Resumo em Inglês:

Abstract Background Pulmonary aspiration during anesthesia, though rare, can be catastrophic. Gastric ultrasound provides an objective assessment of gastric contents and may be particularly relevant for children with Cerebral Palsy (CP), who are at risk of delayed gastric emptying. Methods We conducted a cross-sectional study in a pediatric hospital including children scheduled for elective surgery per ASA fasting guidelines. Preoperative gastric ultrasound measured antral CSA in right lateral decubitus, and gastric volume was estimated using the Perlas formula. Fasting time, medication use, and clinical data were recorded. Group comparisons used Wilcoxon, Fisher’s exact, or Chi-Square tests; multiple linear regression adjusted for confounders. Results Sixty-two children were studied: 30 with Cerebral Palsy (CP) and 32 controls. No patient exceeded the high-risk gastric volume threshold (1.5 mL.kg-1) and no surgeries were cancelled. CP patients had shorter fasting times (6.5 vs. 8.0 h; p < 0.001) and higher medication use (47% vs. 6.3%; p < 0.001). Gastric CSA (4.0 vs. 3.0 cm2; p < 0.001) and estimated gastric volume per kg (0.7 vs. 0.4 mL.kg-1; p < 0.001) were greater in CP. Multivariable models showed attenuation, but quantile regression confirmed higher lower CSA (+1.25 cm2; p = 0.007). Excluding medication users, CP remained associated with greater gastric volume. Conclusions Children with cerebral palsy exhibit larger CSA and higher gastric volumes despite adequate fasting. Although clinically safe, these findings support the role of gastric ultrasound in preoperative risk assessment for this vulnerable group.

Resumo em Inglês:

Abstract Background Sometimes, planned vaginal deliveries with neuraxial analgesia may result in unplanned cesareans. We aimed to determine the incidence of cesarean among parturients receiving neuraxial analgesia for vaginal delivery, identify associated factors, and develop a predictive model. Methods In this prospective observational cohort study, we evaluated parturients receiving neuraxial analgesia for vaginal delivery and analyzed factors associated with progression to cesarean. Multiple logistic regression with a step-up procedure was performed. The dataset was split into training (70%) and testing (30%) databases, with the latter used to assess performance metrics. Bootstrap validation with 5,000 repetitions was performed. Results We evaluated 331 parturients and 94 (28.4%) underwent cesarean. Variables differing between cesarean and vaginal delivery groups (p < 0.05) included patient age, body mass index, gestational age, cervical dilation at analgesia initiation, time under analgesia, labor conducted/monitored by nurses, and oxytocin use after analgesia initiation. Three variables remained predictive [odds ratio (95% Confidence Interval (95% CI))]: patient age: 1.0436 (1.0091 to 1.0835), p = 0.018; time under analgesia: 1.0043 (1.0008 to 1.0081), p = 0.018; and oxytocin use after analgesia initiation: 0.0921 (0.0400 to 0.1945), p < 0.001. Predictive area under the curve (95% CI) was 71.8% (60.5%‒83.1%). Arrest of descent (35.1%) and fetal distress (34.0%) were the leading indications for cesarean. Conclusions Among parturients receiving neuraxial labor analgesia, older patients, longer analgesia duration, and no oxytocin use after analgesia initiation increase the probability of cesarean, with moderate predictivity. Arrest of descent and fetal distress were the main causes of cesarean.

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Abstract Introduction Intracranial pressure can increase during video-laparoscopic prostatectomy due to the Trendelenburg position and pneumoperitoneum, potentially leading to complications. The Optic Nerve Sheath Diameter (ONSD) has emerged as a reliable, non-invasive method to assess ICP. Mannitol is commonly used to reduce ICP, but its intraoperative effects in this surgical setting remain unclear. This study aimed to evaluate the impact of mannitol administration on ICP, as assessed by ONSD. Methods This single-center, randomized, parallel-group, non-blinded clinical trial, 1:1 allocation, included 48 patients undergoing video-laparoscopic prostatectomy at a tertiary hospital in Brazil. Participants were randomly assigned to either the Mannitol Group, receiving 0.5 g.kg-1 of intravenous mannitol after 120 minutes in Trendelenburg, or the Control Group, which did not receive mannitol. ONSD was measured using ultrasonography at four intraoperative time points (T1-T4). Additional variables analyzed included hemodynamic and respiratory parameters, surgery duration, and extubation time. Statistical analysis was conducted using a linear mixed-effects model. Results ONSD increased in both groups between T1 and T3, followed by a reduction at T4. However, the decrease in ONSD in the Mannitol Group was not statistically significant compared to the Control Group. Regarding extubation, the mean extubation time was 24.04 ± 15.71 minutes in the Mannitol Group and 22.79 ± 15.37 minutes in the Control Group (p = 0.782). Conclusion Mannitol administration during video-laparoscopic prostatectomy did not result in significant differences in ONSD trajectory or extubation time compared with the control group. At the dose and timing used, mannitol did not modify intraoperative surrogate measures of intracranial pressure.

