Abstract Difficult airway management in pediatrics during anesthesia 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 containing updated recommendations for the management of difficult airways in children and neonates. These recommendations have been developed based on the consensus of a panel of experts, with the objective of offering strategies to overcome challenges during airway management in pediatric patients. Grounded in evidence published in international guidelines and expert opinions, the report highlights crucial steps for the appropriate management of difficult airways in pediatrics, encompassing assessment, preparation, positioning, pre-oxygenation, minimizing trauma, and, paramountly, the maintenance of arterial oxygenation. The report also delves into additional strategies involving the use of advanced tools, such as video laryngoscopy, flexible intubating bronchoscopy, and supraglottic devices. Emphasis is placed on the simplicity of implementing the outlined recommendations, with a focus on the significance of continuous education, training through realistic simulations, and familiarity with the latest available technologies. These practices are deemed essential to ensure procedural safety and contribute to the enhancement of anesthesia outcomes in pediatrics. challenge approach expertise protocols SBA (SBA neonates experts patients opinions assessment preparation positioning preoxygenation, preoxygenation pre oxygenation, oxygenation pre-oxygenation trauma paramountly tools laryngoscopy bronchoscopy devices education simulations technologies

RESUMO Objetivo: O principal objetivo deste estudo foi comparar os níveis de estresse e ansiedade em crianças submetidas a procedimentos cirúrgicos com ou sem presença dos pais na indução da anestesia, medindo os níveis de cortisol salivar e aplicando o mYPAS. Método: Ensaio quaserandomizado com crianças de 5 a 12 anos, com estado físico ASA I, II ou III, submetidas a cirurgia eletiva. De acordo com a disposição dos pais, o par foi definido como grupo acompanhado ou não acompanhado. Foram utilizados testes de qui-quadrado, exato de Fisher, t de Student, Mann-Whitney, Hodges-Lehman e Spearman para as análises estatísticas. Resultados: Foram incluídas 46 crianças; 63% delas em idade préescolar, principalmente acompanhadas por suas mães (80%). A pontuação mYPAS mediana foi de 37,5 (intervalo interquartil, 23,4–51,6) em crianças não acompanhadas e de 55,0 (intervalo interquartil, 27,9–65,0) em crianças acompanhadas, com uma diferença mediana estimada de +11,8 (IC de 95% de 0 a 23,4; p = 0,044). Não houve diferenças significativas nos níveis médios de cortisol salivar. Conclusão: O nível de ansiedade foi maior em crianças acompanhadas. Não houve diferenças nos níveis de cortisol salivar entre os dois grupos. Registro Brasileiro de Ensaios Clínicos (ReBEC):RBR-9wj4qvy. Objetivo anestesia Método 1 anos I III eletiva quiquadrado, quiquadrado qui quadrado, quadrado qui-quadrado Fisher Student MannWhitney, MannWhitney Mann Whitney, Whitney Mann-Whitney HodgesLehman Hodges Lehman estatísticas Resultados 4 63 préescolar 80%. 80 80% . (80%) 375 37 37, intervalo interquartil 23,4–51,6 234516 23 51 6 550 55 55, 27,9–65,0 279650 27 9 65 118 11 8 +11, IC 95 23,4 234 0,044. 0044 0,044 044 0,044) Conclusão grupos ReBECRBR9wj4qvy. ReBECRBR9wj4qvy ReBECRBRwjqvy ReBEC RBR 9wj4qvy. 9wj4qvy wj qvy (ReBEC):RBR-9wj4qvy (80% 3 23,4–51, 23451 2 27,9–65, 27965 +11 23, 004 0,04 04 ReBECRBR wjqvy (80 23,4–51 2345 27,9–65 2796 +1 00 0,0 (8 23,4–5 27,9–6 279 + 0, ( 23,4– 27,9– 27,9 27,

