Monitoring hypnotic effect and nociception with two EEG-derived indices, qCON and qNOX, during general anaesthesia.

BACKGROUND: The objective of the present study was to validate the qCON index of hypnotic effect and the qNOX index of nociception. Both indices are derived from the frontal electroencephalogram (EEG) and implemented in the qCON 2000 monitor (Quantium Medical, Barcelona, Spain). METHODS: The study was approved by the local ethics committee, including data from 60 patients scheduled for ambulatory surgery undergoing general anaesthesia with propofol and remifentanil, using TCI. The Bis (Covidien, Boulder, CO, USA) was recorded simultaneously with the qCON. Loss of eyelash reflex [loss of consciousness (LOC)] was recorded, and prediction probability for Bis and qCON was calculated. Movement as a response to noxious stimulation [laryngeal mask airway (LMA) insertion, laryngoscopy and tracheal intubation] was registered. The correlation coefficient between qCON and Bis was calculated. The patients were divided into movers/non-movers as a response to noxious stimulation. A paired t-test was used to assess significant difference for qCON and qNOX for movers/non-movers. RESULTS: The prediction probability (Pk) and the standard error (SE) for qCON and Bis for detecting LOC was 0.92 (0.02) and 0.94 (0.02) respectively (t-test, no significant difference). The R between qCON and Bis was 0.85. During the general anaesthesia (Ce propofol > 2 µg/ml, Ce remifentanil > 2 ng/ml), the mean value and standard deviation (SD) for qCON was 45 (8), while for qNOX it was 40 (6). The qNOX pre-stimuli values were significantly different (P < 0.05) for movers/non-movers as a response to LMA insertion [62.5 (24.0) vs. 45.5 (24.1)], tracheal intubation [58.7 (21.8) vs. 41.4 (20.9)], laryngoscopy [54.1 (21.4) vs. 41.0 (20.8)]. There were no significant differences in remifentanil or propofol effect-site concentrations for movers vs. non-movers. CONCLUSION: The qCON was able to reliably detect LOC during general anaesthesia with propofol and remifentanil. The qNOX showed significant overlap between movers and non-movers, but it was able to predict whether or not the patient would move as a response to noxious stimulation, although the anaesthetic concentrations were similar.

Utilización de tramadol/paracetamol oral en única preparaciónfarmacéutica en analgesia multimodal en cirugía mayor ambulatoria / No disponible

La combinación en una misma presentación farmacológica de paracetamol y tramadol a dosis bajas permite un rápido inicio de acción y un efecto sostenido de la analgesia, con disminución de los efectos secundarios derivados de ambos fármacos, dosis dependiente. En cirugía mayor ambulatoria la analgesia multimodal es el tratamiento de elección para poder incluir cada vez procesos de mayor complejidad. Es por ello que la asociación a dosis bajas de un opioide menor, con paracetamol, presenta una analgesia superior por acción sinérgica de los dos componentes, utilizándose en dolor moderado-severo, evitando reingresos y facilitando el cumplimiento del tratamiento analgésico en el domicilio (AU)

The combination of paracetamol, and low doses of tramadol, enables an immediate and constant analgesic response, while at the same time avoiding the negative side effects of both these drugs. Multimodal analgesia in ambulatory surgery permits a better control of pain and the subsequent inclusion of more complex surgery. The use of both components in one tablet, presents a synergic action useful in moderate-severe pain, reducing hospital re-admittance and enhancing the probability of the completion of home treatment (AU)

Comparison of the LMA Supreme™ with the LMA Proseal™ for airway management in patients anaesthetized in prone position.

BACKGROUND: The laryngeal mask airway (LMA) has been successfully used in patients in the prone position either for rescue or elective airway management. The reusable Proseal™ LMA (PLMA) and the single use Supreme™ LMA (SLMA) have been reported to be suitable for this purpose but few comparative data are available. In this study, we compared the clinical use of both devices in adult patients anaesthetized in the prone position. METHODS: One hundred and twenty patients undergoing surgery in the prone position were randomized to receive either the PLMA or the SLMA for airway management. Patients positioned themselves in the prone position and after pre-oxygenation, anaesthesia was induced using a target-controlled i.v. infusion of propofol and remifentanil. All PLMAs and SLMAs were inserted by experienced anaesthetists using a guided and a standard technique respectively. Ease of facemask ventilation, time and number of attempts needed for insertion, quality of ventilation, airway seal pressure, fibreoptic view, and complications were compared. RESULTS: There were no differences between groups in insertion time or first attempt success (100% vs. 98%). The PLMA required fewer manipulations (3% vs. 15%; P=0.02) to achieve effective ventilation and provided a higher seal pressure (mean [sd] 31 [4] vs. 27 [4] cm H2O; P<0.01). The fibrescopic view of the vocal cords was similar, although easier to achieve with the PLMA. The complication rate was low and similar between the groups. Blood was present on masks in 7% vs. 8% and sore throat in 3% vs. 5% of patients with the PLMA and SLMA, respectively. CONCLUSIONS: Airway management in patients anaesthetized in the prone position was efficient with both devices, although the PLMA required fewer manipulations and achieved a higher seal pressure.

