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BACKGROUND AND OBJECTIVES: The subarachnoid administration of morphine is a well-established anesthetic technique of postoperative analgesia due to its efficacy safety and low cost. The objective of this paper was to report the accidental subarachnoid administration of 4 mg of morphine complicated by atrial fibrillation after administration of naloxone. CASE REPORT: A 45-year old male patient with 75 kg, 1.72 m, physical status ASA II, hypertensive, was scheduled for reconstruction of the anterior cruciate ligament of the left knee. After spinal anesthesia, it was noticed that the vial of morphine had been changed resulting in the accidental subarachnoid administration of 4 mg of morphine (0.4 mL of the 10 mg vial). Respiratory rate varied from 12 to 16 bpm and the patient remained hemodynamically stable without intraoperative complaints. Thirty minutes after admission to the post-anesthesia recovery unit the patient developed vomiting and diaphoresis being treated with 0.4 mg of naloxone followed by continuous infusion of 0.2 mg x (-1) until the symptoms had subsided. Continuous naloxone infusion was maintained in the Intensive Care Unit (ICU), where blood pressure, heart rate, respiratory rate and oxygen saturation were monitored as well as the presence of nausea, pruritus, vomiting, sedation, pain and urinary retention. Two hours after arriving at the ICU the patient developed acute atrial fibrillation without hemodynamic instability. Sinus rhythm was reestablished after the administration of 150 mg of amiodarone and discontinuation of the naloxone infusion. During the following 18 hours the patient remained hemodynamically stable and did not experience any other intercurrence until his discharge from the hospital. CONCLUSIONS: The present report is an alert for the risk of inadvertently switching of drugs during anesthesia, stressing the importance of referring patients being treated for opiate overdose to the ICU, due to the potential adverse reactions.

Assuntos

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BACKGROUND AND OBJECTIVES: Post-dural puncture headache is a well-known complication of epidural and subarachnoid blockades and the blood patch is the treatment used more often. In most patients, the blood patch relieves the headache completely, but for the remaining there is no improvement or only partial relief of the symptom. In those cases, it is prudent to look for other differential diagnosis, such as subdural hematoma or pneumoencephalus. In those situations, imaging exams are extremely useful. The objective of this report was to present the case of a patient who developed subdural hematoma after accidental puncture of the dura mater during epidural block. CASE REPORT A 47-year old male patient, 147 kg, 1.90 m, physical status ASA II, was admitted for abdominal dermolipectomy after undergoing gastroplasty. The dura mater was accidentally punctured during the epidural block. The patient developed postdural puncture headache treated with an epidural blood patch, with partial improvement of his symptoms. However, it was followed by worsening of the headache and an MRI showed the presence of an intracranial subdural hematoma, which was treated clinically The patient evolved with progressive improvement of the symptom and full recovery after 30 days. CONCLUSIONS: Subdural hematoma is a rare, but severe, complication of dura mater puncture. It is difficult to diagnose, but it should always be remembered when post-dural puncture headache shows no resolution or even worsens after an epidural blood patch. An imaging exam is fundamental for the diagnosis of this rare complication.

Assuntos

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BACKGROUND AND OBJECTIVES: Arthroscopic shoulder surgeries are associated with severe postoperative pain. Among the analgesic techniques available, brachial plexus block has the best results. The objective of this study was to determine which concentration of local analgesic used in the posterior brachial plexus block provides longer postoperative analgesia. METHODS: Ninety patients undergoing posterior brachial plexus block were randomly divided into three groups of 30 patients each. Group 1: 20 mL of 0.5% ropivacaine; Group 2: 20 mL of 0.75% ropivacaine; and Group 3: 20 mL of 1% ropivacaine. The blockade was evaluated by assessing the thermal sensitivity using a cotton pad with alcohol and postoperative pain was evaluated according to a Verbal Numeric Scale (VNS) in the first 48 hours. RESULTS: Postoperative analgesia was similar in all three groups according to the parameters evaluated: mean VNS, time until the first complaint of pain, and postoperative opioid consumption. CONCLUSIONS: This study demonstrated that posterior brachial plexus block provides effective analgesia for shoulder surgeries. Twenty milliliters of ropivacaine in the different concentrations used in this study promoted similar analgesia.

Assuntos

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BACKGROUND AND OBJECTIVES: Residual neuromuscular block in the post-anesthetic recovery unit (PACU) may increase postoperative morbidity from 0% to 93%. This study aimed at evaluating the incidence of residual neuromuscular block in the PACU. METHODS: Participated in this study 93 patients submitted to general anesthesia with cisatracurium or rocuronium. After PACU admission, neuromuscular function was objectively monitored (acceleromyography - TOF GUARD). Residual neuromuscular block was defined as TOF < 0.9. RESULTS: From 93 patients, 53 received cisatracurium and 40 rocuronium. Demographics, procedure length and the use of antagonists were comparable between groups. Residual neuromuscular block was 32% in subgroup C (cisatracurium) and 30% in subgroup R (rocuronium). Residual neuromuscular block was unrelated to dose, age and use of antagonists, but was related to procedure length. In subgroup C, mean procedure length was 135 minutes for patients with neuromuscular block and 161 minutes for patients without (p < 0.029). In subgroup R, mean surgery length was 122 and 150 minutes, respectively (p < 0.039). CONCLUSIONS: Both groups had high incidence of residual neuromuscular block in the PACU. Residual postoperative curarization is still a problem even with new intermediary action neuromuscular blockers. It is highly important to objectively monitor all patients submitted to general anesthesia with neuromuscular blockers.

RESUMO

BACKGROUND AND OBJECTIVES: Although rare, intraoperative awareness is a severe general anesthesia complication. Anesthesia machine malfunction is one of several causes for anesthetic complications, among them intraoperative awareness. This report aimed at showing a case where the volatile anesthetic monitor has detected machine malfunction which could have led to intraoperative awareness. CASE REPORT: Female patient, 38 years old, 55 kg, physical status ASA I, with right breast cancer, admitted for radical mastectomy and immediate myocutaneous flap reconstruction. Epidural puncture was performed at T8-T9 with a 17-gauge Tuohy epidural needle followed by the introduction of 18-gauge epidural catheter and administration of 0.2% ropivacaine. General anesthesia was then induced, followed by sevoflurane vaporization. Although other monitoring parameters have not detected relevant findings, the inhalational anesthetic monitor has not identified the presence of sevoflurane, thus allowing the diagnostic of vaporizer leakage. CONCLUSIONS: Although rare, intraoperative awareness is a severe complication which should be prevented. Routine and thorough anesthesia equipment inspection before its use may minimize failures. The inhalational anesthetics monitor is useful whenever inhaled anesthetics are being used and may early detect anesthesia machine failures as in this case report.