Resumo em Inglês:

Abstract Background and objectives Postpartum depression affects women, manifesting with depressed mood, insomnia, psychomotor retardation, and suicidal thoughts. Our study examined if there is an association between epidural analgesia use and postpartum depression. Methods Patients were divided into two groups. One group received epidural analgesia during labor while the second group did not. The Edinburgh postnatal depression scale (EPDS) was administered to patients prior to birth and 6 weeks postpartum. Pain severity was assessed by the Visual Analogue Scale (VAS) during labor and at 24 hours postpartum. Results Of the 92 patients analyzed, 47.8% (n = 44) received epidural analgesia. We detected significantly higher VAS score during labor (p = 0.007) and 24 hours postpartum (p = 0.0001) in the group without epidural analgesia. At 6 weeks postpartum, a significant difference was observed between the EPDS scores of both groups (p = 0.0001). Regression analysis revealed higher depression scores in patients experiencing higher levels of pain during labor (OR = 0.572, p = 0.039). Epidural analgesia strongly correlated with lower scores of depression (OR = 0.29, p = 0.0001). Conclusion The group that received epidural analgesia had lower pain scores. A high correlation between epidural analgesia and lower depression levels was found. Pregnant women giving birth via the vaginal route and having high pain scores could reduce postnatal depression scores using epidural labor analgesia. Pregnant women should opt for epidural analgesia during labor to lessen postpartum depression levels.

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Abstract Background and objectives Obesity is becoming a frequent condition among obstetric patients. A high body mass index (BMI) has been closely related to a higher difficulty to perform the neuraxial technique and to the failure of epidural analgesia. Our study is aimed at analyzing obese obstetric patients who received neuraxial analgesia for labor at a tertiary hospital and assessing aspects related to the technique and its success. Methods Retrospective observational descriptive study during one year. Women with a BMI higher than 30 were identified, and variables related to the difficulty and complications of performing the technique, and to analgesia failure rate were assessed. Results and conclusions Out of 3653 patients, 27.4% had their BMI ≥ 30 kg.m-². Neuraxial techniques are difficult to be performed in obese obstetric patients, as showed by the number of puncture attempts (≥ 3 in 9.1% obese versus 5.3% in non-obese being p < 0.001), but the incidence of complications, as hematic puncture (6.6%) and accidental dural puncture (0.7%) seems to be similar in both obese and non-obese patients. The incidence of cesarean section in obese patients was 23.4% (p < 0.001). Thus, an early performance of epidural analgesia turns out to be essential to control labor pain and to avoid a general anesthesia in such high-risk patients.

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Abstract Introduction Spinal anesthesia combined with sedation and general anesthesia combined with epidural are two techniques often used for patients undergoing abdominal hysterectomy. There is no consensus that one of these techniques is superior regarding the perception of patients towards the quality of postoperative recovery. This observational cross-sectional study aimed to assess the quality of postoperative recovery in women undergoing open abdominal hysterectomy by comparing both anesthetic techniques. Method We recruited 162 women aged between 30 and 74 years to be submitted to abdominal hysterectomy. The anesthetic technique used followed the preference of the attending anesthesiologist without interference of the investigators. After applying the exclusion criteria, 80 patients underwent spinal anesthesia combined with sedation (Group 1) and 62 women underwent epidural anesthesia combined with general anesthesia (Group 2). The quality of postoperative recovery was evaluated using the questionnaire Quality of Recovery-40 (QoR-40) completed 24 hours after the end of the surgery. Results Eighty patients in Group 1 answered the QoR-40 questionnaire with an average rating of 179.4 points, median of 186.5, standard deviation of 17.4 and a confidence interval of 3.8. The 60 patients in Group 2 answered the QoR-40 with an average of 174.9 points, median of 178 points, standard deviation of 16 points and a confidence interval of 4.0 (p= 0.024). Conclusion Women who received spinal anesthesia combined with sedation considered quality of postoperative recovery better.

