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BACKGROUND AND OBJECTIVES: Poor monitoring of tracheal tube cuff pressure may result in patient complications. The objective method of using a manometer is recommended to keep safe cuff pressure values (20-30 cm H2O). However, as manometers are not readily available, anesthesiologists use subjective methods. We aimed to assess appropriateness of a subjective method for attaining cuff pressure and the expertise level of manometer handling among anesthesiology staff and residents in a university teaching hospital. METHODS: Prospective observational study, recruiting participants that performed tracheal intubation and the subjective method for tube cuff inflation. Patients with difficult airway, larynx and trachea anatomic abnormality and emergency procedures were not included. Up to 60 minutes after tracheal intubation, an investigator registered the cuff pressure using an aneroid manometer (AMBU®) connected to the tube pilot balloon. RESULTS: Forty-seven anesthesiologists were included in the study - 24 residents and 23 staff. Mean (SD) and medians (IQR) measured in cm H2O were, respectively, 52.5 (27.1) and 50 (30-70). We registered 83% of measurements outside the recommended pressure range, with no difference between specialists and residents. The level of expertise with the objective method was also similar in both groups. Pressure adjustments were performed in 76.6% of cases. CONCLUSION: The subjective method for inflating the tracheal tube cuff resulted in a high rate of inadequate cuff pressures, with no difference in performance between anesthesiology specialists and residents.

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RESUMO O Acesso Avançado (AA) é um formato de organização de agenda em unidades de saúde na Atenção Primária à Saúde que prega a máxima 'Faça hoje o trabalho de hoje!'. Ele busca ativamente reduzir a demanda reprimida de atendimentos, reduzir o absenteísmo e ampliar o acesso aos usuários do Sistema Único de Saúde (SUS). O objetivo deste trabalho foi relatar aspectos da implementação do AA em uma Unidade de Saúde da Família (USF). Foram realizadas entrevistas com os profissionais da USF acerca do AA e, de forma preliminar, foram utilizados os dados do Sistema de Informação de Atenção Básica (Siab), do E-SUS e das agendas físicas, para comparação numérica de alguns parâmetros entre antes e depois da implantação e implementação do AA.

ABSTRACT Advanced Access (AA) is an agenda organization method in Primary Health Care (PHC) units that preaches the saying 'Do today's work today!'. It actively seeks to reduce the repressed demand for care, reduce absenteeism and increase access to users of the Brazilian Unified Health System (SUS). The objective of this study is to report the implementation of AA in a Family Health Unit (FHU). Interviews were conducted with FHU professionals about AA and, in a preliminary way, data from Primary Health Care Information System (Siab), E-SUS and physical agendas were used, for numerical comparison of some parameters between before and after AA implementation.

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Abstract Background and objectives: The weight parameters for use of sugammadex in morbidly obese patients still need to be defined. Methods: A prospective clinical trial was conducted with sixty participants with body mass index ≥ 40 kg.m-2 during bariatric surgery, randomized into three groups: ideal weight (IW), 20% corrected body weight (CW20) and 40% corrected body weight (CW40). All patients received total intravenous anesthesia. Rocuronium was administered at dose of 0.6 mg.kg-1 of Ideal weight for tracheal intubation, followed by infusion of 0.3-0.6 mg.kg-1.h-1. Train of four (TOF) was used to monitor depth of blockade. After spontaneous recovery TOF-count 2 at the end of surgery, 2 mg.kg-1 of sugammadex was administered. Primary outcome was neuromuscular blockade reversal time to TOF ≥ 0.9. Secondary outcome was the occurrence of postoperative residual curarization in post-anesthesia recovery room, searching the patient's ability to pass from the surgical bed to the transport, adequacy of oxygenation, respiratory pattern, ability to swallow saliva and clarity of vision. Results: Groups were homogenous in gender, age, total body weight, ideal body weight, body mass index, type and time of surgery. The reversal times (s) were (mean ± standard deviation) 225.2 ± 81.2, 173.9 ± 86.8 and 174.1 ± 74.9 respectively, in the IW, CW20 and CW40 groups (p = 0.087). Conclusions: No differences were observed between groups with neuromuscular blockade reversal time and frequency of postoperative residual curarization. We concluded that ideal body weight can be used to calculate sugammadex dose to reverse moderate neuromuscular blockade in morbidly obese patients.

