Silicone Líquido Utilizado Com Finalidade Estética Como Potencializador Da Ocorrência De Linfedema Genital Pós-radioterapia: Relato De Caso

Lymphedema consists of extracellular fluid retention caused by lymphatic obstruction. In chronic forms, fat and fibrous tissue accumulation is observed. Genital lymphedema is a rare condition in developed countries and may have primary or acquired etiology. It generally leads to urinary, sexual and social impairment. Clinical treatment usually has low effectiveness, and surgical resection is frequently indicated. CASE REPORT: We report a case of a male-to-female transgender patient who was referred for treatment of chronic genital lymphedema. She had a history of pelvic radiotherapy to treat anal cancer and of liquid silicone injections to the buttock and thigh regions for esthetic purposes. Radiological examinations showed signs both of tissue infiltration by liquid silicone and of granulomas, lymphadenopathy and lymphedema. Surgical treatment was performed on the area affected, in which lymphedematous tissue was excised from the scrotum while preserving the penis and testicles, with satisfactory results. Histopathological examination showed alterations compatible with tissue infiltration by exogenous material, along with chronic lymphedema. CONCLUSION: Genital lymphedema may be caused by an association of lesions due to liquid silicone injections and radiotherapy in the pelvic region. Cancer treatment decisions for patients who previously underwent liquid silicone injection should take this information into account, since it may represent a risk factor for radiotherapy complications.135218518

Eficácia do balonete do tubo endotraqueal sobre a traqueia: aspectos físicos e mecânicos

