Manejo agudo de la intoxicación medicamentosa / Acute management of drug intoxication

Resumen Las intoxicaciones o las sobredosis de drogas constituyen una fuente importante de morbilidad, mortalidad y gasto en salud en todo el mundo. Especialmente en adultos menores de 35 años, las intoxicaciones vienen a ser la principal causa de paro cardíaco no traumático, siendofármacos más comunes involucrados, analgésicos, antidepresivos, opioides, sin embargo, esto puede variar. Es importante realizar un abordaje rápido, con base en interrogatorio, información de cualquier testigo y evidencia, además la clínica del paciente. El paro cardíaco debido a toxicidad se maneja de acuerdo conlos estándares actuales de reanimación cardiopulmonar básica y avanzada, siguiendo los principios del A, B, C, D, E. Las manifestaciones clínicas y abordaje clínico pueden variar bastante dependiendo de la sustancia involucrada. Las pruebas de laboratorio casi nunca están disponibles en un marco de tiempo que respalde las decisiones de reanimación tempranas, aún así, es recomendable realizarlas. En general los efectos tóxicos pueden reducirse si se limita la absorción del o los fármacos o se aumenta su eliminación. Además, se puede bloquear efectos farmacológicos no deseados con los llamados antídotos. El uso del carbón activado, algunos antídotos específicos, y tratamientos extracorpóreos también se contemplan en la presente revisión.

Abstract Poisoning or drug overdose is a major source of morbidity, mortality and health expenditure worldwide, especially in adults under 35, where it is the leading cause of non-traumatic cardiac arrest, being more common drugs involved, analgesics, antidepressants, opioids, however, this may vary. It is important to make a quick approach, based on questioning, information from any witness and evidence, and the patient's clinic. Cardiac arrest due to toxicity is managed according to current Basic and Advanced life support standards, following the principles of A, B, C, D, E. Clinical manifestations and clinical approach can vary considerably depending on the substance involved. Laboratory tests are almost never available in a time frame that supports early resuscitation decisions, yet it is advisable to perform them. In general, the toxic effects can be reduced if the absorption of the drugs is limited or their elimination increased. In addition, you can block unwanted pharmacological effects with so-called antidotes. The use of activated charcoal, specific antidotes, and extracorporeal treatments are also covered in this review.

Atrial fibrillation with hemodynamic instability after the use of the third dose of adenosine during surgery for 7 intracranial aneurysms: case report / Fibrilación auricular con inestabilidad hemodinámica tras el uso de tercera dosis de adenosina durante cirugía de siete aneurismas intracraneales: reporte de caso

Abstract Adenosine-induced asystole is a technique that prevents and controls the intraoperative rupture of cerebral aneurysm, facilitating temporary, and/or definitive clipping of the aneurysm. This is the case of a 58-year-old woman who underwent clipping of 7 intracranial aneurysms, who was induced asystole with adeno-sine 3 times and developed atrial fibrillation with hemodynamic instability after the last dose. Adenosine has been shown to be useful and safe, however, its use should be planned and possible cardiological complications should be considered.

Resumen La asistolia inducida por adenosina es una técnica que previene y controla la ruptura intraoperatoria de aneurisma cerebral, facilitando el clipaje temporal y/o definitivo del mismo. Presentamos el caso de una mujer de 58 años intervenida para clipaje de 7 aneurismas intracraneales, a quien se le indujo asistolia con adenosina en 3 oportunidades y desarrolló fibrilación auricular con inestabilidad hemodinámica tras la última dosis. La adenosina ha demostrado ser útil y segura, sin embargo, debe planificarse su uso y considerar eventuales complicaciones cardiológicas.

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

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

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

Progress on suxamethonium chloride analysis / 法医学杂志

Abstract: Suxamethonium chloride is a depolarizing muscle relaxant used in general anesthesia. In overdose, it causes adverse reactions such as bradycardia, arrhythmia, cardiac arrest, and death. The article reviews the progress on testing methods of suxamethonium chloride such as infrared spectroscopy, chemical color reaction, chemical titration, enzyme electrode, chromatography and mass spectrometry.

