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Abstract Background Hydroxyethyl starches are colloids used in fluid therapy that may reduce volume infusion compared with crystalloids, but they can affect renal function in critical care patients. This study aims to assess renal effects of starches using renal biomarkers in the perioperative setting. Methods This prospective, controlled, randomized study compared Hydroxyethyl starch 6% (HES) with Ringer's lactate (RL) in hysterectomy. Each episode of mean arterial pressure (MAP) below 60 mmHg guided the fluid replacement protocol. The RL group received 300 mL bolus of RL solution while the HES group received 150 mL of HES solution. All patients received RL (2 mL.kg−1.h−1) intraoperatively to replace insensible losses. Blood and urine samples were collected at three time points (preoperatively, 24 hours, and 40 days postoperatively) to assess urinary NGAL and KIM-1, as primary outcome, and other markers of renal function. Results Seventy patients were randomized and 60 completed the study. The RL group received a higher crystalloid volume (1,277 ± 812.7 mL vs. 630.4 ± 310.2 mL; p= 0.0002) with a higher fluid balance (780 ± 720 mL vs. 430 ± 440 mL; p= 0.03) and fluid overload (11.7% ± 10.4% vs. 7.0% ± 6.3%; p= 0.04) compared to the HES group. NGAL and KIM-1 did not differ between groups at each time point, however both biomarkers increased 24 hours postoperatively and returned to preoperative levels after 40 days in both groups. Conclusion HES did not increase renal biomarkers following open hysterectomy compared to RL. Moreover, HES provided better hemodynamic parameters using less volume, and reduced postoperative fluid balance and fluid overload.

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BACKGROUND: Hydroxyethyl starches are colloids used in fluid therapy that may reduce volume infusion compared with crystalloids, but they can affect renal function in critical care patients. This study aims to assess renal effects of starches using renal biomarkers in the perioperative setting. METHODS: This prospective, controlled, randomized study compared Hydroxyethyl starch 6% (HES) with Ringer's lactate (RL) in hysterectomy. Each episode of mean arterial pressure (MAP) below 60 mmHg guided the fluid replacement protocol. The RL group received 300 mL bolus of RL solution while the HES group received 150 mL of HES solution. All patients received RL (2 mL.kg-1.h-1) intraoperatively to replace insensible losses. Blood and urine samples were collected at three time points (preoperatively, 24 hours, and 40 days postoperatively) to assess urinary NGAL and KIM-1, as primary outcome, and other markers of renal function. RESULTS: Seventy patients were randomized and 60 completed the study. The RL group received a higher crystalloid volume (1,277 ± 812.7 mL vs. 630.4 ± 310.2 mL; p = 0.0002) with a higher fluid balance (780 ± 720 mL vs. 430 ± 440 mL; p = 0.03) and fluid overload (11.7% ± 10.4% vs. 7.0% ± 6.3%; p = 0.04) compared to the HES group. NGAL and KIM-1 did not differ between groups at each time point, however both biomarkers increased 24 hours postoperatively and returned to preoperative levels after 40 days in both groups. CONCLUSION: HES did not increase renal biomarkers following open hysterectomy compared to RL. Moreover, HES provided better hemodynamic parameters using less volume, and reduced postoperative fluid balance and fluid overload.

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Abstract Introduction: The importance and benefits of breastfeeding for the babies and mothers are well established and documented in the literature. However, it is frequent that lactating mothers need to undergo general or spinal anesthesia and, due to the lack of information, many of them interrupt breastfeeding after anesthesia. There are limited data available regarding anesthetics transfer to breast milk. This review aims to develop some considerations and recommendations based on available literature. Methods: A systematic search of the literature was conducted by using the following health science databases: Embase, Lilacs, Pubmed, Scopus, and Web of Science. The latest literature search was performed on April 6th, 2018. Additional literature search was made via the World Health Organization's website. We used the following terms for the search strategy: "Anesthesia" and "Breastfeeding", and their derivatives. Results: In this research, 599 registers were found, and 549 had been excluded by different reasons. Fifty manuscripts have been included, with different designs of studies: prospective trials, retrospective observational studies, reviews, case reports, randomized clinical trials, case-control, and website access. Small concentrations of the most anesthetic agents, are transferred to the breast milk; however, their administration seem to be safe for lactating mothers when administered as a single dose during anesthesia and this should not contraindicate the breastfeeding. On the other hand, high-doses, continuous or repeated administration of drugs increase the risk of adverse effects on neonates, and should be avoided. Few drugs, such as diazepam and meperidine, produce adverse effects on breastfed babies even in single doses. Dexmedetomidine seems to be safe if breastfeeding starts 24 h after discontinuation of the drug. Conclusions: Most of the anesthetic drugs are safe for nursing mothers and offer low risk to the breastfed neonates when administered in single-dose. However, high-dose and repeated administration of drugs significantly increase the risk of adverse effects on neonates. Moreover, diazepam and meperidine should be avoided in nursing women. Finally, anesthesiologists and pediatricians should consider individual risk/benefit, with special attention to premature neonates or babies with concurrent diseases since they are more susceptible to adverse effects.

