Dos concentraciones de ketofol en anestesia total intravenosa para cirugía mínimamente invasiva / Tow concentrations of ketofol in total intravenous anesthesia for minimally invasive surgery

Introducción: En los últimos años se ha iniciado un interés especial por la combinación de ketamina/propofol para pacientes intervenidos por procedimientos mínimamente invasivos. Objetivo: Evaluar la efectividad y seguridad de la anestesia intravenosa total con ketofol en concentración 1:4 contra la concentración 1:2 en pacientes intervenidos por cirugía mínimamente invasiva. Métodos: Estudio analítico, cuasiexperimental, prospectivo y longitudinal, en el Hospital Universitario General Calixto García entre diciembre de 2019 a diciembre de 2020, en 30 pacientes divididos en dos grupos de 15 pacientes: grupo estudio (GE): Ketofol 1:4 y grupo control (GC): Ketofol 1:2. Se analizaron: tensión arterial media y frecuencia cardiaca intra operatoria, grado de hipnosis, grado de nocicepción, necesidad de rescate para hipnosis y analgesia, tiempo de recuperación anestésica, analgesia posoperatoria y efectos adversos. Resultados: Entre los grupos fueron similares la edad, el sexo, el peso, estado físico y tipo de intervención quirúrgica. La frecuencia cardiaca no mostró diferencias entre los grupos. En relación a la tensión arterial mediapos-incisión, fue mayor en el grupo control con diferencias significativas (p=0,03). La necesidad de rescate intraoperatorio para la hipnosis y analgesia fue significativamente mayor en el grupo control. Con respecto a la recuperación anestésica, analgesia posoperatoria y efectos adversos no hubo diferencias significativas. Conclusiones: La combinación ketofol resultó segura y efectiva para proveer una adecuada anestesia en procedimientos quirúrgicos mínimamente invasivos con tiempos quirúrgicos menores a 30 min. La concentración de 1:4 brindó mejor estabilidad hemodinámica, adecuada hipnosis y analgesia intraoperatoria, con menor incidencia de efectos adversos(AU)

Introduction: In recent years, a special interest has appeared in the ketamine/propofol combination for patients intervened by minimally invasive procedures. Objective: To evaluate the effectiveness and safety of total intravenous anesthesia with ketofol at 1:4 concentration versus 1:2 concentration in patients undergoing minimally invasive surgery. Methods: An analytical, quasiexperimental, prospective and longitudinal study was carried out at General Calixto García University Hospital, between December 2019 and December 2020, with thirty patients divided into two groups of fifteen patients each: study group (SG; ketofol 1:4) and control group (CG; ketofol 1:2). The following aspects were analyzed: mean blood pressure and intraoperative cardiac frequency, degree of hypnosis, degree of nociception, necessity of rescue for hypnosis and analgesia, anesthetic recovery time, postoperative analgesia and adverse effects. Results: Age, sex, weight, physical condition and type of surgery were similar between groups. Heart rate showed no differences between groups. Mean blood pressure after incision was higher in the control group, with significant differences (P=0.03). The necessity of intraoperative rescue for hypnosis and analgesia was significantly higher in the control group. Regarding anesthetic recovery, postoperative analgesia and adverse effects, there were no significant differences. Conclusion: The ketofol combination was safe and effective for providing adequate anesthesia in minimally invasive surgical procedures with surgical times of less than thirty minutes. The 1:4 concentration provided better hemodynamic stability, adequate hypnosis and intraoperative analgesia, with lower incidence of adverse effects(AU)

Síndrome de dolor crónico postmastectomía: ¿qué podemos hacer en el período perioperatorio para disminuir su incidencia? / Postmastectomy chronic pain syndrome: what can we do to reduce the incidence?

El síndrome de dolor crónico postmastectomía es frecuente en pacientes sometidas a cirugía por cáncer de mamas, llegando a ser invalidante en casos severos. Existen distintos factores de riesgo para que éste se presente, siendo el dolor agudo postoperatorio el único en el cual podemos intervenir. La importancia de implementar estrategias de prevención en el periodo perioperatorio es fundamental. En la mantención de la anestesia general, la utilización de propofol se asocia con menor incidencia de dolor agudo postoperatorio. El uso de anestésicos locales, ya sea por vía tópica, subcutánea y sistémica, ha demostrado su beneficio para disminuir el dolor agudo. No obstante, solo el uso tópico y endovenoso ha sido útil para reducir el dolor hasta 3 meses postcirugía. Técnicas de analgesia regional, como el bloqueo PEC I y II, bloqueo paravertebral y bloqueo del erector de la espina han demostrado ser útiles para reducir el dolor agudo; pero solo el bloqueo paravertebral ha demostrado su utilidad en reducir el dolor hasta 1 año postcirugía. El uso de gabapentina, pregabalina y ketamina desde el periodo preoperatorio disminuyen la incidencia de dolor agudo postoperatorio. En tanto, la venlafaxina y dexmedetomidina demostraron su utilidad para reducir el dolor crónico.

Postmastectomy chronic pain syndrome is common in patients undergoing surgery for breast cancer, becoming invalidating in severe cases. There are different risk factors for this to occur, with acute post-operative pain being the only one in which we can intervene. The importance of implementing prevention strategies in the perioperative period is essential. In the maintenance of general anesthesia, the use of propofol is associated with a lower incidence of acute post-operative pain. The use of local anesthetics, whether topically, subcutaneously and systemically, has shown its benefit in reducing acute pain. However, only topical and endovenous use has been useful to reduce pain up to 3 months after surgery. Regional analgesia techniques, such as PEC I and II block, paravertebral block, and spinal erector block have been shown to reduce acute pain; but only the paravertebral block has shown its usefulness in reducing pain up to 1 year after surgery. The use of gabapentin, pregabalin and ketamine from the preoperative period reduce the incidence of acute postoperative pain. Meanwhile, venlafaxine and dexmedetomidine proved useful in reducing chronic pain.

