Comparison of direct costs associated with the use of balanced general anesthesia and total intravenous anesthesia (TIVA) techniques / Comparación de los costos directos asociados al uso de técnicas de anestesia general balanceada y anestesia total intravenosa (TIVA)

Abstract Introduction: Healthcare costs are increasing against the backdrop of scarce resources. Surgical procedures are an important part of healthcare spending, and the cost of anesthetic techniques is relevant as part of the total cost of care and it is a potential target for expenditure optimization. Although important economic differences have been reported internationally for general anesthesia options, there are no publications in Colombia that compare current costs and allow for informed and financially responsible decision-making. Objective: To quantify and compare direct costs associated with the various general anesthesia options most frequently used at the present time. Methods: Cost minimization analysis based on a theoretical model of balanced general anesthesia using isoflurane, sevoflurane, desflurane in combination with remifentanil, and TIVA (propofol and remifentanil). Initial results were obtained using a deterministic simulation method and a sensitivity analysis was performed using a Monte Carlo simulation. Results: The average total cost per case for the different anesthetic techniques was COP 126381 for sevoflurane, COP 97706 for isoflurane, COP 288605 for desflurane and COP 222 960 for TIVA. Conclusions: Balanced general anesthesia with desflurane is the most costly alternative, 1.2 times more expensive than TIVA, and 2 and 3 times more costly than balanced anesthesia with sevoflurane and isoflurane, respectively. TIVA ranks second with a cost 1.8 times higher than balanced anesthesia with sevoflurane and 2.5 times higher than balanced anesthesia with isoflurane.

Resumen Introducción: Los costos de la atención en salud son crecientes y se enfrentan a un escenario de recursos escasos. La realización de procedimientos quirúrgicos hace parte importante de la atención y del gasto en salud, el costo de las técnicas anestésicas utilizadas es relevante en el costo total de la atención y es un objetivo potencial para la optimización del gasto. Aunque a escala internacional se han reportado diferencias económicas importantes entre las alternativas para anestesia general, en Colombia no se cuenta con publicaciones que comparen los costos actuales y permitan una toma de decisiones informada y responsable económicamente. Objetivo: Cuantificar y comparar los costos directos para Colombia de las diferentes alternativas para anestesia general usadas con más frecuencia en la actualidad. Métodos: Análisis de minimización de costos basado en un modelo teórico de anestesia general balanceada con isoflurano, sevoflurano, desflurano en combinación con remifentanilo y TIVA (propofol y remifentanilo). Se obtuvieron resultados iniciales utilizando una simulación con un método determinista y se realizó un análisis de sensibilidad con una simulación de Montecarlo. Resultados: El costo total promedio por caso para las diferentes técnicas anestésicas fue de COP 126.381 para sevoflurano, COP 97.706 para isoflurano, COP 288.605 para desflurano y COP 222.960 para TIVA. Conclusiones: La anestesia general balanceada con desflurano es la alternativa de mayor costo, es 1,2 veces más costosa que la TIVA, y 2 y 3 veces más que la balanceada con sevoflurano e isoflurano, respectivamente. La TIVA ocupa el segundo lugar con un costo 1,8 veces superior a la balanceada con sevoflurano y 2,5 veces a la balanceada con isoflurano.

Ventajas de la anestesia intravenosa libre de opioides en cirugía ambulatoria oncológica de mama / Advantages of opioid-free intravenous anesthesia over anesthesia in ambulatory breast cancer surgery

RESUMEN Introducción: la anestesia general libre de opioides surge ante la necesidad de evasión del uso de opioides en el transoperatorio y sus efectos indeseados en el posoperatorio. Objetivo: evaluar el comportamiento hemodinámico y la recuperación anestésica en pacientes intervenidas mediante cirugía ambulatoria por cáncer de mama, en las cuales se administró anestesia general total intravenosa libre de opioides o general balanceada. Métodos: se realizó un estudio cuasiexperimental, prospectivo en pacientes a las que se aplicó anestesia general balanceada (n=34) y total intravenosa libre de opioides (n=34) intervenidas quirúrgicamente por cáncer de mama, en el Hospital General Docente "Abel Santamaría Cuadrado", durante el 2018. Resultados: el grupo de anestesia general balanceada mostró mayor variación intraoperatoria de los parámetros evaluados, con diferencias significativas (p=0,019). El tiempo medio de despertar fue menor en el grupo de anestesia total intravenosa (2,10 ± 0,907 min vs 5,35 ± 1,250 min; p<0,01), al igual que el dolor, con diferencia significativa (p<0,05) y el tiempo de recuperación, donde una hora después de la intervención, el 85 % cumplía los criterios de alta anestésica. El retraso en el alta de la unidad de recuperación ocurrió principalmente por el bajo nivel de actividad motora, con mayor incidencia en el grupo de anestesia general balanceada (71 % vs 26 %; p=0,00). Conclusiones: la anestesia total intravenosa libre de opioides fue superior al método general balanceado, pues mostró mayor estabilidad hemodinámica y analgesia, menor incidencia de complicaciones posoperatorias y menor tiempo de estancia en sala de recuperación posanestésica.

ABSTRACT Introduction: opioid-free general anesthesia arises from the need to avoid the use of opioids in the transoperative period and the undesirable effects in the postoperative period. Objective: to assess the hemodynamic behavior and anesthetic recovery in patients who underwent ambulatory surgery for breast cancer and those who were given either opioid-free intravenous general or balanced general anesthesia. Methods: a quasi-experimental, prospective study was carried out on patients who received balanced general anesthesia (n=34) and total opioid-free intravenous anesthesia (n=34), who underwent breast cancer surgery at Abel Santamaria Cuadrado General Teaching Hospital during 2018. Results: the group of balanced general anesthesia showed greater intraoperative variation of the parameters assessed, with significant differences (p=0.019). The mean time of awakening was lower in the intravenous total anesthesia group (2.10 ± 0,907 min vs. 5,35 ± 1,250 min; p<0.01), as was pain, with significant difference (p<0.05) and the recovery time, where one hour after the surgery, 85 % met the criteria for anesthesia discharge. The delay in discharge from the recovery unit occurred mainly because of the low level of motor activity, with a higher incidence in the group of balanced general anesthesia (71% vs. 26 %; p=0.00). Conclusions: intravenous opioid-free total anesthesia was higher to the balanced general approach because it showed greater hemodynamic and analgesic stability, lower incidence of postoperative complications, and shorter time spent in the post-anesthesia recovery room.