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Abstract Fibromyalgia is a syndrome characterized by chronic pain related to the musculoskeletal system. Patients feel incapable and show catastrophic thoughts (exaggeration of the sensations) related to painful events. This study aimed to compare catastrophic thoughts of pain between daughters of women with fibromyalgia and daughters of women without fibromyalgia, no daughter having the syndrome. It was a case-control study in which 76 women were included: 38 daughters of women diagnosed with fibromyalgia (case group), and 38 daughters of women without fibromyalgia (control group). The Brazilian versions of the Profile of Chronic Pain: Screen, the Pittsburgh Sleep Quality Index, the Pain Catastrophizing Scale, Resilience Scale, Beck Depression Inventory-II, and the State-Trait Anxiety Inventory were used. Data were tabulated and analyzed using SPSS 20.0. Continuous variables were compared between the groups using the Mann-Whitney U test or Student’s t-test for independent samples. A significant difference was considered at p < 0.05. Regarding catastrophism, the case group had higher total catastrophism compared to the control group (p = 0.025). Daughters of patients with fibromyalgia showed higher rumination and magnification levels related to pain (p = 0.028 and p = 0.007, respectively) but did not show hopelessness. This study concludes that daughters of women with fibromyalgia are more likely to have symptoms of fibromyalgia due to their visualization of the syndrome. This indicates that emotional aspects may induce changes, and additional research on an individual basis is necessary.

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Abstract Background and objectives Spinal anesthesia is an effective technique for many surgical procedures, but it is often associated with an increased risk of potentially deleterious hemodynamic disturbances. The benefits of prophylactic ondansetron for preventing spinal anesthesia-induced hypotension are still uncertain. Therefore, this study aimed to compare the effect of ondansetron and placebo before spinal block on the incidence of hypotension in patients having non-obstetric surgeries. Methods Randomized, double-blind, parallel-group, superiority trial with a 1:1 allocation ratio. A total of 144 patients scheduled for non-obstetric surgeries with an indication for spinal anesthesia were randomized. Patients received intravenous ondansetron (8 mg) or placebo before standard spinal anesthesia. The primary outcome was the rate of hypotension in the first 30 minutes after spinal anesthesia. Results Hypotension occurred in 20 of 72 patients (27.8%) in the ondansetron group and in 36 of 72 patients (50%) in the placebo group (Odds Ratio-OR = 0.38; 95% Confidence Interval-CI 0.19 to 0.77; p = 0.007). Fewer patients in the ondansetron group required ephedrine compared to the placebo group (13.9% vs. 27.8%; OR = 0.42; 95% CI 0.18 to 0.98; p = 0.04). Exploratory analyses revealed that ondansetron may be more effective than placebo in patients aged 60 years or older (OR = 0.12; 95% CI 0.03 to 0.48; p = 0.03). No difference in heart rate variations was observed. Conclusion Our findings suggest that ondansetron can be a viable and effective strategy to reduce both the incidence of spinal anesthesia-induced hypotension and vasopressors usage in non-obstetric surgeries.

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Abstract Objective In hypertensive patients, the autoregulation curve shifts rightward, making these patients more sensitive than normotensive individuals to hypotension. Hypotension following the induction of anesthesia has been studied in normotensive patients to determine its effects on brain tissue oxygenation, but not enough studies have examined the effect of hypotension on brain oxygenation in hypertensive patients. The current study aimed to use near-infrared spectroscopy to evaluate brain tissue oxygen saturation after the induction of anesthesia in hypertensive patients, who may have impaired brain tissue oxygen saturation. Methods The study included a total of 200 patients aged > 18 years old with ASA I-III. Measurements were taken while the patient was breathing room air, after the induction of anesthesia, when the lash reflex had disappeared following the induction of anesthesia, after intubation, and in the 5th, 10th, and 15th minutes of surgery. The patients were divided into nonhypertensive and hypertensive groups. Results There was a significant difference in age between the groups (p = 0.000). No correlation was found between cerebral tissue oxygen saturation and age (r = 0.015, p = 0.596). Anesthesia induction was observed to decrease mean arterial blood pressure in both groups (p = 0.000). Given these changes, there was no significant difference in brain tissue oxygen saturation between the nonhypertensive and hypertensive groups (p > 0.05). Conclusion There was no difference between hypertensive and normotensive groups in terms of the change rates in cSO2 values. However, there was a difference between the groups in terms of cSO2 values.

