Manejo de la presión arterial en pacientes neuroquirúrgicos y neurocríticos / Management of blood pressure in neurosurgical and neurocritical patients

Las diferencias etiológicas y fisiopatológicas entre las entidades que pueden requerir una intervención neuroquirúrgica o el establecimiento de cuidados neurocríticos hace imposible hablar del control de la presión arterial en el paciente neurocrítico o neuroquirúrgico de un modo genérico. Con este razonamiento en mente, decidimos revisar por separado el control de la presión arterial en algunas de las entidades patológicas a las que más frecuentemente nos enfrentamos en la práctica clínica. Los temas revisados son: traumatismo craneoencefálico, ictus isquémico agudo, cirugía de los aneurismas intracraneales, cirugía de las malformaciones arteriovenosas cerebrales, cirugía tumoral encefálica, cirugía medular y cuidados de la lesión medular aguda

The etiological and pathophysiological differences between diseases that may require a neurosurgical intervention or the establishment of neurocritical care make it impossible to talk about the control of blood pressure in the neurocritical or neurosurgical patient in a generic manner. With this reasoning in mind, we decided to review separately the control of blood pressure in some of the pathologies we most frequently faced in clinical practice. The topics reviewed are: cranial brain trauma, acute ischemic stroke, intracranial aneurysm surgery, cerebral arteriovenous malformation surgery, brain tumor surgery, spinal cord surgery and acute spinal cord injury

Análisis de la insuficiencia de órganos y mortalidad en la sepsis por peritonitis secundaria / Analysis of organ failure and mortality in sepsis due to secondary peritonitis

Objetivos Identificar los órganos más propensos a desarrollar el síndrome de insuficiencia multiorgánica (MODS) en pacientes con sepsis por peritonitis secundaria. Determinar el valor evolutivo y predictivo de mortalidad del sistema Sequential Organ Failure Assessment (SOFA).Diseño Estudio de cohorte observacional prospectivo. Ámbito La unidad de reanimación (UR) de nuestro centro, un hospital universitario de tercer nivel. Pacientes Estudio prospectivo y observacional sobre 102 pacientes con sepsis de origen abdominal e insuficiencia de al menos un órgano relacionado con la infección. Se registraron las características demográficas, el origen abdominal de la sepsis, la mortalidad a los 28 días y la puntuación SOFA diaria. Resultados La mortalidad a los 28 días fue del 55%. El 53% de los pacientes presentaron fracaso de 2 o más órganos en el primer día de estancia. La puntuación SOFA media diaria fue significativamente mayor en los pacientes fallecidos a partir del cuarto día de estancia. Las variables que se asociaron a una mayor mortalidad de manera estadísticamente significativa fueron: MODS (p=0,000), fallo sistema nervioso central (p=0,000) y puntuación SOFA al cuarto día de estancia (p=0,012). El área bajo la curva ROC expresó una capacidad predictiva de mortalidad el SOFA cuarto día de estancia del 0,703 (IC 95%, 0,538-0,853 y p=0,026. El mejor poder discriminativo se observó para el MODS con área bajo la curva ROC del 0,776 (IC 95%, 0,678-0,874 y p=0,000).Conclusiones La evolución en la insuficiencia de órganos determinada por medio de SOFA mostró una alta precisión siendo un buen predictor de mortalidad la puntuación SOFA media cuarto día de estancia. El MODS fue la principal causa de muerte y el fracaso del sistema nervioso central, función renal y sistema respiratorio los factores de riesgo de muerte (AU)

Objectives To identify the organs most susceptible to develop multiorgan dysfunction syndrome (MODS) in patients with sepsis due to secondary peritonitis, and to determine the outcome and mortality predicting utility of the SOFA (Sequential Organ Failure Assessment) system. Design A prospective, observational cohort study was made. Setting The resuscitation unit of a third-level university hospital. Patients A prospective, observational cohort study was made of 102 patients with sepsis of abdominal origin and failure of at least one organ related to the infection. The demographic characteristics were documented, along with the abdominal origin of sepsis, mortality after 28 days, and the daily SOFA score. Results The mortality rate after 28 days was 55%. A total of 53% of the patients presented failure of two or more organs on the first day of admission. The mean daily SOFA score was significantly higher among the patients that died after day 4 of admission. The variables showing a statistically significant correlation to increased mortality were: MODS (P=.000), central nervous system failure (P=.000) and SOFA score on day 4 of admission (P=.012). The area under the ROC curve showed the mortality predicting capacity of the SOFA score on day 4 of admission to be 0.703 (95%CI 0.538-0.853; P=.026). The maximum discriminating capacity was recorded for MODS, with an area under the ROC curve of 0.776 (95%CI 0.678-0.874; P=.000).Conclusions Organ failure outcome as predicted by the SOFA score showed high precision - the mean SOFA score on day 4 of admission being a good mortality predictor. MODS was the main cause of death, while central nervous system, renal and respiratory failure were identified as the mortality risk factors (AU)

[Analysis of organ failure and mortality in sepsis due to secondary peritonitis]. / Análisis de la insuficiencia de órganos y mortalidad en la sepsis por peritonitis secundaria.

