Riesgos y complicaciones durante la sedación para endoscopía diagnóstica del tubo digestivo sin enfermedad concomitante / Risks and complications during sedation for diagnostic endoscopy of the gastrointestinal tract without concomitant disease

Resumen: Durante la sedación en procedimientos endoscópicos del tubo digestivo alto y bajo, es frecuente que se susciten complicaciones ventilatorias y hemodinámicas. Se presenta una revisión de las estrategias para prevenir y tratar las complicaciones ventilatorias más frecuentes: espasmo laríngeo, apnea por fármacos anestésicos endovenosos y broncoespasmo. También se revisan las complicaciones hemodinámicas: reflejo vagal e hipotensión aguda. Se propone un algoritmo de manejo que sintetiza y esquematiza las medidas profilácticas y terapéuticas descritas en la literatura, ordenándolas de acuerdo a su prioridad y eficacia, permitiendo identificar con claridad el nivel de tratamiento necesario y la viabilidad del procedimiento endoscópico.

Abstract: During sedation in endoscopic procedures of the lower and upper digestive tract, it is common for ventilatory and hemodynamic complications to arise. This article presents a review of the strategies to treat and prevent the most common ventilatory complications: laryngeal spasm, apnea due to intravenous anesthetic drugs and bronchospasm. Hemodynamic complications are also reviewed: vagal reflex and acute hypotension. A management algorithm is proposed which synthesizes and schematizes the prophylactic and therapeutic measures described in the bibliography, ordering them by their priority and effectiveness, allowing to clearly identify the degree of treatment necessary and the viability of the endoscopic procedure.

Case Analysis of One Acute Hypotension Adverse Event after PCI Participated by Clinical Pharmacist / 中国药师

Clinical pharmacist participated in the whole process of drug therapy for one case of acute hypotension adverse event af-ter PCI. Based on the patient's preoperative and postoperative medication, the hypothesis was proposed and the causes of acute hypo-tension were positively analyzed. From the perspective of pharmacology, professional advice was given and satisfactory therapeutic effects were obtained. The experience of pharmaceutical care after PCI was summarized as well.

Clinical Research on Reducing Vagal Reflex during RFCA / 昆明医科大学学报

Objective To discusse the mechanism and clinical significance of bradycardia -hypotension phenomenon which is caused by vagal reflex during and after the RFCA and present the experience of using appropriate measures to decrease the incidence of this situation. Methods The patients who were suffering from tachyarrhythmias and treated by RFCA were divided into two groups. The groups were as follows:148 patients who were not taken special measures in the early stage were selected in control group;1 540 patients who were taken measures to prevent vasovagal reflex were selected in observation group. Result During the RFCA, the incidence of bradycardia -hypotension phenomenon in control group was 13.5% (20/148), the incidence of bradycardia-hypotension phenomenon in observation group was 5.0%(77/1540) (<0.01) .Conclusions The incidence of bradycardia-hypotension phenomenon caused by vagal reflex during the RFCA is related to catheter irritation to the heart,pressure on the vessels and hypovolemia. The incidence of this phenomenon can be decreased obviously by some measures,such as non-restricted diet before RFCA,discretion rehydration during and after the RFCA and hemostasis with appropriate force after extubation. The key to rescue patients successfully are early detection and timely processing.

Resposta cronotrópica ao teste anaeróbio máximo de corrida - MART / Chronotropic response to maximal anaerobic running test - MART

INTRODUÇÃO: A frequência cardíaca (FC) no teste anaeróbio máximo de corrida (MART) expressa o comportamento autonômico cardíaco em exercício. Ainda não foi investigado se tais respostas cronotrópicas apresentam associação com o desempenho aeróbio e anaeróbio. OBJETIVOS: Descrever a resposta cronotrópica cardíaca durante o MART nos segundos iniciais de estímulo (FC ON) e de recuperação (FC OFF) e estabelecer a associação entre as variáveis cronotrópicas com o desempenho aeróbio e anaeróbio. MÉTODOS: Foram voluntários 13 homens assintomáticos e fisicamente ativos, com 25,1 ± 4,9 anos, 76,8 ± 12,5 kg, 178,4 ± 9,0 cm e 50,6 ± 4,1 mL×kg‑1×min‑1. Na primeira visita, após a anamnese e medidas antropométricas, foi realizado um teste cardiopulmonar de exercício (TCPE) com monitoração direta dos gases expirados. Na segunda visita, foi feita uma familiarização ao MART e na terceira, o teste de MART conduzido até a exaustão. RESULTADOS: A FC de recuperação (58 ± 20 bpm) comparada à FC de pico alcançada no primeiro e no último estágio de MART (39 ± 14 bpm) apresentou maior inclinação, resultando em maior amplitude de variação ao longo do teste, caracterizando diferenças significativas (P = 0,0017). A FC ON apresentou entre o momento inicial, meio e final do MART diferenças significativas (inicial versus final, p = 0,007). Para FC OFF foram encontradas diferenças significativas do início com o meio (p = 0,035) e do início com o final (p = 0,005) do teste. As correlações entre as variáveis cronotrópicas e de desempenho não apresentaram significância estatística (P < 0,05), assim como com as variáveis de desempenho. CONCLUSÃO: O MART parece ser um modelo de sobrecargas fisiológicas adequado para investigação da modulação autonômica cardíaca. Observou-se atuação do sistema parassimpático mesmo em cargas supramáximas até o final do teste.

