Abstract Diversion of substances from the care of the intended patient is a significant problem in healthcare. Patients are harmed by the undertreatment of pain and suffering, transmission of disease, as well as the risk associated with impaired vigilance. Healthcare providers may be harmed by the physical and mental impact of their addictions. Healthcare systems are placed in jeopardy by the legal impact associated with illegal routes of drug release including sanction and financial liability and loss of public trust. Healthcare institutions have implemented many measures to reduce diversion from the perioperative area. These efforts include education, medical record surveillance, automated medication dispensing systems, urine drug testing, substance waste management systems, and drug diversion prevention teams. This narrative review evaluates strengths, weaknesses, and effectiveness of these systems and provides recommendations for leaders and care providers. healthcare suffering disease vigilance addictions trust area education surveillance testing teams strengths weaknesses

Health professionals are encouraged to attend a residency period of two to seven years after graduating. The typical demands of this in-service training modality have been associated with reduced sleep quality, decreased exercise frequency, and detachment from family and social relationships, leading to an increased diagnosis of anxiety, depression, and burnout syndrome. Therefore, conducting a scoping review to identify strategies aimed at promoting mental health and wellbeing among residents from different health areas is essential to support any forthcoming preventive action.

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 The prevalence of Substance Use Disorders (SUD) and acceptance of drug testing among anesthetists in Brazil has not been determined. Methods An internet-based survey was performed to investigate the prevalence of SUD among anesthetists in Brazil, to explore the attitudes of anesthetists regarding whether SUD jeopardizes the health of an impaired provider or their patient, and to determine the provider's perspective regarding acceptance and effectiveness of drug testing to reduce SUD. The questionnaire was distributed via social media. REDCap was utilized to capture data. A sample size of 350 to achieve a confidence level of 95% and confidence interval of 5 was estimated. Study report was based on STROBE and CHERRIES statements. Results The survey was returned from 1,295 individuals. Most individuals knew an anesthesia provider with a SUD (82.07%), while 23% admitted personal use. The most common identified substances of abuse were opioids (67.05%). Very few respondents worked in a setting that performs drug testing (n = 17, 1.33%). Most individuals believed that drug testing could improve personal safety (82.83%) or the safety of patients (85.41%). Individuals with a personal history of SUD were less likely to believe in the effectiveness of drug testing to reduce one's own risk (74.92% vs. 85.18%, p< 0.0001) or improve the safety of patients (76.27% vs. 88.13%, p< 0.001). Conclusions SUDs are common among anesthetists in Brazil. Drug testing would be accepted as a viable means to reduce the incidence although a larger study should be performed to investigate the logistical feasibility.

JUSTIFICATIVA E OBJETIVOS: O uso de bloqueadores neuromusculares (BNM) na prática anestésica já tem mais de meio século e sempre foi um desafio para os anestesiologistas. Até bem pouco tempo a reversão dos bloqueadores neuromusculares adespolarizantes só possuia uma opção: a utilização de anticolinesterásicos. No entanto em algumas situações como na presença de bloqueio neuromuscular profundo após o uso de altas doses do relaxante, o uso de anticolinesterásicos não possibilita a adequada reversão do bloqueio neuromuscular. Recentemente uma ciclodextrina gama mostrou-se altamente eficaz para a reversão do BNM de agentes esteroidais, o sugamadex. RELATO DO CASO: Paciente do sexo feminino, submetida à laparotomia exploradora de emergência após intubação em sequência rápida com uso de rocurônio 1,2 mg.kg-1. Ao final da cirurgia a paciente foi descurarizada com neostigmina, no entanto a monitoração da junção neuromuscular não apresentou a recuperação esperada, revelando curarização residual. Foi utilizado sugamadex 2 mg.kg-1 e a paciente apresenta reversão completa do BNM em apenas 2 minutos. CONCLUSÃO: A adequada recuperação do bloqueio neuromuscular residual é necessária para o pleno controle das funções da faringe e respiratória, evitando assim complicações. A adequada recuperação só pode ser obtida através da monitoração da junção neuromuscular com uma relação de TOF acima de 0,9. Muitas vezes a reversão do BNM com o uso de anticolinesterásicos pode não reverter completamente o BNM, no entanto na ausência da monitoração objetiva este diagnóstico não é possível. O caso ilustra o diagnóstico de BNM residual mesmo após a reversão com anticolinesterásicos, resolvido com a administração de sugamadex, uma alternativa segura para a reversão dos BNM adespolarizantes esteroidais.