Introduction: The inflation pressure of the endotracheal tube cuff can cause ischemia of the tracheal mucosa at high pressures; thus, it can cause important tracheal morbidity and tracheal microaspiration of the oropharyngeal secretion, or it can even cause pneumonia associated with mechanical ventilation if the pressure of the cuff is insufficient. Objective: In order to investigate the effectiveness of the RUSCH® 7.5 mm endotracheal tube cuff, this study was designed to investigate the physical and mechanical aspects of the cuff in contact with the trachea. Methods: For this end, we developed an in vitro experimental model to assess the flow of dye (methylene blue) by the inflated cuff on the wall of the artificial material. We also designed an in vivo study with 12 Large White pigs under endotracheal intubation. We instilled the same dye in the oral cavity of the animals, and we analyzed the presence or not of leakage in the trachea after the region of the cuff after their deaths (animal sacrifice). All cuffs were inflated at the pressure of 30 cmH2O. Results: We observed the passage of fluids through the cuff in all in vitro and in vivo experimental models. Conclusion: We conclude that, as well as several other cuff models in the literature, the RUSCH® 7.5 mm tube cuffs are also not able to completely seal the trachea and thus prevent aspiration of oropharyngeal secretions. Other prevention measures should be taken.The inflation pressure of the endotracheal tube cuff can cause ischemia of the tracheal mucosa at high pressures, thus, it can cause important tracheal morbidity and tracheal microaspiration of the oropharyngeal secretion, or it can even cause pneumonia a294552558SEM INFORMAÇÃOSEM INFORMAÇÃODobell, A.R., The origins of endotracheal ventilation (1994) Ann Thorac Surg, 58 (2), pp. 578-584Mehta, S., Tracheal tube cuff pressure (1989) Anaesthesia, 44 (12), pp. 1001-1002Mehta, S., Mickiewicz, M., Pressure in large volume, low pressure cuffs: Its significance, measurement and regulation (1985) Intensive Care Med, 11 (5), pp. 267-272Luna, C.M., Legarreta, G., Esteva, H., Laffaire, E., Jolly, E.C., Effect of tracheal dilatation and rupture on mechanical ventilation using a low-pressure cuff tube (1993) Chest, 104 (2), pp. 639-640Bernhard, W.N., Yost, L., Turndorf, H., Danziger, F., Cuffed tracheal tubes--physical and behavioral characteristics (1982) Anesth Analg, 61 (1), pp. 36-41Nordin, U., The trachea and cuff-induced tracheal injury. An experimental study on causative factors and prevention (1977) Acta Otolaryngol Suppl, 345, pp. 1-71Sole, M.L., Su, X., Talbert, S., Penoyer, D.A., Kalita, S., Jimenez, E., Evaluation of an intervention to maintain endotracheal tube cuff pressure within therapeutic range (2011) Am J Crit Care, 20 (2), pp. 109-117Benumof, J.L., Cooper, S.D., Quantitative improvement in laryngoscopic view by optimal external laryngeal manipulation (1996) J Clin Anesth, 8 (2), pp. 136-140Keller, C., Brimacombe, J., Boehler, M., Loeckinger, A., Puehringer, F., The influence of cuff volume and anatomic location on pharyngeal, esophageal, and tracheal mucosal pressures with the esophageal tracheal combitube (2002) Anesthesiology, 96 (5), pp. 1074-1077Cooper, J.D., Grillo, H.C., The evolution of tracheal injury due to ventilatory assistance through cuffed tubes: A pathologic study (1969) Ann Surg, 169 (3), pp. 334-348Seegobin, R.D., Van Hasselt, G.L., Endotracheal cuff pressure and tracheal mucosal blood flow: Endoscopic study of effects of four large volume cuffs (1984) Br Med J (Clin Res Ed), 288 (6422), pp. 965-968Joseph, N.M., Sistla, S., Dutta, T.K., Badhe, A.S., Parija, S.C., Ventilator-associated pneumonia: A review (2010) Eur J Intern