Factores de riesgo de complicaciones respiratorias en cirugía oncológica de mama con anestesia total intravenosa / Risk factors of respiratory complications in breast cancer surgery with total intravenous anesthesia

A prospective longitudinal cohort study was performed in patients with breast cancer operated surgically with the use of total intravenous anesthesia in the provincial hospital Carlos Manuel de Céspedes de Bayamo, from the Cauto region during the period from January 1 from 2014 to December 31, 2016, with the aim of identifying the risk factors hypothetically related to the appearance of respiratory complications. It was established that the exposed cohort was constituted by 79 patients who developed complications during the study period and met the inclusion criteria. The diagnosis of respiratory complications was made during the entire surgical procedure and finished. The magnitude of the associations was estimated by calculating the relative risks (RR) of complications. The age of the patient equal to or greater than 65 years, and smoking were the surgical risk factors depending on the patient related to the onset of respiratory complications in breast cancer surgery with total intravenous anesthesia, not alcoholism. Anemia, obesity, low weight and recent respiratory tract infection were surgical risk factors dependent on associated diseases related to the appearance of respiratory complications. The ASA III-IV classification and the surgical time of more than three hours were surgical risk factors related to surgery related to the appearance of respiratory complications.

Se realizó un estudio longitudinal prospectivo de cohorte en pacientes con cáncer de mama intervenidos quirúrgicamente con el empleo de anestesia total intravenosa en el hospital provincial "Carlos Manuel de Céspedes de Bayamo, procedentes de la región del Cauto durante el período comprendido desde el 1ro de enero de 2014 hasta 31 de diciembre de 2016, con el objetivo de identificar los factores de riesgo hipotéticamente relacionados con la aparición de complicaciones respiratorias. Se estableció que la cohorte expuesta estuvo constituida por 79 pacientes que desarrollaron complicaciones en el período de estudio y cumplieron con los criterios de inclusión. La evaluación del diagnóstico de complicaciones respiratorias se realizó durante todo el procedimiento quirúrgico y terminado éste. La magnitud de las asociaciones se estimó mediante el cálculo de los riesgos relativos (RR) de complicaciones. La edad de la paciente igual o superior a 65 años, y el tabaquismo fueron los factores de riesgo quirúrgico en función del enfermo relacionados con la aparición de complicaciones respiratorias en cirugía oncológica de mama con anestesia total intravenosa, no así el alcoholismo. La anemia, la obesidad, bajo peso y la infección reciente del tracto respiratorio fueron los factores de riesgo quirúrgico dependiente de enfermedades asociadas relacionados con la aparición de complicaciones respiratorias. La clasificación ASA III-IV y un tiempo quirúrgico superior a tres horas se constituyeron en los factores de riesgo quirúrgico en función de la cirugía relacionados con la aparición de complicaciones respiratorias.

Cardiopulmonary parameters in propofol- or thiopental-anesthetized dogs induced to pulmonary hypertension by serotonin / Parâmetros cardiopulmonares em cães anestesiados com propofol ou tiopental e induzidos à hipertensão pulmonar pela serotonina

The cardiopulmonary changes in propofol- or thiopental-anesthetized dogs induced to pulmonary hypertension (PH) were evaluated. Twenty adult animals were randomly assigned to two groups: propofol group (PG) and thiopental group (TG). In PG, propofol was used for induction (8(0.03mg.kg-1) and anesthesia maintenance (0.8mg.kg-1.minute-1), while, in TG, thiopental was used (22±2.92mg.kg-1; 0.5mg.kg-1.minute-1, respectively). Mechanical ventilation using time cycle was started. PH was induced by administration of serotonin (5HT) (10µg.kg-1 and 1mg.kg-1.hour-1) through a thermodilution catheter positioned in the pulmonary artery. The measurements were performed before administration of 5HT (T0), after 30 minutes (T30), then at 15-minute intervals (T45, T60, T75 and T90). No differences between groups were registered for systolic (sPAP) and mean pulmonary arterial pressure (mPAP), mean arterial pressure (MAP), total peripheral resistance index (TPRI) and pulmonary vascular resistance index (PVRI). In PG, sPAP and mPAP increased from T30. While in TG, sPAP and mPAP increased from T75. In PG, heart rate (HR) increased from T30, in which PG was higher than TG. The TPRI values decreased from T30 in PG, and in TG, at T45, T60 and T90. In PG, at T0, PVRI was lower than at other times. In PG, arterial partial pressures of oxygen (PaO2) decreased from T60 and alveolar-arterial oxygen gradient (PA-aO2) increased at T60. In TG, at T0 PaO2 was higher than at T30, T45, T60 and T90, while PA-aO2 at T0 was lower than at T90. From T30 to T90, TG showed higher PaO2 means and lower arterial partial pressures of carbon dioxide (PaCO2) values when compared to PG. In PG, from T30, PaCO2 increased, while in TG this parameter was stable. In conclusion, thiopental anesthesia attenuated the cardiopulmonary changes resulting from serotonin-induced PH, probably by attenuation of vasoconstriction and bronchoconstriction.