Informe diário de evidências COVID-19: busca realizada em 29 de julho de 2020 / COVID-19 daily evidence report: search conducted on July 29, 2020

O Informe Diário de Evidências é uma produção do Ministério da Saúde que tem como objetivo acompanhar diariamente as publicações científicas sobre tratamento farmacológico e vacinas para a COVID-19. Dessa forma, são realizadas buscas estruturadas em bases de dados biomédicas, referentes ao dia anterior desse informe. Não são incluídos estudos pré-clínicos (in vitro, in vivo, in silico). A frequência dos estudos é demonstrada de acordo com a sua classificação metodológica (revisões sistemáticas, ensaios clínicos randomizados, coortes, entre outros). Para cada estudo é apresentado um resumo com avaliação da qualidade metodológica. Essa avaliação tem por finalidade identificar o grau de certeza/confiança ou o risco de viés de cada estudo. Para tal, são utilizadas ferramentas já validadas e consagradas na literatura científica, na área de saúde baseada em evidências. Cabe ressaltar que o documento tem caráter informativo e não representa uma recomendação oficial do Ministério da Saúde sobre a temática. Foram encontrados 16 artigos e 3 protocolos.

Anestesia intravenosa total: Propofol/remifentanil vs. midazolam/remifentanil en cirugía torácica / Total intravenous anesthesia: propofol/remifentanil vs midazolam/remifentanil in thoracic surgery

Introducción: Las técnicas de administración de anestesia en cirugía torácica han experimentado gran evolución y mayor fundamento científico. La anestesia intravenosa total basada en la analgesia favorece a que el período perioperatorio transcurra sin dolor y la recuperación sin complicaciones. Objetivo: Comparar la efectividad y seguridad de dos técnicas de anestesia intravenosa total en cirugía torácica electiva con remifentanilo como base analgésica. Métodos: Estudio causiexperimental, prospectivo realizado en el Hospital Docente Clínico Quirúrgico Dr. Salvador Allende, en el período comprendido entre enero de 2013 a enero de 2015, en 45 pacientes, programados para cirugía torácica electiva, divididos en dos grupos según hipnótico utilizado. Grupo A: Propofol/Remifentanil y Grupo B: Midazolam/Remifentanil. Se evaluaron variables hemodinámicas en diferentes momentos del período intraoperatorio. Variables de oxigenación (PaO2 y SaO2) durante la ventilación unipulmonar y los tiempos de recuperación anestésica. Resultados: Predominaron los pacientes mayores de 60 años en los dos grupos, con estado físico ASA III. No hubo diferencias en la oxigenación arterial entre los grupos. Hubo disminución de la tensión arterial sistólica en el grupo A sin diferencias significativas. La recuperación de la anestesia fue significativamente más demorada en el grupo B. Conclusiones: La técnica de anestesia intravenosa total con remifentanil como base analgésica asociado a propofol resultó segura y efectiva en pacientes operados de cirugía torácica(AU)

Introduction: Anesthesia administration techniques in thoracic surgery have undergone great evolution and greater scientific foundation. Total intravenous anesthesia based on analgesia favors the perioperative period without pain and recovery without complications. Objective: To compare the effectiveness and safety of two techniques of total intravenous anesthesia in elective thoracic surgery with remifentanil as an analgesic base. Methods: Prospective and causiexperimental study carried out at Dr. Salvador Allende Clinical-Surgical Teaching Hospital, in the period from January 2013 to January 2015, with 45 patients scheduled for elective thoracic surgery, who were divided into two groups according to the hypnotic drug used. Group A: propofol/remifentanil, and group B: midazolam/remifentanil. Hemodynamic variables were evaluated at different times during the intraoperative period. Oxygenation variables (PaO2 and SaO2) during unipulmonary ventilation and anesthetic recovery times. Results: Patients older than 60 years predominated in the two groups, with a physical status of ASA III. There were no differences in arterial oxygenation between the groups. There was a decrease in systolic blood pressure in group A without significant differences. The recovery of anesthesia was significantly more delayed in group B. Conclusions: The total intravenous anesthesia technique with remifentanil as an analgesic base associated with propofol was safe and effective in patients undergoing thoracic surgery(AU)

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.

Combination of Transversus abdominis plane block and Serratus plane block anesthesia in dogs submitted to masctetomy / Combinação dos bloqueios anestésicos do plano transverso abdominal e do plano serrátil em cadelas submetidas à mastectomia

This paper pretends to demonstrate the effect of the combination of transversus abdominis plane block (TAP block) and Serratus plane block (SP block) techniques in analgesia of 4 dogs undergoing total unilateral mastectomy. Dogs were premedicated with methadone (0.5mg.kg-1) intramuscularly. Anesthesia was induced with propofol (6mg.kg-1) and midazolam (0.3mg.kg-1) and maintained with isoflurane. SP and TAP block were performed unilaterally using ultrasound by the injection of bupivacaine 0.25% (0.3mL kg-1) diluted with NaCl solution 1:1. Heart rate (HR), respiratory rate (f), non-invasive arterial pressure, esophageal temperature (T), oxygen saturation (SpO2) and electrocardiogram were monitored continuously. Animals were monitored for two and four hours after extubation for pain by using the Canine Acute Pain Scale from Colorado State University. Two hours after extubation, tramadol (4mg.kg-1) and dipyrone (25mg.kg-1) was administered to all dogs. It was not observed any alteration on cardiac rhythm. HR, f, T and mean arterial pressure remained below the preincisional values for all dogs. No dog required intraoperative rescue analgesia. Recovery from anesthesia was without any complication. All animals scored 0 (0/5) at pain scale, two and four hours after extubation and none of them expressed concern over the surgical wound. Dogs were able to walk before two hours after extubation. The combination of both techniques is effective in anesthetic blocking the thoracic and abdominal walls and it is suggested both may be included in the multimodal analgesia protocols for this type of surgery.(AU)

