Role of melatonin in attenuation of hemodynamic response to intubation and anesthetic requirements: a randomized, controlled, double-blind study

Abstract Background Melatonin has been studied to have anxiolytic, sedative, and analgesic effects. However, there is limited data on the effect of melatonin in the attenuation of hemodynamic response to intubation. We aimed to study whether preanesthetic oral melatonin attenuates hemodynamic responses to intubation and anesthetic requirements. Methods Sixty-four patients scheduled for laparoscopic cholecystectomy were randomized into melatonin or placebo group (n = 32 each). Melatonin group received two tablets (3 mg each) of melatonin, and the placebo group received two tablets of vitamin D3 120 min before induction. Hemodynamic parameters were recorded during induction and postintubation for 15 minutes. Total induction dose of propofol, total intraoperative fentanyl consumption, and adverse effects of melatonin were also noted. Results Postintubation rise in heart rate (HR) was less in the melatonin group compared to the placebo group (10.59% vs. 37.08% at 1 min, respectively) (p< 0.0001). Maximum percentage increase in systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean blood pressure (MBP) was lesser in melatonin group than placebo group (SBP 9.25% vs. 37.73%, DBP 10.58% vs. 35.51%, MBP 9.99% vs. 36.45% at 1 min postintubation. respectively) (p< 0.0001). Induction dose of propofol (1.42 mg.kg-1 vs. 2.01 mg.kg-1) and the number of patients requiring additional fentanyl intraoperatively (3 vs. 11) were also significantly reduced in the melatonin group. Conclusion Premedication with 6 mg of oral melatonin resulted in significant attenuation of postintubation rise in HR, SBP, DBP, and MBP. It also reduced the induction dose of propofol, total intraoperative fentanyl consumption without any adverse effects.

Anestesia total intravenosa libre de opioides guiada por qCON y qNOX en paciente obesa / Total Intravenous anesthesia in patients with intestinal occlusive syndrome

Introducción: En los últimos años la anestesia libre de opioides ha constituido una alternativa más a las técnicas tradicionales de anestesia general. Con la exclusión de este grupo de fármacos se evitan los múltiples efectos adversos y complicaciones asociados al mismo. A pesar de que la anestesia libre de opioides tiene sus indicaciones y que ha demostrado sus beneficios en cierto grupo de pacientes, existen aún controversias en relación con su utilidad en el paciente obeso. Características como la obesidad hacen que los modelos multimodales empleados para programar la anestesia libre de opioides sean cada vez más complejos. Objetivos: Describir un caso clínico realizado con la técnica de anestesia libre de opioides que constituye la primera experiencia en Ecuador. Presentación del caso: Se presenta el caso de una paciente obesa intervenida de colecistectomía laparoscópica mediante infusión de propofol, ketamina, lidocaína, sulfato de magnesio, y dexmedetomidina. La titulación de estos fármacos se realizó mediante cálculo de concentraciones plasmáticas a través de modelos farmacocinéticos y guiada por monitorización de profundidad anestésica y analgésica, con lo cual se logró optimizar el consumo de fármacos, disminuir las complicaciones y una evolución clínica favorable. Hasta donde se conoce a nivel local y de país (Ecuador) es la primera experiencia que se reporta con esta técnica. Conclusiones: La anestesia libre de opioides puede resultar una elección en el paciente obeso ya que asegura una adecuada recuperación sin efectos adversos asociados(AU)

Introduction: In recent years, opioid-free anesthesia has become another alternative in front of traditional general anesthesia techniques. The exclusion of this group of drugs avoids the numerous adverse effects and complications associated with its usage. Although opioid-free anesthesia has its indications and has showed its benefits in a certain group of patients, there is still controversy regarding its usefulness in the obese patient. Characteristics such as obesity make the multimodal models used to program opioid-free anesthesia increasingly complex. Objectives: To describe a clinical case involving the opioid-free anesthesia technique, which is the first experience in Ecuador. Case presentation: The case is presented of a female obese patient who underwent laparoscopic cholecystectomy by infusion of propofol, ketamine, lidocaine, magnesium sulfate and dexmedetomidine. Titration of these drugs was carried out by calculating plasma concentrations through pharmacokinetic models and guided by monitoring of anesthetic and analgesic depth, thus optimizing drug consumption, reducing complications and achieving a favorable clinical evolution. As far as known locally and in the country (Ecuador), this is the first reported experience with this technique. Conclusions: Opioid-free anesthesia may be a choice in the obese patient, since it ensures adequate recovery without associated adverse effects(AU)

Impact of vaginal delivery history on anesthesia management of hysteroscopic surgery under intravenous general anesthesia: a cohort study of 99 patients / 南方医科大学学报

OBJECTIVE@#To evaluate the impact of a history of vaginal delivery on anesthesia management of patients undergoing hysteroscopic surgery under intravenous general anesthesia without tracheal intubation.@*METHODS@#Ninety-nine patients undergoing hysteroscopic surgery under intravenous general anesthesia were enrolled in this study, including 43 patients with (VD group) and 56 patients without a history of vaginal delivery (NVD group). For all the patients, blood pressure, heart rate (HR), blood oxygen saturation (SpO2) and bispectral index (BIS) were recorded before anesthesia (T1), after anesthesia (T2), after cervical dilation (T3), and at 3 min after cervical dilation (T4). Propofol and etomidate doses during anesthesia induction, the total dose of propofol administered, additional intraoperative bolus dose and times of propofol, intraoperative body movement, total operation time and surgeons' satisfaction feedback scores were compared between the two groups. The postoperative awake time, recovery time, VAS score at 30 min after operation, and postoperative nausea and vomiting (PONV) were also compared.@*RESULTS@#There was no significant differences in SBP, DBP, HR, SpO2, or BIS between the two groups at T1 and T2, but at T3 and T4, SBP and DBP were significantly higher in NVD group than in VD group (P < 0.01); HR was significantly higher in NVD group only at T3 (P < 0.01). The application of vasoactive drugs did not differ significantly between the two groups. The total dose of propofol, additional intraoperative dose and times of propofol were all greater in NVD group than in VD group (P < 0.01). More body movements of the patients were observed in NVD group (P < 0.01), which also had lower surgeons' satisfaction score for anesthesia (P < 0.01), higher postoperative VAS score (P < 0.05), and shorter postoperative awake time (P < 0.05) and recovery time (P < 0.01).@*CONCLUSION@#A history of vaginal delivery has a significant impact on anesthesia management of patients undergoing hysteroscopic surgery under intravenous general anesthesia without tracheal intubation in terms of hemodynamic changes, anesthetic medication, and postoperative recovery quality, suggesting the necessity of individualized anesthesia management for these patients.

