Calidad de la recuperación posquirúrgica tras cirugía de mama. Anestesia general combinada con bloqueo paravertebral versus bloqueo del espacio serrato-intercostal / Quality of postoperative recovery after breast surgery. General anaesthesia combined with paravertebral versus serratus-intercostal block

Introducción. La cuantificación de la calidad de la recuperación posquirúrgica destaca entre los indicadores de calidad utilizados en clínica. Ello es más importante aún tras cirugía oncológica. Nuestro objetivo fue evaluar la calidad de la recuperación tras cirugía no reconstructiva de mama tras anestesia general combinada con bloqueo paravertebral versus bloqueo del espacio serrato-intercostal en el postoperatorio inmediato y tardío. Material y métodos. Estudio observacional prospectivo en 60 pacientes programadas para cirugía no reconstructiva de mama en un periodo de 6 meses bajo anestesia combinada general y bloqueo paravertebral (25 pacientes) o bloqueo del espacio serrato-intercostal (35 pacientes). La calidad de la recuperación postanestésica se midió con la escala Postoperative Quality Recovery Scale, valorando los dominios fisiológico, nociceptivo, emocional, autonomía, cognitivo y estado general en diferentes momentos: basal (previo a cirugía), 15min tras finalizar la intervención, al alta hospitalaria y al mes postintervención. Resultados. Se consiguió una recuperación total del 95,93% en el postoperatorio inmediato (15 min unidad de recuperación postoperatoria [URPA]), del 99,07% al alta y del 99,25% al mes de la intervención. No se encontraron diferencias significativas entre ambos grupos ni en la puntuación total ni en las diversas áreas medidas por la escala. Conclusiones. Con la técnica descrita se ha objetivado una alta puntuación de recuperación con la Postoperative Quality Recovery Scale, que posibilitaría el alta en el postoperatorio inmediato y la vuelta precoz a la vida activa habitual. En ambos grupos se observó un ahorro de opioides y una recuperación excelente de todos los dominios evaluados, sin diferencias significativas (AU)

Introduction. The quality of postoperative recovery is one of the most important among all the quality indicators used in clinical situations. This is even more important after cancer surgery. Our aim was to evaluate this after non-reconstructive breast surgery under general anesthesia and paravertebral blockade or serratus-intercostal plane blockade, in the early and late post-operative period. Material and methods. A prospective observational study was conducted on 60 patients (25 paravertebral blockade group and 35 serratus-intercostal plane blockade group) scheduled for non-reconstructive breast surgery during a 6 month period. Every patient received general anaesthesia and were randomised to receive either paravertebral blockade or serratus-intercostal plane blockade. The quality of post-anaesthetic recovery was quantified by Postoperative Quality Recovery Scale, which is used to assess physiological, nociceptive, emotional, autonomy, cognitive and general state domains at different times: baseline (before surgery), 15min after the end of surgery, at discharge to home, and one month after surgery. Results. A total recovery of 95.93% was achieved in the early postoperative period (15min PACU), 99.07% at discharge to home, and 99.25% at one month after the intervention. No significant differences were found between groups in total score or in each evaluated area. Conclusions. A progressive improvement was observed in the scores assessed with the Postoperative Quality Recovery Scale, reaching values that would allow the discharge to home and early return to usual active life from the immediate postoperative period, with no significant differences between the 2 analgesic techniques. Savings in opioid use and the excellent recovery were observed in all measured domains observed (AU)

Quality of postoperative recovery after breast surgery. General anaesthesia combined with paravertebral versus serratus-intercostal block. / Calidad de la recuperación posquirúrgica tras cirugía de mama. Anestesia general combinada con bloqueo paravertebral versus bloqueo del espacio serrato-intercostal.

INTRODUCTION: The quality of postoperative recovery is one of the most important among all the quality indicators used in clinical situations. This is even more important after cancer surgery. Our aim was to evaluate this after non-reconstructive breast surgery under general anesthesia and paravertebral blockade or serratus-intercostal plane blockade, in the early and late post-operative period. MATERIAL AND METHODS: A prospective observational study was conducted on 60 patients (25 paravertebral blockade group and 35 serratus-intercostal plane blockade group) scheduled for non-reconstructive breast surgery during a 6 month period. Every patient received general anaesthesia and were randomised to receive either paravertebral blockade or serratus-intercostal plane blockade. The quality of post-anaesthetic recovery was quantified by Postoperative Quality Recovery Scale, which is used to assess physiological, nociceptive, emotional, autonomy, cognitive and general state domains at different times: baseline (before surgery), 15min after the end of surgery, at discharge to home, and one month after surgery. RESULTS: A total recovery of 95.93% was achieved in the early postoperative period (15min PACU), 99.07% at discharge to home, and 99.25% at one month after the intervention. No significant differences were found between groups in total score or in each evaluated area. CONCLUSIONS: A progressive improvement was observed in the scores assessed with the Postoperative Quality Recovery Scale, reaching values that would allow the discharge to home and early return to usual active life from the immediate postoperative period, with no significant differences between the 2 analgesic techniques. Savings in opioid use and the excellent recovery were observed in all measured domains observed.

