Thoracic paravertebral block (TPVB) consists of an injection of local anaesthetic alongside the thoracic vertebra close to where the spinal nerves emerge from the intervertebral foramen. Clinically TPVB can be accomplished either as a single-injection or as a multiple-injection. It can also be used as a continuous paravertebral infusion through an indwelling catheter for continuous pain relief. However compared to an epidural block, TPVB is less well understood and not commonly used for anaesthesia and or analgesia in anaesthetic practice. I hypothesized that TPVB is effective for producing unilateral segmental thoracic anaesthesia and managing pain of unilateral origin from the thorax. / The objective of this thesis was to develop the technique of TPVB so that it becomes a useful technique for anaesthesia and pain management. So to test my hypothesis a series of clinical studies were performed on 416 patients (396 adults and 20 young infants), presenting for anaesthesia and or acute pain management, to evaluate various aspects of TPVB, namely; clinical application, anatomy of the thoracic paravertebral space, technique and safety, and pharmacology of local anaesthetic after TPVB. Also included are 9 published case reports and letters-to-editor (Appendix 1-9) based on my research that have provided new insights into the mechanism and applications of TPVB. The following section summarizes my research... / Karmakar, Manoj Kumar. / Thesis (M.D.)--Chinese University of Hong Kong, 2012. / Includes bibliographical references (leaves 270-285). / Appendix includes Chinese. / ABSTRACT --- p.v / PREFACE --- p.xxvii / STATEMENT OF WORK --- p.xxviii / ACKNOWLEDGEMENTS --- p.xxix / PUBLICATIONS AND PRESENTATIONS --- p.xxxii / LIST OF ABBREVIATIONS --- p.xxxviii / LIST OF TABLES --- p.xli / LIST OF FIGURES --- p.xliii / Chapter Part 1. --- Introduction --- p.1 / Chapter Chapter 1. --- Objective and Plan of Research --- p.2 / Chapter Chapter 2. --- Thoracic Paravertebral Block A Review of the Literature. --- p.7 / Chapter 2.1. --- Introduction --- p.7 / Chapter 2.2. --- History --- p.7 / Chapter 2.3. --- Anatomy: --- p.9 / Chapter 2.4. --- Techniques --- p.17 / Chapter 2.4.1. --- Anatomical Landmark Based Techniques --- p.20 / Chapter 2.4.1.1. --- Loss-of-resistance Technique --- p.20 / Chapter 2.4.1.2. --- Advancing the Block Needle by a pre-determined Distance --- p.23 / Chapter 2.4.1.3. --- Other Landmark Based Techniques --- p.24 / Chapter 2.4.2. --- Fluoroscopic Guidance or Injection of Radiopaque Contrast medium --- p.24 / Chapter 2.4.3. --- Peripheral Nerve Stimulation --- p.25 / Chapter 2.4.4. --- Pressure Measurement Technique --- p.26 / Chapter 2.5. --- Thoracic Paravertebral Catheter Placement --- p.27 / Chapter 2.6. --- Ultrasound Guided Thoracic Paravertebral Block --- p.32 / Chapter 2.6.1. --- Two Dimensional (2D) Sonoanatomy of the Thoracic Paravertebral Region --- p.32 / Chapter 2.6.1.1. --- Basic Considerations --- p.32 / Chapter 2.6.1.2. --- Transverse Scan of the Thoracic Paravertebral Region --- p.33 / Chapter 2.6.1.3. --- Sagittal Scan of the Thoracic Paravertebral Region --- p.42 / Chapter 2.6.2. --- Three Dimensional (3D) Sonoanatomy of the Thoracic Paravertebral Region --- p.46 / Chapter 2.6.3. --- Ultrasound Guided Thoracic Paravertebral Block - Techniques --- p.49 / Chapter 2.6.3.1. --- Transverse scan with short axis needle insertion (Technique 1) --- p.54 / Chapter 2.6.3.2. --- Paramedian Sagittal scan with in-plane needle insertion (Technique 2) --- p.56 / Chapter 2.6.3.3. --- Transverse scan with in-plane needle insertion or the Intercostal approach to the TPVS (Technique 3) --- p.58 / Chapter 2.7. --- Mechanism and Spread of Anaesthesia --- p.58 / Chapter 2.8. --- Indications --- p.65 / Chapter 2.9. --- Contraindications --- p.65 / Chapter 2.10. --- Drugs Used and Dosage --- p.68 / Chapter 2.11. --- Pharmacokinetic Considerations --- p.70 / Chapter 2.12. --- Failure Rate and Complications --- p.72 / Chapter 2.13. --- Clinical Applications of Thoracic Paravertebral Block --- p.76 / Chapter 2.13.1. --- Pain Relief after Thoracic Surgery --- p.76 / Chapter 2.13.2. --- Pain Relief after Multiple Fractured Ribs --- p.78 / Chapter 2.13.3. --- Anaesthesia and Analgesia for Breast Surgery --- p.80 / Chapter 2.13.4. --- Thoracic Paravertebral Block and Chronic Pain after Breast Cancer Surgery --- p.84 / Chapter 2.13.5. --- Thoracic Paravertebral Block and Cancer Recurrence after Breast Cancer Surgery --- p.85 / Chapter 2.13.6. --- Anaesthesia and Analgesia for Inguinal Herniorrhaphy --- p.87 / Chapter 2.13.7. --- Pain Relief after Cholecystectomy and Renal Surgery --- p.90 / Chapter 2.13.8. --- Anaesthesia and Analgesia for Liver and Biliary Tract Surgery --- p.91 / Chapter 2.13.9. --- Analgesia after Cardiac Surgery --- p.92 / Chapter 2.13.10. --- Thoracic Paravertebral Block and Chronic Pain Management --- p.94 / Chapter 2.13.11. --- Bilateral Thoracic Paravertebral Block --- p.94 / Chapter 2.13.12. --- Miscellaneous Applications --- p.95 / Chapter Part 2. --- Studies Evaluating the Efficacy of Thoracic Paravertebral Block in Adults. --- p.96 / Chapter Chapter 3. --- Prospective Randomized Evaluation of the Effects of Combining a Single-injection Thoracic Paravertebral Block with General Anesthesia in Patients Undergoing Modified Radical Mastectomy. --- p.97 / Chapter Chapter 4. --- Continuous Thoracic Paravertebral Infusion of Bupivacaine for Postthoracotomy Analgesia A Prospective, Randomized, Double Blind, Controlled Trial. --- p.120 / Chapter Chapter 5. --- Continuous Thoracic Paravertebral Infusion of Bupivacaine for Pain Management in Patients with Multiple Fractured Ribs. --- p.137 / Chapter Chapter 6. --- Thoracic Paravertebral Block and Its Effects on Chronic Pain and Health-related Quality of Life after Modified Radical Mastectomy. --- p.154 / Chapter Chapter 7. --- Right Thoracic Paravertebral Anaesthesia for Percutaneous Radiofrequency Ablation of Liver Tumours. --- p.186 / Chapter Part 3. --- Studies Evaluating The Efficacy Of Thoracic Paravertebral Block In Children. --- p.198 / Chapter Chapter 8. --- Continuous Extrapleural Paravertebral Infusion of Bupivacaine for Postthoracotomy Analgesia in Young Infants. --- p.199 / Chapter Part 4. --- Studies Evaluating The Anatomy Relevant For Thoracic Paravertebral Block. --- p.213 / Chapter Chapter 9. --- Thoracic Paravertebral Sonography - A Quantitative Evaluation of the Paramedian Sagittal Window for Visualizing the Anatomy Relevant for Thoracic Paravertebral Block. --- p.214 / Chapter Chapter 10. --- Volumetric 3D Ultrasound Imaging of the Anatomy Relevant for Thoracic Paravertebral Block. --- p.228 / Chapter Part 5. --- Pharmacokinetics of Ropivacaine after Thoracic Paravertebral Block. --- p.242 / Chapter Chapter 11. --- Arterial