Cumulative incidence and risks factors for postoperative nausea and vomiting in adult patients undergoing cholecystectomy under balanced general anesthesia: a prospective cohort study / Incidencia acumulada y factores de riesgo para náuseas y vómitos posoperatorios en pacientes adultos sometidos a colecistectomía bajo anestesia general balanceada: estudio prospectivo de cohorte

Abstract Introduction: Postoperative nausea and vomiting (PONV) are common issues arising after general anesthesia, for which several independent risk factors (RF) have been described. Objective: To determine the accumulated incidence of PONV during the first 24hours of the postoperative period. Methods: A cohort observational, prospective study was conducted that included all the adults undergoing cholecystectomy under balanced general anesthesia at the EsSalud Talara Hospital from October 2014 until December 2016. The presence of PONV during the first 24hours after surgery was assessed, and univariate, bivariate, and logistic regression analyses were conducted. Results: A total of 244 patients were included, most of them with 2 RFs in the Apfel scale, that represented an accumulated incidence of PONV of 0.51 (95% confidence interval [CI] 0.45-0.57) during the observation period, notwithstanding the fact that 85.25% received antiemetic prophylaxis. The logistic regression analysis identified that being a female (odds ratio [OR] 3.30,95% CI 1.66-6.55, P = 0.0007) and previous PONV or motion sickness (OR 2.67, 95% CI 1.25-5.68, P = 0.011) were independent RFs for PONV. The administration of antiemetic prophylaxis and the presence of PONV (P = 0.92) were found to be independent. Conclusion: The high cumulative incidence of PONV could be the result of the type of surgery, the use of volatile anesthetic agents, and errors in the antiemetic pharmacological prophylaxis.

Resumen Introducción: Las náuseas y vómitos posoperatorios (NVPO) son problemas comunes que aparecen luego de la anestesia general, para los que se han descrito varios factores independientes de riesgo. Objetivo: Determinar la incidencia acumulada de NVPO durante las primeras 24 horas del periodo posoperatorio. Métodos: Se realizó un estudio observacional prospectivo de cohorte que incluyó a todos los adultos sometidos a colecistectomía bajo anestesia general balanceada en el Hospital EsSalud Talara desde octubre de 2014 hasta diciembre de 2016. Se evaluó la presencia de NVPO durante las primeras 24 horas posoperatorias y se ejecutaron análisis univariado, bivariado y de regresión logística. Resultados: Se incluyeron 244 pacientes, la mayoría con dos factores de riesgo en la escala de Apfel, que presentaron una incidencia acumulada de NVPO de 0.51 (IC 95% 0.45-0.57) en el periodo de observación, a pesar de que el 85.25% recibió profilaxis antiemética. El análisis de regresión logística identificó la presencia de sexo femenino (OR 3.30, IC 95% 1.66-6.55, p = 0.0007) y la historia de NVPO previos o cinetosis (OR 2.67, IC 95% 1.25-5.68, p = 0.011) como factores de riesgo independientes para NVPO. Se halló independencia entre la presencia de profilaxis antiemética y la presencia de NVPO (p=0.92). Conclusiones: La alta incidencia acumulada de NVPO pudiera ser ocasionada por el tipo de cirugía, uso de anestésicos volátiles y falencias en la profilaxis farmacológica antiemética.

Incidencia del déficit cognitivo postoperatorio en anestesia regional y general en una institución de cuarto nivel en Bucaramanga (Santander, Colombia) en el año 2017 / Postoperative cognitive dysfunction incidence for regional and general anesthesia in a level four institution in Bucaramanga (Santander, Colombia) during 2017 / Incidência do déficit cognitivo pós-operatório em anestesia regional e geral em uma instituição de quarto nível em Bucaramanga (Santander, Colômbia) em 2017

Introducción. En el proceso de envejecimiento, la mayoría de los sistemas orgánicos mantienen su funcionamiento basal, pero existe una reducción de la reserva funcional y de la capacidad para compensar el estrés fisiológico, lo que hace que los pacientes de mayor edad sean más propensos a complicaciones postoperatorias. Se realizó un estudio en instituciones de Bucaramanga para determinar la incidencia de déficit cognitivo postoperatorio y los factores de riesgo asociados. Metodología. Estudio observacional analítico de cohorte prospectivo realizado en instituciones de salud de Bucaramanga durante 2017 con pacientes mayores de 55 años intervenidos bajo anestesia regional, general balanceada o anestesia total intravenosa. Resultados. Se estudiaron 173 pacientes, 112 mujeres (64.74%) y 61 hombres (35.26%) operados. Las técnicas anestésicas más empleadas fueron: Regional (46.24%) y General balanceada (44.51%). La incidencia de Déficit Cognitivo Postoperatorio a corto plazo fue 6.36% en pacientes previamente sanos, con valor P significativo (0.001) ajustado. Se detectó deterioro cognitivo del 51.41% con alteraciones en los dominios de lenguaje, atención y memoria; con aumento en la evaluación a largo plazo. Durante el seguimiento de pacientes a largo plazo resultó en un 11.55%, determinando la incidencia de Déficit Cognitivo Postoperatorio tardío en un 17.91%. La técnica anestésica con mayor proporción de déficit a largo plazo fue la anestesia mixta, comparada con anestesia regional. Discusión. En la actualidad no existe una definición estandarizada de Déficit Cognitivo Postoperatorio, se ha observado mayor frecuencia y mayor prolongación en pacientes de edad avanzada. El estudio demostró una incidencia temprana significativamente menor, comparándolo con artículos internacionales, pero una incidencia mayor en déficit postoperatorio tardío, resultado de mayores complicaciones intraoperatorias, comparado con otros estudios. Conclusiones. El Déficit Cognitivo Postoperatorio involucra múltiples factores de riesgo; en el estudio se encontró mayor asociación con la edad, la escolaridad, la hipotensión y la anestesia general. No hubo asociación entre comorbilidades y el Déficit Cognitivo Postoperatorio. Se determinó la presencia de hipotensión para desarrollo de este déficit. Cómo citar: Contreras-Forero FJ, Ochoa ME, Perez M, Pinillos M, Celis L, Valencia-Guampe JS, et al. Incidencia del déficit cognitivo postoperatorio en anestesia regional y general en una institución de cuarto nivel en bucaramanga (santander, colombia) en el año 2017. MedUNAB. 2020;23(3): 450-463. Doi: https://doi.org/10.29375/01237047.3711

Introduction. Within the aging process, most organic systems maintain their basal functions. However, there is a reduction in functional reserve and the capacity to compensate physiological stress, which makes older patients more prone to postoperative complications. A study was performed in institutions in Bucaramanga to determine the incidence of postoperative cognitive dysfunction and the associated risk factors. Methodology. This was a analytical observational prospective cohort study performed in healthcare institutions in Bucaramanga in 2017 with patients older than 55 years of age under regional, balanced general or total intravenous anesthesia. Results. One hundred and seventy-three operated patients were studied, among which 112 (64.74%) were women and 61 (35.26%) were men. The most commonly used anesthetic techniques were: regional (46.24%) and balanced general (44.51%). Short-term Postoperative Cognitive Dysfunction incidence was 6.36% in previously healthy patients, with an adjusted significant P value (0.001). Cognitive deterioration was detected in 51.41% of patients, with alterations in their mastery of language, attention and memory. This increased for the long-term evaluation. During long-term patient follow-up, it resulted in 11.55%, determining the incidence of delayed Postoperative Cognitive Dysfunction at 17.91%. The anesthetic technique with the highest proportion of long- term dysfunction was mixed anesthesia, compared to regional anesthesia. Discussion. There is currently no standardized definition for Postoperative Cognitive Dysfunction. It has been observed more frequently and for longer extensions in older patients. The study demonstrated a significantly lower early incidence when compared to international articles, but a greater incidence of delayed postoperative dysfunction as a result of more intraoperative complications compared to other studies. Conclusions. Postoperative Cognitive Dysfunction involves multiple risk factors. The study observed a greater association with age, level of education, hypotension and general anesthesia. There was no association between comorbidities and Postoperative Cognitive Dysfunction. The presence of hypotension was determined for developing this dysfunction. Cómo citar: Contreras-Forero FJ, Ochoa ME, Perez M, Pinillos M, Celis L, Valencia-Guampe JS, et al. Incidencia del déficit cognitivo postoperatorio en anestesia regional y general en una institución de cuarto nivel en bucaramanga (santander, colombia) en el año 2017. MedUNAB. 2020;23(3): 450-463. Doi: https://doi.org/10.29375/01237047.3711