BACKGROUND AND OBJECTIVES: Neuromuscular blockers (NMB) have been used for more than half of a century in anesthesia and have always been a challenge for anesthesiologists. Until recently, the reversal of nondepolarizing neuromuscular blockers had only one option: the use of anticholinesterase agents. However, in some situations, such as deep neuromuscular blockade after high doses of relaxant, the use of anticholinesterase agents does not allow adequate reversal of neuromuscular blockade. Recently, sugammadex, a gamma-cyclodextrin, proved to be highly effective for reversal of NMB induced by steroidal agents. CASE REPORT: A female patient who underwent an emergency exploratory laparotomy after rapid sequence intubation with rocuronium 1.2 mg.kg-1. At the end of surgery, the patient received neostigmine reversal of NMB. However, neuromuscular junction monitoring did not show the expected recovery, presenting residual paralysis. Sugammadex 2 mg.kg-1 was used and the patient had complete reversal of NMB in just 2 minutes time. CONCLUSION: Adequate recovery of residual neuromuscular blockade is required for full control of the pharynx and respiratory functions in order to prevent complications. Adequate recovery can only be obtained by neuromuscular junction monitoring with TOF ratio greater than 0.9. Often, the reversal of NMB with anticholinesterase drugs may not be completely reversed. However, in the absence of objective monitoring this diagnosis is not possible. The case illustrates the diagnosis of residual NMB even after reversal with anticholinesterase agents, resolved with the administration of sugammadex, a safe alternative to reverse the NMB induced by steroidal non-depolarizing agents.

JUSTIFICATIVA Y OBJETIVOS: El uso de bloqueantes neuromusculares (BNM) en la práctica anestésica cuenta ya con más de medio y siempre fue un reto para los anestesiólogos. Hasta hace poco tiempo la reversión de los bloqueantes neuromusculares adespolarizantes solo tenía una opción: la utilización de antocolinesterásicos. Sin embargo, en algunas situaciones como en presencia de bloqueo neuromuscular profundo después del uso de altas dosis del relajante, el uso de anticolinesterásicos no posibilita la adecuada reversión del bloqueo neuromuscular. Recientemente una ciclodextrina gama mostró ser altamente eficaz para la reversión del BNM de agentes esteroidales, como el sugamadex. RELATO DE CASO: Paciente del sexo femenino, sometida a la laparotomía exploradora de emergencia después de la intubación en secuencia rápida con el uso de rocuronio 1,2 mg.kg-1. Al término de la operación, la paciente fue descurarizada con neostigmina, pero la monitorización de la junción neuromuscular no presentó la recuperación esperada, revelando la curarización residual. Fue utilizado sugamadex 2 mg.kg-1 y comprobamos que la paciente presenta una reversión completa del BNM en solamente 2 minutos. CONCLUSIONES: La correcta recuperación del bloqueo neuromuscular residual es necesaria para el pleno control de las funciones de la faringe y respiratoria, evitando así complicaciones. La adecuada recuperación solo puede obtenerse por medio de la monitorización de la junción neuromuscular con una relación de TOF por encima de 0,9. En muchas ocasiones, la reversión del BNM con el uso de anticolinesterásicos puede no revertir completamente el BNM, pero sin embargo en ausencia de la monitorización objetiva, ese diagnóstico no puede ser alcanzado. El caso ilustra el diagnóstico de BNM residual incluso después de la reversión con anticolinesterásicos, resuelto con la administración de sugamadex, una alternativa segura para la reversión de los BNM adespolarizantes esteroidales.

JUSTIFICATIVA E OBJETIVOS: Os aparelhos de anestesia vêm possibilitando reduzir repercussões fisiológicas e problemas causados por ventilação mecânica. O objetivo deste estudo foi avaliar, retrospectivamente, os métodos e recursos de suporte ventilatório utilizados por um grupo de anestesiologistas em pacientes sem lesão pulmonar prévia no período intraoperatório. MÉTODO: Um questionário anônimo, com 27 questões objetivas, foi aplicado em um grupo composto por médicos anestesiologistas e em especialização que atuam em diferentes hospitais privados na cidade de São Paulo. Os questionários foram aplicados em um período de 15 dias. Observaram-se os padrões ventilatórios, a pressão positiva ao final da expiração (PEEP), o recrutamento alveolar e o cálculo do volume-corrente empregado com intubação traqueal. RESULTADOS: Os participantes foram predominantemente do sexo masculino, 40,5% com título superior em Anestesiologia (TSA), e a maioria concluiu a especialização há menos de 10 anos. A maior parte dos anestesiologistas faz uso de PEEP rotineiramente, entre 5 e 10 cmH2O. Fluxo de gases frescos acima de 1.000 mL.min-1 ainda é utilizado pela maior parte dos anestesiologistas. Manobras de recrutamento alveolar são realizadas por 80% dos entrevistados, logo após a intubação e antes da desintubação, sendo a estratégia mais comum a insuflação com 40 cmH2O por 15 segundos. Quanto às estratégias protetoras de ventilação, apenas 30% utilizam volume-corrente < 7 mL.kg-1, com frações inspiradas de oxigênio entre 40% e 60%. CONCLUSÕES: Este estudo descritivo permite afirmar que, nos hospitais avaliados, grande parte dos anestesiologistas utiliza recursos visando minimizar eventual repercussão da ventilação controlada mecânica. Esses dados podem orientar o desenvolvimento de programas de educação médica continuada em ventilação mecânica associada à anestesia, visando à segurança e à melhora do atendimento ao paciente.