and Venous Pharmacokinetics of Ropivacaine With and Without Epinephrine after Thoracic Paravertebral Block. --- p.243 / Chapter Part 6. --- Summary and Conclusions --- p.266 / Chapter Chapter 12. --- Summary and Conclusions --- p.266 / Chapter Part 7. --- Bibliography --- p.270 / Chapter Part 8. --- Appendix --- p.296 / Chapter A. --- Published Case Reports and Letters-to-editor. --- p.297 / Chapter Appendix: 1.0. --- Variability of a Thoracic Paravertebral Block. Are we ignoring the endothoracic fascia? (Published Commentary) --- p.297 / Chapter Appendix: 2.0. --- Ipsilateral Thoraco-lumbar Anaesthesia and Paravertebral Spread after Low Thoracic Paravertebral Injection. (Published Case Report) --- p.301 / Chapter Appendix: 3.0. --- The Use of a Nerve Stimulator for Thoracic Paravertebral Block Reply. (Published Letter-to-editor) --- p.310 / Chapter Appendix: 4.0. --- Bilateral Continuous Paravertebral Block Used for Postoperative analgesia in an Infant having Bilateral Thoracotomy. (Published Case Report) --- p.312 / Chapter Appendix: 5.0. --- Thoracic Paravertebral Block: Radiological evidence of Contralateral Spread Anterior to the Vertebral Bodies. (Published Case Report) --- p.317 / Chapter Appendix: 6.0. --- Lymphatic Drainage of the Thoracic Paravertebral Space A Reply. (Published Letter-to-editor) --- p.325 / Chapter Appendix: 7.0. --- Thoracic Paravertebral Block for Management of Pain Associated with Multiple Fractured Ribs in Patients with Concomitant lumbar Spinal Trauma. (Published Case Report) --- p.328 / Chapter Appendix: 8.0. --- Right Thoracic Paravertebral Analgesia for Hepatectomy. (Published Case Report) --- p.340 / Chapter Appendix: 9.0. --- Resolution of ST-segment Depression after High Thoracic Paravertebral Block during General Anesthesia. (Published Case Report) --- p.348 / Chapter B. --- Medical Outcomes Study 36-Item Short-Form Questionnaire (SF-36) - Appendix 10. --- p.353 / Chapter C. --- Hospital Anxiety and Depression Scale - Appendix 11. --- p.362 / Chapter D. --- Postoperative Telephone Follow Up Questionnaire: Appendix 12. --- p.364

RESUMO Comparou-se os períodos de latência e duração da lidocaína 2% associada à adrenalina 1:100.000 (Lidocaína 100 ® da DFL), e da articaína 4% associada à adrenalina 1:200.000 (Septanest 1:200.000 ® da Septodont) e 1:100.000 (Septanest 1:100.000 ® da Septodont), na polpa dentária e gengiva vestibular, em anestesias locais infiltrativas maxilares. Vinte pacientes voluntários, saudáveis, de ambos os sexos, entre 18 e 50 anos de idade receberam tratamento restaurador de baixa complexidade ou selamento de cicatrículas e fissuras nas superfícies oclusais de três dentes superiores posteriores de uma mesma hemiarcada. Cada paciente recebeu, aleatoriamente, um tubete (1,8 ml) de cada solução anestésica local em três consultas. Os períodos de latência e duração da anestesia local na polpa dentária foram monitorados com um aparelho estimulador pulpar elétrico (Vitality Scanner Model 2005 ® da Analytic Endodontics) e na gengiva vestibular por meio do estímulo com a ponta de um explorador. Através do Teste de Kruskal-Wallis foram detectadas diferenças estatisticamente significantes ao nível de 5% entre lidocaína 2% associada à adrenalina 1:100.000, quando comparada tanto com a articaína 4% associada à adrenalina 1:200.000 quanto com a articaína 4% associada à adrenalina 1:100.000, para as