Abstract Introduction: Methylene Blue (MB) has been shown to attenuate oxidative, inflammatory, myocardial, and neurological lesions during ischemia-reperfusion and has great potential during cardiac arrest. This study aimed to determine the effects of MB combined with epinephrine during cardiac arrest on myocardial and cerebral lesions. Method: Thirty-eight male Wistar rats were randomly assigned to four groups: the sham group (SH, n = 5), and three groups subjected to cardiac arrest (n = 11 /group) and treated with EPI 20 μg.kg−1 (EPI), EPI 20 μg.kg−1 + MB 2 mg.kg−1 (EPI + MB), or saline 0.9% 0.2 ml (CTL). Ventricular fibrillation was induced by direct electrical stimulation in the right ventricle for 3 minutes, and anoxia was maintained for 5 minutes. Cardiopulmonary Resuscitation (CPR) consisted of medications, ventilation, chest compressions, and defibrillation. After returning to spontaneous circulation, animals were observed for four hours. Blood gas, troponin, oxidative stress, histology, and TUNEL staining measurements were analyzed. Groups were compared using generalized estimating equations. Results: No differences in the Returning of Spontaneous Circulation (ROSC) rate were observed among the groups (EPI: 63%, EPI + MB: 45%, CTL: 40%, p = 0.672). The mean arterial pressure immediately after ROSC was higher in the EPI+MB group than in the CTRL group (CTL: 30.5 [5.8], EPI: 63 [25.5], EPI+MB: 123 [31] mmHg, p = 0.007). Serum troponin levels were high in the CTL group (CTL: 130.1 [333.8], EPI: 3.70 [36.0], EPI +MB: 43.7 [116.31] ng/mL, p < 0.05). Conclusion: The coadministration of MB and epinephrine failed to yield enhancements in cardiac or brain lesions in a rodent model of cardiac arrest. Introduction (MB inflammatory ischemiareperfusion ischemia reperfusion Method Thirtyeight Thirty eight SH, SH (SH 5, , 5) 1 /group μgkg1 μgkg μg kg μg.kg− EPI, (EPI) mgkg1 mgkg mg mg.kg− MB, MB) 09 0 9 0.9 02 0. CTL. . (CTL) minutes CPR (CPR medications ventilation compressions defibrillation circulation hours gas stress histology analyzed equations Results (ROSC 63% 45 45% 40 40% 0.672. 0672 0.672 672 0.672) EPIMB (CTL 305 30 30. 5.8, 58 5.8 8 [5.8] 6 25.5, 255 25.5 25 [25.5] 12 31 [31 mmHg 0.007. 0007 0.007 007 0.007) 1301 130 130. 333.8, 3338 333.8 333 [333.8] 370 70 3.7 36.0, 360 36.0 36 [36.0] +MB 437 43 7 43. 116.31 11631 116 [116.31 ngmL ng mL ng/mL 0.05. 005 0.05 05 0.05) Conclusion μg.kg mg.kg 4 067 0.67 67 5. [5.8 25. [25.5 [3 000 0.00 00 13 333. 33 [333.8 37 3. 36. [36.0 116.3 1163 [116.3 0.0 06 0.6 [5. [25. [ [333. [36. 116. [116. [5 [25 [333 [36 [116 [2 [33 [11 [1