Propofol-ketamine versus dexmedetomidine-ketamine for sedation during upper gastrointestinal endoscopy in pediatric patients: a randomized clinical trial / Propofol­cetamina versus dexmedetomidina­cetamina para sedação durante endoscopia digestiva alta em pacientes pediátricos: estudo clínico randomizado

Abstract Background and objectives Day-case pediatric sedation is challenging. Dexmedetomidine is a sedative analgesic that does not induce respiratory depression. We compared dexmedetomidine to propofol when it was added to ketamine for sedation during pediatric endoscopy, regarding recovery time and hemodynamic changes. Methods We enrolled 120 patients (2−7 years in age) and randomly assigned them into two groups. Each patient received intravenous (IV) ketamine at a dose of 1 mg.kg-1 in addition to either propofol (1 mg.kg-1) or dexmedetomidine (0.5 µg.kg-1). The recovery time was compared. Hemodynamics, oxygen saturation, need for additional doses, postoperative complications and endoscopist satisfaction were monitored. Results There was no significant difference in hemodynamics between the groups. The Propofol-Ketamine (P-K) group showed significantly shorter recovery times than the Dexmedetomidine-Ketamine (D-K) group (21.25 and 29.75 minutes, respectively, p < 0.001). The P-K group showed more oxygen desaturation. Eleven and 6 patients experienced SpO2 < 92% in groups P-K and D-K, respectively. A significant difference was noted regarding the need for additional doses; 10% of patients in the D-K group needed one extra dose, and 5% needed two extra doses, compared to 25% and 20% in the P-K group, respectively (p = 0.001). The P-K group showed less post-procedure nausea and vomiting. No statistically significant difference between both groups regarding endoscopist satisfaction. Conclusions The P-K combination was associated with a shorter recovery time in pediatric upper gastrointestinal endoscopy, while the D-K combination showed less need for additional doses. Registration number Clinical trials.gov (NCT02863861).

Resumo Justificativa e objetivos A sedação ambulatorial pediátrica é um desafio. A dexmedetomidina é um analgésico sedativo que não induz à depressão respiratória. Comparamos a dexmedetomidina ao propofol quando associados à cetamina para sedação durante endoscopia pediátrica, quanto ao tempo de recuperação e às alterações hemodinâmicas. Métodos Foram recrutados 120 pacientes (2−7 anos de idade) que foram aleatoriamente alocados em dois grupos. Cada paciente recebeu cetamina IV na dose de 1 mg.kg‐1, além de propofol (1 mg.kg‐1) ou dexmedetomidina (0,5 µg.kg‐1). Comparamos o tempo de recuperação. A hemodinâmica, saturação de oxigênio, necessidade de doses adicionais, complicações pós‐operatórias e satisfação do endoscopista foram monitoradas. Resultados Não houve diferença significante entre os grupos no que diz respeito à hemodinâmica. O grupo Propofol‐Cetamina (P‐C) apresentou tempos de recuperação significantemente mais curtos do que o grupo Dexmedetomidina‐Cetamina (D‐C) (21,25 e 29,75 minutos respectivamente, p < 0,001). Observou‐se frequência maior de dessaturação de oxigênio no grupo P‐C. Onze e 6 pacientes apresentaram SpO2 < 92% nos grupos P‐C e D‐C, respectivamente. Uma diferença significante foi observada em relação à necessidade de doses adicionais; 10% dos pacientes no grupo D‐C precisaram de uma dose extra e 5% precisaram de duas doses extras, em comparação com 25% e 20% no grupo P‐C, respectivamente (p = 0,001). O grupo P‐C apresentou menos náuseas e vômitos após o procedimento. Não houve diferença estatisticamente significante entre os dois grupos em relação à satisfação do endoscopista. Conclusões A combinação P‐C foi associada a tempo mais curto de recuperação na endoscopia digestiva alta pediátrica, enquanto a combinação D‐C mostrou menor necessidade de doses adicionais. Número de registro Clinical trials.gov (NCT02863861).

Comparison of post-operative nausea and vomiting with intravenous versus inhalational anesthesia in laparotomic abdominal surgery: a randomized clinical trial / Comparação entre anestesia intravenosa e inalatória na náusea e vômito pós-operatórios em laparotomia: estudo clínico randomizado

Abstract Background: Postoperative Nausea and Vomiting (PONV) is a multifactorial surgical complication with an unclear underlying cause. Anesthetic methods, patients' characteristics and the type of surgery are considered as factors affecting PONV. This study was designed to compare the effect of inhalational and intravenous anesthesia in abdominal surgery on the incidence and severity of PONV. Methods: A single-blinded prospective randomized clinical trial on 105 patients aged 18 − 65 years was carried out. Patients were divided into two groups of Total Intravenous Anesthesia (TIVA) and inhalational anesthesia. The incidence and the severity of PONV were examined at 0, 2, 6, 12 and 24 hours after the surgery. The use of a rescue antiemetic was also evaluated. Results: 50.9% of the patients in the inhalation group and 17.3% of the patients in the intravenous group developed PONV (p < 0.001). The incidence of vomiting was reported in 11.3% of the inhalational group and 3.8% of the TIVA group (p = 0.15). 24.5% of patients in the inhalation group and 9.6% of patients in the intravenous group needed an antiemetic medication (p = 0.043). Conclusion: The incidence of postoperative nausea and vomiting and the need for administration of an antiemetic rescue drug and the severity of nausea in patients were significantly lower in the TIVA group.

Resumo Justificativa: Náusea e Vômito no Pós-Operatório (NVPO) é uma complicação multifatorial com etiologia não esclarecida. A técnica anestésica, as características dos pacientes e o tipo de cirurgia são considerados fatores que afetam a NVPO. O presente estudo foi desenhado para comparar o efeito da anestesia inalatória com anestesia intravenosa na incidência e gravidade de NVPO na cirurgia abdominal. Método: Foi realizado estudo clínico mono-cego prospectivo randomizado com 105 pacientes com idades de 18 − 65 anos. Os pacientes foram divididos em dois grupos, Anestesia Total Intravenosa (TIVA) e anestesia inalatória. A incidência e gravidade de NVPO foram avaliadas em cinco momentos: 0, 2, 6, 12 e 24 horas pós-cirurgia. O uso de antiemético de resgate também foi avaliado. Resultados: NVPO ocorreu em 50,9% dos pacientes no grupo inalatória e 17,3% dos pacientes no grupo TIVA (p< 0,001). A incidência de vômitos relatados foi 11,3% no grupo Inalatória e 3,8% no grupo TIVA (p = 0,15). Necessitaram de medicação antiemética 24,5% dos pacientes no grupo Inalatória e 9,6% dos pacientes no grupo TIVA (p = 0.043). Conclusão: A incidência de náusea e vômito no pós-operatório, a necessidade de administração de droga antiemética de resgate e a gravidade da náusea foram significantemente mais baixas no grupo TIVA.