INTRODUCTION: Heart rate (HR) in maximal anaerobic running test (MART) expresses the cardiac autonomic behavior in exercise. It has not been investigated whether such responses are associated with chronotropic aerobic and anaerobic performance. OBJECTIVE: To describe the cardiac chronotropic response during the MART in seconds of stimulation (HR ON) and recovery (HR OFF), and establish the association between chronotropic variables with aerobic and anaerobic performance. METHODS: Thirteen male volunteers were asymptomatic and physically active, with 25.1 ± 4.9 years, 76.8 ± 12.5 kg, 178.4 cm and 50.6 ± 9.0 ± 4.1 mL×kg-1×min-1. On the first visit after the interview and anthropometric measurements, we performed a cardiopulmonary exercise testing (TCPE) with direct monitoring of expired gases. The second visit was carried to familiarize the MART and the third, the test was performed until exhaustion MART. RESULTS: Heart rate recovery (58 ± 20 bpm) compared to the peak HR achieved in the first and last stage of MART (39 ± 14 bpm) had a higher slope, resulting in greater range of variation over the test, characterizing differences (P = 0.0017). The HR ON presented between the time the initial, middle and end of the MART significant differences (start versus final, p = 0.007). To HR OFF significant differences were found starting with the middle (p = 0.035) and the starting to the final (p = 0.005) test. The chronotropic correlations between variables, including decrease in HR, and TCPE performance were not statistically significant (P < 0.05), as nor as the performance variables. CONCLUSION: The MART model seems to be a physiological overload suitable for investigation of cardiac autonomic modulation. There was action of the parasympathetic system even in supramaximal loads by the end of the test.

Asystole during manipulation with a curved-blade laryngoscope and tracheal intubation in patient with a history of syncope: A case report

Vagal reflex during manipulation with a curved-blade laryngoscope and tracheal intubation may result in severe bradycardia and even, asystole. Manipulation with laryngoscope and tracheal intubation leaded to bradycardia and asystole at a 47-year-old woman during induction of anesthesia with propofol, remifentanil and cisatracurium and sevoflurane inhalation. Withdrawal of laryngoscope and atropine 0.5 mg injection, her heart rate was recovered to normal sinus rhythm. Intubation at secondary trial was done with bradycardia and heart rate was returned to normal sinus rhythm soon. She had a history of syncope in interview after surgery and was examined tilt test to find of cause of syncope. Although the result of the test was negative, the bradycardia and asystole seemed to be caused by vagal reflex.

Severe bradycardia during suspension laryngoscopy performed after tracheal intubation using a direct laryngoscope with a curved blade: A case report / 대한마취과학회지

There are a few reports about bradycardia or asystole caused by direct laryngoscopy. However, we encountered severe bradycardia in response to suspension laryngoscopy for laryngeal polypectomy after safely completing tracheal intubation using a direct laryngoscope with a curved blade. The tip of the curved blade of the direct laryngoscope is positioned at the vallecula (between the base of the tongue and the pharyngeal surface of the epiglottis) during tracheal intubation, while the blade tip of the suspension laryngoscope lifts the laryngeal surface of the epiglottis or supraglottic area during surgery. Therefore, suspension laryngoscopy can be said more vagotonic than curved-blade direct laryngoscopy. Because of the possibility of bradycardia induced by suspension laryngoscopy, clinicians must be careful about severe bradycardia even after safely completing intubation using direct laryngoscopy.

A Case of Bradycardia due to Vagal Reflex during Laryngeal Microsurgery / 대한이비인후과학회지

Laryngeal microsurgery has been used popularly for phonosurgery. Sometimes, this procedure is complicated by cardiovascular changes due to insertion of laryngosope. Tachycardia and elevation of blood pressure are common but bradycardia induced by vagal reflex is very rare. The authors report the case of severe bradycardia induced by vagal reflex experienced during laryngeal microsurgery with a review of the literature.

Causes of a Sudden Hypotension on Preanhepatic Stage during Liver Transplantation / 대한마취과학회지

BACKGROUND: Various hemodynamic disturbances and a rapidly changing circulatory blood volume necessitate the proper management of fluid administration. The causes of sudden hypotension can be anticipated with the usual monitoring devices. However, more accurate diagnosis of such event can only be made by actual measurement of cardiac output. And such an event may be related to cardiac depression due to autonomic disturbances. To elucidate the cause of sudden unexplainable hypotension during the preanhepatic stage, we analysed the hemodynamic data of patients undergoing liver transplantation prospectively. METHODS: Patients were divided into a normal and a hypotensive group, according to the presence of an episode of hypotension. The hypotensive group was further divided into an explainable and an unexplainable group, if causes were known or not. Preoperative echocardiograms and Child-Pugh scors were also analysed. The normal and unexplainable hypotensive groups were compared using Mann-Whitney non-parametric, Chi-square and Wilcoxon-signed rank tests. P<0.05 was considered statistically significant. RESULTS: The incidence of hypotension was 25.2%. A severe unexplainable hypotensive episode occurred 9.3% of the the liver transplantations. Causes of hypotension were preload deficiency, vena caval compression, bleeding, and vagal reflex. Unexplainable hypotensive patients showed decreased ejection fraction (cardiac depression) and systemic vasodilatation. CONCLUSIONS: These results suggest hepato-dyscirculatory syndrome is the main cause of unexplainable hypotension during the preanhepatic stage.