Avaliaram-se as alterações cardiopulmonares em cães anestesiados com propofol ou tiopental induzidos à hipertensão pulmonar (HP). Vinte animais adultos foram distribuídos aleatoriamente em dois grupos: grupo propofol (PG) e grupo tiopental (TG). No PG, o propofol foi usado para indução (8(0,03mg.kg-1) e manutenção da anestesia (0,8mg.kg-1minuto-1), enquanto no TG foi empregado o tiopental (22(2,92mg.kg-1; 0,5mg.kg-1.minute-1, respectivamente). Em seguida, a ventilação mecânica ciclada a tempo foi iniciada. A HP foi induzida pela administração de serotonina (5HT) (10µg.kg-1e 1mg.kg-1.hour-1) por meio de cateter de termodiluição posicionado na artéria pulmonar. As mensurações tiveram início antes da administração da 5HT (T0), depois de 30 minutos (T30), seguida de intervalos de 15 minutos (T45, T60, T75 e T90). Diferenças entre os grupos não foram registradas para pressões sistólica (PAPs) e média (PAPm) da artéria pulmonar, pressão arterial média (PAM), índices da resistência periférica total (IRPT) e da resistência vascular pulmonar (IRVP). A PAPs e a PAPm aumentaram a partir de T30, no PG, e a partir de T75, no TG. No PG, a frequência cardíaca (FC) aumentou a partir de T30, no qual PG foi maior que TG. O IRPT diminuiu no T45, T60 e T90, no TG, e a partir de T30 no PG. No PG, no T0, IRVP foi menor que nos outros momentos. No PG, a pressão parcial de oxigênio no sangue arterial (PaO2) diminuiu a partir de T60, e a diferença de tensão entre o oxigênio alveolar e arterial (PA-aO2) aumentou no T60. No TG, no T0, a PaO2 foi maior que no T30, T45, T60 e T90, enquanto a PA-aO2,, no T0, foi menor que no T90. Entre T30 e T90, TG apresentou maior PaO2 e menor pressão parcial de dióxido de carbono no sangue arterial (PaCO2) quando comparado ao PG. No PG, a partir de T30, a PaCO2 aumentou. A anestesia com tiopental abrandou as mudanças cardiopulmonares resultantes da indução da HP pela serotonina, provavelmente devido à atenuação da vasoconstrição e broncoconstrição.

A randomized, double blind comparison of pethidine and ketoprofen as adjuvants for lignocaine in intravenous regional anaesthesia / Estudo comparativo, randômico e duplo-cego de petidina e cetoprofeno como adjuvantes de lidocaína em anestesia regional intravenosa / Estudio comparativo, aleatorizado y doble ciego, de la petidina y del ketoprofeno como adyuvantes de la lidocaína en la anestesia regional intravenosa

BACKGROUND AND OBJECTIVES: A review of all the adjuncts for intravenous regional anaesthesia concluded that there is good evidence to recommend NonSteroidal Anti-Inflammatory agents and pethidine in the dose of 30 mg dose as adjuncts to intravenous regional anaesthesia. But there are no studies to compare pethidine of 30 mg dose to any of the NonSteroidal Anti-Inflammatory agents. METHODS: In a prospective, randomized, double blind study, 45 patients were given intravenous regional anaesthesia with either lignocaine alone or lignocaine with pethidine 30 mg or lignocaine with ketprofen 100 mg. Fentanyl was used as rescue analgesic during surgery. For the first 6 h of postoperative period analgesia was provided by fentanyl injection and between 6 and 24 h analgesia was provided by diclofenac tablets. Visual analogue scores for pain and consumption of fentanyl and diclofenac were compared. RESULTS: The block was inadequate for one case each in lignocaine group and pethidine group, so general anaesthesia was provided. Time for the first dose of fentanyl required for postoperative analgesia was significantly more in pethidine and ketoprofen groups compared to lignocaine group (156.7 ± 148.8 and 153.0 ± 106.0 vs. 52.1 ± 52.4 min respectively). Total fentanyl consumption in first 6 h of postoperative period was less in pethidine and ketoprofen groups compared to lignocaine group (37.5 ± 29.0 mcg, 38.3 ± 20.8 mcg vs. 64.2 ± 27.2 mcg respectively). Consumption of diclofenac tablets was 2.4 ± 0.7, 2.5 ± 0.5 and 2.0 ± 0.7 in the control, pethidine and ketoprofen group respectively, which was statistically not significant. Side effects were not significantly different between the groups. CONCLUSION: Both pethidine and ketoprofen are equally effective in providing postoperative analgesia up to 6 h, without significant difference in the side effects and none of the adjuncts provide significant ...

