Bloqueo del plexo braquial por vía interescalénica: efectos sobre la función pulmonar

BACKGROUND AND OBJECTIVES: The interscalene is one of the most common approaches used in brachial plexus block. However, the association of this approach with the ipsilateral blockade of the phrenic nerve has been demonstrated. The resulting diaphragmatic dysfunction causes changes in lung mechanics, which can be potentially deleterious in patients with limited respiratory reserve. The objective of the present study was to evaluate the repercussion of interscalene brachial plexus block on pulmonary function by measuring forced vital capacity (FVC). METHODS: This is a double-blind study with 30 patients, physical status ASA I or II, randomly separated into two groups of 15 patients each; 0.5% ropivacaine (Ropi Group) or 0.5% bupivacaine with epinephrine (Bupi Group) was administered. A peripheral nerve stimulator was used, and 30 mL of the local anesthetic were administered. Four spirometries were done in each patient: before the blockade, 30 minutes, four hours, and six hours after the blockade. Patients were not sedated. RESULTS: One patient in the Ropi Group and three patients in the Bupi Group were excluded from the study due to failure of the blockade. The Ropi Group showed maximal FVC reduction at 30 minutes (25.1%), with a tendency for recovery from this point on. With bupivacaine, the reduction in FVC was less important at the different study moments; an additional reduction was observed between 30 (15.8%) and four hours (17.3%), but it was not statistically significant. A tendency for recovery was observed from four hours on. In both groups, the FVC six hours after the blockade was still below baseline levels. CONCLUSIONS: Interscalene block reduces FVC in most cases. Changes were more pronounced in the Ropivacaine group.JUSTIFICATIVA Y OBJETIVOS: La vía interescalénica es uno de los accesos más a menudo utilizados en el bloqueo del plexo braquial. Sin embargo, se ha demostrado una asociación de esa técnica con el bloqueo del nervio frénico ipsilateral. La disfunción diafragmática de resultas de esa asociación, provoca alteraciones en la mecánica pulmonar, potencialmente perjudiciales en pacientes con una limitación de la reserva ventilatoria. El objetivo del estudio fue evaluar la repercusión del bloqueo interescalénico sobre la función pulmonar por medio de la medida de la capacidad vital forzada (CVF). MÉTODO: Estudio doble ciego, con 30 pacientes, estado físico I o II (ASA), distribuidos aleatoriamente en dos grupos de 15. Se administró solución a 0,5% de ropivacaína (Grupo Ropi) o bupivacaína a 0,5% con epinefrina (Grupo Bupi). El bloqueo fue realizado utilizando estimulador de nervio periférico e inyectando 30 mL de anestésico local. Cuatro espirometrías se hicieron en cada paciente: antes del bloqueo, 30 minutos, 4 y 6 horas después. Los pacientes no recibieron sedación. RESULTADOS: Un paciente del Grupo Ropi y tres pacientes del Grupo Bupi, quedaron excluidos del estudio por fallos de bloqueo. La reducción de la CVF en el Grupo Ropi se hizo máxima a los 30 minutos (25,1%) y a partir de entonces, hubo una tendencia progresiva a la recuperación. Ya con la bupivacaína, la reducción de la CVF pareció ser menos acentuada en los diversos momentos estudiados; se observó una reducción adicional entre 30 minutos (15,8%) y 4 horas (17,3%), siendo esa sin diferencia estadística. A partir de 4 horas, se notó una tendencia a la recuperación. En los dos grupos, después de 6 horas de bloqueo, la CVF todavía estaba por debajo de los valores previos. CONCLUSIONES: El bloqueo interescalénico reduce la CVF en la mayoría de los casos; las alteraciones fueron más acentuadas en el Grupo Ropivacaína.JUSTIFICATIVA E OBJETIVOS: A via interescalênica é um dos acessos mais comumente utilizados no bloqueio do plexo braquial. Todavia, tem-se demonstrado associação dessa técnica com o bloqueio do nervo frênico ipsilateral. A disfunção diafragmática daí resultante provoca alterações na mecânica pulmonar, potencialmente deletérias em pacientes com limitação da reserva ventilatória. O objetivo do estudo foi avaliar a repercussão do bloqueio interescalênico sobre a função pulmonar por meio da medida da capacidade vital forçada (CVF). MÉTODO: Estudo duplamente encoberto com 30 pacientes, estado físico I ou II (ASA), distribuídos aleatoriamente em dois grupos de15. Foi administrada solução a 0,5% de ropivacaína (Grupo Ropi) ou bupivacaína a 0,5% com epinefrina (Grupo Bupi). O bloqueio foi realizado utilizando estimulador de nervo periférico e sendo injetados 30 mL de anestésico local. Quatro espirometrias foram realizadas em cada paciente: antes do bloqueio, 30 minutos, 4 e 6 horas após. Os pacientes não receberam sedação. RESULTADOS: Um paciente do Grupo Ropi e três pacientes do Grupo Bupi foram excluídos do estudo por falha de bloqueio. A redução da CVF no Grupo Ropi foi máxima aos 30 minutos (25,1%) e a partir de então houve tendência progressiva à recuperação. Já com bupivacaína, a redução da CVF pareceu ser menos acentuada nos diversos momentos estudados; observou-se redução adicional entre 30 minutos (15,8%) e 4 horas (17,3%), sendo esta sem diferença estatística. A partir de 4 horas, notou-se tendência à recuperação. Em ambos os grupos, após 6 horas de bloqueio a CVF encontra-se ainda abaixo dos valores prévios. CONCLUSÕES: O bloqueio interescalênico reduz a CVF na maioria dos casos; as alterações foram mais acentuadas no Grupo Ropivacaína.UNIFESP Hospital São PauloUNIFESP Hospital São Paulo Casa da MãoUNIFESP Disciplina de Anestesiologia Dor e Terapia IntensivaUNIFESP Hospital São Paulo UTIUNIFESP, Hospital São PauloUNIFESP, Hospital São Paulo Casa da MãoUNIFESP, Disciplina de Anestesiologia Dor e Terapia IntensivaUNIFESP, Hospital São Paulo UTISciEL

