Effects of droperidol and ondansetron on dispersion of ventricular repolarization: A randomized double-blind clinical study in anesthetized adult patients.

BACKGROUND AND OBJECTIVE: Droperidol and ondansetron prolong QT interval, a circumstance that has raised some concerns regarding the possibility of inducing torsades de pointes (TdP). However drug-induced spatial dispersion of ventricular repolarization has been shown to be the principal arrhythmogenic substrate for TdP. The aim of this study is to explore the effects of droperidol and ondansetron on the dispersion of repolarization, measured using the T peak-to-end interval (Tp-e) and Tp-e/QT and Tp-e/RR(1/2) ratios in surgical anesthetized patients. METHODS: A randomized, double-blind study carried out on sixty-three adult patients without cardiac disease or factors favoring QT prolongation and undergoing non-cardiac surgery were randomly assigned to the droperidol or ondansetron group. Under propofol anesthesia, a 12-lead EKG was obtained, and 1.25mg droperidol or 4mg ondansetron was injected. Five minutes later, a new 12-lead EKG was recorded. EKG analyses were independently performed by two cardiologists blinded to the state of the traces or group allocation. QT, RR and Tp-e intervals were measured by averaging five successive beats in leadII (QT) or V5 (Tp-e). The mean value for each measurement was calculated for statistical analysis. RESULTS: Thirty-two patients (19 women) received droperidol, and 31 (22 women) ondansetron. Droperidol and ondansetron prolonged the QTcF interval (Fridericia formula) by 6.8 and 7.2ms (mean values) respectively, but neither droperidol nor ondansetron increased the Tp-e interval or Tp-e/QT and Tp-e/RR(1/2) ratios. CONCLUSION: At antiemetic doses, neither ondansetron (4mg) nor droperidol (1.25mg) increases the dispersion of ventricular repolarization in healthy adult patients anesthetized with propofol.

National critical incident reporting systems relevant to anaesthesia: a European survey.

BACKGROUND: Critical incident reporting is a key tool in the promotion of patient safety in anaesthesia. METHODS: We surveyed representatives of national incident reporting systems in six European countries, inviting information on scope and organization, and intelligence on factors determining success and failure. RESULTS: Some systems are government-run and nationally conceived; others started out as small, specialty-focused initiatives, which have since acquired a national reach. However, both national co-ordination and specialty enthusiasts seem to be necessary for an optimally functioning system. The role of reporting culture, definitional issues, and dissemination is discussed. CONCLUSIONS: We make recommendations for others intending to start new systems and speculate on the prospects for sharing patient safety lessons relevant to anaesthesia at European level.

Errores de medicación y etiquetado de las jeringas / Medication errors and syringe labeling

Los problemas asociados con el tratamiento farmacológico en el entorno hospitalario son frecuentes y se asocian, en ocasiones, a daño para el paciente y mayores costes. La Declaración de Helsinki sobre seguridad del paciente en anestesiología incluye, entre otras recomendaciones, que todos los servicios de anestesia tengan protocolos para el adecuado etiquetado de las jeringas que contienen la medicación necesaria durante la anestesia. Recientemente, el Sistema Español de Notificación de Seguridad en Anestesia y Reanimación y la Sociedad Española de Anestesiología y Reanimación, junto al Instituto para el Uso Seguro de los Medicamentos-España, han publicado las recomendaciones de etiquetado de jeringas, líneas y envases de acuerdo a dichas normas. En este trabajo se revisan brevemente los errores de medicación en anestesia y el papel del etiquetado de la medicación en la seguridad del paciente (AU)

Drug-related problems are frequent in the hospital setting and sometimes lead to patient harm and increased costs. The “Helsinki Declaration on Patient Safety in Anesthesiology” includes, among other recommendations, that all anesthesia departments have protocols for the correct labelling of syringes containing the medication required for anesthesia. In accordance with this document, the Spanish System of Safety Reporting in Anesthesia and Resuscitation and the Spanish Society of Anesthesiology and Resuscitation, together with the Institute for Safe Medication Practices in Spain have recently published their recommendations on the labelling of syringes, lines and bags. The present article briefly reviews medication errors in anesthesia and the role of medication labelling in patient safety (AU)

[Postoperative nausea and vomiting and opioid-induced nausea and vomiting: guidelines for prevention and treatment]. / Recomendaciones de prevención y tratamiento de las náuseas y vómitos postoperatorios y/o asociados a las infusiones de opioides.