Introdução. No processo de envelhecimento, a maioria dos sistemas orgânicos mantém seu funcionamento basal, mas há uma diminuição da reserva funcional e da capacidade de compensar o estresse fisiológico que torna os pacientes idosos mais sujeitos a complicações pós-operatórias. Foi realizado um estudo em instituições da cidade de Bucaramanga para determinar a incidência de déficit cognitivo pós-operatório e os fatores de risco associados. Métodos. Estudo observacional analítico de coorte prospectivo realizado em instituições de saúde em Bucaramanga durante o ano de 2017 em pacientes com idade superior a 65 anos operados sob anestesia regional, geral balanceada ou anestesia geral intravenosa. Resultados. Foram estudados 173 pacientes, 112 mulheres (64.74%) e 61 homens (35.26%) operados. As técnicas anestésicas mais utilizadas foram: regional (46.24%) e geral balanceada (44.51%). A incidência de déficit cognitivo pós-operatório de curto prazo foi de 6.36% em pacientes previamente saudáveis, com um valor P significativo (0.001) ajustado. Detectou- se deterioração cognitiva de 51.41% com alterações nos domínios da linguagem, atenção e memória; com aumento na avaliação de longo prazo. No seguimento a longo prazo dos pacientes resultou em 11.55%, determinando a incidência de déficit cognitivo pós-operatório tardio em 17.91%. A técnica anestésica com maior proporção de déficit no longo prazo foi a anestesia mista, em comparação com a anestesia regional. Discussão. Atualmente não existe uma definição padronizada de Déficit Cognitivo Pós-operatório, a qual observa-se com maior frequência e por mais tempo em pacientes idosos. O estudo demonstrou incidência precoce significativamente menor, em comparação com resultados de artigos internacionais, mas maior incidência de déficit pós-operatório tardio, resultado de maiores complicações intraoperatórias, em comparação com outros estudos. Conclusões. O Déficit Cognitivo Pós-operatório envolve múltiplos fatores de risco; o estudo encontrou maior associação com idade, escolaridade, hipotensão e anestesia geral. Não houve associação entre comorbidades e Déficit Cognitivo Pós-operatório. Determinou-se a presença de hipotensão para o desenvolvimento desse déficit. Cómo citar: Contreras-Forero FJ, Ochoa ME, Perez M, Pinillos M, Celis L, Valencia-Guampe JS, et al. Incidencia del déficit cognitivo postoperatorio en anestesia regional y general en una institución de cuarto nivel en bucaramanga (santander, colombia) en el año 2017. MedUNAB. 2020;23(3): 450-463. Doi: https://doi.org/10.29375/01237047.3711

De la farmacocinética a la farmacodinámica, ¿estamos listos para los software 3D? / From pharmacokinetics to pharmacodynamics -Are we ready for 3D software?

Abstract The relationship between the dose and plasma concentration of a drug is determined by pharmacokinetics. However, difficulties arise when more than one drug is administered simultaneously. There is currently a gap in the teaching model when trying to convey the significance of pharmacodynamic interactions. In this article the authors reflect on the importance of developing a software that simplifies the pharmacokinetic concepts of two drugs, turning them into one single variable in space as a function of time. Together with depth of anesthesia monitoring and the pain control variables, this model will bring pharmacokinetics and pharmacodynamics together and provide a teaching tool for improved understanding of these concepts.

Resumen La relación entre la dosis y la concentración plasmática de un fármaco está determinada por la farmacocinética. Sin embargo, se presentan dificultades cuando hay más de un medicamento administrado de forma simultánea. En la actualidad hay un vacío en el modelo de enseñanza cuando se pretende difundir la importancia de las interacciones farmacodinámicas. En el presente artículo los autores hacen una reflexión sobre la importancia de poder construir un software que simplifique los conceptos farmacocinéticos de dos medicamentos, convirtiéndolos en una sola variable de espacio en función del tiempo. Este modelo permitiría, junto con la monitorización de la profundidad anestésica y las variables de control del dolor, acoplar la farmacocinética a la farmacodinámica, y brindaría una herramienta de educación para la comprensión de estos conceptos.

Bispectral index assessment in calves subjected to the continuous infusion of propofol combined with fentanyl administration / Indice biespectral em bezerros submetidos à infusão contínua de propofol associado ao fentanil

ABSTRACT: The aim of this study was to evaluate the bispectral index (BIS) effects in calves through continuous infusion of propofol with or without fentanyl. Eight Holstein male calves (ages from six to twelve months old) with an average weight of 123±18kg were used. All animals participated in both groups, always keeping a minimum interval of one week between the anesthetic procedures; the calves were randomly distributed between groups. Anesthesia was induced with an intravenous (IV) dose of propofol of 5mg kg-1 in control group (GP) or with propofol (4mg kg-1) associated with IV fentanyl 0.001mg kg-1(GF). All the calves were positioned in right lateral recumbency and were allowed to spontaneously breathe room air. Subsequently, the anesthesia was maintained by continuous infusion of propofol at the rate of 0.6mg kg-1 min-1 IV in GP, and associated with the infusion of fentanyl 0.001mg kg-1 hour-1 in GF. Measurements of BIS, signal quality index (SQI) and electromyography (EMG) were evaluated before anesthesia induction (TB), and at 15, 30, 45 and 60 minutes after the beginning of continuous drugs infusion (T15, T30, T45 and T60, respectively). The heart rate (HR), respiratory rate (f), end-tidal carbon dioxide tension (ETCO2) and recovery times were evaluated as well. No significant differences were observed between the groups in the BIS variables and the recovery time was longer in GF. Co-administration of propofol and fentanyl infusions, at the doses reported here, did not change the values of BIS in cattle, but delayed the recovery time.