Resumo Justificativa e objetivos: Os parâmetros de peso para o uso de sugamadex em pacientes com obesidade mórbida ainda precisam ser definidos. Métodos: Um ensaio clínico prospectivo foi feito com 60 participantes com índice de massa corporal ≥ 40 kg.m-2, submetidos a cirurgia bariátrica, randomizados em três grupos: peso ideal (PI), peso corrigido em 20% (PC20) e peso corrigido em 40% (PC40). Todos os pacientes receberam anestesia intravenosa total. Rocurônio foi administrado em dose de 0,6 mg.kg-1 para intubação traqueal pelo peso ideal, seguido de infusão (0,3 a 0,6 mg.kg-1.h-1). A sequência de quatro estímulos (TOF) foi usada para monitorar a profundidade do bloqueio. Após recuperação espontânea da segunda resposta do TOF no fim da cirurgia, 2 mg.kg-1 de sugamadex foi administrado. O desfecho primário foi o tempo de reversão do bloqueio neuromuscular até obter TOF ≥ 0,9. O desfecho secundário foi a ocorrência de curarização residual pós-operatória na sala de recuperação pós-anestésica, avaliaram-se a capacidade do paciente de passar do leito cirúrgico para o de transporte, a adequação da oxigenação, o padrão respiratório, a habilidade para deglutir saliva e a clareza de visão. Resultados: Os grupos foram homogêneos quanto a gênero, idade, peso corporal total, peso corporal ideal, índice de massa corporal, tipo e tempo de cirurgia. Os tempos de reversão (segundos) foram (média ± desvio-padrão) 225,2 ± 81,2, 173,9 ± 86,8 e 174,1 ± 74,9, respectivamente, nos grupos PI, PC20 e PC40 (p = 0,087). Conclusões: Não foram observadas diferenças entre os grupos quanto ao tempo de reversão do bloqueio neuromuscular e frequência de curarização residual pós-operatória. Concluímos que o peso corporal ideal pode ser usado para calcular a dose de sugamadex para reverter o bloqueio neuromuscular moderado em pacientes com obesidade mórbida.

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BACKGROUND AND OBJECTIVES: The weight parameters for use of sugammadex in morbidly obese patients still need to be defined. METHODS: A prospective clinical trial was conducted with sixty participants with body mass index≥40kg.m-2 during bariatric surgery, randomized into three groups: ideal weight (IW), 20% corrected body weight (CW20) and 40% corrected body weight (CW40). All patients received total intravenous anesthesia. Rocuronium was administered at dose of 0.6mg.kg-1 of Ideal weight for tracheal intubation, followed by infusion of 0.3-0.6mg.kg-1.h-1. Train of four (TOF) was used to monitor depth of blockade. After spontaneous recovery TOF-count 2 at the end of surgery, 2mg.kg-1 of sugammadex was administered. Primary outcome was neuromuscular blockade reversal time to TOF≥0.9. Secondary outcome was the occurrence of postoperative residual curarization in post-anesthesia recovery room, searching the patient's ability to pass from the surgical bed to the transport, adequacy of oxygenation, respiratory pattern, ability to swallow saliva and clarity of vision. RESULTS: Groups were homogenous in gender, age, total body weight, ideal body weight, body mass index, type and time of surgery. The reversal times (s) were (mean±standard deviation) 225.2±81.2, 173.9±86.8 and 174.1±74.9 respectively, in the IW, CW20 and CW40 groups (p=0.087). CONCLUSIONS: No differences were observed between groups with neuromuscular blockade reversal time and frequency of postoperative residual curarization. We concluded that ideal body weight can be used to calculate sugammadex dose to reverse moderate neuromuscular blockade in morbidly obese patients.