Impact of a continuous education program on the quality of assistance offered by intensive care physiotherapy

Objective:To evaluate the role of quality indicators and adverse events registering in the quality assessment of intensive care physiotherapy and to evaluate the impact of implementing protocolized care and professional training in the quality improvement process. Methods:A prospective before-after study was designed to assess 15 indicators of the quality of care. Baseline compliance and adverse events were collected before and after the implementation of treatment protocols and staff training. Results:Eighty-nine patients admitted, being 48 in the pre-intervention period and 41 in the post-intervention period with a total of 1246 and 1191 observations respectively. Among the indicators related to the global population, there was a significant improvement in chest x-ray control, multidisciplinary rounds and shift changes as well as in compliance with these decisions. Indicators related to the population under mechanical ventilation, obtained by direct observation at bedside, showed a significant improvement in the compliance with the tidal volume of 6-8mL/Kg, plateau pressure <30cmH2O, adequate mechanical ventilation alarm setting, mechanical ventilation humidification control, adequate humidification line exchange and orotracheal tube position. Among the mechanical ventilation indicators collected through the physiotherapy records, there was significantly improved compliance with the predicted tidal volume registry and cuff pressure registry. There was a significant reduction in the number of adverse events. There was no impact on intensive care unit mortality, length of stay, duration of mechanical ventilation and ventilator-free days.Conclusion:It is possible to measure the quality of physiotherapy care using indicators of quality control. The implementation of care protocols and training of the professionals can improve team performance.Objetivo:Avaliar o papel de indicadores de qualidade e registro de eventos adversos na qualidade assistencial da fisioterapia em terapia intensiva, bem como o impacto da implantação de protocolos de cuidado e treinamento profissional no processo de melhoria da qualidade.Métodos:Estudo prospectivo antes-depois para avaliar 15 indicadores de qualidade assistencial. Dados basais a respeito de adesão e eventos adversos foram coletados antes e após a implantação de protocolos de tratamento e treinamento da equipe.Resultados:Foram avaliados 89 pacientes, sendo 48 admitidos no período préintervenção e 41 no período pós-intervenção, com um total de 1.246 e 1.191 observações, respectivamente. Entre os indicadores relacionados à população global, houve melhora significativa no controle radiográfico, passagem de plantão, visita multiprofissional, assim como na adesão a essas decisões. Os indicadores relacionados com a população sob ventilação mecânica, obtidos por observação direta no leito, mostraram melhora significativa na adesão ao volume corrente de 6 a 8mL/kg, pressão platô <30cmH2O, adequação dos alarmes da ventilação mecânica, controle de umidificação da ventilação mecânica, troca dos equipos de umidificação, e posicionamento do tubo orotraqueal. Entre os indicadores de ventilação mecânica coletados por meio de registros da fisioterapia, ocorreu melhora significativa da adesão ao registro do volume corrente predito e ao registro da pressão do balonete. Houve redução significativa no número de eventos adversos. Não houve impacto na mortalidade na unidade de terapia intensiva, no tempo de internação, tempo de ventilação mecânica e no tempo livre da ventilação mecânica.Conclusão:É possível medir a qualidade do cuidado fisioterapêutico utilizando indicadores de controle de qualidade. A implantação de protocolos de cuidado e treinamento dos profissionais pode melhorar o desempenho da equipe.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de MedicinaUNIFESP, EPMSciEL