Lipídeos nas intoxicações por anestésicos locais / Lipids in local anesthetic toxicity

INTRODUÇÃO: Com o advento dos anestésicos locais de longa duração, a anestesia locorregional ganhou grande impulso sendo cada vez mais utilizada. Novas técnicas de bloqueios foram descritas e a técnica é frequentemente associada à anestesia geral com o objetivo de proporcionar analgesia pós-operatória. A contra-partida é a necessidade da utilização de grandes doses com risco de acidentes por injeção intravascular inadvertida; trata-se de complicação grave sem tratamento específico até há alguns anos. Em 1998 foi proposta a utilização de emulsões lipídicas em animais e a partir de 2006 vários trabalhos demonstraram o interesse dessas soluções nos casos de intoxicações por anestésicos locais com diminuição da morbi-mortalidade. O objetivo desta revisão foi fazer um levantamento da metodologia, revisando os mecanismos, interesses, limites e as condutas preconizadas atualmente. MÉTODO: Foram revistas algumas referências históricas sobre anestésicos locais, artigos publicados nos últimos 30 anos em revistas indexadas no Medline e em dois livros-texto. Foram selecionados os artigos que tratavam da intoxicação por anestésicos locais, da terapia com emulsões lipídicas, os de revisão sobre o assunto e as condutas adotadas em diversos serviços e países, sendo realizada uma síntese. CONCLUSÕES: A eficiência e interesse da terapia com emulsões lipídicas nas intoxicações por anestésicos locais não é mais a demonstrar; várias sociedades da especialidade já publicaram suas diretrizes e aconselham que se disponha desses produtos nos locais onde se pratica a anestesia locorregional.

INTRODUCTION: With the advent of long-lasting local anesthetics, local and regional anesthesia gained considerable impetus and the use of these techniques has become increasingly widespread. New block techniques have been described and regional anesthesia is frequently associated with general anesthesia to provide postoperative analgesia. In contrast, large doses of local anesthetics are required with the risk of accidents due to inadvertent intravascular injection, which is a severe complication without a specific treatment until a few years ago. In 1998, the use of lipid emulsions was proposed in animals. Since 2006, many studies have demonstrated an interest in these solutions in cases of local anesthetic-induced toxicity with a decrease in morbidity and mortality. The aim of this review article was to research the methodology, reviewing mechanisms, interests, limitations and currently recommended treatment. METHOD: Some historical references on local anesthetics, articles published during the last 30 years in journals indexed in Medline and in two textbooks were reviewed. Articles on local anesthetic toxicity, lipid emulsion therapy, review articles on the topic and treatment adopted in diverse services and countries were selected, producing a summary. CONCLUSIONS: It is no longer necessary to show the effectiveness and interest in lipid emulsion therapy for local anesthetic toxicity. Various specialty societies have already published their guidelines and advice about stocking these products in any setting in which local and regional anesthetic techniques are practiced.

Neem oil poisoning.

We report an unusual case of neem oil poisoning in a previously normal 5 year old child. The child presented with refractory seizures and was having metabolic acidosis. Late neurological sequelae in the form of auditory and visual disturbances, and ataxia were present.

The Hemodynamic Effects of Insulin Following Overdosage with Levobupivacaine or Racemic Bupivacaine in Dogs

Although levobupivacaine (LBUP) is less cardiotoxic than racemic bupivacaine (RBUP), the resuscitation from the LBUP-induced cardiovascular collapse (CVC) has not been easy as expected. Following the recent reports that proposed the resuscitative action of insulin for the RBUP-induced CVC, a controlled trial was performed to assess the feasibility of insulin for the LBUP-induced CVC. Fourteen dogs were randomly allocated into two groups: the RBUP and LBUP groups. Each group received continuous intravenous infusions of RBUP or LBUP until the mean arterial pressure (MAP) reached 40 mmHg. Then, an intravenous bolus of insulin (2 U/kg) was administered. Both groups were successfully resuscitated. At CVC, a decrease of cardiac output and an increase of systemic vascular resistance were observed but to a lesser degree in the LBUP group (p<0.05). After insulin injection, the MAP further declined to under 40 mmHg for several minutes, which was more protracted in the LBUP group (p<0.05). The CVCs induced by LBUP or RBUP in anesthetized dogs could be successfully resuscitated by insulin. Compared with RBUP, however, the less degree of vasoconstriction by LBUP and the innate vasodilatory property of insulin yielded a delayed increment of MAP during the immediate resuscitation period in the LBUP-induced CVC.