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ABSTRACTThe objective of this study was to evaluate how Brazilian anesthesiologists are using neuromuscular blockers, focusing on how they establish the diagnosis of postoperative residual curarization and the incidence of complications associated with the use of neuromuscular blockers. A questionnaire was sent to anesthesiologists inviting them to participate in the study. The online data collection remained open from March 2012 to June 2013. During the study period, 1296 responses were collected. Rocuronium, atracurium, and cisatracurium were the main neuromuscular blockers used in cases of elective surgery. Succinylcholine and rocuronium were the main neuromuscular blockers used in cases of emergency surgery. Less than 15% of anesthesiologists reported the frequent use of neuromuscular function monitors. Only 18% of those involved in the study reported that all workplaces have such a monitor. Most respondents reported using only the clinical criteria to assess whether the patient is recovered from the muscle relaxant. Most respondents also reported always using some form of neuromuscular blockade reversal. The major complications attributed to neuromuscular blockers were residual curarization and prolonged blockade. Eighteen anesthesiologists reported death attributed to neuromuscular blockers. Residual or prolonged blockade is possibly recorded as a result of the high rate of using clinical criteria to diagnose whether the patient has recovered or not from motor block and, as a corollary, the poor use of neuromuscular transmission monitors in daily practice.

RESUMOO objetivo desta pesquisa foi avaliar como os anestesiologistas brasileiros estão usando os bloqueadores neuromusculares (BNM), com foco na forma de estabelecer o diagnóstico da curarização residual pós-operatória e a incidência de complicações atribuídas ao uso de BNM. Um questionário foi enviado a anestesiologistas convidando-os a participar da pesquisa (tabela 1). A coleta online de dados permaneceu aberta de março de 2012 a junho de 2013. Durante o período de estudo foram coletadas 1.296 respostas. Rocurônio, atracúrio e cisatracúrio foram os principais bloqueadores neuromusculares usados em casos de cirurgia eletiva. Succinilcolina e rocurônio foram os principais BNM usados em casos de cirurgia de emergência. Menos de 15% dos anestesiologistas referiram que usam frequentemente monitores da função neuromuscular. Apenas 18% dos envolvidos no estudo referiram que todos os locais de trabalho têm tal monitor. A maioria dos entrevistados afirmou que usa somente o critério clínico para avaliar se o paciente está recuperado do relaxante. A maioria dos entrevistados também relatou que sempre usa algum tipo de reversão de bloqueio neuromuscular. As principais complicações atribuídas aos BNM foram curarização residual e bloqueio prolongado. Houve relato por 18 anestesiologistas de óbito atribuído a BNM. O bloqueio residual ou prolongado se registra, possivelmente, como consequência do alto índice do uso de critérios clínicos para diagnosticar se o paciente está recuperado ou não do bloqueio motor e, como um corolário, o baixo uso de monitores da transmissão neuromuscular na prática diária.

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The objective of this study was to evaluate how Brazilian anesthesiologists are using neuromuscular blockers, focusing on how they establish the diagnosis of postoperative residual curarization and the incidence of complications associated with the use of neuromuscular blockers. A questionnaire was sent to anesthesiologists inviting them to participate in the study. The online data collection remained open from March 2012 to June 2013. During the study period, 1296 responses were collected. Rocuronium, atracurium, and cisatracurium were the main neuromuscular blockers used in cases of elective surgery. Succinylcholine and rocuronium were the main neuromuscular blockers used in cases of emergency surgery. Less than 15% of anesthesiologists reported the frequent use of neuromuscular function monitors. Only 18% of those involved in the study reported that all workplaces have such a monitor. Most respondents reported using only the clinical criteria to assess whether the patient is recovered from the muscle relaxant. Most respondents also reported always using some form of neuromuscular blockade reversal. The major complications attributed to neuromuscular blockers were residual curarization and prolonged blockade. Eighteen anesthesiologists reported death attributed to neuromuscular blockers. Residual or prolonged blockade is possibly recorded as a result of the high rate of using clinical criteria to diagnose whether the patient has recovered or not from motor block and, as a corollary, the poor use of neuromuscular transmission monitors in daily practice.

