{"id":4801,"date":"2022-07-01T13:57:49","date_gmt":"2022-07-01T13:57:49","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/?p=4801"},"modified":"2022-11-29T13:58:42","modified_gmt":"2022-11-29T13:58:42","slug":"anestesia-topica","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/anestesia-topica\/","title":{"rendered":"Anestesia t\u00f3pica das vias a\u00e9reas superiores"},"content":{"rendered":"\n

A anestesia t\u00f3pica das vias a\u00e9reas superiores para realiza\u00e7\u00e3o de endoscopia alta \u00e9 um procedimento muito utilizado no dia a dia, e que devemos estar familiarizados. Na maioria dos casos, n\u00e3o h\u00e1 necessidade de um bloqueio sensitivo profundo dessa regi\u00e3o, mas existem situa\u00e7\u00f5es em que a endoscopia deve ser realizada com paciente acordado devido ao risco de broncoaspira\u00e7\u00e3o.<\/p>\n\n\n\n

A seguir, resumimos alguns conceitos importantes que todo endoscopista deve estar familiarizado a respeito da nesstesia t\u00f3pica.<\/p>\n\n\n\n

O benef\u00edcio da aplica\u00e7\u00e3o da anestesia t\u00f3pica em pacientes submetidos a seda\u00e7\u00e3o com propofol \u00e9 question\u00e1vel<\/strong>.<\/h2>\n\n\n\n

Se a anestesia t\u00f3pica resulta em menos desconforto para os pacientes com seda\u00e7\u00e3o moderada \u00e9 incerto. <\/p>\n\n\n\n

Em uma meta-an\u00e1lise incluindo 491 pacientes submetidos \u00e0 endoscopia, os pacientes submetidos \u00e0 anestesia t\u00f3pica relataram menos desconforto em compara\u00e7\u00e3o com o grupo sem anestesia t\u00f3pica (raz\u00e3o de chances [OR] 1,88, IC 95% 1,13-3,12). <\/p>\n\n\n\n

No entanto, outros estudos sugerem que, para pacientes submetidos \u00e0 seda\u00e7\u00e3o com propofol, n\u00e3o foram observadas diferen\u00e7as nas respostas som\u00e1ticas ou reflexo de engasgo em compara\u00e7\u00e3o com placebo.<\/p>\n\n\n\n

Est\u00e1 indicada em casos de risco de broncoaspira\u00e7\u00e3o, em suspeita de est\u00f4mago cheio e recusa do paciente \u00e0 seda\u00e7\u00e3o. Entretanto podem ser utilizados f\u00e1rmacos com o objetivo de atingir ansi\u00f3lise ou seda\u00e7\u00e3o consciente para maior conforto<\/strong>.<\/h2>\n\n\n\n

Al\u00e9m das situa\u00e7\u00f5es em que \u00e9 evidente a presen\u00e7a de est\u00f4mago cheio, s\u00e3o considerados fatores de risco para est\u00f4mago cheio e broncoaspira\u00e7\u00e3o: diabetes descompensado, uremia, obstru\u00e7\u00e3o intestinal, ascite, distens\u00e3o abdominal, dist\u00farbios da motilidade esof\u00e1gica, entre outros. Nestes casos, est\u00e1 contraindicada a seda\u00e7\u00e3o moderada e profunda, j\u00e1 que podem abolir o reflexo de tosse e de prote\u00e7\u00e3o das vias a\u00e9reas inferiores, podendo ocorrer broncoaspira\u00e7\u00e3o em caso de regurgita\u00e7\u00e3o de conte\u00fado g\u00e1strico.<\/p>\n\n\n\n

Entretanto pode-se administrar seda\u00e7\u00e3o leve ou consciente, na qual o paciente permanece acordado, por\u00e9m levemente sonolento, e tranquilizado, sem necessidade de suporte de oxig\u00eanio. Esse n\u00edvel de seda\u00e7\u00e3o pode ser obtido com pequenas doses fracionadas e subsequentes de midazolam (0,5 a 1mg) e fentanil (25mcg), aguardando-se adequado intervalo de tempo entre as doses, at\u00e9 atingir o n\u00edvel desejado de ansi\u00f3lise. Pode ser administrado antes ou durante a topicaliza\u00e7\u00e3o da mucosa.<\/p>\n\n\n\n

A inerva\u00e7\u00e3o sensitiva \u00e9 feita pelos pares de nervos cranianos VII (facial), IX (glossofar\u00edngeo) e X (vago)<\/strong>.<\/h2>\n\n\n\n