Este trabalho pretende demonstrar o efeito analgésico da combinação das técnicas de bloqueio do plano transverso abdominal (TAP block) e bloqueio do plano serrátil (SP block) em 4 cadelas submetidas à mastectomia unilateral total. Os animais foram pré-medicados com metadona (0,5mg.kg-1) por via intramuscular. A anestesia foi induzida com propofol (6mg.kg-1) e midazolam (0,3mg.kg-1) e mantida com isoflurano. Os bloqueios SP e TAP foram realizados unilateralmente, utilizando ultrassonografia, pela injeção de bupivacaína a 0,25% (0,3mL.kg-1), diluída com solução de NaCl a 1:1. A frequência cardíaca (FC), frequência respiratória (f), pressão arterial não invasiva, temperatura esofágica (T), saturação de oxigênio (SpO2) e eletrocardiograma foram monitorados continuamente. Os animais foram monitorizados durante duras e quatro horas após a extubação para a dor usando a Escala de Dor Aguda Canina da Universidade Estadual do Colorado. Duas horas após a extubação, tramadol (4mg.kg-1) e dipirona (25mg.kg-1) foram administrados a todos os cães. Não foi observada qualquer alteração no ritmo cardíaco. HR, f, T e pressão arterial média permaneceram abaixo dos valores basais para todos os cães. Nenhum cão requereu resgate analgésico intra-operatório. Não houve complicações na recuperação anestésica. Todos os animais apresentaram escore 0 (0/5) na escala de dor, duras e 4 quatro horas após a extubação e nenhum expressou desconforto com a ferida cirúrgica. Todos os cães foram capazes de caminhar antes de duas horas após extubação. A combinação de ambas as técnicas é eficaz no bloqueio anestésico das paredes torácica e abdominal e sugere-se que ambos podem ser incluídos nos protocolos de analgesia multimodal para este tipo de cirurgia.(AU)

Traqueostomía percutánea por dilatación sin broncoscopía: Experiencia en la Unidad de Terapia Intensiva del Insttuto Guatemalteco de Seguridad Social / Percutaneos dilatatonal tracheostomy without fber optc bronchoscopy. Experience at Intensive Care Unit

Introducción: La traqueostomía percutánea es un procedimiento frecuente en la Unidad de Terapia Intensiva indicado en el manejo del paciente críticamente enfermo que requiere ventilación mecánica prolongada. El objetivo del estudio es describir la experiencia de traqueostomía percutánea sin broncoscopía, utilizando la técnica Ciaglia Blue Rhino en la unidad de terapia intensiva del IGSS. Métodos: Estudio descriptvo, observacional, longitudinal y analítco, incluyendo a 42 pacientes críticos ingresados a UTIA del Instituto Guatemalteco de Seguridad Social, a los que se realizó traqueostomía percutánea durante un periodo de 12 meses (Febrero 2016 a Febrero 2017). Se registraron variables demográficas, de severidad, días de ventilación mecánica antes del procedimiento y las complicaciones. Resultados: Se reclutaron 42 pacientes con una edad media de 68 años, con predominio del sexo masculino (28 pacientes). La media de puntuación del Sofa Score fue de 9.3 puntos. Los pacientes requirieron en promedio 13.4 días de ventilación mecánica antes del procedimiento. El 9.53% de pacientes presentaron complicaciones transoperatorias siendo estas: punción inadvertida del tubo orotraqueal (2 casos) y sangrado autolimitado del sito de la traqueostomía (2 casos). Mientras que el 4.76% presentaron complicaciones post-operatorias. Conclusiones: La traqueostomía percutánea por dilatación sin broncoscopía mediante la técnica Ciaglia Blue Rhino es un procedimiento seguro, que se puede realizar al pie de la cama del paciente, con un bajo índice de complicaciones.

Background: Percutaneos dilatatonal tracheostomy techniques have facilitated the procedure in the Intensive Care Unit. The purpose of the study is to describe our experience using this technique, in the ICU. Methods: We collected data from forty two patents during a year. The demographic variables were recorded, also we reviewed the severity of illness, number of days of mechanical ventlaton prior to the procedure, intraoperatve and postoperatve complicatons as well. Results: Forty two patents were included, mean age was 68 years old, most of them were men (28 patents). The mean Sofa Score was 9.3 points. In average, the patents requiered 13.4 days of mechanical ventlaton prior to the perutaneos dilatatonal tracheostomy. In two patents the endotracheal tube was accidentally punctured and two patents had self-limited bleeding at the surgical site. None of the complications were life-threatng to the patents. Conclusions: Percutaneos dilatatonal tracheostomy techniques using the Ciaglia Blue Rhino technique without fber optc bronchoscope is an easy procedure with a low incidence of complications.

Prevención y tratamiento de pacientes con náuseas y vómitos postoperatorios / Prevention and treatment of patients with postoperative nausea and vomiting