Effect of palonosetron, ondansetron and dexamethasone in the prevention of postoperative nausea and vomiting in video cholecystectomy with total venous anesthesia with propofol-remifentanil - randomized clinical trial / Efeito da palonosetrona, ondansetrona e dexametasona na prevenção de náusea e vômito pós-operatório em videocolecistectomia com anestesia venosa total com propofol-remifentanil - ensaio clínico randomizado duplo cego

Abstract Introduction and objectives: The incidence of Postoperative Nausea and Vomiting (PONV) after video cholecystectomy is high. Progress in pharmacological PONV prophylaxis includes a new generation of 5-HT3 antagonists. This study aims to assess the effect of the 5-HT3 antagonist in postanesthetic antiemetic management of patients submitted to laparoscopic cholecystectomy with total intravenous anesthesia. Methods: Sixty individuals who underwent video cholecystectomy were randomized into three groups of 20 individuals according to the treatment administered: 0.125 mg of palonosetron (Group 1); 4 mg of ondansetron associated with 4 mg of dexamethasone (Group 2); 4 mg of dexamethasone (Group 3). General intravenous anesthesia was performed with propofol, remifentanil and rocuronium. The group to which the participant belonged was concealed from the investigator who assessed drug effect. PONV was assessed using the Rhodes Scale at 12 and 24 hours after surgery. Rescue medication was 0.655 to 1.5 mg of droperidol. Results: Group 1 presented a lower incidence of PONV and required less rescue medication in the first postoperative hour. There was no significant difference among the three groups regarding PONV incidence in the first 12 postoperative hours. Groups 1 and 2 were superior to Group 3 regarding the control of PONV from 12 to 24 hours, and after rescue medication from 12 to 24 hours. Group 1 showed significantly superior nausea control in the first 12 postoperative hours. Conclusions: The present study showed evidence that palonosetron is superior to the drugs compared regarding a protracted antiemetic effect and less requirement of rescue drugs, mainly related to its ability to completely inhibit the uncomfortable symptom of nausea.

Resumo Justificativa e objetivo: Náuseas e Vômitos no Pós-Operatório (NVPO) têm alta incidência após videocolecistectomia. Avanços na profilaxia farmacológica de NVPO incluem a nova geração de antagonista 5-HT3. O objetivo deste estudo foi avaliar o efeito do antagonista 5-HT3 no controle antiemético pós-anestésico em videocolecistectomia com anestesia venosa total. Método: Estudo realizado no HC-UFU (Hospital Terciário). Sessenta indivíduos submetidos a videocolecistectomia foram randomizados em três grupos de igual número, sendo administrados 0,125 mg de palonosetrona (Grupo 1); 4 mg de ondasetrona e 4 mg de dexametasona (Grupo 2); ou 4 mg de dexametasona (Grupo 3). A anestesia geral venosa foi realizada com propofol, remifentanil e rocurônio. O avaliador do efeito da droga desconhecia o grupo ao qual o indivíduo pertencia. NVPO foi avaliada aplicando a Escala de Rhodes após 12 e 24 horas do término da cirurgia. Para resgate terapêutico, foi estabelecido 0,655−1,5 mg de droperidol. Resultado: Observou-se no Grupo 1 menor incidência de NVPO e de resgate terapêutico na primeira hora de PO. Não foi observada diferença significativa entre os três grupos com relação a ocorrência de NVPO nas primeiras 12 horas de pós-operatório. Os grupos 1 e 2 foram superiores ao Grupo 3 no que se refere ao controle de NVPO de 12 a 24 horas e após o resgate de 12−24 horas. Observou-se que o controle de náuseas nas primeiras 12 horas de pós-operatório do Grupo 1 foi significantemente superior. Conclusão: O presente estudo mostrou evidências da superioridade da palonosetrona às demais drogas empregadas no que se refere ao efeito antiemético prolongado e menor necessidade de resgate, principalmente na capacidade de inibir completamente o desconfortável sintoma de náusea.

Comparison of anesthesia effects between closed / 中南大学学报(医学版)

OBJECTIVES@#Bispectral index (BIS) can reflect the depth of propofol sedation. This study aims to compare the anesthetic satisfaction, anesthetic dose, and hemodynamic changes between closed-loop target controlled infusion (CLTCI) and open-loop target controlled infusion (OLTCI) during abdominal surgery.@*METHODS@#From December 2016 to December 2018, 70 patients undergoing abdominal surgery under general anesthesia were selected in Beijing Hospital, including 51 males and 19 females, at the age from 49 to 65 years old. They were classified as grade I-II by the American Society of anesthesiologists (ASA) and were randomly divided into the CLTCI group and the OLTCI group (@*RESULTS@#In the induction stage, the percentage of adequate anesthesia time in the CLTCI group was higher than that in the OLTCI group, and the percentage of deep anesthesia time in the CLTCI group was significantly lower than that in the OLTCI group (both @*CONCLUSIONS@#Compared with propofol OLTCI, anesthesia with propofol CLTCI under BIS guidance can maintain a more appropriate depth of anesthesia sedation and more stable hemodynamics.

Application of intravenous sedation in 2 582 cases of oral and maxillofacial surgery / 北京大学学报(医学版)

OBJECTIVE@#To analyze the clinical data of patients undergoing intravenous sedation in oral and maxillofacial surgery, to understand the epidemiological characteristics, to evaluate the efficacy and safety of intravenous sedation for oral surgery, and to summarize our experience.@*METHODS@#We retrospectively reviewed the clinical data of patients undergoing intravenous sedation between January 2010 and December 2018 in the Department of Oral and Maxillofacial Surgery, Peking University School of Stomatology. The gender, age, source, disease types, the values of perioperative vital signs, the use of sedatives and analgesics, duration of surgery and sedation, effect of sedation during the operation and the postoperative anterograde amnesia were analyzed.@*RESULTS@#A total of 2 582 patients experienced oral surgery by intravenous sedation. The peak age was 3.5 to 10 years and between 21 to 40 years. Supernumerary teeth (38%, 981/2 582) and impacted third molars (30%, 775/2 582) were the major disease types, and other types of disease accounted for 32 percent (826/2 582). The values of heart rate(HR), mean arterial pressure(MAP), respiration rate(RR) and bispectral index(BIS) showed statistically significant differences at the time of before sedation, local anesthesia injection, surgical incision, 10 min after operation and the end of operation. In the study, 69%(1 781/2 582) cases received midazolam alone, 7%(181/2 582) cases received propofol alone, and 24% (620/2 582) cases received midazolam and propofol combined for intravenous sedation. Fentanyl (33%, 852/2 582)was the most common intravenous analgesic we used, followed by flurbiprofen axetil (23%, 594/2 582) and ketorolac tromethamine (6%, 157/2 582). Besides, 35% (907/2 582) patients didn't use any intravenous analgesic during the surgery. The average operation time was (31.2±20.8) min, and the average sedation time was (38.4±19.2) min. During the surgery procedure, most of the patients scored on a scale of 2 to 4 according to the Ramsay sedation score (RSS). The postoperative anterograde amnesia rates of local anesthesia injection, surgical incision and dental drill during surgery were 94% (2 431/2 582), 92% (2 375/2 582) and 75% (1 452/1 936).@*CONCLUSION@#Intravenous sedation on the oral and maxillofacial surgery is effective and safe, can make the patients more comfortable, and should be further promoted and applied.

Malignant hyperthermia in a child after magnetic resonance imaging: a case report / Hipertermia maligna em criança após exame de ressonância magnética: relato de caso

ABSTRACT Objective: To report on a case of malignant hyperthermia in a child after a magnetic resonance imaging of the skull was performed using sevoflurane anesthesia. Case description: A 3-year-old boy admitted to the pediatric intensive care unit after presenting clinical and laboratory findings consistent with unspecified viral meningoencephalitis. While the patient was sedated, a magnetic resonance imaging of the skul was performed using propofol followed by the administration of sevoflurane through a laryngeal mask in order to continue anesthesia. Approximately three hours after the start of the procedure, the patient presented persistent tachycardia, tachypnea, generalized muscular stiffness and hyperthermia. With a diagnostic hypothesis of malignant hyperthermia, dantrolene was then administered, which immediately induced muscle stiffness, tachycardia, tachypnea and reduced body temperature. Comments: Malignant hyperthermia is a rare pharmacogenetic syndrome characterized by a severe hypermetabolic reaction after the administration of halogenated inhalational anesthetics or depolarizing muscle relaxants such as succinylcholine, or both. Although it is a potentially fatal disease, the rapid administration of continued doses dantrolene has drastically reduced the morbidity and mortality of the disease.