Med, 21 (5), pp. 360-368Dave, M.H., Koepfer, N., Madjdpour, C., Frotzler, A., Weiss, M., Tracheal fluid leakage in benchtop trials: Comparison of static versus dynamic ventilation model with and without lubrication (2010) J Anesth, 24 (2), pp. 247-252Lucangelo, U., Zin, W.A., Antonaglia, V., Petrucci, L., Viviani, M., Buscema, G., Effect of positive expiratory pressure and type of tracheal cuff on the incidence of aspiration in mechanically ventilated patients in an intensive care unit (2008) Crit Care Med, 36 (2), pp. 409-413Young, P.J., Burchett, K., Harvey, I., Blunt, M.C., The prevention of pulmonary aspiration with control of tracheal wall pressure using a silicone cuff (2000) Anaesth Intensive Care, 28 (6), pp. 660-665Dave, M.H., Frotzler, A., Spielmann, N., Madjdpour, C., Weiss, M., Effect of tracheal tube cuff shape on fluid leakage across the cuff: An in vitro study (2010) Br J Anaesth, 105 (4), pp. 538-543Pavlin, E.G., Vannimwegan, D., Hornbein, T.F., Failure of a high-compliance low-pressure cuff to prevent aspiration (1975) Anesthesiology, 42 (2), pp. 216-219Macrae, W., Wallace, P., Aspiration around high-volume, low-pressure endotracheal cuff (1981) Br Med J (Clin Res Ed), 283 (6301), p. 1220Windsor, H.M., Shanahan, M.X., Cherian, K., Chang, V.P., Tracheal injury following prolonged intubation (1976) Aust N Z J Surg, 46 (1), pp. 18-25Lewis, F.R., Jr., Schiobohm, R.M., Thomas, A.N., Prevention of complications from prolonged tracheal intubation (1978) Am J Surg, 135 (3), pp. 452-457Servin, S.O., Barreto, G., Martins, L.C., Moreira, M.M., Meirelles, L., Neto, J.A., Atraumatic endotracheal tube for mechanical ventilation (2011) Rev Bras Anestesiol, 61 (3), pp. 311-319Lima, L.C., Avelar, S.F., Westphal, F.L., Lima, I., Lung nodule, tracheal stenoses and coronary disease: How to approach when are all associated to? (2007) Rev Bras Cir Cardiovasc, 22 (3), pp. 359-361Conti, M., Pougeoise, M., Wurtz, A., Porte, H., Fourrier, F., Ramon, P., Management of postintubation tracheobronchial ruptures (2006) Chest, 130 (2), pp. 412-418Marjot, R., Pressure exerted by the laryngeal mask airway cuff upon the pharyngeal mucosa (1993) Br J Anaesth, 70 (1), pp. 25-29. , Erratum in: Br J Anaesth. 1993;70(6):711Peták, F., Janosi, T.Z., Myers, C., Fontao, F., Habre, W., Impact of elevated pulmonary blood flow and capillary pressure on lung responsiveness (2009) J Appl Physiol (1985), 107 (3), pp. 780-786Iglesias, J.L., Lanoue, J.L., Rogers, T.E., Inman, L., Turnage, R.H., Physiologic basis of pulmonary edema during intestinal reperfusion (1998) J Surg Res, 80 (2), pp. 156-163Dullenkopf, A., Gerber, A., Weiss, M., Fluid leakage past tracheal tube cuffs: Evaluation of the new Microcuff endotracheal tube (2003) Intensive Care Med, 29 (10), pp. 1849-1853Lomholt, N., A device for measuring the lateral wall cuff pressure of endotracheal tubes (1992) Acta Anaesthesiol Scand, 36 (8), pp. 775-778Young, P.J., Pakeerathan, S., Blunt, M.C., Subramanya, S., A low-volume, low-pressure tracheal tube cuff reduces pulmonary aspiration (2006) Crit Care Med, 34 (3), pp. 632-639Blunt, M.C., Young, P.J., Patil, A., Haddock, A., Gel lubrication of the tracheal tube cuff reduces pulmonary aspiration (2001) Anesthesiology, 95 (2), pp. 377-381Sanjay, P.S., Miller, S.A., Corry, P.R., Russell, G.N., Pennefather, S.H., The effect of gel lubrication on cuff leakage of double lumen tubes during thoracic surgery (2006) Anaesthesia, 61 (2), pp. 133-137A pressão de insuflação do balonete (cuff) do tubo endotraqueal tanto pode causar isquemia de mucosa traqueal em pressões elevadas, e assim ocasionar morbidade traqueal importante, quanto pode causar microaspiração traqueal de secreção de orofaringe ou,