variáveis: período de latência e duração na polpa dentária e período de duração na gengiva, sendo que a lidocaína 2% associada à adrenalina 1:100.000 apresentou a maior média para o período de latência pulpar e as menores médias para os períodos de duração na polpa dentária e na gengiva (respectivamente, 2,8, 39,2 e 42,2 minutos),quando comparada à articaína 4% associada à adrenalina 1:200.000 (respectivamente, 1,6, 56,7 e 55,3 minutos) e 1:100.000 (respectivamente, 1,4, 66,3 e 64,7 minutos). Houve diferença estatisticamente significante entre as duas soluções de articaína apenas para o período de duração na gengiva, cuja maior média foi a da articaína 4% associada à adrenalina 1:100.000. Não houve diferença estatisticamente significante entre os grupos para o período de latência gengival. Conclui-se que as soluções de articaína apresentam latência mais curta e duração mais longa do que a solução de lidocaína quando da anestesia pulpar. Para a latência gengival não há diferença entre as três soluções testadas, porém, para a duração gengival, a solução de articaína 4% associada à adrenalina 1:100.000 apresenta a maior duração. / SUMMARY Local anesthesias by maxillar infiltration with 2% lidocaine associated with 1:100.000 adrenalin (Lidocaina 100 ® by DFL), 4% articaine associated with 1:200.000 (Septanest 1:200.000 ® by Septodont) and 1:100.000 adrenalin (Septanest 1:100.000 ® by Septodont) were compared concerning to their onset and duration on dental pulp and gingiva. Twenty healthy volunteer patients, of both gender, between 18 and 50 years of age, received filling treatment of low complexity or fissure sealing on the occlusal surface of three superior posterior teeth of the same side. Each patient randomly received an ampoule (1,8ml) of each local anesthetic solution on three appointments. The onset and duration periods of local anesthesia on dental pulp were monitored with an electric pulptester (Vitality Scanner Model 2005 ® by Analytic Endodontics) and on buccal gingiva by the stimulus performed with the point of a probe. Kruskall-Wallis test identified statistic significant difference by the level of 5% between 2% lidocaine associated with 1:100.000 adrenalin when compared with both 4% articaine associated with 1:200.000 or 1:100.000 adrenalin for the following variants: onset and duration periods on dental pulp and duration period on gingiva. 2% lidocaine associated with 1:100.000 adrenalin presented the longest average for onset period on dental pulp and the minorest averages for duration periods on dental pulp and gingiva (respectively, 2,8, 39,2 and 42,2 minutes), when compared with 4% articaine associated with 1:200.000 (respectively, 1,6, 56,7 and 55,3 minutes) and 1:100.000 adrenalin (respectively, 1,4, 66,3 and 64,7 minutes). There was statistic significant difference between the two articaine solutions just for duration period on gingiva, whose longest average was that of 4% articaine associated with 1:100.000 adrenalin. There was no statistic significant difference between the groups for onset period on gingiva. It can be concluded that both articaine solutions present faster onset and longer duration than the lidocaine solution on pulpal anesthesia. For gingival onset there is no difference between the three tested solutions, however, for gingival duration, 4% articaine associated with 1:100.000 adrenalin presents the longest duration.