BACKGROUND AND OBJECTIVES: Anesthesia devices have been making it possible to reduce the physiological repercussions and problems caused by mechanical ventilation. The objective of this study was to evaluate, retrospectively, ventilatory methods and support resources used by a group of anesthesiologists in patients without prior lung damage in the intraoperative period. METHODS: A non-identifiable questionnaire composed of 27 questions was applied to a group of anesthesiologists and anesthesiology residents who work at different private hospitals in the city of São Paulo. The questionnaires were applied over a 15-day period. Ventilation patterns, positive end-expiratory pressure (PEEP), alveolar recruitment maneuvers, and the calculation of the tidal volume used with tracheal intubation were observed. RESULTS: Participants were predominantly males, 40.5% bearing the Anesthesiology Superior Title (TSA), and the majority concluded their residency less than 10 years ago. Most anesthesiologists used PEEP, between 5 and 10 cmH2O, routinely. Fresh gas flow above 1,000 mL.min-1 is still used by most anesthesiologists. Alveolar recruitment maneuvers were performed by 80% of those interviewed, shortly after intubation and before removing the ET tube with the most common strategy insufflation with 40 cmH2O for 15 seconds. As for strategies to protect ventilation, only 30% used a tidal volume with less than 7 mL.kg-1 with inspired oxygen fraction between 40% and 60%. CONCLUSIONS: This descriptive study allows us to state that in the hospitals evaluated the majority of anesthesiologists uses resources to minimize eventual repercussions of controlled mechanical ventilation. This data can orient the development of continuing medical education programs in mechanical ventilation associated with anesthesia aiming to safety and improvement of patient care.

JUSTIFICATIVA Y OBJETIVOS: Los aparatos de anestesia han venido posibilitando la reducción de las repercusiones fisiológicas y de los problemas causados por la ventilación mecánica. El objetivo de este estudio fue evaluar de forma retrospectiva, los métodos y los recursos de ayuda ventilatoria utilizados por un grupo de anestesiólogos en pacientes sin lesión pulmonar previa en el período intraoperatorio. MÉTODO: Un cuestionario no identificado, con 27 preguntas objetivas, se aplicó a un grupo compuesto por médicos anestesiólogos y en especialización que actúan en diferentes hospitales privados en la ciudad de São Paulo. Los cuestionarios se aplicaron en un período de 15 días. Se observaron los estándares ventilatorios, la presión positiva al final de la expiración (PEEP), el reclutamiento alveolar y el cálculo del volumen corriente que se usó con intubación traqueal. RESULTADOS: Los participantes fueron predominantemente del sexo masculino, un 40,5% con título superior en Anestesiología (TSA), y la mayoría que terminó la especialización hace menos de 10 años. La mayor parte de los anestesiólogos utiliza el PEEP como rutina, entre 5 y 10 cmH2O. Gran parte de los anestesiólogos todavía usa el flujo de gases frescos por encima de 1000 mL.min-1. Las maniobras de reclutamiento alveolar son hechas por un 80% de los entrevistados después de la intubación y antes de la retirada de los tubos, siendo la estrategia más común la insuflación con 40 cmH2O por 15 segundos. En cuanto a las estrategias protectoras de ventilación, apenas 30% utilizan volumen corriente < 7 mL.kg-1, con fracciones inspiradas de oxígeno entre 40 y 60%. CONCLUSIONES: Este estudio descriptivo permite afirmar que en los hospitales evaluados, gran parte de los anestesiólogos utiliza recursos para minimizar una eventual repercusión de la ventilación controlada mecánica. Esos datos pueden orientar el desarrollo de programas de educación médica continua en ventilación mecánica, asociada a la anestesia para garantizar así la seguridad y la mejoría de la atención al paciente.