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Background and Objectives: Limited data are present on safety and efficiency of epinephrine for the prophylaxis and treatment of spinal-hypotension. This study was conducted to compare the effect of epinephrine with norepinephrine and phenylephrine on the treatment of spinal-hypotension and ephedrine requirement during cesarean delivery., Methods: One hundred and sixty parturients with uncomplicated pregnancies undergoing elective cesarean delivery under spinal anesthesia were recruited. They were allocated randomly to receive norepinephrine 5 μg.mL -1 (n=40), epinephrine 5 μg.mL -1 (n=40), phenylephrine 100 μg.mL -1 (n=40) or 0.9% saline infusions (n=40) immediately after induction of spinal anesthesia. Whenever systolic blood pressure drops to less than 80% of baseline, 5 mg of iv ephedrine was administered as rescue vasopressor. The incidence of hypotension, total number of hypotension episodes, the number of patients requiring ephedrine, the mean amount of ephedrine consumption and side effects were recorded., Results: There was no statistically significant difference in incidence of maternal hypotension between groups. The number of patients requiring ephedrine was significantly greater in group saline than in group phenylephrine (p <0.001). However, it was similar between phenylephrine, norepinephrine, and epinephrine groups. The mean ephedrine consumption was significantly higher in group saline than in norepinephrine, epinephrine, phenylephrine groups (p=0.001)., Conclusion: There is no statistically significant difference in incidence of hypotension and ephedrine consumption during spinal anesthesia for cesarean delivery with the use of epinephrine when compared to norepinephrine or phenylephrine. Epinephrine can be considered as an alternative agent for management of spinal hypotension., (Copyright © 2020 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.)

Purpose: This study aimed to investigate factors associated with postoperative Acute Kidney Injury (AKI) focusing on intraoperative hypotension and blood loss volume., Methods: This was a retrospective cohort study of patients undergoing pancreas surgery between January 2013 and December 2018. The primary outcome was AKI within 7 days after surgery and the secondary outcome was the length of hospital stay. Multivariate analysis was used to determine explanatory factors associated with AKI; the interaction between the integrated value of hypotension and blood loss volume was evaluated. The differences in length of hospital stay were compared using the Mann-Whitney U-test., Results: Of 274 patients, 22 patients had experienced AKI. The cube root of the area under intraoperative mean arterial pressure of < 65 mmHg (Odds Ratio = 1.21; 95% Confidence Interval 1.01-1.45; p = 0.038) and blood loss volume of > 500 mL (Odds Ratio = 3.81; 95% Confidence Interval 1.51-9.58; p = 0.005) were independently associated with acute kidney injury. The interaction between mean arterial hypotension and the blood loss volume in relation to acute kidney injury indicated that the model was significant (p < 0.0001) with an interaction effect (p = 0.0003). AKI was not significantly related with the length of hospital stay (19 vs. 28 days, p = 0.09)., Conclusion: The area under intraoperative hypotension and blood loss volume of > 500 mL was associated with postoperative AKI. However, if the mean arterial pressure is maintained even in patients with large blood loss volume, the risk of developing postoperative AKI is comparable with that in patients with small blood loss volume., (Copyright © 2020 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.)

Background and Objectives: Bilateral quadratus lumborum block has been described for major abdominal procedures when sepsis is present, because risks associated to epidural are considered elevated. In an open aortic surgery, a single-shot bilateral quadratus lumborum block type 1 may be an alternative to thoracic epidural block for post-operative analgesia in a patient having an increased cumulative risk for thoracic epidural hematoma., Case Report: A 56-year-old female patient presenting controlled hypertension, chronic renal disease stage 3b, dyslipidemia and a platelet count of 102,000/μl, and taking aspirin, was scheduled for bilateral aortoiliac endarterectomy. She was submitted to a sole general anesthesia plus, at end of the surgery, a bilateral quadratus lumborum block type 1 for post-operative analgesia with 20mL of ropivacaine 0.5%, per side, before extubation. Immediately after post anesthesia care unit admission, patient developed moderate hypotension (dopamine infusion was needed during 18h), concomitantly with a rapid reduction in the pain scores. Low numeric rating scale and opioid consumption were noted, particularly in the first 24h post-operatively., Conclusions: Quadratus lumborum block was an effective analgesic technique for open aortic surgery in this case, although hypotension associated to bilateral quadratus lumborum block type 1 may occur. Associated sympathetic block probably related to the bilateral paravertebral extension of the block, may contribute for post-operative hypotension associated to reperfusion-ischemia syndrome in a patient that had long-lasting intraoperative aortic cross-clamping. The use of high concentration of local anesthetic to obtain longer duration of action of a single-shot quadratus lumborum block to avoid thoracic epidural or bilateral quadratus lumborum block catheterization should be used judiciously., (Copyright © 2018 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.)

