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Background and Goal of studyThe pre hospital approach to myocardial infarction involves its initial diagnostic suspicion, risk assessment, ECG, transfer to the appropriate hospital center, all while minimizing delays. Pre-hospital approach and diagnosis helps minimizing delays in treatment.One of our hospitalu2019s pre-hospital serviceu2019s most frequent diagnosis is acute myocardial infarction. Like in many other systems, as a way to bypass normal ER referral and shorten the time between first medical contact and reperfusion therapy, a u201ccoronary fast-track protocolu201d (CFTP) was implemented.The goal of this study is to describe and characterize the initial approach and treatment of myocardial infarction patients referred to ER or CFTP.Material and MethodsPatients with u201cacute coronary syndromeu201d between April 2014 and November 2015 were studied. The patients were divided in two groups, no-CFTP and CFTP, and demographic data, initial triage of the ambulance dispatching service, whether an ECG was performed, initiated treatment (Morphine, Oxygen, Nitrates, Clopidogrel and Acetylsalicylic acid) and Morrow score (age, heart rate and arterial tension) was retrieved. Results were registered in MSu2122 Excelu00ae and analyzed in SPPSu00ae statistics software.Results and DiscussionA total of 234 patients were studied, 39 in the CFTP group and 195 in the no-CFTP group. Mean age was 69,03 u00b1 15,03 in the no-CFPT group, and 60,2 u00b1 11,91 in the CFTP group. Main initial triage symptom was thoracic pain in both the no-CFTP group (79%) and CFTP group (74%). ECG was performed in all the patients in both groups. Treatment was initiated in both the no-CFTP vs CFTP as follows: Morphine 22% vs 56%; Oxygen 100% vs 100%; Nitrates 35% vs 58%; Clopidogrel 27% vs 82%; AAS 44,6% vs 76,9%.The CFTP patients appear to be younger and their diagnosis and initial treatment appears to be started earlier than in patients in the no-CFTP group. ConclusionThere are differences between patients in both groups, concerning initial approach and treatment. Some hypothesis to explaic these differences can be given, and they can be further assessed.Optimization of care in cases of acute coronary syndrome can be achieved by better logistics, risk assessment, triage and early initiation of treatment.ReferencesPostma, S., Bergmeijer, T., ten Berg, J., & van u2019t Hof, A. (2012). Pre-hospital diagnosis, triage and treatment in patients with ST elevation myocardial infarction. Heart (British Cardiac Society), 98(22), 1674u20138. http://doi.org/10.1136/heartjnl-2012-302035

Background: Burning victims in countries with less access to specialized medical care are often exposed to avoidable sequelae. These sequelae include post-burn scars and scar contractures, with a huge impact on the patient daily life. When these patients are proposed for any anesthesia procedure, pre-anesthetique assesment is essential.Case report: 38 year old woman evacuated from Su00e3o Tomu00e9 e Pru00edncipe 15 months after a severe burning accident with gasoline, was proposed for a cervical scar contraction repair. The procedure was to be done under general anesthesia. The patient was evaluated at the preanesthestic assessment one month prior to the surgery. The main problem encountered was a difficult airway. Her cervical contracture scarring impaired neck mobility, extension and obliged her to a hyperflexion position, as see in the pictures1. Intubation using a laryngoscope was impossibe, and glidescope was also not helpful. Tracheotomy was also impractical, because of impossible access to the trachea. What to do?Discussion: u007f Difficult airway has always been an anesthesiologist's challenge. In this case, the patient had not only a previsible difficult intubation, but also external distorion of the airway impeded ventilation. Furthermore there was no possiblity of a surgical airway: an awake nasotracheal fibroscopic intubation was the only option. Fibroscopic intubation was planned in advance and successful.References: 1Jasper AO. Anaesthetic management of post-burn contractures, a recurrent challenge from oil pipeline vandalization in Nigeria: a case report. Cases Journal. 2009;2:9141. doi:10.1186/1757-1626-2-9141.Learning points: Preparing for anesthesia is an essential step on our daily activity. Prevention is the keyword to avoid intraoperative complications, mortality and morbidity.

