Effect of operative trauma and multiple propofol anesthesia on neurodevelopment and cognitive function in developmental rats / 浙江大学学报·医学版

To investigate the effect of multiple propofol anesthesia and operative trauma on neuroinflammation and cognitive function in development rats and its mechanism. A total of 104 13-day-old neonatal Sprague-Dawley rats were randomly divided into 4 groups with 26 rats in each group: control group was treated with saline q.d for propofol group was treated with propofol q.d for surgery group received abdominal surgery under local anesthesia and then treated with saline q.d for surgery with propofol group received propofol anesthesia plus abdominal surgery under local anesthesia with ropivacaine at d1, then treated with propofol q.d for At d2 of experiment, 13 rats from each group were sacrificed and brain tissue samples were taken, the concentration of TNF-α in hippocampus was detected with ELISA, the expression of caspase-3 and c-fos in hippocampal tissue was determined with immunohistochemical method, the number of apoptotic neurons in hippocampus was examined with TUNEL assay. Morris water maze test was used to examine the cognitive function of the rest rats at the age of 60 d, and the TNF-α concentration, caspase-3, c-fos expressions and the number of apoptotic neurons in hippocampus were also detected. Compared with control group, TNF-α concentration, caspase-3, c-fos expression and the neuroapoptosis in hippocampus increased significantly in other three groups (all 0.05). Morris water maze test showed that there were no significant differences in swimming speed, escape latency, target quadrant residence time and crossing times among groups (all >0.05). TNF-α level, expressions of caspase-3 and c-fos and apoptotic cell numbers in hippocampus had no significant differences among the 4 adult rats groups (all >0.05). Abdominal surgery and multiple propofol treatment can induce neuroinflammation and neuroapoptosis in hippocampus of neonatal rats, however, which may not cause adverse effects on neurodevelopment and cognitive function when they grown up.

Sangrado intraoperatorio de amigdalectomía en población pediátrica. Influencia de factores quirúrgicos y anestésicos / Intraoperative bleeding of tonsillectomy in pediatric patients. Effects of surgical and anesthesia technique

INTRODUCTION: Tonsillectomy with or without adenoidectomy is one of the most frequent surgeries in the pediatric population. It has become predomi- nantly an outpatient procedure. Therefore, it is of utmost importance identi- fying the factors that influence the intraoperative bleeding to prevent posto- perative complications and rehospitalization. MATERIAL AND METHODS: An observational cross-sectional study was carried out. Patients between 1 and 14 years old that underwent to tonsillectomy with or without adenoidectomy since November 2015 to May 2017 were included. 709 cases were evaluated. Intraoperative bleeding was assessed by the volumetric method. A multivariate analysis was performed using a generalized linear regression model. RESULTS: The average intraoperative bleeding was estimated in 1.9 ml/kg (95% CI: 1.7 -2.05). The use of propofol (30% increase in bleeding) and surgical time (2% increase for every minute) were risk factors. The use of electrocautery was as- sociated with a 50% decrease in bleeding in comparison with conventional dis- section (p = 0.001). CONCLUSION: The use of propofol and a prolonged surgical time were risk factors for intraoperative bleeding. The use of electrosurgery was a protective factor.

INTRODUCCIÓN: La amigdalectomía con o sin adenoidectomía, es una de las cirugías más frecuente en población pediátrica. Desde hace varios años se ha vuelto una intervención predominantemente ambulatoria, por lo que lograr identificar los factores que influyen en el sangrado intraoperatorio es de suma importancia para prevenir complicaciones postoperatorias y reshospitalización. MATERIAL Y MÉTODO: Se realizó un estudio observacional de corte-transversal. Se incluyó a pacientes entre 1 y 14 años sometidos a amigdalectomía con o sin adenoidectomía entre noviembre de 2015 y mayo de 2017, obteniendo un total de 709 casos evaluados. Se determinó el sangrado intraoperatorio de forma volumétrica. Posteriormente, se realizó un análisis multivariado con un modelo de regresión lineal generalizado. RESULTADOS: Se cuantificó el sangrado intraoperatorio promedio en 1,9 ml/kg (IC 95%; 1,7-2,05). El uso de propofol (aumento del 30% del sangrado) y tiempo quirúrgico (2% por cada incremento de un minuto) fueron factores de riesgo. Mientras que el uso de electro bisturí se asoció con una disminución del 50% en relación al no uso (p = 0,001). CONCLUSIONES: Fueron factores de riesgo para sangrado intraoperatorio el uso de propofol y un tiempo quirúrgico prolongado. El uso de electrobisturí constituyó un factor protector.

Prevalence of delirium in intensive care patients and association with sedoanalgesia, severity and mortality / Prevalencia de delirio en pacientes de cuidados intensivos y asociación con la sedoanalgesia, gravedad y mortalidad / Prevalência de delirium em pacientes de terapia intensiva e associação com sedoanalgesia, gravidade e mortalidade

ABSTRACT Objective: To establish the prevalence of delirium and its subsyndrome in intensive care and to associate it with the use of sedative and analgesia, severity and mortality. Method: Carried out in two intensive care units of adult patients, this is a quantitative and transversal study, with 157 patients, using the Richmond Agitation-Sedation Scale to assess the level of sedation and the Intensive Care Delirium Screening Checklist for delirium. The T test and Chi-square test were applied for statistical analysis. Results: The prevalence of delirium was 22.3%, and 49.7% of the subsyndrome. Associations of the use of midazolam with the presence of delirium (p=0.05) and subsyndromal delirium (p<0.01), use of clonidine with the appearance of delirium (p<0.01) and of fentanyl with subsyndromal delirium (p=0.09). There were no significant differences between the mortality of patients with delirium (p=0.40) and subsyndromal delirium (p=0.86), as well as association with the mortality score. Conclusion: The use of sedoanalgesia is associated with the presence of delirium and subsyndromal delirium. No significant statistical associations were found between the severity and mortality scores.