JUSTIFICATIVA E OBJETIVOS: uma revisão de todos os adjuvantes para anestesia regional intravenosa concluiu que há boas evidências para recomendar os agentes anti-inflamatórios não esteroides e petidina em dose de 30 mg como adjuvantes para anestesia regional intravenosa. Porém, não há estudos que comparem petidina (30 mg) com quaisquer dos agentes anti-inflamatórios não esteroides. MÉTODOS: em um estudo prospectivo, randômico e duplo-cego, 45 pacientes receberam anestesia regional intravenosa com apenas lidocaína ou lidocaína com petidina (30 mg) ou lidocaína com cetoprofeno (100 mg). Fentanil foi usado como analgésico de resgate durante a cirurgia. Durante as seis primeiras horas de pós-operatório, analgesia foi fornecida via injeção de fentanil e, entre seis e 24 horas, analgesia foi fornecida via comprimidos de diclofenaco. Os escores visuais analógicos para dor e do consumo de fentanil e diclofenaco foram comparados. RESULTADOS: o bloqueio foi inadequado para um caso tanto do grupo lidocaína quanto do grupo petidina; portanto, anestesia geral foi administrada. O tempo para a primeira dose necessária de fentanil para analgesia pós-operatória foi significativamente maior nos grupos petidina e cetoprofeno em comparação com o grupo lidocaína (156,7 ± 148,8 e 153,0 ± 106,0 vs. 52,1 ± 52,4 minutos, respectivamente). O consumo total de fentanil nas primeiras seis horas de pós-operatório foi menor nos grupos petidina e cetoprofeno em comparação com o grupo lidocaína (37,5 ± 29,0 mcg, 38,3 ± 20,8 mcg vs. 64,2 ± 27,2 mcg, respectivamente). O consumo de comprimidos de diclofenaco foi de 2,4 ± 0,7, 2,5 ± 0,5 e 2,0 ± 0,7 no grupo controle, petidina e cetoprofeno, respectivamente, o que não foi estatisticamente significante. ...

JUSTIFICACIÓN Y OBJETIVOS: una revisión sobre todos los adyuvantes para la anestesia regional intravenosa concluyó que hay buenas evidencias para recomendar los agentes antiinflamatorios no esteroideos y la petidina en dosis de 30 mg como adyuvantes para la anestesia regional intravenosa. Sin embargo, no hay estudios comparando la petidina (30 mg) con cualesquiera de los agentes antiinflamatorios no-esteroideos. MÉTODOS: en un estudio prospectivo, aleatorizado y doble ciego, 45 pacientes recibieron anestesia regional intravenosa con solamente lidocaína o lidocaína con petidina (30 mg) o lidocaína con ketoprofeno (100 mg). El fentanilo fue usado como analgésico de rescate durante la cirugía. Durante las 6 primeras horas del postoperatorio, la analgesia fue suministrada vía inyección de fentanilo y entre 6 y 24 h, la analgesia fue suministrada vía comprimidos de diclofenaco. Se compararon las puntuaciones visuales analógicas para el dolor y el consumo de fentanilo y diclofenaco. RESULTADOS: el bloqueo fue inadecuado para un caso tanto del grupo lidocaína como del grupo petidina; por tanto, se administró anestesia general. El tiempo para la primera dosis necesaria de fentanilo para analgesia postoperatoria fue significativamente mayor en los grupos petidina y ketoprofeno en comparación con el grupo lidocaína (156,7 ± 148,8 y 153,0 ± 106,0 vs. 52,1 ± 52,4 min, respectivamente). El consumo total de fentanilo en las primeras 6 h del postoperatorio fue menor en los grupos petidina y ketoprofeno en comparación con el grupo lidocaína (37,5 ± 29,0 mcg; 38,3 ± 20,8 mcg vs. 64,2 ± 27,2 mcg, respectivamente). El consumo de comprimidos de diclofenaco fue de 2,4 ± 0,7; 2,5 ± 0,5; y 2 ± 0,7 en el grupo control, petidina y ketoprofeno, respectivamente, lo que no fue estadísticamente significativo. Los ...

Comparison of the Effects of Propofol and Midazolam on Inflammation and Oxidase Stress in Children with Congenital Heart Disease Undergoing Cardiac Surgery

PURPOSE: To investigate and compare the effects of propofol and midazolam on inflammation and oxidase stress in children with congenital heart disease undergoing cardiac surgery. MATERIALS AND METHODS: Thirty-two ASA class I-II children with congenital heart disease undergoing cardiac surgery were randomly divided into two groups: propofol combined with low dose fentanyl (PF group, n = 16) and midazolam combined with low dose fentanyl (MF group, n = 16). Tracheal extubation time and length of Intensive Care Unit (ICU) stay were recorded. Blood samples were taken before operation (T0), at 2 h after release of the aorta cross-clamp (T3) and at 24 h after operation (T4) to measure interleukin 6 (IL-6), IL-8, superoxide dismutase (SOD) and malondialdehyde (MDA) levels. Myocardium samples were collected at 10-20 min after aorta cross-clamp (T1) and at 10-20 min after the release of the aorta cross-clamp (T2) to detect heme oxygenase-1 (HO-1) expression. RESULTS: Tracheal extubation time and length of ICU stay in PF group were significantly shorter than those of the MF group (p < 0.05, respectively). After cardiopulmonary bypass, IL-6, IL-8 and MDA levels were significantly increased, and the SOD level was significantly reduced in both two groups, but PF group exhibited lower IL-6, IL-8 and MDA levels and higher SOD levels than the MF group (p < 0.05, respectively). The HO-1 expression in the PF group was significantly higher than that in MF group at the corresponding time points (p < 0.05, respectively). CONCLUSION: Propofol is superior to midazolam in reducing inflammation and oxidase stress and in improving post-operation recovery in children with congenital heart disease undergoing cardiac surgery.

Convulsions with propofol: a rare adverse event.