Abstract Introduction: This study aimed to assess the learning curves of peribulbar anesthesia and estimate the number of blocks needed to attain proficiency. Methods: Anonymized records of sequential peribulbar blocks performed by first-year anesthesia residents were analyzed. The block sequential number and the outcomes were extracted from each record. Success was defined as a complete sensory and motor block of the eye, and failure was defined as an incomplete block requiring supplemental local anesthetic injections or general anesthesia. Learning curves using the LC-CUSUM method were constructed, aiming for acceptable and unacceptable failure rates of 10% and 20%, and 10% probability of type I and II errors. Simulations were used to determine the proficiency limit h0. Residents whose curves reached h0 were considered proficient. The Sequential Probability Ratio Test Cumulative Sum Method (SPRT-CUSUM) was used for follow-up. Results: Thirty-nine residents performed 2076 blocks (median = 52 blocks per resident; Interquartile Range (IQR) [range] = 27–78 [4–132]). Thirty residents (77%) achieved proficiency after a median of 13 blocks (13–24 [13–24]). Conclusions: The LC-CUSUM is a robust method for detecting resident proficiency at peribulbar anesthesia, defined as success rates exceeding 90%. Accordingly, 13 to 24 supervised double-injection peribulbar blocks are needed to attain competence at peribulbar anesthesia. Introduction Methods firstyear first year analyzed record eye LCCUSUM LC CUSUM constructed 10 20 20% errors h proficient SPRTCUSUM SPRT (SPRT-CUSUM followup. followup follow up. up follow-up Results Thirtynine nine 207 5 IQR (IQR range [range 2778 27 78 27–7 4–132. 4132 4–132 . 4 132 [4–132]) 77% 77 (77% 1 13–24 1324 (13–2 13–24. [13–24]) Conclusions 90 90% Accordingly 2 doubleinjection double injection 277 7 27– 413 4–13 [4–132] (77 13–2 (13– [13–24] 9 41 4–1 [4–132 (7 13– (13 [13–24 4– [4–13 ( (1 [13–2 [4–1 [13– [4– [13 [4 [1 [

Abstract Background and objectives: Chronic shoulder pain is a frequent cause of suffering and impaired quality of life. Treatment includes non-pharmacological and pharmacological therapies, and interventional procedures such as suprascapular nerve blocks and radiofrequency. This prospective study aims to evaluate the efficacy of ultrasound-guided pulsed radiofrequency of suprascapular nerve for chronic shoulder pain in a clinical setting. Methods: Therapeutic efficacy was evaluated through pain intensity using numeric pain rating scale at baseline, immediately, 3, and 6 months after, and patient’s motor function improvement. The secondary outcome was patient satisfaction. Results: A total of 34 patients were enrolled and all patients presented a reduction in the numeric pain rating scale immediately after treatment. Pain reduction from baseline to 6 months after the procedure was 34.4% and 36.9% static and dynamic, respectively. The median percentage reduction was statistically significant immediately, 3 and 6 months after. There was also an improvement in range of motion, 39.6% in abduction, 24.1% in flexion, and 29.5% in extension. Ninety percent of patients reported patient’s global impression of change superior to six. Conclusion: This study concludes that ultrasound-guided pulsed radiofrequency of suprascapular nerve reduces pain intensity for at least 6 months, accompanied by improvement of motor function and higher levels of patients’ satisfaction. Therefore, this technique represents a valid analgesic approach to chronic shoulder pain. objectives life nonpharmacological non therapies ultrasoundguided ultrasound guided setting Methods s satisfaction Results treatment 344 4 34.4 369 36 9 36.9 dynamic respectively motion 396 39 39.6 abduction 241 24 1 24.1 flexion 295 29 5 29.5 extension six Conclusion Therefore 34. 36. 39. 2 24. 29.

Abstract Intracranial pial Arteriovenous Fistulas (AVFs) are rare cerebral vascular lesions composed of one or more arterial connections to a single venous channel. We report a 50-year-old patient with a ruptured pial AVF located in an eloquent area. Microsurgery for pial AVF occlusion was proposed with awake craniotomy for motor function and neurological evaluation. Awake craniotomy is a technique that is especially useful for cerebral vascular lesions in eloquent areas, where an occlusion often compromises or suppresses the blood supply, culminating in ischemia with consequent transient or definitive deficits in neurological function. AVFs (AVFs channel 50yearold yearold 50 year old area evaluation areas supply 5