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Abstract Background Percutaneous Nephrolithotomy (PCNL) is a well-established surgical procedure for removal of large, multiple, and complex renal calculi in children. Combining loco-regional techniques with general anesthesia has gained increasing popularity in pediatric anesthesia. The objective of this trial was to evaluate the efficacy of Erector Spinae Plane Block (ESPB) versus thoracic Paravertebral Block (PVB) in pediatric patients undergoing PCNL procedure. Methods Fifty-six children, aged 2‒7 years, who underwent PCNL procedure under general anesthesia were randomly assigned to receive either ESPB (n = 28) or thoracic PVB (n = 28) with the same anesthetic mixture of 0.3 mL.kg-1 bupivacaine 0.25% in epinephrine 1:100000. The primary outcome was time to first rescue analgesia (nalbuphine). Results The time to first rescue analgesia was 15.98 ± 10.17 hours (95% CI: 12.14-19.82) in the ESPB group versus 18.18 ± 9.18 hours (95% CI: 14.7-21.58) in the thoracic PVB group with no significant difference (p = 0.464, log-rank test). Moreover, the total dose and frequency of administration of nalbuphine during the first 24 postoperative hours were comparable between the two studied groups (p = 0.488 and 0.479 respectively). However, the time to conduct the block was significantly shorter in the ESPB group versus the thoracic PVB group (4.37 ± 1.08 minutes vs. 5.05 ± 1.17 minutes respectively, p = 0.028). Conclusion ESPB was not found to be more effective than thoracic PVB for postoperative pain management in children undergoing PCNL procedure. Moreover, intraoperative hemodynamics and maximum sevoflurane concentration were comparable. The time to conduct ESPB was significantly shorter; hence, it could be considered as an easy alternative to thoracic PVB for this procedure.

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Abstract Introduction The Voluntary Breath-Hold Test (VBHT) is a simple, bedside, and rapid assessment that measures the duration of voluntary apnea. It has shown potential for clinical use, including as a triage tool prior to spirometry in primary care. However, its diagnostic accuracy in detecting abnormal pulmonary function before non-thoracic surgeries has not been established. This study aimed to determine the correlation between VBHT results, Maximal Voluntary Apnea Inspiratory Time (MVAIT) and Maximal Voluntary Apnea Expiratory Time (MVAET), and spirometry, the reference test for assessing pulmonary function. Methods This diagnostic-accuracy study included adults with normal spirometry and those with obstructive or restrictive ventilatory defects. Participants were divided into normal and abnormal spirometry groups. Maximal Voluntary Apnea Inspiratory Time (MVAIT) and Expiratory Time (MVAET) were evaluated using Receiver Operating Characteristic (ROC) curve analysis to assess their accuracy in distinguishing between normal and abnormal spirometry patterns. Results The study included 293 participants. MVAIT and MVAET were significantly lower for the abnormal (median: 29.32 s; 95% Confidence Interval [95% CI]: 25.99‒32.35 s and median: 20.40 s; 95% CI: 18.66‒22.88 s) than for the normal (median: 47.55 s; 95% CI: 43.93‒51.87 s and median: 28.53 s; 95% CI: 26.74‒30.63 s) group. For the prediction of normal spirometry, MVAIT ≥ 45.49 s and MVAET ≥ 32.86 s had sensitivity and specificity of (90.43%, 55.06%) and (90.43%, 33.71%), respectively. Conclusion VBHT is a bedside, low-cost, and safe method that shows moderate-to-good discriminative ability for identifying abnormal spirometry results. As an innovative adaptation of a long-known physiological maneuver, VBHT may serve as a rapid preliminary triage (rule-out) tool prior to formal spirometry, pending external validation in preoperative populations. CTRI Register Number - ReBEC (Registro Brasileiro de Ensaios Clínicos) RBR-8hknmn.