We present a rare but potentially harmful adverse reaction of propofol. A 50-year-old patient was posted for laparoscopic cholecystectomy, developed generalized convulsions after few seconds of propofol administration at anesthesia induction. Convulsions subsided with intravenous administrations of thiopentone and midazolam. Patient remained hemodynamically stable and surgery was uneventful. Blood sugar, serum electrolytes and arterial blood gas analysis were normal. Postoperatively, there was no evidence of postictal phase, serum electrolytes and postoperative computerized tomographic scanning of the head were normal. Patient had uneventful recovery. The administration of propofol has been associated with abnormal movements collectively termed as seizure-like phenomenon. Despite the claims that propofol may have proconvalsant activity, there is significant amount of evidence to the contrary also. The pathophysiological mechanisms behind the neuroexcitatory symptoms with propofol are unknown. Propofol alters the conscious state, the transition from the conscious state to anesthesia or vice versa may be a particularly vulnerable period and may be prolonged after the end of propofol administration.

effect of nitroglycerin as an adjuvant to lidocaine in intravenous regional anesthesia

The disadvantages of intravenous regional anesthesia [IVRA] include slow onset, poor muscle relaxation, tourniquet pain, and rapid onset of pain after tourniquet deflation. In this randomized, double-blind study, we evaluated the effect of nitroglycerin [NTG] in quality improvement when added to lidocaine in IVRA. Forty-six patients [20?50 yrs], were randomly allocated in two equal groups. Under identical condition, the control group received a total dose of 3mg/kg of lidocaine 1% diluted with saline, and the study group received an additional 200 microg NTG. Vital signs and tourniquet pain, based on visual analog scale [VAS] score were measured and recorded before and 5, 10, 15, 20, and 30 min after anesthetic solution administration. The onset times of sensory and motor block were measured and recorded in all patients. After the tourniquet deflation, at 30 min and 2, 4, 6, 12 and 24h, VAS score, time to first analgesic requirement, total analgesic consumption in the first 24 h after operation, and side effects were noted. The sensory and motor block onset time were shortened in study group [2.61 vs. 5.09 and 4.22 vs. 7.04 min, respectively] [p <0.05]. The recovery time of sensory and motor block and onset of tourniquet pain were also prolonged [7.26 vs. 3.43, 9.70 vs. 3.74 and 25 vs. 16.65min., respectively] [p <0.05]. Analgesia time after tourniquet deflation was prolonged and tourniquet pain intensity was lowered in study group [p <0.05]. Intraoperative fentanyl and meperedine requirement during first postoperative day and pain intensity at 4, 6, 12 and 24 hr postoperatively were lower in the study group [p <0.05]. There were no significant side effects...The NTG adding to lidocaine in intravenous regional anesthesia shortens onset times of sensory and motor block and decreases the tourniquet and postoperative pain, without any side effect

The Thai Anesthesia Incidents Study (THAI study) of ambulatory anesthesia: II. Anesthetic profiles and adverse events.

BACKGROUND: There is a continuing trend to have more elective surgery performed on an outpatient basis. OBJECTIVE: To determine anesthetic profiles and adverse events in practice of ambulatory anesthesia for elective surgery in different levels of hospitals across Thailand. MATERIAL AND METHOD: A prospective descriptive study was conducted in 20 hospitals comprising seven university, five regional four general and four district hospitals across Thailand. Consecutive patients undergoing anesthesia for elective surgery were included. The included patients, classified as outpatients, were selected and extracted for summary of the result by using descriptive statistics. RESULTS: The authors reported 7786 outpatients receiving anesthesia for elective surgery. The majority of patients were in ASA class 1 and 2 (96.2%) while the rest were in ASA class 3 (3.8%). Nearly 90% of the ASA class 3 patients were in university hospitals. The majority of patients (83.1%) did not receive premedication. Diazepam was used more frequently (11.5% vs. 0.1%) than other drugs. Noninvasive blood pressure monitoring and pulse oximetry were used in greater than 90%, while electrocardiogram (EKG) was used in 67.2% and end tidal CO2 in only 6.8%. The three most common anesthetic techniques were general anesthesia (including inhalation anesthetics), total intravenous anesthesia (TIVA), and monitored anesthesia care (MAC). Regional anesthesia was performed in 12% of cases. The three most common regional anesthetic techniques were brachial plexus block (7.1%), spinal anesthesia (2.21%), and other peripheral nerve blocks (2.06%). Propofol was the most common drug for induction. Succinylcholine was used for intubation in 8.8%. The three most common nondepolaring neuromuscular blocking agents were atracurium, cisatracurium, and vecuronium. Fentanyl was the most common drug used among opioids. The three most common volatile anesthetics were sevoflurane, halothane, and isolurane. Lidocaine was the most frequently used in 29.76% of cases, while bupivacaine in 7.9% and ropivacaine only in 0.05%. The majority of the events relating to respiratory system were hypoxia or oxygen desaturation (18:10,000), reintubation (2.6:10,000) and difficult intubation (2.6:10,000), pulmonary aspiration (2.6:10,000), and esophageal intubation (1.3:10,000). Other adverse events included awareness (1.3:10,000), suspected myocardial infarction or ischemia (1.3:10,000), and drug error (1.3:10,000). Five patients (0.06%) received unplanned hospital admission. No patients developed cardiac arrest or died. CONCLUSION: The incidence of major adverse events was low in ambulatory anesthesia for elective surgery when compared to the incidence in general surgical population. The majority of the events occurred in the respiratory system. The authors did not find any complications relating to regional anesthesia. Despite a low incidence of adverse events in ambulatory anesthesia, anesthesia personnel who are responsible for ambulatory anesthesia should have adequate knowledge and skills in selection and preparation of the patients. Therefore, a system of preanesthesia evaluation is very important.