RESUMEN Objetivo: Establecer la prevalencia del delirio y su subsíndrome en pacientes de cuidados intensivos y asociarlos con el uso de la sedoanalgesia, con la gravedad y con la mortalidad. Método: Realizado en dos unidades de cuidados intensivos de pacientes adultos, se trata de un estudio cuantitativo y transversal, con 157 pacientes, utilizando las escalas Richmond Agitation-Sedation Scale (Escala de agitación-sedación de Richmond) para evaluar el nivel de sedación y la de la Intensive Care Delirium Screening Checklist (Lista de verificación para la detección del delirio en cuidados intensivos) para el delirio. Se aplicaron las pruebas de T y Chi-cuadrado para el análisis estadístico. Resultados: La prevalencia del delirio fue del 22,3%, y la del subsíndrome fue del 49,7%. Se han encontrado asociaciones del uso de midazolan con la presencia de delirio (p = 0,05) y del deilirio subsindromático (p < 0,01), del uso de clonidina con la aparición de delirio (p < 0,01) y de fentanil con el delirio subsindromático (p = 0,09). No se registraron diferencias significativas entre la mortalidad de los pacientes con delirio (p = 0,40) y el delirio. Conclusión: El uso de sedoanalgesia se asocia con la presencia de delirio y delirio subsindromático. No se encontraron asociaciones estadísticas significativas entre la gravedad y las puntuaciones de mortalidad.

RESUMO Objetivo: Estabelecer a prevalência do delirium e sua subsíndrome em pacientes de terapia intensiva e associar com uso de sedoanalgesia, gravidade e mortalidade. Método: Realizado em duas Unidades de Terapia Intensiva de pacientes adultos, trata-se de estudo quantitativo e transversal, com 157 pacientes, utilizando as escalas Richmond Agitation-Sedation Scale para avaliação do nível de sedação e Intensive Care Delirium Screening Checklist para delirium. Foi aplicado o teste t e qui-quadrado para análise estatística. Resultados: A prevalência de delirium foi 22,3% e da subsíndrome 49,7%. Foram encontradas associações do uso de midazolan com a presença de delirium (p=0,05) e delirium subsindromático (p<0,01), uso de clonidina com o aparecimento de delirium (p<0,01) e de fentanil com o delirium subsindromático (p=0,09). Não houve diferenças significativas entre mortalidade de paciente com delirium (p=0,40) e delirium subsindromático (p= 0,86), bem como associação com o escore de mortalidade. Conclusão: O uso de sedoanalgesia está associado à presenta de delirium e delirium subsindromático. Não foram encontradas associações estatísticas significativas entre os escores de gravidade e mortalidade.

Prevalence of delirium in intensive care patients and association with sedoanalgesia, severity and mortality / Prevalencia de delirio en pacientes de cuidados intensivos y asociación con la sedoanalgesia, gravedad y mortalidad / Prevalência de delirium em pacientes de terapia intensiva e associação com sedoanalgesia, gravidade e mortalidade

ABSTRACT Objective: To establish the prevalence of delirium and its subsyndrome in intensive care and to associate it with the use of sedative and analgesia, severity and mortality. Method: Carried out in two intensive care units of adult patients, this is a quantitative and transversal study, with 157 patients, using the Richmond Agitation-Sedation Scale to assess the level of sedation and the Intensive Care Delirium Screening Checklist for delirium. The T test and Chi-square test were applied for statistical analysis. Results: The prevalence of delirium was 22.3%, and 49.7% of the subsyndrome. Associations of the use of midazolam with the presence of delirium (p=0.05) and subsyndromal delirium (p<0.01), use of clonidine with the appearance of delirium (p<0.01) and of fentanyl with subsyndromal delirium (p=0.09). There were no significant differences between the mortality of patients with delirium (p=0.40) and subsyndromal delirium (p=0.86), as well as association with the mortality score. Conclusion: The use of sedoanalgesia is associated with the presence of delirium and subsyndromal delirium. No significant statistical associations were found between the severity and mortality scores.

RESUMEN Objetivo: Establecer la prevalencia del delirio y su subsíndrome en pacientes de cuidados intensivos y asociarlos con el uso de la sedoanalgesia, con la gravedad y con la mortalidad. Método: Realizado en dos unidades de cuidados intensivos de pacientes adultos, se trata de un estudio cuantitativo y transversal, con 157 pacientes, utilizando las escalas Richmond Agitation-Sedation Scale (Escala de agitación-sedación de Richmond) para evaluar el nivel de sedación y la de la Intensive Care Delirium Screening Checklist (Lista de verificación para la detección del delirio en cuidados intensivos) para el delirio. Se aplicaron las pruebas de T y Chi-cuadrado para el análisis estadístico. Resultados: La prevalencia del delirio fue del 22,3%, y la del subsíndrome fue del 49,7%. Se han encontrado asociaciones del uso de midazolan con la presencia de delirio (p = 0,05) y del deilirio subsindromático (p < 0,01), del uso de clonidina con la aparición de delirio (p < 0,01) y de fentanil con el delirio subsindromático (p = 0,09). No se registraron diferencias significativas entre la mortalidad de los pacientes con delirio (p = 0,40) y el delirio. Conclusión: El uso de sedoanalgesia se asocia con la presencia de delirio y delirio subsindromático. No se encontraron asociaciones estadísticas significativas entre la gravedad y las puntuaciones de mortalidad.

RESUMO Objetivo: Estabelecer a prevalência do delirium e sua subsíndrome em pacientes de terapia intensiva e associar com uso de sedoanalgesia, gravidade e mortalidade. Método: Realizado em duas Unidades de Terapia Intensiva de pacientes adultos, trata-se de estudo quantitativo e transversal, com 157 pacientes, utilizando as escalas Richmond Agitation-Sedation Scale para avaliação do nível de sedação e Intensive Care Delirium Screening Checklist para delirium. Foi aplicado o teste t e qui-quadrado para análise estatística. Resultados: A prevalência de delirium foi 22,3% e da subsíndrome 49,7%. Foram encontradas associações do uso de midazolan com a presença de delirium (p=0,05) e delirium subsindromático (p<0,01), uso de clonidina com o aparecimento de delirium (p<0,01) e de fentanil com o delirium subsindromático (p=0,09). Não houve diferenças significativas entre mortalidade de paciente com delirium (p=0,40) e delirium subsindromático (p= 0,86), bem como associação com o escore de mortalidade. Conclusão: O uso de sedoanalgesia está associado à presenta de delirium e delirium subsindromático. Não foram encontradas associações estatísticas significativas entre os escores de gravidade e mortalidade.