Abstract Background and objective: Anesthesia induction can produce severe propofol dose-dependent hypotension. Fentanyl coadministration reduces the catecholaminergic response to orotracheal intubation allowing propofol dose reduction. The aim of this study is to determine whether the hemodynamic response is improved by increasing the time between fentanyl and propofol administration and reducing the dose of the latter without increasing the time to achieve optimal hypnosis. Methods: After approval by the Research Ethics Committee, patients undergoing non-cardiac surgery with endotracheal intubation were randomized by a computer-generated table into six time-dose groups (1 or 2 minutes/1, 1.5, or 2mg.kg-1 of propofol). Patients with high bronchoaspiration risk, a difficult airway, hemodynamic instability, or anesthetic allergies were excluded. After giving intravenous fentanyl (2 μg.kg-1 ), each group received different doses of propofol after 1 or 2 minutes. Non-invasive blood pressure (BP) and heart rate (HR) were measured at pre-induction, pre-intubation, and post-intubation. Time to hypnosis (bispectral index < 60) was also recorded. Results: Of the 192 recruited patients, 186 completed the study (1 min group n = 94; 2 min group n = 92). It was observed that HR and BP decreased after propofol administration and increased after intubation in all groups (p<0.0001). In patients over 55 years, the 2 min – 2 mg.kg-1 group showed the greatest systolic BP reduction (36 ± 12%) at pre-intubation, while the 1 min – 1.5 mg.kg-1 group showed the least hemodynamic alteration between pre- and post-intubation (-4 ± 13%). No significant differences were found in younger patients or in the time to reach hypnosis between the six groups. While no cases of severe bradycardia were recorded, 5,4% of the sample required vasopressors. Conclusion: Increasing the time between the administration of fentanyl and propofol by up to two minutes results in greater hypotension in patients over 55 years. objective dosedependent dependent Methods Committee noncardiac non cardiac computergenerated computer generated timedose ( minutes1 minutes/1 15 5 2mg.kg1 2mgkg1 mgkg 2mg.kg 2mg kg mg 2mg.kg- propofol. . propofol) risk airway instability excluded μg.kg1 μgkg1 μgkg μg.kg μg μg.kg- , ) Noninvasive Non invasive (BP (HR preinduction, preinduction pre induction, pre-induction preintubation, preintubation intubation, pre-intubation postintubation. postintubation post intubation. bispectral 60 recorded Results 19 18 94 92. 92 92) p<0.0001. p00001 p p<0.0001 0 0001 (p<0.0001) years mg.kg1 mgkg1 mg.kg mg.kg- 36 (3 12% 12 1. 4 (- 13%. 13 13% 13%) 54 5,4 vasopressors Conclusion minutes/ kg1 2mgkg 6 9 p0000 p<0.000 000 (p<0.0001 3 5, p000 p<0.00 00 (p<0.000 p00 p<0.0 (p<0.00 p0 p<0. (p<0.0 p<0 (p<0. p< (p<0 (p< (p

Abstract Background: Emergence Delirium (ED) is an essential condition in the immediate postoperative period. Systematic review and meta-analysis of randomized controlled trials have concluded that the effect of ketamine on postoperative delirium remains unclear. The present study sought to evaluate if the intraoperative use of ketamine for postoperative analgesia is associated with postoperative ED in laparoscopic surgeries. Methods: A prospective observational study was performed in the PostAnesthetic Care Unit (PACU) to evaluate patients who had undergone laparoscopic surgery under a rigid intraoperative anesthesia protocol from July 2018 to January 2019. Patients submitted to laparoscopic surgery for cholecystectomy, oophorectomy, or salpingectomy with a score ≥1 on the Richmond Assessment Sedation Scale (RASS) or ≥2 on the Nursing Delirium Screening Scale (Nu-DESC) were considered to have ED. t-test, Chi-Square test or Fisher’s exact tests were used for comparison. Results: One hundred and fifteen patients were studied after laparoscopic surgery. Seventeen patients (14.8%) developed ED, and the incidence of ED in patients who received ketamine was not different from that of other patients (18.3% vs. 10.6%, p = 0.262). Patients with ED had more postoperative pain and morphine requirement at the PACU (p = 0.005 and p = 0.025, respectively). Type of surgery (general surgery, OR = 6.4, 95% CI 1.2‒35.2) and postoperative pain (OR = 3.7, 95% CI 1.2‒11.4) were risk factors for ED. Conclusion: In this study, no association was found between ED and intraoperative administration of ketamine in laparoscopic surgeries. Type of surgery and postoperative pain were risk factors for ED. Background (ED period metaanalysis meta analysis unclear surgeries Methods (PACU 201 2019 cholecystectomy oophorectomy 1 ≥ RASS (RASS 2 NuDESC Nu DESC (Nu-DESC ttest, ttest t test, t-test ChiSquare Chi Square Fishers Fisher s comparison Results 14.8% 148 14 8 (14.8% 18.3% 183 18 3 (18.3 vs 106 10 6 10.6% 0.262. 0262 0.262 . 0 262 0.262) 0005 005 0.00 0025 025 0.025 respectively. respectively respectively) general 64 4 6.4 95 1.2‒35.2 12352 35 37 7 3.7 1.2‒11.4 12114 11 Conclusion 20 14.8 (14.8 18.3 (18. 10.6 026 0.26 26 000 00 0.0 002 02 0.02 6. 9 1.2‒35. 1235 3. 1.2‒11. 1211 14. (14. 18. (18 10. 0.2 0. 1.2‒35 123 1.2‒11 121 (14 (1 1.2‒3 12 1.2‒1 ( 1.2‒ 1.2 1.

