Bioética en donantes en asistolia controlada

Las campañas de prevención y promoción de salud, así como los avances en las medidas terapéuticas destinadas a los pacientes neurocríticos, han logrado reducir la incidencia de pacientes con injuria encefálica aguda (IEA) que evolucionan a la muerte encefálica (ME). Sin embargo, en la mayoría de los países de América Latina, los órganos perfusibles aptos para trasplante (TX) provienen de donantes fallecidos en ME. La donación en asistolia (DA), y en particular la donación en asistolia controlada (DAC), constituye una opción aceptada y válida para la obtención de órganos que contribuiría a la disminución de las listas de espera para trasplante. Durante el proceso de DAC, se aplican conceptos con fuerte impronta bioética cuya aplicación resulta fundamental en el momento de la toma de decisiones. El presente artículo tiene el objetivo de analizar dichos conceptos con la finalidad de otorgar herramientas válidas al equipo asistencial para aquellos procesos en los que existe deliberación moral, como ocurre en la donación de órganos en asistolia controlada, considerada parte integral de los cuidados al final de la vida.

Campaigns for health prevention and promotion, along with advancements in therapeutic measures for neurocritical patients, have succeeded in reducing the incidence of patients with acute brain injury (ABI) progressing to brain death (BD). However, in most Latin American countries, suitable perfusable organs for transplantation (TX) come from deceased donors in brain death (BD). Donation after circulatory death (DCD), particularly controlled donation after circulatory death (cDCD), represents an accepted and valid option for organ procurement that would contribute to reducing transplant waiting lists. During the cDCD process, strong bioethical principles are applied, and their implementation is crucial when making decisions. The purpose of this article is to analyze these concepts, aiming to provide valid tools to the healthcare team for processes involving moral deliberation, such as controlled circulatory death organ donation, considered an integral part of end-of-life care.

As campanhas de prevenção e promoção da saúde, bem como os avanços na medidas terapêuticas voltadas para pacientes neurocríticos conseguiram reduzir a incidência de pacientes com lesão cerebral aguda que evoluem para morte encefálica (ME). No entanto, na maioria dos países latino-americanos, os órgãos que podem ser perfundidos adequados para transplante (TX) vêm de doadores falecidos em ME. A doação em assistolia e em particular a doação em assistolia controlada (DAC),é uma opção aceita e válida para a obtenção de órgãos, o que contribuiria para a redução das listas de espera para transplantes. Durante o processo DAC, são aplicados conceitos com forte cunho bioético, que são fundamentais na o momento da tomada de decisão. Este artigo tem como objetivo analisar esses conceitos, com o objetivo de oferecer ferramentas válidas à equipe de saúde, para os processos em que há deliberação moral como ocorre na doação de órgãos em assistolia controlada considerada parte integrante dos cuidados de fim de vida.

Epidemiology of pediatric cardiopulmonary resuscitation / Epidemiologia da ressuscitação cardiopulmonar pediátrica

Abstract Objective: To analyze the main epidemiological aspects of prehospital and hospital pediatric cardiopulmonary resuscitation and the impact of scientific evidence on survival. Source of data: This was a narrative review of the literature published at PubMed/MEDLINE until January 2019 including original and review articles, systematic reviews, meta-analyses, annals of congresses, and manual search of selected articles. Synthesis of data: The prehospital and hospital settings have different characteristics and prognoses. Pediatric prehospital cardiopulmonary arrest has a three-fold lower survival rate than cardiopulmonary arrest in the hospital setting, occurring mostly at home and in children under 1 year. Higher survival appears to be associated with age progression, shockable rhythm, emergency medical care, use of automatic external defibrillator, high-quality early life support, telephone dispatcher-assisted cardiopulmonary resuscitation, and is strongly associated with witnessed cardiopulmonary arrest. In the hospital setting, a higher incidence was observed in children under 1 year of age, and mortality increased with age. Higher survival was observed with shorter cardiopulmonary resuscitation duration, occurrence on weekdays and during daytime, initial shockable rhythm, and previous monitoring. Despite the poor prognosis of pediatric cardiopulmonary resuscitation, an increase in survival has been observed in recent years, with good neurological prognosis in the hospital setting. Conclusions: A great progress in the science of pediatric cardiopulmonary resuscitation has been observed, especially in developed countries. The recognition of the epidemiological aspects that influence cardiopulmonary resuscitation survival may direct efforts towards more effective actions; thus, studies in emerging and less favored countries remains a priority regarding the knowledge of local factors.