OBJECTIVES: To identify the organs most susceptible to develop multiorgan dysfunction syndrome (MODS) in patients with sepsis due to secondary peritonitis, and to determine the outcome and mortality predicting utility of the SOFA (Sequential Organ Failure Assessment) system. DESIGN: A prospective, observational cohort study was made. SETTING: The resuscitation unit of a third-level university hospital. PATIENTS: A prospective, observational cohort study was made of 102 patients with sepsis of abdominal origin and failure of at least one organ related to the infection. The demographic characteristics were documented, along with the abdominal origin of sepsis, mortality after 28 days, and the daily SOFA score. RESULTS: The mortality rate after 28 days was 55%. A total of 53% of the patients presented failure of two or more organs on the first day of admission. The mean daily SOFA score was significantly higher among the patients that died after day 4 of admission. The variables showing a statistically significant correlation to increased mortality were: MODS (P=.000), central nervous system failure (P=.000) and SOFA score on day 4 of admission (P=.012). The area under the ROC curve showed the mortality predicting capacity of the SOFA score on day 4 of admission to be 0.703 (95%CI 0.538-0.853; P=.026). The maximum discriminating capacity was recorded for MODS, with an area under the ROC curve of 0.776 (95%CI 0.678-0.874; P=.000). CONCLUSIONS: Organ failure outcome as predicted by the SOFA score showed high precision - the mean SOFA score on day 4 of admission being a good mortality predictor. MODS was the main cause of death, while central nervous system, renal and respiratory failure were identified as the mortality risk factors.

Influencia de la elevación de la cabeza sobre la presiónintracraneal, presión de perfusión cerebral y saturación de oxígenocerebral regional en pacientes con hemorragia cerebral / Effect of head elevation on intracranial pressure, cerebral perfusion pressure, and regional cerebral oxygen saturation in patients with cerebral hemorrhage

OBJETIVO: Estudiar los efectos de la posición semisentadacon la cabecera a 30 y 45 grados sobre la dinámicacerebral y oxigenación cerebral regional en pacientes conhemorragia cerebral.PACIENTES Y MÉTODOS: Estudio prospectivo sobre 10pacientes con hemorragia cerebral, sometidos a sedoanalgesiay ventilación mecánica. Se recogieron los valores dePIC, presión arterial media (PAM), presión de perfusióncerebral (PPC) y oximetría cerebral regional por infrarrojos(SrO2) con la cabeza en posición horizontal (0º) y elevada30º y 45º, tras un periodo de estabilización de 5 minutos.RESULTADOS: La PIC disminuyó significativamente enlas posiciones de 30º y 45º con respecto a los valores enposición horizontal (disminuyeron 2,8 ± 1,4 mmHg y4,4 ± 1,4 mmHg, respectivamente). La PPC descendió ligeramentea 30º de elevación de la cabeza (3,5 ± 3,1 mmHg,p=0,048), siendo la reducción más importante a 45º(7,1 ± 4,8 mmHg, p < 0,01). Asimismo, la mayor reducciónde la PAM se registró con la cabeza elevada 45º(11,8 ± 4,6 mmHg, p < 0,001). La SrO2 se redujo al elevarla cabeza 30º y 45º, existiendo la mayor diferencia cuandola cabeza se elevó a 45º (7% ± 2% p < 0,001). Una correlaciónmoderada fue observada entre los valores de PPC ylos cambios de la SrO2 (r2 = 0,45, p < 0,001).CONCLUSIÓN: La elevación de la cabeza produce unadisminución significativa de la PIC y la PPC en pacientescon hemorragia cerebral. Asimismo, la elevación de lacabeza disminuye la SrO2, dependiendo los cambios de laSrO2 del grado de elevación de la cabeza (AU)