u007fBackground: Cerebrospinal fluid (CSF) leak may occur after CSE labor analgesia, and can be a cause of Post Dural Puncture Headache (PDPH). If headache persists after treatment measures, continual leakage of CSF should be considered. Although rare, this leakage may lead to a fistulous tract - a cerebrospinal fistula1. Case report: 22 year-old woman, with no underlying diseases and an uneventful pregnancy underwent CSE labor analgesia. Three punctures were necessary for a successful technique, but no accidental dural puncture was reported. 24 hours after labour, the patient complained of nausea and headache that worsened after standing position. Conservative treatment was initiated: paracetamol, caffeine, hydratation and bed rest. After 72 hours with no improvement, a successful blood patch was performed and she was discharged. The patient returned to the hospital 2 days later, with the same symptoms. She was again given conservative therapy and 2 more blood patches with no success. Her spine CT-scan and MRI were normal. A myelography computerized tomography was performed, showing a CSF fistula in the CSE puncture site. Neurosurgery was contacted and it was decided to attempt a fluoroscopic guided blood patch, before any surgical approach. The blood patch was successful and the patient was asymptomatic at the time of discharge.Discussion: Although most cases of CSF leakage are iatrogenic2, it is very rare to encounter CSF fistulas as a complication of CSE puncture. During CSE, no accidental dural puncture was reported, but 3 punctures were necessary, indicating a higher risk of lesion. Orthostatic headaches are the main symptom of CSF fistulas2. Initially fistulas can be hard to detect on spinal CT or MRI. Myelography-CT was essential to the diagnosis3.Treatment is at first conservative. If symptoms persist, targeted blood patch is a safe technique and was more effective than blindly placed blood patch in this case.2u007fReferences: 1Couture D, Branch CL., Jr Spinal pseudomeningoceles and cerebrospinal fluid fistulas. Neurosurg Focus. 2003;15(6):E6.2Gottschalk A. Cerebrospinal fluid leakage. Indications, technique and results of treatment with a blood patch. Radiologe. 2015;55(6):471-4783Schievink WI. Spontaneous spinal cerebrospinal fluid leaks: a review. Neurosurg Focus, 2000Jul15;9(1):e8.Learning Points: Although CSE labour analgesia is often performed with no associated complications, the anesthesiology must be able to recognize and manage iatrogenic lesions.

OBJECTIVES: The objectives of this study were to determine the incidence of Postoperative Delirium and to identify specific perioperative risk factors in patients undergoing Vascular Surgery. Other goals were to study its impact in hospital length of stay and to create an algorithm to deal with patients under suspicion of Postoperative Delirium. MATERIAL AND METHODS: A total of 56 consecutive vascular surgery patients were prospectively evaluated. Exclusion criteria were age less than 18, dementia, abnormal level of consciousness, psychiatric disorder and visual or hearing impairment. Mini Mental State Examination were applied during pre-anesthetic visit. In patients with clinical indicators of delirium the Confusion Assessment Method was applied. Patients were assessed during 5 days after surgery. RESULTS: The overall incidence of delirium was 12,5%, developped mostly by the second to fifth postoperative day. Patients with delirium presented moderate to severe pain. Patients who received combined general and regional anesthesia didn't develop delirium. The median hospital length of stay was 21 in patients with delirium and 7 days in patients without (p 0.001). CONCLUSIONS: The overall incidence of postoperative delirium was lower than previously reported. The incidence of delirium was higher in ICU patients and pain was associated with postoperative delirium suggesting the opportunity to control postoperative factores. The development of delirium in the second and fifth day indicated the need for early and more prolonged preventive and diagnosing measures. Clinical and costly considerations of prolonged hospital stay shown in this cohort warrant strong debate strategies to be applied. info:eu-repo/semantics/publishedVersion

INTRODUCTION: Hypoplastic left heart syndrome (HLHS) is a major cause of cardiac death during the first week of life. The hybrid approach is a reliable, reproducible treatment option for patients with HLHS. Herein we report our results using this approach, focusing on its efficacy, safety and late outcome. METHODS: We reviewed prospectively collected data on patients treated for HLHS using a hybrid approach between July 2007 and September 2014. RESULTS: Nine patients had a stage 1 hybrid procedure, with seven undergoing a comprehensive stage 2 procedure. One patient completed the Fontan procedure. Five patients underwent balloon atrial septostomy after the hybrid procedure; in three patients, a stent was placed across the atrial septum. There were three deaths: two early after the hybrid procedure and one early after stage two palliation. Overall survival was 66%. CONCLUSIONS: In our single-center series, the hybrid approach for HLHS yields intermediate results comparable to those of the Norwood strategy. The existence of dedicated teams for the diagnosis and management of these patients, preferably in high-volume centers, is of major importance in this condition.