Creation of an institucional protocol and pilot study for postoperative monitoring of free flaps reconstructions

Orientadores: Paulo Kharmandayan, Alfio José TincaniDissertação (mestrado profissional) - Universidade Estadual de Campinas, Faculdade de Ciências MédicasResumo: Introdução: A técnica cirúrgica microvascular para realização de retalhos microcirúrgicos foi sendo aprimorada nos últimos 30 anos, com taxas de sucesso reportadas entre 94% a 99%. A despeito dessa evolução, complicações vasculares (tromboses venosa, arterial e hematomas) nos pedículos dos retalhos microcirúrgicos podem levar à isquemia e congestão. Sinais de má perfusão tecidual, quando identificados precocemente, possibilitam intervenção imediata, elevando as taxas de sobrevivência do retalho. A partir da década de 1980, as tentativas de padronizar uma técnica ideal de monitoramento objetivando minimizar as perdas aumentaram. O modelo ideal seria não invasivo, confiável, objetivo, reprodutível por qualquer indivíduo treinado, com monitoramento contínuo para todos os tipos de retalho e economicamente viável. O modelo preconizado nos dias de hoje ainda consiste na observação clínica: avaliação da cor do tecido, temperatura do retalho, sangramento dérmico (pin prick test) e enchimento capilar, apesar de serem baseados em variáveis subjetivas e dependentes de avaliação pessoal. Métodos auxiliares vêm ganhando espaço visando serem mais objetivos (ex.: clearence de hidrogênio, ultrassom Doppler portátil, ultrassom Doppler implantável, temperatura por infravermelho, avaliação da oxigenação tecidual, microdiálise, angiografia com verde de indocianina). Todavia ainda não há consenso sobre um monitoramento de retalhos microcirúrgicos que seja tão sensível, específico e que promova uma reintervenção cirúrgica mais eficaz que o monitoramento clínico. Objetivo:?Criação e elaboração de estudo piloto de um protocolo de monitoramento pós-operatório dos pacientes candidatos à reconstrução microcirúrgica do Hospital de Clínicas da UNICAMP, adequado ao Serviço, visando minimizar a taxa de perda destes retalhos. Método:?Revisão de dados da literatura sobre monitoramento pós-operatório de retalhos microcirúrgicos para criação de um protocolo adequado ao Serviço utilizando a observação clínica acrescida de dois métodos auxiliares de interpretação mais objetiva: o ultrassom Doppler portátil e o termômetro infravermelho. Elaboração de estudo piloto sequencialmente. Resultados:?Após revisão de dados da literatura (PubMed e LILACS) com os termos "FREE FLAPS and MONITORING" foram identificados 188 artigos, dos quais 4 revisões sistemáticas e 20 estudos prospectivos. Tomando como base os 24 artigos (revisões sistemáticas e estudos prospectivos), foi criado um protocolo de monitoramento para o Serviço, que consistiu em: 1) avaliação do estado hemodinâmico do paciente anteriormente ao monitoramento propriamente dito; 2) realização do monitoramento do retalho por meio da observação clínica, ultrassom Doppler portátil e termômetro infravermelho; 3) registro fotográfico do padrão de perfusão do retalho. No estudo piloto foram acompanhados três pacientes (setembro a dezembro de 2019), com reintervenção precoce em um caso e salvamento do retalho. Conclusão: A criação do protocolo institucional de monitoramento pós-operatório dos retalhos microcirúrgicos utilizando a associação da observação clínica e de dois métodos auxiliares de interpretação (ultrassom Doppler portátil e termômetro infravermelho) adequou-se às características deste Serviço e foi reprodutível pelos residentes treinados após estudo piloto. É necessária a aplicação do protocolo para um maior número de pacientesAbstract: Introduction: The microvascular surgical technique for performing microsurgical flaps has improved over the last 30 years, with reported success rates ranging from 94% to 99%. Despite this evolution, vascular complications (venous, arterial thrombosis and hematomas) in the microsurgical flap pedicles may lead to ischemia and congestion. Signs of poor tissue perfusion, when identified early, allow immediate intervention for flap salvage attempt, increasing flap survival rates. Starting in the 1980¿s, attempts to standardize an ideal monitoring technique to minimize flap losses have increased. The ideal model would be non-invasive, reliable, objective, reproducible, with continuous monitoring for all types of flaps and economically feasible. The gold-standard method until today consists of clinical observation: evaluation of tissue color, flap temperature, dermal bleeding (pin prick test) and capillary filling, despite being based on subjective variables and dependent on personal evaluation. New auxiliary methods can provide more objective readings (eg. hydrogen clearance, portable Doppler ultrasound, implantable Doppler ultrasound, infrared temperature, assessment of tissue oxygenation, microdialysis, indocyanine green angiography). However, there is still no consensus on which objective microsurgical flap monitoring method is as sensitive and specific as clinical monitoring. Objective: Creation and design of a postoperative free flap monitoring protocol for patients who will undergo microsurgical flap reconstruction at UNICAMP (Hospital de Clínicas da UNICAMP), suitable to the Plastic Surgery Service, aiming to minimize free flap complications. Method: Review of literature on postoperative monitoring methods with development of a free flap monitoring protocol suitable to the UNICAMP Plastic Surgery Service based on clinical observation associated to two auxiliary objective reading methods: the portable Doppler ultrasound and the infrared thermometer. Results: The review of literature (PubMed and LILACS) with the terms "FREE FLAPS and MONITORING" retrieved 188 articles, with 4 systematic reviews and 20 prospective studies. Based on the 24 later articles, a monitoring protocol was created, which consisted of: 1) assessment of the patient's hemodynamic status prior to the monitoring itself; 2) flap monitoring through clinical observation, portable Doppler ultrasound and infrared thermometer; 3) photographic record of the flap perfusion pattern. Three patients were included in the initial study (September to December 2019), one of them required early take back for flap salvage. Conclusion: The creation of an institutional protocol for postoperative free flap monitoring using a combination of clinical observation and two auxiliary objective interpretation methods (portable Doppler ultrasound and infrared thermometer) was suitable to the characteristics of the Service and was reproducible by trained residents after an initial study. A larger number of patients is necessary for further assessment of the efficacy of the proposed protocolMestradoEficácia e Efetividade de Testes Diagnósticos e Protocolos de Tratamento em SaúdeMestra em Ciência