Abstract Platypnea-orthodeoxia syndrome (POS) is a rare condition of positional hypoxemia and dyspnea. The following is a case of hypoxemia for no obvious reason in the perioperative scenario. A 70-year-old male patient was submitted to a radical prostatectomy. On several occasions after anesthetic induction, peripheral oxygen saturation decreased without any understandable cause. In the postanesthesia care unit, severe hypoxemia occurred in the upright position, oddly correcting with recumbency. An echocardiography showed a right-to-left intracardiac shunt through a patent foramen ovale with no pulmonary hypertension, establishing POS. Achieving this diagnosis required a broad workup with a high degree of suspicion. Platypneaorthodeoxia Platypnea orthodeoxia POS (POS dyspnea scenario 70yearold yearold 70 year old prostatectomy induction cause unit position recumbency righttoleft right left hypertension suspicion 7

Abstract Difficult airway management represents a major challenge, requiring a careful approach, advanced technical expertise, and accurate protocols. The task force of the Brazilian Society of Anesthesiology (SBA) presents a report with updated recommendations for the management of difficult airway in adults. These recommendations were developed based on the consensus of a group of expert anesthesiologists, aiming to provide strategies for managing difficulties during tracheal intubation. They are based on evidence published in international guidelines and opinions of experts. The report underlines the essential steps for proper difficult airway management, encompassing assessment, preparation, positioning, pre-oxygenation, minimizing trauma, and maintaining arterial oxygenation. Additional strategies for using advanced tools, such as video laryngoscopy, flexible bronchoscopy, and supraglottic devices, are discussed. The report considers recent advances in understanding crisis management, and the implementation seeks to further patient safety and improve clinical outcomes. The recommendations are outlined to be uncomplicated and easy to implement. The report underscores the importance of ongoing education, training in realistic simulations, and familiarity with the latest technologies available. challenge approach expertise protocols SBA (SBA adults anesthesiologists intubation experts assessment preparation positioning preoxygenation, preoxygenation pre oxygenation, oxygenation pre-oxygenation trauma tools laryngoscopy bronchoscopy devices discussed outcomes implement education simulations available

Abstract Introduction: Bone cancer metastasis may produce severe and refractory pain. It is often difficult to manage with systemic analgesics. Chemical neurolysis may be an effective alternative in terminally ill patients. Case report: Female terminally ill patient with hip metastasis of gastric cancer in severe pain. Neurolytic ultrasound-guided blocks of the pericapsular nerve group and obturator nerve were performed with 5% phenol. This led to satisfactory pain relief for 10 days, until the patient’s death. Discussion: This approach may be effective and safe as an analgesic option for refractory hip pain due to metastasis or pathologic fracture in terminally ill patients. Introduction analgesics patients report ultrasoundguided ultrasound guided 5 phenol 1 days s death Discussion

