Robotic prostatectomy: the anesthetist's view for robotic urological surgeries, a prospective study / Prostatectomia robótica: análise anestesiológica de cirurgias urológicas robóticas: estudo prospectivo / Prostatectomía robótica: análisis anestesiológico de cirugías urológicas robóticas, un estudio prospectivo

Background and objectives: Although many features of robotic prostatectomy are similar to those of conventional laparoscopic urological procedures (such as laparoscopic prostatectomy), the procedure is associated with some drawbacks, which include limited intravenous access, relatively long operating time, deep Trendelenburg position, and high intra-abdominal pressure. The primary aim was to describe respiratory and hemodynamic challenges and the complications related to high intra-abdominal pressure and the deep Trendelenburg position in robotic prostatectomy patients. The secondary aim was to reveal safe discharge criteria from the operating room. Methods: Fifty-three patients who underwent robotic prostatectomy between December 2009 and January 2011 were prospectively enrolled. Main outcome measures were non-invasive monitoring, invasive monitoring and blood gas analysis performed at supine (T0), Trendelenburg (T1), Trendelenburg + pneumoperitoneum (T2), Trendelenburg-before desufflation (T3), Trendelenburg (after desufflation) (T4), and supine (T5) positions. Results: Fifty-three robotic prostatectomy patients were included in the study. The main clinical challenge in our study group was the choice of ventilation strategy to manage respiratory acidosis, which is detected through end-tidal carbon dioxide pressure and blood gas analysis. Furthermore, the mean arterial pressure remained unchanged, the heart rate decreased significantly and required intervention. The central venous pressure values were also above the normal limits. Conclusion: Respiratory acidosis and "upper airway obstruction-like" clinical symptoms were the main challenges associated with robotic prostatectomy procedures during this study. .

Justificativa e objetivos: Embora muitas características da prostatectomia robótica sejam semelhantes àquelas de laparoscopias urológicas convencionais (como a prostatectomia por laparoscopia), o procedimento está associado a alguns inconvenientes, incluindo acesso intravenoso limitado, tempo cirúrgico relativamente longo, posição de Trendelenburg profunda e pressão intra-abdominal alta. O objetivo principal foi descrever as alterações respiratória e hemodinâmica e as complicações relacionadas à pressão intra-abdominal elevada e à posição de Trendelenburg profunda em pacientes submetidos à prostatectomia robótica. O objetivo secundário foi revelar critérios seguros de alta do centro cirúrgico. Métodos: Foram inscritos prospectivamente 53 pacientes submetidos à prostatectomia robótica entre dezembro de 2009 e janeiro de 2011. As medidas de desfecho primário foram: monitoramento não invasivo, monitoramento invasivo e gasometria feita em decúbito dorsal (T0), Trendelenburg (T1), Trendelenburg + pneumoperitônio (T2), Trendelenburg pré-desinsuflação (T3), Trendelenburg pós-desinsuflação (T4) e posições supinas (T5). Resultados: O principal desafio clínico em nosso grupo de estudo foi a escolha da estratégia de ventilação para controlar a acidose respiratória, que é detectada por meio da pressão de dióxido de carbono expirado e da gasometria. Além disso, a pressão arterial média permaneceu inalterada e a frequência cardíaca diminuiu significativamente e precisou de intervenção. Os valores da pressão venosa central também estavam acima dos limites normais. Conclusão: A acidose respiratória e sintomas clínicos "semelhantes à obstrução ...