Short-term effects of passive mobilization on the sublingual microcirculation and on the systemic circulation in patients with septic shock

Background: Active mobilization is not possible in patients under deep sedation and unable to follow commands. In this scenario, passive therapy is an interesting alternative. However, in patients with septic shock, passive mobilization may have risks related to increased oxygen consumption. Our objective was to evaluate the impact of passive mobilization on sublingual microcirculation and systemic hemodynamics in patients with septic shock. Methods: We included patients who were older than 18 years, who presented with septic shock, and who were under sedation and mechanical ventilation. Passive exercise was applied for 20 min with 30 repetitions per minute. Systemic hemodynamic and microcirculatory variables were compared before (T0) and up to 10 min after (T1) passive exercise. p values <0.05 were considered significant. Results: We included 35 patients (median age [IQR 25-75%]: 68 [49.0-78.0] years mean (+/- SD) Simplified Acute Physiologic Score (SAPS) 3 score: 66.7 +/- 12.1 median [IQR 25-75%] Sequential Organ Failure Assessment (SOFA) score: 9 [7.0-12.0]). After passive mobilization, there was a slight but significant increase in proportion of perfused vessels (PPV) (T0 [IQR 25-75%]: 78.2 [70.9-81.9%] T1 [IQR 25-75%]: 80.0 [75.2-85.1] % p = 0.029), without any change in other microcirculatory variables. There was a reduction in heart rate (HR) (T0 (mean +/- SD): 95.6 +/- 22.0 bpm T1 (mean +/- SD): 93.8 +/- 22.0 bpm p < 0.040) and body temperature (T0 (mean +/- SD): 36.9 +/- 1.1 degrees C T1 (mean +/- SD): 36.7 +/- 1.2 degrees C p < 0.002) with no change in other systemic hemodynamic variables. There was no significant correlation between PPV variation and HR (r = -0.010, p = 0.955), cardiac index (r = 0.218, p = 0.215) or mean arterial pressure (r = 0.276, p = 0.109) variation. Conclusions: In patients with septic shock after the initial phase of hemodynamic resuscitation, passive exercise is not associated with relevant changes in sublingual microcirculation or systemic hemodynamics.Fundacao de Apoio a Pesquisa do Estado de Sao Paulo FAPESPUniv Fed Sao Paulo, Anesthesiol Pain & Intens Care Dept, Napoleao Barros 737, BR-04024002 Sao Paulo, SP, BrazilUniv Fed Sao Paulo, Anesthesiol Pain & Intens Care Dept, Napoleao Barros 737, BR-04024002 Sao Paulo, SP, BrazilFAPESP: 2012 19 051-1Web of Scienc

Effects of prone position on the oxygenation of patients with acute respiratory distress syndrome

CONTEXT AND OBJECTIVE: Acute respiratory distress syndrome (ARDS) is characterized by arterial hypoxemia, and prone position (PP) is one possible management strategy. The objective here was to evaluate the effects of PP on oxygenation. DESIGN AND SETTING: Non-randomized, open, prospective, controlled clinical trial, in a surgical intensive care unit at a tertiary university hospital. METHODS: Forty-one ARDS patients underwent PP for three-hour periods. Arterial partial oxygen pressure (PaO2) was measured immediately before changing to PP, after 30, 60, 120 and 180 minutes in PP and 60 minutes after returning to dorsal recumbent position (DP). The paired-t and Dunnett tests were used. RESULTS: A notable clinical improvement in oxygenation (> 15%) was detected in 78.0% of patients. This persisted for 60 minutes after returning to DP in 56% and lasted for 12 and 48 hours in 53.6% and 46.3%, respectively. Maximum improvement was seen after 30 minutes in 12.5% of responding patients and after 180 minutes in 40.6%. No statistically significant associations between PP response and age, gender, weight, PEEP level, tidal volume, respiratory rate, PaO2/FiO2 or duration of mechanical ventilation were detected. One accidental extubation and four cases of deterioration through oxygenation were detected. The 48-hour mortality rate was 17%. CONCLUSIONS: For a significant number of ARDS patients, PP may rapidly enhance arterial oxygenation and its inclusion for management of severe ARDS is justified. However, it is not a cost-free maneuver and caution is needed in deciding on using PP

Efeitos da posição em pronação na oxigenação de pacientes com síndrome do desconforto respiratório agudo