Abstract Background: The present study explored the role of continuous erector spinae plane (ESP) block for analgesia as well as its impact on pulmonary functions in patients with multiple rib fractures. Methods: Ten patients with multiple rib fractures were enrolled after getting informed and written consent. Ultrasound-guided ESP block was performed at the level midway between the fractured ribs followed by the insertion of the catheter. Pre- and post-block VAS score, hemodynamics, respiratory rate (RR), peripheral oxygen saturation (SpO2), inspiratory capacity (IC), blood gases (PaO2 and PCO2), and complications were compared. Results: Pain scores at rest as well as on movement showed a significant reduction from 5.9 and 7.5 pre block to 1.6 and 2.5 respectively at 96 hours (p < 0.0001). Similarly, RR, SpO2, IC, and PaO2 were significantly better after the block placement (p < 0.001). Conclusion: Continuous ESP block provide adequate analgesia with better respiratory functions in patients with multiple rib fractures. Background (ESP Methods consent Ultrasoundguided Ultrasound guided catheter Pre postblock post score hemodynamics RR , (RR) SpO2 SpO (SpO2) IC (IC) PaO (PaO PCO2, PCO2 PCO PCO2) compared Results 59 5 9 5. 75 7 7. 16 1 6 1. 25 2 2. p 0.0001. 00001 0.0001 . 0 0001 0.0001) Similarly 0.001. 0.001 001 0.001) Conclusion (RR (SpO2 (IC 0000 0.000 000 0.00 00 (SpO 0.0 0.

Abstract Background: We tested the hypothesis that, within the margin of 15% of risk difference, palonosetron is not inferior to ondansetron in reducing the incidence of postoperative nausea and vomiting (PONV) in laparoscopic cholecystectomy. Methods: We conducted a double-blind, non-inferiority, randomized, controlled trial of 212 patients aged 18 to 65 years undergoing laparoscopic cholecystectomy under general anesthesia in two secondary care hospitals. Patients were randomly assigned to receive either palonosetron (0.075 mg) or ondansetron (8 mg) intravenously at induction of anesthesia. Ondansetron (8 mg) was also administered 8 and 16 hours postoperatively. All anesthetic and surgical procedures were standardized. Patients were evaluated for 24 hours postoperatively for the occurrence of PONV. Results: A high incidence of PONV was observed at 2–6 hours postoperatively, with a rate of 36.8% (95% confidence interval [CI] 28.2-46.3) in the palonosetron group, as compared to 43.4% (95% CI 34.4–52.9) in the ondansetron group. The risk difference (95% CI) between palonosetron and ondansetron for PONV was 0 (-10.9 to 10.9) at 0–2 hours, -6.6 (-19.4 to 6.5) at 2–6 hours, -0.9 (-11.0 to 9.2) at 6–12 hours, and -2.8 (-9.6 to 3.6) at 12–24 hours. There was no statistically significant difference between the palonosetron and ondansetron groups in the use of rescue medication (dimenhydrinate). There were no adverse events associated with the medications under study. Conclusion: Palonosetron is not inferior to ondansetron in patients at risk of PONV undergoing laparoscopic cholecystectomy, providing a good option for PONV prophylaxis, as it can be administered in a single dose. Background that 15 (PONV Methods doubleblind, doubleblind double blind, blind double-blind noninferiority, noninferiority non inferiority, inferiority non-inferiority randomized 21 1 6 hospitals 0.075 0075 075 (0.07 mg ( standardized 2 Results 26 2– 368 36 36.8 95% 95 (95 [CI 28.246.3 282463 28.2 46.3 28 46 3 28.2-46.3 group 434 43 4 43.4 34.4–52.9 344529 34 52 9 10.9 109 10 (-10. 02 0– 6.6 66 -6. 19.4 194 19 (-19. 6.5 5 0.9 09 -0. 11.0 110 11 (-11. 9.2 92 612 12 6–1 2.8 -2. 9.6 96 (-9. 3.6 1224 12–2 dimenhydrinate. dimenhydrinate . (dimenhydrinate) study Conclusion prophylaxis dose 0.07 007 07 (0.0 36. (9 246 28.246. 28246 282 28. 463 46. 28.2-46. 43. 34.4–52. 34452 10. (-10 6. -6 19. (-19 0. -0 11. (-11 9. 61 6– 2. -2 (-9 3. 122 12– (dimenhydrinate 0.0 00 (0. 28.246 2824 28.2-46 34.4–52 3445 (-1 - (- (0 28.24 28.2-4 34.4–5 344 28.2- 34.4– 34.4 34.