Resumen Las náuseas y vómitos postoperatorios (NVPO) son un problema frecuente en los pacientes quirúrgicos. Cuando no son prevenidos adecuadamente pueden provocar mayor morbilidad, estadía prolongada en la unidad de recuperación postoperatoria y hospitalización no planificada. El objetivo del equipo quirúrgico debe ser la profilaxis de las NVPO más que su tratamiento, con el fin de disminuir significativamente su incidencia y complicaciones asociadas. Los principales factores de riesgo para NVPO son: sexo femenino, historia de NVPO en cirugías previas y/o cinetosis, no fumar, uso de opioides sistémicos en el postoperatorio, someterse a ciertos tipos de cirugía (como colecistectomía, cirugía laparoscópica y cirugía ginecológica), utilizar anestésicos volátiles y/u óxido nitroso intraoperatorios, y duración de la cirugía. Sugerimos objetivar el riesgo de NVPO utilizando las escalas de riesgo de NVPO de Apfel o Koivuranta. Los principales fármacos antieméticos usados como profilaxis y tratamiento en el período perioperatorio son dexametasona, ondansetrón y droperidol. Existen estrategias generales que se pueden utilizar para reducir el riesgo quirúrgico basal de NVPO como evitar la anestesia general, privilegiando la anestesia regional, utilizar propofol para la inducción y mantención de la anestesia, evitar el uso de óxido nitroso y/o anestésicos inhalatorios, minimizar el uso postoperatorio de opioides sistémicos y recibir una hidratación intravenosa abundante durante la cirugía. La etiología de las NVPO es multifactorial, por lo que la prevención y tratamiento deben incluir diferentes clases de antieméticos, que actúen sobre los diferentes receptores de náuseas y/o vómitos hasta el momento conocidos, junto con las estrategias generales antes mencionadas.

Abstract Postoperative nausea and vomiting (PONV) are a common problem in surgical patients. When not properly prevented, they can lead to increased morbidity, prolonged stay in the postoperative recovery unit and unplanned hospitalization. The objective of the surgical team should be the prophylaxis of PONV rather than its treatment, in order to significantly reduce its incidence and associated complications. The main risk factors for PONV are: female sex, history of PONV in prior surgeries and/or motion sickness, non-smoking, use of systemic opioids postoperatively, undergo certain types of surgery (such as cholecystectomy, laparoscopic surgery and gynecological surgery), use volatile anesthetics and/or intraoperative nitrous oxide, and duration of surgery. We suggest to objectify the risk of PONV using the Apfel or Koivuranta PONV risk scales. The main anti-emetic drugs used as prophylaxis and treatment in the perioperative period are dexamethasone, ondansetron and droperidol. There are general strategies that can be used to reduce the baseline surgical risk of PONV such as avoiding general anesthesia, favoring regional anesthesia, using propofol for induction and maintenance of general anesthesia, avoiding the use of nitrous oxide and/or inhalational anesthetics, minimizing the postoperative use of systemic opioids and to receive an abundant intravenous hydration during surgery. The etiology of PONV is multifactorial, so prevention and treatment should include different classes of antiemetics, acting on the different receptors of nausea and/or vomiting so far known, together with the general strategies mentioned above.

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.

Propofol inhibits invasion and growth of ovarian cancer cells via regulating miR-9/NF-kappaB signal

Propofol is one of the most commonly used intravenous anesthetic agents during cancer resection surgery. A previous study has found that propofol can inhibit invasion and induce apoptosis of ovarian cancer cells. However, the underlying mechanisms are not known. miR-9 has been reported to be little expressed in ovarian cancer cells, which has been related to a poor prognosis in patients with ovarian cancer. Studies have also demonstrated that propofol could induce microRNAs expression and suppress NF-κB activation in some situations. In the present study, we assessed whether propofol inhibits invasion and induces apoptosis of ovarian cancer cells by miR-9/NF-κB signaling. Ovarian cancer ES-2 cells were transfected with anti-miR-9 or p65 cDNA or p65 siRNA for 24 h, after which the cells were treated with different concentrations of propofol (1, 5, and 10 μg/mL) for 24 h. Cell growth and apoptosis were detected using MTT assay and flow cytometry analysis. Cell migration and invasion were detected using Transwell and Wound-healing assay. Western blot and electrophoretic mobility shift assay were used to detect different protein expression and NF-κB activity. Propofol inhibited cell growth and invasion, and induced cell apoptosis in a dose-dependent manner, which was accompanied by miR-9 activation and NF-κB inactivation. Knockdown of miR-9 abrogated propofol-induced NF-κB activation and MMP-9 expression, reversed propofol-induced cell death and invasion of ES-2 cells. Knockdown of p65 inhibited NF-κB activation rescued the miR-9-induced down-regulation of MMP-9. In addition, overexpression of p65 by p65 cDNA transfection increased propofol-induced NF-κB activation and reversed propofol-induced down-regulation of MMP-9. Propofol upregulates miR-9 expression and inhibits NF-κB activation and its downstream MMP-9 expression, leading to the inhibition of cell growth and invasion of ES-2 cells.

Effect of Propofol and Desflurane on Immune Cell Populations in Breast Cancer Patients: A Randomized Trial

Several factors can affect the perioperative immune function. We evaluated the effect of propofol and desflurane anesthesia on the surgery-induced immune perturbation in patients undergoing breast cancer surgery. The patients were randomly assigned to receive propofol (n = 20) or desflurane (n = 20) anesthesia. The total and differential white blood cell counts were determined with lymphocyte subpopulations before and 1 hr after anesthesia induction and at 24 hr postoperatively. Plasma concentrations of interleukin (IL)-2 and IL-4 were also measured. Both propofol and desflurane anesthesia preserved the IL-2/IL-4 and CD4+/CD8+ T cell ratio. Leukocytes were lower in the propofol group than in the desflurane group at 1 hr after induction (median [quartiles], 4.98 [3.87-6.31] vs. 5.84 [5.18-7.94] 10(3)/microL) and 24 hr postoperatively (6.92 [5.54-6.86] vs. 7.62 [6.22-9.21] 10(3)/microL). NK cells significantly decreased 1 hr after induction in the propofol group (0.41 [0.34-0.53] to 0.25 [0.21-0.33] 10(3)/microL), but not in the desflurane group (0.33 [0.29-0.48] to 0.38 [0.30-0.56] 10(3)/microL). Our findings indicate that both propofol and desflurane anesthesia for breast cancer surgery induce a favorable immune response in terms of preservation of IL-2/IL-4 and CD4+/CD8+ T cell ratio in the perioperative period. With respect to leukocytes and NK cells, desflurane anesthesia is associated with less adverse immune responses than propofol anesthesia during surgery for breast cancer. (Clinical trial registration at https://cris.nih.go.kr/cris number: KCT0000939)