Postoperative nausea and vomiting (PONV) causes patient discomfort, lowers patient satisfaction, and increases care requirements. Opioid-induced nausea and vomiting (OINV) may also occur if opioids are used to treat postoperative pain. These guidelines aim to provide recommendations for the prevention and treatment of both problems. A working group was established in accordance with the charter of the Sociedad Española de Anestesiología y Reanimación. The group undertook the critical appraisal of articles relevant to the management of PONV and OINV in adults and children early and late in the perioperative period. Discussions led to recommendations, summarized as follows: 1) Risk for PONV should be assessed in all patients undergoing surgery; 2 easy-to-use scales are useful for risk assessment: the Apfel scale for adults and the Eberhart scale for children. 2) Measures to reduce baseline risk should be used for adults at moderate or high risk and all children. 3) Pharmacologic prophylaxis with 1 drug is useful for patients at low risk (Apfel or Eberhart 1) who are to receive general anesthesia; patients with higher levels of risk should receive prophylaxis with 2 or more drugs and baseline risk should be reduced (multimodal approach). 4) Dexamethasone, droperidol, and ondansetron (or other setrons) have similar levels of efficacy; drug choice should be made based on individual patient factors. 5) The drug prescribed for treating PONV should preferably be different from the one used for prophylaxis; ondansetron is the most effective drug for treating PONV. 6) Risk for PONV should be assessed before discharge after outpatient surgery or on the ward for hospitalized patients; there is no evidence that late preventive strategies are effective. 7) The drug of choice for preventing OINV is droperidol.

Association between nitrous oxide and the incidence of postoperative nausea and vomiting in adults: a systematic review and meta-analysis.

Some, but not all studies have suggested intra-operative use of nitrous oxide is correlated with postoperative nausea and vomiting. We performed a meta-analysis of randomised controlled trials to compare the incidence of nausea and vomiting in adults following general anaesthesia with or without nitrous oxide. We retrieved 30 studies (incorporating 33 separate trials) that investigated a 'nitrous oxide group' (total 2297 patients) vs a 'no-nitrous oxide group' (2301 patients). Omitting nitrous oxide significantly reduced postoperative nausea and vomiting (pooled relative risk 0.80, 95% CI 0.71-0.90, p = 0.0003). However, the absolute incidence of nausea and vomiting was high in both the nitrous oxide and no-nitrous oxide groups (33% vs 27%, respectively). In subgroup analysis, the maximal risk reduction was obtained in female patients (pooled relative risk 0.76, 95% CI 0.60-0.96). When nitrous oxide was used in combination with propofol, the antiemetic effect of the latter appeared to compensate the emetogenic effect of nitrous oxide (pooled relative risk 0.94, 95% CI 0.77-1.15). We conclude that avoiding nitrous oxide does reduce the risk of postoperative nausea and vomiting, especially in women, but the overall impact is modest.

Causes for cancellation of elective surgical procedures in a Spanish general hospital.

Cancellation of scheduled surgery is undesirable for patients and an inefficient use of resources. We prospectively collected data for 52 consecutive months in a public general hospital to estimate the prevalence and causes. The overall cancellation rate was 6.5% (2559 of 39 115 scheduled operations). Cancellation by broad category was for 'medical reasons' in 50%, 'patient-related factors' in 23%, and due to 'administrative/logistic problems' in 25%. The commonest specific causes within these categories were respectively: infections/fever (18%), patient did not attend (20%) and lack of theatre time (23%). This data will help direct resources to target prevention of cancellations as a result of these main problems.

Predictive value of six risk scores for outcome after surgical repair of hip fracture in elderly patients.