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Abstract Background Nitrous Oxide (N2O) is a potent greenhouse gas with significant environmental impact and is currently the leading ozone depleting substance in use. Despite its long-standing role in anesthetic practice, data on N2O use and the environmental awareness of Brazilian anesthesiologists are scarce. This study aimed to describe patterns of N2O use and assess the level of awareness among anesthesiologists regarding its environmental impact. Methods A nationwide cross-sectional survey was conducted among anesthesiologists in a private Brazilian hospital network. The questionnaire addressed the frequency of N2O use in adult and pediatric anesthesia, knowledge of its environmental effects, and attitudes toward its continued availability. Results Of 1,238 eligible anesthesiologists, 941 completed the survey (response rate 76%). Overall, 59.3% (n = 558) reported never using N2O in adult patients, while 14.5% (n = 136) reported frequent or constant use. In pediatric patients, 27.5% (n = 259) reported never using N2O, and 38.9% (n = 366) reported frequent or constant use. Eighty percent (n = 753) indicated a reduction in N2O use since the beginning of their careers, and 34.5% (n = 325) were unaware of its contribution to climate change. Age and years of professional experience were directly proportional to N2O use in adults (p < 0.05), while awareness of its environmental impact was inversely associated with use in pediatric cases (p < 0.05). Conclusion The survey demonstrates a shift toward reduced N2O use, particularly among younger anesthesiologists, although substantial use in adult practice remains. Persistent knowledge gaps highlight the importance of targeted education and policy interventions to mitigate environmental impact.

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Abstract Background Outpatient preanesthetic consultation improves patient assessment and anesthetic planning, enhancing safety and reducing complications. Conducted in advance, it allows systematic, individualized planning. Uncontrolled hypertension, common in 60% of people over 60, is a major cause of surgery cancellation and increases cardiovascular risk. This study evaluates its impact on preventing perioperative complications and optimizing clinical and surgical outcomes in urological patients. Methods This retrospective observational study analyzed 700 patients (≥ 18 years) who attended outpatient preanesthetic consultation before urological surgery. Clinical conditions, systemic blood pressure, heart rate was analyzed during outpatient, preoperative, and intraoperative periods. Preoperative and intraoperative complications were recorded to evaluate consultation impact. Results Among 700 patients (89.6% male, mean age 64.2), ASA II was most common classification. Hypertension was identified in 53.7% of patients during outpatient evaluation. All hypertensive patients received antihypertensive treatment until surgery, with blood pressure maintained within normal limits. Preoperative findings in the operating room included hypertension (2.0%), anemia (0.57%), atrial fibrillation (0.14%), and asthma (0.14%). Intraoperative events included hypertension (2.28%), hypotension (8.14%), bradycardia (1.14%), and inadequate neuraxial block (2.85%). One surgery was canceled due to hypertension. Blood pressure significantly decreased preoperatively and intraoperatively compared to outpatient values (p < 0.0001). Heart rate also decreased significantly intraoperatively. This single-center study has limitations, including absence of comparison groups assessed by other specialties or only day of surgery. Conclusion Reductions in systolic and diastolic blood pressure were documented upon operating room entry among patients evaluated in outpatient preanesthetic consultation, with a very low surgery cancellation rate.

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Abstract Introduction Surgery remains one of the most important treatments for breast cancer. In this context, the quality of postoperative recovery has become a key concern. Adequate control of acute pain is essential to optimize patient comfort and recovery. Pregabalin may contribute to this goal by preventing central sensitization and reducing perioperative anxiety. Objectives To evaluate the effect of perioperative pregabalin versus placebo on postoperative recovery quality in patients undergoing breast cancer surgery. Method In this randomized controlled trial, 92 patients received either pregabalin (150 mg orally, 1 hour before surgery) or a matching placebo, both prepared in identical capsules. The primary outcome was the QoR-15 score measured preoperatively, and at 24 and 48 hours postoperatively. The 24- and 48-hour assessments were conducted via telephone. The QoR-15 is a validated instrument that assesses the quality of recovery, with total scores ranging from 0 (very poor recovery) to 150 (excellent recovery). Secondary outcomes included opioid consumption, pain scores, incidence of nausea and vomiting, and lengths of stay in the Post-Anesthesia Care Unit (PACU) and hospital. An exploratory analysis of longitudinal changes in QoR-15 scores within each group was also performed. Analyses were performed per protocol. Results Eighty-four patients completed the study. There were no differences in overall QoR-15 score between the groups at any of the three assessment time points (preoperative, 24h, and 48h). In the exploratory longitudinal within-group analysis, better maintenance of recovery quality was observed in the pregabalin group compared with baseline, with medians (IQR) of 138 (122.3-145), 132.5 (125.8-135.3), and 134 (131.5-136) [p = 0.006 between 24h and 48h]. In the placebo group, the medians (IQR) were 140 (128-145.3), 129 (126-134.3), and 134 (126.8-136.3) [p = 0.002 between pre and 24h; p = 0.026 between pre and 48h]. Conclusion Although exploratory analysis showed a trend toward improvement within the pregabalin group, there was no significant difference in QoR-15 scores between groups.

