients with impaired respiratory function.

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Abstract Background The efficacy and safety profiles of prone ventilation among intubated Coronavirus Disease 2019 (COVID-19) patients remain unclear. The primary objective was to examine the effect of prone ventilation on the ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2) in intubated COVID-19 patients. Methods Databases of MEDLINE, EMBASE and CENTRAL were systematically searched from inception until March 2021. Case reports and case series were excluded. Results Eleven studies (n = 606 patients) were eligible. Prone ventilation significantly improved PaO2/FiO2 ratio (studies: 8, n = 579, mean difference 46.75, 95% CI 33.35‒60.15, p < 0.00001; evidence: very low) and peripheral oxygen saturation (SpO2) (studies: 3, n = 432, mean difference 1.67, 95% CI 1.08‒2.26, p < 0.00001; evidence: ow), but not the arterial partial pressure of carbon dioxide (PaCO2) (studies: 5, n = 396, mean difference 2.45, 95% CI 2.39‒7.30, p= 0.32; evidence: very low), mortality rate (studies: 1, n = 215, Odds Ratio 0.66, 95% CI 0.32‒1.33, p= 0.24; evidence: very low), or number of patients discharged alive (studies: 1, n = 43, Odds Ratio 1.49, 95% CI 0.72‒3.08, p= 0.28; evidence: very low). Conclusion Prone ventilation improved PaO2/FiO2 ratio and SpO2 in intubated COVID-19 patients. Given the substantial heterogeneity and low level of evidence, more randomized- controlled trials are warranted to improve the certainty of evidence, and to examine the adverse events of prone ventilation.

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Abstract Idiopathic intracranial hypertension (IIH) is a neurological condition characterized by raised intracranial pressure of unknown etiology with normal cerebrospinal fluid (CSF) composition and no brain lesions. It occurs in pregnant patients at approximately the same frequency as in general population, but obstetric and anesthetic management of the pregnancy and labor remains controversial. In this article we provide a multidisciplinary review of the main aspects of IIH in pregnancy including treatment options, mode of delivery and anesthetic techniques. Additionally, we report three cases of pregnant women diagnosed with IIH between 2012 and 2019 in our institution.

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Abstract Tranexamic acid (TXA) significantly reduces blood loss in a wide range of surgical procedures and improves survival rates in obstetric and trauma patients with severe bleeding. Although it mainly acts as a fibrinolysis inhibitor, it also has an anti-inflammatory effect, and may help attenuate the systemic inflammatory response syndrome found in some cardiac surgery patients. However, the administration of high doses of TXA has been associated with seizures and other adverse effects that increase the cost of care, and the administration of TXA to reduce perioperative bleeding needs to be standardized. Tranexamic acid is generally well tolerated, and most adverse reactions are considered mild or moderate. Severe events are rare in clinical trials, and literature reviews have shown tranexamic acid to be safe in several different surgical procedures. However, after many years of experience with TXA in various fields, such as orthopedic surgery, clinicians are now querying whether the dosage, route and interval of administration currently used and the methods used to control and analyze the antifibrinolytic mechanism of TXA are really optimal. These issues need to be evaluated and reviewed using the latest evidence to improve the safety and effectiveness of TXA in treating intracranial hemorrhage and bleeding in procedures such as liver transplantation, and cardiac, trauma and obstetric surgery.

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Abstract Lung transplantation is the last resort for end-stage lung disease treatment. Due to increased survival, lung recipients present an increased likelihood to be submitted to anesthesia and surgery. This case report describes a 23-year-old female patient with history of lung transplantation for cystic fibrosis, with multiple complications, and chronic kidney disease, and who underwent kidney transplantation under general anesthesia. Understanding the pathophysiology and changes related to immunosuppressive therapy is essential to anesthetic technique planning and safety, and for perioperative management. The success of both anesthesia and surgery requires a qualified multidisciplinary team due to the rarity of the clinical scenario and high incidence of associated morbidity and mortality.

Resumo em Inglês:

Abstract Factor X deficiency ranks among the rarest coagulopathies and has a variable presentation spectrum. We intend to present a proposal for anesthesia protocol for individuals with the coagulopathy. The excision of an ovarian neoplasm was proposed for a 26-year-old, female, ASA II patient, with congenital Factor X deficiency. Physical examination and lab tests were normal, except for Prothrombin Time (PT) 22.1s (VR: 8-14s), International Normalized Ratio (INR) 1.99 (VR: 0.8-1.2) and Activated Partial Thromboplastin Time (aPTT) 41.4s (VR: 25-37s). We concluded that a history of bleeding should always be investigated, along with a pre-anesthetic coagulation study.

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Abstract Neisseria meningitidis, also known as meningococcus, is a relatively uncommon cause of invasive infection, but when it occurs, it is frequently severe and potentially life-threatening. A ten-year-old female patient developed a purpuric rash with fever. Upon arrival to the pediatric intensive care department, she was unconscious and in a poor general condition. We combined treatment with antibiotics, volume resuscitation, hydrocortisone, and CytoSorb® therapy resulted in a stabilization of hemodynamics, as well as control of hyperinflammation. We observed a significant decrease in vasopressor dosage in this patient.

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Abstract Glanzmannʼs Trombasthenia (GT) is a genetic disorder, that develops with a tendency toward bleeding and is characterized by the absence or decrease in platelet aggregation. Surgical bleeding may be difficult to control. Platelet transfusion is the main treatment, albeit refractoriness can occur. We describe the case of a patient with GT and platelet refractoriness, who was submitted to radical prostatectomy and dental extraction. The perioperative treatment with apheresis platelet concentrate and activated recombinant factor seven allowed the procedures to be performed uneventfully. We discuss the complexity of the case and the treatment option.

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Abstract Mutations in SCN8A gene lead to changes in sodium channels in the brain, which are correlated with severe epileptic syndrome. Due to the rarity, there are few studies that support anesthesia in that population. The present study aims to report alternatives to inhalation anesthesia at epileptic encephalopathy. Case report: Male, 4 years old, with SCN8A encephalopathy with surgical indication of orchidopexy. Neuroaxis block was performed and dexmedetomidine was used as a pre-anesthetic and sedation. The anestheticsurgical act was uneventful. Conclusion: The association of neuraxial block and dexmedetomidine proved to be a viable alternative for surgery in patients with SCN8A encephalopathy.