Anestesia libre de opioides para cistectomía radical laparotómica en obesidad mórbida / Opioid-free anesthesia for open radical cystectomy in morbid obesity

El estudio de la técnica anestésica libre de opioides aporta evidencias de su efectividad y seguridad. Sin embargo, aún no están bien definidos todos sus riesgos y beneficios, ni en qué pacientes o intervenciones puede ser superior a la técnica anestésica convencional basada en opioides. Las cirugías intensivas y/o duraderas plantean dudas para la utilización de esta técnica por la respuesta a cambios hemodinámicos bruscos, al no producir la simpaticolisis a través de la actuación sobre el receptor μ y haber poca experiencia de uso. Una paciente con obesidad mórbida fue sometida a cistectomía radical con derivación urinaria tipo Bricker mediante laparotomía infraumbilical, consiguiéndose una adecuada estabilidad hemodinámica y una analgesia óptima en el postoperatorio sin emplear opioides intraoperatorios. La anestesia libre de opioides está en expansión con una evidencia creciente. No obstante, es necesario seguir investigando sobre sus posibilidades de utilización, las distintas combinaciones de fármacos que se puedan emplear y la resolución de complicaciones que puedan ocurrir.(AU)

Opioid-free anaesthesia shows evidence about its efectivity and security, even though its risks and benefits are not well defined. Neither are the patient profile or sort of surgery where it could be superior to the conventional opioid-based anaesthetic technique. Aggressive and/or long-lasting surgeries set out several queries on this technique regarding sudden hemodynamic changes, as it does not produce sympatholysis through μ receptor and there is modest experience in this technique. A morbidly obese patient received open radical cystectomy with Bricker-type urinary diversion using infraumbilical incision under OFA protocol, maintaining an adequate hemodynamic stability and excellent analgesia in postoperatory care without using any intraoperative opioids. Opioid-free anaesthesia technique is developing its evidence. However, it is necessary to keep on researching its clinical applications, different drug combinations and solutions to its expected complications.(AU)

Opioid-free anesthesia for open radical cystectomy in morbid obesity.

Opioid-free anaesthesia shows evidence about its efectivity and security, even though its risks and benefits are not well defined. Neither are the patient profile or sort of surgery where it could be superior to the conventional opioid-based anaesthetic technique. Aggressive and/or long-lasting surgeries set out several queries on this technique regarding sudden hemodynamic changes, as it does not produce sympatholysis through µ receptor and there is modest experience in this technique. A morbidly obese patient received open radical cystectomy with Bricker-type urinary diversion using infraumbilical incision under OFA protocol, maintaining an adequate hemodynamic stability and excellent analgesia in postoperatory care without using any intraoperative opioids. Opioid-free anaesthesia technique is developing its evidence. However, it is necessary to keep on researching its clinical applications, different drug combinations and solutions to its expected complications.

Manejo perioperatorio del paciente con lesión medular crónica portador de marcapasos frénico bilateral. Descripción de un caso / Perioperative management of the patient with chronic spinal cord injury using bilateral diaphragmatic pacemaker. Clinical case

Los pacientes con lesión medular crónica tienenunas alteraciones fisiopatológicas que determinan unaimportante morbilidad y mortalidad en el periodo perioperatorio. El marcapasos diafragmático es un dispositivo que permite la ventilación pulmonar en pacientescon lesiones cervicales altas y mejora la calidad de vidafrente al uso de ventilación mecánica. Presentamos el caso de una paciente con lesiónmedular crónica y portadora de un marcapasos diafragmático que fue programada para realización de nefrolitotomía percutánea y colocación de catéter doble Jderecho. El anestesista debe conocer la situación fisiopatológica de estos pacientes para asegurar la seguridad en el proceso perioperatorio.(AU)

Patients with chronic spinal cord injury suffer froma number of pathophysiological alterations that canlead to important morbidity and mortality in the perioperative period. The diaphragmatic pacemaker is adevice that enables pulmonary ventilation in patientswith high cervical cord injuries and provides them witha better quality of life when compared to mechanicalventilation. We present here the clinical case of a patient withchronic spinal cord injury who used a diaphragmaticpacemaker, and who was scheduled for percutaneousnephrolithotomy and double-J stent implantation. Theanesthesiologist should know the pathophysiologicalsituation of these patients in order to provide a safeperioperatory care.(AU)

Opioid-free anesthesia for open radical cystectomy in morbid obesity. / Anestesia libre de opioides para cistectomía radical laparotómica en obesidad mórbida.

Opioid-free anaesthesia shows evidence about its efectivity and security, even though its risks and benefits are not well defined. Neither are the patient profile or sort of surgery where it could be superior to the conventional opioid-based anaesthetic technique. Aggressive and/or long-lasting surgeries set out several queries on this technique regarding sudden hemodynamic changes, as it does not produce sympatholysis through µ receptor and there is modest experience in this technique. A morbidly obese patient received open radical cystectomy with Bricker-type urinary diversion using infraumbilical incision under OFA protocol, maintaining an adequate hemodynamic stability and excellent analgesia in postoperatory care without using any intraoperative opioids. Opioid-free anaesthesia technique is developing its evidence. However, it is necessary to keep on researching its clinical applications, different drug combinations and solutions to its expected complications.