ABSTRACT Objective: The main objective of this study was to compare stress and anxiety levels in children undergoing surgical procedures with or without parental presence at induction of anesthesia by measuring salivary cortisol levels and applying the mYPAS. Method: Quasi-randomized trial with children aged 5–12 year, with ASA physical status I, II, or III, undergoing elective surgery. According to parents’ willingness, the pair were defined as accompanied or unaccompanied group. Chi-square, Fisher’s exact tests, Student’s t test, Mann-Whitney, Hodges-Lehman and Spearman’s tests were used for statistical analyzes. Results: We included 46 children; 63% were preschool children mostly accompanied by their mothers (80%). The median mYPAS score was 37.5 (quartile range, 23.4–51.6) in unaccompanied children, and 55.0 (quartile range, 27.9–65.0) in accompanied children, with an estimated median difference of +11.8 (95% CI of 0 to 23.4; p = 0.044). There were no significant differences in the mean salivary cortisol levels. Conclusion: The level of anxiety was higher in accompanied children. There were no differences in salivary cortisol levels between both groups. Brazilian Registry of Clinical Trials (ReBEC):RBR-9wj4qvy. Objective Method Quasirandomized Quasi randomized 512 5 12 5–1 year I II III surgery parents willingness group Chisquare, Chisquare Chi square, square Chi-square Fishers Fisher s Students Student test MannWhitney, MannWhitney Mann Whitney, Whitney Mann-Whitney HodgesLehman Hodges Lehman Spearmans Spearman analyzes Results 4 63 80%. 80 80% . (80%) 375 37 37. quartile range 23.4–51.6 234516 23 51 6 550 55 55. 27.9–65.0 279650 27 9 65 118 11 8 +11. 95% 95 (95 23.4 234 0.044. 0044 0.044 044 0.044) Conclusion groups ReBECRBR9wj4qvy. ReBECRBR9wj4qvy ReBECRBRwjqvy ReBEC RBR 9wj4qvy. 9wj4qvy wj qvy (ReBEC):RBR-9wj4qvy 1 5– (80% 3 23.4–51. 23451 2 27.9–65. 27965 +11 (9 23. 004 0.04 04 ReBECRBR wjqvy (80 23.4–51 2345 27.9–65 2796 +1 ( 00 0.0 (8 23.4–5 27.9–6 279 + 0. 23.4– 27.9– 27.9 27.

RESUMEN Objetivo: El objetivo principal de este estudio fue comparar los niveles de estrés y ansiedad en niños sometidos a procedimientos quirúrgicos con o sin presencia de los padres en la inducción de la anestesia mediante la medición de los niveles de cortisol salival y la aplicación del mYPAS. Método: Ensayo cuasi-aleatorio con niños de 5 a 12 años, con estado físico ASA I, II o III, sometidos a cirugía electiva. Según la disposición de los padres, se definieron como grupo acompañado o no acompañado. Se utilizaron pruebas de chi-cuadrado, exacta de Fisher, t de Student, Mann-Whitney, Hodges-Lehman y Spearman para los análisis estadísticos. Resultados: Se incluyeron 46 niños; el 63% eran niños en edad preescolar, en su mayoría acompañados por sus madres (80%). La puntuación mYPAS mediana fue de 37,5 (rango intercuartílico, 23,4–51,6) en niños no acompañados y de 55,0 (rango intercuartílico, 27,9–65,0) en niños acompañados, con una diferencia mediana estimada de +11,8 (IC del 95% de 0 a 23,4; p = 0,044). No hubo diferencias significativas en los niveles medios de cortisol salival. Conclusión: El nivel de ansiedad fue mayor en los niños acompañados. No hubo diferencias en los niveles de cortisol salival entre ambos grupos. Registro Brasileño de Ensayos Clínicos (ReBEC):RBR-9wj4qvy. Objetivo Método cuasialeatorio cuasi aleatorio 1 años I III electiva chicuadrado, chicuadrado chi cuadrado, cuadrado chi-cuadrado Fisher Student MannWhitney, MannWhitney Mann Whitney, Whitney Mann-Whitney HodgesLehman Hodges Lehman estadísticos Resultados 4 63 preescolar 80%. 80 80% . (80%) 375 37 37, rango intercuartílico 23,4–51,6 234516 23 51 6 550 55 55, 27,9–65,0 279650 27 9 65 118 11 8 +11, IC 95 23,4 234 0,044. 0044 0,044 044 0,044) Conclusión grupos ReBECRBR9wj4qvy. ReBECRBR9wj4qvy ReBECRBRwjqvy ReBEC RBR 9wj4qvy. 9wj4qvy wj qvy (ReBEC):RBR-9wj4qvy (80% 3 23,4–51, 23451 2 27,9–65, 27965 +11 23, 004 0,04 04 ReBECRBR wjqvy (80 23,4–51 2345 27,9–65 2796 +1 00 0,0 (8 23,4–5 27,9–6 279 + 0, ( 23,4– 27,9– 27,9 27,