Resumo Objetivo: Analisar os principais aspectos epidemiológicos da ressuscitação cardiopulmonar pediátrica pré-hospitalar e hospitalar e o impacto das evidências científicas na sobrevida. Fonte de dados: Revisão narrativa da literatura publicada em Pubmed/Medline até janeiro de 2019, inclusive artigos originais e de revisão, revisões sistemáticas, metanálises, anais de Congresso, além de busca manual dos artigos selecionados. Síntese dos dados: Os cenários pré-hospitalar e hospitalar apresentam características e prognósticos distintos. A parada cardiorrespiratória pré-hospitalar pediátrica apresenta sobrevida três vezes menor do que a hospitalar, ocorre em sua maioria nas residências e nos menores de um ano. A maior sobrevida parece estar associada a progressão da idade, ritmo chocável, atendimento por serviço médico de emergência, uso de desfibrilador externo automático, suporte básico de vida precoce de alta qualidade e orientação de ressuscitação cardiopulmonar via telefônica por atendente e está fortemente associada com parada cardiorrespiratória presenciada. No cenário hospitalar, observou-se maior incidência em menores de um ano e mortalidade crescente com a idade. Maior sobrevida foi observada quanto a menor duração da ressuscitação cardiopulmonar, ocorrência em dias da semana e período diurno, ritmo chocável inicial e monitoração prévia. Apesar do prognóstico reservado da ressuscitação cardiopulmonar pediátrica, observou-se nos últimos anos incremento da sobrevida com bom prognóstico neurológico no cenário hospitalar. Conclusões: Houve grande avanço na ciência da ressuscitação cardiopulmonar pediátrica, especialmente em países desenvolvidos. O reconhecimento dos aspectos epidemiológicos que influenciam a sobrevida da ressuscitação cardiopulmonar pode direcionar esforços para ações mais efetivas. Assim, a pesquisa em países emergentes e menos favorecidos persiste como prioridade no conhecimento de fatores locais.

Asystole in an older patient with recurrent falls. case report

ABSTRACT Introduction: Recurrent falls are a usual problem in older patients. It is therefore important to learn how to differentiate a pathological or syncopal episode from a simple stumbling fall, especially in patients who have limitations for communicating clearly and are poorly understood, in general terms, during the medical consultation. Implantable loop recorders (ILR) have been used as an investigation tool in selected cases of recurrent falls in older patients. Consequently, this case report aims to describe its usefulness in this type of patients. Case presentation: An 87-year-old female patient, hypertensive, with a history of recent stroke and frequent falls -referred to as stumbling-, received an implantable loop recorder due to atrial fibrillation. During one follow-up appointment, a 36-second pause related to a fall was documented, so a bicameral pacemaker was implanted. Conclusions: Evaluating repeated falls in older patients is complex; it must be done in detail to rule out syncopal episodes. Implantable devices to diagnose arrhythmic causes are useful and allow achieving accurate diagnoses and establish specific behaviors aimed at improving the quality of life of patients.