Propofol pretreatment attenuates lipopolysaccharide-induced acute lung injury in rats by activating the phosphoinositide-3-kinase/Akt pathway

The aim of this study was to investigate the effect of propofol pretreatment on lipopolysaccharide (LPS)-induced acute lung injury (ALI) and the role of the phosphoinositide-3-kinase/protein kinase B (PI3K/Akt) pathway in this procedure. Survival was determined 48 h after LPS injection. At 1 h after LPS challenge, the lung wet- to dry-weight ratio was examined, and concentrations of protein, tumor necrosis factor-α (TNF-α), and interleukin-6 (IL-6) in bronchoalveolar lavage fluid (BALF) were determined using the bicinchoninic acid method or ELISA. Lung injury was assayed via lung histological examination. PI3K and p-Akt expression levels in the lung tissue were determined by Western blotting. Propofol pretreatment prolonged survival, decreased the concentrations of protein, TNF-α, and IL-6 in BALF, attenuated ALI, and increased PI3K and p-Akt expression in the lung tissue of LPS-challenged rats, whereas treatment with wortmannin, a PI3K/Akt pathway specific inhibitor, blunted this effect. Our study indicates that propofol pretreatment attenuated LPS-induced ALI, partly by activation of the PI3K/Akt pathway.

Propofol exerts anti-inflammatory effects in rats with lipopolysaccharide-induced acute lung injury by inhibition of CD14 and TLR4 expression

We investigated the effect of propofol (Prop) administration (10 mg kg-1 h-1, intravenously) on lipopolysaccharide (LPS)-induced acute lung injury and its effect on cluster of differentiation (CD) 14 and Toll-like receptor (TLR) 4 expression in lung tissue of anesthetized, ventilated rats. Twenty-four male Wistar rats were randomly divided into three groups of 8 rats each: control, LPS, and LPS+Prop. Lung injury was assayed via blood gas analysis and lung histology, and tumor necrosis factor-α (TNF-α) and interleukin-1β (IL-1β) levels were determined in bronchoalveolar lavage fluid using ELISA. Real-time polymerase chain reaction was used to detect CD14 and TLR4 mRNA levels, and CD14 and TLR4 protein expression was determined by Western blot. The pathological scores were 1.2 ± 0.9, 3.3 ± 1.1, and 1.9 ± 1.0 for the control, LPS, and LPS+Prop groups, respectively, with statistically significant differences between control and LPS groups (P < 0.05) and between LPS and LPS+Prop groups (P < 0.05). The administration of LPS resulted in a significant increase in TNF-α and IL-1β levels, 7- and 3.5-fold, respectively (P < 0.05), while treatment with propofol partially blunted the secretion of both cytokines (P < 0.05). CD14 and TLR4 mRNA levels were increased in the LPS group (1.48 ± 0.05 and 1.26 ± 0.03, respectively) compared to the control group (1.00 ± 0.20 and 1.00 ± 0.02, respectively; P < 0.05), while propofol treatment blunted this effect (1.16 ± 0.05 and 1.12 ± 0.05, respectively; P < 0.05). Both CD14 and TLR4 protein levels were elevated in the LPS group compared to the control group (P < 0.05), while propofol treatment partially decreased the expression of CD14 and TLR4 protein versus LPS alone (P < 0.05). Our study indicates that propofol prevents lung injury, most likely by inhibition of CD14 and TLR4 expression.

Anestesia intravenosa total en cirugía de tumor carotídeo / Total intravenous anesthesia in carotid surgery tumor

Mujer de 18 años operada en junio del 2011 por el Servicio de Cabeza y Cuello del Hospital Nacional Arzobispo Loayza, por una tumoración cervical izquierda. La tomografía en fase angiográfica mostró un tumor estadio Shamblin III en bifurcación carotidea. Programada para exeresis de glomus carotídeo y ante los antecedentes de secuelas neurológicas postquirúrgicas de este estadio, se elige la técnica de anestesia intravenosa total con propofol, modo infusión controlada por objetivo, por sus propiedades de protección cerebral, e infusión de remifentanilo. Se monitorizó profundidad anestésica continua con índice biespectral. En el transoperatoio se lacera carótida común, se clampa la arteria durante 5 horas con liberación intermitente al cabo distal para evidenciar circulación cerebral colateral. Se coloca bypass con injerto de safena externa y se realiza exeresis final de tumor. Paciente hemodinámicamente estable, pasa a la unidad de recuperación con Ramsay y luego de 11 horas de anestesia.

Female, 18 years old, operated in June 2011 by Servicio de Cabeza y Cuello del Hospital Nacional Arzobispo Loayza, because of a left cervical tumor. The angiography phase of the CT scan showed a carotid bifurcation tumor Shamblin III stage. Scheduled for exeresis of carotid glomus and aware of the fact of postoperative neurological sequelae of this stage tumor, we choose the total intravenous anesthesia technique with propofol in target controlled infusion, because of its brain protective properties, and infusion of remifentanil. Depth of anesthesia was monitors continuously with bispectral index. Common carotid artery was lacerated during surgery, and it was clamped for 5 hours with intermittent release of the distal stump to asses collateral cerebral circulation. A bypass with saphenous graft was placed and the tumor exeresis was performed. A stabled patient went to the recovery unit with Ramsay 52 after 11 hours of anesthesia.