OBJECTIVE: To study the effects on cerebral dynamicsand regional oxygenation (rSO2) of the semi-sittingposition, with the head at either 30° or 45°, in surgery forcerebral hemorrhage.PATIENTS AND METHODS: We performed a prospectivestudy of 10 patients undergoing surgery for cerebralhemorrhage under sedation and analgesia and withmechanical ventilation. Intracranial pressure (ICP), meanarterial pressure (MAP), cerebral perfusion pressure(CPP), and rSO2 measured using near-infraredspectroscopy were recorded with the head in the supineposition (0°) and elevated to an angle of 30° and then 45°,following a stabilization period of 5 minutes.RESULTS: Mean (SD) ICP values were significantlylower in both semi-sitting positions than in the supineposition: 2.8 (1.4) mm Hg lower at 30° and 4.4 (1.4) mmHg lower at 45°. Mean CPP values were fell slightly whenthe head was elevated to 30° (3.5 [3.1] mm Hg, P=.048); agreater reduction was achieved when the head waselevated 45° (7.1 [4.8] mm Hg, P<.01). The greatestreduction in mean MAP values also occurred with thehead elevated to 45° (11.8 [4.6] mm Hg, P<.001). MeanrSO2 values fell when the head was elevated to 30° and45°; the greatest reduction occurred when the head waselevated to 45° (7% [2%], P<.001). There was a moderatecorrelation between CPP values and changes in rSO2(r2=0.45, P<.001).CONCLUSION: Head elevation significantly reducesICP and CPP in patients with cerebral hemorrhage.Head elevation also reduces rSO2, to a greater or lesserextent depending on the degree to which the head iselevated (AU)

[Cranial nerve block with bupivacaine for postoperative analgesia following supratentorial craniotomy]. / Bloqueo craneal con bupivacaína para analgesia postoperatoria en craneotomía supratentorial.

OBJECTIVE: To assess the effectiveness of analgesia by cranial nerve block with bupivacaine in the first 24 hours following elective supratentorial craniotomy. PATIENTS AND METHODS: A prospective, randomized, double-blind study was performed in 30 patients who underwent craniotomy for excision of a tumor. The cranial nerve block was performed using saline (control group, n=15) or 0.25% bupivacaine with epinephrine at 1:200 000 (bupivacaine group, n=15). Morphine (2 mg, intravenous bolus) was used for rescue analgesia. Pain was assessed on a visual analog scale (VAS) at 2, 4, 8, 12, 16, and 24 hours following the cranial nerve block. The following data were recorded: time elapsed until appearance of pain, use of rescue analgesia, and incidence of adverse effects. RESULTS: The use of morphine was significantly lower in the group of patients who received a cranial nerve block with bupivacaine than in the control group (mean [SD], 3.7 [1.6] mg vs 172 [2.5] mg). The mean time to the first requirement for rescue analgesia was longer in the bupivacaine group than in the control group (731 [247] minutes vs 80 [71] minutes). The VAS score during the first 16 hours was significantly lower in the bupivacaine group than in the control group. The incidence of nausea and vomiting was significantly higher in the control group (67% vs 13%). CONCLUSIONS: Cranial nerve block with 0.25% bupivacaine following supratentorial craniotomy improves postoperative analgesia, reduces the requirement for morphine, and contributes to reducing nausea and vomiting.

Bloqueo craneal con bupivacaína para analgesia postoperatoria en craneotomía supratentorial / Cranial nerve block with bupivacaine for postoperative analgesia following supratentorial craniotomy

OBJETIVO: Valorar la efectividad analgésica del bloqueocraneal con bupivacaína en las primeras 24 horasdel postoperatorio en pacientes sometidos a craneotomíasupratentorial electiva.PACIENTES Y MÉTODOS: Estudio prospectivo, aleatorio ydoble ciego de 30 pacientes sometidos a craneotomía porneoplasia. El bloqueo fue realizado con bupivacaína al0,25% con epinefrina 1:200.000 (grupo bupivacaína,n = 15) y con salino (grupo control, n = 15). Se utilizócomo analgesia de rescate morfina en bolo intravenoso de2 mg. Se analizó el grado de dolor mediante la escala analógicavisual (EAV) a las 2, 4, 8, 12, 16 y 24 h tras el bloqueo.Se registró el tiempo transcurrido hasta la apariciónde dolor, consumo analgésico e incidencia de efectosadversos.RESULTADOS: El consumo de morfina fue significativamentemenor en el grupo de pacientes que recibieronbupivacaína para el bloqueo craneal que en el grupocontrol (3,7 ± 1,6 mg frente 17,2 ± 2,5 mg). El tiempomedio del primer requerimiento de analgesia fue mayoren el grupo bupivacaína que en el grupo control (731 ±247 min frente a 80 ± 71). La puntuación de la EAV fuesignificativamente menor en el grupo bupivacaínadurante las primeras 16 horas que en el grupo control.La incidencia de NVPO fue significativamente superioren el grupo control (67% frente 13%).CONCLUSIONES: El bloqueo craneal con bupivacaínaal 0,25% tras craneotomía supratentorial mejora lacalidad de la analgesia postoperatoria, disminuye losrequerimientos de morfina y contribuye a reducir lasNVPO