RESUMEN Introducción. Las caídas frecuentes son un problema común en pacientes de la tercera y la cuarta edad, por tanto es importante saber diferenciar cuando se trata de un evento patológico o sincopal, y cuando es un simple tropiezo, sobre todo en pacientes que tienen limitaciones para comunicarse de forma clara y son poco entendidos en términos generales durante la consulta médica. Los monitores de eventos cardiacos pueden ser usados en casos seleccionados de caídas frecuentes en adultos mayores para determinar las posibles causas de estos eventos, por lo que el presente reporte de caso pretende mostrar cuál es su utilidad en un paciente con caídas no sincopales a repetición. Presentación del caso. Paciente femenina de 87 años, hipertensa, con evento cerebrovascular reciente e historia de caídas a repetición referidas como tropiezos, a quien se le implantó un dispositivo diagnóstico de fibrilación auricular. En uno de los controles se observó pausa de 36 segundos relacionada con episodio de caída, por lo que se implantó un marcapasos bicameral. Conclusiones. La evaluación de caídas a repetición en pacientes mayores es compleja y debe realizarse de forma detallada para descartar síncope. El uso de monitores de eventos cardiacos para la identificación de causas arrítmicas de estos eventos permite diagnósticos certeros, con lo que a su vez es posible establecer tratamientos específicos que mejoren la calidad de vida de los pacientes.

Severe bradycardia and asystole associated with sugammadex: case report / Bradicardia grave e assistolia associadas ao sugamadex: relato de caso

Abstract Background and objectives: Sugamadex is a modified gamma-cyclodextrin, the first selective agent for reversal of neuromuscular blockade induced by steroidal non-depolarizing muscle relaxants, with greater affinity for rocuronium. In this article we present a case of severe bradycardia and asystole following sugammadex administration. Case report: A 54-year-old male patient, ASA II, with a history of hypertension, dyslipidemia and obesity, who underwent an emergency umbilical herniorrhaphy under balanced general anesthesia. Intraoperative muscle relaxation was maintained with rocuronium. At the end of the surgery, the patient maintained a neuromuscular block with two TOF responses, and sugammadex (200 mg) was administered. About thirty seconds after its administration, the patient developed marked bradycardia (HR 30 bpm) followed by asystole. Conclusions: Documented bradycardia and asystole were attributed to the administration of sugammadex. This case shows that, although rare, cardiac arrest is a possible adverse effect of this drug, and that the knowledge of this situation can be determinant for the patient's evolution.

Resumo Justificativa e objetivos: O sugamadex é uma gama ciclodextrina modificada, o primeiro agente seletivo para reversão do bloqueio neuromuscular induzido pelos relaxantes musculares não despolarizantes do tipo esteroide, com maior afinidade para o rocurônio. Neste artigo apresentamos um caso de bradicardia grave e assistolia após administração de sugamadex. Relato do caso: Doente do sexo masculino, 54 anos, ASA II, com antecedentes pessoais de hipertensão, dislipidemia e obesidade, submetido à herniorrafia umbilical em regime de urgência sob anestesia geral balanceada. O relaxamento muscular intraoperatório foi mantido com rocurônio. No fim da cirurgia o doente mantinha bloqueio neuromuscular com duas respostas no TOF, pelo que foi administrado sugamadex 200 mg. Cerca de trinta segundos após a sua administração, o doente desenvolveu bradicardia acentuada (FC 30 bpm) seguida de período de assistolia. Conclusões: A bradicardia e a assistolia documentadas foram atribuídas à administração do sugamadex. Este caso evidencia que, apesar de rara, a parada cardíaca é um efeito adverso possível desse fármaco e que o conhecimento dessa situação pode ser determinante para a evolução do doente.

Breve reseña del reflejo trigémino cardíaco / Trigeminocardiac Reflex: an Overview

RESUMEN El reflejo trigémino cardíaco es un reflejo único del tallo cerebral que se manifiesta como perturbaciones cardiorespiratorias, y ocurre principalmente en cirugías o intervenciones de la base del cráneo. Sin embargo, recientemente se lo ha vinculado a muchos procedimientos de neurocirugía e intervenciones neurológicas y condiciones no relacionadas a neurocirugía y no quirúrgicas. Este reflejo presenta muchas alteraciones cardiovasculares que pueden provocar complicaciones adversas, empeorar la evolución y producir problemas diagnósticos. Esta reseña intenta profundizar su definición, mecanismos, fisiopatología, manifestaciones, diagnóstico y manejo.