RESUMO Objetivo: Relatar um caso de hipertermia maligna em criança após exame de ressonância magnética de crânio realizada sob efeito anestésico de sevoflurano. Descrição do caso: Menino de três anos de idade, admitido na Unidade de Terapia Intensiva Pediátrica (UTIP) após apresentar quadros clínico e laboratorial compatíveis com meningoencefalite viral não especificada. Foi realizado um exame de ressonância magnética de crânio com sedação utilizando, na indução anestésica, o propofol seguido pela administração de sevoflurano por meio de máscara laríngea para manutenção anestésica. Aproximadamente três horas após o início do procedimento, o paciente apresentou taquicardia, taquipneia, rigidez muscular generalizada e hipertermia persistentes. Com hipótese diagnóstica de hipertermia maligna, foi então administrado dantrolene, que fez ceder de forma imediata a rigidez muscular, a taquicardia, a taquipneia e reduziu a temperatura corporal. Comentários: A hipertermia maligna é uma síndrome farmacogenética rara, que se caracteriza por reação hipermetabólica grave após administração de anestésicos inalatórios halogenados e/ou relaxantes musculares despolarizantes, como a succinilcolina. Apesar de ser uma doença potencialmente fatal, a rápida administração de dantrolene, junto às doses de manutenção, tem reduzido drasticamente a morbimortalidade da doença.

Evaluation of Bispectral Index time delay in response to anesthesia induction: an observational study / Avaliação do tempo de atraso do índice bispectral na resposta à indução da anestesia: estudo observacional

Abstract Background and objectives According to the manufacturer, the Bispectral Index (BIS) has a processing time delay of 5-10 s. Studies addressing this have suggested longer delays. We evaluated the time delay in the Bispectral Index response. Methods Based on clinical data from 45 patients, using the difference between the predicted and the real BIS, calculated during a fixed 3 minutes period after the moment the Bispectral Index dropped below 80 during the induction of general anesthesia with propofol and remifentanil. Results The difference between the predicted and the real BIS was in average 30.09 ± 18.73 s. Conclusion Our results may be another indication that the delay in BIS processing may be much longer than stated by the manufacture, a fact with clinical implications.

Resumo Justificativa e objetivos De acordo com o fabricante, o índice bispectral (BIS) tem um tempo de processamento de cinco a dez segundos. Estudos que avaliaram esse tempo de processamento sugeriram atrasos mais longos. Nós avaliamos o tempo de atraso na resposta do BIS. Métodos Com base em dados clínicos de 45 pacientes, calculamos a diferença entre o tempo de atraso previsto e real do índice bispectral durante um período fixo de três minutos após o momento em que o BIS caiu abaixo de 80 durante a indução da anestesia geral com propofol e remifentanil. Resultados A diferença entre o BIS previsto e real foi em média 30,09 ± 18,73 segundos. Conclusão Nossos resultados sugerem que o atraso no processamento do índice bispectral pode ser muito maior do que o declarado pelo fabricante, um fato com implicações clínicas.

Evaluation of a closed-loop intravenous total anesthesia delivery system with BIS monitoring compared to an open-loop target-controlled infusion (TCI) system: randomized controlled clinical trial / Evaluación de un sistema de administración de Anestesia Total Intravenosa en lazo cerrado con neuromonitoría, comparado con un sistema de lazo abierto de infusión controlada por objetivo (TCI): Ensayo clínico controlado

Abstract Introduction: Intravenous general anesthesia is an anesthetic technique that can be administered with TCI (target-controlled infusion) or closed-loop systems. The authors designed an automatic delivery system using clinical variables such as bispectral index (BIS), heart rate, and blood pressure. Objective: To evaluate the clinical and technical performance of this controller by comparing it to a TCI system. Methods: This was a single-blind, randomized, controlled clinical trial in which 150 patients were recruited: 75 for the TCI group and 75 for the closed loop with BIS. Clinical performance was determined according to the mean percentage of time spent in the BIS range of 40 to 60 during anesthetic maintenance. In addition, adequate intraoperative analgesia, technical performance, intraoperative awakening, and intraoperative recall were evaluated. Results: The primary outcome showed a mean BIS time between 40 and 60 for the closed loop of 75.24% (± 15.78) versus 59.5% (± 20.3) for the TCI system, with an absolute difference of 15.8%, 95% confidence interval (CI): 9.9 to 21.65, P < 0.0001. The mean time in intraoperative analgesia was 82.4% (25.1) in closed loop and 70.77% (± 32.8) in TCI, with a difference of 4.76 (95% CI: 2.23-21.06), P = 0.016. There was no difference in intraoperative recall. Conclusion: The closed-loop system was better at maintaining a BIS in the range of 40 to 60 during a general anesthetic than the open system or TCI.

Resumen Introducción: La anestesia total endovenosa es una técnica anestésica que puede administrarse con sistemas de TCI (Target Controlled Infusión) o de lazo cerrado. Los autores diseñaron un sistema de administración automática empleando variables clínicas como índice biespectral (BIS), frecuencia cardiaca y presión arterial. Objetivo: Evaluar el desempeño clínico y técnico de este controlador, comparándolo con un sistema de TCI. Métodos: Este fue un ensayo clínico controlado, aleatorizado y de ciego único, en el cual se reclutaron 150 pacientes: 75 en el grupo de TCI y 75 en lazo cerrado con BIS. El desempeño clínico fue determinado de acuerdo al porcentaje promedio de tiempo de permanencia en el rango de BIS entre 40-60 durante el mantenimiento anestésico. Adicionalmente se evaluó analgesia intraoperatoria adecuada, desempeño técnico, despertar intraoperatorio y recuerdo intraoperatorio. Resultados: Para el desenlace primario se encontró un tiempo promedio de BIS entre 40-60 para el lazo cerrado de un 75.24% (+/-15.78) vs. 59.5% (+/- 20.3) para el sistema TCI, con una diferencia del 15.8%, IC del 95%: 9.9 a 21.65, p < 0.0001. El promedio de tiempo en analgesia intraoperatoria adecuada fue del 82.4% (25.1) en lazo cerrado y 70.77% (+/- 32.8) en TCI, con una diferencia de 4.76 (IC del 95%: 2.23 a 21.06), p=0.016. No hubo diferencias en recuerdo intraoperatorio. Conclusión: El sistema de lazo cerrado fue mejor para mantener un BIS en rango de 40-60 durante un acto anestésico que el sistema abierto o TCI.