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Abstract Background This study aimed to analyze the effects of preoperative oral intake of liquid carbohydrate on postoperative blood glucose, fasting-thirst, and fatigue levels in patients undergoing arthroscopic surgery. Methods This randomized controlled clinical trial enrolled 82 patients, who were scheduled to undergo arthroscopic surgery, and divided them into two groups: (1) those who consumed a carbohydrate-rich drink, and (2) those not consuming anything after midnight. Pre- and postoperative fasting-thirst (visual analog scale) and blood glucose levels were measured. Likewise, the Brief Fatigue Inventory was applied to patients 24 hours after surgery. Results The mean blood glucose levels in the first postoperative hour were 90.90 ± 13.56 mg.dL-1 and 107.00 ± 15.84 mg.dL-1 in the intervention group and control group, respectively (p < 0.001). The postoperative mean thirst scores were 4.70 ± 1.59 and 6.36 ± 2.07 in the intervention group and control group, respectively (p < 0.001). Their corresponding postoperative mean fasting scores were 5.54 ± 1.76 and 5.86 ± 1.79 (p > 0.05) and the mean fatigue levels in the 24th postoperative hour were 4.80 ± 2.13 and 5.48 ± 1.46, respectively (p > 0.05). Conclusions Oral intake of liquid carbohydrate before spinal anesthesia was found to have positive effects on patients’ postoperative blood glucose and thirst levels.

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Abstract Introduction Decreased rates of General Anesthesia (GA) for Cesarean Section (C-section) create a learning problem for anesthesia trainees. In this context, training the management of GA for C-section using simulation techniques allows a safe environment for exposure, learning, performance improvement, and capability retention. Objective Analyze anesthesia residents’ performance regarding a simulated clinical case of GA for emergency C-section and identify specific deficits in skill acquisition. Methods Between 2015 and 2018, we evaluated the performance of 25 anesthesiology residents challenged by a simulated clinical case of GA for emergency C-section after the conclusion of the obstetric anesthesia rotation. Each resident performed the clinical case once followed by the assessment of their performance. Final scores were given according to the completion rate of 14-tasks, going from 0% to 100%. Two study groups were considered according to residency year for subsequent comparison of results (Group 1, second and third residency years and Group 2, fourth and fifth residency years). Results and discussion Mean score was 64.29% ± 13.62. Comparatively, Group 1 obtained a higher score than Group 2 (70.63% ± 14.02 vs. 60.27% ± 11.94), although with no statistically significant difference (p = 0.063). The tasks most frequently accomplished were opioid administration (100%), rapid sequence technique (100%), pre-oxygenation (92%), gastric content aspiration prophylaxis (84%), and previous clinical history (84%). Conversely, the tasks less frequently accomplished were confirming presence of pediatrician (64%), oxytocin administration (56%), PONV prophylaxis (56%), and preoperative airway assessment (48%). Conclusion The performance of the residents observed in this study was comparable to results previously published. The final score did not depend on the residency year.

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Abstract Background and objectives Awake fiberoptic intubation (AFOI) is usually performed in patients with an anticipated difficult airway. Various sedation regimens are used during AFOI, however, most of them cause respiratory depression. The present study aims to compare the effectiveness of fentanyl with ketamine versus dexmedetomidine in search of a better sedation regimen which would achieve desirable intubating conditions and hemodynamic stability without causing respiratory depression. Methods This is a single centered randomized, double-blind clinical trial. Patients of both sexes between age 18-55 years and ASA (American Society of Anesthesiologists) physical status I-II with an anticipated difficult airway were randomly divided into two groups of thirty each. Group FK patients received intravenous fentanyl and ketamine, and group DX patients received dexmedetomidine, until Ramsay sedation scale ≥ 2. Heart rate (HR), mean blood pressure (MBP), oxygen saturation (SpO2), respiratory rate (RR), endoscopy time, intubation time, first end-tidal carbon dioxide (ETCO2) after intubation, endoscopist satisfaction score, and patient discomfort score were recorded during the study period. The level of recall was assessed on the next postoperative day. Results Endoscopist satisfaction score was better in group DX patients (p < 0.05). There was a smaller variation in HR and MBP from baseline with dexmedetomidine compared to fentanyl with ketamine. First ETCO2 after intubation was higher in group FK patients (p < 0.05). No significant difference was found in patient discomfort score, intubation time, RR, SpO2 and level of recall of the event. Conclusions The use of dexmedetomidine in AFOI provides better intubating conditions and hemodynamic stability compared to fentanyl with ketamine.