Resumo Introdução: A importância e os benefícios do aleitamento materno para os bebês e para as mães estão bem estabelecidos e documentados na literatura. No entanto, é frequente que mães lactantes precisem se submeter à anestesia geral ou raquianestesia e, devido à falta de informações, muitas delas interrompem a amamentação após a anestesia. Existem poucos dados disponíveis sobre a transferência de anestésicos para o leite materno. O objetivo desta revisão foi desenvolver algumas considerações e recomendações com base na literatura disponível. Métodos: Uma busca sistemática da literatura realizada usando com os seguintes bancos de dados em ciências da saúde: Embase, Lilacs, Pubmed, Scopus e Web of Science. A pesquisa bibliográfica mais recente foi realizada em 6 de abril de 2018. Uma pesquisa bibliográfica adicional foi realizada através do site da Organização Mundial da Saúde. Usamos os seguintes termos para a estratégia de busca: "Anestesia" e "Aleitamento materno" e seus derivados. Resultados: Nesta pesquisa, 599 registros foram encontrados e 549 foram excluídos por diferentes razões. Foram incluídos 50 manuscritos, com diferentes modelos de estudo: estudos prospectivos, estudos observacionais retrospectivos, revisões, relatos de casos, ensaios clínicos randômicos, caso-controle e acesso a sites. Pequenas concentrações da maioria dos agentes anestésicos são transferidas para o leite materno; entretanto, sua administração parece ser segura para mães lactantes quando administrados em dose única durante a anestesia e isso não deve contraindicar o aleitamento materno. Por outro lado, altas doses, administração contínua ou repetida dos fármacos aumentam o risco de efeitos adversos em neonatos e devem ser evitados. Poucas drogas, como diazepam e meperidina, produzem efeitos adversos em bebês amamentados, mesmo quando administradas em doses únicas. Dexmedetomidina parece ser segura se a amamentação começar 24 horas após a interrupção do medicamento. Conclusões: A maioria dos anestésicos é segura para mães que amamentam e oferecem baixo risco para os recém-nascidos amamentados quando a administração é em dose única. No entanto, altas doses e repetidas administrações de drogas aumentam significativamente o risco de efeitos adversos em recém-nascidos. Além disso, diazepam e meperidina devem ser evitados em mulheres que amamentam. Finalmente, anestesiologistas e pediatras devem considerar o risco-benefício individual, com atenção especial para os recém-nascidos prematuros ou bebês com doenças concomitantes, pois são mais suscetíveis a efeitos adversos.

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BACKGROUND AND OBJECTIVES: As the number of people with tattoos has been increasing, anesthesiologists are more and more faced with the decision to perform a neuraxial blockage through tattooed skin. In this study, we evaluated the possibility of puncture through tattooed skin determines acute inflammatory changes in the meninges and spinal cord and later evolve into adhesive arachnoiditis. METHOD: Forty-two male rabbits were randomized into 3 groups of 14: G1, spinal puncture through non-tattooed skin and saline solution injection; G2, spinal puncture through tattooed skin and saline solution injection, captive for 30 days; G3, spinal puncture through tattooed skin and saline solution injection, captive for 360 days. The animals were anesthetized and ultrasound-guided spinal puncture was performed in the intervertebral spaces between S1 - S2. During the period of captivity, the animals were clinically assessed for sensitivity and motor function. After that, they were sacrificed and the lumbosacral portion of the spinal cord was excised for histological analysis. RESULTS: No histological changes were found on group 1. Eleven animals from group two presented with foci of perivascular lymphocytic inflammatory infiltrate in the pia mater and/or arachnoid. In Group 3, eight rabbits presented with inflammatory changes in the meninges, which were associated with thickening and/or adhesion of the pia mater and arachnoid in some cases and five rabbits presented only thickening of pia-mater. CONCLUSIONS: Spinal puncture through tattooed skin of rabbits can trigger acute inflammatory changes in the meninges and after a prolonged period of observation evolve into adhesive arachnoiditis.