Sleep disruption has been implicated in morbidity after major surgery since 1974. Sleep-related upper airway obstruction has been associated with death after upper airway surgery and profound episodic hypoxaemia in the early postoperative period. There is also evidence for a rebound in rapid eye movement (REM) sleep that might be contributing to an increase in episodic sleep-related hypoxaemic events later in the first postoperative week. Speculation regarding the role of REM sleep rebound in the generation of late postoperative morbidity and mortality has evolved into dogma without any direct evidence to support it. The research presented in this thesis involved two main areas: a search for evidence of a clinically important contribution of REM sleep rebound to postoperative morbidity, and a re-examination of the role of sleep in the causation of postoperative episodic hypoxaemic events. To assess the latter, a relationship between airway obstruction under anaesthesia and the severity of sleep-disordered breathing was sought. In 148 consecutive sleep clinic patients, 49% of those with sleep-disordered breathing (SDB) had a number of events in non-rapid eye movement sleep (NREM) that was greater than or equal to that in REM and 51% had saturation nadirs in NREM that were equal to or worse than their nadirs in REM. This suggests SDB is not a REM-predominant phenomenon for most patients. Of 1338 postoperative deaths occurring over 6.5 years in one hospital only 37 were unexpected, most of which were one or two days after surgery with no circadian variation in the time of death, casting further doubt on the potential role of REM rebound. Five of nine subjects studied preoperatively had moderately severe SDB. Unrecognised and significant SDB is common in middle-aged and elderly patients presenting for surgery suggesting overall perioperative risk of important adverse events from SDB is probably small. In 17 postoperative patients, sleep macro-architecture was variably altered with decreases in REM and slow wave sleep while stage 1 sleep and a state of pre-sleep onset drowsiness, both associated with marked ventilatory instability, were increased. Sleep micro-architecture was also changed with an increase in power in the alpha-beta electroencephalogram range. These micro-architectural changes result in ambiguity in the staging of postoperative sleep that may have affected the findings of this and other studies. Twenty-four subjects with airway management difficulty under anaesthesia were all found to have some degree of SDB. Those with the most obstruction-prone airways while anaesthetised had a very high incidence of severe SDB. Such patients warrant referral to a sleep clinic.

Übergewicht und Adipositas im Kindes- und Jugendalter sind Gesundheitsprobleme, die auch auf dem Gebiet der Anästhesie zunehmend relevant werden. In der vorliegenden Dissertationsschrift wurde untersucht, inwiefern übergewichtige Kinder und Jugendliche, im Vergleich zu nicht-übergewichtigen, Komplikationen des Atemwegsmanagementes und der Oxygenierung während einer Allgemeinanästhesie aufweisen und welche Bedeutung die Thematik in der deutschen Population für die Kinderanästhesie hat. Mit Hilfe spezieller Erfassungsbögen wurden folgende Parameter ermittelt und die übergewichtigen mit den nicht-übergewichtigen Studienteilnehmern verglichen: der Mallampati Score, schwierige Maskenventilation und Intubation, die Verwendung eines Atemwegshilfsmittels, der Cormack-Lehane Score und die Anzahl der Intubationsversuche. Daneben wurde die Inzidenz von Atemwegsobstruktionen (Broncho- und Laryngospasmen), Husten als Zeichen der Atemwegsirritation und Sauerstoffsättigungsabfälle um mehr als 10 % des Ausgangswertes erfasst. Es zeigte sich ein signifikant höherer Mallampati Score und ein signifikant häufigeres Auftreten von Husten (p < 0,05). Alle weiteren Parameter blieben ohne statistisch relevanten Unterschied, obwohl Atemwegshilfsmittel prozentual häufiger bei Übergewichtigen eingesetzt wurden. Bei einer gesonderten Analyse der in die Studie eingeschlossenen Untergewichtigen zeigte sich eine überraschend gehäufte Inzidenz hinsichtlich der schwierigen Laryngoskopie und einer Reintubation. Die verschiedenen Ursachen für die vorliegenden Ergebnisse werden in der Promotionsschrift detailliert diskutiert. Es wird insgesamt deutlich, dass nicht alleine Übergewicht und Adipositas ausschlaggebend für Atemwegskomplikationen sind, aber durchaus einen Risikofaktor darstellen. Darüber hinaus scheinen auch untergewichtige Kinder ein erhöhtes Risiko für Atemwegskomplikationen zu habe.