CONTEXT AND OBJECTIVE: Acute respiratory distress syndrome (ARDS) is characterized by arterial hypoxemia, and prone position (PP) is one possible management strategy. The objective here was to evaluate the effects of PP on oxygenation. DESIGN AND SETTING: Non-randomized, open, prospective, controlled clinical trial, in a surgical intensive care unit at a tertiary university hospital. METHODS: Forty-one ARDS patients underwent PP for three-hour periods. Arterial partial oxygen pressure (PaO2) was measured immediately before changing to PP, after 30, 60, 120 and 180 minutes in PP and 60 minutes after returning to dorsal recumbent position (DP). The paired-t and Dunnett tests were used. RESULTS: A notable clinical improvement in oxygenation (> 15%) was detected in 78.0% of patients. This persisted for 60 minutes after returning to DP in 56% and lasted for 12 and 48 hours in 53.6% and 46.3%, respectively. Maximum improvement was seen after 30 minutes in 12.5% of responding patients and after 180 minutes in 40.6%. No statistically significant associations between PP response and age, gender, weight, PEEP level, tidal volume, respiratory rate, PaO2/FiO2 or duration of mechanical ventilation were detected. One accidental extubation and four cases of deterioration through oxygenation were detected. The 48-hour mortality rate was 17%. CONCLUSIONS: For a significant number of ARDS patients, PP may rapidly enhance arterial oxygenation and its inclusion for management of severe ARDS is justified. However, it is not a cost-free maneuver and caution is needed in deciding on using PP.CONTEXTO E OBJETIVO: A síndrome de desconforto respiratório agudo (SDRA) é caracterizada por hipoxemia arterial e a posição em pronação (PP) é uma das estratégias de tratamento. O objetivo do trabalho é avaliar os efeitos da PP na oxigenação. TIPO DE ESTUDO E LOCAL: Estudo clínico não randomizado, aberto, prospectivo, controlado, realizado em uma unidade de terapia intensiva cirúrgica de hospital universitário terciário. MÉTODOS: 41 pacientes com SDRA com idade variando entre 17 e 83 anos foram submetidos a PP durante três horas. Determinou-se a pressão parcial de oxigênio arterial imediatamente antes da mudança para PP, após 30, 60, 120 e 180 minutos em PP e 60 minutos depois de retornar para a posição dorsal (PD). Os resultados foram analisados através dos testes T pareado e Dunnett, e considerados significantes se p 15%) foi detectada em 78% dos pacientes. Após 60 minutos do retorno para a posição dorsal, o efeito persistiu em 56% dos pacientes e, após 12 e 48 horas, em 53.6% e 46.3%, respectivamente. A melhora máxima ocorreu após 30 minutos apenas em 12.5% dos respondedores e em 40,6% após 180 minutos. Não foi demonstrada associação significativa entre a resposta à PP e idade, gênero, peso, nível de pressão expiratória final positiva, volume corrente, freqüência respiratória, relação PaO2/FiO2 ou duração da ventilação mecânica. Somente uma desintubação acidental e sete casos de deterioração da oxigenação foram detectados. A mortalidade em 48 horas foi de 17%. CONCLUSÕES: Em um número significativo de pacientes com SDRA, a PP pode rapidamente melhorar a oxigenação arterial e sua inclusão no tratamento da SDRA grave está justificada. Entretanto, não se trata de uma manobra inócua e cautela é necessária quando da decisão de colocar um paciente em pronação.UNIFESP Intensive Care Unit Discipline of AnesthesiologyUNIFESP, Intensive Care Unit Discipline of AnesthesiologySciEL

Interscalene Brachial Plexus Block. Effects on Pulmonary function

SummaryBackground and objectivesThe interscalene is one of the most common approaches used in brachial plexus block. However, the association of this approach with the ipsilateral blockade of the phrenic nerve has been demonstrated. The resulting diaphragmatic dysfunction causes changes in lung mechanics, which can be potentially deleterious in patients with limited respiratory reserve. The objective of the present study was to evaluate the repercussion of interscalene brachial plexus block on pulmonary function by measuring forced vital capacity (FVC).MethodsThis is a double-blind study with 30 patients, physical status ASA I or II, randomly separated into two groups of 15 patients each; 0.5% ropivacaine (Ropi Group) or 0.5% bupivacaine with epinephrine (Bupi Group) was administered. A peripheral nerve stimulator was used, and 30 mL of the local anesthetic were administered. Four spirometries were done in each patient: before the blockade, 30 minutes, four hours, and six hours after the blockade. Patients were not sedated.ResultsOne patient in the Ropi Group and three patients in the Bupi Group were excluded from the study due to failure of the blockade. The Ropi Group showed maximal FVC reduction at 30 minutes (25.1%), with a tendency for recovery from this point on. With bupivacaine, the reduction in FVC was less important at the different study moments; an additional reduction was observed between 30 (15.8%) and four hours (17.3%), but it was not statistically significant. A tendency for recovery was observed from four hours on. In both groups, the FVC six hours after the blockade was still below baseline levels.ConclusionsInterscalene block reduces FVC in most cases. Changes were more pronounced in the Ropivacaine group