Síndrome por Infusión de propofol en un caso de estatus epiléptico refractario / Propofol infusion syndrome in a refractory epileptic status case

INTRODUCCIÓN: El síndrome por infusión de propofol (SIP) es una reacción adversa poco frecuente, pero potencialmente letal descrita por la utilización de dicho fármaco en infusión intravenosa (IV) continua. El diagnóstico se basa en la combinación de acidosis metabólica, rabdomiolisis, hiperkalemia, hepatomegalia, insuficiencia renal, hiperlipidemia, arritmias e insuficiencia cardiaca rápida mente progresiva. OBJETIVO: Presentación de un caso clínico de SIP y revisión de literatura. CASO CLÍNICO: Paciente femenino de 6 años de edad con antecedentes de epilepsia secundaria a extensa alteración del desarrollo cortical hemisférico derecho. Presentó estatus epiléptico refractario que requirió ingreso a Unidad de Cuidados Intensivos para soporte vital y tratamiento, el que incluyó como terapia de tercera línea infusión intravenosa continua de propofol en dosis progresivas hasta alcanzar una tasa 10 mg/kg/h. Cursó con compromiso hemodinámico y a las 24 h de iniciado el tratamiento se observó alza de la creatinifosfokinasa (CK), acidosis metabólica y lactacidemia elevada, y luego de descartar otras causas se planteó el diagnóstico de SIP por lo que se suspendió la droga, logrando estabilización hemodinámica a las 24 h. DISCUSIÓN: El diagnóstico de SIP es complejo, se debe considerar en pacientes que estén recibiendo el fármaco y presenten acidosis metabólica o insuficiencia cardiaca. Los factores que más influyen en la mortalidad son la dosis acumulativa de la droga, la presencia de fiebre y lesión encéfalo craneana. En el caso descrito la paciente recibió una dosis mayor a 4 mg/ kg/h que es la dosis máxima recomendada y respondió favorablemente luego de 12 h después de la suspensión del fármaco.

INTRODUCTION: Propofol Infusion Syndrome (PRIS) is a rare but potentially lethal adverse reaction secondary to the continuous intravenous infusion of this drug. The diagnosis is based on the com bination of metabolic acidosis, rhabdomyolysis, hyperkalemia, hepatomegaly, renal failure, hyperli pidemia, arrhythmias, and rapidly progressive heart failure. OBJECTIVE: To report a case of PRIS and literature review. CLINICAL CASE: A 6-year-old female patient with history of epilepsy secondary to large malformation of cortical development of the right hemisphere. The patient presented a refractory status epilepticus that required admission to the Intensive Care Unit for life support and treatment, which included continuous intravenous infusion of propofol at 10 mg/kg/h. She developed hemo dynamic instability, and after 24 h of treatment an increase of creatine phosphokinase (CPK) levels, metabolic acidosis and elevated lactacidemia were observed. After ruling out other causes, PRIS was diagnosed; therefore, the drug was suspended, achieving hemodynamic stabilization after 24 hours. DISCUSSION: The diagnosis of PRIS is complex and should be considered in patients who are receiving this drug and present metabolic acidosis or heart failure. The factors that most influence mortality are the cumulative dose of the drug, the presence of fever, and cranial brain injury. In the case described, the patient received a dose higher than 4 mg/kg/h, which is the maximum recommended dose, and responded favorably 12 hours after stopping the drug.

Síndrome de infusión por propofol en el adulto / Propofol infusion syndrome

Propofol infusion syndrome is a rare but lethal complication of propofol administration. The most common clinical presentation is high anion-gap metabolic acidosis, heart failure, rhabdomyolysis and hyperkalemia in patients receiving a prolonged propofol infusion. It has an estimated incidence of 1,1% in patients receiving propofol and its mortality varies between 18 and 81%. The most important risk factor is an infusion over 4 mg/kg/h of propofol and a critically sick patient. Management of a diagnosed PRIS is based on immediate discontinuation of propofol and support therapy.

El síndrome de infusión de propofol es una complicación rara, pero posiblemente letal de la administración de propofol (Propofol Infusion Syndrome, PRIS) Generalmente, se presenta como una acidosis metabólica con anion Gap aumentado, falla cardiaca rápidamente progresiva, rabdomiólisis e hiperkalemia, junto con el antecedente claro de una infusión prolongada de la droga. La incidencia se estima en un 1,1% en los pacientes que reciben propofol y su mortalidad varía entre el 18 al 81%. Los factores de riesgo son: una infusión de propofol mayor a 4 mg/kg/h y pacientes críticos. El tratamiento se basa en la suspensión de la droga y medidas de soporte hemodinámico.

Síndrome por infusión de propofol: reporte de un caso / Propofol infusion syndrome: a case report

El propofol es un anestésico ampliamente utilizado en las unidades de cuidados intensivos. Su empleo puede provocar un efecto adverso poco frecuente pero extremadamente grave, conocido como síndrome por infusión de propofol (SIP), caracterizado por inestabilidad hemodinámica, rabdomiólisis, acidosis láctica y disfunción multiorgánica. Presentamos un caso de SIP con desenlace fatal, discutiendo su fisiopatología, clínica y consideraciones a tener en cuenta al emplear propofol.

Propofol is a widely used anesthetic in the Intensive Care Unit. At times it may cause rather an unusual adverse reaction known as propofol infusion syndrome (PRIS), characterized by hemodynamic instability, rhabdomyolysis, lactic acidosis, and multiple-organ dysfunction. The study presents a case of PRIS with fatal outcome, including a discussion of its physiopathology, clinical aspects and considerations to be borne in mind when using propofol.