Síndrome coronariana aguda em paciente com doença coronariana de alto risco no pós-operatório de colecistectomia videolaparoscópica / Acute coronary syndrome in a patient with severe coronary artery disease after laparoscopic cholecystectomy

JUSTIFICATIVA E OBJETIVOS: A isquemia miocárdica perioperatória é um evento incomum e quase sempre está relacionada com taquicardia e/ou hipotensão arterial em pacientes com doença coronariana de alto risco. RELATO DO CASO: Paciente do sexo masculino, 71 anos, diabético, hipertenso e com doença coronariana, submetido à colecistectomia videolaparoscópica. A anestesia foi induzida com propofol, cisatracúrio e remifentanil e mantida com sevoflurano e remifentanil. Durante o fechamento da parede o paciente apresentou hipertensão arterial, sem alterações ao ECG. A velocidade de infusão de remifentanil foi aumentada e, após cinco minutos, o paciente apresentou bloqueio atrioventricular total associado à redução da pressão arterial média (PAM). Após a administração de 1,0 mg de atropina e 0,1 mg de adrenalina, o paciente apresentou taquicardia temporária e a PAM se normalizou. Ele foi transferido consciente e extubado para UTI, onde, após 12 horas, apresentou dor precordial e ECG com infradesnivelamento ST de V4 a V6. O ecocardiograma revelou boa função sistólica, sem alterações segmentares e curva de CK-MB normal. O paciente foi tratado em protocolo de angina instável. CONCLUSÕES: O paciente apresentava risco aumentado para isquemia pós-operatória e foi submetido a um procedimento no qual as alterações hemodinâmicas são profundas. É sabido que instabilidades hemodinâmicas perioperatórias em pacientes com doença coronariana aumentam o risco de síndromes coronarianas no pós-operatório e estas podem ocorrer até 72 horas após o ato cirúrgico, apresentando-se, na maioria dos casos, de forma silenciosa. A administração pré-operatória de betabloqueadores e, mais recentemente, de estatinas têm se mostrado eficiente na redução de eventos isquêmicos perioperatórios nesses pacientes.

BACKGROUND AND OBJECTIVES: Perioperative myocardial ischemia is rare, being frequently related with tachycardia and/or hypotension in patients with severe coronary artery disease. CASE REPORT: A male patient, 71 years old, with diabetes, hypertension, and coronary artery disease underwent laparoscopic cholecystectomy. Anesthesia was induced with propofol, cisatracurium, and remifentanil and maintained with sevoflurane and remifentanil. During closure of the abdominal wall, the patient became hypotensive without ECG changes. The rate of remifentanil infusion was increased and, after five minutes, the patient developed complete atrioventricular block and reduction in mean arterial pressure (MAP). After the administration of 1.0 mg of atropine and 0.1 mg of adrenaline, the patient developed temporary tachycardia and MAP returned to normal. He was transferred to the ICU awake and after being extubated; after 12 hours, the patient complained of chest pain and the ECG demonstrated depression of the ST segment from V4 to V6. The echocardiogram demonstrated good systolic function without segmental changes. The CPK-MB curve was normal. The patient was treated with the protocol for unstable angina. CONCLUSIONS: The patient presented a high risk for postoperative ischemia and underwent a surgical procedure with important hemodynamic changes. It is known that perioperative hemodynamic instability in patients with coronary artery disease increase the risk of postoperative coronary syndrome, which may happen up to 72 hours after the procedure and, in the majority of the cases, it is silent. The preoperative administration of beta-blockers and, more recently, statins have proved to be effective in reducing perioperative ischemia in these patients.

JUSTIFICATIVA Y OBJETIVOS: La isquemia miocárdica perioperatoria es un evento no común y está relacionada frecuentemente con la taquicardia y/o hipotensión arterial en pacientes con enfermedad coronaria de alto riesgo. RELATO DEL CASO: Paciente del sexo masculino, 71 años, diabético, hipertenso y con enfermedad coronaria, sometido a colecistectomía videolaparoscópica. La anestesia fue inducida con propofol, cisatracurio y remifentanil y mantenida con sevoflurano y remifentanil. Durante el cierre de la pared el paciente presentó hipertensión arterial sin alteraciones al ECG. La velocidad de infusión de remifentanil fue aumentada y después de cinco minutos, el paciente presentó bloqueo atrio ventricular total asociado a la reducción de la presión arterial promedio (PAM). Después de la administración de 1.0 mg de atropina y 0.1 mg de adrenalina, el paciente presentó taquicardia temporal y la PAM se normalizó. Fue transferido consciente y extubado para la UTI, y después de 12 horas, presentó dolor precordial y ECG con infra desnivelación ST de V4 a V6. El ecocardiograma reveló una buena función sistólica sin alteraciones segmentarias. Curva de CK-MB normal. El paciente fue tratado en protocolo de angina inestable. CONCLUSIONES: El paciente presentaba riesgo aumentado para isquemia postoperatoria y fue sometido a un procedimiento en el cual las alteraciones hemodinámicas son profundas. Se sabe que inestabilidades hemodinámicas perioperatorias en pacientes con enfermedad coronaria aumentan el riesgo de síndromes coronarias en el postoperatorio y estas pueden ocurrir hasta 72 horas después de la cirugía, presentándose, en la mayoría de los casos, de forma silenciosa. La administración preoperatoria de beta-bloqueadores y más recientemente, estatinas se han mostrado eficiente en la reducción de eventos isquémicos perioperatorios en esos pacientes.