Comparación de dos técnicas anestésicas: intravenosa total con propofol-remifentanilo vs. general balanceada con isoflurano-remifentanilo para colecistectomía laparoscópica en el Hospital Nacional Cayetano Heredia, enero a marzo 2008 / Comparison of two anesthetic techniques: intravenous total with propofol-remifentanil vs. balanced General with isoflurane-remifentanil for Hospital Nacional Cayetano Heredia laparoscopic cholecystectomy, January to March 2008

Objetivos: Evaluar los efectos de dos técnicas anestésicas sobre: los parámetros hemodinámicos y ventilatorios durante el transoperatorio; la recuperación anestésica; y el dolor postoperatorio. Material y Métodos: Estudio observacional, analítico y prospectivo realizado en pacientes programados para colecistectomía laparoscópica en el Hospital Nacional Cayetano Heredia entre enero a marzo del 2008, quienes recibieron anestesia intravenosa total con propofol-remifentanilo (Grupo 1, n = 20) o anestesia general balanceada con saturación de oxígeno y dióxido de carbono espirado; los tiempos de ventilación, apertura ocular, extubación y para alcanzar el estado de alerta; y la escala visual análoga (EVA). Resultados: Las variables hemodinámicas y ventilatorias fueron similares en ambos grupos. No hubo diferencias en los tiempos de ventilación y apertura ocular. El tiempo de extubación fue menor en el grupo 2 (7.32±2.3 min vs. 6.17±1.2, p<0.05). El tiempo para alcanzar el estado de alerta fue el más corto en el grupo 1 (9.17 vs. 11.32min, p<0.05). No se encontraron diferencias en los valores de EVA entre ambos grupos. Conclusiones: La anestesia intravenosa total y la general balanceada proporcionan una similar y óptima estabilidad hemodinámica y ventilatoria.

Estudo comparativo entre três técnicas de anestesia geral para biópsia de próstata dirigida por ultrassonografia transretal / A comparative study among three techniques of general anesthesia for ultrasound-guided transrectal prostate biopsy / Estudio comparativo entre tres técnicas de anestesia general para biopsia de próstata dirigida por ultrasonido transrectal

JUSTIFICATIVA E OBJETIVOS: A biópsia de próstata dirigida por ultrassonografia transretal constitui referência no diagnóstico das neoplasias da próstata. Quanto maior o número de amostras colhidas, maiores a dor e o desconforto relatados pelo paciente. O objetivo do estudo foi comparar três técnicas anestésicas neste grupo de pacientes. MÉTODO: Foram estudados 45 pacientes separados em três grupos: 1 - Propofol; 2 - Propofol + Bloqueio de Plexo Prostático; 3 - Propofol + Fentanil. Os pacientes foram monitorados com pressão arterial não invasiva, eletrocardioscopia contínua, oximetria de pulso (SpO2) e Índice Bispectral. Não receberam medicação pré-anestésica. Foram avaliados os parâmetros hemodinâmicos no intra e pós-operatório, Índice bispectral no intraoperatório, avaliação da dor pela escala numérica verbal (ENV) no pós-operatório imediato e uso de dipirona como tratamento da dor pós-operatória. RESULTADOS: Não houve diferença significativa entre os três grupos: variáveis antropométricas, quantidade de propofol, número de fragmentos e tempo do exame. Os parâmetros hemodinâmicos e a SpO2 apresentaram comportamento semelhante nos três grupos durante o estudo. No grupo 1, a dor avaliada pela ENV foi mais elevada e houve maior necessidade de dipirona que nos outros grupos. CONCLUSÕES: Sedação com propofol isolado para biópsia causa maior dor e desconforto pós-operatório do que quando associado a bloqueio do plexo prostático ou a fentanil sistêmico. Além de hipnose, é necessária a realização de analgesia intraoperatória para garantir conforto pósoperatório.

BACKGROUND AND OBJECTIVES: Ultrasound-guided transrectal prostate biopsy is a reference in the diagnosis of prostate neoplasias. The higher the number of samples, the greater is the pain and discomfort. The objective of this study was to compare three anesthetic techniques in this group of patients. METHODS: Forty-five patients were included in this study. Patients were divided into three groups: 1 - Propofol; 2 - Propofol + Prostatic Plexus Block; 3 - Propofol + Fentanyl. Patients were monitored with non-invasive blood pressure, continuous electrocardioscopy, pulse oximetry (SpO2), and Bispectral Index. Patients did not receive pre-anesthetic medication. Intraoperative and postoperative hemodynamic parameters, intraoperative bispectral index, and postoperative visual analogue scale (VAS) and the use of dypirone to treat postoperative pain were evaluated. RESULTS: A significant difference among the three groups was not observed for: anthropometric parameters, amount of propofol, number of fragments, and duration of the exam. Hemodynamic parameters and SpO2 presented similar behavior in all three groups. In group 1, the pain evaluated by the VAS was more severe and required more dypirone than in the other groups. CONCLUSIONS: Sedation with propofol alone for biopsy is associated with greater postoperative pain and discomfort than in prostatic plexus block or systemic fentanyl. Besides hypnosis, intraoperative analgesia is required to guarantee postoperative comfort.