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The objective of this study was to evaluate how Brazilian anesthesiologists are using neuromuscular blockers (NMB), focusing on how they establish the diagnosis of postoperative residual curarization and the incidence of complications associated with the use of NMB. A questionnaire was sent to anesthesiologists inviting them to participate in the study. The online data collection remained open from March 2012 to June 2013. During the study period, 1296 responses were collected. Rocuronium, atracurium, and cisatracurium were the main neuromuscular blockers used in cases of elective surgery. Succinylcholine and rocuronium were the main NMB used in cases of emergency surgery. Less than 15% of anesthesiologists reported the frequent use of neuromuscular function monitors. Only 18% of those involved in the study reported that all workplaces have such a monitor. Most respondents reported using only the clinical criteria to assess whether the patient is recovered from the muscle relaxant. Most respondents also reported always using some form of neuromuscular blockade reversal. The major complications attributed to NMB were residual curarization and prolonged blockade. Eighteen anesthesiologists reported death attributed to NMB. Residual or prolonged blockade is possibly recorded as a result of the high rate of using clinical criteria to diagnose whether the patient has recovered or not from motor block and, as a corollary, the poor use of neuromuscular transmission monitors in daily practice.

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JUSTIFICATIVA E OBJETIVOS: A peridural contínua é utilizada para alívio da dor do trabalho de parto e associada a baixos índices de complicações. Estudos com enantiômeros levógiros dos anestésicos locais demonstraram maior segurança em função de menor cardiotoxicidade. O objetivo deste estudo foi comparar a analgesia e o bloqueio motor entre a bupivacaína (S50-R50) a 0,125 por cento e a bupivacaína em excesso enantiomérico de 50 por cento (S75-R25) a 0,125 por cento e 0,25 por cento em peridural contínua para analgesia de parto. MÉTODO: Realizou-se ensaio clínico duplamente encoberto, com distribuição aleatória de 75 participantes em trabalho de parto, distribuídas em três grupos: GI - bupivacaína (S50-R50) a 0,125 por cento; GII - bupivacaína (S75-R25) a 0,125 por cento; e GIII - bupivacaína (S75-R25) a 0,25 por cento. A inclusão no estudo foi feita após assinatura do Consentimento Livre e Esclarecido. RESULTADOS: Não foram encontradas diferenças estatísticas significativas quanto à latência da analgesia, nível sensorial do bloqueio, volume de anestésico local, duração do trabalho de parto e da analgesia, freqüência de parto instrumental, escores de Apgar ou pH do cordão umbilical. O intervalo para a primeira dose resgate foi maior e os escores de dor em 45 min foram menores no grupo bupivacaína (S75-R25) a 0,25 por cento. A intensidade do bloqueio motor foi maior no grupo bupivacaína (S50-R50) a 0,125 por cento. CONCLUSÕES: A bupivacaína (S75-R25) determinou um bloqueio motor menos intenso, mesmo quando utilizada em maior concentração (0,25 por cento), resultando em melhor qualidade de analgesia, sem interferir na evolução do trabalho de parto ou na vitalidade dos recém-nascidos.

BACKGROUND AND OBJECTIVES: Continuous epidural block is used for relief of labor pain and it is associated with a low incidence of complications. Studies with the levorotatory isomer of local anesthetics demonstrated that they are safer regarding the cardiotoxicity. The objective of this study was to compare analgesia and motor blockade of 0.125 percent bupivacaine (S50-R50) and 0.125 percent and 0.25 percent 50 percent enantiomeric excess bupivacaine (S75-R25) in continuous epidural block for labor analgesia. METHODS: Seventy-five patients in labor participated in this randomized, double-blind study after signing an informed consent. Patients were divided in three groups: GI - 0.125 percent bupivacaine (S50-R50); GII - 0.125 percent bupivacaine (S75-R25) and GIII - 0.25 percent bupivacaine (S75-R25). RESULTS: The latency of analgesia, levels of sensorial blockade, volume of local anesthetic, duration of labor and analgesia, frequency of instrumental delivery, Apgar scores, or pH of umbilical cord blood showed no statistically significant differences. The length of time until the first rescue dose was greater and pain scores at 45 minutes were also greater in the 0.25 percent bupivacaine (S75-R25) group. The intensity of the motor blockade was greater in the 0.125 percent bupivacaine (S50-R50) group. CONCLUSIONS: The motor blockade was less intense with bupivacaine (S75-R25) regardless the concentration, resulting in analgesia of better quality without interfering with the evolution of labor or the vitality of newborns.

