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Bloqueio do nervo supraclavicular e do tronco superior para tratamento cirúrgico de fratura de clavícula em paciente portador de doença de Steinert – Relato de caso

Leonardo Diniz Correa Pinto, Cláudia Helena Ribeiro Da Silva, Pedro Marcos Silva E Gonçalves, Roberto José Valadares

Publication date: Available online 6 October 2018

Source: Brazilian Journal of Anesthesiology

Author(s): Leonardo Diniz Correa Pinto, Cláudia Helena Ribeiro da Silva, Pedro Marcos Silva e Gonçalves, Roberto José Valadares

Resumo
Justificativa e objetivos

Bloqueios seletivos dos membros superiores guiados por ultrassom podem trazer grandes benefícios em pacientes portadores de doenças graves. Pacientes portadores da doença de Steinert apresentam fraqueza muscular e riscos de desencadear miotonia ou hipertermia maligna devido ao uso de agentes anestésicos e ao estresse cirúrgico. O objetivo deste relato foi mostrar uma opção viável para a cirurgia de fratura de clavícula com bloqueio do tronco superior e nervo supraclavicular, diminui‐se assim a dispersão do anestésico local para o nervo frênico em paciente com distrofia muscular.

Relato de caso

Paciente do sexo masculino, 53 anos, portador de doença de Steinert, associada a dispneia, rouquidão e disfagia. Encaminhado ao bloco cirúrgico para osteossíntese de fratura de clavícula. Feito bloqueio de tronco superior (1 mL ropivacaína a 0,75%) e de nervo supraclavicular (1 mL de ropivacaína 0,75 em cada ramificação) associado à anestesia venosa com propofol sob máscara laríngea (alvo de 4 mcg.mL‐1 em bomba de infusão). Ao despertar, o paciente apresentava‐se sem dor ou queixas respiratórias. Admitido em CTI para acompanhamento do pós‐operatório imediato com alta dessa unidade após 24 horas sem intercorrências.

Conclusões

O bloqueio do tronco superior e do plexo cervical associado à anestesia venosa sob máscara laríngea, sem uso de opioides, mostrou‐se adequado no caso de fratura da clavícula em paciente com doença de Steinert. Com o uso da ultrassonografia em anestesia regional é possível fazer bloqueios cada vez mais seletivos e possibilitar assim maior segurança para o procedimento anestésico‐cirúrgico e menor morbidade para o paciente.

Abstract
Background and objectives

Ultrasound‐guided upper limb blocks may provide great benefits to patients with serious diseases. Patients with Steinert's disease have muscle weakness and risk of triggering myotony or malignant hyperthermia due to the use of anesthetic agents and surgical stress. The objective of this report was to demonstrate a viable alternative for clavicle fracture surgery with upper trunk and supraclavicular nerve block, thus reducing the spread of local anesthetic to the phrenic nerve in a patient with muscular dystrophy.

Case report

A 53‐year‐old male patient with Steinert's disease, associated with dyspnea, hoarseness and dysphagia, referred to the surgical theater for osteosynthesis of clavicle fracture. Upper limb (1 mL 0.75% ropivacaine) and supraclavicular nerve block (1 mL 0.75% ropivacaine in each branch) were combined with venous anesthesia with propofol under laryngeal mask (infusion pump target of 4 mcg.Ml‐1). Upon awakening, the patient had no pain or respiratory complaints. He was transferred to the ICU for immediate postoperative follow‐up with discharge from this unit after 24 hours without complications.

Conclusions

The superior trunk and cervical plexus block associated with venous anesthesia under laryngeal mask, without the use of opioids, proved to be adequate in the case of a patient with clavicle fracture and Steinert's disease. With the use of ultrasonography in regional anesthesia it is possible to perform increasingly selective blocks, thus allowing greater security for the anesthetic‐surgical procedure and lower morbidity for the patient.

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