JUSTIFICATIVA Y OBJETIVOS: La biopsia de próstata dirigida por ultrasonido transrectal constituye una referencia en el diagnóstico de las neoplasias de la próstata. Mientras mayor es el número de muestras escogidas, mayores son el dolor y la incomodidad relatados por el paciente. El objetivo del estudio fue comparar tres técnicas anestésicas en ese grupo de pacientes. MÉTODO: Fueron estudiados 45 pacientes divididos en tres grupos: 1- Propofol; 2- Propofol + Bloqueo de Plexo Prostático; 3- Propofol + Fentanil. Los pacientes fueron monitorizados con presión arterial no invasiva, electrocardioscopia continua, oximetría de pulso (SpO2) e Índice Bispectral. No recibieron medicación preanestésica. Se evaluaron los parámetros hemodinámicos en el intra y postoperatorio, índice bispectral en el intraoperatorio, el dolor por la escala numérica verbal (ENV) en el postoperatorio inmediato y el uso de dipirona como tratamiento del dolor postoperatorio. RESULTADOS: No hubo diferencia significativa entre los tres grupos: en las variables antropométricas, cantidad de propofol, número de fragmentos y tiempo del examen. Los parámetros hemodinámicos y la SpO2 presentaron un comportamiento semejante en los tres grupos durante el estudio. En el grupo 1, el dolor evaluado por la ENV fue más elevado y hubo una mayor necesidad de aplicar la dipirona que en los otros grupos. CONCLUSIONES: La sedación con propofol aislado para la biopsia causa un mayor dolor e incomodidad en el postoperatorio que cuando se asocia al bloqueo del plexo prostático o al fentanil sistémico. Además de la hipnosis, se hace necesario realizar la analgesia intraoperatoria para garantizar la comodidad en el postoperatorio.

Estudo comparativo de eficácia e segurança entre propofol e midazolam durante sedação para colonoscopia / Comparative study of efficacy and safety between propofol and midazolam for sedation during colonoscopy

OBJETIVO: Comparar a segurança e a eficácia do propofol com a do midazolam na sedação profunda durante colonoscopias. MÉTODOS: Sessenta e seis pacientes foram submetidos à colonoscopias e estudados prospectivamente. Um total de 50 pacientes recebeu 3,25 mg.kg-1 de peso de propofol. No grupo controle de 16 pacientes foi administrado 2,05 mg.kg-1 de peso de midazolam. A dose de manutenção foi titulada de acordo com a necessidade. Os parâmetros cardiovasculares e respiratórios observados foram a saturação de oxigênio, pressão arterial sistólica e diastólica e frequência cardíaca. Após o procedimento foi realizado um questionário sobre intercorrências como dor, desconforto e satisfação após a colonoscopia, utilizando uma escala visual de zero a dez. Foi aplicado o teste t de Student para a análise estatística. RESULTADOS: A amostra foi similar com relação às variáveis idade, peso, sexo e condição física. Houve diferença estatística significativa para os parâmetros saturação de oxigênio do sangue e pressão arterial sistólica entre os dois grupos. Não houve diferença estatística significativa para os parâmetros pressão arterial diastólica e pulso. Apesar das diferenças nos parâmetros cardiovasculares e respiratórios, não houve repercussões hemodinâmicas significativas. Não houve diferença estatística no parâmetro dor e satisfação. Os pacientes que apresentaram agitação (25 por cento) no grupo midazolam, relataram mais desconforto (p=0,038). CONCLUSÃO: As variações nos parâmetros cardiovasculares e respiratórios, mesmo com diferenças significativas entre os grupos, não causaram repercussões clínicas significativas nos dois grupos, caracterizando a segurança na sedação profunda. A sedação com midazolam ou propofol não está associada a níveis de dor e satisfação diferentes entre os dois grupos. O grupo midazolan referiu significativamente mais desconforto que o grupo propofol.

OBJECTIVE: To compare safety and efficacy of propofol with midazolam for deep sedation in the colonoscopy. METHODS: In a prospective way, 66 patients underwent colonoscopy - 50 patients received propofol in an average dose of 3,25 mg.kg-1 and 16 patients (control group) received midazolam with total average dose of 2,05 mg.kg-1. The dose of medication was titrated according to patient need. The analyzed cardiovascular and respiratory parameters were: oxygen saturation, systolic and diastolic blood pressure and heart rate. After the colonoscopy, a survey with a visual scale from 0 to 10 and questions regarding the pain, discomfort and satisfaction was applied. The statistics analyzed by the t Student test. RESULTS: Groups were similar regarding the age, weight, sex and physical conditions (ASA grade). None of the patient required emergencial treatment. None of the cardiovascular and respiratory parameters with statistics differences produced hemodynamic repercussions. The pain and satisfaction parameters showed no significant difference between the midazolam group and propofol group The discomfort parameter during the colonoscopic showed significant difference (p=0,038) between the midazolam group (score 2,81) and propofol group (score 1,18) and all the patients wich had presented paradoxal excitation (25 percent) in this group reported discomfort. CONCLUSION: The cardiovascular and respiratory parameters variation, even when different between groups, didn't produced clinical repercussions. The pain and satisfaction parameters showed no significant difference between groups. It was demonstrated that the midazolam group referred more discomfort than the propofol group.

Emulsión lipídica: ¿nuevo paradigma para el tratamiento de la toxicidad sistémica por anestésicos locales? / Lipidic emulsion: a new paradigm for the treatment of systemic toxicity due to local anesthetics?

La toxicidad sistémica por sobredosis de anestésico local es una complicación rara pero potencialmente devastadora de la anestesia regional y central neuraxial. El colapso cardiovascular que sigue a la toxicidad sistémica por sobredosis de anestésico local, especialmente la bupivacaína, es extremadamente difícil de tratar usando los fármacos estándares de resucitación, con el potencial resultado de paro cardíaco refractario a esta acción. La terapia con emulsión lipídica puede restaurar rápidamente la circulación luego del colapso cardiovascular inducido por anestésicos locales. Modelos experimentales de toxicidad por anestésicos locales han mostrado un retorno acelerado de la función cardíaca espontánea posterior a una infusión lipídica, tanto en animales intactos como en corazones aislados. Varios reportes de caso se refieren a la extensión de estos hallazgos al área clínica, citando rápidas resucitaciones con lípidos de sujetos con paro cardíaco luego de una anestesia regional. El tratamiento precoz con emulsión lipídica de pacientes con signos neurológicos puede prevenir la parada cardíaca o acelerar el retorno del latido cardíaco espontáneo. Cuando se presenta un individuo con signos de severa toxicidad por anestésico local (inconsciencia, convulsiones tónico-clónicas, colapso cardiovascular), se debe suspender la inyección de anestésico local, pedir ayuda, mantener la vía aérea permeable, administrar oxígeno al 100 por ciento, mantener una adecuada ventilación pulmonar, lograr el control de las convulsiones (benzodiazepinas, tiopental o propofol en dosis incrementales), comenzar una reanimación, administrar bolo intravenoso de Intralipid ® 20 por ciento, 1,5 ml/kg en 1 minuto, continuar RCP, comenzar la infusión intravenosa de Intralipid ® 20 por ciento,0,25 ml/kg.min, continuar RCP y repetir el bolo dos veces con intervalos de 5 minutos si no se restauró una adecuada circulación...