Seguridad de la sedación con propofol administrado por gastroenterólogos en endoscopia digestiva / Safety of propofol sedation administered by gastroenterologists in digestive endoscopy

Resumen Objetivo: tradicionalmente, la sedación con propofol ha estado a cargo de especialistas en anestesiología; sin embargo, una extensa cantidad de información publicada ha demostrado que la sedación con propofol administrado por no anestesiólogos, es segura y eficaz. El estudio se realizó con el objetivo de evaluar la seguridad en la administración de propofol por gastroenterólogos, para la realización de procedimientos en endoscopia digestiva. Métodos: se hizo un estudio retrospectivo en el cual se revisaron los expedientes de 1135 pacientes sometidos a endoscopias digestivas diagnósticas y terapéuticas, en el período comprendido entre enero de 2016 y marzo de 2017. Los pacientes se organizaron por su: edad, género, clasificación de riesgo de la Sociedad Americana de Anestesiólogos, indicación para la endoscopia, y dosis utilizada de propofol. Se registraron los efectos adversos asociados al uso de Propofol, tales como: episodios de hipoxemia transitoria, complicaciones cardiopulmonares serias y muerte. Resultados: se incluyeron los datos de 1135 pacientes (56 % fueron mujeres) que se practicaron endoscopia digestiva bajo sedación con propofol administrado por gastroenterólogos, en un período de 14 meses. La dosis promedio utilizada de propofol fue de 154 +/- 66 mg. Según la clasificación de riesgo de la Sociedad Americana de Anestesiólogos, el 84 % de los pacientes corresponde a las clasificaciones I y II, un 14,8 % a pacientes con clasificación de riesgo III y un 1,1 %, riesgo IV. Los estudios efectuados fueron mayoritariamente gastroscopias (52,6 %) y según la indicación, el 79,6 % corresponde a estudios diagnósticos, seguido de un 12,1% para los sangrados digestivos altos de emergencia. En cuanto a las complicaciones documentadas, se identificaron 70 episodios de hipoxemia que corresponden a un 6,2 % de las sedaciones realizadas. (IC 95%, 4,7-7,6). Solamente un 3,7 % de los pacientes presentó un episodio de hipoxemia por debajo del 80 %. Todos los episodios de hipoxemia, excepto uno, resolvieron con maniobras simples, como la elevación del mentón. Durante el estudio no se presentaron complicaciones cardiopulmonares serias o muertes. Se identificaron, como factores de riesgo para la aparición de hipoxemia, una clasificación de riesgo de la Sociedad Americana de Anestesiólogos mayor a 3, y la realización del estudio endoscópico para dilatación esofágica o colocación de gastrostomía percutánea. Conclusiones: el uso de sedación con propofol administrado por no anestesiólogos en el estudio, no evidenció incremento en la aparición de complicaciones cardiopulmonares serias, ni en los episodios de hipoxemia.

Abstract Aim: Traditionally, sedation with propofol has been approved exclusively for use by anethesiologists, however, an extensive amount of published information has shown that sedation with propofol administered by non-anesthesiologists is safe and effective. The present study was conducted with the objective of evaluating the safety in the administration of propofol by gastroenterologists for the performance of procedures in digestive endoscopy. Methods: A retrospective study was conducted in which the records of 1135 patients who underwent digestive and therapeutic digestive endoscopies were reviewed in the period between January 2016 and March 2017. The patients were classified by age, gender, risk classification of the American Society of Anesthesiologists (ASA), indication for endoscopy, and dose of propofol. The adverse effects associated with the use of propofol were recorded, such as episodes of transient hypoxemia, serious cardiopulmonary complications and death. Results: We included data from 1135 patients (56% were women) who underwent gastrointestinal endoscopy under sedation with propofol administered by gastroenterologist in a period of 14 months. The average dose used for propofol was 154 +/- 66 mg of propofol. According to the American Society of Anesthesiologists risk classification, 84% of the patients correspond to risk I and II, 14.8% to risk level III and 1.1% to risk level IV. The study carried out the most were gastroscopies (52.6%) and according to the indication, 79.6% corresponded to diagnostic studies, followed by 12.1% for upper gastrointestinal bleeding. Regarding the documented complications,70 episodes of hypoxemia were identified, corresponding to 6.2% of the sedations performed. (95% CI, 4.7-7.6). Only 3.7% of patients had an episode of hypoxemia below 80%. All episodes of hypoxemia, except one, resolved with simple maneuvers such as chin elevation. There were no serious cardiopulmonary complications or deaths during the study. We identified as risk factors for the appearance of hypoxemia a risk classification of the American Society of Anesthesiologists greater than 3 and performance of the endoscopic study for esophageal dilation or percutaneous gastrostomy placement. Conclusions: The use of sedation with propofol administered by non-anesthesiologists in the present study did not show an increase in the appearance of serious cardiopulmonary complications, or in episodes of hypoxemia.

The role of PI3K/Akt signal pathway in the protective effects of propofol on intestinal and lung injury induced by intestinal ischemia/reperfusion

Abstract Purpose: To investigate the role of PI3k/Akt signal pathway in the protective effects of propofol on intestinal and lung injury induced by intestinal ischemia/reperfusion(I/R). Methods: Male Sprague-Dawley rats were subjected to 45 min of ischemia by occluding the superior mesenteric artery and to 2h of reperfusion to establish the model of I/R. Twenty four rats were randomly divided into four groups: Sham, intestinal I/R (II/R), propofol (P), wortmannin (W). In groups P, W, propofol was injected intravenously and continuously at the onset of reperfusion via infusion pump. PI3K inhibitor (wortmannin) was administered intravenously in group W 25 min before ischemia. Intestinal tissues and lung tissues were obtained for determination of histologic injury, wet/dry weight ratio, malondialdehyde (MDA) levels, superoxide dismutase (SOD) and myeloperoxidase (MPO) activities. Meanwhile, the expressions of caspase-3 and phosphorylated Akt (p-Akt) in intestines and lungs were detected by western blot. Results: Propofol treatment alleviated intestinal and lung morphological changes which were observed in II/R group，Moreover, wet/dry weight ratio, the MDA level, MPO activity and expression of caspase-3 were significantly decreased whereas the SOD activity and p-Akt expression were significantly increased. Notably, the protections were significantly reversed by pretreatment of wortmannin. Conclusion: PI3K/Akt pathway activation play a critical role in the protective effects of propofol on intestinal and lung injury induced by ischemia/reperfusion.

Dexmedetomidine: present and future directions / 대한마취과학회지

Dexmedetomidine is a potent, highly selective α-2 adrenoceptor agonist, with sedative, analgesic, anxiolytic, sympatholytic, and opioid-sparing properties. Dexmedetomidine induces a unique sedative response, which shows an easy transition from sleep to wakefulness, thus allowing a patient to be cooperative and communicative when stimulated. Dexmedetomidine may produce less delirium than other sedatives or even prevent delirium. The analgesic effect of dexmedetomidine is not strong; however, it can be administered as a useful analgesic adjuvant. As an anesthetic adjuvant, dexmedetomidine decreases the need for opioids, inhalational anesthetics, and intravenous anesthetics. The sympatholytic effect of dexmedetomidine may provide stable hemodynamics during the perioperative period. Dexmedetomidine-induced cooperative sedation with minimal respiratory depression provides safe and acceptable conditions during neurosurgical procedures in awake patients and awake fiberoptic intubation. Despite the lack of pediatric labelling, dexmedetomidine has been widely studied for pediatric use in various applications. Most adverse events associated with dexmedetomidine occur during or shortly after a loading infusion. There are some case reports of dexmedetomidine-related cardiac arrest following severe bradycardia. Some extended applications of dexmedetomidine discussed in this review are promising, but still limited, and further research is required. The pharmacological properties and possible adverse effects of dexmedetomidine should be well understood by the anesthesiologist prior to use. Moreover, it is necessary to select patients carefully and to determine the appropriate dosage of dexmedetomidine to ensure patient safety.