RESUMO: O estudo teve por objetivo avaliar o índice biespectral (BIS) durante a infusão contínua de propofol associado ou não ao fentanil em bezerros. Foram utilizados oito animais machos entre seis e doze meses de idade, holandeses, com massa corporal média de 123±18kg. Todos os animais participaram de ambos os grupos, respeitando-se sempre um intervalo mínimo de uma semana entre uma anestesia e outra, sendo aleatoriamente distribuídos entre os grupos. A anestesia nos bezerros foi induzida com propofol na dose de 5mg kg-1; intravenoso (IV), grupo controle (GP) ou propofol 4mg kg-1 associado ao fentanil 0,001mg kg-1; IV, grupo fentanil (GF) e posicionados em decúbito lateral direito, onde permaneceram respirando espontaneamente ar ambiente. Ato contínuo, a manutenção anestésica foi realizada pela infusão contínua de propofol na taxa de 0,6mg kg-1 min-1; IV GP, associado ou não à infusão de fentanil 0.001mg kg-1 hora-1 GF. A mensuração das variáveis do BIS, índice de qualidade de sinal (IQS) eletromiografia (EMG), frequência cardíaca (FC), frequência respiratória (f) e dióxido de carbono ao final da expiração (ETCO2) foram avaliadas antes da indução anestésica no momento basal (MB), e 15, 30, 45 e 60 minutos após o início da infusão contínua dos fármacos (M15, M30, M45 e M60, respectivamente); o tempo de recuperação também foi avaliado. Não foram observadas diferenças significativas entre os grupos nas variáveis do BIS e o tempo de recuperação foi maior no GF. A co-administração das infusões de propofol e fentanil, nas doses utilizadas nesse estudo, não alterou os valores do BIS em bezerros, porém, prolongou o tempo de recuperação.

Anesthesia recovery comparison between remifentanil-propofol and remifentanil-desflurane guided by Bispectral Index® monitoring / Comparação da recuperação pós-anestésica entre remifentanil-propofol e remifentanil-desflurano guiada pela monitoração do Índice Bispectral®

Abstract Background and objectives There is a strong demand for fast and predictable anesthesia recovery with few side effects. Choice of the hypnotic agent could impact on that. This study investigated the differences between recoveries after remifentanil-propofol and remifentanil-desflurane anesthesias guided by bispectral index (BIS®). Methods Forty patients were randomly assigned into 2 groups according to the anesthesia technique applied: remifentanil-propofol (REM-PRO) and remifentanil-desflurane (REM-DES). After the discontinuation of the anesthetics, the times to extubation, to obey commands and to recover the airway protection reflex were recorted. In the post-anesthetic recovery room (PACU) it was recorded the occurrence of nausea and vomiting (PONV), scores of Ramsay sedation scale and of numeric pain scale (NPS), morphine dose and length of stay in the unit. Results Data from 38 patients were analyzed: 18 from REM-PRO and 20 from REM-DES group. Anesthesia times were similar (REM-PRO = 193 min, SD 79.9 vs. 175.7 min, SD 87.9 REM-DES; p = 0.5). REM-DES had shorter times than REM-PRO group: time to follow command (8.5 min; SD 3.0 vs. 5.6 min; SD 2.5; p = 0.0) and extubation time (6.2 min; 3.1-8.5 vs. 9.5 min; 4.9-14.4; p = 0.0). Times to recover airway protective reflex were similar: 16 patients from REM-PRO (88.9%) restored the airway protective reflex 2 min after extubation vs. 17 from REM-DES (89.5%); and 2 patients from REM-PRO (11.1%) vs. 2 from REM-DES (10.5%) 6 min after extubation, p = 1. Ramsay sedation score, NPS, PONV incidents, morphine dose and PACU stay of length PACU were also similar. Conclusion Remifentanil-desflurane-based anesthesia has a faster extubation time and to follow command than remifentanil-propofol-based anesthesia when both guided by BIS®.

Resumo Justificativa e objetivos Há uma forte demanda por recuperação pós-anestésica rápida e previsível com poucos efeitos adversos. A escolha do agente hipnótico pode influenciar isso. Este estudo investigou as diferenças da recuperação no pós-operatório entre as técnicas anestésicas com remifentanil-propofol e com remifentanil-desflurano ambas com monitoração guiada pelo índice bispectral (BIS ®). Métodos Foram randomicamente distribuídos 40 pacientes em dois grupos de acordo com a técnica anestésica aplicada: remifentanil-propofol (REM-PRO) e remifentanil-desflurano (REM-DES). Após a descontinuação dos anestésicos foram registrados os tempos para extubação, obedecer a comandos e recuperar o reflexo de proteção das vias aéreas. Na sala de recuperação pós-anestésica (SRPA) foi registrado a ocorrência de náuseas e vômitos (NVPO), os escores na escala de sedação de Ramsay e na escala numérica de dor (END), a dose de morfina utilizada e o tempo de permanência nesta unidade. Resultados Os dados de 38 pacientes foram analisados: 18 do grupo REM-PRO e 20 do grupo REM-DES. Os tempos de anestesia foram semelhantes (REM-PRO = 193 minutos, DP 79,9 vs. 175,7 minutos, DP 87,9 REM-DES; p = 0,5). O grupo REM-DES apresentou tempos mais curtos do que o grupo REM-PRO: tempo para obedecer a comandos (8,5 minutos; DP 3,0 vs. 5,6 minutos; DP 2,5; p = 0,0) e tempo de extubação (6,2 minutos; 3,1-8,5 vs. 9,5 minutos; 4,9-14,4; p = 0,0). Os tempos para recuperação do reflexo de proteção das vias aéreas foram semelhantes: 16 pacientes do grupo REM-PRO (88,9%) recuperaram o reflexo de proteção das vias aéreas dois minutos após a extubação vs. 17 do grupo REM-DES (89,5%) e dois pacientes do grupo REM-PRO (11,1%) vs. dois do REM-DES (10,5%) seis minutos após a extubação, p = 1. Os escores de Ramsay, NPS, a incidência de NVPO, a dose de morfina e o tempo de permanência na SRPA também foram semelhantes. Conclusão A anestesia com remifentanil-desflurano tem um perfil de recuperação da anestesia pós-anestésica mais rápido do que o da anestesia com remifentanil-propofol quando ambas guiadas pelo BIS®.

Principles of anesthesia for craniotomy in awake patients / Principios de la anestesia para craneotomía en paciente vigil

La realización de una craneotomía con el paciente despierto se está utilizando cada vez más en diversas situaciones, como en neurocirugía funcional sobre la estimulación cerebral para tratar la enfermedad de Parkinson y la cirugía para tratar la epilepsia, así como los procedimientos neuroquirúrgicos destinadas a resección de tumores cerebrales en áreas elocuentes. Los principios anestésicos para realizar la craneotomía despierta tienen el objetivo de realización de una analgesia adecuada,sedación, la estabilidad hemodinámica sistémica y la permeabilidad de la vía aérea con el tipo de procedimiento neuroquirúrgico a realizar. El objetivo de este estudio es revisar los principios que rigen la conducta de la anestesia para la neurocirugía que es necesario para lograr la craneotomía con el paciente despierto.

