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Brazilian Journal of Anesthesiology, Volume: 73, Issue: 3, Published: 2023
  • Anesthesia services management, economics, and new technologies Editorial

    Guimarães, Gabriel Magalhães Nunes; Bogniotti, Lauro Afonso Côrtes; Alecrim, Hugo Muscelli; Baldo, Lucas Teixeira
  • Contribution margin per hour of operating room to reallocate unutilized operating room time: a cost-effectiveness analysis Original Investigation

    Saporito, Andrea; Regina, Davide La; Perren, Andreas; Gabutti, Luca; Anselmi, Luciano; Cafarotti, Stefano; Mongelli, Francesco

    Abstract in English:

    Abstract Background and objectives: Contribution margin per hour (CMH) has been proposed in healthcare systems to increase the profitability of operating suites. The aim of our study is to propose a simple and reproducible model to calculate CMH and to increase cost-effectiveness. Methods: For the ten most commonly performed surgical procedures at our Institution, we prospectively collected their diagnosis-related group (DRG) reimbursement, variable costs and mean procedural time. We quantified the portion of total staffed operating room time to be reallocated with a minimal risk of overrun. Moreover, we calculated the total CMH with a random reallocation on a first come-first served basis. Finally, prioritizing procedures with higher CMH, we ran a simulation by calculating the total CMH. Results: Over a two-months period, we identified 14.5 hours of unutilized operating room to reallocate. In the case of a random ‘‘first come -first serve’’ basis, the total earnings were 87,117 United States dollars (USD). Conversely, with a reallocation which prioritized procedures with a high CMH, it was possible to earn 140,444 USD (p < 0.001). Conclusion: Surgical activity may be one of the most profitable activities for hospitals, but a cost-effective management requires a comprehension of its cost profile. Reallocation of unused operating room time according to CMH may represent a simple, reproducible and reliable tool for elective cases on a waiting list. In our experience, it helped improving the operating suite cost-effectiveness.
  • Low-cost versus high-fidelity pediatric simulators for difficult airway management training: a randomized study in continuing medical education Original Investigation

    Lejus-Bourdeau, Corinne; Pousset, Florence; Magne, Cécile; Bazin, Olivier; Grillot, Nicolas; Pichenot, Vincent

    Abstract in English:

    Abstract Background: High-fidelity (HF) pediatric patient simulators are expensive. This randomized study aimed to compare the quality and educational impact of a full-scale simulation workshop with an HF infant simulator (SimBaby™, Laerdal) or with a low-cost (LC) simulator composed of an inert infant manikin with SimBaby™ software that displays respiratory/hemodynamic parameters on a monitor for medical education in pediatric difficult airway management. Methods: After written informed consent, anesthetists and emergency or ICU physicians participated in teams (4 to 6 participants) in a training session that included direct participation and observation of two difficult intubation scenarios. They were randomized into two groups (HF group, n = 65 and LC group, n = 63). They filled out a simulation quality score (SQS, 0 to 50), self-evaluated their anesthetists’ non-technical skills (ANTS) score (15 to 60), and an educational quality score (EQS, 0 to 60) immediately (T0, main criteria), as well as 3 (T3) and 6 (T6) months after the training session. Results: We enrolled 128 physicians. Direct participation SQS (39 ± 5 HF group versus 38 ± 5 LC group), observation SQS (41 ± 4 H F group versus 39 ± 5 LC group), ANTS scores (38 ± 4 HF group versus 39 ± 6 LC group), T0 SQS (44 ± 5 HF group versus 43 ± 6 LC group), T3 and T6 SQS were not different between groups. Conclusion: Our low-cost simulator should be suggested as a less expensive alternative to an HF simulator for continuing medical education in pediatric difficult airway management.
  • Patient satisfaction in ambulatory anesthesia assessed by the Heidelberg Peri-anaesthetic Questionnaire: a cross-sectional study Original Investigation

    Lemos, Jeconias Neiva; Lemos, Lavínia Dantas Cardoso Neiva; Solla, Davi Jorge Fontoura; Lemos, Danilo Dantas Cardoso Neiva; Módolo, Norma Sueli Pinheiro

    Abstract in English:

    Abstract Background: Service quality in anesthesiology has been frequently measured by morbidity and mortality. This measure increasingly considers patient satisfaction, which is the result of care from the client’s perspective. Therefore, anesthesiologists must be able to build relationships with patients, provide understandable information and involve them in decisions about their anesthesia. This study aimed to evaluate the peri-anesthetic care provided by the anesthesia service in an ambulatory surgery unit using the Heidelberg Peri-anaesthetic Questionnaire. Methods: This cross-sectional study used the Heidelberg Peri-anaesthetic Questionnaire to evaluate 1211 patients undergoing ambulatory surgery. We selected questions that showed a greater degree of dissatisfaction and correlated them with patient characterization data (age, sex, education, and ASA physical status), anesthesia data (type, time, and prior experience), and surgical specialty. Results: Questions in which patients tended to show dissatisfaction involved fear of anesthesia and surgery, feeling cold, the urgent need to urinate, pain at the surgical site, and the team’s level of concern and speed of response in relieving the patient’s pain. Conclusion: The Heidelberg Peri-anaesthetic Questionnaire proved to be a useful tool in identifying points of dissatisfaction, mainly fear of anesthesia and surgery, feeling cold, the urgent need to urinate, pain at the surgical site, and the team's level of concern and speed of response in relieving the patient's pain in the population studied. These were correlated with patient, anesthesia, and surgical variables. This allows the establishment of priorities at the different points of care, with the ultimate goal of improving patient satisfaction regarding anesthesia care.
  • Multitasking in postanesthesia care unit following nurse interruptions, an analysis of the causes and consequences using classification tree: an observational prospective study Original Investigation

    Vacheron, Charles-Hervé; Peyrouset, Olivier; Incagnoli, Pascal; Charra, Virginie; Parat, Stéphanie; David, Jean-Stephane; Theissen, Alexandre; Piriou, Vincent; Friggeri, Arnaud

    Abstract in English:

    Abstract Background: Postanesthesia Care Unit (PACU) is an environment associated with an important workload which is susceptible to lead to task interruption (TI), leading to task-switching or concurrent multitasking. The objective of the study was to determine the predictors of the reaction of the nurses facing TI and assess those who lead to an alteration of the initial task. Methods: We conducted a prospective observational study into the PACU of a university hospital during February 2017. Among 18 nurses, a selected one was observed each day, documenting for each TI the reaction of the nurse (task switching or concurrent multitasking), and the characteristics associated with the TI. We performed classification tree analyses using C5.0 algorithm in order to select the main predictors of the type of multitasking performed and the alteration of the initial task. Results: We observed 1119 TI during 132 hours (8.5 TI/hour). The main reaction was concurrent multitasking (805 TI, 72%). The short duration of the task interruption (one minute or less) was the most important predictor leading to concurrent multitasking. Other predictors of response to TI were the identity of the task interrupter and the number of nurses present. Regarding the consequences of the task switching, long interruption (more than five minutes) was the most important predictor of the alteration of the initial task. Conclusions: By analysing the predictors of the type of multitasking in front of TI, we propose a novel approach to understanding TI, offering new perspective for prevention strategies.
  • Mobile phones of anesthesiologists as reservoirs of nosocomial bacteria in a quaternary teaching hospital: an observational study Original Investigation

    Correa, Guilherme Haelvoet; Formigoni, Carla de Souza; Sasagawa, Suzethe Matiko; Arnoni, Mariana Volpe; Mathias, Lígia Andrade da Silva Telles; Mimica, Marcelo Jennè

    Abstract in English:

    Abstract Background: Mobile phones in hospital settings have been identified as an important source of cross-contamination because of the low frequency with which mobile phones are cleaned by health workers and cyclical contamination of the hands and face. The aim of this study was to investigate whether the mobile phones of the anesthesia team at a teaching hospital are potential reservoirs of nosocomial bacteria. In addition, differences in device sanitization and hand hygiene habits between attending and resident anesthesiologists were correlated with mobile phone colonization. Methods: A prevalence study was conducted over a 6-month period from 2017 to 2018 that involved the collection of samples from the mobile phones of the anesthesiology team and culturing for surveillance. A questionnaire was administered to assess the mobile phone sanitization and hand washing routines of the anesthesia team in specific situations. Results: Bacterial contamination was detected for 86 of the 128 mobile phones examined (67.2%). A greater presence of Micrococcus spp. on devices was correlated with a higher frequency of mobile phone use (p = 0.003) and a lower frequency of sanitization (p = 0.003). The presence of bacteria was increased on the mobile phones of professionals who did not perform handwashing after tracheal intubation (p = 0.003). Conclusion: Hand hygiene and device sanitization habits were more important than the use behavior, as a higher presence of bacteria correlated with poorer hygiene habits. Furthermore, handwashing is the best approach to prevent serious colonization of mobile devices and the possible transmission of pathogens to patients under the care of anesthesiologists.
  • Comparison between oral midazolam versus oral ketamine plus midazolam as preanesthetic medication in autism spectrum disorder: double-blind randomized clinical trial Original Investigation