BACKGROUND: Hip fracture surgery is associated with high post-operative mortality and poor functional results: the excess mortality is 20% in the first year; of those patients who survive, only 50% recover their previous ability to walk. The purpose of this study was to assess the predictive value of six functional status and/or surgical risk scoring systems with regard to serious complications after hip fracture surgery in the elderly. METHODS: We performed a prospective study of a consecutive series of 232 patients (aged 65 years or older) undergoing hip fracture surgery. We pre-operatively applied: The American Society of Anesthesiologists classification, the Barthel index, the Goldman index, the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) scoring system, the Charlson index and the Visual Analogue Scale for Risk (RISK-VAS) scale. These scales were evaluated with respect to three variables: incidence of serious complications, the ability to walk after a 3-month period and 90-day survival. The predictive value of the different scales was assessed by the calculated area under a receiver operating characteristic curve. RESULTS: The RISK-VAS scale, the POSSUM scoring system and the Charlson index reached a sufficient predictive value with regard to serious post-operative complications. The Barthel index and the RISK-VAS scale were those most useful for predicting ambulation at 3 months. None of the scales proved to be capable of predicting 90-day mortality. CONCLUSIONS: A simple index such as the RISK-VAS scale was the best predictor of serious post-operative complications. The functional level before the fracture, measured with the Barthel index, had a major influence on the ambulation recovery.

Uso de ropivacaína nebulizada en un paciente con obstrucción distal de la vía aérea / No disponible

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[Epidural obstetric analgesia, maternal fever and neonatal wellness parameters]. / Analgesia epidural obstétrica, fiebre materna y parámetros de bienestar neonatal.

OBJECTIVE: To study the relation between epidural analgesia and the development of maternal fever during labor and childbirth, and to determine the possible relation between that association and neonatal welfare and in the performance of tests to rule out sepsis in newborns. PATIENTS AND METHODS: Prospective study of all women who gave birth at Fundación Hospital Alcorcón over a period of 3 years. All the women were offered epidural analgesia based on infusion of 0.0625% bupivacaine and 2 microg x mL(-1). Data collected were age, nulliparity, epidural analgesia infusion, induction of labor, uterine stimulation with oxytocin, type of birth, fetal weight, duration of dilation and expulsion, Apgar score (at 1 and 5 minutes), umbilical artery pH, and maternal temperature. RESULTS: Data for 4364 women were analyzed. Fever developed during labor in 5.7%; 93.7% of the fevers occurred in women receiving epidural analgesia (P<0.05). Logistic regression analysis revealed that independent risk factors for the development of fever were epidural analgesia (odds ratio [OR], 1.78; 95% confidence interval [CI], 1.05-3.04), nulliparity (OR, 2,929; 95% CI, 2.005-4.279), fetal weight (OR, 1.484; 95% CI, 1.102-2.001), and duration of labor (OR, 1.003; 95% CI, 1.003-1.004). No significant differences in Apgar score at 5 minutes or umbilical artery pH were found between the women with and without fever. Tests to rule out sepsis were ordered for 85.1% of the infants of mothers with fever after epidural analgesia. CONCLUSIONS: Epidural analgesia was associated with greater risk of developing fever in mothers giving birth, but that association had no repercussion on the neonatal wellness parameters studied.

[Pulsed radiofrequency treatment in idiopathic and secondary glossopharyngeal neuralgia: preliminary results in 2 cases]. / Tratamiento con radiofrecuencia pulsada en dos casos de neuralgia glosofaríngea idiopática y secundaria. Resultados preliminares.

OBJECTIVES: To describe the use of pulsed radiofrequency (PRF) to treat 2 cases of glossopharyngeal neuralgia, 1 idiopathic and 1 secondary. PATIENTS: The first case involved a man diagnosed with Hodgkin's lymphoma involving the tonsils and manifesting as glossopharyngeal neuralgia that was refractory to all treatment approaches tried, including opioids and neuromodulation. The second case involved a patient diagnosed with essential glossopharyngeal neuralgia that was also resistant to drug treatment. The PRF procedure was performed in the operating room on an outpatient basis, under fluoroscopic guidance and with conventional monitoring. No perioperative events were reported. RESULTS: The treatment was effective for both patients, leading to decreases in visual analog scale pain reports between 5 and 7 points that were maintained over 6 months, although improvement for the patient with essential neuralgia was less intense and of shorter duration. Overall self-reported improvement assessed subjectively 6 months after PRF was 75% for the patient with Hodgkin's lymphoma and 50% for the patient with essential neuralgia, for whom a second PRF procedure was scheduled. Neither patient suffered complications or side effects that were potentially attributable to the procedure. CONCLUSIONS: PRF seems to be a safe, effective approach to treating neuralgia of the glossopharyngeal nerve, whether the condition is essential or secondary to another process. It is possible that if the condition is secondary, the clinical response may be greater in intensity and last longer.