O propofol é um anestésico amplamente utilizado nas Unidades de Cuidados Intensivos. Sua utilização pode provocar um efeito adverso pouco frequente mas extremamente grave conhecido como síndrome por infusão de propofol (SIP), caracterizado por instabilidade hemodinâmica, rabdomiólise, acidose lática e disfunção múltipla de órgãos. Apresentamos um caso fatal de SIP e discutimos a fisiopatologia, clínica e os aspectos que devem ser considerados quando se utiliza esta droga.

The effects of memantine on recovery, cognitive functions, and pain after propofol anesthesia / Efeitos da memantina sobre a recuperação, funções cognitivas e dor após a anestesia com propofol

Abstract Objectives: Postoperative cognitive dysfunction refers to the problems associated with thought and memory that are often experienced after major surgery. The aim of this study is to evaluate the effects of intraperitoneally administered memantine on recovery, cognitive functions, and pain after propofol anesthesia. Methods: The study was conducted in Gazi University Animal Research Laboratory, Ankara, Turkey in January 2012. Twenty-four adult female Wistar Albino rats weighing 170-270 g were educated for 300 s in the radial arm maze (RAM) over three days. Group P was administered 150 mg kg−1 of intraperitoneal (IP) propofol; Group M was given 1 mg kg−1 of IP memantine; and Group MP was given 1 mg kg−1 of IP memantine before being administered 150 mg kg−1 of IP propofol. The control group received only IP saline. RAM and hot plate values were obtained after recovery from the groups that received propofol anesthesia and 30 min after the administration of drugs in other two groups. Results: The duration of recovery for Group MP was significantly shorter than Group P (p < 0.001), and the number of entries and exits in the RAM by Group MP was significantly higher during the first hour when compared to Group P (p < 0.0001). Hot plate values, on the other hand, were found to be significantly increased in all groups when compared to the control values, aside from Group C (p < 0.0001). Conclusion: In this study, memantine provided shorter recovery times, better cognitive functions, and reduced postoperative pain. From this study, we find that memantine has beneficial effects on recovery, cognitive functions, and pain after propofol anesthesia.

Resumo Objetivos: A disfunção cognitiva no pós-operatório refere-se a problemas associados ao pensamento e à memória que são frequentemente manifestados após uma cirurgia de grande porte. O objetivo deste estudo foi avaliar os efeitos da memantina administrada por via intraperitoneal sobre a recuperação, as funções cognitivas e a dor após a anestesia com propofol. Métodos: O estudo foi feito no Laboratório de Pesquisa com Animais da Universidade de Gazi, Ankara, Turquia, em janeiro de 2012. Vinte e quatro ratos albinos do sexo feminino, adultos, da linhagem Wistar, com 170-270 g, foram treinados durante 300 segundos no labirinto radial de oito braços (LRB) durante três dias. O Grupo P recebeu 150 mg/kg−1 de propofol por via intraperitoneal (IP), o Grupo H recebeu 1 mg/kg−1 de memantina IP e o Grupo MP recebeu 1 mg/kg−1 de memantina IP antes da administração de 150 mg/kg−1 de propofol (IP). O grupo controle recebeu apenas solução salina IP. Os valores do LRB e da placa quente foram obtidos após a recuperação dos grupos que receberam propofol e 30 minutos após a administração dos fármacos nos outros dois grupos. Resultados: O tempo de recuperação do Grupo MP foi significativamente menor do que o do Grupo P (p < 0,001) e o número de entradas e saídas do LRB do Grupo MP foi significativamente maior durante a primeira hora, em comparação com o Grupo P (p < 0,0001). Os valores da placa quente, por outro lado, foram significativamente maiores em todos os grupos, em comparação com os valores do grupo controle, exceto pelo Grupo C (p < 0,0001). Conclusão: No presente estudo, memantina proporcionou tempos mais curtos de recuperação, funções cognitivas melhores e reduziu a dor no pós-operatório. A partir deste estudo, descobrimos que a memantina tem efeitos benéficos sobre a recuperação, as funções cognitivas e a dor após anestesia com propofol.

Complicaciones cardiopulmonares asociadas a propofol versus sedación tradicional para procedimientos endoscópicos digestivos en adultos: revisión sistemática y metaanálisis de estudios clínicos randomizados (ECR) / Cardiopulmonary complications associated with traditional versus propofol sedation for gastrointestinal endoscopic procedures in adults: systematic review and metaanalysis of randomized clinical trials (RCT)

Abstract Background: For sedation in endoscopy, propofol offers advantages for its fast recovery profile compared with traditional sedation (opioids and/or benzodiazepines). However, their use may be associated with deeper levels of sedation, increasing the risk of complications. Aims: To evalúate the safety of propofol compared with traditional endoscopic procedures. To analyze influence of operator sedation in endoscopic procedures. Materials and Methods: ECR comparing cardiopulmonary complications (hypoxia, hypotension, bradycardia) between propofol and traditional sedation in adults undergoing endoscopy, were included. Wesearched MEDLINE, EMBASE, Cochrane Controlled Trials Registry, LILACS. Relative risk (RR) was calculated. The data were analyzed using Rev Man v.5.3 (The Cochrane Collaboration). Results: 8 ECR were selected, totaling 739 patients; of these, 381 received propofol and 358 traditional sedation. An anesthesiologistadministered sedation in 3 of the 8 papers, in patients with greater comorbidity and deeper level of sedation.Compared with traditional sedation, the RR of developing hypoxia, hypotension or bradycardia with propofolwas 0.78 (95% CI, 0.56-1.08), 1.37 (95% CI, 0.82-2.28), 0.57 (95% CI, 0.27-1.24) respectively. The RR of hypoxia in using propofol by an anesthesiologist was 1.59 (95% CI, 0.38-6.72) and non-anesthesiologist was0.75 (95% CI, 0.53-1.05). No statistically significant differences between propofol and traditional sedation for the analyzed adverse effects were found. Conclusions: Use of propofol compared with traditional sedation forendoscopic procedures do not increase the risk of cardiopulmonary complications. There were no significant differences when analyzing the professional in charge of sedation.