OBJETIVO: To assess the effectiveness of analgesia by cranial nerve block with bupivacaine in the first 24 hours following elective supratentorial craniotomy. PATIENTS AND METHODS: A prospective, randomized, double-blind study was performed in 30 patients who underwent craniotomy for excision of a tumor. The cranial nerve block was performed using saline (control group, n=15) or 0.25% bupivacaine with epinephrine at 1:200 000 (bupivacaine group, n=15). Morphine (2 mg, intravenous bolus) was used for rescue analgesia. Pain was assessed on a visual analog scale (VAS) at 2, 4, 8, 12, 16, and 24 hours following the cranial nerve block. The following data were recorded: time elapsed until appearance of pain, use of rescue analgesia, and incidence of adverse effects. RESULTS: The use of morphine was significantly lower in the group of patients who received a cranial nerve block with bupivacaine than in the control group (mean [SD], 3.7 [1.6] mg vs 17.2 [2.5] mg). The mean time to the first requirement for rescue analgesia was longer in the bupivacaine group than in the control group (731 [247] minutes vs 80 [71] minutes). The VAS score during the first 16 hours was significantly lower in the bupivacaine group than in the control group. The incidence of nausea and vomiting was significantly higher in the control group (67% vs 13%). CONCLUSIONS: Cranial nerve block with 0.25% bupivacaine following supratentorial craniotomy improves postoperative analgesia, reduces the requirement for morphine, and contributes to reducing nausea and vomiting

[Postoperative delirium in patient neurosurgical: evaluation by means of the Abbreviated Mental Test]. / Delirio postoperatorio en pacientes neuroquirúrgicos: evaluación mediante el Test Mental Abreviado.

OBJECTIVES: To assess the incidence and characteristics of postoperative changes in the higher cerebral functions after elective intracranial surgery under general anesthesia. PATIENTS AND METHODS: This is a prospective study of 60 patients, aged 18-81 years, submitted to neurosurgical operations, allocated into two groups of 30 patients each: intracranial surgery group, patients submitted to craniotomy, and extracranial surgery group or control group, patients submitted to spinal procedures. All patients were given the Abbreviated Mental Test (AMT) on the day before to the operation, and then 2 and 24 hours after the end of the procedure. All individuals were managed with the same anesthetic technique. RESULTS: No differences in regard to demographics, duration of the operation, ASA physical state, and habits were found between the two groups. No differences in the pre-surgical and post-surgical AMT mean score were encountered between patients submitted to intracranial 9.87 +/- 0.35 or to spinal surgeries 9.80 +/- 0.41. Similarly, there were no significant differences between the two groups in the results of the AMT performed at 2 and 24 hours after the end of the surgeries. Only two subjects undergoing spinal procedures had a score of < or = 8 in the AMT performed 2-hours after the operation, while none showed a decrease in the 24-hour test score. CONCLUSIONS: Patients submitted to intracranial surgery did not show any changes in cognitive or attention functions during the first postoperative 24 hours as assessed by the AMT.

Delirio postoperatorio en pacientes neuroquirúrgicos: evaluación mediante el Test Mental Abreviado / Postoperative delirium in patient neurosurgical: evaluation by means of the Abbreviated Mental Test