    Penna, Heber de Moraes; Paiva, Andreia Portela Martins; Romano, Antônio José Marques; Alves, Rodrigo Leal; Nascimento Junior, Paulo do; Módolo, Norma Sueli Pinheiro

    Abstract in English:

    Abstract Background: Conventional dental care is often impossible in patients with Autism Spectrum Disorder (ASD). Non-collaborative behaviors, sometimes associated with aggressiveness, are usual justifications for premedication in this population. Thereby, this research focuses on the effects of oral midazolam versus oral ketamine plus midazolam as preanesthetic medication in ASD. Methods: The sample included 64 persons with ASD, aged 2-59 years, scheduled for dental care under general anesthesia. The primary objective of this study was to compare degrees of sedation between two parallel, double-blinded, equally proportional groups randomized to receive oral midazolam (0.5−1, maximum 15 mg) or oral midazolam (0.5−1) associated with oral S(+)-ketamine (3−1, maximum 300 mg). The secondary outcomes were the need of physical stabilization to obtain intravenous line, awakening time, and occurrence of adverse events. Results: According to the dichotomous analysis of sedation level (Ramsay score 1 and 2 versus Ramsay ≥ 3), oral association of S(+)-ketamine and midazolam improved sedation, with increased probability of Ramsay ≥ 3, Relative Risk (RR) = 3.2 (95% Confidence Interval [95% CI] = 1.32 to 7.76) compared to midazolam alone. Combined treatment also made it easier to obtain venous access without physical stabilization, RR = 2.05 (95% CI = 1.14 to 3.68). There were no differences between groups regarding awakening time and the occurrence of adverse events. Conclusion: The association of oral S(+)-ketamine with midazolam provides better preanesthetic sedation rates than midazolam alone and facilitates intravenous line access in patients with autism.
  • Cardiopulmonary effects of prolonged surgical abdominal retractors application during general anesthesia: a prospective observational comparative study Original Investigation

    Ghanem, Mohamed A.; El-Hefnawy, Ahmed S.

    Abstract in English:

    Abstract Introduction: Increasing abdominal pressures could affect pulmonary compliance and cardiac performance, a fact based on which the aim of the present study to detect the cardiopulmonary burden of multiple retractors application during supine versus lateral abdominal surgeries. We hypothesized that surgical ring multiple retractors application would affect the pulmonary and cardiac functions during both lateral and supine abdominal surgeries. Methods: Prospective observational comparative study on forty surgical patients subdivided into two groups twenty each, comparing pulmonary compliance and cardiac performance before, during and after retractors application, group (S) supine position cystectomy surgery, and group (L) lateral position nephrectomy surgery under general anesthesia, Composite 1ry outcome; dynamic compliance C-dyn and cardiac index CI and Other outcome variables ICON cardio-meter were also recorded. Results: C-dyn and C-stat were significantly decreased late during retractor application in lateral compared to supine surgery with significant decrease compared to basal values all over the surgical time. CI was significantly increased after retractor removal in both of the study groups compared to basal values. PAW P was significantly increased in -lateral compared to supine surgery -with significant increase compared to basal value all over the surgical time in both of the study groups. significant increase in DO2I compared to basal value during both supine and lateral positions. Conclusion: Surgical retraction results in a short-lived significant decreases in lung compliance and cardiac output particularly during the lateral-kidney position than the supine position compliance.
  • A way forward in pulmonary aspiration incidence reduction: ultrasound, mathematics, and worldwide data collection Narrative Review

    Zdravkovic, Marko; Berger-Estilita, Joana; Kovacec, Jozica Wagner; Sorbello, Massimiliano; Mekis, Dusan

    Abstract in English:

    Abstract Aspiration of gastric contents during induction of general anesthesia remains a significant cause of mortality and morbidity in anesthesia. Recent data show that pulmonary aspiration still accounts for many cases with implications on mortality despite technical and technological evolution. Practical, ethical, and methodological issues prevent high-quality research in the setting of aspiration and rapid sequence induction/intubation, and significant controversy is ongoing. Patients’ position, drugs choice, dosing and timing, use of cricoid force, and a reliable risk assessment are widely debated with significant questions still unanswered. We focus our discussion on three approaches to promote a better understanding of rapid sequence induction/intubation and airway management decision-making. Firstly, we review how we can use qualitative and quantitative assessment of fasting status and gastric content with the point-of-care ultrasound as an integral part of preoperative evaluation and planning. Secondly, we propose using imaging-based mathematical models to study different patient positions and aspiration mechanisms, including identifying aspiration triggers. Thirdly, we promote the development of a global data collection system aiming to obtain precise epidemiological data. Therefore, we fill the gap between evidence-based medicine and experts’ opinion through easily accessible and diffused computer-based databases. A better understanding of aspiration epidemiology obtained through focused global data gathering systems, the widespread use of ultrasound-based prandial status evaluation, and development of advanced mathematical models might potentially guide safer airway management decision making in the 21st century.
  • Identification and economic burden of main adverse events of nerve injuries caused by regional anesthesia: a systematic review Systematic Review