Resumen Introducción: Para sedación en endoscopia, el propofol ofrece ventajas por su rápido perfil de recuperación comparado con sedación tradicional (opiodes y/o benzodiacepinas). Sin embargo, su uso podría estar asociado a niveles de sedación más profunda, aumentando el riesgo de complicaciones. Objetivos: Evaluarla seguridad del propofol comparado con sedación tradicional para procedimientos endoscópicos. Analizar la influencia del operador de la sedación en procedimientos endoscópicos. Materiales y Métodos: Se incluyeron ECR que compararan complicaciones cardiopulmonares (hipoxia, hipotensión, bradicardia) entre propofol y sedación tradicional, en adultos sometidos a endoscopia. Se buscó en: MEDLINE, EMBASE, Cochrane Controlled Trials Registry, LILACS. Se calculó riesgo relativo (RR). Los datos se analizaron con RevManv.5.3 (The Cochrane Collaboration). resultados: 8 ECR fueron seleccionados, sumando 739 pacientes; de ellos, 381 recibieron propofol y 358 sedación tradicional. Un anestesiólogo administró la sedación en 3 de los8 trabajos, en pacientes con mayor comorbilidad y nivel de sedación más profunda. Comparado con sedación tradicional, el RR de desarrollar hipoxia, hipotensión o bradicardia con propofol fue de 0,78 (IC 95%, 0,561,08), 1,37 (IC 95%, 0,82-2,28), 0,57 (IC 95%, 0,27-1,24) respectivamente. El RR de hipoxia al usar propofolpor anestesiólogo fue de 1,59 (IC 95%, 0,38-6,72) y por no-anestesiólogo fue de 0,75 (IC 95%, 0,53-1,05).No se encontraron diferencias estadísticamente significativas entre propofol y sedación tradicional para los efectos adversos analizados. conclusiones: El uso de propofol comparado con sedación tradicional para procedimientos endoscópicos no aumenta el riesgo de complicaciones cardiopulmonares. No hubo diferencias significativas al analizar el profesional a cargo de la sedación.

Comparative study between propofol and propofol-ketamine for induction of anesthesia in dogs / Estudo comparativo entre propofol e propofol-cetamina para a indução anestésica em cães

Anesthetic procedures in animals are widely used in hospital for routine surgery. For induction of anesthesia in dogs, propofol has been shown to be the drug of choice. The objectives of this study were the assessment of induction of anesthesia using propofol or propofol-ketamine. Twenty client-owned dogs were randomly assigned to treatment and control groups. All patients were administered acepromazine (0.05 mg kg-1) and fentanyl (5 μg kg-1) for premedication by intramuscular (IM) injection. Dogs in the treatment group were administered ketamine (1 mg kg-1), while dogs in the control group were administered 0.9% saline solution, by intravenous (IV) injection. Induction of anesthesia was done using IV propofol at a rate of 1 mL minute-1. Cardiopulmonary patterns were assessed before application of premedication, 15 minutes after application of premedication and after induction of anesthesia with propofol. Additionally, data regarding tracheal intubation score, presence of adverse effects and dose of propofol necessary for induction of anesthesia were collected. The control group showed significantly more adverse effects and changes in cardiopulmonary patterns when compared to the treatment group. There was a clinically significant reduction in the dose of propofol necessary for induction of anesthesia when associated with ketamine. The association of ketamine for induction of anesthesia in healthy dogs using propofol was able to reduce the dose of the induction agent necessary for tracheal intubation. Moreover, there was a reduction in the occurrence of adverse effects and cardiopulmonary depression, which allowed for a safer procedure for the patients...

Os procedimentos anestésicos em animais são amplamente utilizados em hospitais para cirurgias de rotina. Para a indução anestésica em cães o propofol tem se mostrado o fármaco de escolha. O objetivo deste estudo foi a avaliação da indução anestésica com propofol ou propofol-cetamina. Vinte cães foram divididos de forma aleatória nos grupos com tratamento e controle. Em todos os pacientes administrou-se acepromazina (0,05 mg kg-1) e fentanil (5 µg kg-1) como medicação pré-anestésica por via intramuscular (IM). Nos cães do grupo de tratamento foi administrado cetamina (1 mg kg-1), enquanto que os cães do grupo controle receberam solução salina a 0,9%, pela via intravenosa (IV). A indução da anestesia foi realizada com propofol IV a uma taxa de 1 mL minuto-1. Os padrões cardiopulmonares foram avaliados antes da aplicação da medicação pré-anestésica, 15 minutos após a mesma e após a indução da anestesia. Além disso, avaliou-se o escore de intubação traqueal, a presença de efeitos adversos e a dose de propofol necessária para a indução da anestesia. De forma significativa, o grupo controle apresentou mais efeitos adversos e alterações nos padrões cardiopulmonares quando comparado com o grupo de tratamento. Houve uma redução clinicamente importante da dose de propofol necessária para a indução de anestesia quando associado à cetamina. A associação de cetamina ao propofol para indução de anestesia em cães saudáveis foi capaz de reduzir a dose do anestésico geral necessária para intubação traqueal. Além disso, houve uma redução na ocorrência de efeitos adversos e depressão cardiopulmonar, o que permitiu um procedimento mais seguro para os pacientes...

To study the effect of injection dexmedetomidine for prevention of pain due to propofol injection and to compare it with injection lignocaine / Avaliação do efeito de dexmedetomidina na prevenção da dor relacionada à injeção de propofol e comparação com o efeito da injeção de lidocaína

BACKGROUND: Pain due to injection propofol is a common problem. Different methods are used to decrease the pain but with limited success. The objective of this study was to assess the effect of injection dexmedetomidine 0.2 mcg/kg for prevention of pain due to propofol injection and compare it with injection lignocaine 0.2 mg/kg. METHOD: After taking permission of the Institutional Ethical Committee, written informed consent was obtained from all patients, in a randomized prospective study. 60 American Society of Anesthesiology I and II patients of age range 20-60 years of either sex posted for elective surgeries under general anaesthesia were randomly allocated into two groups. Group I (dexmedetomidine group): Inj. dexmedetomidine 0.2 mcg/kg diluted in 5 mL normal saline and Group II (lignocaine group): Inj. lignocaine 0.2 mg/kg diluted in 5 mL normal saline. IV line was secured with 20 G cannula and venous occlusion was applied to forearm using a pneumatic tourniquet and inflated to 70 mm Hg for 1 min. Study drug was injected, tourniquet released and then 25% of the calculated dose of propofol was given intravenously over 10 s. After 10 s of injection, severity of pain was evaluated using McCrirrick and Hunter scale and then remaining propofol and neuromuscular blocking agent was given. Endotracheal intubation was done and anaesthesia was maintained on O2, N2O and isoflurane on intermittent positive pressure ventilation with Bain's circuit and inj. vecuronium was used as muscle relaxant. RESULTS: Demographic data showed that there was no statistically significant difference between the 2 groups. There was no statistically significant difference between 2 groups in respect to inj. propofol pain. No adverse effects like oedema, pain, wheal response at the site of injection were observed in the two groups.