¿Por qué el propofol en el paciente con cáncer? / ¿Why propofol in the cancer patient?

INTRODUCTION: Cancer is a chronic, incapacitating and high mortality disease. OBJECTIVE: To carry out an update on the beneficial properties of the use of propofol as an anesthetic agent in cancer patients. METHODOLOGICAL DESIGN: A manual and digital search was performed in different databases such as MEDLINE, Scielo, IBECS and Cochrane, with the following descriptors: propofol, cancer, immunity and cancer. Development: 90% of deaths related to cancer are due to the progression of the disease, to metastases and not to the primary tumor. Therefore, preventing immunosuppression in the perioperative period is particularly important. During the perioperative period, there are factors that activate or inhibit immune responses. Recent findings have suggested that anesthesia can induce metabolic, inflammatory and immunological changes in the perioperative period. Propofol promotes the cytotoxicity of natural killer cells, reduces the motility of tumor cells, inhibits cyclo-oxygenase. It has been revealed that this drug exhibits anticancer properties in some types of cancer: colon cancer, gastric cancer, bile duct cancer. CONCLUSIONS: Propofol has a potential benefit as an anesthetic agent in patient with cancer. Only the accumulation of even more scientific evidence would allow us to give greater value to the use of this drug.

INTRODUCCIÓN: El cáncer es una enfermedad crónica, incapacitante y de gran mortalidad. OBJETIVO: Realizar una actualización sobre las beneficiosas propiedades del uso del propofol como agente anestésico en el paciente oncológico. DISEÑO METODOLÓGICO: Se realizó una búsqueda manual y digital en diferentes bases de datos como MEDLINE, Scielo, IBECS y Cochrane, con los descriptores siguientes: propofol, cáncer, inmunidad y cáncer. Desarrollo: El 90% de las muertes relacionadas con el cáncer son debido a la progresión de la enfermedad, a las metástasis y no al tumor primario. Por ello, prevenir la inmunosupresión en el período perioperatorio toma particular importancia. Durante el periodo perioperatorio existen factores que activan o inhiben las respuestas inmunitarias. Los descubrimientos recientes han sugerido que la anestesia puede inducir cambios metabólicos, inflamatorios e inmunológicos en el período perioperatorio. El propofol favorece la citotoxicidad de las células naturalkiller, reduce la motilidad de las células tumorales, inhibe la ciclooxigenasa. Ha sido revelado que este fármaco exhibe propiedades anticancerosas en algunos tipos de cáncer: cáncer de colon, cáncer gástrico, cáncer de vías biliares. CONCLUSIONES: El propofol presenta un potencial beneficio como agente anestésico en el paciente con cáncer. Solo bastaría la acumulación de aún más evidencia científica que nos permita darle mayor valor al uso de este fármaco.

Effects of propofol pretreatment on myocardial cell apoptosis and SERCA2 expression in rats with hepatic ischemia/reperfusion / Efeitos do pré-tratamento com propofol sobre a apoptose de células miocárdicas e expressão de SERCA2 em ratos com isquemia/reperfusão hepática

Abstract Introduction: Hepatic ischemia-reperfusion injury is a common pathophysiological process in liver surgery. Whether Propofol can reduce myocardial ischemia-reperfusion injury induced by hepatic ischemia-reperfusion injury in rats, together with related mechanisms, still needs further studies. Objective: To investigate if propofol would protect the myocardial cells from apoptosis with hepatic ischemia-reperfusion injury. Methods: Male Sprague-Dawley rats (n = 18) were randomly allocated into three groups: Sham Group (Group S, n = 6), Hepatic Ischemia-reperfusion Injury Group (Group IR, n = 6) and Propofol Group (Group P, n = 6). Group S was only subjected to laparotomy. Group IR was attained by ischemia for 30 min and reperfusion for 4 h. Group P was subjected identical insult as in Group IR with the administration of propofol started 10 min before ischemia with 120 mg.kg−1, following by continuous infusion at 20 mg.kg−1.h−1. Cell apoptosis was examined by terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling assay. Endoplasmic reticulum Ca2+-ATPase2 (SERCA2) and cysteine-containing aspartic acid cleaved-caspase3 (cleaved-caspase3) were assayed by western blot and Altimeter polymerase chain reaction. Results: Apoptosis rate was increased, with mRNA and protein of SERCA2 down-regulated and cleaved-caspase3 up-regulated in Group IR compared with Group S (p < 0.01). Apoptosis rate was decreased, with mRNA and protein of SERCA2 up-regulated and cleaved-caspase3 down-regulated in Group P compared with Group IR (p < 0.01). Conclusions: Propofol can reduce hepatic ischemia-reperfusion injury-induced myocardial cell apoptosis, meanwhile, can up-regulate mRNA and protein of SERCA2 in rats.

Resumo Introdução: A lesão hepática por isquemia-reperfusão é um processo fisiopatológico comum em cirurgias hepáticas. Mais estudos ainda são necessários para avaliar se o propofol pode reduzir a lesão de isquemia-reperfusão miocárdica induzida pela lesão de isquemia-reperfusão hepática em ratos, juntamente com os mecanismos que estão relacionados. Objetivo: Investigar se propofol protege as células do miocárdio da apoptose com a lesão hepática por isquemia-reperfusão. Métodos: Ratos machos da raça Sprague-Dawley (n = 18) foram alocados aleatoriamente em três grupos: Grupo Sham (Grupo S, n = 6), Grupo Lesão Hepática por Isquemia-reperfusão (Grupo IR, n = 6) e Grupo Propofol (Grupo P, n = 6). O Grupo S foi submetido apenas à laparotomia. O grupo IR foi submetido à isquemia por 30 min e reperfusão por 4 h. O grupo P foi submetido à mesma isquemia do grupo IR, com a administração de 120 mg.kg-1 de propofol iniciada 10min antes da isquemia, seguida de infusão contínua a 20 mg.kg-1.h-1. A apoptose celular foi examinada por meio do ensaio de marcação de terminações dUTP pela deoxinucleotidil transferase. Retículo endoplasmático Ca2+-ATPase2 (SERCA2) e caspase-3 do ácido aspártico contendo cisteína (caspase-3 clivada) foram avaliados com o ensaio western blot e reação em cadeia da polimerase. Resultados: A taxa de apoptose foi maior com mRNA e proteína de SERCA2 regulados para baixo e caspase-3 clivada suprarregulada no Grupo IR, em comparação com o Grupo S (p < 0,01). A taxa de apoptose foi menor com mRNA e proteína de SERCA2 suprarregulada e caspase-3 clivada sub-regulada no Grupo P, em comparação com o Grupo IR (p < 0,01). Conclusões: O propofol pode reduzir a apoptose de células miocárdicas induzida por lesão hepática por isquemia-reperfusão. Entretanto, pode suprarregular o mRNA e a proteína de SERCA2 em ratos.