Tratamiento con radiofrecuencia pulsada en dos casos de neuralgia glosofaríngea idiopática y secundaria. Resultados preliminares / Pulsed radiofrequency treatment in idiopathic and secondary glossopharyngeal neuralgia: preliminary results in 2 cases

OBJETIVOS: Describir la utilidad de la radiofrecuencia pulsada (RFP)en el tratamiento de dos casos de neuralgia glosofaríngea, uno diopático y, otro, secundario. PACIENTES: El primer caso es un varón con diagnóstico de linfoma de Hodgkin amigdalar, manifestado como una neuralgia glosofaríngea refractario a diferentes estrategias terapéuticas ensayadas, incluidos fármacos opioides y neuromoduladores. El segundo caso es un paciente con diagnóstico de neuralgia glosofaríngea esencial, también rebelde al tratamiento farmacológico. El procedimiento se realizó en quirófano en régimen ambulante, bajo control fluoroscópico y monitorización convencional. No se registraron incidentes perioperatorios. RESULTADOS: Aunque en el caso de origen esencial la mejoría clínica fue de menor intensidad y duración, la RFP resultó eficaz en ambos casos, con descensos de la Escala Visual Analógica entre de 5 y 7 puntos que se mantuvieron a los 6 meses de aplicado el tratamiento. La mejo- ría subjetiva, valorada por los propios pacientes a los 6 meses de aplicada la RFP, fue de 75%en el Hodgkin y de 50%en la neuralgia esencial. En este paciente se realizará una nueva sesión de RFP, las próximas semanas. En ninguno de los dos casos se presentaron complicaciones o efec- tos secundarios potencialmente atribuibles a la RFP. CONCLUSIONES: La RFP parece una técnica eficaz y segura en el tratamiento de la neuralgia del nervio gloso- faríngeo, tanto en la de origen esencial como en las secundarias, si bien, es posible que en estas últimas la respuesta clínica sea de mayor intensidad y duración

OBJECTIVES: To describe the use of pulsed radiofrequency (PRF)to treat 2 cases of glossopharyngeal neuralgia,1 idiopathic and 1 secondary. PATIENTS: The first case involved a man diagnosed with Hodgkin ’s lymphoma involving the tonsils and manifesting as glossopharyngeal neuralgia that was refractory to all treatment approaches tried,including opioids and neuro- modulation. The second case involved a patient diagnosed with essential glossopharyngeal neuralgia that was also resistant to drug treatment. The PRF procedure was per- formed in the operating room on an outpatient basis, under fluoroscopic guidance and with conventional monitoring. No perioperative events were reported. RESULTS: The treatment was effective for both patients, leading to decreases in visual analog scale pain reports between 5 and 7 points that were maintained over 6 months, although improvement for the patient with essential neuralgia was less intense and of shorter duration. Overall self-reported improvement assessed subjectively 6 months after PRF was 75%for the patient with Hodgkin ’s lymphoma and 50%for the patient with essential neuralgia, for whom a second PRF procedure was scheduled. Neither patient suffered complications or side effects that were potentially attributable to the procedure. CONCLUSIONS: PRF seems to be a safe, effective approach to treating neuralgia of the glossopharyngeal nerve, whether the condition is essential or secondary to another process. It is possible that if the condition is secondary, the clinical response may be greater in intensity and last longer

[Obstetric epidural analgesia: relationship between obstetric variables and the course of labor]. / Analgesia epidural obstétrica: relación con diversas variables obstétricas y con la evolución del parto.