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Abstract Background Opioid Epidural Labor Analgesia (OLEA) is commonly used during labor. However, opioid use has been associated with adverse effects on maternal and fetal outcomes. Medications administered during epidural analgesia are systemically absorbed; therefore, we performed a retrospective cohort study to investigate whether Opioid-Free Labor Epidural Analgesia (OFLEA) is comparable to OLEA regarding maternal and infant outcomes at delivery. Methods Of 1,423 patients initially identified, we excluded those with twin deliveries, duplicate records, or incomplete data. We then matched 1:1 on the mother’s age, including 618 patients for final data analysis. Our OLFEA group included an epidural solution of 0.2% ropivacaine, while our OLEA group included an epidural solution of 0.1% ropivacaine + 250 mcg fentanyl. Wilcoxon rank-sum tests were performed to assess our primary outcome of time-weighted pain scores before and after epidural placement. Secondary outcomes included duration (minutes) of maternal hypotension, tachycardia, and bradycardia episodes during labor, and incidence of neonatal fever, C-section, and Apgar scores (1 and 5 mins after delivery). Results There was no significant difference between the OLEA and OFLEA groups in the time-weighted pain scores during labor before epidural placement. However, the time-weighted pain score was significantly lower in the OFLEA group (1.05 ± 1.52) compared to OLEA (1.43 ± 1.77, p = 0.006). Similarly, maximum pain scores after epidural were lower in OFLEA (3.32 ± 3.23) vs. OLEA (3.87 ± 3.33, p = 0.03). There were no significant differences in maternal hemodynamic events, Apgar scores, neonatal fever, or cesarean delivery rates. Conclusions OFLEA is a safe and feasible alternative to OLEA. Avoidance of opioids may support safer maternal and neonatal care in obstetric anesthesia.

Resumo em Inglês:

Abstract Background Severe odontogenic infections requiring surgical drainage pose significant airway management challenges. This study aimed to compare perioperative characteristics and clinical outcomes between patients managed with conventional laryngoscopy versus awake fiberoptic intubation, to identify factors associated with the selection of airway management technique, and to determine predictors of hospital length of stay. Methods This single-center retrospective study included 85 adult patients who underwent surgical drainage of severe odontogenic infections under general anesthesia between 2015 and 2024. The primary objective was to identify factors associated with awake fiberoptic intubation selection. Secondary objectives included comparison of perioperative outcomes and identification of predictors of hospital discharge. Multivariable logistic regression and Cox proportional hazards modeling were used. Results Of 85 patients, 60% were managed with AFOI. Multivariable analysis identified trismus (OR = 6.67, 95% CI 1.53, 39.53, p = 0.010) and higher BMI (OR = 1.15, 95% CI 1.03, 1.33, p = 0.013) as independent predictors of AFOI selection. AFOI patients experienced more complex postoperative courses, with intraoperative tracheostomy, ICU admission, and septic shock occurring exclusively in this group. Spontaneous ventilation postoperatively was associated with earlier discharge (HR = 2.14, 95% CI 1.23, 3.73, p = 0.007), while septic shock (HR = 0.26, 95% CI 0.07, 0.91, p = 0.036) and lower BMI (HR = 0.95, 95% CI 0.90, 1.00, p = 0.040) were associated with delayed discharge. Conclusion AFOI was preferentially selected for anatomically complex odontogenic infections based on objective criteria, particularly trismus and elevated BMI. The ability to achieve spontaneous ventilation postoperatively serves as a key prognostic indicator, while septic shock is strongly associated with prolonged recovery. These findings support evidence-based airway management protocols and early identification of high-risk patients to optimize outcomes in this challenging population.

