Fisioterapia na assistência ao paciente com COVID-19: da terapia intensiva à reabilitação. Relato de caso / Physiotherapy for a patient with COVID-19: from intensive care to rehabilitation. A case report

Introdução: A pandemia da COVID-19 exigiu recursos e esforços de diversos profissionais de saúde para melhorar a assistência aos pacientes acometidos. A fisioterapia ganhou destaque na redução da progressão da doença em sintomas respiratórios e na manutenção da capacidade funcional e física. Objetivo: Apresentar um dos casos de assistência fisioterapêutica de um paciente com COVID-19, da internação na unidade de terapia intensiva (UTI) à reabilitação ambulatorial e os recursos utilizados, de forma a demonstrar o benefício da fisioterapia ao longo de todo o percurso do paciente até a alta. Relato do caso: Homem de 53 anos foi internado devido a piora clínica, queixa de dispneia em repouso associada a febre, tosse seca, agenesia e hipoxemia. Admitido à UTI com acometimento de 50% do parênquima pulmonar em tomografia computadorizada, recebeu oxigênio a 10 L/min, para atingir saturação periférica de oxigênio (SpO2) a 99% e relação de pressão parcial de oxigênio arterial (PaO2/FiO2) a 95. Durante nove dias de internação, recebeu atendimento de fisioterapia quatro vezes ao dia, com recursos de ventilação não invasiva, prona ativa, sedestação, deambulação precoce e recursos de aumento de demanda física ajustada progressivamente de acordo com a avaliação e objetivo terapêutico. Na alta hospitalar, com remissão dos sintomas importantes, sem oxigênio e SpO2 a 96%, PaO2/FiO2 a 302, foi encaminhado para reabilitação cardiopulmonar e, após 38 sessões, recuperou a capacidade funcional e recebeu alta do serviço com teste de caminhada de seis minutos com valores adequados para a idade e sexo. Conclusão: Neste caso de COVID19, os objetivos terapêuticos da fisioterapia foram alcançados desde a internação até a reabilitação, com utilização de recursos conhecidos pela especialidade e priorizando os cuidados contínuos e a personalização da terapia. Palavras chave: COVID-19, Modalidades de fisioterapia, Ventilação não invasiva, decúbito ventral, Deambulação precoce ABSTRACT Introduction: The COVID-19 pandemic required resources and efforts from health professionals to improve care for affected patients. Physical therapy has gained prominence in reducing the progression of the disease in respiratory symptoms and in maintaining functional and physical capacity. Objective: To report one of the cases of physiotherapy care of a patient with COVID-19, from admission to the intensive care unit (ICU) to outpatient rehabilitation and the resources used, in order to demonstrate the benefit of physiotherapy throughout the course of the patient until discharge. Case report: A 53 -year-old man was admitted due to clinical worsening, complaint of dyspnea at rest associated with fever, dry cough, agenesis and hypoxemia. Admitted to ICU with 50% involvement of the lung parenchyma on computed tomography, he received oxygen at 10 L/min to achieve peripheral oxygen saturation (SpO2) at 99% and arterial oxygen partial pressure ratio (PaO2/FiO2) at 95. During nine days of hospitalization, he received physiotherapy care four times a day, with non-invasive ventilation, prone position, sitting, early ambulation and resources for increasing physical demand, progressively adjusted according to the assessment and therapeutic objective. At hospital discharge, with remission of important symptoms, without oxygen and SpO2 96%, PaO2/FiO2 to 302, he was referred for cardiopulmonary rehabilitation and, after 38 sessions, he recovered functional capacity and was discharged from the service with a six-walk test minutes with appropriate values for age and sex. Conclusion: In this case of COVID19, the therapeutic objectives of physiotherapy were achieved from hospitalization to rehabilitation, using resources known by the specialty and prioritizing continuous care and personalized therapy.Keywords: COVID-19, Physical therapy modalities, Noninvasive ventilation, Prone position, Early ambulation