JUSTIFICATIVA E OBJETIVO: A dor relacionada à injeção de propofol é um problema comum. Métodos diferentes são usados para diminuí-la, mas com sucesso limitado. O objetivo deste estudo foi avaliar o efeito da dexmedetomidina (0,2 mcg kg-1) na prevenção da dor relacionada à injeção de propofol e compará-lo com lidocaína (0,2 mg kg-1). MÉTODO: Depois da permissão do Comitê de Ética Institucional, a assinatura do termo de consentimento informado foi obtida de todos os participantes deste estudo prospectivo e randomizado. Sessenta pacientes com estado físico ASA I-II, idades entre 20-60 anos, de ambos os sexos e programados para cirurgias eletivas sob anestesia geral foram randomicamente alocados em dois grupos: Grupo I (dexmedetomidina) recebeu injeção de dexmedetomidina (0,2 mcg kg-1) diluída em 5 mL de solução salina normal e Grupo II (lidocaína) recebeu injeção de lidocaína (0,2 mg kg-1) diluída em 5 mL de solução salina normal. O acesso IV foi obtido com uma cânula de calibre 20G e a oclusão venosa aplicada no antebraço com o uso de um torniquete pneumático e inflado a 70 mm Hg durante um minuto. Os medicamentos em estudo foram injetados, o torniquete foi liberado e, em seguida, 25% da dose calculada de propofol foi administrada por via intravenosa durante 10 segundos. Após 10 segundos de injeção, a intensidade da dor foi avaliada com o uso da escala de McCrirrick e Hunter e, em seguida, o restante do propofol e um agente bloqueador neuromuscular foram administrados. A intubação endotraqueal foi feita e a anestesia mantida com O2, N2O e isoflurano em ventilação com pressão positiva intermitente, com o circuito de Bain e uso de vecurônio como relaxante muscular. RESULTADOS: Os dados demográficos mostraram que não houve diferença estatisticamente significante entre os dois grupos. Não houve diferença estatisticamente significante entre os dois grupos em relação à dor relacionada à injeção de propofol. Não houve efeitos adversos, como edema, dor e pápula no local da injeção nos dois grupos.

Lidocaine alleviates propofol related pain much better than metoprolol and nitroglycerin / Lidocaína é mais eficaz do que metoprolol e nitroglicerina para o alívio da dor relacionada à injeção de propofol

ABSTRACTBACKGROUND AND OBJECTIVES: Injection pain after propofol administration is common and maydisturb patients' comfort. The aim of this study was to compare effectiveness of intravenous(iv) nitroglycerin, lidocaine and metoprolol applied through the veins on the dorsum of hand orantecubital vein on eliminating propofol injection pain.METHOD: There were 147 patients and they were grouped according to the analgesic adminis-tered. Metoprolol (n = 31, Group M), lidocaine (n = 32, Group L) and nitroglycerin (n = 29, GroupN) were applied through iv catheter at dorsum hand vein or antecubital vein. Pain was evalu-ated by 4 point scale (0 - no pain, 1 --- light pain, 2 --- mild pain, 3 --- severe pain) in 5, 10, 15and 20th seconds. ASA, BMI, patient demographics, education level and the effect of pathwaysfor injection and location of operations were analyzed for their effect on total pain score.RESULTS: There were no differences between the groups in terms of total pain score (p = 0.981).There were no differences in terms of total pain score depending on ASA, education level,location of operation. However, lidocaine was more effective when compared with metoprolol(p = 0.015) and nitroglycerin (p = 0.001) among groups. Although neither lidocaine nor metopro-lol had any difference on pain management when applied from antecubital or dorsal hand vein(p > 0.05), nitroglycerin injection from antecubital vein had demonstrated statistically lowerpain scores (p = 0.001).CONCLUSION: We found lidocaine to be the most effective analgesic in decreasing propofolrelated pain. We therefore suggest iv lidocaine for alleviating propofol related pain at operations.

RESUMOJUSTIFICATIVA E OBJETIVOS: A dor no local da injeção após a administração de propofol é comum e pode causar desconforto nos pacientes. O objetivo deste estudo foi comparar a eficácia de nitroglicerina, lidocaína e metoprolol, aplicados intravenosamente através de veias do dorso das mãos ou antecubitais, para eliminar a dor causada pela injeção de propofol.MÉTODOS: Foram alocados em grupos 147 pacientes de acordo com o analgésico administrado: metoprolol (n = 31, Grupo M), lidocaína (n = 32, Grupo L) e nitroglicerina (n = 29, Grupo N). Os analgésicos foram aplicados via cateter intravenoso em veia do dorso da mão ou antecubital. A dor foi avaliada com uma escala de quatro pontos (0 = sem dor, 1 = dor leve, 2 = dor moderada, 3 = dor intensa) nos segundos cinco, 10, 15 e 20. Os dados demográficos dos pacientes, estado físico ASA, IMC, nível de escolaridade, efeito das vias de injeção e local das cirurgias foram analisados quanto a seus efeitos no escore total de dor.RESULTADOS: Não houve diferença entre os grupos em relação ao escore total de dor (p = 0,981). Não houve diferença no escore total de dor em relação ao estado físico ASA, escolaridade e local da cirurgia. No entanto, lidocaína foi mais eficaz em comparação com metoprolol (p = 0,015) e nitroglicerina (p = 0,001), na comparação entre os grupos. Embora lidocaína e metoprolol não tenham apresentado diferença no tratamento da dor quando aplicados em veia antecubital ou do dorso da mão (p > 0,05), a injeção de nitroglicerina em veia antecubital apresentou escores de dor estatisticamente menores (p = 0,001).CONCLUSÃO: Lidocaína mostrou-se como analgésico mais eficaz para diminuir a dor relacionada à injeção de propofol. Sugerimos, portanto, lidocaína IV para aliviar a dor relacionada à injeção de propofol em operações.