Background: Post-operative delirium is a serious complication in patients undergoing major abdominal surgery. It remains unclear whether peri-operative hemodynamic and perfusion variables affect the risk for postoperative delirium. The objective of this pilot study was to evaluate the association between perfusion and hemodynamics peri-operative with the appearance of post-operative delirium., Methods: Prospective cohort study of adults 60 years or older undergoing elective open colon surgery. Multimodal hemodynamic and perfusion variables were monitored, including central venous oxygenation (ScvO 2 ), lactate levels, and non-invasive cerebral oxygenation (rSO 2 ), according to a standard anesthesia protocol. Fisher's exact test or Student's t-test were used to compare patients who developed post-operative delirium with those who did not (p<0.05)., Results: We studied 28 patients, age 73±7 years, 60.7% female. Two patients developed post-operative delirium (7.1%). These two patients had fewer years of education than those without delirium (p=0.031). None of the peri-operative blood pressure variables were associated with incidence of post-operative delirium. In terms of perfusion parameters, postoperative ScvO 2 was lower in the delirium than the non-delirium group, without reaching statistical significance (65±10% vs. 74±5%; p=0.08), but the delta-ScvO 2 (the difference between means post-operative and intra-operative) was associated with post-operative delirium (p=0.043). Post-operative lactate and rSO 2 variables were not associated with delirium., Conclusions: Our pilot study suggests an association between delta ScvO 2 and post-operative delirium, and a tendency to lower post-operative ScvO 2 in patients who developed delirium. Further studies are necessary to elucidate this association., (Copyright © 2017 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.)

I report a case of hypotension and bradycardia before spinal anesthesia in a pregnant woman with mild to moderate hypertension treated with nifedipine and methyldopa, scheduled for an elective cesarean delivery. She had the history of neurally-mediated syncopes. Two main factors (increased vagal tone and adverse effects of antihypertensive drugs) could explain the hypotension and bradycardia before spinal anesthesia. Monitoring allowed recognizing the problem and corrected it. Thus, it was avoided a disaster in anesthesia, as hemodynamic changes after spinal anesthesia, they would have joined to previous hypotension and bradycardia, which would have caused even a cardiac arrest., (Copyright © 2015 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.)

Background and Objectives: Even a small amount of bleeding during endoscopic sinus surgery can corrupt the endoscopic field and complicate the procedure. Various techniques, including induced hypotension, can minimize bleeding during endoscopic sinus surgery. The aim of this study was to compare the surgical vision quality, haemodynamic parameters, postoperative pain, and other effects of magnesium, a hypotensive agent, with that of dexmedetomidine, which was initially developed for short-term sedation in the intensive care unit but also is an alpha 2 agonist sedative., Method: 60 patients between the ages of 18 and 45 years were divided into either the magnesium group (Group M) or the dexmedetomidine group (Group D). In Group M, magnesium sulphate was given at a pre-induction loading dose of 50mgkg(-1) over 10min and maintained at 15mgkg(-1)h(-1); in Group D, dexmedetomidine was given at 1mcgkg(-1) 10min before induction and maintained at 0.6mcgkg(-1)h(-1). Intraoperatively, the haemodynamic and respiratory parameters and 6-point intraoperative surgical field evaluation scale were recorded. During the postoperative period, an 11-point numerical pain scale, the Ramsay sedation scale, the nausea/vomiting scale, the adverse effects profile, and itching parameters were noted., Results: Group D showed a significant decrease in intraoperative surgical field evaluation scale scale score and heart rate. The average operation time was 50min, and Group M had a higher number of prolonged surgeries. No significant difference was found in the other parameters., Conclusions: Due to its reduction of bleeding and heart rate in endoscopic sinus surgery and its positive impacts on the duration of surgery, we consider dexmedetomidine to be a good alternative to magnesium., (Copyright © 2014 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.)

Maternal hypotension is a common complication after spinal anesthesia for cesarean section, with deleterious effects on the fetus and mother. Among the strategies aimed at minimizing the effects of hypotension, vasopressor administration is the most efficient. The aim of this study was to compare the efficacy of phenylephrine, metaraminol, and ephedrine in the prevention and treatment of hypotension after spinal anesthesia for cesarean section. Ninety pregnant women, not in labor, undergoing cesarean section were randomized into three groups to receive a bolus followed by continuous infusion of vasopressor as follows: phenylephrine group (50μg+50μg/min); metaraminol group (0.25mg+0.25mg/min); ephedrine group (4mg+4mg/min). Infusion dose was doubled when systolic blood pressure decreased to 80% of baseline and a bolus was given when systolic blood pressure decreased below 80%. The infusion dose was divided in half when systolic blood pressure increased to 120% and was stopped when it became higher. The incidence of hypotension, nausea and vomiting, reactive hypertension, bradycardia, tachycardia, Apgar scores, and arterial cord blood gases were assessed at the 1st and 5th minutes. There was no difference in the incidence of hypotension, bradycardia, reactive hypertension, infusion discontinuation, atropine administration or Apgar scores. Rescue boluses were higher only in the ephedrine group compared to metaraminol group. The incidence of nausea and vomiting and fetal acidosis were greater in the ephedrine group. The three drugs were effective in preventing hypotension; however, fetal effects were more frequent in the ephedrine group, although transient., (Copyright © 2014 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.)