Early Ambulation After Transfemoral Diagnostic Cerebral Angiography: A Pilot Study

BackgroundA significant proportion of transfemoral cerebral angiography complications are related to the access site, with no clear consensus concerning the optimal closure technique. In this study, we examined the usefulness of a new closure protocol for transfemoral diagnostic cerebral angiography.MethodsWe performed a retrospective review of patients who underwent transfemoral (4Fr sheath) diagnostic cerebral angiography procedures at our institution. We included patients >18 years old who underwent the new closure protocol to achieve hemostasis at the access site. The new protocol entailed the use of nonocclusive manual compression for 15 minutes followed by 2 hours of bed rest, with additional 10-15 minutes of compression for new hematoma. We collected and analyzed the patients’ demographics, use of antiplatelet and anticoagulation medications, sheath size, and others.ResultsThe study cohort comprised 119 patients with a mean age was 54 years with (88%) females. Forty-one patients (34%) were on antiplatelet medications, with 12 (10%) on dual antiplatelet therapy (DAPT). Four patients (3%) (two on DAPT, one on Aspirin alone, and one was not on any antiplatelet medication) had access site hematoma that required additional compression. Subgroup analysis showed that within the DAPT, Aspirin alone, and no antiplatelet medications groups, (17%), (3%), and (1%) of patients developed access site hematoma, respectively.ConclusionThis pilot study demonstrates that our closure protocol for transfemoral angiograms is safe and effective. There was a trend toward higher access-site complications in patients on DAPT. Further studies are required to expand on and validate our results.

Post-dural Puncture Headache in Cesarean Section; Frequency and Risk Factors: A Report From the North of Iran

Background: Spinal Anesthesia (SA) as a safe, reliable, and cost-effective method is widely used for Cesarean Section (CS). However, it is sometimes complicated by Post-Dural Puncture Headache (PDPH). Objectives: We investigated the frequency of PDPH in CS under SA and related risk factors in an academic referral hospital in the north of Iran. Materials & Methods: This descriptive cross-sectional prospective study was conducted at Alzahra hospital as an academic referral center affiliated with the Guilan University of Medical Sciences on 147 eligible cases During from May 2019 to October 2019. Then questionnaires containing questions about patients’ demographic data and some PDPH-related factors were filled out via face-to-face interviews. The collected data were analyzed by SPSS v. 21 using Chi-squared and and Fisher’s exact test. Results: The incidence of PDPH was 6.1%. Early ambulation, the number of attempts, and having a history of headache were significantly associated with a higher incidence of PDPH (P=0.001), while body mass index (P=0.106), age (P=0.093), and residents’ experience (P=0.384) had no significant association. None of our cases experienced a severe or persistent headache. Conclusion: The main predisposing factors for PDPH were found to be the history of HA, early ambulation, and the number of dura punctures. Women at risk for PDPH should be objectively screened before CS under SA.

A STUDY TO DETERMINE THE FUNCTIONAL OUTCOME IN THE MANAGEMENT OF STABLE PER TROCHANTERIC HIP FRACTURES WITH DYNAMIC HIP SCREW.

BACKGROUND: The use of a dynamic hip screw (DHS) for stable as well as unstable intertrochanteric hip fracture xation has been successfully applied in fracture healing for more than 25years. DHS xation on unstable trochanteric fractures still has a more failure rate compared to stable fractures, mostly due to osteoporosis in patients. Thus, this study is aimed to investigate the biomechanical property of the DHS system to provide the stable xation in intertrochanteric A1 and A2 fractures1. MATERIAL AND METHODS: This is a retrospective study of 54 patients with trochanteric fractures of the femur that were treated with DHS (Dynamic hip screw) during the period of two years from April 2019 to March 2021 in a tertiary care hospital. All surgeries were performed under spinal and epidural anaesthesia. Surgery done was an internal xation with DHS plate. Results: Among 54 cases, 55.5% were A1, and 44.4% were A2 pertrochanter fractures. The clinical and functional outcomes of the procedure were excellent in 25 patients (46.29%), good in 19 patients (35.18%), fair in 8 patients (14.81%), and 2 (3.7%) of the patients had poor results. CONCLUSIONS: Intertrochanteric fractures are essentially fractures of the elderly, which demand prompt treatment and early ambulation. The dynamic hip screw is the operative treatment of choice for stable trochanteric fractures