Det är välkänt att patienter känner oro inför generell anestesi vilket utgör ett problem i den anestesiologiska omvårdnaden. Studier gjorda över olika decennier visar att över 80 % av patienter som ska genomgå operation känner oro inför generell anestesi. Det patienter känner oro inför är exempelvis att tappa kontrollen, vakna under anestesin, att inte vakna efter operationen, erhålla perifer venkateter och lång väntan. Anestesisjuksköterskan träffar patienten först i det preoperativa samtalet och ska då under några minuter identifiera  patientens oro samt planera omvårdnadsåtgärderna för att försöka lindra den. Detta medför ett stort behov av adekvata omvårdnadsåtgärder som kan hjälpa patienten lindra sin oro. Syftet med studien var att beskriva anestesisjuksköterskans omvårdnadsstrategier för att lindra patientens oro inför generell anestesi. Studien har en deskriptiv kvalitativ design med semistrukturerade intervjuer som datainsamlingsmetod. Studien innefattade intervjuer med fyra verksamma anestesisjuksköterskor på ett sjukhus i västra Sverige. Efter  dataanalysen framkom två kategorier som beskriver anestesisjuksköterskans omvårdnadsstrategier preoperativt för att lindra patientens oro inför generell anestesi. En spridning av studiens material kan kanske öka medvetenheten om användningen av olika omvårdnadsstrategier. Detta skulle i sin tur kunna bidra till att lindra den preoperativa oron inför generell anestesi. / It is well-known that patients feel anxious about general anesthesia and that makes a problem in the nursing of anesthesia. Studies made over decades show that over 80% of the patients undergoing operation feel anxious about general anesthesia. Patients feel anxious about to lose control, wake up during the operation, never wake up, to get a needle and to wait long. The anesthesia nurse sees the patient at the first time in the preoperative meeting and have to identify anxiety and plan the nursing strategies in a few minutes. This lead to a large need of adequate nursing strategies which can mitigate patients anxiety. The aim of this study was to describe nursing strategies preoperative to mitigate patients anxiety before general anesthesia. The study has a descriptive qualitative design and semi structured interviews were used to collect data. The study was based on four working anesthesia nurses in a hospital in the west of Sweden. After the analysis two categories were identified to describe the nursing strategies to ease the patients anxiety before operation. The results of the study can get around and add the consciousness to use different nursing strategies. This could in turn conduct to help patients ease the preoperative anxiety before general anesthesia.

Sleep disruption has been implicated in morbidity after major surgery since 1974. Sleep-related upper airway obstruction has been associated with death after upper airway surgery and profound episodic hypoxaemia in the early postoperative period. There is also evidence for a rebound in rapid eye movement (REM) sleep that might be contributing to an increase in episodic sleep-related hypoxaemic events later in the first postoperative week. Speculation regarding the role of REM sleep rebound in the generation of late postoperative morbidity and mortality has evolved into dogma without any direct evidence to support it. The research presented in this thesis involved two main areas: a search for evidence of a clinically important contribution of REM sleep rebound to postoperative morbidity, and a re-examination of the role of sleep in the causation of postoperative episodic hypoxaemic events. To assess the latter, a relationship between airway obstruction under anaesthesia and the severity of sleep-disordered breathing was sought. In 148 consecutive sleep clinic patients, 49% of those with sleep-disordered breathing (SDB) had a number of events in non-rapid eye movement sleep (NREM) that was greater than or equal to that in REM and 51% had saturation nadirs in NREM that were equal to or worse than their nadirs in REM. This suggests SDB is not a REM-predominant phenomenon for most patients. Of 1338 postoperative deaths occurring over 6.5 years in one hospital only 37 were unexpected, most of which were one or two days after surgery with no circadian variation in the time of death, casting further doubt on the potential role of REM rebound. Five of nine subjects studied preoperatively had moderately severe SDB. Unrecognised and significant SDB is common in middle-aged and elderly patients presenting for surgery suggesting overall perioperative risk of important adverse events from SDB is probably small. In 17 postoperative patients, sleep macro-architecture was variably altered with decreases in REM and slow wave sleep while stage 1 sleep and a state of pre-sleep onset drowsiness, both associated with marked ventilatory instability, were increased. Sleep micro-architecture was also changed with an increase in power in the alpha-beta electroencephalogram range. These micro-architectural changes result in ambiguity in the staging of postoperative sleep that may have affected the findings of this and other studies. Twenty-four subjects with airway management difficulty under anaesthesia were all found to have some degree of SDB. Those with the most obstruction-prone airways while anaesthetised had a very high incidence of severe SDB. Such patients warrant referral to a sleep clinic.