Total intravenous anesthesia versus inhalational anesthesia in patients undergoing laparoscopic cholecystectomy. A comparative study of postoperative subclinical hepatic dysfunction

Inhalational anesthetics are reported to cause mild liver dysfunction in some cases. This dysfunction reflected as asymptomatic transient elevation in liver enzyme. On the other hand no reports have indicated that total intravenous anesthetics [TIVA] cause liver or other organ dysfunction. In addition the use of TIVA become popular due to the availability of new drugs which have short acting effects and TIVA technique produce less air pollution. 40 patients undergoing laparoscopic cholecystectomy were randomized into two equal groups. The first group received inhalational anesthesia. Anesthesia induced with fentanyl 2 microg/kg, atracurium 0.5 mg/kg, propofol 2.5mg/kg and was maintained using sevoflurane 2-3%, nitrous oxide 66% in oxygen with atracurium infusion at rate of 0.5 mg/kg/hr. The second group received TIVA. Anesthesia was induced with fentanyl 2 microg /kg and atracurium 0.5 mg/kg and propofol 2.5 mg/kg. and anesthesia was maintained using propofol infusion using a syringe pump at a rate of 10 mg/kg/hr for 10 mm then 8 mg/kg for the next 10 mm and finally maintained at 6mg/kg/hr with nitrous oxide 66% in oxygen and muscle relaxation was maintained with infusion of atracurium in rate of 0.5 mg/kg/h. Liver enzymes were measured preoperative, at the end of operation, 3h, 6h, and 24 hours postoperative and compared to the preoperative values. There were transient significant increase in the values of AD, GST, and AST in inhalational group and ALT significantly increased in both groups. There were insignificant changes in hemodynamic parameters. TIVA technique is superior to inhalational technique during laparoscopic cholecystectomy as regards its effect on the liver enzymes

Comparación entre anestesia general endovenosa con ketalar, utilizando premedicación y sin ella / Comparison between general endovenous anesthesia with ketalar, using premedication and without it

Se realizó un estudio descriptivo y transversal de 50 pacientes atendidas en el servicio de legrados del Hospital General Docente "Alberto Fernández Montes de Oca", del municipio San Luis, en el período comprendido desde abril hasta mayo de 1998, con el fin de determinar las ventajas del ketalar como anestesia general endovenosa, a través de la premedicación con difenhidramina y sin ella. Se determinó la aparición de complicaciones en cada uno de los grupos, así como también el costo de los medicamentos, donde se comprobó que éstos se reducen notablemente con la premedicación, lo que significa un ahorro para la unidad y para el Sistema Nacional de Salud(AU)

A descriptive and cross-sectional study of 50 patients cared at the service of curettages of "Alberto Fernández Montes de Oca" General Teaching Hospital, of San Luis municipality, was conducted in the period comprised from April to May of 1998 so as to determine the advantages of ketalar as a general endovenous anesthesia, through the premedication with diphenhydramine and without it. The appearance of complications in each of the groups was determined, as well as the medicines cost and it was checked that the costo can be remarkably reduced with the premedication which means a saving for the unit and for the National Health System(AU)

Anestesia por infusäo contínua de propofol em cäes pré-medicados com acerpromazina e fentanil / Anesthesia by continuous infusion of propofol in dogs premedicated with acepromazine and fentanyl

O propofol (2,6 diisopropilfenol) é um agente hipnótico de ultra curta duraçäo que produz sedaçäo e hipnose similar aos barbitúricos, sendo desprovido de açäo analgésica. Quimicamente, é o único agente anestésico venoso que pode ser usado tanto na induçäo como na manutençäo anestésica. O presente trabalho objetivou avaliar freqüência cardíaca, respiratória, oximetria, pressäo arterial média, volume minuto e volume corrente em cäes pré-medicados com acepromazina e fentanil e anestesiados por infusäo contínua de propofol. Dez cäes foram submetidos à medicaçäo pré-anestésica com acepromazina (0,1mg.kg-1) e fentanil (0,01mg.kg-1),induçäo (3,16mg.kg-1) e manutençäo anestésica com propofol em infusäo contínua por noventa minutos, na velocidade de 0,4mg.kg-1.min-1. Os parâmetros foram mensurados imediatamente após a induçäo, 10, 20, 30, 60 e 90 minutos após; final da infusäo e 30 minutos após o seu término. Os parâmetros foram analisados por análise de variância para valores repetidos e as médias foram analisadas pelo teste de Tuckey em nível de 5 por cento. O protocolo utilizado näo produziu variaçöes estatisticamente significativas em nenhum dos parâmetros analisados. Um animal apresentou apnéia durante a induçäo. Embasado nesses resultados, verifica-se que o presente protocolo é seguro e eficaz para a realizaçäo de anestesia venosa em caninos.