[Perioperative management of the patient with chronic spinal cord injury using bilateral diaphragmatic pacemaker. Clinical case].

Patients with chronic spinal cord injury suffer from a number of pathophysiological alterations that can lead to important morbidity and mortality in the perioperative period. The diaphragmatic pacemaker is a device that enables pulmonary ventilation in patients with high cervical cord injuries and provides them with a better quality of life when compared to mechanical ventilation. We present here the clinical case of a patient with chronic spinal cord injury who used a diaphragmatic pacemaker, and who was scheduled for percutaneous nephrolithotomy and double-J stent implantation. The anesthesiologist should know the pathophysiological situation of these patients in order to provide a safe perioperatory care.

Narcolepsia y anestesia libre de opioides: revisión y caso clínico / Narcolepsy and opioid-free anesthesia: a review and case report

Introducción: La narcolepsia es el segundo trastorno del sueño en frecuencia y se caracteriza por somnolencia excesiva durante el día junto con otros síntomas como cataplejía, parálisis del sueño y alucinaciones. Su fisiopatología y tratamiento, así como los síndromes que asocia, pueden interferir de forma severa con el acto anestésico. Metodología: Debido al déficit de evidencia de calidad que aporte un grado de recomendación alto en la anestesia de estos pacientes, se realizó una revisión narrativa de la literatura no sistemática en Pubmed. Como descriptores se usaron narcolepsy, anesthesia, surgery, perioperative, opioid, obstructive, apnea y sleep y se emplearon de forma individual y cruzándolos con conectores AND y OR. Conclusión: La recomendación de evitar opioides y la estabilidad de la anestesia libre de opioides (OFA), hace de esta última una opción para estos pacientes. Se describe un caso en el que se empleó de forma segura.(AU)

Introduction: Narcolepsy is the second most common sleep disorder. It is characterised by excessive daytime sleepiness together with other symptoms such as cataplexy, sleep paralysis, and hallucinations. The pathophysiology and treatment of this disease, together with its associated syndromes, can severely interfere with anaesthesia. Methodology: Due to the lack of quality evidence on which to base a high grade of recommendation for anaesthesia in these patients, we performed a non-systematic, narrative review of the literature in Pubmed. We used the descriptors narcolepsy, anesthesia, surgery, perioperative, opioid, obstructive, apnea and sleep both individually and with AND and OR connectors. Conclusion: The recommendation to avoid opioids and the stability of opioid-free anaesthesia (OFA) make this approach an option to consider in these patients. We describe a case in which it was used safely.(AU)

Narcolepsy and opioid-free anesthesia: a review and case report. / Narcolepsia y anestesia libre de opioides: revisión y caso clínico.

INTRODUCTION: Narcolepsy is the second most common sleep disorder. It is characterised by excessive daytime sleepiness together with other symptoms such as cataplexy, sleep paralysis, and hallucinations. The pathophysiology and treatment of this disease, together with its associated syndromes, can severely interfere with anaesthesia. METHODOLOGY: Due to the lack of quality evidence on which to base a high grade of recommendation for anaesthesia in these patients, we performed a non-systematic, narrative review of the literature in Pubmed. We used the descriptors narcolepsy, anesthesia, surgery, perioperative, opioid, obstructive, apnea and sleep both individually and with AND and OR connectors. CONCLUSION: The recommendation to avoid opioids and the stability of opioid-free anaesthesia (OFA) make this approach an option to consider in these patients. We describe a case in which it was used safely.

[Impact of opioid free anaesthesia in bariatric surgery]. / Impacto de la anestesia libre de opioides en cirugía bariátrica.

BACKGROUND: Patients subjected to bariatric surgery present a greater risk of complications due to the use of opioids. The goal is to evaluate the security and suitability of the Opioid Free Anaesthesia (OFA) protocol implemented in the Hospital Universitario Virgen de la Victoria in 2018. METHOD: Prospective study carried out on 38 patients subjected to laparoscopic bariatric surgery under the OFA protocol in the year 2018 at the H.U. Virgen de la Victoria (Málaga, Spain). Variables were gathered to establish haemodynamic control and perioperative pain, which were analysed using Stata v.16. RESULTS: The average age was 43 years, the average body mass index was 48.14 and the average stay in the operating theatre was 178 minutes. Control of hypertensive response following laryngoscopy occurred in 88.1% of the cases. On entering the Post Anaesthesia Care Unit (PACU), SpO2 without a supplementary contribution in the transfer showed a median of 97% with p75 = 95%, while the p75 of pain evaluation by means of Visual Analogue Scale (VAS) was 3, with 68% of patients without pain. On discharge from the PACU, all presented VAS below 4 and it was only necessary to administer a low dose of Pethidine in seven patients. CONCLUSION: The OFA has proved to be secure and achieves optimum pain control. In the reconverted cases, good control of the parameters opens up the possibility of its use in more painful surgeries.