Objetivo. Evaluar la incidencia y características de la alteración postoperatoria de las funciones cerebrales superiores en los pacientes sometidos a cirugía intracraneal electiva bajo anestesia general. Pacientes y método. Estudio prospectivo de 60pacientes ASA I-III, de edades comprendidas entre los 18 y 81 años, intervenidos quirúrgicamente por el Servicio de Neurocirugía de nuestro Hospital, distribuidos en dos grupos de 30 pacientes cada uno: grupo cirugía intracraneal, pacientes sometidos a cirugía por procesos intracraneales, y grupo cirugía extracraneal o grupo control, pacientes intervenidos de columna cervical o lumbar. Se registraron los datos demográficos de edad, sexo, peso, talla, así como hábitos, enfermedades coexistentes y medicación habitual. A todos los pacientes se les realizó el test mental abreviado (AMT) el día previo a la intervención quirúrgica y a las 2 y 24horas del periodo postoperatorio. Todos los pacientes fueron sometidos a la misma técnica anestésica. Fueron excluidos los pacientes que presentaron un AMT preoperatorio ≤ 8.Resultados. No hubo diferencias en los datos demográficos, duración de la cirugía, estado físico ASA y consumo de alcohol y tabaco. No se hallaron diferencias significativas entre grupos en la puntuación media obtenida en el AMT realizado el día antes de la cirugía, que fue de 9,87 ± 0,35 para los pacientes sometidos a cirugía intracraneal y de 9,80 ± 0.41 para los pacientes intervenidos de columna. Así mismo, no se observaron diferencias significativas entre los dos grupos en el AMT realizado a la 2 y 24 horas del postoperatorio: 4 de los pacientes sometidos a cirugía intracraneal presentaron una puntuación en el AMT ≤ 8 a las 2 horas de finalizada la cirugía, y 3 pacientes del mismo grupo, a las 24horas del postoperatorio; tan solo 2 pacientes intervenidos de columna presentaron una puntuación en el AMT≤ 8 a las 2 horas de finalizada la cirugía y ninguno a las 24 horas del postoperatorio. Conclusiones. Según los resultados obtenidos en este estudio podemos concluir que los pacientes sometidos a cirugía intracraneal no sufren alteraciones de la función cognitiva ni de la atención durante las primeras 24horas del postoperatorio, evaluados mediante el AMT

Objectives. To assess the incidence and characteristics of postoperative changes in the higher cerebral functions after elective intracranial surgery under general anesthesia. Patients and methods. This is a prospective study of60 patients, aged 18-81 years, submitted to neurosurgical operations, allocated into two groups of 30 patient seach: intracranial surgery group, patients submitted to craniotomy, and extracranial surgery group or control group, patients submitted to spinal procedures. All patients were given the Abbreviated Mental Test (AMT)on the day before to the operation, and then 2 and 24hours after the end of the procedure. All individuals were managed with the same anesthetic technique. Results. No differences in regard to demographics, duration of the operation, ASA physical state, and habits were found between the two groups. No differences in the pre-surgical and post-surgical AMT mean score were encountered between patients submitted to intracranial 9.87 ± 0.35 or to spinal surgeries 9.80 ±0.41. Similarly, there were no significant differences between the two groups in the results of the AMT performed at 2 and 24 hours after the end of the surgeries. Only two subjects undergoing spinal procedures had as core of ≤ 8 in the AMT performed 2-hours after the operation, while none showed a decrease in the 24-hourtest score. Conclusions. Patients submitted to intracranial surgery did not show any changes in cognitive or attention functions during the first postoperative 24 hours as assessed by the AMT

[Comparison of anesthetic maintenance and recovery with propofol versus sevoflurane combined with remifentanil in craniotomy for supratentorial neoplasm]. / Estudio comparativo de remifentanilo combinado con propofol o sevofluorano para el mantenimiento y recuperación de la anestesia en craneotomía por neoplasia supratentorial.

OBJECTIVE: To compare the effectiveness of propofol versus sevoflurane associated with remifentanil on the maintenance of anesthesia and on recovery in patients undergoing elective supratentorial craniotomy. PATIENTS AND METHODS: Prospective randomized trial enrolling 90 patients scheduled for excision of a brain neoplasm. All received an infusion of remifentanil at a dose of 0.5 microg x Kg(-1) x min(-1) until tracheal intubation and then 0.25 microg x Kg(-1) x min(-1) during surgery. Induction was achieved with propofol and anesthesia was maintained with either sevoflurane at a maximum alveolar concentration of 0.4 (45 patients) or propofol by target controlled infusion at a concentration of 2.5 microg x mL(-1) (45 patients, group P). Variables assessed were hemodynamic stability during anesthesia and times and quality of recovery from anesthesia (eye opening, initiation of spontaneous ventilation, extubation, cough reflex, and temporal and spacial orientation 3 minutes after extubation. During the first 24 hours after surgery, pain intensity was evaluated on a verbal visual analog scale (VAS) and the incidence of nausea and vomiting was recorded. RESULTS: Times until eye opening upon request and until extubation were significantly shorter in the sevoflurane group than in the propofol group: 3.7 (SD, 1.2) minutes vs 5 (3.1) minutes, respectively, for eye opening and 6.6 (1.2) minutes vs 8.1 (3.3) minutes for extubation (P<0.01). The incidence of nausea and vomiting was significantly higher in the sevoflurane group (40% vs 13%, respectively, P<0.01). CONCLUSIONS: Combining remifentanil with propofol or with sevoflurane provides satisfactory anesthesia during elective supratentorial craniotomy to remove a brain neoplasm. Hemodynamic stability is appropriate and recovery from anesthesia is rapid.

