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 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 Background: Pediatric emergence delirium is characterized by a disturbance of a child’s awareness during the early postoperative period that manifests as disorientation, altered attention and perception. The incidence of emergence delirium varies between 18% and 80% depending on risk factors and how it is measured. Reports from Canada, Germany, Italy, United Kingdom, and France demonstrated a wide range of preventive measures and definitions, indicating that there is a lack of clarity regarding emergence delirium. We aimed to assess the practices and beliefs among Brazilian anesthesiologists regarding emergence delirium. Methods: A web-based survey was developed using REDCap®. A link and QR Code were sent by email to all Brazilian anesthesiologists associated with the Brazilian Society of Anesthesiology (SBA). Results: We collected 671 completed questionnaires. The majority of respondents (97%) considered emergence delirium a relevant adverse event. Thirty-two percent of respondents reported routinely administrating medication to prevent emergence delirium, with clonidine (16%) and propofol (15%) being the most commonly prescribed medications. More than 70% of respondents reported a high level of patient and parent anxiety, a previous history of emergence delirium, and untreated pain as risk factors for emergence delirium. Regarding treatment, thirty-five percent of respondents reported using propofol, followed by midazolam (26%). Conclusion: Although most respondents considered emergence delirium a relevant adverse event, only one-third of them routinely applied preventive measures. Clonidine and propofol were the first choices for pharmacological prevention. For treatment, propofol and midazolam were the most commonly prescribed medications.

Abstract Objective: Cognitive dysfunction may occur postoperatively. Fast and efficient assessment of Postoperative Cognitive Dysfunction (POCD) can minimize loss of quality of life, and therefore, a study comparing a digital game with standard neuropsychological tests to assess executive, mnemonic, and attention functions to evaluate POCD seems to be relevant both for research and clinical practice. Methods: A battery of standardized tests and a digital game (MentalPlus®) were administered to 60 patients at the Central Institute of Hospital das Clínicas in São Paulo (36 women and 24 men), with ages between 29 and 82 years, preand post-surgery performed under anesthesia. Correlation and linear regression model were used to compare the scores obtained from the standardized tests to the scores of the six executive and cognitive functions evaluated by the game (shortand long-term memory, selective and alternating attention, inhibitory control, and visual perception). Results: After correlation analysis, a statistically significant result was found mainly for the correlation between the scores from the phase of the digital game assessing the visuoperception function and the scores from the A and B cards of the Stroop Test (p < 0.001, r = 0.99 and r = 0.64, respectively), and the scores from TMTA (p = 0.0046, r = 0.51). We also found a moderate correlation between the phase of the game assessing short-memory function and VVLT (p < 0.001, r = 0.41). No statistically significant correlations were found for the other functions assessed. Conclusion: The digital game provided scores in agreement with standardized tests for evaluating visual perception and possibly short-term memory cognitive functions. Further studies are necessary to verify the correlation of other phases of the digital game with standardized tests assessing cognitive functions.

Abstract Objective: Postoperative cognitive dysfunction may result from worsening in a condition of previous impairment. It causes greater difficulty in recovery, longer hospital stays, and consequent delay in returning to work activities. Digital games have a potential neuromodulatory and rehabilitation effect. In this study, a digital game was used as a neuropsychological test to assess postoperative cognitive dysfunction, with preoperative patient performance as control. Methods: It was a non-controlled study, with patients selected among candidates for elective non-cardiac surgery, evaluated in the preand postoperative periods. The digital game used has six phases developed to evaluate selective attention, alternating attention, visuoperception, inhibitory control, short-term memory, and long-term memory. The digital game takes about 25 minutes. Scores are the sum of correct answers in each cognitive domain. Statistical analysis compared these cognitive functions preand post-surgery using a generalized linear mixed model (ANCOVA). Results: Sixty patients were evaluated, 40% male and 60% female, with a mean age of 52.7 ± 13.5 years. Except for visuoperception, a reduction in post-surgery scores was found in all phases of the digital game. Conclusion: The digital game was able to detect decline in several cognitive functions postoperatively. As its completion is faster than in conventional tests on paper, this digital game may be a potentially recommended tool for assessing patients, especially the elderly and in the early postoperative period.

Abstract Both robotic surgery and head-down tilt increase intracranial pressure by impairing venous blood outflow. Prostatectomy is commonly performed in elderly patients, who are more likely to develop postoperative cognitive disorders. Therefore, increased intracranial pressure could play an essential role in cognitive decline after surgery. We describe a case of a 69-year-old male who underwent a robotic prostatectomy. Noninvasive Brain4care™ intraoperative monitoring showed normal intracranial compliance during anesthesia induction, but it rapidly decreased after head-down tilt despite normal vital signs, low lung pressure, and adequate anesthesia depth. We conclude that there is a need for intraoperative intracranial compliance monitoring since there are major changes in cerebral compliance during surgery, which could potentially allow early identification and treatment of impaired cerebral complacency.

Abstract Background Anesthetic and/or opioid abuse is more prevalent among anesthesiologists than in other medical specialties and it has been associated with high mortality. The aim of this study was to evaluate factors associated with lethal anesthetic and/or opioid abuse among anesthesiologists. Methods We evaluated psychological factors, and occupational history and circumstances of death of anesthesiologists who died from anesthetic abuse. Data were obtained post-mortem from colleagues, and relatives. After finding eligible cases, we identified the key informants, who were interviewed personally or via email, through the qualitative method known as “Psychological Autopsy”. Results Eighteen cases of death were identified, but we were able to interview 44% of them (n = 8), most of whom were young males. They died at home or at the hospital and were found “at the scene”. Being an introspective person who did not share personal issues at workplace was the most prevalent personal characteristic. At work, they seemed to perform very well their functions, but some presented subtle changes such as to staying more than usual at the workplace and/or neglecting some of their responsibilities. The main reported factors to explain their substance abuse were emotional problems including psychiatric, excessive hours of work, and other health factors. Conclusion This study identified that emotional disturbances, compulsive work, and general health problems were the more prominent factors involved with those deaths. Further, larger studies are needed to better understand how these factors could be early identified in order to timely prevent anesthetic and/or opioid abuse and several deaths among anesthesiologists.