Incidencia de reacciones adversas en sedación con midazolam endovenoso o intramuscular en niños y jóvenes en situación de discapacidad: experiencia de dos años / Incidence of side effects during i.v. or i.m. midazolam sedation in children and young people with disabilities: two-year experience

Introducción: Los pacientes no cooperadores con trastorno neuromotor generan dificultad para realizar tratamientos dentales y exámenes diagnósticos. En el Instituto Teletón de Santiago estos procedimientos se realizan bajo sedación, por profesional no anestesiólogo. Se administra midazolam para sedación leve o moderada (nivel II a IV, escala de Ramsay), guiada por un protocolo específico. Las reacciones adversas al medicamento en pacientes con discapacidad neuromotora es-tán escasamente documentadas en los últimos 10 años en la literatura. Objetivo: Determinar la incidencia de reacciones ad-versas a la administración de midazolam endovenoso o intramuscular en pacientes con trastorno neuromotor, no cooperado-res que requieren sedación para recibir tratamientos dentales y otros procedimientos como potencial evocado visual (PEV), potencial evocado auditivo (BERA) y toma de moldes para órtesis de tronco y extremidades. Material y Método: Estudio de vigilancia farmacológica, basado en 389 registros de sedación de la Unidad de Enfermería del Instituto Teletón de Santiago, en los años 2014 y 2015. Se consignaron las variables: vía de administración, tipo de procedimiento, presencia de reacción adversa, tipo de reacción adversa. Resultados: De los 389 procedimientos de sedación, 255 (65,5%) fueron para atención dental; 83% utilizó vía endovenosa; se registraron 10 (2,6%) eventos de reacción adversa, de los cuales 6 fueron reacción paradojal, 3 hipotensión, 1 taquicardia y 1 evento de desaturación a 60%. Conclusión: Midazolam usado sin asociación con otro medicamento, siguiendo protocolos de administración y vigilancia, es una alternativa segura para la sedación leve a mo-derada, administrado por profesional no anestesiólogo, ocasionando mínimas reacciones adversas. Palabras clave: Midazolam, sedación consciente, efectos adversos, odontopediatría.(AU)

Introduction: It is difficult to perform dental treatment and diagnostic examinations in non-cooperative patients with neuro-motor disorders. At Teletón Institute in Santiago, Chile, these procedures are performed while the patient is under seda-tion, administered by non-anesthesiologist health professionals. Midazolam is used for mild or moderate sedation (level II to IV, Ramsay scale), guided by a specific protocol. Side effects and adverse drug reactions in patients with neuro-motor disabili-ties are scarcely documented for the last 10 years. Objective: To establish the incidence of side effects after the administration of intravenous or intramuscular Midazolam in non-cooperative patients with neuromotor disorders, requiring sedation in order to receive dental treatment and other procedures such as visual evoked potentials (VEP), brain-stem evoked response audio-metry (BERA) and for the preparation of custom made trunk and limb orthoses. Materials and Methods: Drug surveillance study, based on 389 sedation records of the nurses' unit at Teleton Institute in Santiago, Chile during 2014 and 2015. The fo-llowing variables were recorded: route of administration, procedure, adverse drug reaction, and type of reaction. Results: Of 389 sedation procedures, 255 (65.5%) were for dental treatment; 83% were administered intravenously; 10 adverse drug reac-tion events (2.6%) were recorded: paradoxical reactions (6), low blood pressure (3), tachycardia (1) and 60% oxygen desatura-tion (1). Conclusion: Isolated use of midazolam, in compliance with administration and surveillance protocols, is a safe alter-native for mild to moderate sedation, administered by non-anesthesiologist health professionals, showing minimum adverse effects. Key words: Midazolam, conscious sedation, adverse effects, pediatric dentistry.(AU)

Seguridad en la administración de propofol dirigido por gastroenterólogo entrenado en procedimientos endocópicos: experiencia de 10 años en clínica privada en Lima, Perú / Safety of gastroenterologist-directed propofol administration for endoscopic procedures: 10-year experience in a private clinic in Lima, Peru

Objetivo: Evaluar la seguridad de propofol combinado con meperidina y midazolam en colonoscopías, endoscopías y ecoendoscopía administrado por una enfermera supervisada por un gastroenterólogo entrenado y comparar su requerimiento en pacientes menores y mayores de 75 años. Material y métodos: Estudio descriptivo retrospectivo, que incluyó a pacientes mayores de 18 años de edad que recibieron propofol durante la endoscopía, colonoscopía (o endoscopía+colonoscopía) y ecoendoscopía. A los pacientes se les administró una dosis inicial de Meperidina (25 mg) y Midazolam (1-3 mg) por vía intravenosa (IV). Después de 2-3 minutos recibieron un bolo IV de propofol entre 10-30 mg. Se administraron bolos repetidos de 10-20 mg a intervalos no menores a 60 segundos durante cada procedimiento, titulado según necesidad y tolerancia del paciente. Resultados: Entre septiembre del 2006 y septiembre del 2016, se realizaron 9 704 procedimientos endoscópicos: 1 598 endoscopías, 3 065 colonoscopías, 2 492 endoscopía + colonoscopía y 57 eco-endoscopías. Hubo 3 912 mujeres (59,1%), la edad promedio fue de 57,1 ± 14,6 años, 880 pacientes (12,5%) mayores de 75 años. La dosis media de propofol para todos los procedimientos fue de 83,2 ± 48,1 mg, para la endoscopía y colonoscopía fue de 59,7 ± 36,2 mg y 77,2 ± 41 mg respectivamente. La dosis media utilizada en pacientes mayores de 75 años en endoscopía fue de 47,5 ± 37,8 mg, colonoscopías de 58,3 ± 33,4 mg y endoscopía + colonoscopía de 78,7 ± 42,7 mg en comparación con pacientes < 75 años en los que la dosis promedio de endoscopía fue de 61,1±35,8 mg (p <0,05), en colonoscopías de 80,5±41,3 mg (p<0,05) y en endoscopías+colonoscopías 105,9 ± 50,2 mg (p<0,05). No hubo complicaciones relacionadas con la sedación. Conclusiones: Propofol combinado con meperidina y midazolam en procedimientos endoscópicos, administrado por enfermera y dirigidos por un gastroenterólogo entrenado, es seguro. Los pacientes mayores de 75 años, necesitaron dosis significativamente menores de propofol para endoscopía, colonoscopia, endoscopía + colonoscopia y ecoendoscopía.