A reconstrução endoluminal com sistemas de derivação de fluxo (flow diverter devices) constitui uma técnica inovadora no tratamento de aneurismas intra-cranianos. Estes novos stents, auto-expansíveis e de reduzida porosidade, são libertados através de microcateterização da artéria portadora do aneurisma, reconstruindo assim a sua parede e excluindo a formação aneurismática da circulação arterial. Neste trabalho mostramos os resultados preliminares obtidos no tratamento de 10 doentes no Hospital de São José, Lisboa. Estes doentes, com aneurismas de colo largo (> 4mm) ou ratio saco/colo não favorável (< 1,5), foram tratados com o sistema PIPELINE®, e estudos angiográficos de controlo foram efectuados aos três e seis meses. Novo controlo será feito aos 12 meses. A idade media dos doentes envolvidos é de 54,3 anos, oito doentes são do sexo feminino e dois doentes do sexo masculino. Os aneurismas foram incidentalmente descobertos em dois doentes e os restantes foram diagnosticados no contexto de investigação imagiológica por cefaleias (n = 3), defeito de campo visual (n = 1), vertigens (n = 1) e parésia de pelo menos um par craniano (n = 2). Em apenas dois doentes foi observada hemorragia subaracnoideia e outros dois doentes foram submetidos a terapêutica endovascular prévia, com espiras metálicas. As localizações dos aneurismas tratados são o segmento M1/M2 da artéria cerebral média (n = 1) e os segmentos da artéria carótida interna para-oftálmico (n = 6), oftálmico (n = 2) e cavernoso (n = 4). Treze aneurismas intra-cranianos foram tratados uma vez que três doentes apresentavam múltiplos aneurismas. Os estudos de controlo efectuados demonstram um grau de oclusão médio aos três meses de 74% e aos seis meses de 86%. Não se observou qualquer redução das dimensões do saco de um dos aneurismas para-oftálmico. A experiência deste serviço é muito favorável a utilização de sistemas de derivação de fluxo no tratamento de aneurismas seleccionados, tendo obtido taxas de oclusão elevadas dados os desafios existentes na terapêutica deste tipo de aneurismas.

As complicações tromboembólicas são as mais frequentemente reportadas durante a terapêutica endovascular de aneurismas intracranianos com espiras metálicas. A frequência deste tipo de complicação varia na literatura, contudo autores referem uma incidência entre 2,5 e 28%. Diversos mecanismos poderão estar envolvidos na formação e migração do trombo: pode ser já preexistente no interior do aneurisma a tratar e deslocar-se para o vaso portador; pode formar-se de novo na superfície das espiras ou dos cateteres utilizados; ou ainda no eventual colo residual se o grau de oclusão não for completo. Estudos demonstraram maior incidência de complicações tromboembólicas em aneurismas de colo largo. Neste trabalho discutimos a importância e justificação de medidas utilizadas na prevenção de complicações tromboembólicas durante e após a terapêutica endovascular de aneurismas rotos intra-cranianos. Referem-se ainda as opções e estratégias a adoptar na eventualidade de uma oclusão vascular ser detectada durante o procedimento, como a administração de inibidores da glicoproteina IIb/IIIa ou mesmo a libertação de stents intra-cranianos. Diversos casos exemplificativos são exibidos. A prevenção de complicações tromboembólicas e a rápida actuação perante a oclusão vascular são essenciais para a melhoria do prognóstico dos doentes submetidos a terapêutica endovascular de aneurismas rotos. O conhecimento profundo das opções disponíveis é essencial para a persecução desse objectivo.

A trombose venosa cerebral (TVC) é uma doença relativamente rara mas grave, potencialmente reversível com diagnóstico atempado e terapêutica médica adequada. A gravidez e o puerpério são um factor predisponente de TVC, que é responsável por 6% das causas de morte materna. As manifestações clínicas dependem da localização, extensão do trombo, bem como da rede de colaterais existente. Apresentamos o caso duma doente do sexo feminino, 33 anos, grávida de 13 semanas que recorreu ao serviço de urgência por quadro de cefaleias e cujo estudo por Ressonância Magnética revelou aspectos compatíveis com doença venosa oclusiva subtotal do seio longitudinal superior em fase aguda. A propósito deste caso discutimos as manifestações imagiológicas da trombose venosa dural na fase aguda.

O bloqueio neuromuscular (BNM) residual é um fenómeno frequente em doentes cirúrgicos após administração de relaxantes musculares. Está associado a um aumento da morbilidade e mortalidade pós-operatória devido às complicações clínicas dos eventos associados. O sugamadex é um novo fármaco para reversão do BNM induzido por rocurónio ou vecurónio. Como primeiro agente selectivo de ligação aos relaxantes musculares, é promissor em termos de eficácia e perfil de segurança. Apresenta um perfil de eficácia e segurança significativamente diferente ao verificado actualmente com as opções farmacológicas disponíveis. É expectável um valor terapêutico acrescentado significativo sobre estas mesmas opções, com importantes alterações na prática clínica anestésica e cirúrgica, com ganhos para os doentes, para os médicos e para o próprio hospital. Baseados na literatura e na experiência clínica, os autores partilham as suas reflexões relativas ao uso de sugamadex. Apresentam uma proposta para a sua utilização na prática clínica corrente, de acordo com as indicações do RCM, características dos doentes e situações clínicas específicas.