Ramos do nervo facial conduzem a sensibilidade dos dois ter\u00e7os anteriores da l\u00edngua. J\u00e1 o nervo glossofar\u00edngeo tem como territ\u00f3rio sensitivo o ter\u00e7o posterior da l\u00edngua, a val\u00e9cula, a superf\u00edcie anterior da epiglote, as paredes posteriores e laterais da faringe e os pilares tonsilares. J\u00e1 o nervo vago, atrav\u00e9s do ramo lar\u00edngeo superior \u00e9 respons\u00e1vel pela sensibilidade da laringe.<\/p>\n\n\n\n

IMPORTANTE:<\/strong> Em casos de risco de broncoaspira\u00e7\u00e3o, o bloqueio do territ\u00f3rio sensitivo do nervo lar\u00edngeo superior<\/strong> (ramo do vago) n\u00e3o \u00e9 desejado<\/strong>. O bloqueio do nervo lar\u00edngeo superior ou seu territ\u00f3rio, ir\u00e1 abolir completamente os reflexos de prote\u00e7\u00e3o das vias a\u00e9reas inferiores, levando ao risco de broncoaspira\u00e7\u00e3o em caso de regurgita\u00e7\u00e3o, e por isso n\u00e3o deve ser realizado nessa situa\u00e7\u00e3o. Para endoscopia digestiva alta, a aus\u00eancia desse bloqueio dificilmente ir\u00e1 ocasionar desconforto ao paciente, desde que a laringe n\u00e3o seja tocada com a ponta do endosc\u00f3pio.<\/p>\n\n\n\n

O uso de f\u00e1rmacos antisialogogos aumenta a absor\u00e7\u00e3o de anest\u00e9sico local pela mucosa, aumentando a efici\u00eancia do bloqueio<\/strong>.<\/h2>\n\n\n\n

Caso as condi\u00e7\u00f5es cl\u00ednicas e cardiovasculares permitam, a administra\u00e7\u00e3o endovenosa de atropina, escopolamina ou glicopirrolato (indispon\u00edvel no Brasil), antes da topicaliza\u00e7\u00e3o, ao diminu\u00edrem a presen\u00e7a de muco e saliva, aumentam a efici\u00eancia dos anest\u00e9sicos locais. \u00c9 importante aguardar o tempo de a\u00e7\u00e3o de cada medicamento.<\/p>\n\n\n\n

A lidoca\u00edna pode ser utilizada para topicaliza\u00e7\u00e3o das vias a\u00e9reas superiores na forma de spray 10%, gel 2% e ampola sem vasoconstritor a 2%<\/strong>.<\/h2>\n\n\n\n

T\u00e9cnica sugerida para uso rotineiro (associada a seda\u00e7\u00e3o)<\/h3>\n\n\n\n
    \n
  • Em geral utiliza-se 4-6 instila\u00e7\u00f5es de lidoca\u00edna spray direcionados para base da l\u00edngua, palato mole, pilares amigdalianos e \u00favula.<\/li>\n\n\n\n
  • Tal dose de lidoca\u00edna \u00e9 bem inferior aos n\u00edveis t\u00f3xicos da droga. Al\u00e9m do mais, boa parte \u00e9 inativada pelo suco g\u00e1strico, sem ser absorvida.<\/li>\n\n\n\n
  • Em adulto, n\u00e3o se deve fazer mais de 20 nebuliza\u00e7\u00f5es para se alcan\u00e7ar a anestesia desejada. O n\u00famero de nebuliza\u00e7\u00f5es depende da extens\u00e3o da \u00e1rea a ser anestesiada.<\/li>\n\n\n\n
  • A experi\u00eancia do m\u00e9dico e conhecimento do estado f\u00edsico do paciente s\u00e3o importantes para calcular a dose necess\u00e1ria. Nos pacientes idosos, debilitados, com doen\u00e7as agudas ou em crian\u00e7as, deve-se adequar as doses de acordo com a idade, peso e condi\u00e7\u00f5es f\u00edsicas. <\/li>\n<\/ul>\n\n\n\n

    Cada nebuliza\u00e7\u00e3o libera 100 mg de spray que corresponde a 10 mg de lidoca\u00edna.<\/h4>\n\n\n\n