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Abstract Introduction and objective Due to the high cost and insufficient offer, the request for Intensive Care (ICU) beds for postoperative recovery needs adequate criteria. Therefore, we studied the characteristics of patients referred to postoperative care at an ICU from the perspective of anesthesiologists, surgeons, and intensive care physicians. Methods A questionnaire on referrals to postoperative intensive care was applied to physicians at congresses in Brazil. Anesthesiologists, surgeons, and intensive care physicians who agreed to fill out the questionnaire were included. The questionnaire consisted of hypothetical clinical scenarios and cases for participants to choose which would be the priority for referral to the ICU. Results 360 physicians participated in the study, with median time of 10 (5-18) years after graduation. Of the interviewees, 36.4% were anesthesiologists, 30.0% surgeons, and 33.6% intensive care physicians. We found that anesthesiologists were more conservative, and surgeons less conservative in ICU referrals. As to patients with risk of bleeding, 75.0% of the surgeons would refer them to the ICU, in contrast with 52.1% of the intensive care physicians, and 43.5% of the anesthesiologists (p< 0.001). As to elderly persons with limited reserve, 62.0% of the surgeons would refer them to the ICU, in contrast with 47.1% of the intensive care physicians, and 22.1% of the anesthesiologists (p< 0.001). As to patients with risk of respiratory complications, 64.5% of the surgeons would recommend the ICU, versus 43.0% of the intensive care physicians, and 32.1% of the anesthesiologists (p< 0.001). Intensive care physicians classified priorities better in indicating ICU, and the main risk indicator was the ASA physical status in all specialties (p< 0.001). There was no agreement among the specialties and surgeries on prioritizing post-operative intensive care. Conclusion Anesthesiologists, surgeons, and intensive care physicians presented different perspectives on postoperative referral to the ICU.

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Abstract Background Sepsis is one of the leading causes of death in intensive care units. Dexmedetomidine is a sedative agent with anti-inflammatory properties. This study is designed to differentiate the impact of two different doses of dexmedetomidine on lung injury induced by sepsis. Methods Adult male Wistar rats were randomly divided into four groups: sham (n = 6), control (n = 12), 5DEX (n = 12), and 10DEX (n = 12). Cecal ligation puncture (CLP) was applied for sepsis initiation. The 5DEX group received 5 µg.kg-1.h-1 and the 10DEX group received 10 µg.kg-1.h-1 dexmedetomidine intravenous infusions for a 1-hour period. Six hours after CLP, tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), and intercellular adhesion molecule-1 (ICAM-1) levels were analyzed in blood samples. Twenty-four hours after CLP, lung samples from the remaining rats were collected for the measurement of myeloperoxidase (MPO) activity, histological examination, and TdT- (terminal deoxynucleotidyl transferase) mediated fluorescent-dUTP labeling staining for apoptosis detection. Results Serum cytokine release, MPO activity, and apoptosis in the lung were significantly increased in the CLP group compared with the sham and dexmedetomidine groups (p < 0.05). TNF-α, ICAM-1, and MPO were significantly lower in the 10DEX group compared with both 5DEX and control groups, while IL-1β, total injury score, and apoptotic cell count had significantly lower values in both 10DEX and 5DEX groups compared with the control group (p < 0.05). Conclusion Dexmedetomidine administration played a protective role against CLP-induced lung injury. High-dose dexmedetomidine was needed for suppressing the leukocyte-mediated lung injury and apoptosis of lung tissue.