Estudio comparativo de remifentanilo combinado con propofol o sevofluorano para el mantenimiento y recuperación de la anestesia en craneotomía por neoplasia supratentorial / Comparison of anesthetic maintenance and recovery with propofol versus sevoflurane combined with remifentanil in craniotomy for supratentorial neoplasm

OBJETIVO. Comparar el uso de propofol o sevofluoranoasociados a remifentanilo para el mantenimiento yrecuperación de la anestesia en pacientes sometidos acraneotomía supratentorial electiva.PACIENTES Y MÉTODOS. Estudio prospectivo y aleatoriosobre 90 pacientes programados para exéresis deneoplasia cerebral. Todos recibieron remifentanilo a 0,5µg Kg-1 min-1 hasta la intubación traqueal seguido de0,25 µg Kg-1 min-1 durante la cirugía. Inducción con propofoly mantenimiento con sevoflurano 0,4 CAM (45pacientes, grupo S) o propofol con TCI (target controlinfusion) a 2,5 µg mL-1 (45 pacientes, grupo P). Se valoróla estabilidad hemodinámica durante la anestesia, lostiempos y calidad de la recuperación tras la anestesia:apertura de los ojos, inicio de la ventilación, extubación,capacidad para toser y orientación temporoespacial a los3 minutos de la extubación. Durante las primeras 24horas del postoperatorio se evaluó la intensidad deldolor mediante la escala de valoración verbal (EVS) y seregistró la incidencia de náuseas y vómitos (NVPO).RESULTADOS. Los tiempos de apertura de los ojos pororden y de extubación fueron significativamente menoresen el grupo S (3,7 ± 1,2 min frente 5 ± 3,1 min y 6,6± 1,2 min frente 8,1 ± 3,3 min (p<0,01 respectivamente).La incidencia de NVPO fue significativamente superioren el grupo S (40% frente 13%, p<0,01).CONCLUSIONES. La combinación de remifentanilo conpropofol o con sevoflurano proporcionan una anestesiasatisfactoria durante la craneotomía supratentorial electivapor neoplasia cerebral, consiguiendo la estabilidadhemodinámica apropiada y la recuperación rápida de laanestesia

OBJECTIVE: To compare the effectiveness of propofolversus sevoflurane associated with remifentanil on themaintenance of anesthesia and on recovery in patientsundergoing elective supratentorial craniotomy.PATIENTS AND METHODS: Prospective randomized trialenrolling 90 patients scheduled for excision of a brainneoplasm. All received an infusion of remifentanil at adose of 0.5 µg·Kg-1·min-1 until tracheal intubation andthen 0.25 µg·Kg-1·min-1 during surgery. Induction wasachieved with propofol and anesthesia was maintainedwith either sevoflurane at a maximum alveolar concentrationof 0.4 (45 patients) or propofol by target controlledinfusion at a concentration of 2.5 µg·mL-1 (45patients, group P). Variables assessed were hemodynamicstability during anesthesia and times and qualityof recovery from anesthesia (eye opening, initiation ofspontaneous ventilation, extubation, cough reflex, andtemporal and spacial orientation 3 minutes after extubation.During the first 24 hours after surgery, pain intensitywas evaluated on a verbal visual analog scale (VAS)and the incidence of nausea and vomiting was recorded.RESULTS: Times until eye opening upon request anduntil extubation were significantly shorter in the sevofluranegroup than in the propofol group: 3.7 (SD, 1.2)minutes vs 5 (3.1) minutes, respectively, for eye openingand 6.6 (1.2) minutes vs 8.1 (3.3) minutes for extubation(P<0.01). The incidence of nausea and vomiting was significantlyhigher in the sevoflurane group (40% vs 13%,respectively, P<0.01).CONCLUSIONS: Combining remifentanil with propofolor with sevoflurane provides satisfactory anesthesiaduring elective supratentorial craniotomy to remove abrain neoplasm. Hemodynamic stability is appropriateand recovery from anesthesia is rapid

[Precurarization with rocuronium prevents fasciculations and biochemical changes after succinylcholine administration]. / La precurarización con rocuronio previene las fasciculaciones y los cambios bioquímicos tras la administración de succinilcolina.