Objective: To evaluate safety of propofol combined with Meperidine and Midazolam in colonoscopies, upper endoscopies (EGD) and Endoscopic Ultrasound (EUS) administered by a nurse supervised by a trained gastroenterologist. To compare the required doses of propofol among older and younger than 75 years old. Materials and methods: Retrospective descriptive study including patients 18 years of age and older who received propofol for EGD, colonoscopy (or EGD + colonoscopy) and EUS. The patients were given a baseline dose of Meperidine (25 mg) and Midazolam (1-3 mg) intravenously (IV). After 2-3 minutes, they received an IV bolus of propofol between 10-30 mg. Repeat boluses of 10-20 mg were administered at intervals no lesser than 60 seconds during the procedure, as needed according to patient`s tolerance to the procedure. Results: Between September 2006 and September 2016, 9,704 procedures were performed, of which 1,598 were EGD, 3,065 colonoscopies, 2,492 EGD + colonoscopies and 57 EUS. There were 3,912 women (59.1%), and the average age was 57.1 ± 14.6 years. Eight hundred eighty (12.5%) were older than 75 years. The average dose of propofol for all the procedures was 83.2 ± 48.1 mg, for EGD and colonoscopy was 59.7 ± 36.2 mg and 77.2 ± 41 mg respectively. The average dose used in patients >75 years for EGD was 47.5 ± 37.8 mg, for colonoscopies 58.3 ± 33.4 mg and for EGD + colonoscopies was 78.7 ± 42.7 mg compared to patients <75 years in whom the average dose for EGD was 61.1 ± 35.8 mg (p<0.05), in colonoscopies was 80.5 ± 41.3 mg (p<0.05) and in EGD + colonoscopies 105.9 ± 50.2 mg (p<0.05). There were no sedation-related complications. Conclusions: Propofol combined with meperidine and midazolam in endoscopic procedures directed by a trained gastroenterologist is safe. Elderly patients (>75 years old) required significantly less doses of propofol for EGD, colonoscopy, EGD/colonoscopy and EUS.

Ecocardiografia Padrão, com Strain e Strain Rate com Speckle Tracking Bidimensional em Macaco-Capuchinho (Cebus Apella, Linnaeus, 1758) / Standard Echocardiography, Strain and Strain Rate by Two-Dimensional Speckle Tracking in Capuchin Monkey (Cebus Apella, Linnaeus, 1758)

Introdução: O macaco-capuchinho é uma espécie de primata não humano que demonstra grande potencial para estudos pré-clínicos devido às semelhanças anatômicas e fisiológicas com os seres humanos. Objetivo: Estudar os índices de deformação miocárdica em macacos-capuchinhos anestesiados utilizando speckle tracking. Métodos: Foram utilizados dezesseis animais do Parque Zoobotânico, em Teresina, Piauí, Brasil, com restrição química, utilizando uma combinação de cetamina e midazolam. Os estudos ecocardiográficos foram obtidos nos modos B, M e Doppler, medindo-se strain e strain rate através de speckle tracking. Resultados: As variáveis que apresentaram coeficientes de correlação estatisticamente significativos em relação ao peso foram a parede livre do ventrículo esquerdo em diástole (PLVEd), diâmetro interno do ventrículo esquerdo em diástole (DIVEd), diâmetro interno do ventrículo esquerdo em sístole (DIVEs), onda E, A'VD, movimento do anel mitral (MAM) e excursão sistólica do plano do anel tricúspide (TAPSE). A frequência cardíaca (FC) mostrou correlação positiva com a onda E e a onda A e correlação negativa com o tempo de relaxamento isovolumétrico (TRIV). A fração de encurtamento (FS) apresentou correlação positiva com a razão entre as ondas E e A (r = 0,61). TAPSE mostrou correlações positivas com E'VD e A'VD. Os valores obtidos para o strain circunferencial (-18,17 ± 4,68%), radial (47,13 ± 5,24%) e longitudinal (-26,46 ± 5,155%) para os macacos-capuchinhos estavam dentro dos intervalos normais para machos e fêmeas. Conclusão: O presente estudo fornece os primeiros valores de referência para medidas ecocardiográficas em modos B, M e Doppler para macacos-capuchinhos anestesiados com cetamina e midazolam. Os valores de strain e strain rate obtidos utilizando a técnica de speckle tracking mostraram-se semelhantes aos obtidos em seres humanos, sugerindo que esta ferramenta pode ser explorada em estudos pré-clínicos utilizando o modelo do macaco-capuchinho

Introduction: The capuchin monkey is a type of nonhuman primate that has shown great potential for preclinical studies because of its anatomical and physiological similarities to humans. Objective: To study the indices of myocardial deformation in anesthetized capuchin monkeys using speckle tracking. Methods: Sixteen animals from the Zoobotanical Park, Teresina, Piauí, Brazil, were used and chemically restrained using a combination of ketamine and midazolam. Echocardiography recordings were obtained in B, M and Doppler modes, and strain and strain rate were measured using speckle tracking. Results: The variables that showed statistically significant correlation coefficients in relation to weight were LVFWd, LVIDd, LVIDs, E wave, A'RV, MAM and TAPSE. HR showed a positive correlation with the E wave and A wave and a negative correlation with IVRT. FS presented a positive correlation with the E/A wave relationship (r = 0.61). TAPSE showed positive correlations with E'RV and A'RV. The values obtained for circumferential (-18.17 ± 4.68%), radial (47.13 ± 5.24%) and longitudinal (- 26.46 ± 5.15%) strain for the capuchin monkeys were within the normal ranges for males and females. Conclusion: The present study provides the first reference values for echocardiographic measurements in B, M and Doppler modes for capuchin monkeys anesthetized with ketamine and midazolam. The strain and strain rate values obtained using speckle tracking showed similarities with those obtained in humans, suggesting that this tool has the potential to be exploited in preclinical studies using the capuchin monkey model

Application of a pharmacokinetics-pharmacodynamics approach to the free propofol plasma levels during coronary artery bypass grafting surgery with hypothermic cardiopulmonary bypass

OBJECTIVES: The objective of this study was to apply a pharmacokinetics-pharmacodynamics approach to investigate the free propofol plasma levels in patients undergoing coronary artery bypass grafting under hypothermic conditions compared with the off-pump procedure. METHODS: Nineteen patients scheduled for on-pump coronary artery bypass grafting under hypothermic conditions (n=10) or the equivalent off-pump surgery (n=9) were anesthetized with sufentanil and propofol target-controlled infusion (2 μg/mL) during surgery. The propofol concentration was then reduced to 1 μg/mL, and a pharmacokinetics-pharmacodynamics analysis using the maximum-effect-sigmoid model obtained by plotting the bispectral index values against the free propofol plasma levels was performed. RESULTS: Significant increases (two- to five-fold) in the free propofol plasma levels were observed in the patients subjected to coronary artery bypass grafting under hypothermic conditions. The pharmacokinetics of propofol varied according to the free drug levels in the hypothermic on-pump group versus the off-pump group. After hypothermic coronary artery bypass was initiated, the distribution volume increased, and the distribution half-life was prolonged. Propofol target-controlled infusion was discontinued when orotracheal extubation was indicated, and the time to patient extubation was significantly higher in the hypothermic on-pump group than in the off-pump group (459 versus 273 min, p=0.0048). CONCLUSIONS: The orotracheal intubation time was significantly longer in the hypothermic on-pump group than in the off-pump group. Additionally, residual hypnosis was identified through the pharmacokinetics-pharmacodynamics approach based on decreases in drug plasma protein binding in the hypothermic on-pump group, which could explain the increased hypnosis observed with this drug in this group of patients.