Diagnóstico presuntivo de metahemoglobinemia con infusión intravenosa continua de procaína al 1 por ciento: la importancia del gráfico de tendencias en anestesiología / Presumptive diagnosis of methemoglobinemia: the graphic of tendencies in anesthesiology

Se describe un caso donde se utiliza anestesia intravenosa total (midazolam-propofol-fentanilo-procaína) para la realización de una colecistectomía. Durante el intraoperatorio se detecta saturación de la oxihemoglobina coincidentemente con la infusión de una solución de procaína al 1 por ciento como complemento analgésico. Se analizan las causas que provocan la caída de la saturación y la fisiopatología de la metahemoglobinemia. La detección del fenómeno fue posible gracias a la visualización gráfica de la caída constante de la saturación de la hemoglobina en porcentajes aislados no significativos. La asociación de procaína con desaturación acompañada o no de cianosis debe hacer pensar en una posible metahemoglobinemia. Se destaca el valor del gráfico de tendencias en el monitoreo anestésico y su importancia para la detección precoz de problemas intraoperatorios.

Presentación de un caso de hipertermia maligna con diagnóstico ratificado por el puntaje de NAMHR (North American Malignant Hyperthermia Registry) / Presentation of a case of malignant hyperthermia ratified by NAMHR's (North American Malignant Hyperthermia Registry) score

Introducción: Desarrollo de cuadro clínico de hipertermia maligna en un paciente anestesiado con anestesia endovenosa total. Diagnóstico a través del puntaje del North American Malignant Hyperthermia Registry. Caso clínico: Se presenta un caso clínico de hipertermia maligna acontecido en nuestro servicio, con la particularidad de haberse desencadenado durante el intraoperatorio de una cirugía bajo anestesia intravenosa total. Paciente de 30 años, con diagnóstico de hidronefrosis; se anestesió con midazolam, remifentanilo y mivacurio. Luego de 1 hora de cirugia y sin causa clínica aparente, comenzó con hipotensión. Simultánea y progresivamente, se taquicardizó alcanzando valores de 155'. Se tomó 37.8 §C de temperatura axilar. La ETCO2 era de 75 mmHg. Luego, la temperatura se elevó a 43 §C y se decidió tratar con dantrolene. Discusión: La carencia de un método precoz de diagnóstico de HM, sumada a cambios metabólicos rápidos, hipermetabolismo marcado y excesiva producción de calor, nos enfrenta al dilema de iniciar el tratamiento específico -dantrolene-, que evite secuelas irreversibles o la muerte. Conclusiones: Creemos que la clasificación con el puntaje del North American Malignant Hyperthermia Registry, por la simplicidad de su diseño y facilidad de aplicación, puede ser un método útil e indispensable como método de screening en aquellos pacientes en que por alguna causa se sospecha una susceptibilidad o un cuadro de HM.

Anestesia en cuerpo extraño de vía aérea y esófago: tres años de experiencia / Anaesthesia in airway and esophagus foreign bodies: 3 years experience

Se intenta identificar los factores de riesgo relacionados con las complicaciones y anestesia utilizada en pacientes con cuerpos extraños en vía aérea y en esófago. Para ellos se realizó un protocolo recolectando antecedentes clínicos y epidemiológicos durante tres años consecutivos, con un total de 102 fichas clínicas de pacientes con sospecha o diagnóstico confirmado de esta emergencia. De estos, 60 se localizaban en esófago y 42, en vía aérea. Se analizaron los resultados, haciendo énfasis respecto a la elección de la inducción anestésica empleada en ambos grupos por separados y su relacion con las complicaciones encontradas. Se pesquisó un mayor porcentaje de complicaciones de origen respiratorio, en pacientes con cuerpos extraños en vía aérea, al utilizar inducción de tipo endovenosa en comparación con la inducción inhalatoria

Efeitos da anestesia endovenosa total com alfentanil e/ou propofol utilizada para a aspiraçäo folicular dirigida por ultra-sonografia transvaginal sobre os oócitos humanos em ciclos de fertilizaçäo in vitro e transferência de embriöes / The effects of total intravenous anesthesia with alfentanil and/or propofol for transvaginal untrasound-guided oocyte retrieval on the outcome of in vitro fertilization of human oocytes