ABSTRACT Trigemino-cardiac reflex is a unique brain stem reflex that manifests as negative cardio-respiratory perturbations. This reflex is largely reported in skull base surgeries/interventions; however, in recent times, it has been also linked with many neurosurgical, neurointerventional procedures, non-neurosurgical and non-surgical conditions. This reflex presents with many cardiovascular changes that can create catastrophic complications, worse outcome as well as diagnostic dilemmas. Therefore, this narrative review intends to elaborate on its mechanisms, definition, pathophysiology, manifestations, diagnosis and management.

Ictal Asystole Caused by Epileptic Seizure due to Brain Metastases

<p>Bradycardia or asystole during epileptic seizure are referred to as ictal bradycardia syndrome. Ictal asystole is very rare, and there is no report about ictal bradycardia syndrome caused by brain metastases. A 62-year old man was diagnosed as having lung cancer and had multiple brain metastases. The patient had no history of epilepsy and syncope. The patient developed cardiac asystole with sinus arrest for up to 16 seconds. The bradycardia was associated with other signs and symptoms, including abdominal pain, nausea, low blood pressure, sinus arrest, decreased level of consciousness, and staring at a single point. Electroencephalograms showed multiple sharp waves. Repeated seizures, ictal asystole, and coexisting symptoms disappeared after improved treatment of brain metastases by radiation therapy. Therefore, a diagnosis of ictal asystole caused by brain metastases was made. There is no recommended treatment for ictal bradycardia syndrome. However, in the case of ictal bradycardia syndrome caused by brain metastases, treatment of the metastatic tumor might be useful. When patients with cancer present with syncope or sick sinus syndrome, we should consider the possibility of cardiac arrest caused by an epileptic seizure.</p>

Cardiac complications in a metamizole-induced type I Kounis syndrome / Complicações cardíacas em síndrome de Kounis tipo I induzida por metamizol

ABSTRACT Kounis syndrome is defined as the coincidental occurrence of allergic reaction and acute coronary syndrome secondary to vasospasm. Anti-inflammatory drugs are included as one of the multiple causes. Current data available about this syndrome come from case reports. We present the case of a patient who suffered Kounis syndrome with cardiogenic shock and asystole after intravenous infusion of Metamizole, and in which no lesions were observed in coronariography.

RESUMO A síndrome de Kounis é definida como a ocorrência concomitante de reação alérgica e síndrome coronariana aguda secundária ao vasoespasmo. Os medicamentos anti-inflamatórios estão incluídos como uma das múltiplas causas. Os dados atuais disponíveis sobre essa síndrome são provenientes de relatos de caso. Relatamos o caso de um paciente que apresentou síndrome de Kounis com choque cardiogênico e assistolia após infusão intravenosa de metamizol e no qual não foram observadas lesões na coronariografia.

Ictal sinus pause and myoclonic seizure in a child / 소아과

Ictal tachycardia and bradycardia are common arrhythmias; however, ictal sinus pause and asystole are rare. Ictal arrhythmia is mostly reported in adults with temporal lobe epilepsy. Recently, ictal arrhythmia was recognized as a major warning sign of sudden unexpected death in epilepsy. We present an interesting case of a child with ictal sinus pause and asystole. A 27-month-old girl was hospitalized due to 5 episodes of convulsions during the past 2 days. Results of routine electroencephalography (EEG) were normal, but she experienced brief generalized tonic seizure for 3 days. During video-monitored EEG and echocardiography (ECG), she showed multiple myoclonic seizures simultaneously or independently, as well as frequent sinus pauses. After treatment with valproic acid, myoclonus and generalized tonic seizures were well controlled and only 2 sinus pauses were seen on 24-hour Holter ECG monitoring. Sinus dysfunction should be recognized on EEG, and it can sometimes be treated successfully with only antiepileptic medication.