OBJECTIVE: To determine the efficacy of rocuronium to prevent fasciculations and biochemical changes after succinylcholine administration. PATIENTS AND METHODS: Prospective, randomized double-blind trial enrolling 60 ASA I-II patients scheduled for elective surgery under general anesthesia. The patients were assigned to 2 groups to receive either 0.06 mg x Kg(-1) of rocuronium or physiological saline solution 90 seconds before administration of 1.5 mg x Kg(-1) of succinylcholine. The incidence and severity of fasciculations and serum concentrations of potassium before anesthesia and 3, 5, and 20 minutes after succinylcholine administration were recorded. Other serum concentrations recorded were myoglobin, creatinine phosphokinase and lactate before anesthesia and 20 minutes after succinylcholine administration. RESULTS: The increases in potassium levels at 3 and 5 minutes (0.3 +/- 0.3 and 0.2 +/- 0.4 mmol x L(-1)) and in myoglobin levels at 20 minutes (38.9 +/- 31.7 ng x mL(-1)) were attenuated by precurarization with rocuronium. The incidence of fasciculations was significantly lower (p<0.001) and their severity significantly less (p<0.001) in patients who received rocuronium before administration of succinylcholine. CONCLUSIONS: Precurarization with rocuronium 90 seconds before succinylcholine administration reduces the incidence and severity of fasciculations and prevents increases in serum potassium and myoglobin concentrations.

[Effects of sevoflurane on mid-latency auditory evoked potentials and the 95% spectral frequency limit]. / Efectos del sevoflurano sobre los potenciales evocados auditivos de latencia media y límite de frecuencia espectral 95%.

OBJECTIVES: To investigate the effects of sevoflurane on mid-latency auditory evoked potentials (MLAEP) and compare them to changes in the encephalographic 95% spectral edge frequency (SEF95). PATIENTS AND METHODS: The effect of sevoflurane on MLAEP and SEF95 was studied in 15 patients. Anesthetic induction was carried out with propofol, remifentanil, and cisatracurium. After anesthetic induction, the patients were ventilated to achieve different expired concentrations of sevoflurane (1%, 1.5%, and 2%) during 3 consecutive 10-minute periods before the start of surgery. SEF95 and the amplitude and latency of the Na, Pa and Nb MLAEP waves were recorded. All the parameters were measured at baseline and during the different expired fractions of sevoflurane. RESULTS: The increase in sevoflurane concentration was accompanied by a significant decrease in amplitude and a statistically significant increase in latency of the Na, Pa and Nb waves. Likewise, SEF95 decreased significantly. A linear relation was demonstrated between sevoflurane concentration and the variables Na, Pa, Nb and SEF95. CONCLUSIONS: Our results indicate that the effect of sevoflurane on the MLEAP of Na, Pa and Nb is similar to that of other anesthetic gases. Even though the amplitude of the Na, Pa and Nb waves decreased in a dose-dependent way, SEF95 correlated more strongly with sevoflurane concentration.

[Pulse oximetry reduces the unnecessary administration of oxygen in the postanesthesia recovery period]. / La pulsioximetría reduce la administración innecesaria de oxígeno en el período de recuperación postanestésica.

OBJECTIVES: To investigate whether patients admitted to the postanesthesia recovery unit (PRU) need routine oxygen supplementation in the immediate postoperative period, by measuring changes in arterial oxygen saturation (SpO2) with a pulse oximeter. MATERIAL AND METHODS: Two hundred ninety-nine patients were admitted to the PRU after surgery. All breathed room air after their operations. During transfer to and time in the PRU, SpO2 was recorded. We administered oxygen through a face mask to patients whose SpO2 fell below 94% and to patients whose SpO2 levels fell below baseline, when baseline values were less than 94%. We recorded patient data, physical status (ASA), type of anesthesia, duration of surgery, Aldrete score upon admission to the PRU and SpO2 before and after surgery while the patient breathed room air. RESULTS: General anesthesia was used in 82.3% of the patients and local-regional anesthesia with sedation in 17.7%. PRU stay was 75.6 +/- 92.4 min. Twenty-five percent of the patients were treated with oxygen after surgery and 75% did not require supplemental oxygen. Time until the appearance of desaturation was 3.3 +/- 2.8 min. The coefficient of multiple correlation between postoperative SpO2 while breathing room air (dependent variable) and preoperative SpO2, age and duration of surgery was R = 0.522 (p < 0.001). CONCLUSIONS: Our results are sufficient to demonstrate the validity of pulse oximetry for avoiding indiscriminate oxygen supplementation in patients admitted to the PRU.