Abstract Background There are few studies related to Coronavirus Disease 2019 (COVID-19) on the prevalence and nature of pain symptoms after hospital discharge, especially in individuals who develop moderate to severe disease forms. Therefore, this study aimed to evaluate the presence of chronic pain in patients discharged after hospitalization for COVID-19, and the relationship between the presence of chronic pain and intensive care stay, demographics, and risk factors for the worst Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) outcome. Methods A cross-sectional observational study was carried out on patients with COVID-19 who recovered after hospitalization. Patients were recruited at the least 3 months after discharge and their hospital's health files were prospected. The variables evaluated were demographics, the severity of SARS-CoV-2 infection (considering the need for intensive care), and the presence of chronic pain. The results were shown in a descriptive manner, and multivariate analysis expressed as Odds Ratios (ORs) and respective Confidence Intervals (CIs) for the outcomes studied. Statistical significance was set at p < 0.05. Results Of 242 individuals included, 77 (31.8%) reported chronic pain related to COVID-19, with no correlation with the severity of infection. Female sex and obesity were associated with a higher risk for chronic pain with ORs of 2.69 (Confidence Interval [95% CI 1.4 to 5.0]) and 3.02 (95% CI 1.5 to 5.9). The limbs were the most affected areas of the body. Conclusion Chronic pain is common among COVID-19 survivors treated in hospital environments. Female sex and obesity are risk factors for its occurrence. 201 COVID19 COVID 19 (COVID-19 forms Therefore COVID19, 19, stay demographics SARSCoV2 SARSCoV SARS CoV (SARS-CoV-2 outcome crosssectional cross sectional COVID-1 hospitals s prospected SARS-CoV- considering care, , care) manner (ORs CIs (CIs studied 005 0 05 0.05 24 included 7 31.8% 318 31 8 (31.8% 269 69 2.6 95% 95 [95 14 1 4 1. 5.0 50 5 5.0] 302 02 3.0 (95 15 5.9. 59 5.9 . 9 5.9) body environments occurrence 20 COVID1 (COVID-1 (SARS-CoV- COVID- SARS-CoV 00 0.0 31.8 (31.8 26 6 2. [9 5. 30 3. (9 (COVID- (SARS-CoV 0. 31. (31. [ ( (COVID (31 (3

Abstract There is growing interest in using cannabinoids across various clinical scenarios, including pain medicine, leading to the disregard of regulatory protocols in some countries. Legislation has been implemented in Brazil, specifically in the state of São Paulo, permitting the distribution of cannabinoid products by health authorities for clinical purposes, free of charge for patients, upon professional prescription. Thus, it is imperative to assess the existing evidence regarding the efficacy and safety of these products in pain management. In light of this, the São Paulo State Society of Anesthesiology (SAESP) established a task force to conduct a narrative review on the topic using the Delphi method, requiring a minimum agreement of 60% among panelists. The study concluded that cannabinoid products could potentially serve as adjuncts in pain management but stressed the importance of judicious prescription. Nevertheless, this review advises against their use for acute pain and cancer-related pain. In other clinical scenarios, established treatments should take precedence, particularly when clinical protocols are available, such as in neuropathic pain. Only patients exhibiting poor therapeutic responses to established protocols or demonstrating intolerance to recommended management may be considered as potential candidates for cannabinoids, which should be prescribed by physicians experienced in handling these substances. Special attention should be given to individual patient characteristics and the likelihood of drug interactions. scenarios medicine countries Brazil purposes prescription Thus SAESP (SAESP method 60 panelists Nevertheless cancerrelated cancer related precedence available substances interactions 6

Abstract The International Association for the Study of Pain chose pain prevention as the theme for the 2020 Global Year. Chronic postoperative pain is one the many types of pain that can be potentially prevented. It develops or increases in severity after a surgery, persists for at least three months, even after ruling out all other possible causes of pain. To perform the present narrative review, the authors searched the PubMed database using the following keywords “postoperative pain” OR “postsurgical pain” AND “chronic” OR “persistent”. The present review focused on the incidence, pain development and chronification, and predisposing factors. It also discusses prevention, diagnosis, and treatment of chronic postoperative pain. Awareness of occurrence of chronic postoperative pain and recognizing risk factors is crucial for the day-to-day practice of the anesthesiologist. Hence, numerous surgical patients can have their outcome improved by preventing chronic postoperative pain, a condition scarcely identified and without a well-established treatment.