Systemic toxicity caussed by overdose of local anesthetics is a rare complication but it is potentially devastating in regional and central neuraxial anesthesia. The cardiovascular collapse that follows systemic toxicity due to local anesthetics, particularly bupivacaine, is extremely hard to treat with standard resuscitation drugs, with the potential result of treatment-resistant cardiac arrest. Treatment with lipidic emulsion can rapidly restore circulation after cardiovascular collapse induced by local anesthetics. Experimental models of toxicity due to local anesthetics have shown a fast return of spontaneous cardiac function following a lipidic infusion in intact animals as web as in isolated hearts. Several case reports refer to this findings extended to the clinical area, citing fast resuscitation with lipids in patients with cardiac arrest following regional anesthesia. Early treatment with lipidic emulsion of patients with neurological symptoms can prevent cardiac arrest or quicken the return of spontaneous heartbeat. When faced with a patient with signs of severe toxicity due to local anesthetics (unconsciousness, tonic-clonic convulsions, cardiovascular collapse, the following steps must be taken: suspend local anesthetic injection, request help, keep respiratory ducts permeable, supply oxygen at 100 per cent, maintain adequate pulmonary ventilation, control convulsions (benzodiazepine, tiopenthal or propofol in incremental doses), begin cardiopulmonary reanimation, intravenous bolus of Intralipid@ 20 per cent, 1,5 ml/kg in 1 minute, continue CPR and repeat bolus twice at 5 minute intervals if adequate circulation has not been restores. After 5 minutes, increase the rate of infusion to 0,5 ml/kg.min, continue infusion of lipidic emulsion until adequate circulation has be en achieved and continue CPR thraughout the treatment with lipidic emulsion...

A toxicidade sistêmica causada por superdose de anestésico local é uma complicação rara, mas potencialmente devastadora, da anestesia regional e central neuroaxial. O colapso cardiovascular que segue à toxicidade sistêmica por superdose de anestésico local, especialmente a bupivacaína, é extremamente difícil de tratar usando os fármacos padrões de ressuscitação; o resultado potencial é uma parada cardíaca refratária a esta ação. A emulsão lipídica pode restaurar rapidamente a circulação depois de um colapso cardiovascular induzido por anestésicos locais. Modelos experimentais de toxicidade por anestésicos locais mostraram rápida recuperação da função cardíaca espontânea após infusão lipídica, tanto em animais intactos como em corações isolados. Diversos relatórios de caso referidos à extensão destes achados à área clínica citam o uso de lipídeos para a rápida ressuscitação de pacientes com parada cardíaca causada por anestesia regional. O tratamento precoce com emulsão lipídica de pacientes com sinais neurológicas pode prevenir a parada cardíaca ou acelerar o retorno do batimento cardíaco espontâneo. Quando um indivíduo apresenta sintomas de grave toxicidade por anestésico local (inconsciência, convulsões tônico-clônicas, colapso cardiovascular), é necessário suspender a injeção de anestésico local, pedir ajuda, manter a via aérea permeável, administrar oxigênio a 100 por cento, manter uma adequada ventilação pulmonar, controlar as convulsões (benzodiazepinas, tiopental ou propofol em doses incrementais), começar a reanimação cardiopulmonar, administrar bolo intravenoso de Intralipid® 20 por cento, 1,5 ml/kg em 1 minuto, continuar RCP, iniciar infusao intravenosa de Intralipid® 20 por cento, 0,25 ml/kg.min, continuar RCP e repetir duas vezes o bolo, em intervalos de 5 minutos, se nao for restaurada uma adequada circulação...

Despertar controlado por ordenador en infusión con propofol vs. sevofluorane asociado a remifentanilo en histerectomía abdominal. HGAL / Wake controlled for computer in infusion with propofol vs. sevofluorane associated with remifentanil in abdominal hysterectomy. HGAL

Dentro de algunas de la características que posee el Remifentanilo en relación con otros opiodes son: depresión respiratoria, analgesia potente reduce la CAM de los agentes anestésicos inhalatorios, ofrece gran estabilidad hemodinámica, menos estrés, provoca nauseas, rigidez muscular y prurito, causa los mismos efectos sobre el EEG como los otros opiáceos y tiene potencial adictivo lo que permite una recuperación rápida. Debido a estas cualidades específicas permiten que el fármaco pueda ser útil como analgésico y coadyuvante anestésico en cirugía ambulatoria y población pediátrica y en adultos. Así mismo permite realizar anestesias basadas en la analgesia en todo tipo de patologías y pacientes no demorando el despertar ni causando depresión respiratoria independiente de las dosis utilizadas y del tiempo de administración. Esto tiene un efecto hipnótico sinérgico y no es aditivo que hace posible disminuir las concentraciones de los agentes inhalatorios e intravenosos entre un 50 y 75 por ciento pero sin poder no hacer caso de ellos. Se evidencia un menor MAC del agente inhalatorio en este caso del Sevofluorane menor del 50 por ciento que el habitual. Con respecto al propofol una diana y consumo similares a otros estudios. La concentración cerebral al despertar es ligeramente mayor al reportado por otros estudios.