La pulsioximetría reduce la administración innecesaria de oxígeno en el período de recuperación postanestésica / Pulse oximetry reduces unnecessary oxygen administration during recovery from anesthesia

Objetivos: Investigar si los pacientes ingresados en la Unidad de Recuperación Postanestésica (URPA) necesitan O2 suplementario de rutina en el postoperatorio inmediato, midiendo las variaciones saturación arterial de oxígeno (SpO2) mediante la pulsioximetría. Material y Métodos: Se incluyó a 299 pacientes intervenidos y que asistimos en la URPA una vez finalizada la cirugía. Todos los pacientes respiraban aire ambiente después de haber sido intervenidos. Durante el traslado y permanencia en la URPA se registró SpO2. Administramos O2 mediante mascarilla en los casos de SpO2 < 94 por ciento y en aquellos pacientes con valores de SpO2 inferiores a los basales, cuando éstos eran < 94 por ciento. Durante el estudio se registraron: datos demográficos, estado físico ASA, tipo de anestesia, duración de la intervención, puntuación de la aplicación del test de Aldrete en el momento del ingreso en la URPA y SpO2 pre y postoperatoria respirando aire ambiente. Resultados: La anestesia general se utilizó en el 82,3 por ciento de los pacientes, siendo la técnica lo corregional con sedación en el 17,7 por ciento. El tiempo de estancia en la URPA fue de 75,6 ñ 92,4 min. El 25 por ciento de los pacientes fueron tratados con O2 en el postoperatorio frente al 75 por ciento que no precisaron O2 suplementario. El intervalo de tiempo de la aparición de la desaturación fue de 3,3 ñ 2,8 min. El coeficiente de correlación múltiple entre la SpO2 postoperatoria respirando aire ambiente (variable dependiente) y las variables SpO2 preoperatoria, edad y duración de la intervención fue R = 0,522 (p < 0,001).Conclusiones: Nuestros resultados prueban suficientemente la validez de la pulsioximetría en los pacientes ingresados en la URPA toda vez que evita el uso indiscriminado de O2 en dicha unidad. (AU)

[Puerperal cardiomyopathy and pulmonary edema after cesarean section]. / Miocardiopatía periparto y edema pulmonar tras cesárea.

A 26-year-old woman in the thirty-second week of her fifth pregnancy was admitted with diffuse sudden-onset abdominal pain. Examination revealed cervical dilation to 8 cm, a ruptured uterine cerclage and transverse presentation of the fetus, indicating a need for emergency cesarean section, which was performed under uneventful spinal anesthesia. Three days after surgery the patient presented signs consistent with acute pulmonary edema coinciding with blood transfusion. Echocardiography demonstrated left ventricular systolic dysfunction with an ejection fraction of 35%. The diagnosis was peripartum myocardiopathy with acute respiratory insufficiency due to heart failure. Furosemide and captopril were prescribed and the outcome was satisfactory. The discharge echocardiogram showed a left ventricle of normal size and thickness, and the ejection fraction was 55%. Peripartum myocardiopathy is a type of heart failure that develops during the third trimester or during the first six months after delivery, in the absence of signs of ventricular dysfunction or previous heart disease. Based on clinical presentation and echocardiographic findings, we believe that peripartum myocardiopathy was the cause of acute pulmonary edema in this patient.

Miocardiopatía periparto y edema pulmonar tras cesárea / Peripartum cardiomyopathy and pulmonary edema after cesarean delivery

Una mujer de 26 años, en la semana 32 de su quinta gestación, ingresó por dolor abdominal difuso de instauración brusca. En la exploración se objetivó una dilatación de 8 cm del cuello uterino, rotura del cerclaje uterino y presentación transversa del feto, por lo que se indicó cesárea urgente, que se realizó bajo anestesia subaracnoidea sin incidencias. Al tercer día del postoperatorio la paciente inició un cuadro compatible con edema agudo de pulmón coincidiendo con la administración de sangre. Se le realizó una ecocardiografía que mostró una disfunción sistólica global del ventrículo izquierdo con fracción de eyección del 35 por ciento, y se diagnosticó de miocardiopatía periparto, con insuficiencia respiratoria aguda por insuficiencia cardíaca. Se trató con furosemida y captopril y la evolución fue favorable. Al alta hospitalaria, la ecocardiografía mostró un ventrículo izquierdo de tamaño y espesor normal y fracción de eyección del 55 por ciento. La miocardiopatía periparto es un modo de insuficiencia cardíaca que se produce en el último trimestre de embarazo o durante los seis primeros meses del puerperio, en ausencia de una causa demostrable de disfunción ventricular y de enfermedad cardíaca previa. De acuerdo con la presentación clínica y con los hallazgos ecocardiográficos encontrados en esta paciente, consideramos que la miocardiopatía periparto fue la causa del edema agudo de pulmón (AU)