Trigemino-cardiac reflex: occurrence of asystole during trans-sphenoidal adenomectomy: a case report / 대한마취과학회지

The trigemino-cardiac reflex has been reported to occur during various craniofacial surgeries or procedures including manipulation of the trigeminal ganglion, tumor resection in the cerebellopontine angle, various facial reconstructions and trans-sphenoidal adenomectomy. Regarding risk factors during trans-sphenoidal adenomectomy, invasiveness closely related to the size of tumor and the degree of manipulation of cavernous sinus wall have been reported. We report the case of a 40-year-old female patient who had a relatively small-sized (< 10 mm) pituitary adenoma. Repetitive asystoles occurred during microscopic trans-sphenoidal operation of the wall of the cavernous sinus, which strongly suggests the importance of careful manipulation of the cavernous sinus wall. In addition to reporting this rare complication of trans-sphenoidal adenomectomy, we reviewed its clinical management by performing a literature search.

Recurrent Syncope Triggered by Ictal Asystole

No abstract available.

Permanent Pacemaker Implantation in a Patient with Cardiac Syncope Associated with Glossopharyngeal Neuralgia / 대한내과학회지

Glossopharyngeal neuralgia is a rare disease that is characterized by sharp pain in the posterior pharynx, tonsils, and larynx, triggered by swallowing. Glossopharyngeal neuralgia can trigger bradycardia or asystole, which can induce life-threatening cardiac syncope. A 55-year-old male was admitted with severe paroxysmal pain in his left jaw and ear, followed by asystole and syncope. We report a patient with cardiac syncope associated with glossopharyngeal neuralgia treated with a permanent pacemaker.

Permanent Pacemaker Implantation in a Patient with Cardiac Syncope Associated with Glossopharyngeal Neuralgia / 대한내과학회지

Glossopharyngeal neuralgia is a rare disease that is characterized by sharp pain in the posterior pharynx, tonsils, and larynx, triggered by swallowing. Glossopharyngeal neuralgia can trigger bradycardia or asystole, which can induce life-threatening cardiac syncope. A 55-year-old male was admitted with severe paroxysmal pain in his left jaw and ear, followed by asystole and syncope. We report a patient with cardiac syncope associated with glossopharyngeal neuralgia treated with a permanent pacemaker.

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.

Transient adenosine-induced asystole in the surgical treatment of intracranial aneurysms: A report of two cases

Advances in anesthetic and surgical management, such as deep hypothermic circulatory arrest and temporary clipping, have improved outcomes for intracranial aneurysm patients. However, these techniques are associated with significant risks. We report on two cases in which adenosine administration was used to induce transient periods of cardiac asystole during intracranial aneurysm surgery. This asystole resulted in profound hypotension and collapse of the aneurysm, which facilitated its safe clipping.

Ventricular Asystole and Arrhythmia during Surgery Provoked by Profound Hypothermia / 대한내과학회지

A 55-year-old man underwent a posterior decompression and fusion under general anesthesia. Near the end of the operation, the pressure waveform from the radial artery became flat, and his oxygen level could not be measured using pulse oximetry. Palpation of the carotid artery revealed no heart rate, and ventricular asystole was diagnosed. The patient was given cardiovascular drugs, but his hemodynamic status deteriorated, leading to severe hypotension, with sinus bradycardia, sinus tachycardia, sinus arrest, and paroxysmal supraventricular tachycardia. The patient had hypothermia based on an axillary temperature of 31.9degrees C. After active warming, his cardiovascular status stabilized.

Asystole induced by laryngosopy and tracheal intubation after induction of general anesthesia: A case report / 대한마취과학회지

Vagal reflex during laryngosopy and tracheal intubation may result in cardiac arrhythmia such as bradyarrhythmia and asystole. A 66-year-old woman, scheduled for coronary artery bypass surgery, received intravenous bolus of midazolam 2 mg, sufentanil 50 microgram, and vecuronium 10 mg for induction of general anesthesia. After two minutes of manual ventilation, tracheal intubation was attempted and the patient became asystolic during laryngoscopic manipulation. The laryngoscope was immediately withdrawn, and the patient returned to normal sinus rhythm. Ten minutes later, more experienced practitioner performed the second laryngoscopic intubation, but it eventually induced asystole again. External cardiac massage was commenced and normal sinus rhythm retuned at a rate of 60 beats/min after 1-2 minute later.