Abstract Background and aims: Rocuronium may provide excellent onset time, but high doses are required for effective action. Several strategies have managed to shorten rocuronium onset time, including the use of Magnesium Sulphate (MgSO4). Methods: One hundred and eighty patients were randomized into six groups according to rocuronium dose received (0.3, 0.6 or 1.2 mg.kg-1) and the administration of saline or MgSO4 (60 mg.kg-1). Correlations between tissue perfusion and rocuronium onset time was determined by variations in perfusion index. Results: Median (quartiles) rocuronium onset times were 85.5 (74.0–92.0); 76.0 (52.0–87.0) and 50.0 (41.0–59.5) seconds for 0.3, 0.6 mg.kg-1 and 1.2 mg.kg-1 doses, respectively. MgSO4 decreased rocuronium onset at doses of 0.3 mg.kg-1 (60.0 [48.0–74.3] seconds) and 0.6 mg.kg-1 (44.0 [39.0–49.0] seconds) but not at 1.2 mg.kg-1 (38.0 [33.5–56.3] seconds) (p< 0.001). Perfusion index variations in groups that received MgSO4 were greater than in controls. A negative correlation between shorten onset and increased perfusion index was observed in rocuronium doses of 0.3 mg.kg-1 (r = -0.50; p < 0.001) and 0.6 mg.kg-1 (r = -0.424; p< 0.001), but not for 1.2 mg.kg-1 dose (r = -0.25; p = 0.07). Conclusion: MgSO4 reduces rocuronium onset time at doses of 0.3 mg.kg-1 and 0.6 mg.kg-1 being that the latter has a similar effect when compared to the dose of 1.2 mg.kg-1, with or without the use of MgSO4.

Resumo Justificativa e objetivos: Os avanços da medicina, incluindo a anestesiologia e reanimação, têm tornado cada vez mais rara a ocorrência da morte natural. Como consequência, as práticas de distanásia se tornaram habituais em uma realidade que não mais se justifica. Este estudo objetiva avaliar o conhecimento de anestesiologistas brasileiros dos institutos da distanásia e ortotanásia. Para tal, investigamos as preferências de condutas desses profissionais, dentre aquelas práticas, bem como a contribuição da graduação médica na abordagem das questões relacionadas à morte. Método: Coorte prospectivo, descritivo, com abordagem quantitativa, com a inclusão de 150 anestesiologistas inscritos na Sociedade Brasileira de Anestesiologia e que foram convidados a participar por mensagem de e-mail. Aplicou-se questionário online, contendo 38 questões, elaborado pelos pesquisadores. A pesquisa foi aprovada pela Comissão de Ética em Pesquisa instrucional. Resultados: Os anestesiologistas, embora afirmem conhecer a distanásia e a ortotanásia, em sua maioria adquiriram esse conhecimento fora da graduação. Diante da terminalidade do próprio entrevistado, do seu paciente ou de um ente querido, prefere a ortotanásia, a morte em casa, priorizando a dignidade. Entretanto, esses especialistas afirmam já terem praticado, contrariados, a distanásia, mesmo quando a ortotanásia era a melhor conduta, o que lhes gerou sentimentos negativos. Quase a integralidade dos entrevistados afirmou não ter tido, na graduação, treinamento prático de conduta frente à terminalidade, embora se sinta capaz de identificá-la. A maioria não conhece a Resolução do Conselho Federal de Medicina 1.805/06 que viabiliza a prática da ortotanásia. Não há influência da religião e da região político-administrativa de residência do anestesiologista sobre as suas preferências. Conclusões: Os anestesiologistas afirmam ter conhecimento sobre distanásia e ortotanásia e preferem, diante da terminalidade, praticar a ortotanásia, embora a distanásia seja habitual, o que resulta em frustração e indignação. O ensino da graduação médica é deficitário em questões relacionadas à morte.