Tez (Tıpta Uzmanlık) - Süleyman Demirel Üniversitesi, Tıp Fakültesi, Anesteziyoloji ve Reanimasyon Anabilim Dalı, 2005. / Bibliyografya var.

Diss. (sammanfattning) Stockholm : Karol. inst., 2003. / Härtill 5 uppsatser.

Made available in DSpace on 2015-06-17T19:34:23Z (GMT). No. of bitstreams: 0 Previous issue date: 2014-02-21. Added 1 bitstream(s) on 2015-06-18T12:48:57Z : No. of bitstreams: 1 000823232.pdf: 3517524 bytes, checksum: 29912e2c797a4635feb5d355d8d76b33 (MD5) / Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) / Justificativa e Objetivos: O bloqueio periconal é uma técnica anestésica muito utilizada em cirurgias oftalmológicas. Atualmente, existem poucos relatos na literatura sobre a anestesia oftalmológica guiada por ultrassom (US). No entanto, assim como em outras áreas da anestesia regional, o ultrassom pode contribuir para melhorar a segurança dos bloqueios oftalmológicos, particularmente pela redução da incidência de perfuração ou penetração ocular associada aos bloqueios oftalmológicos que introduzem a agulha às cegas. Com isso, o presente estudo visou avaliar a viabilidade do ultrassom como guia na realização do bloqueio periconal, assim como a identificação do real posicionamento da agulha na cavidade orbitária e a ocorrência de complicações em comparação com a técnica às cegas em pacientes com olhos sem patologias. Métodos: Após a aprovação do Comitê de Ética em Pesquisa, um ensaio clínico prospectivo randomizado foi realizado. Assim, 129 pacientes (ASA I-II) foram alocados de forma aleatória entre os grupos Bloqueio Periconal Guiado por Ultrassom (Grupo USG, n=69) e Bloqueio Periconal Convencional com confirmação posterior do posicionamento da agulha, pelo ultrassom (Grupo C, n=60). Pacientes com olho único e pacientes alto míopes (comprimento axial > 26 mm), com a presença de estafiloma foram excluídos do estudo. Os testes, qui-quadrado ou o teste Exato de Fisher, foram usados para análise das variáveis qualitativas; já o teste t de Student foi usado para análise das variáveis quantitativas. O nível de significância do estudo foi de 5%. Resultados: Houve uma maior incidência de posicionamento da agulha intraconal não intencional (n=12) no Grupo C em relação ao Grupo USG (n=1) (P<0,0001). A distância entre a ponta da agulha e o nervo óptico foi de 12,1±4,4 mm (média±DP) no Grupo USG e 8,2±3,7 mm no Grupo C (P<0,0001). Já, a profundidade de inserção da agulha foi ... / Background and Goal of study: Periconal anesthesia has long been the choice technique for ophthalmic surgery. Currently, there is limited published data on ultrasound-guided ophthalmic anesthesia. Nevertheless, as in other areas of regional anesthesia, ultrasonography may contribute to improve the safety of ophthalmic blocks, particularly by reducing globe perforation or penetration incidence associated with the needle-based techniques. This study aimed to evaluate the benefits of the ultrasound-guided periconal block in comparison to the blind periconal technique with regard to the feasibility, positioning of the needle and occurrence of complications, in patients with healthy eyes. Methods: Upon the approval of the Institutional Ethics Committee, a prospective clinical study was carried out. One hundred and twenty-nine patients (ASA I-II) undergoing cataract surgery were randomly assigned to have their eyes anesthetized using either the Real-Time Ultrasound-Guided Periconal Blockade (USGblock, n=69) or the Conventional Periconal Blockade Technique (Cblock, n=60), followed by ultrasound examination of the eye. Patients with single eye and with high myopia (axial length greater than 26 mm) with the presence of staphyloma were excluded. The Chi-square and Fisher's exact tests were used for qualitative variables and the Student's t-test for quantitative variables. The significance level was 5%. Results: There was a higher incidence of unintentional intraconal needle placement (n=12) in Cblock than in USGblock (n=1) (P<0.0001). The distance between the needle tip and the optic nerve was 12.1±4.4 mm (mean±SD) in USGblock and 8.2±3.7 mm in Cblock (P<0.0001). Needle insertion depth was 25.1±1.6 mm in USGblock and 26.7±2.4 mm in Cblock (P<0.0001). Needle length displayed in the ultrasound image was 11.7±2.6 mm in USGblock and 14.7±3.5 mm in Cblock (P<0.0001). Only one patient presented with conjunctival edema (chemosis). No further ... / FAPESP: 10/19556-0