Ocular risk management in patients undergoing general anesthesia: an analysis of 39,431 surgeries

OBJECTIVE: This study sought to describe and analyze ocular findings associated with nonocular surgery in patients who underwent general anesthesia. METHODS: The authors retrospectively collected a series of 39,431 surgeries using standardized data forms. RESULTS: Ocular findings were reported in 9 cases (2.3:10,000), which involved patients with a mean age of 58.9±19.5 years. These cases involved patients classified as ASA I (33%), ASA II (55%) or ASA III (11%). General anesthesia with propofol and remifentanil was used in 4 cases, balanced general anesthesia was used in 4 cases, and regional block was used in combination with balanced general anesthesia in one case. Five patients (55%) underwent surgery in the supine position, one patient (11%) underwent surgery in the lithotomy position, two patients (22%) underwent surgery in the prone position, and one patient (11%) underwent surgery in the lateral position. Ocular hyperemia was detected in most (77%) of the 9 cases with ocular findings; pain/burning of the eyes, visual impairment, eye discharge and photophobia were observed in 55%, 11%, 11% and 11%, respectively, of these 9 cases. No cases involved permanent ocular injury or vision loss. CONCLUSION: Ophthalmological findings after surgeries were uncommon, and most of the included patients were relatively healthy. Minor complications, such as dehydration or superficial ocular trauma, should be prevented by following systematic protocols that provide appropriate ocular occlusion with a lubricating ointment and protect the eye with an acrylic occluder. These procedures will refine the quality of anesthesia services and avoid discomfort among patients, surgeons and anesthesia staff. .

Assistolia pós-cardioversão elétrica: efeito do soco precordial / Asystole after electrical cardioversion: effect of precordial thump

O soco precordial, descrito na década de 1960, tem sua utilidade questionada nas bradiarritmiase pode gerar taquiarritmias. Apresentamos o caso de paciente do sexo masculino, com 24 anos de idade, semantecedentes cardiovasculares relevantes e com história de palpitações recorrentes desde os 17 anos, que, apóscardioversão elétrica durante monitorização para realização de ablação por cateter, apresentou assistolia por mais de30 segundos, mantido com punho percussão, cujo registro pode demonstrar a eficácia em induzir a despolarizaçãoventricular. Duas considerações são relevantes nesse contexto: 1) presença de assistolia pós-cardioversão, compoucos relatos na literatura, relacionada a disfunção sinusal ou a uso de fármacos (que não é o caso de nossorelato, que pode ter sido induzida pelo reflexo vagal produzido pela cardioversão elétrica); e 2) impacto precordial,que produz aumento da pressão ventricular, distensão miocárdica, ativação dos canais iônicos e consequentedespolarização, gerando batimentos eficazes, capazes de manter a estabilidade hemodinâmica. A cardioversãoelétrica pode induzir a assistolia e o soco precordial pode ser útil na assistolia.

The use of precordial thump, described in the 60s, has been questioned in the management ofbradyarrhythmias and due the potential to generate tachyarrhythmias. We present the case of a 24-years-old malepatient, without relevant cardiovascular history, with recurrent palpitations since the age of 17, who after electricalcardioversion during monitoring for a catheter ablation procedure, developed asystole for over 30 seconds, treatedby precordial thump, whose recording demonstrates its effectiveness in inducing ventricular depolarization. Tworelevant considerations in ventricular depolarization induction: 1) the presence of asystole after cardioversionwith few reports in the literature attributed to sinus node dysfunction or drug therapy (which is not the caseof our patient, that may have been induced by the vagal reflexes produced by electrical cardioversion); and 2)the precordial impact, that increases ventricular pressure, myocardial stretch, activation of ion channels andsubsequent depolarization, generating effective beats, capable of maintaining hemodynamic stability. Electricalcardioversion may induce asystole and the precordial thump may be helpful in asystole.

Safety of Gastroenterologist-Guided Sedation with Propofol for Upper Gastrointestinal Therapeutic Endoscopy in Elderly Patients Compared with Younger Patients

BACKGROUND/AIMS: Propofol sedation for elderly patients during time-consuming endoscopic procedures is controversial. Therefore, we investigated the safety of using propofol in elderly patients during upper gastrointestinal therapeutic endoscopy. METHODS: The medical records of 160 patients who underwent therapeutic endoscopic procedures under gastroenterologist-guided propofol sedation at a single institution were retrospectively reviewed. The subjects were divided into two groups: a younger group, patients or =75 years old. The two groups were compared with respect to the therapeutic regimen, circulatory dynamics, and presence/absence of discontinuation of propofol treatment. RESULTS: Although the number of patients with liver dysfunction was higher in the elderly group, there were no other significant differences in the baseline characteristics, including the American Society of Anesthesiologists classification, between the elderly and younger groups. The average maintenance rate of continuous propofol infusion was lower in the elderly patients. No statistically significant differences were found in the occurrence of adverse events between the elderly and younger groups. None of the patients returned to a resedated state after the initial recovery from sedation. CONCLUSIONS: Gastroenterologist-guided propofol sedation in elderly patients can be safely achieved in the same manner as that in younger patients, even for time-consuming upper gastrointestinal therapeutic endoscopic procedures.

Propofol or sevoflurane anaesthesia does not affect hepatic integrity as assessed by the M30 & M65 cell death markers & liver enzymes.