JUSTIFICATIVA Y OBJETIVOS: La peridural continua se utiliza para el alivio del dolor del trabajo de parto y asociada a bajos índices de complicaciones. Estudios con enantiómeros levógiros de los anestésicos locales demostraron una mayor seguridad en función de una menor cardiotoxicidad. El objetivo de este estudio fue comparar la analgesia y el bloqueo motor entre la Bupivacaina (S50-R50) a 0,125 por ciento y la Bupivacaina en exceso enantiomérico de 50 por ciento (S75-R25) a 0,125 por ciento e 0,25 por ciento en peridural continua para analgesia de parto. MÉTODO: Se realizó un ensayo clínico doblemente encubierto, con distribución aleatoria de 75 participantes en trabajo de parto, distribuidas en tres grupos: GI - Bupivacaina (S50-R50) a 0,125 por ciento, GII - Bupivacaina (S75-R25) a 0,125 por ciento y GIII - Bupivacaina (S75-R25) a 0,25 por ciento. La inclusión en el estudio fue hecha después de la firma del Consentimiento Libre y Aclarado. RESULTADOS: No se encontraron diferencias estadísticas significativas en cuanto a la latencia de la analgesia, nivel sensorial del bloqueo, volumen de anestésico local, duración del trabajo de parto y de la analgesia, frecuencia de parto instrumental, puntuaciones de Apgar o pH del cordón umbilical. El intervalo para la primera dosis rescate fue mayor y los puntajes de dolor en 45 minutos fueron menores en el grupo Bupivacaina (S75-R25) a 0,25 por ciento. La intensidad del bloqueo motor fue mayor en el grupo Bupivacaina (S50-R50) a 0,125 por ciento. CONCLUSIONES: La Bupivacaina (S75-R25) determinó un bloqueo motor menos intenso, incluso cuando se utilizó en mayor concentración (0,25 por ciento), resultando en una mejor calidad de analgesia, sin interferir en la evolución del trabajo de parto o en la vitalidad de los recién nacidos.

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BACKGROUND AND OBJECTIVES: Continuous epidural block is used for relief of labor pain and it is associated with a low incidence of complications. Studies with the levorotatory isomer of local anesthetics demonstrated that they are safer regarding the cardiotoxicity. The objective of this study was to compare analgesia and motor blockade of 0.125% bupivacaine (S50-R50) and 0.125% and 0.25% 50% enantiomeric excess bupivacaine (S75-R25) in continuous epidural block for labor analgesia. METHODS: Seventy-five patients in labor participated in this randomized, double-blind study after signing an informed consent. Patients were divided in three groups: GI - 0.125% bupivacaine (S50-R50); GII - 0.125% bupivacaine (S75-R25) and GIII - 0.25% bupivacaine (S75-R25). RESULTS: The latency of analgesia, levels of sensorial blockade, volume of local anesthetic, duration of labor and analgesia, frequency of instrumental delivery, Apgar scores, or pH of umbilical cord blood showed no statistically significant differences. The length of time until the first rescue dose was greater and pain scores at 45 minutes were also greater in the 0.25% bupivacaine (S75-R25) group. The intensity of the motor blockade was greater in the 0.125% bupivacaine (S50-R50) group. CONCLUSIONS: The motor blockade was less intense with bupivacaine (S75-R25) regardless the concentration, resulting in analgesia of better quality without interfering with the evolution of labor or the vitality of newborns.

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