Asystole via Trigeminocardiac Reflex during Skin Flap Elevation in a Patient Undergoing Craniotomy for Cerebral Aneurysm Clipping: A case report / 대한마취과학회지

The trigeminocardiac reflex (TCR) consists of the sudden development of severe bradycardia or even asystole with arterial hypotension during manipulation of branches of the trigeminal nerve. TCR can occur during craniofacial surgery, rhizolysis of the trigeminal ganglion, and tumour resection in the cerebellopontine angle. We report a case of TCR-induced asystole during skin flap elevation in a patient undergoing craniotomy for cerebral aneurysm clipping.

The Effect of Mild Therapeutic Hypothermia on the non-Vf Cardiac arrest

PURPOSE: Therapeutic hypothermia has been recommended for postcardiac arrest coma due to ventricular fibrillation (Vf). However, although it is well known that the cardiac arrest due to non-Vf is associated with poorer neurologic outcome that Vf, there is no study that evaluates the effect of mild hypothermia on the cardiac arrests due to non-Vf. So, we intend whether mild hypothermia would improve the neurologic outcome of them saftly. METHODS: We retrospectively analyzed the patients with cardiac arrest due to asystole or pulseless electrical activity who was presented at hopsital and successfully showed the return of spontaneous circulation. We divided the patients to two groups according to implementation of hypothermia and statistically compared the complication and neurologic outcome at discharge. RESULTS: A total of sixty one patients were analyzed in this study. Baseline clinical and physiological characteristic were similar between patients treated with mild hypothermia or with conservative treatment. The complication rate did not differ significantly between the two groups. However, the good outcome at hospital discharge was observed in 13 of 41 patients treated with mild hypothermia compared with 0 of 27 patients treated with conservative treatment. CONCLUSION: Mild therapeutic hypothermia for the treatment of postcardiac arrest due to non-Vf can be saftly implemented with a major benefit on patient outcome.

Severe bradycardia and transient asystole during epidural anesthesia: A case report / 대한마취과학회지

The severe bradycardia and asystole are uncommon complications of epidural anesthesia but can be life threatening if not managed properly. A 73-year-old, ASA class 3, male patient was admitted for a total knee replacement under epidural anesthesia. Approximately 10 minutes after epidural anesthesia, the heart rate decreased significantly to 20 beats/min with asystole. The heart rate returned to 80 beats/min after administering atropine, ephedrine, and external cardiac compression. Severe bradycardia and asystole may be induced by vagal activation as a result of the low venous return and sympathetic blockade.

Cardiac Asystole Following a Single Dose of Succinylcholine: A case report / 대한마취과학회지

A 28-yr-old woman, weighing 61 kg with bleeding myoma of uterus was scheduled for total abdominal hysterectomy. There was no history of cardiac arrhythmia or syncope. She was not premedicated. The heart rate was 115 beats/min and arterial pressure was 155/95 mmHg, immediately before the induction of anesthesia. Under the preoxygenation, anesthesia was induced with IV injection of thiopental sodium 250 mg followed by succinylcholine 75 mg. About 20 seconds after the succinylcholine bolus, the ECG showed an abrupt change from sinus rhythm to asystole without any stimulus including laryngoscopy. After a precordial thump and atropine 0.5 mg IV, tracheal intubation and ventilation with 100% O2 were quickly accomplished. Normal sinus rhythm with heart rate of 87 beats/min returned during laryngoscopy and intubation. The interval from the sinus arrest to the reestablishment of normal sinus rhythm was only 15 seconds. Surgery proceeded uneventfully and the patient recovered without any complication.