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Abstract Background Tracheostomy is an option to ensure airway safety in patients with severe traumatic brain injury. However, the optimal timing for tracheostomy remains unclear based on current evidence. Methods Umbrella systematic review to determine the effectiveness of early tracheostomy in TBI. Databases: PubMed, Embase, Scopus, Web of Science, Lilacs, Cochrane, Open Grey, and clinical trials. Inclusion criteria: Meta-analysis of early tracheostomy in severe TBI patients. Exclusion criteria: if there was no data regarding the time of death or the follow-up period. Data extraction: Selection, risk of bias evaluation, and data extraction were performed by two independent authors. Results Four meta-analyses were included from 5673 initial records, and a new meta-analysis was performed from data obtained in primary studies. The evidence included in this umbrella review showed that early tracheostomy reduced ICU (MD = -5.69 days; 95% CI [-7.78, -3.59]) and Hospital (MD = -3.53 days; 95% CI [-4.44, -2.62]) length of stay, time in mechanical ventilation (MD = -5.08; 95% CI [-7.12, -3.05]) and risk of ventilator associated pneumonia (RR = 0.78; 95% CI [0.70, 0.86],). These studies cannot determine the effectiveness of early tracheostomy on mortality (RR = 1.32; 95% CI [0.89, 1.96],) or neurological prognosis. Conclusions This umbrella review suggests that early tracheostomy is effective in reducing ICU and Hospital length of stay, time in mechanical ventilation, and ventilator-associated pneumonia. Inplasy protocol 202280096.

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Abstract Background Remimazolam, a short-acting benzodiazepine, has emerged as a potential safer alternative for sedation in Flexible Bronchoscopy (FB). This meta-analysis compares its efficacy and safety with Propofol, Dexmedetomidine, and Midazolam in adult patients undergoing FB. Methods PubMed, Embase, and Cochrane databases were searched on July 17, 2025, for trials comparing Remimazolam with other sedatives. Primary outcomes included hypotension, bradycardia, and intraprocedural opioid consumption; secondary outcomes were hypoxia, respiratory depression, patient satisfaction, induction time, and recovery time. Pooled Risk Ratios (RR), Mean Differences (MD), and Standardized Mean Differences (SMD) were calculated using a random-effects model in R (4.4.0). Risk of bias was assessed using the RoB2 tool, and subgroup analyses were conducted for each comparator. Results Eleven trials (1,884 patients) were included. Remimazolam reduced respiratory depression (RR = 0.44 [95% CI 0.29; 0.67]; p = 0.0002; I² = 0%), hypoxia incidence (RR = 0.60 [95% CI 0.39; 0.93]; p = 0.0227; I² = 64.7%), bradycardia (RR = 0.39 [95% CI 0.20; 0.77]; p = 0.0069; I² = 52.3%), and hypotension (RR = 0.61 [95% CI 0.40; 0.95]; p = 0.0289; I² = 74.0%) compared to all sedatives. Compared to Propofol, Remimazolam reduced the incidence of hypotension (RR = 0.42 [95% CI 0.31; 0.58]; p < 0.0001; I² = 0%), respiratory depression (RR = 0.41 [95% CI 0.25; 0.68]; p = 0.0005; I² = 12.3%), but increased induction time (MD = 0.61 min [95% CI 0.23; 0.99]; p = 0.002; I² = 90.9%). Compared to Dexmedetomidine, it improved satisfaction (SMD = 0.23 [95% CI 0.07; 0.39]; p = 0.004; I² = 0%) and reduced recovery time (MD = -1.79 min [95% CI -2.66; -0.92]; p < 0.001; I² = 90.7%), hypoxia incidence (RR = 0.49 [95% CI 0.28; 0.88]; p = 0.0162; I² = 60.3%), and induction time (MD = -2.21 min [95% CI -2.41; -2.00]; p < 0.001; I² = 0%). Compared to Midazolam, Remimazolam increased sedation success (RR = 2.03 [95% CI 1.40; 2.95]; p = 0.0002; I² = 50%), shortened induction time (MD = -0.69 min [95% CI -1.37; -0.01]; p = 0.047; I² = 81.5%), and recovery time (MD = -4.49 min [95% CI -7.06; -1.92]; p < 0.001; I² = 40.9%). Conclusions Remimazolam reduced respiratory depression overall and demonstrated improved safety, faster recovery, and greater efficacy compared to Propofol, Dexmedetomidine, and Midazolam, respectively, supporting its potential as an effective alternative for sedation in FB. Nonetheless, substantial heterogeneity in certain outcomes and the relatively small sample size in some comparisons limit the generalizability of our findings. Systematic review protocol PROSPERO (CRD 42024568148).