Background & objectives: General anaesthetics may induce apoptosis. The pro-apoptotic/necrotic markers M30 (caspase-cleaved cytokeratin-18) and M65 (intact cytokeratin-18) have been used to identify early apoptosis in liver disease. The aim of this study was to detect the effect of propofol and sevoflurane anaesthesia on these markers and blood transaminase levels in female patients undergoing elective surgery. Methods: Sixty-seven women undergoing mastectomy or thyroidectomy under general anaesthesia were randomly allocated to the propofol or sevoflurane groups. Venous blood samples for measuring the apoptotic and necrotic markers M30 and M65 as well as for measuring the alanine aminotransferase (ALT) and the aspartate aminotransferase (AST) liver enzymes were collected before induction of anaesthesia, immediately after completion of surgery, and 24 and 48 h postoperatively. Results. The M30 values preoperatively and 0, 24 and 48 h postoperatively were 280±229, 300±244, 267±198 and 254±189 U/l in the propofol group and 237±95, 242±109, 231±94 and 234±127 U/l in the sevoflurane group, respectively. The M30 values did not differ within or between the groups. The M65 levels at the same time intervals were 470±262, 478±271, 456±339 and 485±273 in the propofol group and 427±226, 481±227, 389±158 and 404±144 U/l in the sevoflurane group, respectively. No significant changes were found in the M65 either within or between the propofol and the sevoflurane groups. The ALT and AST levels did not change at these time intervals. Interpretation & conclusions: Under the present study design propofol or sevoflurane anaesthesia did not induce apoptosis or affected the liver function as assessed by the M30, M65 markers and liver enzymes in patients undergoing mastectomy or thyroidectomy under general anaesthesia.

Comparing the pain of propofol via different combinations of fentanyl, sufentanil or remifentanil in gastrointestinal endoscopy

PURPOSE: To evaluate the pain on injection of propofol via different combinations of fentanyl, sufentanil or remifentanil in gastrointestinal endoscopy. METHODS: Total 439 patients were randomly allocated into 6 groups. Propofol & fentanil (PF) group received 1 μg/kg fentanyl, propofol & sufentanil (PS) group received 0.1 μg/kg sufentanil and propofol & remifentanyl (PR) group received 1 μg/kg remifentanyl prior to administration of 1-2 mg/kg of propofol. The propofol & half-fentanil (Pf) group, propofol & half-sufentanil (Ps) group and propofol & half-remifentanyl (Pr) group were given 0.5 μg/kg fentanyl, 0.05 μg/kg sufentanil and 0.5 μg/kg remifentanyl, respectively and later administrated 1-2 mg/kg propofol. All patients were monitored for the blood pressure (MAP), heart rate (HR), and oxygen saturation (SpO2). Additionally, the pain intensity was assessed using a 4-point verbal rating scale (VRS) by professional doctors. RESULTS: The incidence of pain due to propofol injection in Ps group (33.8%) was significantly lower than other 5 groups. The heart rate (HR) and mean arterial pressure (MAP) were maintained within the normal limits in all six groups and there was no hypotension or bradycardia encountered during the study period. CONCLUSION: Propofol and sufentanil group was the most suitable program for painless gastroscopy. .

Remifentanil-based total intravenous anesthesia for pediatric rigid bronchoscopy: comparison of adjuvant propofol and ketamine

OBJECTIVE: Laryngoscopy and stimuli inside the trachea cause an intense sympatho-adrenal response. Remifentanil seems to be the optimal opioid for rigid bronchoscopy due to its potent and short-acting properties. The purpose of this study was to compare bolus propofol and ketamine as an adjuvant to remifentanil-based total intravenous anesthesia for pediatric rigid bronchoscopy. MATERIALS AND METHODS: Forty children under 12 years of age who had been scheduled for a rigid bronchoscopy were included in this study. After midazolam premedication, a 1 µg/kg/min remifentanil infusion was started, and patients were randomly allocated to receive either propofol (Group P) or ketamine (Group K) as well as mivacurium for muscle relaxation. Anesthesia was maintained with a 1 µg/kg/min remifentanil infusion and bolus doses of propofol or ketamine. After the rigid bronchoscopy, 0.05 µg/kg/min of remifentanil was maintained until extubation. Hemodynamic parameters, emergence characteristics, and adverse events were evaluated. RESULTS: The demographic variables were comparable between the two groups. The decrease in mean arterial pressure from baseline values to the lowest values during rigid bronchoscopy was greater in Group P (p = 0.049), while the reduction in the other parameters and the incidence of adverse events were comparable between the two groups. The need for assisted or controlled mask ventilation after extubation was higher in Group K. CONCLUSION: Remifentanil-based total intravenous anesthesia with propofol or ketamine as an adjuvant drug along with controlled ventilation is a viable technique for pediatric rigid bronchoscopy. Ketamine does not provide a definite advantage over propofol with respect to hemodynamic stability during rigid bronchoscopy, while propofol seems more suitable during the recovery period. .

Is propofol safe when administered to cirrhotic patients during sedative endoscopy?

BACKGROUND/AIMS: In patients with liver cirrhosis, drugs acting on the central nervous system can lead to hepatic encephalopathy and the effects may be prolonged. Recently, misuse of propofol has been reported and the associated risk of death have become an issue. Propofol is commonly used during sedative endoscopy; therefore, its safety in high-risk groups must be further investigated. We performed a pilot study of the safety and efficacy of propofol during endoscopy in Korean patients with cirrhosis. METHODS: Upper gastrointestinal endoscopy was performed under sedation with propofol along with careful monitoring in 20 patients with liver cirrhosis and 20 control subjects. The presence or development of hepatic encephalopathy was assessed using the number connection test and neurologic examination. RESULTS: Neither respiratory depression nor clinically significant hypotension were observed. Immediate postanesthetic recovery at 5 and 10 minutes after the procedure was delayed in the cirrhotic patients compared with the control group; however, at 30 minutes, the postanesthetic recovery was similar in both groups. Baseline psychomotor performance was more impaired in cirrhotic patients, but propofol was not associated with deteriorated psychomotor function even in cirrhotic patients with a minimal hepatic encephalopathy. CONCLUSIONS: Sedation with propofol was well tolerated in cirrhotic patients. No newly developed hepatic encephalopathy was observed.