Craniotomy in awake patients is becoming more widely used in a range of situations, such as functional neurology, brain stimulation for treatment of Parkinson disease, surgery for treating epilepsy, as well as in neurological procedures to resect brain tumors in eloquent area. The main anesthesia regimen for craniotomy in the awake patient is chosen to provide the appropriate analgesia, sedation, systemic hemodynamic stability and airway patency for the type of neurosurgical procedure being carried out. The objective of the present study was to conduct a review of the principles governing anesthesia for neurosurgeries involving craniotomy in awake patients.

Reincidencia intraoperatoria de probable reacción alérgica al remifentanilo. Informe de caso / Intraoperative recurrence of probable allergic reaction to remifentanil. Case report

Introduction: Although rare, intraoperative anaphylaxis may be life-threatening. Opioids, including remifentanil, have the lowest rates of association with allergic reactions during anaesthesia. Recurrence of anaphylactic reaction after continuation of a remifentanil infusion creates the suspicion of a causal relationship between this agent and the reaction. Case description. Case presentation of anaphylactic reaction during balanced anaesthesia in a 19 year-old female patient. At the start of the surgical procedure, the patient developed refractory hypotension and generalized erythema, which responded to vasopressors, antihistamines and the discontinuation of the anaesthetic agents. The remifentanil infusion was reinitiated later in response to the need of increasing the depth of the anaesthesia, and the anaphylactic reaction recurred. Conclusion: Any medication or potential allergen to which a patient is exposed during the perioperative period may cause anaphylaxis; the usual culprits are neuromuscular blocking agents (NMBA). In 80% of cases of hypersensitivity to medications, the origin is not immunological; the only way to confirm anaphylaxis is by means of biological and skin testing performed in a unit specializing in allergy and anaesthesia. In this case, confirmation was not possible because, in Colombia, the specific technological and biological resources are lacking.

Introducción: La aparición de anafilaxia intraoperatoria es rara pero amenaza la vida de los pacientes. Los opioides son los agentes que menos producen reacciones alérgicas en anestesia, entre ellos el remifentanilo. La reincidencia de la reacción anafiláctica al continuar la infusión de remifentanilo hace particularmente sospechoso este agente como causante de la reacción. Descripción del caso: Se presenta el caso de una reacción anafiláctica durante anestesia balanceada en una paciente de 19 años. Al inicio del acto quirúrgico la paciente presenta hipotensión refractaria y eritema generalizado, que responde al manejo con vasopresores, antihistamínicos y suspensión de los anestésicos. Posteriormente se requiere aumentar la profundidad de la anestesia por lo cual se reinicia infusión de remifentanilo y la reacción anafiláctica reaparece. Conclusión: Cualquier medicamento o posible alérgeno al cual sea expuesto un paciente en el perioperatorio puede ocasionar anafilaxia; los medicamentos más involucrados son los bloqueantes neuromusculares (BNM). El 80% de los eventos de hipersensibilidad a medicamentos no es de origen inmunológico; la única manera de confirmar una anafilaxia es mediante pruebas biológicas y pruebas cutáneas realizadas en una unidad especializada en alergia y anestesia. Este caso no pudo confirmarse debido a que en Colombia no existe este recurso técnico y biológico específico.

Anestesia geral inalatória ou total intravenosa associada à anestesia subaracnoidea, em ovinos / General inhalation anesthesia or total intravenous associated with subarachnoid anesthesia in sheep

Avaliou-se a eficácia e a segurança anestésica em ovinos mantidos sob anestesia geral inalatória com isofluorano ou anestesia total intravenosa com propofol, ambas associadas à anestesia subaracnoidea. Quatorze ovinos foram pré-medicados com 0,3mg.kg-1 de morfina IM, e cinco minutos após, receberam 20mcg.kg-1 de detomidina IV. Posteriormente, foram alocados aleatoriamente em dois grupos: GISO (n=7), os quais foram induzidos à anestesia geral com 0,5mg.kg-1 de diazepam e 5mg.kg-1 de cetamina IV, e mantidos em anestesia geral inalatória com isoflurano diluído em oxigênio a 100%; e GPRO (n=7), induzidos com 4mg.kg-1 de propofol IV seguido inicialmente de infusão contínua na taxa de 0,3mg.kg-1.min-1. Para realização da osteotomia bilateral, todos os animais receberam 0,5mg.kg-1 de ropivacaína 0,75% associado a 0,1mg.kg-1 de morfina pela via subaracnoidea. Houve redução de 40% nos valores médios de frequência cardíaca após sedação em ambos os grupos, permanecendo em média 23% reduzida até o final da avaliação. A pressão arterial média aumentou 16%, após a indução anestésica no GISO, mas se reduziu até o final do procedimento, assim como no GPRO. A EtISO média foi de 0,57V% e a taxa média de infusão do propofol foi de 0,24mg.kg-1.min-1. Os tempos totais de cirurgia, anestesia e extubação foram de 66±9,8, 92±13,8 e 7,0±1,5 minutos no GISO e 56±2,4, 82,9±4,6 e 5,4±1,5 minutos no GPRO, não havendo diferença significativa entre grupos. A manutenção anestésica com isoflurano ou propofol promoveu plano anestésico similar com mínimos efeitos cardiovasculares ou hemogasométricos, que são bem tolerados em ovinos hígidos.

The purpose of this study was to evaluate the efficacy and safety of sheep submitted to inhalation anesthesia with isoflurane or total intravenous anesthesia with propofol, both associated with subarachnoid anesthesia. Fourteen animals were pre-medicated with 0.3mg.kg-1 morphine IM, and 5 minutes later received 20mcg.kg-1 detomidine IV. Then they were allocated into two groups: GISO (n=7), which were induced with 0.5mg.kg-1 of diazepam and 5mg.kg-1 of ketamine IV, and anesthesia maintenance was performed by isoflurane diluted in 100% oxygen; or GPRO (n=7), where animals were induced with 4mg.kg-1 propofol IV and subsequent maintenance anesthesia with its own infusion of 0.3mg.kg.min-1. To perform the bilateral tibial osteotomy, all animals received 0.5mg.kg-1 0.75% ropivacaine combined with 0.1mg.kg-1 morphine by the intrathecal route. There was a 40% reduction in mean heart rate after the sedative protocol in both groups, resulting in a 23% average reduction until the end of the review. Mean arterial pressure showed transient elevation of around 16%, after induction of anesthesia in GISO, but reducing it to the end of the procedure, as well as in GPRO. The average EtISO was 0.57 V% and average infusion rate of propofol was 0.24mg.kg-1.min-1. The total time of surgery, anesthesia and extubation was 66± 9.8, 92±7.0 and 13.8±1.5 minutes in GISO and 56±2.4, 82.9±4.6 and 5.4±1.5 minutes in GPRO. The maintenance of anesthesia with propofol or isoflurane produced similar anesthesia with minimal cardiovascular and blood gas effects, which are well tolerated in healthy sheep.