Preservation of renal function in cardiac surgery patients with low cardiac output syndrome: levosimendan vs beta agonists.

BACKGROUND: Some studies have been performed to assess the effects of levosimendan on cardiac function when administered to cardiac surgery patients with low cardiac output syndrome (LCOS) in the immediate postoperative period. Levosimendan is an inotropic agent for the treatment of low cardiac output syndrome that seems to have a protective effect on renal function. METHODS: It is a quasi-experimental study. A total of 100 patients with LCOS received either beta-agonists or levosimendan. We assessed the incidence of postoperative kidney failure in cardiac surgery patients. In patients who had kidney failure at diagnosis of LCOS, we examined whether differences existed in the evolution of kidney failure based on the treatment administered for LCOS. The parameters measured included haemodynamics, oxygen supply, and renal function as assessed by the AKI scale. ANOVA, Student's t-test and Wilcoxon or Friedman tests were used. RESULTS: Up to 30% of cardiac surgery patients had kidney failure at diagnosis of LCOS. Kidney failure at discharge from the ICU was more frequent in patients who received beta-agonist drugs as compared to those who received levosimendan (p < 0.05). CONCLUSION: The incidence of kidney failure decreased with the postoperative administration of levosimendan to cardiac surgery patients with LCOS, as compared to beta-agonists. TRIAL REGISTRATION: Current Controlled Trials ISRCTN 46058317. Date of registration: 7/10/2019. Retrospectively registered.

[Laparotomy in a patient under opioid free anesthesia]. / Laparotomía en un paciente bajo anestesia libre de opiáceos.

Obese patients subjected to bariatric surgery have a high probability of presenting complications that worsen with the use of opioids and can be reduced thanks to anaesthetic techniques like opioid-free anaesthetics (OFA). The risk of having to convert the laparoscopic surgical technique into open surgery is one of the criticisms aimed at this anaesthetic modality, facing the possibility of there not being a correct sympathetic or nociceptive control. We present the case of a patient scheduled for laparoscopic bariatric surgery who, while maintaining OFA, was converted to open surgery (exploratory laparoscopy), with correct control achieved of both haemodynamics and perioperative pain.

Calcium Sensitizers in Cardiac Surgery: Who, When, How and Why?

Inodilators are a heterogeneous group of drugs with vasodilatory and inotropic effects. The cardioprotective effect of levosimendan is multifactorial, but now research on levosimendan is focused on the organ-protective properties of this drug in different settings, the regimen that seems to provide the greatest cardiologic and systemic benefits is early administration of levosimendan. We try to answer four questions in this review, which type of patients need this drug? what is the best time to start with it? and the best way that we could give it and finally the reasons for use it.

Mechanisms of Cardioprotection of Halogenated Agents During Extracorporeal Circulation in Cardiac Surgery.

The implementation of cardioprotective strategies involving pre-, intra-, and postoperative interventions is key during cardiac surgery requiring extracorporeal circulation (ECC). The primary goal of this study was to review the physiopathology and protection strategies against myocardial damage secondary to ECC during cardiac surgery. The administration halogenated anesthetics for cardiac anesthesia is common place due to their well-known cardioprotective effects and their capacity to ensure hypnosis. An optimal myocardial protection strategy requires that a comprehensive approach should be adopted to cover pre-, intra-, and post-operative interventions. Pre-conditioning and post-conditioning share numerous pathways, mainly based on mitochondrial signaling, antiapoptotic pathways, and reduced inflammatory mediators. However, volatile anesthetic can also be administered during ECC, in which mechanism of action has been scantly investigated, during this period and its biology is still unknown.

Cardioprotective efficacy of sevoflurane vs. propofol during induction and/or maintenance in patients undergoing coronary artery revascularization surgery without pump: A randomized trial.

PURPOSE: Pre and post-operative administration of sevoflurane in myocardial revascularization surgery provides enhanced cardioprotective effects exerted by pharmacologic pre- and post-conditioning, as compared to propofol. The identification of the enzymes involved in conditioning mechanisms is crucial to the understanding of the effects of sevoflurane in cardiac surgery patients. The impact of sevoflurane on another crucial target organ-the kidney-was also assessed. METHODS: Ninety patients undergoing off-pump myocardial revascularization surgery were allocated to receive either intra- and postoperative sevoflurane (SS), intraoperative sevoflurane and postoperative propofol (SP), or intra- and postoperative propofol (PP)). Troponin I and hemodynamic parameters were monitored during the first 48 postoperative hours; blood and urine samples were collected at baseline and at 24h to determine Akt, ERK1/2, PKG, iNO, bradykinin receptor, caspase 3, NT proBNP and urinary NGAL. RESULTS: The enzymes were overexpressed in the SS group, remained unchanged in the SP group, and decreased in the PP group. Renal function was best preserved in the SS group. CONCLUSIONS: The overexpression of enzymes induced by intraoperative anesthesia and postoperative sedation with sevoflurane reduces myocardial damage and improves renal function in patients undergoing off-pump myocardial revascularization surgery.