Justificación y objetivos: Aunque muchas características de la prostatectomía robótica sean similares a las de las laparoscopias urológicas convencionales (como la prostatectomía laparoscópica), el procedimiento está asociado con algunos inconvenientes, incluyendo el acceso intravenoso limitado, tiempo quirúrgico relativamente largo, posición de Trendelenburg profunda y presión intraabdominal alta. El objetivo principal fue describir las alteraciones respiratorias y hemodinámicas y las complicaciones relacionadas con la presión intraabdominal elevada y con la posición de Trendelenburg profunda en pacientes sometidos a prostatectomía robótica. El objetivo secundario fue revelar criterios seguros de alta del quirófano. Métodos: Cincuenta y tres pacientes sometidos a prostatectomía robótica entre diciembre de 2009 y enero de 2011 fueron incluidos en un estudio prospectivo. Las principales medidas de resultado fueron: monitorización no invasiva, monitorización invasiva y gasometría realizada en decúbito dorsal (T0), Trendelenburg (T1), Trendelenburg + neumoperitoneo (T2), Trendelenburg predesinsuflación (T3), Trendelenburg posdesinsuflación (T4) y posiciones supinas (T5). Resultados: Cincuenta y tres pacientes sometidos a prostatectomía robótica fueron incluidos en el estudio. El principal reto clínico en nuestro grupo de estudio fue la elección de la estrategia de ventilación para controlar la acidosis respiratoria, que es detectada por medio de la presión de dióxido de carbono espirado y la gasometría. Además, la presión arterial media permaneció inalterada, y la frecuencia cardíaca disminuyó significativamente y fue necesario intervenir. Los valores de la presión venosa central también estaban por encima de los límites normales. ...

Analytical calculation and acid-base analysis for detection of mixed disorders in critical care medicine.

Aim: The purpose of the study was to validate the systematic six-step arterial blood gas (ABG) analysis in critically ill patients to diagnose mixed ABG disorders. Materials and method: The study was conducted in the ICU of a tertiary care hospital (between 1 June and 30 September, 2007) for 4 months. A total of 560 ABG samples were evaluated from 183 patients. 50 samples were randomly picked and evaluated by single step, quick look method and six-step approaches for detecting mixed ABG disorders. Results: Single, quick and six-step methods when applied on same data, revealed higher number of mixed disorders with systematic six-step approach. Quick-step method revealed only 48% mixed disorders while six-step analysis confirmed 62% having mixed disorders, from the samples which initially appeared to be single disorder. Metabolic acidosis with respiratory acidosis (26%) was the commonest disorder. Metabolic acidosis with respiratory alkalosis (20%), respiratory alkalosis with metabolic alkalosis (6%), metabolic alkalosis with respiratory acidosis (4%), metabolic acidosis with NGMA (4%) and metabolic acidosis with metabolic alkalosis (2%) were the other mixed disorders seen. Conclusion: Mixed disorders as suspected on clinical grounds can only be validated after complete analysis by six-step approach in critically ill patients. pH, PaCO2, and HCO3 – allow determination of primary disorder, but it is only the inequality between predicted and actual compensatory response for simple acid-base disorders which reveals a mixed disorder.

Bronchopulmonary dysplasia in very low birth weight infants.

Objective. To determine the risk factors for development of bronchopulmonary dysplasia (BPD) by evaluating mild and moderate/severe BPD in extramural neonates with a birth weight <1501 g. Methods. A case-control study was conducted between January 1, 2004- December 31, 2006. Patients with BPD and without BPD were compared. Bronchopulmonary dysplasia was diagnosed and classified according to the Bancalari criteria. One-hundred and six (106) extramural premature infants with a birth weight <1501 g and admitted to the Neonatal Unit in the first three days of life and survived for more than 28 postnatal days were included. Patients with multiple congenital anomalies and complex cardiac pathologies were excluded. The maternal and neonatal risk factors, clinical features, mechanical ventilation treatment were compared. The principal risk factors for BPD development were analyzed and followed by logistic regression test. Results. The diagnosis was mild BPD in 27 of the 106 patients and moderate/severe BPD in 29. The incidence of BPD was 52.8%. Fifty of 106 patients had no BPD. Analysis of risk factors revealed that gestational age ≤28 weeks (p=0.019), birth weight ≤1000 g (p=0.007), hypothermia (p=0.003), acidosis (p=0.003) and hypotension (p=0.005) at admission, respiratory distress syndrome (RDS) ( p<0.001), mechanical ventilation therapy (p<0.001), surfactant therapy (p=0.005), higher amount of mean fluid therapy on 7th days (p=0.008), nosocomial infection (p<0.001), higher amount of mean packed red cell transfusions (p<0.001) and more than two packed red cell transfusions (p=0.033) were risk factors associated with the development of BPD. Multivariant logistic regression analysis showed acidosis at admission (OR 5.12, 95%CI 1.17–22.27, p=0.029), surfactant treatment (OR 7.53, 95%CI 2.14–26.45, p=0.002), nosocomial infections (OR 4.66, 95%CI 1.27–17.12, p=0.02) and PDA (OR 9.60, 95%CI 2.23–41.22, p=0.002) were risk factors increasing the severity of BPD. Conclusion. The most important risk factors for BPD development in our study were RDS and nosocomial infections while the presence of acidosis at admission, surfactant administration, nosocomial infections and the presence of PDA were the most important risk factors regarding BPD severity. Presence of acidosis at admission as a risk factor emphasized the importance of suitable transport conditions for premature infants.