Efeitos hemodinâmicos da anestesia em plano profundo com infusão intravenosa contínua de propofol ou propofol associado à lidocaína em cães / Hemodynamic effects of deep anesthesia with a constant rate infusion of propopol or propofol combined with lidocaine in dogs

Os efeitos hemodinâmicos da anestesia total intravenosa com propofol ou propofol associado à lidocaína foram estudados em 12 cães. No grupo P (n=6), os animais receberam bolus de 6mg kg-1 de propofol e infusão contínua de 1,25mg kg-1 min-1. No grupo PL (n=6), os animais receberam bolus de 6mg kg-1 de propofol e 1,5mg kg-1 de lidocaína, seguido de infusão de 1,0mg kg-1 min-1 e 0,25mg kg-1 min-1, dos mesmos fármacos, respectivamente. Os animais foram instrumentados para mensuração das variáveis hemodinâmicas e do índice bispectral (BIS), aos 75, 90, 105 e 120 minutos de anestesia. Foram observados valores menores de índice cardíaco, índice sistólico, pressões arteriais sistólica, diastólica e média no grupo P do que no grupo PL (P<0,05). Não foram observadas diferenças entre os grupos na frequência cardíaca, índice de resistência vascular sistêmica e BIS. As concentrações plasmáticas de propofol foram menores no grupo PL do que no grupo P (medianas de 5,7 a 6,1µg mL-1 no grupo P versus 3,1 a 3,7µg mL-1 no grupo PL). As concentrações plasmáticas de lidocaína (medianas de 2,27 a 2,51µg mL-1) mensuradas encontram-se na faixa que resulta em analgesia e abaixo de valores que resultam em toxicidade em cães. Os valores de BIS obtidos nos dois grupos foram compatíveis com plano profundo de anestesia (médias de 43 a 46 e 45 a 49 nos grupos P e PL, respectivamente). A manutenção da anestesia em plano profundo com lidocaína-propofol causa menor depressão cardiovascular do que a anestesia com dose equipotente de propofol isoladamente.

The hemodynamic effects of total intravenous anesthesia with propofol or propofol in combination with lidocaine were investigated in 12 dogs. In the P group (n=6), the dogs received a loading dose (LD) of 6mg kg-1 of propofol followed by a constant rate infusion (CRI) of 1.25mg kg-1 min-1. In the PL group (n=6), dogs received a LD of 6mg kg-1 of propofol and 1.5mg kg-1 of lidocaine followed by CRIs of 1.0mg kg-1 min-1 and 0.25mg kg-1 min-1 of propofol and lidocaine, respectively. The animals were instrumented for measurement of hemodynamic variables and bispectral index (BIS), recorded at 75, 90, 105 and 120 minutes during anesthesia. Cardiac index, stroke index, systolic, diastolic and mean arterial blood pressures were lower in the P group compared to the PL group (P<0.05). There were no significant differences between groups in heart rate, systemic vascular resistance index and BIS. Plasma concentrations of propofol were lower in group PL than in group P (medians of 5.7 to 6.1mg mL-1 in the P group versus 3.1 to 3.7mg mL-1 in the PL group). Measured lidocaine plasma concentrations (medians of 2.27 to 2.51mg mL-1) were in the range that result in analgesia and were below values that result in toxicity in dogs. The BIS values observed in the two groups of dogs were compatible with deep anesthesia (mean values of 43-46 and 45-49 in groups P and PL, respectively). Maintenance of deep anesthesia with lidocaine-propofol causes less cardiovascular depression than equipotent doses of propofol alone.

Research on sevoflurane combined with remifentanil anesthesia inabdominal surgeries / 实用医学杂志

Objective To observe the anesthesia and recovery results of sevoflrane and remifentanil combined anesthesia in open or laparoscopic surgeries. Methods 60 cases of ordinary surgeries from the department of gynecology and general surgeries were included in this study with 30 cases in each group. (1)recording total sevoflurane inhalation time, muscular relaxant amount, end tidal sevoflurane concentration;(2)recording BP,HR at 10 min after induction,operation staring and ending,ventilation recovery, opening eye and extubation period;also sevoflurane concentration 5 min after stopping medicine and ventilation recovery;recording time period between surgery ending and autonomous respiration recovery , eye opening and extubation. Results No any adverse events happen in each patient.the sevoflurane inhalation time in open surgery group was (157.20 ± 47.28) min, longer than that of laparoscopic surgeries group (73.50 ± 11.23)min(P0.05). Conclusion Sevoflurane combined remifentanil anesthesia can achieve stable intra-operative maintenance and rapid postoperative recovery quality , we suggest the widespread usage of it in clinic.

Effects of balanced anesthesia with sevoflurane-remifentanil and total intravenous anesthesia with propofol-remifentanil on postoperative stress responses in patients with stomach cancer

BACKGROUND: The effects of anesthetics on postoperative stress response remains not fully understood. We evaluated the effects of sevoflurane-remifentanil balanced anesthesia and propofol-remifentanil total intravenous anesthesia (TIVA) on postoperative interleukin 6 (IL-6), tumor necrosis factor alpha (TNF-alpha), cortisol, and laboratory test values for patients with stomach cancer. METHODS: Forty patients were randomly assigned to sevoflurane-remifentanil group (group S) and propofol-remifentanil group (group P). Anesthesia was maintained with balanced anesthesia (group S) or TIVA (group P). We measured the IL-6, TNF-alpha, cortisol and performed laboratory tests before (T1) and after surgery (T2). RESULTS: Concentration of IL-6 and cortisol increased (group S: 1.89 +/- 1.69 pg/ml to 47.11 +/- 44.37 pg/ml, 10.68 +/- 4.89 pg/ml to 14.93 +/- 6.79 pg/ml, group P: 1.74 +/- 1.60 pg/ml to 61.58 +/- 48.65 pg/ml, 9.96 +/- 4.40 pg/ml to 14.27 +/- 7.43 pg/ml, respectively) postoperatively in both groups, but there were not different between group S and group P. There were no differences of TNF-alpha between T1 and T2 in both groups. Changes of other laboratory values were indifferent between groups. CONCLUSIONS: The effects of sevoflurane-remifentanil balanced anesthesia and propofol-remifentanil TIVA on postoperative stress responses in patients with stomach cancer were not different. Further investigations are required to assess the effects of anesthetics on other stress response profiles and such significances.