OBJECTIVES: To analyze the relationship between epidural analgesia and diverse obstetric and fetal variables as well as the impact of epidural analgesia on the rates of instrumental and cesarean delivery. PATIENTS AND METHODS: Observational study of women who gave birth at Fundación Hospital Alcorcón over a period of 3 years. All the women were offered obstetric epidural analgesia based on 0.0625% bupivacaine plus 2 microg/mL of fentanyl. The following data were recorded: age, nulliparity (yes/no) administration of epidural analgesia (yes/no), induction of labor (yes/no), stimulation of uterine activity with oxytocin (yes/no), type of delivery, fetal weight, duration of dilation, duration of expulsion, cause of cesarean. RESULTS: The records of 4364 women were gathered. The percentages of inductions, nulliparas, oxytocin stimulation, and fetal weight greater than 4 kg and less than 2.5 kg were higher among women taking epidural analgesia. The age of women who received epidurals was significantly lower. The durations of dilation and expulsion were longer among women receiving epidural analgesia, and epidural analgesia was associated with greater risk of instrumental and cesarean deliveries. The significant increase in administration of epidural blocks over the 3-year period of the study was not accompanied by an increased rate of instrumentally assisted deliveries or cesareans. CONCLUSIONS: It is difficult to evaluate the real influence of epidural analgesia on certain aspects of labor and its evolution. The strength of the association between epidural analgesia and greater risk of increased rates of instrumental and cesarean deliveries may be influenced by factors not considered in the present study.

Analgesia epidural obstétrica: relación con diversas variables obstétricas y con la evolución del parto / Obstetric epidural analgesia: relationship between obstetric variables and the course of labor

OBJETIVO: Analizar la relación entre la analgesia epidural y diversas variables obstétrico-fetales, así como su posible repercusión sobre la tasa de partos instrumentales y cesáreas. PACIENTES Y MÉTODOS: Estudio observacional que incluyó a todas las mujeres que dieron a luz en la Fundación Hospital Alcorcón durante un período de 3 años. Se ofertó la administración de analgesia epidural -basada en una perfusión de bupivacaína al 0,0625 por ciento más fentanilo a 2 µg/ml- a todas las gestantes. Se recogieron los siguientes parámetros: edad, nuliparidad (sí/no), administración de analgesia epidural (sí/no), inducción del parto (sí/no), estimulación de la actividad uterina con oxitocina (sí/no), tipo de parto, peso fetal, duración de la dilatación, duración del expulsivo, y causa de cesárea. RESULTADOS: Se recogieron los datos de 4.364 gestantes. El porcentaje de inducciones, nulíparas, partos estimulados con oxitocina y gestantes con fetos de peso mayor de 4.000 g e inferior a 2.500 g fue superior entre las mujeres con analgesia epidural; la edad de las mujeres que la recibieron fue significativamente menor. La duración de los períodos de dilatación y expulsivo fue más larga entre las mujeres con analgesia epidural. Ésta también se asoció a un mayor riesgo de parto instrumental y cesárea. El incremento significativo en la administración de bloqueo epidural a lo largo de los 3 años del estudio no se acompañó de aumento de la tasa de partos instrumentales y cesáreas. CONCLUSIONES: Resulta complicado evaluar la influencia real de la analgesia epidural sobre determinados aspectos del parto así como sobre la evolución del mismo. La magnitud de la asociación entre la analgesia epidural y el mayor riesgo de tasa de partos instrumentales y cesáreas pudo estar influida por factores no considerados en el presente estudio (AU)

Anaesthesia-related diplopia after cataract surgery.

BACKGROUND: We studied the incidence and clinical characteristics of persistent diplopia related to anaesthesia for cataract surgery in a general hospital. METHODS: This was a retrospective review of anaesthesia for 3587 cataract surgeries. Of all the cases of diplopia referred to the ocular motility clinic after cataract surgery, those involving anaesthesia-related diplopia lasting longer than 1 month were studied. RESULTS: During the study period, 3450 cataract surgeries were performed by phacoemulsification and 137 by extracapsular extraction. Retrobulbar block was used in 2024 cases, peribulbar block in 98, topical anaesthesia in 1420 and general anaesthesia in 43. Twenty-six cases of persistent diplopia were found (0.72% incidence), nine of which (0.25%) were considered to be related to anaesthetic factors; five of the latter involved the left eye. Five were caused by paresis of the inferior rectus muscle and three by fibrosis. In one patient, the inferior oblique muscle was affected. Anaesthesia was by retrobulbar block in eight cases (0.39%) and by peribulbar block in one. No diplopia was found in patients who had topical or general anaesthesia. Treatment was with surgery in two patients and with prisms in six. One patient continues to be studied. CONCLUSIONS: Persistent diplopia can occur after cataract surgery using retrobulbar block predominantly through direct damage to the inferior rectus muscle. The overall incidence of anaesthesia-related diplopia in this series was 0.25%.