Early Ambulation Training as Impairment-Driven Rehabilitation in Cancer Patients with Cervical Spine Metastases After Palliative Spine Surgery

Background Cervical spine metastasis worsens the quality of life (QOL) of patients with cancer. While the beneficial effects of surgery have been reported, the detailed course of functional recovery remains unclear, especially in the acute phase of rehabilitation. We previously reported on impairment-driven rehabilitation in patients with thoracic or lumbar level metastases. The present study assessed the effects of an impairment-driven strategy on the early recovery of ambulatory function in patients with cervical spine metastasis. Methods We retrospectively reviewed 13 consecutive patients with cervical neoplastic spinal compression. The patients were those whose primary impairment with spinal instability identified by a multidisciplinary tumor board who underwent palliative spine surgery. In addition, we examined neurological deficits; ambulation status; pathological fracture, collapse, and postoperative implant failure progress; and Barthel Index (BI). Results The average duration of ambulation was 3.75 ± 3.92 days after surgery. One case showed collapse and two showed progressions of paralysis. However, all patients had early ambulation after surgery, except for one patient who developed postoperative cerebral infarction. The BI scores showed an improving tendency; however, the difference before and after rehabilitation was not statistically significant. Conclusions We reviewed the recovery course of ambulation in patients with cervical spine metastases who underwent impairment-driven rehabilitation. Combined with surgery and early mobilization, this strategy may improve the QOL of patients with cancer and cervical spine metastasis.

A comparative study between total laparoscopic hysterectomy and total abdominal hysterectomy for benign uterine pathologies at tertiary care institute, Udaipur

Background: Hysterectomy is one of the most commonly performed procedures in gynaecological surgery. The most common indication is benign uterine disease. As the time is passing trend is towards those approaches which are minimally invasive, less painful, have less complications, less blood loss and are more cosmetic. Thus, total laparoscopic hysterectomy has gained popularity. The purpose of this study was to compare the 2 different routes of hysterectomy.Methods: In this prospective randomized observational study patients undergoing both the types of hysterectomy, that is, TAH (total abdominal hysterectomy) and TLH (total laparoscopic hysterectomy) during 2 year period at Rajkiya Pannadhay Mahila Chikitsalaya RNT medical college Udaipur were included in the study. 50 women (25 in each group) aged between 31-72 years were included into the study.Results: We observed that duration of surgery was found to be longer in TLH than TAH (112.56±19.45 min versus 57.9±19.26 min, P<0.001 (HS)). The length of hospital stay was less in TLH than TLH (p=0.0001) and the amount of intra-operative blood loss were also less in TLH than TAH (163.60±44.15 versus 313.20±123.48 ml, p<0.001). TLH group had early ambulation compared to TAH group (2.24±0.44 day versus 3.12 ±0.33 day, p<0.001), difference on the basis of length of hospital stay was highly significant which was shorter in TLH than TAH (4.40±1.15 versus 10.32±8.19 days, respectively; p<0.001). In current study patient satisfaction level was found highly significant between TLH and TAH (100% versus 56%, p<0.001).Conclusions: TLH is a safe and effective method of doing hysterectomy. The present study concluded that TLH is associated with less hospital stay, less blood loss, less use of analgesics, early ambulation, early start of oral feed, and better patient satisfaction.

