Conceptos sobre tránsito rápido (fast-track concepts). Primera parte: elección de técnicas anestésicas / Fast-track concepts. First part: selection of anesthesic techniques

No hay una droga o tecnica anestésica unica que sea ideal para el "tránsito rápido": sin embargo, los relajantes musculares, los analgésicos y anestésicos disponibles, asi como tambien las nuevas drogas coadyuvantes y tecnicas de monitoria, pueden ser utilizados en una manera racional para producir excelentes condiciones quirurgicas en un amplia variedad de procedimientos diagnosticos y quirúrgicos. Ha sido descrito recientemente un nuevo criterio de "tránsito rápido", el cual debe facilitar el proceso para determinar cuando los pacientes pueden obviar la Unidad de Cuidado Postoperatorio Intensivo (PACU), de forma segura. En esta presentación, se revisa el uso clinico de los nueuos hipnoticos-sedantes, anestésicos inhalados, analgésicos opioides, relajantes musculares, drogas coadyuvantes (e.g. NSAIDs), anestésicos locales, y drogas antiemeticas, facilitando la recuperación. Adicionalmente, se describe el papel de la monitoria del sistema nervioso central (e.g. Indice EEG-BIS) como un medio para mejorar la titulación de las drogas anestésicas generales. Finalmente, se introduce una aproximación multimodal novedosa para controlar la fisiopatologia postoperatoria y facilitar el proceso de rehabilitación

Conceptos sobre tránsito rápido (fast-track concepts). Segunda parte: prevención del dolor y la émesis postoperatoria / Fast-track concepts. Second part: prevention of postoperative pain and nausea

El uso de drogas anestésicas de acción corta y rápida facilita la recuperación temprana luego de procedimientos quirurgicos ambulatorios. Sin embargo, a menos que los pacientes ambulatorios puedan salir del medio ambulatorio más temprano, sera dificil alcanzar ahorros reales de costos con el uso de drogas anestésicas más costosos (a disponibilidad de "tránsito rápido" para pacientes ambulatorios les permite obviar el paso por el área de recuperación de cuidado intensivo de Fase I y ser egresados más rápido. La mayor limitación al proceso de '''tránsito rápido" es la habilidad para controlar la nausea y el vómito postoperatorio. El uso de agentes coadyuvantes (e.g. anestésicos locales, NSAIDs, y tecnicas no-farmacologicas, para limitar los requerimientos de analgesicos opioides, asi como tambien el uso costo-efectivo de agentes antiemeticos profilácticos habilitara a mas pacientes ambulatorios a encontrar los criterios de salida más tempranamente

Papel de las técnicas no farmacológicas en el tratamiento y la prevención del dolor y la emesis postoperatoria / Non-pharmacologic techniques for the prevention and treatment of both acute and chronic pain

Los pacientes estan pasando a practicas medicas "alternativas" no convencionales, de una forma que va en incremento. Los anestesiologos tienen una variedad cada vez. mayor de opciones no farmacologicas disponibles para la prevención y tratamiento del dolor agudo y cronico. En adición a la electroanalgesia, la terapia laser puede ademas proveer un alivio efectivo para una variedad amplia de sintomas dolorosos agudos y cronicos. Las terapias medicas altemativas estan cada vez mas siendo sujetas a evaluaciones clinicas mas rigurosas para validar su papel en el futuro de la medicina

Effect of severity of pulmonary disease on nitrous oxide washin and washout characteristics.

The influence of chronic obstructive pulmonary disease (COPD) on the nitrous oxide (N2O) washin and washout characteristics was evaluated in 90 (ASA II-III) males undergoing elective peripheral surgery under general anaesthesia with controlled ventilation. Patients were classified by preoperative bedside pulmonary function testing into three groups. Group I (n = 30), patients without COPD (FEV1/FVC > 80% predicted values; control group); Group II (n = 30), patients with mild COPD (FEV1/FVC = 65-79% of predicted values); and Group III (n = 30), patients with moderate COPD (FEV1/FVC = 50-64% of predicted values). The anaesthetic technique was standardized for all patients. The Datex Capnomac Ultima monitor was used to measure the inspired and expired concentrations of nitrous oxide (N2O), carbon dioxide (CO2), and isoflurane. The duration of both N2O washin (time from start of N2O administration to equilibrium of inspired and expired N2O concentrations) and 5 per cent washout (time from discontinuation of N2O to an expired N2O concentration of 5 per cent of the equilibrium value) were recorded. The duration of N2O washin and washout were significantly prolonged in Groups II and III (P < 0.001) as compared to the control group (Group I). The end-tidal CO2 concentration decreased significantly during N2O washout without causing oxygen desaturation (SpO2 < 90%). We conclude that the duration of N2O washin and washout were significantly prolonged in anaesthetized patients with COPD which may delay the induction and recovery from N2O anaesthesia.

Effects of nebulized beta 2-adrenergic agonists on pulmonary mechanics in anesthetized patients with chronic obstructive pulmonary disease.

We evaluated the effects of nebulized beta 2-adrenergic agonists on pulmonary mechanics in patients with COPD undergoing peripheral surgery with a standardized general anesthetic technique. Thirty males with COPD were randomized into one of three groups. Group I (control group; n = 10) received nebulized saline 3 ml, Group II (n = 10) received nebulized albuterol (2.5 mg in 3 ml), and Group III (n = 10) received nebulized metaproterenol (15 mg in 3 ml). At 20 min after tracheal intubation, the study drugs were nebulized over 20 min. Datex Capnomac Ultima monitor was used to measure pulmonary mechanics on a breath-by-breath basis. There was no difference between the three groups with respect to demographic data and preoperative respiratory parameters. A similar degree of DPH occurred with the initiation of mechanical ventilation in all three groups. Patients receiving nebulized bronchodilators (Groups II and III) displayed a significant decrease in DPH and an increase in total dynamic compliance. However, there were no differences in DPH and total dynamic compliance between Groups II and III. We conclude that nebulization of either albuterol or metaproterenol can alleviate DPH resulting from mechanical ventilation in anesthetized patients with COPD.