Principios generales de organización y gestión clínica de un bloque quirúrgico / General principles for the clinical organization and management of a surgical unit

Debido al aumento de los costes y de la demanda asistencial, la gestión adecuada de los recursos es hoy día una exigencia a añadir a la práctica clínica eficaz. Los bloques quirúrgicos, por sus características especiales, son en este sentido motivo de especial preocupación.Aunque cada hospital puede ser objeto de estudio individualizado, los problemas de gestión en los bloques quirúrgicos son muchas veces comunes.Con el fin de aumentar su eficiencia, actualmente se tiende a reorganizar los bloques quirúrgicos dotándolos de un comité de quirófano, un director o coordinador médico y una normativa de funcionamiento, considerando el bloque quirúrgico como un sistema y no como la suma de componentes individuales. La actividad es gestionada por objetivos, como comienzo y final puntuales, flexibilidad en el uso de quirófanos, capacidad de reserva para cirugías no programadas, baja cancelación y buen rendimiento, siendo esencial el uso de indicadores de tiempo.Otros factores a tener en cuenta en la gestión del bloque quirúrgico son la universalización de la información, que debe ser veraz y actual, la implicación de colectivos como anestesia-reanimación, una programación realista y ajustada, el diseño y uso adecuado de los circuitos y el empleo de técnicas de mejora continua para la solución de dificultades. Algunos programas, como la cirugía mayor ambulatoria, la cirugía traumatológica u otras, pueden requerir un enfoque especial (AU)

[Combined subarachnoid-epidural technique for obstetric analgesia]. / Técnica combinada subaracnoidea-epidural para la analgesia obstétrica.

Combined spinal-epidural blockade for labor pain has enjoyed increasing popularity in obstetric anesthesia. The usual procedure is to use a single space and a single needle for dural puncture, inserting a spinal needle through an epidural needle followed by insertion of a catheter. A small dose of one or several substances (usually a lipophilic opioid and a local anesthetic) is first injected in the intrathecal space to provide rapid, effective analgesia with minimal muscle blockade. The epidural catheter is used if labor lasts longer than the spinal block, if the spinal block is insufficient, or in case of cesarean section. Combined spinal-epidural blockade is a safe, valid alternative to conventional epidural analgesia and has become the main technique for providing obstetric analgesia in many hospitals. The most widely-recognized advantage of the technique is high maternal satisfaction with rapid and effective analgesia. Mobility of the lower extremities is preserved and the mother is often able to walk. Because opioids are injected into the intrathecal space and because the technique is more invasive than standard epidural analgesia, the potential risk to mother and fetus increases.

Técnica combinada subaracnoidea-epidural para la analgesia obstétrica / Combined spinal-epidural analgesia in obstetrics

El uso del bloqueo combinado subaracnoideo-epidural para el dolor de parto ha cobrado cada vez mayor interés en la anestesia obstétrica. El procedimiento más habitual se efectúa en un solo espacio y con una única aguja y consiste en la realización de una punción dural -pasando una aguja espinal a través de una epidural- seguida de la introducción de un catéter epidural. Primero se administran pequeñas dosis de una o varias sustancias por vía intratecal (habitualmente un opiáceo liposoluble y un anestésico local) con el objetivo de conseguir una analgesia rápida y eficaz con un bloqueo muscular mínimo. El catéter epidural se aprovecha si el parto dura más que el bloqueo subaracnoideo, si éste no es completamente eficaz, y en caso de cesárea.El bloqueo combinado subaracnoideo-epidural constituye una alternativa válida y segura a la epidural convencional, y en muchos centros se ha convertido en el método principal de analgesia obstétrica. La ventaja más aceptada de esta técnica es su alta satisfacción materna debido a su rapidez y eficacia analgésica y a que preserva la movilidad de las piernas, que en muchas ocasiones hace posible la deambulación de la parturienta. El uso de opiáceos intratecales y el hecho de ser una técnica más invasiva que la epidural estándar conlleva mayores riesgos potenciales para la madre y el feto (AU)

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