Anestesia local por tumescência com lidocaína em cadelas submetidas a mastectomia / Tumescent local anesthesia with lidocaine in dogs undergoing mastectomy

O presente estudo investigou os benefícios da anestesia por tumescência com lidocaína em cadelas submetidas à mastectomia, visando ao conforto do paciente e à sua recuperação pós-operatória. Foram utilizados sete animais, de peso e raças variadas, que apresentavam neoplasia em região de cadeia mamária e que foram submetidos à cirurgia de mastectomia. Todos os animais receberam o mesmo protocolo anestésico, sendo utilizado como MPA a associação entre acepromazina e morfina, nas doses de 0,04mg/kg e 0,4mg/kg (IM), respectivamente. Após 15 minutos, foi alocado um cateter em veia cefálica e realizou-se a indução com propofol 4mg/kg e midazolam 0,2mg/kg, seguida de manutenção anestésica com isofluorano. Posteriormente à instrumentação, procedeu-se à técnica de anestesia por tumescência com solução gelada composta por ringer lactato, lidocaína 2% sem vasoconstritor e adrenalina, em um volume total de 15mL/kg. Em média, o tempo de duração do procedimento foi de 74±18 minutos. O pico plasmático de lidocaína deu-se entre 30 e 60 minutos após a infiltração da solução. O resgate analgésico foi realizado após sete horas, aproximadamente, da infiltração. Pode-se concluir que a anestesia por tumescência com lidocaína deve ser considerada como constituinte do protocolo anestésico e analgésico de cadelas a serem submetidas à cirurgia de mastectomia, proporcionando estabilidade de parâmetros, segurança e recuperação pós-operatória de boa qualidade.

The present study investigated the benefits of tumescent anesthesia with lidocaine in dogs undergoing mastectomy, seeking the patients' comfort and their postoperative recovery. Seven animals, with different weight and breed, who had cancer in the region of mammary chain underwent mastectomy surgery. All animals received the same anesthetic protocol being used as the association between acepromazine and morphine doses of 0.04mg.kg-1 and 0.4mg.kg-1 (IM), respectively. After 15 minutes a catheter was placed in the cephalic vein and induction with propofol 4mg.kg-1 and 0.2mg.kg-1 followed by maintenance with isoflurane anesthesia was done. After instrumentation, we proceeded to the tumescent anesthesia technique with ice-cold solution consisting of Ringer's lactate, lidocaine 2% without epinephrine and adrenaline in a total volume of 15mL.kg-1. The average duration of the procedure was 74±18 minutes. The plasmatic peak of lidocaine was between 30 and 60 minutes after infiltration. The rescue analgesic was performed after approximately seven hours of infiltration. It can be concluded that the tumescent anesthesia with lidocaine should be considered as a constituent of anesthetic and analgesic protocol in dogs undergoing mastectomy surgery providing parameter stability, safety and good quality postoperative recovery.

The difference in the dose of vasoactive drugs and rocuronium according to the general anesthesia method during open gastrectomy

BACKGROUND: Recently, balanced anesthesia (BA: halogenated volatile anesthetics + remifentanil) has been useful for abdominal surgery. The authors therefore performed a retrospective study about the difference in the dose of vasoactive drugs and rocuronium according to the general anesthesia type. METHODS: BA was compared with inhalational anesthesia (IA: halogenated volatile anesthetics + N2O) and total intravenous anesthesia (TIVA: propofol + remifentanil). The records of a total of 415 patients (IA : TIVA : BA = 126 : 157 : 132) who received open gastrectomy between 2004 to 2010 were analyzed. The types of vasoactive drugs and dosage as well as infusion time were calculated. The total amounts of vasoactive drugs were scored by two different methods. Infusion drugs were scored as 30 points, whereas bolus drugs were scored as 5 points. Drug score is the total sum of each score, where each drug score point split either into Plus or Minus. Plus means raising the blood pressure whereas Minus means the opposite. For rocuronium dosage, a total of 286 patients (IA : TIVA : BA = 89 : 78 : 119) who met the criteria were enrolled, and this formula was used (total rocuronium/weight/time, microg/kg/hr). RESULTS: The BA group showed a lower (P = 0.01) Minus score (1.8 +/- 4.0) compared to the IA group (3.6 +/- 5.2). Less amount of rocuronium (P = 0.001) was administered in the BA (327 +/- 72 microg/kg/hr), compared to the IA (368 +/- 93 microg/kg/hr) and TIVA (356 +/- 81 microg/kg/hr). CONCLUSIONS: BA seems to require less hypotensive agent and rocuronium compared with IA and TIVA for open gastrectomy. But, well-designed prospective studies are required.

NGAL como marcador precoce de lesão renal em ratos submetidos à isquemia renal sob anestesia geral balanceada / NGAL as an early marker of renal injury in rats submitted to renal ischemia under general balanced anesthesia

A lesão renal aguda (LRA) caracterizada como redução abrupta da função renal tem incidência variável, dependendo dos critérios utilizados para sua definição. Atualmente, o mais empregado para avaliação de função renal é a dosagem de creatinina plasmática, porém, por sofrer interferência de vários fatores faz com que a mesma não seja o marcador ideal. Um novo biomarcador da função renal, a lipocalina associada à gelatinase dos neutrófilos (NGAL), tem sido estudado como um dos mais precoces e sensíveis marcadores de lesão de rins após isquemia/reperfusão ou lesão nefrotóxica, sendo facilmente identificada no sangue e na urina. A classificação RIFLE para LRA com a validação da NGAL é uma nova perspectiva para o diagnóstico precoce da LRA e instituição de medidas preventivas e protetoras em situações de risco. O objetivo dessa pesquisa foi avaliar a LRA por meio da dosagem plasmática da NGAL em ratos submetidos à isquemia renal sob anestesia geral balanceada e hidratados com Ringer lactato ou com hidroxietilamido e correlacionar a dosagem da NGAL plasmática com a lesão histológica renal. Em trinta ratos Wistar machos (>350g) distribuídos aleatoriamente em três grupos de dez animais, induzidos com isoflurano a 4%, foi realizada intubação orotraqueal e colocados sob ventilação mecânica. Foram cateterizadas a artéria carótida esquerda e a veia jugular direita para monitorização e coletas sanguíneas. ETCO2, PAMI, T foram continuamente monitorizados (Datex, AS3)...

Acute renal injury (ARI), characterized by abrupt renal function decline, has variable incidence, depending on the criteria used for its definition. Presently, the criterion most often used for kidney function evaluation is plasma creatinine dosing; however, because it suffers interference, it is not an ideal marker. A new renal function biomarker, neutrophil gelatinase-associated lipocalin (NGAL) has been studied as one of the earliest and most sensitive kidney injury marker following ischemia/reperfusion or nephrotoxic injury, and it is easily identified in blood and urine. The RIFLE classification for ARI with NGAL validation is a new perspective for early ARI diagnosis and institution of preventive and protective measures in risk situations. This study aimed at evaluating ARI by means of NGAL plasma dosing in rats submitted to renal ischemia under general balanced anesthesia and hydrated with ringer lactate or hydroxyethylamide and at correlating plasma NGAL dosing with histological renal injury. Thirty male Wistar rats (>350g) were used. They were randomly distributed into three groups with ten animals each and induced by 4% isoflurane. Orotracheal intubation was performed and the animals were placed under mechanical ventilation. The left carotid artery and the right jugular vein were catheterized for monitorization and blood collection. ETCO2, PAMI, T were continuously monitorized (Datex, AS3)...