OBJETIVO: Comparar os efeitos de dois protocolos de anestesia (grupo A: alfentanil/propofol; grupo B: propofol), utilizados para a aspiraçao folicular dirigida por ultra-sonografia transvaginal, nos resultados de um programa ambulatorial de fertilizaçao in vitro e tranasferência de embrioes (FIVETE). MÉTODO: Trinta e seis pacientes submetidas ao seu primeiro ciclo de FIVETE foram selecionadas. Casais com fator masculino de infertilidade foram excluídos. A estimulaçao ovariana foi realizada utilizando-se o protocolo longo de inibiçao com um análogo do GnRH (GnRH-a) seguido da administraçao de FSH/hMG. A aspiraçao folicular ocorreu cerca de 35 a 36 horas após a administraçao do hCG. A anestesia foi induzida com alfentanil 20 a 60 mg/Kg e propofol 2,5 mg/Kg em 17 pacientes (grupo A) e propofol 2,5 mg/Kg em 19 pacientes (grupo B). No grupo A, a anestesia foi mantida através da administraçao de doses de alfentanil de 7 a 15 mg/Kg e de propofol de 0,2 a 0,4 mg/Kg a cada 10 minutos. No grupo B, a anestesia foi mantida através da administraçao de doses de propofol de 0,4 a 0,8 mg/Kg a cada 10 minutos. A seleçao do protocolo de anestesia nao foi randomizada, mas resultado da preferência do anestesista em cada caso. RESULTADOS: As pacientes dos dois grupos nao revelaram diferença em termos de idade, duraçao da infertilidade, índice de massa corpórea, número de ampolas de FSH/hMG utilizadas e da duraçao da estimulaçao ovariana. O tempo total de anestesia foi de 34,9 + 3,4 (média+desvio padrao) minutos para o grupo A e 9,9+1,0 minutos para o grupo B (p<0.001). Contudo, a dose total de propofol utilizada foi similar nos dois grupos: 204,4+16,2 mg e 233,2+24,0 mg para os grupos A e B, respectivamente. O número total de oócitos MII inseminados foi 179 e 156 para os grupos A e B, respectivamente, nao revelando diferença entre os grupos. As taxas de fertilizaçao normal e de clivagem foram de 36,3 por cento (65/179) e 47,7 por cento (31/65) para o grupo A e, 77,6 por cento (121/156) e 84,3 por cento (102/121) para o grupo B, revelando uma diferença estatisticamente significativa entre os grupos (p<0.001; p=0.03, respectivamente). O grau embrionário médio (classificaçao de Veeck) e o número médio de embrioes transferidos foram de 2,3+1,20 e 2,1+0,23 para o grupo A e de 1,6+0,99 e 4,2+0,77 para o grupo B (p=0.01; p=0.02, respectivamente). As taxas de implantaçao/embriao transferido e de gestaçao clínica/ciclo com transferência no grupo A foram de 5,3 por cento e...

Anestesia total intravenosa. Comparación de tres técnicas

Se realizó un trabajo de observación clínica en el cual se tomaron 52 pacientes ASA 1 y 3 de cirugía general, ginecología, plástica. que fueron distribuidos no aleatoriamente en tres grupos; el primero con 22 pacientes; el segundo con 13 y el tercero con 17. Se aplicaron tres tipos de mantenimiento anestésico total endovenoso. En el grupo 1 se asoció propofol-alfentanil; en el grupo 2 se utilizó propofol soló y en el grupo 3 propofol-ketamina; en todos los casos se dió una infusión continua; utilizando bomba de infusión, jeringa infusora, o conteo manual en equipo de macrogoteo. Se encontró que la anestesia total endovenosa es una técnica segura, confiable, eficaz y de fácil aplicación. El ketalar como analgésico a las dosis usadas (0.25 - 0.5 mg/kg) es menos potente que el alfentanil (25 a 100 mcg/kg); pero que mejora la estabilidad hemodinámica al impedir el descenso de PAM y la FC producidas por el propofol; a estas dosis no se observaron efectos importantes residuales de la ketamina. La recuperación post anestésica es muy rápida con las tres técnicas; el grupo más rápido fue el de propofol solo, seguido del grupo 1 (propofol-alfentanil) y el más lento el grupo 3 (propofol-ketamina). La incidencia de vómito POP fue menor del 10 por ciento; el grupo que más vómito tuvo fue el número 1 de propofol-alfentanil. Las náuseas fueron más frecuentes en el grupo de propofol sólo con incidencias por debajo del 10 por ciento. Los pacientes coincidieron en señalar el acto anestésico como agradable; sin sensaciones molestas en más de un 95 po ciento. No fueron reportadas complicaciones graves con ninguna de las técnicas

Atracurio en anestesia general / Atracurio in general anesthesia

Este trabajo busca evidenciar las caracteristicas de accion relajante, interaccion relajante con los anestesicos mas empleados en el medio. Se estudiaron 122 pacientes, tomando en cuenta la medicacion preanestesica empleada, la inclusion del halotano cruzando datos con el peso de los pacientes y tiempo de duracion de accion. En general existe en este estudio mayor tiempo de duracion de accion (41-61) que el teorico 17-40'. El empleo de benzodiazepinas no prolonga significativamente esta duracion, siendo el halotano el que mas prolonga el tiempo de relajacion. En todos los casos el atracurio resulto ser un buen relajante para la intubacion, su reversion casi no es necesaria luego de 30' de accion. Los efectos adversos en este estudio practicamente fueron insignificantes

Anestesia inhalatoria versus anestesia intravenosa

Aunque la anestesia total intravenosa puede ser una alternativa a la inhalatoria o balanceada, se precisan más estudios para delimitar cuales son realmente sus ventajas