Orientador: Flavio Massone / Banca: Valéria Nobre Leal de Souza Oliva / Banca: André Leguthe Rosa / Resumo: Objetivou-se um estudo com infusão contínua de xilazina ou medetomidina associada à cetamina e midazolam, para a constatação do grau de hipnose, miorrelaxamento e qualidade anestésica verificada através do conforto do paciente durante a anestesia, bem como, a verificação das alterações paramétricas, qualidade de recuperação e segurança dos mesmos. Foram utilizadas 20 cadelas, clinicamente sadias, descartando-se as gestantes ou em fase estral. Os animais foram distribuídos de forma aleatória em dois grupos de 10 animais cada (n=10), designados como GI e GII. Os animais de GI foram submetidos a um pré-tratamento com levomepromazina e buprenorfina pela via intravenosa e induzidos à anestesia com cetamina e midazolam em bolus pela mesma via e mantidos por infusão contínua de midazolam-cetamina-xilazina por um período de 30 minutos. Em GII utilizou-se a mesma técnica empregada em GI substituindo-se, porém a xilazina pela medetomidina. A monitoração foi realizada durante todo o período experimental sendo que a colheita dos dados em momentos onde, M0, imediatamente antes do pré-tratamento; M1 decorridos 15 minutos após a administração do pré-tratamento e imediatamente anterior à indução. Em ato contínuo após a indução à anestesia iniciou-se a administração por via intravenosa contínua, sendo realizadas as aferições dos parâmetros em intervalos de 10 minutos referentes à M2 até M4. Conclui-se que, o GII apresentou vantagens clínicas sobre GI por apresentar um menor período de recuperação, menor incidência de efeitos indesejáveis na recuperação anestésica. Ambos os protocolos empregados permitiram a realização do ato cirúrgico (ovário-salpingo-histerectomia) embora ambos os grupos tenham apresentados arritmias dentro de algum momento estudado em GII este ocorreu com menor incidência. / Abstract: The objective of the present study was to verify the degree of hypnosis, muscle relaxation and quality of anesthesia while using a continuous infusion of xylazine and medetomidine associated with ketamine and midazolam. Those parameters were evaluated by patient well - being throughout anesthesia added to the parametric alterations, recovery quality and security. Twenty bitches were used, being clinically healthy, with exception of all pregnant females and bitches in estrus. The animals were randomly assigned into two groups (G1 and G2), with 10 animals per group. The females in G1 were submitted to pre- treatment with methotrimeprazine and buprenorphine (IV), being induced to anesthesia with ketamine and midazolam in bolus both by intra-venous administration during 30 minutes. The animals from group 2 received the same protocol used for G1 animals, except for the replacement of xylazine by medetomidine. The bitches were monitored during all experimental period at determined moments: M0, immediately before pre-treatment; M1, 15 minutes after pre-treatment administration and immediately before induction. The intra-venous and continuos administration started right after induction of anesthesia, and the parameters were evaluated within 10 minutes interval which corresponded to M 2 and M4. In conclusion, G2 presented advantages, at least considering clinical aspects in relationship to G1 due to a shorter recovery period followed by less side effects incidence during this period. Both protocols allowed surgery to be performed (hysterectomy). Even tough an arrhythmia was observed at determined moment in both groups, G2 had the lowest incidence of this side effect, requiring further studies to clarify such effects. / Mestre