    Calciolari, Stefano; González-Ortiz, Laura Guadalupe; Mongelli, Francesco; Cantini, Laura; Capdevila, Xavier; Regina, Davide La; Saporito, Andrea

    Abstract in English:

    Abstract Background and objectives: Anesthesiologists and hospitals are increasingly confronted with costs associated with the complications of Peripheral Nerve Blocks (PNB) procedures. The objective of our study was to identify the incidence of the main adverse events associated with regional anesthesia, particularly during anesthetic PNB, and to evaluate the associated healthcare and social costs. Methods: According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a systematic search on EMBASE and PubMed with the following search strategy: (‟regional anesthesia” OR ‟nerve block”) AND (‟complications” OR ‟nerve lesion” OR ‟nerve damage” OR ‟nerve injury”). Studies on patients undergoing a regional anesthesia procedure other than spinal or epidural were included. Targeted data of the selected studies were extracted and further analyzed. Results: Literature search revealed 487 articles, 21 of which met the criteria to be included in our analysis. Ten of them were included in the qualitative and 11 articles in the quantitative synthesis. The analysis of costs included data from four studies and 2,034 claims over 51,242 cases. The median claim consisted in 39,524 dollars in the United States and 22,750 pounds in the United Kingdom. The analysis of incidence included data from seven studies involving 424,169 patients with an overall estimated incidence of 137/10,000. Conclusion: Despite limitations, we proposed a simple model of cost calculation. We found that, despite the relatively low incidence of adverse events following PNB, their associated costs were relevant and should be carefully considered by healthcare managers and decision makers.
  • Perioperative costs of local or regional anesthesia versus general anesthesia in the outpatient setting: a systematic review of recent literature Systematic Review

    Graff, Valérie; Gabutti, Luca; Treglia, Giorgio; Pascale, Mariarosa; Anselmi, Luciano; Cafarotti, Stefano; Regina, Davide La; Mongelli, Francesco; Saporito, Andrea

    Abstract in English:

    Abstract Background and objectives: In this systematic review, we carried out an assessment of perioperative costs of local or regional anesthesia versus general anesthesia in the ambulatory setting. Methods: A systematic literature search was conducted to find relevant data on costs and cost-effectiveness analyses of anesthesia regimens in outpatients, regardless of the medical procedure they underwent. The hypothesis was that local or regional anesthesia has a lower economic impact on hospital costs in the outpatient setting. The primary outcome was the average total cost of anesthesia calculated on perioperative costs (drugs, staff, resources used). Results: One-thousand-six-hundred-ninety-eight records were retrieved, and 28 articles including 27,581 patients were selected after reviewing the articles. Data on the average total costs of anesthesia and other secondary outcomes (anesthesia time, recovery time, time to home readiness, hospital stay time, complications) were retrieved. Taken together, these findings indicated that local or regional anesthesia is associated with lower average total hospital costs than general anesthesia when performed in the ambulatory setting. Reductions in operating room time and postanesthesia recovery time and a lower hospital stay time may account for this result. Conclusions: Despite the limitations of this systematic review, mainly the heterogeneity of the studies and the lack of cost-effectiveness analysis, the economic impact of the anesthesia regimes on healthcare costs appears to be relevant and should be further evaluated.
  • Ultrasound-guided central venous access for patients in the Intensive Care Unit in prone position: report of three cases Case Report

    Lima, Bruno Manuel Marques; Cheung, Linda

    Abstract in English:

    Abstract The prone position is extensively used to improve oxygenation in patients with severe acute respiratory distress syndrome caused by SARS-CoV-2 pneumonia. Occasionally, these patients exhibit cardiac and respiratory functions so severely compromised they cannot tolerate lying in the supine position, not even for the time required to insert a central venous catheter. The authors describe three cases of successful ultrasound-guided internal jugular vein cannulation in prone position. The alternative approach here described enables greater safety and well-being for the patient, reduces the number of episodes of decompensation, and risk of tracheal extubation and loss of in-situ vascular lines.
  • Pudendal nerve block for circumcision of pediatric patient with Pierre Robin Sequence: case report Case Report