Las lecciones derivadas del ASA Closed Claims Project (ASACCP): proyecto de la ASA acerca de las razones que promovieron demandas contra anestesiólogos cuyos casos estuviesen ya archivados. 3a. parte, Paro cardíaco infantil perioperatorio (Registro POCA). (Con 3 apéndices) / Lessons learned from the ASA Closed Claims Project (ASACCP): ASA project about the reasons for wich claims against anesthesiologists were renewed in cases that had already been closed. 3rd. part, Infantile perioperative cardiac arrest (POCA register). (With 3 appendices)

Se definen los paros cardíacos infantiles como aquellas situaciones que se producen durante la inducción o durante el mantenimiento de la anestesia, o que se originan en las unidades de cuidados posanestésicos y requieren una resucitación cardiopulmonar en niños de hasta dieciocho a±os de edad. La muerte dentro de las 24 horas fue el resultado final en el 43 por ciento de los casos de los ni±os estudiados, mientras que el 4 por ciento murió dentro de 4 días de la operación. En el 42 por ciento de los casos el da±o fue menor, mientras que el 6 por ciento requirió de cuidados especiales (siguientes a una reanimación cardiopulmonar). El 4 por ciento de los ni±os quedaron con secuelas definitivas. Ni±os menores de 1 mes de edad presentaron el 25 por ciento de todos los paros cardíacos y tuvieron una mortalidad elevada (66 por ciento). Esta tasa de mortalidad es mßs elevada que la que corresponde a cualquier otro grupo etario. Un 24 por ciento de paros cardíacos adicionales ocurrieron en niños entre 1 y 5 meses de edad. La mortalidad en el grupo fue del 39 por ciento. Los niños mayores de 6 meses de edad, pero menores de los 12 meses fueron el 49 por ciento, lo que representa el 20 por ciento de los 289 casos estudiados. Faltan datos adecuados para calcular la incidencia de los paros cardíacos y de muerte basado únicamente en la edad de los pacientes (ver introducción de la primera parte para encontrar la razón de este hecho). Sin embargo, considerando que los ni±os menores de 1 año de edad constituyen la mayoría de los pequeños anestesiados, estos hallazgos no hacen mes que confirmar que los niños por debajo del año de vida son mes susceptibles de sufrir eventos adversos con peligro de muerte que los niños mayores. El estado fésico ASA P1-P2 correspondió a 26 (20 por ciento) de todos los casos. Aún cuando el paro cardíaco en este grupo fue también frecuentemente relacionado a causas cardiovasculares (50 por ciento), los problemas vinculados con la administración de drogas (sobredosis anestésica relativa, error de dosis y reacción alérgica) fue observado en el 27 por ciento de los casos cuando se los compara con sólo el 8 por ciento en los pacientes con un estado físico P3-P5. El impacto de la anestesia fue descrito por los revisores institucionales como la mayor causa total del paro cardíaco (81 por ciento) de los pacientes con estado físico P1-P2, comparado con únicamente el 29 po ciento de los pacientes con estado físico P3-P5...

Perioperative cardiac arrest at Siriraj Hospital between 1999-2001.

Cardiac arrest during the perioperative period is a good indicator of the quality of anesthetic management. The incidence of perioperative cardiac arrest in Siriraj Hospital hasn't been reported before. Our objectives were to determine the incidence of perioperative anesthesia-related cardiac arrest and the results of cardiopulmonary resuscitation in these cases in order to find out how to improve our anesthetic care. This prospective study was undertaken between 1999-2001 by sending a questionnaire to those witnessing a cardiac arrest. The incidence of perioperative cardiac arrest was 8.2:10,000 instances of anesthesia with a mortality of 5.6:10,000 within 48 hours of the arrest. The incidence of perioperative cardiac arrest that was related to anesthesia was 0.7:10,000 instances of anesthesia and the anesthesia related mortality was 0.19: 10,000 within 48 hours of arrest. Failed cardiopulmonary resuscitation occurred in of occasions 41.7 per cent. There was no difference between intraoperative and postoperative cardiopulmonary resuscitation. Twenty-one per cent of patients experiencing a cardiac arrest were discharged from hospital. Seventy-three per cent of events occurred in patients with an ASA rating 3-5 and most often the cause of arrest was massive or uncontrolled bleeding. In those patients with an ASA rating 1-2 there were no outstanding cause of arrest.