Diagnostico e terapia da hipoxia fetal durante o parto / Diagnosis and treatment of the intrapartum fetal hypoxia

Os autores discutem brevemente os mecanismos patofisiologicos das causas mais frequentes da hipoxia e acidose fetal intraparto, ou seja, a reducao da perfusao utero-placentaria e feto placentaria decorrentes principalmente da hiperatividade uterina e/ou compressao funicular. Tres metodos diagnosticos da hipoxia fetal intraparto sao abordados: a amnioscopia, cardiotocografia e a pHmetria do sangue no couro cabeludo fetal. Concluem que a pHmetria apresenta os melhores resultados em sensibilidade, especifidade e valores preditivos. O seu emprego na obstetricia atual e limitado pela falta de condicoes do seu uso de maneira continua, tornando-a um metodo complementar da cardiotocografia continua intraparto. E apresentado pelos autores um esquema de aplicacao pratica combinada dos tres metodos acima citados na vigilancia do bem estar fetal no trabalho de parto. A principal terapeutica da hipoxia fetal intraparto e a rapida interrupcao do parto, por intervencao obstetrica adequada ao periodo do trabalho de parto. Novos metodos como tocolise e amnioinfusao podem melhorar os resultados perinatais e ajudar a diminuir a incidencia de casareas.

Extrapulmonary Oxygenation by Giving Hydrogen Peroxide by Enema

An investigation of extrapulmonary oxygenation was made in dogs, rabbits and, finally, in a case of Tetralogy of Fallot using an intestinal perfusion of hydrogen peroxide (H2O2). For a single administration, 0.4 per cent H2O2 can be given safely by enema, in doses of 10ml./Kg. of body weight, this would give maximum oxygenation in both the portal vein and inferior vena cava without the formation of gas emboli. Concentrations higher than this caused gas bubbles in the portal vein. For serial administrations, 0.2 per cent H2O2 can be given by enema exchanging the intestinal contents at 10 to 15 minutes intervals. When given concomitantly with human whole blood, 1.0ml./Kg. of body weight, there is a prolonged higher oxygenation in the portal vein, inferior vena cava and femoral artery. This concentation of H2O2 would not cause gas emboli in the portal vein. Although extrapulmonary oxygenation is possible by giving oxygen by enema, this method would cause too much abdominal distension. In experiments of death by suffocation, the group given H2O2 had doubled the duration of E.K.G. activity when compared with controls. One patient with Tetralogy of Fallot, confirmed by clinical findings, X-ray studies, E.K.G. and cardiac catheterization, who was not suitable for cardiac surgery because of low mentality, was selected for this study. 0.2 per cent H2O2, 10ml. per Kg. of body weight by enema, exchanging intestinal contents at 30 minutes intervals, resulted in a marked elevation of the pO2 in the venous blood and in the inferior vena cava. There was a disappearance of finger tip and toe tip cyanosis and flushing of the soles and palms was noted during the procedure.