    Kayhan, Munevver; Kendigelen, Pinar; Tutuncu, Ayse Cigdem; Kaya, Guner

    Abstract in English:

    Abstract Pierre Robin Sequence (PRS) is a congenital condition characterized by micrognathia, glossoptosis, and cleft palate that presents with airway obstruction and developmental delay with or without other congenital anomalies. These patients’ anesthesia management is challenging because of difficult ventilation and intubation. Regional anesthesia methods should be considered for these patients on a case-by-case basis. This report presents primary use of regional anesthesia for circumcision of a 9-year-old boy with PRS.
  • Ultrasound-guided continuous costoclavicular block through retrograde stimulating catheter technique for postoperative analgesia in shoulder surgery: a case series Case Report

    Diwan, Sandeep; Sethi, Divya; Sancheti, Parag; Nair, Abhijit

    Abstract in English:

    Abstract In five patient undergoing surgery for proximal humerus fracture we investigated into postoperative analgesia provided by continuous costoclavicular block using continuous stimulating catheter. The postoperative pain scores were less than 4 in all patients except in two patients who required intravenous tramadol 50 mg as a rescue analgesic. The radiocontrast dye study executed in two patients revealed contiguous contrast spread through the brachial plexus sheath with the catheter tip in the interscalene space. We propose that a continuous costoclavicular block with a retrograde stimulating catheter is a feasible alternative regional anesthesia technique for postoperative analgesia in shoulder surgery.
  • Management of airway obstruction following lidocaine nebulization in a case of tracheal stenosis: case report Case Report

    Chaudhary, Kriti; Kumari, Kamlesh; Chhabra, Swati; Choudhary, Garima

    Abstract in English:

    Abstract Stenting for lower tracheal stenosis is a tricky situation and for the safe conduct of anesthesia, it is imperative to maintain spontaneous respiration. Airway topicalization is routinely recommended for anticipated difficult airway. We report a case of upper airway obstruction following lidocaine nebulization in a patient to be taken for tracheal stenting for lower tracheal stenosis. We would like to highlight that close monitoring of the patient is advisable during airway topicalization to detect any airway obstruction at the earliest and how fiberoptic intubation can play a pivotal role to secure the airway in an emergency scenario.
  • Entrapped thrombus in transit Clinical Images

    Khanna, Sandeep; Mehta, Anand
  • Intraoperative point-of-care subcostal Inferior Vena Cava (IVC) imaging to detect embolism during hip arthroplasty: clinical image Clinical Images

    Corujo, Alejandro; Girón-Arango, Laura; Irizaga, Gonzalo; Perlas, Anahi
  • Cost-minimization analysis of the continuous real-time pressure sensing technology in parturients requesting labor epidural analgesia Letter To The Editor

    Babazade, Rovnat; Lin, Yu-li; Valles, Guillermo Hidalgo; Capogna, Giorgio; Micaglio, Massimo; Vadhera, Rakesh B.; Gebhard, Ralf E.
  • Comparison of tranexamic acid and stapling line reinforcement in laparoscopic sleeve gastrectomy in postoperative bleeding outcomes Letter To The Editor

    Brito, Roger Moura de; Oliveira, Caio Marcio Barros de; Moura, Ed Carlos Rey; Campelo, Giuliano Peixoto; Lima, Roclides Castro de; Servin, Elizabeth Teixeira Noguera; Gomes, Lyvia Maria Rodrigues de Sousa; Fe, Ciro Sousa de Moura; Oliveira, Eduardo José Silva Gomes de; Leal, Plínio da Cunha
  • Letter to the Editor regarding “Comparison of the intubation success rate between the intubating catheter and videolaryngoscope in difficult airways: a prospective randomized trial.” Braz J Anesthesiol. 2022;72 (1):55-62 Letter To The Editor

    Muller, Matthew D.
  • Comment on: Effect of magnesium sulfate with ketamine infusions on intraoperative and postoperative analgesia in cancer breast surgeries: a randomized doubleblind trial Letter To The Editor

    Magoon, Rohan; Mahajan, Shalvi
Sociedade Brasileira de Anestesiologia (SBA) Rua Professor Alfredo Gomes, 36, Botafogo , cep: 22251-080 - Rio de Janeiro - RJ / Brasil , tel: +55 (21) 97977-0024 - Rio de Janeiro - RJ - Brazil