    T\u00e9cnica sugerida de bloqueio:<\/strong><\/h3>\n\n\n\n
      \n
    • Obt\u00e9m-se consentimento do paciente, que deve ser esclarecido da import\u00e2ncia e seguran\u00e7a de n\u00e3o ser sedado profundamente. Obter a colabora\u00e7\u00e3o do paciente \u00e9 fundamental para o sucesso da t\u00e9cnica.<\/li>\n\n\n\n
    • Com o paciente sentado, procede-se a seda\u00e7\u00e3o consciente e administra\u00e7\u00e3o de antissialogogo.<\/li>\n\n\n\n
    • Territ\u00f3rio do nervo facial \u00e9 topicalizado primeiro com lidoca\u00edna 10% spray nos dois ter\u00e7os anteriores da l\u00edngua.<\/li>\n\n\n\n
    • Com uma gaze, segurar a ponta da l\u00edngua por alguns segundos para impedir que o paciente degluta o anest\u00e9sico, aumentando sua efici\u00eancia.<\/li>\n\n\n\n
    • A seguir, \u00e9 poss\u00edvel bloquear diretamente o nervo glossofar\u00edngeo, que situa-se poucos mil\u00edmetros posterior ao pilar amigdaliano posterior, podendo ser anestesiado por via t\u00f3pica, desde que a absor\u00e7\u00e3o seja eficiente.<\/li>\n\n\n\n
    • Com uso suave de laringosc\u00f3pio com l\u00e2mina de Macintosh, afastar a l\u00edngua para exibir o pilar amigdaliano posterior e borrifar lidoca\u00edna 10% diretamente sobre o pilar, aguardando sua absor\u00e7\u00e3o e impedindo a degluti\u00e7\u00e3o, bilateralmente.<\/li>\n\n\n\n
    • Por fim, depositar lidoca\u00edna gel 2% na por\u00e7\u00e3o posterior da l\u00edngua, deixando que escorra at\u00e9 a val\u00e9cula. Pode-se empurrar o gel com o dedo indicador e ao mesmo tempo, palpar a val\u00e9cula e testar se o bloqueio do glossofar\u00edngeo foi eficaz, observando aus\u00eancia de reflexo de n\u00e1usea mediado por este par craniano.<\/li>\n\n\n\n
    • Nota:<\/strong> essa \u00e9 a t\u00e9cnica utilizada pelos anestesiologistas para maximizar bloqueio sensitivo das vias a\u00e9reas superiores. Na endoscopia de rotina n\u00e3o h\u00e1 necessidade de seguir todos esses passos. Mas importante conhece-los para poder utilizar em situa\u00e7\u00f5es de alto risco de broncoaspira\u00e7\u00e3o<\/em><\/li>\n<\/ul>\n\n\n\n

      Refer\u00eancias<\/h2>\n\n\n\n
        \n
      • Sakai P, et al. Tratado de Endoscopia Diagn\u00f3stica e Terap\u00eautica – vol1 – 3a edi\u00e7\u00e3o. Atheneu. <\/li>\n\n\n\n
      • Evans LT, Saberi S, Kim HM, et al. Pharyngeal anesthesia during sedated EGDs: is “the spray” beneficial? A meta-analysis and systematic review. Gastrointest Endosc 2006; 63:761.<\/li>\n\n\n\n
      • de la Morena F, Santander C, Esteban C, et al. Usefulness of applying lidocaine in esophagogastroduodenoscopy performed under sedation with propofol. World J Gastrointest Endosc 2013; 5:231.<\/li>\n\n\n\n
      • Tsai HI, Tsai YF, Liou SC, et al. The questionable efficacy of topical pharyngeal anesthesia in combination with propofol sedation in gastroscopy. Dig Dis Sci 2012; 57:2519.<\/li>\n<\/ul>\n","protected":false},"excerpt":{"rendered":"

        A anestesia t\u00f3pica das vias a\u00e9reas superiores para realiza\u00e7\u00e3o de endoscopia alta \u00e9 um…<\/p>\n","protected":false},"author":1224,"featured_media":9072,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[151],"tags":[417,418,419,421,420],"ano":[309],"tipo":[153,159],"volume":[263],"class_list":["post-4801","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-assuntosgerais","tag-anestesia","tag-anestesia-topica","tag-lidocaina","tag-sedacao","tag-xilocaina","ano-309","tipo-endoscopia-digestiva-alta","tipo-outros","volume-volume-i"],"yoast_head":"\nAnestesia t\u00f3pica das vias a\u00e9reas superiores • Endoscopia Terapeutica<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" 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