Toxicity of Nerium oleander leaf extract in mice.

Non-lethal dose of 70% ethanol extract of the Nerium oleander dry leaves (1000 mg/kg body weight) was subcutaneously injected into male and female mice once a week for 9 weeks (total 10 doses). One day after the last injection, final body weight gain (relative percentage to the initial body weight) had a tendency, in both males and females, towards depression suggesting a metabolic insult at other sites than those involved in myocardial function. Multiple exposure of the mice to the specified dose failed to express a significant influence on blood parameters (WBC, RBC, Hb, HCT, PLT) as well as myocardium. On the other hand, a lethal dose (4000 mg/kg body weight) was capable of inducing progressive changes in myocardial electrical activity ending up in cardiac arrest. The electrocardiogram abnormalities could be brought about by the expected Na+, K(+)-ATPase inhibition by the cardiac glycosides (cardenolides) content of the lethal dose.

Anestesia local em Otorrinolaringologia e suas complicaçöes / Local Anesthesia in Otorhinolaryngology and its complications

O uso de anestesia local para procedimentos otorrinolaringológicos encontra-se cada vez mais corriqueiro. Desta forma, o cirurgião deve estar apto a lidar com quaisquer complicações, estando familiarizado com propriedades farmacológicas, doses e concentrações dos anestésicos empregados. Em vista do exposto, apresentaremos três casos em que foi empregado lidocaína spray a 10 por cento como pré-anestésico, a infiltração de bupivacaína 0,5 por cento com complicações imediatas de convulsões e parada cardiorespiratória; as quais foram revertidas com intubação traqueal e uso de drogas como succinil-colina e thiopental.

Parada cardíaca durante anestesia em hospital universitário de atendimento terciário (1988 a 1996) / Cardiac arrest during anesthesia at a tertiary teaching hospital (1988 to 1996)

Justificativas e objetivos - a incidência e causas de parada cardíaca durante anestesia variam e säo difíceis de serem comparadas por causa da grande variabilidade existente entre os estudos. A pesquisa teve como objetivo estudar a incidência de parada cardíaca (PC) em hospital de ensino de atendimento terciário. Método - foi realizada investigaçäo retrospectiva da incidência de PC ocorrida durante anestesia em 58.533 pacientes consecutivos, submetidos à anestesia no Hospital das Clínicas da Faculdade de Medicina de Botucatu, UNESP. O estudo utilizou ficha computadorizada e ficha especial para cada óbito ocorrido. Os casos de PC foram estudados em relaçäo à idade, sexo, estado físico segundo a classificaçäo da ASA, tipo de atendimento, fatores desencadeantes, como alteraçäo do estado físico do paciente e complicaçöes cirúrgicas e anestésicas, tipo de anestesia, incidência de óbito e condiçöes de alta da SRPA. Resultados - ocorreram 184 PC (31,4:10.000), sendo a maioria na SO (88,59 por cento), em idosos, no sexo masculino (84,3 por cento), em pacientes com estado físico ASA III ou superior, em atendimento de emergência e durante anestesia geral. Alteraçöes do estado físico foram o principal fator de PC (21,7:10.000), sendo a letalidade da PC de causa anestésica (0,85:10.000) menor em comparaçäo com as do estado físico do paciente (15,7:10.000) ou complicaçöes da cirurgia (4,6:10.000)

Assistolia durante ecocardiograma de estresse com dobutamina / Cardiac asystole during dobutamine stress echocardiography

We report a case of cardiac asystole during dobutamine stress echocardiography in a 59 year-old woman presenting with chest pain and a positive treadmill test for ischemia. Cardiac asystole was not associated with myocardial ischaemia and was probably related to a powerful cardioinhibitory reflex caused by dobutamine stimulation.

Frusemide--digitalis interaction on experimental model.

Interaction of frusemide and digitalis on frog heart has been studied. It was found that like digitalis, frusemide did not have any effect on normal heart, but restored the normal myocardial contraction of the hypodynamic frog heart. Frusemide induced cardiac arrest when administered during digoxin infusion. It is suggested that interaction of frusemide and digoxin has additive effect.