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INTRODUCTION: The importance and benefits of breastfeeding for the babies and mothers are well established and documented in the literature. However, it is frequent that lactating mothers need to undergo general or spinal anesthesia and, due to the lack of information, many of them interrupt breastfeeding after anesthesia. There are limited data available regarding anesthetics transfer to breast milk. This review aims to develop some considerations and recommendations based on available literature. METHODS: A systematic search of the literature was conducted by using the following health science databases: Embase, Lilacs, Pubmed, Scopus, and Web of Science. The latest literature search was performed on April 6th, 2018. Additional literature search was made via the World Health Organization's website. We used the following terms for the search strategy: "Anesthesia" and "Breastfeeding", and their derivatives. RESULTS: In this research, 599 registers were found, and 549 had been excluded by different reasons. Fifty manuscripts have been included, with different designs of studies: prospective trials, retrospective observational studies, reviews, case reports, randomized clinical trials, case-control, and website access. Small concentrations of the most anesthetic agents, are transferred to the breast milk; however, their administration seem to be safe for lactating mothers when administered as a single dose during anesthesia and this should not contraindicate the breastfeeding. On the other hand, high-doses, continuous or repeated administration of drugs increase the risk of adverse effects on neonates, and should be avoided. Few drugs, such as diazepam and meperidine, produce adverse effects on breastfed babies even in single doses. Dexmedetomidine seems to be safe if breastfeeding starts 24h after discontinuation of the drug. CONCLUSIONS: Most of the anesthetic drugs are safe for nursing mothers and offer low risk to the breastfed neonates when administered in single-dose. However, high-dose and repeated administration of drugs significantly increase the risk of adverse effects on neonates. Moreover, diazepam and meperidine should be avoided in nursing women. Finally, anesthesiologists and pediatricians should consider individual risk/benefit, with special attention to premature neonates or babies with concurrent diseases since they are more susceptible to adverse effects.

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PURPOSE:: To evaluate a model for studying the toxicity in nervous tissue and meninges using ultrasound to guide needle insertion into the subarachnoid space of rabbits, with the objective of avoiding injuries triggered by the puncture and by intraneural injection of solutions. METHODS:: Forty-five adult female rabbits were divided into 3 groups (G): G1 underwent subarachnoid puncture, G2 underwent subarachnoid injection of saline solution and G3 underwent subarachnoid injection of 0.5% hyperbaric bupivacaine. A needle was inserted into the S1-S2 subarachnoid space guided by ultrasound. The sensitivity and motility of the animals were evaluated for 3 days, after which the animals were sacrificed for removal of lumbar and sacral portions of the spinal cord for histological examination by light microscopy and immunohistochemistry. RESULTS:: All animals had motor function and pain sensitivity on the evaluation period. No animal had complication during or after the procedures. CONCLUSION:: Ultrasound is a useful and safe method for the correct identification of the subarachnoid space of rabbits.

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Abstract Purpose: To evaluate a model for studying the toxicity in nervous tissue and meninges using ultrasound to guide needle insertion into the subarachnoid space of rabbits, with the objective of avoiding injuries triggered by the puncture and by intraneural injection of solutions. Methods: Forty-five adult female rabbits were divided into 3 groups (G): G1 underwent subarachnoid puncture, G2 underwent subarachnoid injection of saline solution and G3 underwent subarachnoid injection of 0.5% hyperbaric bupivacaine. A needle was inserted into the S1-S2 subarachnoid space guided by ultrasound. The sensitivity and motility of the animals were evaluated for 3 days, after which the animals were sacrificed for removal of lumbar and sacral portions of the spinal cord for histological examination by light microscopy and immunohistochemistry. Results: All animals had motor function and pain sensitivity on the evaluation period. No animal had complication during or after the procedures. Conclusion: Ultrasound is a useful and safe method for the correct identification of the subarachnoid space of rabbits.