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Abstract Neuraxial anesthesia is a standard of care during parturition. Since bleeding diathesis is a contraindication to neuraxial techniques, data about its safe administration in a thrombocytopenic milieu is limited and evolving. Thrombocytopenia associated with preeclampsia or eclampsia and hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome leads to significant maternal and neonatal morbidity. We present a case of uneventful spinal anesthesia for urgent cesarean section in an eclamptic patient with a precipitous drop in platelet count from 124,000 to 97,000 per cubic millimeter under thromboelastography (TEG) guidance.

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Abstract Mediastinal masses in pregnancy, although rare, can present with life threatening central airway obstruction if general anesthesia is required. In patients with central airway obstruction who are classified as being high risk for anesthesia, specific cardiothoracic interventions are usually required when there is no alternative to general anesthesia. We describe the case of a young female who presented in her second trimester with severe tracheal compression and worsening dyspnea secondary to a mediastinal mass. Intravenous dexamethasone was started, following which her symptoms improved and a drastic reduction in her tracheal compression was observed. The patient subsequently underwent successful vaginal delivery under epidural anesthesia. We discuss the complexities in perioperative decision making for this rare presentation and potential therapeutic options.

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Abstract Quadratus lumborum block (QLB) is a technique that is not widely applied for gynecological surgery. Endometriosis affects 10% of the female population and chronic pelvic pain is one of the most prevalent symptoms. Laparoscopic surgery for removal of endometriosis may present a long intra-operative duration and this technique might improve postoperative pain control. We described a case report of a patient submitted to general anesthesia associated to bilateral QLB for pelvic endometriosis. QLB was an adjuvant anesthetic technique for endometriosis, providing somatic and visceral analgesia. However, prospective studies are needed to identify the standard dosage and total duration of analgesia.

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Abstract Wada test is an invasive procedure used in the preoperative evaluation for epilepsy surgery to determine language lateralization, postoperative risk of amnesia syndrome, and to assess the risk of memory deficits. It involves injection of amobarbital into internal carotid artery of the affected hemisphere followed by the healthy hemisphere to shut down brain function. We performed an observational study evaluating the density spectral array (DSA) of the bilateral bispectral index VISTA™ Monitoring System (BVMS) in 6 patients with drug-resistant epilepsy undergoing Wada test. DSA revealed the presence of bifrontal alpha waves in absence of loss of consciousness in all patients.

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Abstract Catatonic patients may develop deep vein thrombosis (DVT) and pulmonary embolism (PE) due to prolonged periods of immobility. These life-threatening conditions demand prompt recognition and management. We describe the case of a patient with catatonia who presented to anesthesia for electroconvulsive therapy (ECT) at the outset of the current coronavirus disease 2019 pandemic. She complained of breathing difficulty and was suspected to have COVID-19 infection. On further evaluation, she was found to have DVT and PE and required oxygen therapy and intensive care management. The diagnostic delay in our patient would have probably not occurred, had it not been for the existing pandemic situation.

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Abstract Introduction Pneumocephalus is a rare neuraxial blockade complication, which can be associated with severe neurologic changes. Clinical case A 51-year-old patient was submitted to left total knee arthroplasty. Postoperatively, a pneumocephalus associated with decreased consciousness was diagnosed as a complication of the epidural analgesia. The treatment used was Hyperbaric Oxygen Therapy (HBOT) due to the severity of symptoms. Just after one session of HBOT, there was nearly full pneumocephalus resorption and significant clinical recovery. Conclusion This case report enables anesthesiologists to recognize HBOT as a therapeutic option to be considered when treating severe cases of pneumocephalus.

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Abstract We report the anesthetic management with combined spinal-epidural in a patient with limb-girdle muscular dystrophy type 2A, submitted to abdominoplasty and liposuction. The patient had onset of symptoms at 8 years old, diagnosed by muscular biopsy, presenting muscle weakness in the scapular and pelvic girdles, with reduced mobility. We performed monitorization with noninvasive blood pressure, oximeter, thermometer, and electrocardiogram. In the postoperative period, she showed no clinical signs of rhabdomyolysis, myotonia, or adverse effects, maintaining hemodynamic stability. The anesthesia technique allowed spontaneous ventilation, monitoring of clinical parameters close to physiological conditions and used smaller doses of medication, reducing related risks.