Anestesia inalatória ou anestesia balanceada em suínos / Inhalation anesthesia or balanced anesthesia in swine

Introdução: O suíno é utilizado como modelo animal em cirurgias experimentais. Objetivos: Visando determinar possíveis alterações nos parâmetros fisiológicos, determinados pela anestesia inalatória e pela anestesia balanceada em pacientes submetidos a toracoscopia, foram utilizados 14 animais entre 15 e 20 Kg, divididos em grupo I (anestesia inalatória) e grupo II (anestesia balanceada). Métodos: Todos os suínos receberam como medicação pré-anestésica, atropina e midazolam. No grupo I (anestesia inalatória), a anestesia geral foi induzida com tiopental sódico e a manutenção realizada com oxigênio em fluxo constante e isoflurano. No grupo II (anestesia balanceada), a anestesia foi induzida por uma associação de fentanil e midazolan, seguidos de tiopental sódico e pancurônio, e submetidos à ventilação mecânica. Além do anestésico inalatório esse grupo recebeu a administração contínua de fentanil e pancurônio a cada 20 minutos. Para comparar os grupos, as variáveis cardiocirculatórias, respiratórias e temperatura foram mensuradas. Resultados: A PaO2 do grupo II, em T0 apresentou uma redução significativa quando comparada ao grupo I, de 415,43 ± 47,35 para 332,06 ± 55,81 mmHg, que pode ser causada pela apnéia após o uso do pancurônio. A PaCO2 do grupo II apresentou uma redução significativa em todos os tempos. Os valores médios dos 04 tempos em mmHg foram no grupo I de 35,33 ± 8,67 e do grupo II de 24,20 ± 10,98, justificada pelo menor metabolismo e menor produção de CO2 com o uso do pancurônio associado aos efeitos da ventilação artificial. Conclusão: O dado sugeri que o uso de bloqueadores neuromusculares associado à ventilação artificial pode reduzir a PaCO2 em cirurgias torácicas em suínos.

Background: Swine have been used as animal models in experimental surgeries. In order to determine possible alterations in the physiological parameters caused by inhalation anesthesia and balanced anesthesia in swine undergoing lateral thoracoscopy, 14 animals weighing 15 to 20 kg were used. The animals were divided into two groups, group I (inhalation anesthesia) and group II (balanced anesthesia). Methods: Both groups received preanesthetic medication (atropine sulphate and midazolam). In group I, anesthesia was induced by the administration of thiopental sodium. Anesthesia was maintained by administering oxygen and isoflurane. In group II, anesthesia was induced by an association between fentanyl and midazolam, followed by thiopental sodium and pancuronium. Then the animals were mechanically ventilated. Anesthesia was maintained with isoflurane and continuous administration of fentanyl and pancuronium every 20 minutes. Cardiocirculatory variables, respiratory and body temperature were measured every 15 minutes during 60 minutes of anesthesia. Results: PaO2 (in mmHg) of group II at T0 presented a significant reduction from 415.43 ± 47.35 to 332.06 ± 55.81, which may be explained by the occurrence of apnea caused by the use of pancuronium. PaCO2 of group II presented a significant reduction at all times measured. Mean values (in mmHg) of the four times in group I and group II were 35.33 ± 8.67 and 24.20 ± 10.98, respectively, which may be explained by reduced muscle metabolism and decreased CO2 production due to the useof pancuronium associated with the effect of artificial ventilation. Conclusion: We concluded that the use of neuromuscular blockers associated with artificial ventilation may reduce the concentrations of PaCO2 in thoracic surgeries in swine.

Compare effects of total intravenous anesthesia and balanced anesthesia on stress response on suspensive laryngoscope vocal cords surgery / 中国临床药理学与治疗学

AIM: To compare the effects of total intravenous anesthesia and balanced anesthesia on stress response on suspensive laryngoscope vocal cords surgery. METHODS: Thirty patients undergone microlaryngeal surgery were randomly divided into two groups(n=15). Analgesia and amnesia slow induction was used in all patiens with nosal incubation. During maintenance of anesthesia, propofol, remifentanil and scopolamine were used in total intravenous anesthesia group(group TIVA); fentanyl, scopolamine and isoflurane were used in balanced anesthesia group(group BAL). Record the data of each group,including base data, after induction, end of tracheal intubation,3 min after intubation, setting the suspensive laryngosopy, 3 min after setting the suspensive laryngosopy, removing the trachea, MAP, HR of each time, the time of recovery. The blood concentrations of epinephrine (E), noradrenalin(NE),cortisol,IL-6 were measured at each time point of base data, end of tracheal intubation, setting the suspensive laryngosopy, 3 min after setting the suspensive laryngosopy. RESULTS: There is no significant difference of HR, MAP, blood concentration of E,NE, cortisol, IL-6 at end of tracheal intubation compared with base data. AT setting the suspensive laryngosopy,3 min after setting the suspensive laryngosopy, HR, MAP, blood concentrations of E, NE, cortisol, IL-6 in group BAL were all higher than that of base data,and were also higher than group TIVA at the same time. The recovery time of group TIVA was shorter than that of group BAL. CONCLUSION: Analgesia and amnesia slow induction with nosal intubaion and maintenance with remifentanil, propofol can inhibit sudden change of hemodynamics and stress response of intubation and setting the suspensive laryngoscope, with quicker recovery .It is an ideal anesthesia method for suspensive laryngoscope vocal cords surgery.

Anesthetic Management for Surgical Ablation of Accessory Conduction Pathways / 대한마취과학회지

The Wolff-Parkinson-White (W-P-W) syndrome and variants are called the pre-excitation sydrome. The prevalence has been estimated 0.15 pereent. Advances in electrophysiological mapping and increasing sophistication of surgical techniques have been resulted in an increasing role for definitive surgical treatment. The anesthetic management of patients with this syndrome is aimed at avoiding tachyarrhythmias. Anesthesia for surgical ablation of accessory conducting pathways was successfully performed under general balanced technique with fentantyl, vecuronium, isoflurane which were avoid of sympathetic stimulation.

Balanced Anesthesia with Buprenouphine - N2O - O2 for Cesarean Section / 대한마취과학회지

Balanced anesthesia with the potent opioid analgesics for cesarean section is preferential technique than N2O-O2 with single inhalation anesthetics due to avoid the decreased uterine muscle tone or vigorous postpartum blood loss. The 60 patients were randomly assigned to study the two group so that 30 patients were administered Buprenorphine(B group) or fentanyl(F group) anesthesia. The hemodynamic responses and recovery characteristics of the two groups were compared with each other. The patients who received the analgesics for postoperative pain control were observed. The results were as follows ; 1) The systolic and diastolic blood pressure at 10 min after injection of fentanyl was significantly lower than preinduction time. 2) The diastolic pressure at 10 minute after injection of buprenorphine was significantly lower than pre-induction. 3) There was no difference between the two patient groups in the blood pressure, the heart rate. 4) postoperative recall was 1 patients in the F group and 3 patients in B group. 5) The 24 patients were injected analgesics. Among them 10 patients(33.3%) were in the B group and 16 patients(53.3%) were in the F group. The authors conclude that balanced anesthesia with buprenorphine is a practical altemative technique to fentanyl for cesarean section patients.