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Purpose: To evaluate a model for studying the toxicity in nervous tissue and meninges using ultrasound to guide needle insertion into the subarachnoid space of rabbits, with the objective of avoiding injuries triggered by the puncture and by intraneural injection of solutions. Methods: Forty-five adult female rabbits were divided into 3 groups (G): G1 underwent subarachnoid puncture, G2 underwent subarachnoid injection of saline solution and G3 underwent subarachnoid injection of 0.5% hyperbaric bupivacaine. A needle was inserted into the S1-S2 subarachnoid space guided by ultrasound. The sensitivity and motility of the animals were evaluated for 3 days, after which the animals were sacrificed for removal of lumbar and sacral portions of the spinal cord for histological examination by light microscopy and immunohistochemistry. Results: All animals had motor function and pain sensitivity on the evaluation period. No animal had complication during or after the procedures. Conclusion: Ultrasound is a useful and safe method for the correct identification of the subarachnoid space of rabbits.(AU)

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BACKGROUND AND OBJECTIVES: Although there is no documented evidence that tattoo pigments can cause neurological complications, the implications of performing neuraxial anesthesia through tattooed skin are unknown. In this study, we aimed to assess whether spinal puncture performed through tattooed skin of rabbits determines changes over the spinal cord and meninges. In addition, we sought to evaluate the presence of ink fragments entrapped in spinal needles. METHODS: Thirty-six young male adult rabbits, each weighing between 3400 and 3900 g and having a spine length between 38.5 and 39 cm, were divided by lot into 3 groups as follows: GI, spinal puncture through tattooed skin; GII, spinal puncture through tattooed skin and saline injection; and GIII, spinal puncture through skin free of tattoo and saline injection. After intravenous anesthesia with ketamine and xylazine, the subarachnoid space was punctured at S1-S2 under ultrasound guidance with a 22-gauge 2½ Quincke needle. Animals in GII and GIII received 5 µL/cm of spinal length (0.2 mL) of saline intrathecally. In GI, the needle tip was placed into the yellow ligament, and no solution was injected into the intrathecal space; after tattooed skin puncture, 1 mL of saline was injected through the needle over a histological slide to prepare a smear that was dyed by the Giemsa method to enable tissue identification if present. All animals remained in captivity for 21 days under medical observation and were killed by decapitation. The lumbosacral spinal cord portion was removed for histological analysis using hematoxylin-eosin stain. RESULTS: None of the animals had impaired motor function or decreased nociception during the period of clinical observation. None of the animals from the control group (GIII) showed signs of injuries to meninges. In GII, however, 4 animals presented with signs of meningeal injury. The main histological changes observed were focal areas of perivascular lymphoplasmacyte infiltration in the pia mater and arachnoid. There was no signal of injury in neural tissue in any animal of both groups. Tissue coring containing ink pigments was noted in all GI smears from the spinal needles used to puncture the tattooed skin. CONCLUSIONS: On the basis of the present results, intrathecal injection of saline through a needle inserted through tattooed skin is capable of producing histological changes over the meninges of rabbits. Ink fragments were entrapped inside the spinal needles, despite the presence of a stylet.

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This study aimed to compare the efficiency of the thermal blanket and thermal mattress in the prevention of hypothermia during surgery. Thirty-eight randomized patients were divided into two groups (G1 - thermal blanket and G2 - thermal mattress). The variables studied were: length of surgery, length of stay in the post-anesthetic care unit, period without using the device after thermal induction, transport time from the operating room to post-anesthetic care unit, intraoperative fluid infusion, surgery size, anesthetic technique, age, body mass index, esophageal, axillary and operating room temperature. In G2, length of surgery and starch infusion longer was higher (both p=0.03), but no hypothermia occurred. During the surgical anesthetic procedure, the axillary temperature was higher at 120 minutes (p=0.04), and esophageal temperature was higher at 120 (p=0.002) and 180 minutes (p=0.03) and at the end of the procedure (p=0.002). The thermal mattress was more effective in preventing hypothermia during surgery.

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