Abstract Background and objectives: Advances in medicine, including anesthesiology and resuscitation, have made natural death increasingly rare. As a consequence, dysthanasia has become usual in a scenario for which there is not rationale. The present study aimed to assess the level of knowledge of Brazilian anesthesiologists on the principles of dysthanasia and orthothanasia. Thence, we studied the management preferences of these professionals, vis-à-vis those practices, as well as how medical school contributed to addressing death-related issues. Method: Quantitative approach, prospective and descriptive cohort that included 150 anesthesiologists, members of the Brazilian Society of Anesthesiology, and who were invited to participate by email. An online questionnaire containing 38 questions was prepared by the authors. The study was approved by the Instructional Research Ethics Committee. Results: Anesthesiologists, although claiming to know dysthanasia and orthothanasia, mostly acquired knowledge outside medical school. If faced with their own end of care, or of a patient or a loved one, they prefer orthothanasia, to die at home, prioritizing dignity. However, the specialists claimed to have already practiced dysthanasia, even when orthothanasia was the choice management, which caused them negative feelings. Almost all respondents stated that they did not have practical training in undergraduate school on how to face end-of-life issues, although they felt capable of identifying it. Most were not aware of the Brazilian Federal Council of Medicine Resolution 1.805/06 that makes practicing orthothanasia feasible. Anesthesiologists’ religion or the political-administrative region of residence had no effect on their preferences. Conclusions: Anesthesiologists claim to have knowledge on dysthanasia and orthothanasia, but prefer, in the face of a terminally ill patient, to practice orthothanasia, although dysthanasia is usual, and results in frustration and indignation. The medical school curriculum is unsatisfactory in addressing death-related issues.

Resumo Justificativa e objetivos: Há poucos dados na literatura que caracterizam o padrão de uso de analgésicos na América Latina e no Brasil. Também se sabe pouco sobre o subtratamento da dor e sua influência no hábito de automedicação analgésica. O objetivo desta pesquisa é definir o padrão de uso de analgésicos entre os portadores de dor crônica (DC) e a sua potencial associação à automedicação analgésica. Método: Estudo observacional transversal com amostra de população urbana. A dor crônica foi definida como aquela presente por pelo menos 90 dias. A pesquisa foi aprovada pelo Comitê de Ética em Pesquisa institucional. Resultados: Foram incluídos 416 indivíduos; 45,7% (n = 190) portadores de dor crônica, sendo os do sexo feminino (72,3%; p = 0,04) os mais acometidos. A automedicação analgésica é praticada por 78,4% dos portadores de dor crônica. O tratamento analgésico vigente mais frequente é composto pelos anti-inflamatórios não esteroides (AINES), dipirona e paracetamol. Os opioides fracos são pouco usados e apenas 2,6% dos indivíduos com dor crônica fazem uso desses analgésicos. Nenhum dos indivíduos estava em uso de opioides potentes. Conclusões: A prática de automedicação analgésica é frequente entre os portadores de dor crônica, o que pode ser consequência da pouca prescrição de analgésicos mais potentes, como os opioides. Pode-se também dizer que, pelos dados apresentados, não ocorre uma crise de uso recreativo de opioides na população estudada.

Abstract Background and objectives: There are few data in the literature characterizing the pattern of analgesic use in Latin American countries, including Brazil. Little is known about the undertreatment of pain and its influence on the habit of self-medication with analgesics. The aim of this study is to define the pattern of analgesic use among chronic pain patients and its potential association with self-medication with analgesics. Method: Cross-sectional observational study with an urban population sample. Chronic pain was defined as a pain lasting for at least 90 days. The study was approved by the Research Ethics Committee of the institution. Results: 416 subjects were included; 45.7 % (n = 190) had chronic pain, with females (72.3 %; p = 0.04) being the most affected. Self-medication with analgesics is practiced by 78.4% of patients with chronic pain. The most common current analgesic treatment consists of non-steroidal anti-inflammatory drugs (dipyrone and acetaminophen). Weak opioids are rarely used and only 2.6% of subjects with chronic pain were taking these analgesics. None of the subjects were taking potent opioids. Conclusions: The practice of self-medication with analgesics is frequent among patients with chronic pain, which may be due to the underprescription of more potent analgesics, such as opioids. It can also be said that, given the data presented, there is no crisis of recreational opioid use in the studied population.