Cavopulmonary connections have been extensively used in the palliation of complex forms of congenital heart disease requiring some form of right heart bypass. We examine the mid term outcomes of pulmonary ventricle bypass operations in a single institution and performed by the same surgical team. POPULATION: Between March 1999 and April 2006, 62 patients underwent pulmonary ventricle bypass operations: bidirectional cavopulmonary anastomosis (Glenn procedure), total cavopulmonary connections (Fontan procedure) and one and a half ventricle correction in two cases. Age at operation averaged three years (range: 0.42-25 years) for the Glenn procedure and seven years (range: 3-14 years) for the Fontan procedure. There were 36 male patients (58%) and 26 female patients (42%). The most common indication for surgery was the single ventricle defect, present in 66% of patients. Associated lesions included: transposition of the great arteries in 16 patients (35.6%), bilateral superior vena cava in four patients (8.9%), situs ambigus in five patients (11%), situs inversus in another patient (2.2%), Ebstein disease in one patient (2.2) and coronary fistula in another patient (2.2%). Sub-aortic stenosis was present in one patient (2.2%). Palliative surgery was performed in all, but three patients (5%), before the Fontan procedure. RESULTS: Thirty two patients underwent bidirectional cavopulmonary anastomosis and thirty patients underwent cavopulmonary connections, total or 2nd stage. Mean cardiopulmonary bypass times were 50.6+/-21.9 minutes for the Glenn procedure and 88.5+/-26.3 minutes for the Fontan procedure. There was no intra-operative mortality, but two patients (3.2% (died in the first month after surgery; one due to failure of the Glenn circuit and sepsis and the other due to a low cardiac output syndrome and multi-organ dysfunction. Mean ventilation time was 5.2+/-1.7 hours for the Glenn operation and 6.2+/-3.2 hours for the Fontan operation. The mean length of stay in ICU was 3.4+/-2.8 days for patients undergoing the Glenn operation and 4.6+/-3.1 days for patients undergoing the Fontan operation and the mean length of hospital stay was 10.6+/-5.8 days for the Glenn operation and 19.1+/-12.6 days for the Fontan operation respectively. The mean follow up time was 4+/-2.1 years (minimum 0 years and maximum seven years), most patients being in NYHA class I. Epicardiac pacemakers were implanted in three patients due to arrhythmias. Two re-operations (6.7%) were needed, both in the same patient, after the Fontan procedure, this patient eventually died a few years after surgery. CONCLUSIONS: The immediate and mid term outcomes of pulmonary ventricle bypass operations can have excellent results. From our point of view there has been an improvement, namely in the use of the extracardiac conduit technique in the 2nd stage of the Fontan operation.

Submitted by Ana Quininha (ana.quininha@chlc.min-saude.pt) on 2011-05-12T11:30:16Z No. of bitstreams: 1 AMP 2006 503.pdf: 226890 bytes, checksum: 8ecd0fabc180b2c04075dd05b08168c5 (MD5) Made available in DSpace on 2011-05-12T11:30:16Z (GMT). No. of bitstreams: 1 AMP 2006 503.pdf: 226890 bytes, checksum: 8ecd0fabc180b2c04075dd05b08168c5 (MD5) Previous issue date: 2006

BACKGROUND: Atherosclerotic carotid disease represents approximately 20% of the causes of ischemic stroke. Effective treatment options, such as endovascular or surgical revascularization procedures, are available. Doppler Ultrasound (DUS) is a non-invasive, inexpensive, routine exam used to evaluate the presence of internal carotid artery (ICA) stenosis. We retrospectively analysed the prevalence of severe atherosclerotic carotid disease in a population of patients with acute ischemic stroke/transitory ischemic attacks (TIAs), and the role of DUS in the detection of ICA stenosis and treatment decisions in these patients. METHODS: A total of 318 patients with ischemic stroke or TIAs was admitted to our stroke unit, and 260 patients were studied by DUS. ICA stenosis was evaluated by DUS according to peak systolic velocity. All DUS exams were performed by the same operator. ICA stenosis was further assessed in 43 patients by digital subtraction angiography (DSA) using NASCET criteria. RESULTS: Of the total 318 patients, 260 (82%) had DUS evaluation. Of the total 520 ICAs studied by DUS, degrees of ICA stenosis were: 0-29% n= 438 (84%); 30-49% n= 8 (2%); 50-69% n= 27 (5%); 70-89% n= 15 (3%); 90-99% n= 20 (4%); oclusão n= 14 (2%). Of the total 260 patients studied, 43 (16.5%) underwent DSA. Sensibility and specificity of DUS in the diagnosis of carotid stenosis over 70% were, respectively, 91% e 84%. Of the total 31 patients with significant carotid stenosis (70-99%), 23 (74%) underwent subsequent carotid revascularization procedures. DISCUSSION: DUS is an important screening test in our stroke unit, justifying its use as a routine exam for all patients with ischemic stroke/TIAs. Moreover, our results show the relevance of severe carotid disease in a population with acute ischemic stroke/TIAs (16.5%), with a total of 9% of patients being submitted to carotid revascularization procedures.