Awake intubation using the LMA-CTrach in patients with difficult airways.

We studied 21 patients with known difficult airways who underwent awake tracheal intubation using the LMA CTrach. Patients were given midazolam, atropine, a continuous infusion of remifentanil and topical lidocaine applied to the oropharyx. We limited the number of insertion attempts to three and the time to adjust the view to 5 min. In case of failure, we performed awake fibreoptic tracheal intubation. We found insertion of the device was successful and well tolerated in all patients. Vocal cords could be seen immediately in nine patients and following corrective manoeuvres in 10 patients. Tracheal intubation was successful in 20 patients: 19 cases under direct vision and in one blindly. In one patient with undiagnosed lingual tonsil hyperplasia, tracheal intubation was impossible using the device. No patient had an unpleasant recall of the procedure. We conclude that the LMA CTrach is easy to use, well tolerated and suitable for awake orotracheal intubation in patients with known difficult airways.

Role of dopamine in renal dysfunction during laparoscopic surgery.

BACKGROUND: Sympathetic vascular insult and hemodynamic changes represent the most reliable explanation of renal impairment resulting from acute intraabdominal pressure. We evaluated the effects of low-dose dopamine administration during a long-lasting surgical laparoscopic procedure. METHODS: For this study 40, patients submitted to a colorectal laparoscopic procedure with 15 mmHg of intraabdominal pressure were randomly allocated to two groups: 20 receiving 2 mg/kg/min of dopamine and 20 receiving the same perfusion of saline. Hemodynamic parameters, renal function, urinary output, and creatinine clearance, were studied. RESULTS: The hemodynamic parameters were similar in both groups. The urinary output decreased during the intraoperative period only the saline group (p = 0.4). Then 2 h postoperatively, it increased in both groups, and no statistically significant differences were found between the groups. The creatinine clearance decreased in both groups during the intraoperative time, but it was worse in the saline group (-28 +/- 120 vs -194 +/- 106; p = 0.022). During the postoperative period, both groups showed improvement, but in control group the values remained lower than at baseline (p = 0.04), and significantly lower than in the dopamine group (230 +/- 337 vs 100 +/- 192; p = 0.012). CONCLUSIONS: An intrabdominal pressure of 15 mmHg induces a time-limited renal dysfunction, and low doses of dopamine could prevent this undesirable effect.

Prolonged pneumoperitoneum at 15 mmHg causes lactic acidosis.

BACKGROUND: Acute increases in intraabdominal pressure (IAP) induce systemic and regional circulatory changes. Besides, mechanical compression on the capillary beds may decrease oxygen availability to the tissues. The purpose of this clinical study was to analyze the effects of increased IAP on acid-base disturbances and plasma lactate levels during prolonged carbon dioxide pneumoperitoneum. METHODS: Twenty-eight patients undergoing laparoscopic sigmoidectomy were included in this study. Fourteen of them (group A) had IAP of 15 +/- 1 mmHg while the remaining 14 (group B) had IAP of 10 +/- 1 mmHg. The control group included six patients undergoing conventional sigmoidectomy. RESULTS: A progressive significant increase in PaCO2 was observed in the laparoscopic groups (p < 0.01). Plasma lactate levels in group A significantly increased 90 min after insufflation (p < 0.05) and reached the highest value 1 h after deflation (9.9 +/- 1 vs 31.9 +/- 2.5 mg/dl, p < 0.005). Simultaneously, arterial pH decreased in all groups; however, at 1 h after surgery, it was significantly lower (p = 0.02) in group A. There was a significant correlation between acid concentration due to lactate and lactate concentration (GA: R2 = 0.717, p = 0.03; GB: R2 = 0.879, p = 0.006 and GC: R2 = 0.853, p = 0.008). CONCLUSION: High IAP causes lactic acidic accumulation in patients undergoing prolonged laparoscopic procedures.

Hepatocellular carcinoma and cirrhosis. Results of surgical treatment in a European series.

OBJECTIVE: The authors analyze the outcomes of patients with hepatocellular carcinoma (HCC) and cirrhosis who underwent liver resections. BACKGROUND: Liver resection is the best option for HCC arising from hepatic cirrhosis. The experience of Western centers with these patients is shorter than the Asian series. METHODS: Forty-eight consecutive patients with cirrhosis and HCC who underwent liver resections were studied after a similar diagnostic and therapeutic process. Survival and cumulative recurrence were calculated according to pathologic findings. RESULTS: Factors influencing survival at 3 years were as follows: type of resection, absence of vascular invasion, size of the tumor, absence of satellite nodules, and the number of nodules. Factors influencing the rate of recurrence at 3 years were the presence of vascular invasion and the presence of satellite nodules. Patients with favorable prognostic factors have a good survival rate with an acceptable recurrence rate. CONCLUSIONS: Identification of prognostic factors may help in the selection of the appropriate treatment for these patients with HCC and cirrhosis.

The effect of venovenous bypass on lactic acid levels during human liver transplantation (OLT).

Lactate determinations did not contribute to the quantification of the systemic and regional tissue oxygenation during OLT. Venous stasis was not an important factor in the tissue imbalance between oxygen supply and oxygen demand.