Effect of intrathecal buprenorphine on the haemodynamic response in patients undergoing laparoscopic appendicectomy under general anaesthesia

: Combined regional and general anaesthesia for laparoscopic appendicectomy offers better intraoperative haemodynamic stability. Buprenorphine is a long acting opioid which can be administered intrathecally and provides excellent analgesia intraoperatively and post operatively while allowing early ambulation without prolonged motor block. The study aimed to compare the haemodynamic response during laparoscopic appendicectomy using combined general anaesthesia with intrathecal buprenorphine and general anaesthesia alone. In this observational study 80 patients who underwent laparoscopic appendicectomy were divided into two groups of 40 each by random sampling. The patients in the GA group received general anaesthesia whereas patients in the GA+SAB group received intrathecal buprenorphine along with general anaesthesia. The heart rate, systolic and diastolic blood pressures and SpOwere noted after induction of general anaesthesia, immediately after endotracheal intubation, after creating pneumoperitonium and post extubation. Student’s t test was used for comparing the haemodynamic variables There were no statistically significant differences between GA and GA+SAB group in the heart rate, systolic and diastolic blood pressure after pneumoperitonium was created. When compared to general anaesthesia alone, addition of intrathecal burenorphine provides little advantage in preventing stress response during laparoscopic appendicectomy.

Distal Femur Tumor Megaprosthesis for Non-union of Supracondylar Femur Fracture after Failed Osteosynthesis. An Ingenious Solution.

Introduction: Incidence of non-union of fracture involving the supracondylar region of femur in an elderly is increasing due to bone loss from trauma and availability of poor quality bone in geriatric population. Distal femur megaprosthesis can provide a single stage solution for resistant non-union of supracondylar femur. Case Report: We are reporting two cases of non-union of supracondylar femur with implant failure treated with distal femoral tumor megaprosthesis. We achieved excellent improvement of the Knee Society Score from 15 to 75; Knee Society Function Score from 0 to 60, good range of motion, and pain free ambulation without support at 3 months follow-up. Conclusion: Management of non-union of supracondylar femur with implant failure is challenging task. Distal femur replacement using tumor megaprosthesis is useful option for such resistant cases in achieving early ambulation and overall good functional outcome. Keywords: Non-union, distal femur fracture, megaprosthesis, supracondylar femur fracture.

Início da mobilização em pacientes com hemorragia subaracnoidea aneurismatica

Introdução. As diretrizes para o manejo de pacientes com Hemorragia Subaracnóidea Aneurismática não apontam o momento ideal para iniciar a mobilização. Objetivo. Identificar critérios de segurança para o início da fisioterapia motora nesses pacientes. Método. Foi realizada uma revisão sistemática, desenvolvida conforme as recomendações do Preferred Reporting Intens for Systematic Reviews and Meta-Analyses (PRISMA). A busca foi feita por dois pesquisadores independentes nas bases de dados eletrônicos LILACS, SciELO, MedLine/PubMed e PEDro, utilizando a combinação dos termos: “Early Ambulation”, “Early Mobilization”, “Intracranial aneurysms”, “Subarachnoid hemorrhage. Definidos os critérios de inclusão: artigos publicados desde o início das bases até agosto de 2020, sem restrição de idioma, que abordam sobre intervenção com fisioterapia motora e/ou sobre efeitos da quebra do repouso no paciente adulto com Hemorragia Subaracnóidea Aneurismática. Resultados. Foram incluídos nove artigos a partir dos 95 estudos encontrados na busca. Foram excluídos estudos que não atenderam aos critérios acima estabelecidos e revisões de literatura. A qualidade metodológica dos ensaios clínicos foi avaliada de acordo com a escala PEDro. O nível de evidência destes variou de quatro a cinco, sendo considerados de qualidade baixa e intermediária respectivamente. Os resultados permitiram a sumarização dos critérios de segurança em três categorias: cardiovascular, respiratória e neurológica. Nesta obtivemos maior número de itens com variáveis a serem consideradas para a elegibilidade do paciente a iniciar a mobilização. Conclusão. Os critérios de segurança concentraram-se em garantir a estabilidade neurológica e fisiológica do paciente antes do início das primeiras sessões de mobilização.