Liquid silicone used for esthetic purposes as a potentiator for occurrence of post-radiotherapy genital lymphedema: case report

ABSTRACT CONTEXT: Lymphedema consists of extracellular fluid retention caused by lymphatic obstruction. In chronic forms, fat and fibrous tissue accumulation is observed. Genital lymphedema is a rare condition in developed countries and may have primary or acquired etiology. It generally leads to urinary, sexual and social impairment. Clinical treatment usually has low effectiveness, and surgical resection is frequently indicated. CASE REPORT: We report a case of a male-to-female transgender patient who was referred for treatment of chronic genital lymphedema. She had a history of pelvic radiotherapy to treat anal cancer and of liquid silicone injections to the buttock and thigh regions for esthetic purposes. Radiological examinations showed signs both of tissue infiltration by liquid silicone and of granulomas, lymphadenopathy and lymphedema. Surgical treatment was performed on the area affected, in which lymphedematous tissue was excised from the scrotum while preserving the penis and testicles, with satisfactory results. Histopathological examination showed alterations compatible with tissue infiltration by exogenous material, along with chronic lymphedema. CONCLUSION: Genital lymphedema may be caused by an association of lesions due to liquid silicone injections and radiotherapy in the pelvic region. Cancer treatment decisions for patients who previously underwent liquid silicone injection should take this information into account, since it may represent a risk factor for radiotherapy complications

Evaluation of the Efficiency of the Atraumatic Endotracheal Tube in the Pulmonary-Gas Exchange: an Experimental Study

ABSTRACT OBJECTIVE: Mechanical ventilation is frequently necessary, in which case the use of an endotracheal tube is mandatory. The tube has an inflatable balloon in its distal extremity, whose aim is, among other functions, an efficient arterialization. However, serious injuries in the place of contact of the balloon with the trachea can be frequent. Some studies point out that balloons with permanent pressure may reduce this complication. Nevertheless, air scape, expressed by the inspiratory (IV) and expiratory volume (EV) variation (Δ IV-EV), may occur, possibly leading to hypoxemia. Thus, the goal of this study was to verify the efficiency of a modified endotracheal tube on arterializations compared to the traditional endotracheal tube. METHODS: The modified endotracheal tube presents intermittent insufflation, with three drillings in the internal region of the cuff, allowing for insufflation in the inspiratory phase of the mechanical ventilation. Three animals were used for the control group, with a cuff pressure of 30 cmH2O, and seven pigs had the modified endotracheal tube. Each animal was kept under mechanical ventilation (FIO2=0.21) for 6 hours. Arterial and venous gases were measured every three hours (T0; T3; T6). RESULTS: The gases confirmed the lack of hypoxia between the Groups, with a difference in the ΔIV-EV at T0 (P=0.0486). CONCLUSIONS: In this study, the lack of hypoxia showed the efficiency of the modified endotracheal tube. However, new studies are necessary, particularly in diseased lungs, in order to evaluate the real efficiency of the mentioned device on the pulmonary gas exchange