A preocupação em tratar adequadamente a dor dos doentes do Serviço de Angiologia e Cirurgia Vascular (SACV) do Hospital de Santa Marta levou ao desenvolvimento de uma estrutura organizada, destinada à optimização da analgesia peri-operatória. Pretendemos descrever neste artigo o processo de implementação da Unidade de Dor Vascular (UDV) do Hospital de Santa Marta, cujo projecto se iniciou em 2003 e que viria a culminar na sua inauguração em Janeiro de 2005.

Mais do que a transcrição de um protocolo anestésico, o nosso objectivo foi salientar a importância dos protocolos anestésicos em geral e do transplante pulmonar em particular como indicador de processo na qualidade de cuidados anestésicos perioperatórios. Para isso exemplificamos a forma como foi elaborado um protocolo específico como o do transplante pulmonar e evidenciamos a necessidade de articulação com as diferentes especialidades e grupos profissionais directamente envolvidos.

The Ross procedure has been used in children and young adults for aortic valve replacement and the correction of complex obstruction syndromes of the left ventricular outflow tract. We report the mid-term results of the Ross procedure in a single institution and performed by the same surgical team. Population: Between March 1999 and December 2005, 18 patients were operated on using the Ross procedure. The mean age at the time of surgery was 12 years, being 12 patients male (67%). The primary indication for surgery was isolated aortic valve disease, being the predominant abnormality in 58% of cases aortic regurgitation and in 42% left ventricular outflow tract obstruction. Associated lesions included sub-aortic membrane in 3 patients (16%), small VSD in 2 patients (11%), bicuspid aortic valve in 4 patients (22%) and severe left ventricular dysfunction and mitral valve regurgitation in 1 patient (6%). Ten of the 18 patients (56%) had been submitted to previous surgical procedures or percutaneous interventions. Results: Early post-operative mortality was not seen, but two patients (11%), had late deaths, one due to endocarditis, a year after the Ross procedure, and the other due to dilated cardiomiopathy and mitral regurgitation. The shortest time of follow-up is 6 months and the longest 72 months (median 38 months). Of the 16 survivors, 14 patients are in class I of the NYHA and 2 in class II, without significant residual lesions or need for re-intervention. The 12 patients with more than a year of follow up revealed normal coronary perfusion in all patients and no segmental wall motion abnormalities. Nevertheless, two of the 12 patients developed residual dynamic obstruction of LVOT and in three patients aortic regurgitation of a mild to moderate degree was evident. Significant gradients were not verified in the RVOT. Conclusions: The Ross procedure, despite its complexity, can be undertaken with excellent immediate results. Aspects such as the dilation of the neo aortic root and homograft evolution can not be considered in a study of this nature, seeing that the mean follow up time does not exceed 5 years.

Submitted by Ana Quininha (ana.quininha@chlc.min-saude.pt) on 2011-07-18T16:44:08Z No. of bitstreams: 1 RPCCTV 2005 203.pdf: 425909 bytes, checksum: 23928a23f0aed2997ab03d41017e1743 (MD5) Made available in DSpace on 2011-07-18T16:44:08Z (GMT). No. of bitstreams: 1 RPCCTV 2005 203.pdf: 425909 bytes, checksum: 23928a23f0aed2997ab03d41017e1743 (MD5) Previous issue date: 2005

Descreve-se a utilização de um sistema de assistência mecânica bi-ventricular, para-corpórea (Berlin Heart), como ponte para transplante, numa criança de dois anos, sofrendo de miocardiopatia dilatada. O período de assistência durou três meses e meio e o transplante foi bem sucedido. Descreve-se o caso clínico, os protocolos usados e revêem-se as indicações, as técnicas e os problemas com a assistência ventricular mecânica em crianças.