Sangre y Cirugía. EStrategia de Ahorro en cirugía cardiaca / Blood and Surgery. Strategic saving in cardiac surgery

El incremento de intervenciones quirúrgicas y su mayor complejidad y agresividad, especialmente en cirugía cardiovascular y trasplantes, junto con el envejecimiento de la población ha supuesto un considerable aumento de la demanda de transfusión sanguínea y derivados hemáticos. Los riesgos médicos inherentes al uso de sangre homóloga, el rechazo por motivaciones personales, éticas o creencias religiosas y una insuficiente disponibilidad de hemoderivados consecuencia de la escasezde donaciones, ha condicionado la necesidad del desarrollo de procesos de ahorro de sangre en cirugía y la búsqueda de técnicas alternativas a la transfusión. Problemática que alcanza su máxima expresión en cirugía cardiaca bajo circulación extracorpórea, como consecuencia del alto consumo de sangre de los enfermos cardiológicos intervenidos. Con la experiencia que aporta un promedio de quinientas cirugías anuales de corazón se realiza una revisión sobre las diferentes medidas y procedimientos asociados al ahorro de sangre en cirugía, especialmente en cirugía cardiovascular (AU)

The increase in the number of operations and their greater complexity and aggressiveness, especially in cardiovascular surgery and transplants, together with the aging of the population, has entailed an increase in the demand for transfusion and haematological derivates. The inherent medical risks of homolog blood usage, rejection for personal motivations, ethical and religious beliefs and insufficient availability of haematological derivates as a consequence of the shortage of donations, have conditioned the necessity for the development of processes for saving blood during surgery and the search for alternative techniques to transfusion. This is a problem which has its highest repercussions in cardiac surgery with cardio-pulmonary by-pass because of the high consumption of blood of patients undergoing cardiac surgery. With the experience of approximately 500 operations per year a review of the different measures and procedures associated with saving blood in surgery has been carried out, especially with regard to cardiovascular surgery (AU)

Analgo-sedación consciente con midazolam y fentanilo oral transmucosa (OTFC) en niños / Conscious analgo-sedation with midazolam and fentanyl (OTFC) in children

Con elevada frecuencia, a los niños afectos de leucemias y otras enfermedades neoplásicas se les deben realizar una seriede pruebas diagnósticas y de tratamientos (punciones demédula ósea, administración intratecal de medicamentos…) que producen dolor y que aumentan considerablemente el disconforty sufrimiento o impiden la realización de las técnicas.La realización de técnicas de sedación consciente con fármacos utilizados por vía oral como el fentanilo (Citrato de Fentanilo Oral Transmucosa -OTFC-) junto con midazolam, y el empleo de anestésico local en el lugar de punción, puedehacer que estas técnicas dolorosas sean bien toleradas por parte del paciente, evitando así el dolor y disminuyendo la angustia, el miedo y sufrimiento que representa para los niñosla realización de cualquier prueba o tratamiento (AU)

Multiple bone marrow aspirations and lumbar punctures are performed on children with leukaemia and other neoplastic disorders during the course of their illnesses. These procedures may give rise to considerable pain and distress inchildren.Fentanyl, a short-acting potent synthetic opioid, can produce sedation through oral transmucosal (Oral Transmucosal Fentanyl Citrate -OTFC-) administration. The combination of OTFC and oral midazolam was a useful conscious sedation technique for painful procedures, such as lumbar punctures and bone marrow aspirations in this patients (AU)

Tratamiento del dolor en un caso de osteogénesis imperfecta tipo III / Treatment of pain in a case of osteogenesis imperfecta tipe III

No disponible

[Hypertension emergency during surgery of renal carcinoma associated with non-diagnosed pheochromocytoma]. / Emergencia hipertensiva durante la cirugía de un carcinoma renal asociado a feocromocitoma no diagnosticado.

OBJECTIVE: To present an uncommon association of renal carcinoma with an undiagnosed ipsilateral pheochromocytoma that caused severe cardiovascular disorders during surgical treatment of the renal carcinoma, and emphasize the need for careful assessment of these adrenal nodules before resection although they may appear to be clinically irrelevant. METHODS: A 61-year-old male with mild arterial hypertension controlled with drug therapy for 40 years was diagnosed as having a right renal hypernephroma and a probable adrenal adenoma by IVP, abdominal ultrasound, CT, bone scintiscan and renal arteriography. Preoperative values were within the normal limits. The patient developed severe hypertension intraoperatively, which was controlled by administration of lidocaine, nitroglycerine, sodium nitroprusside and labetalol. Surgery was interrupted and completed when the patient was stable. RESULTS: The pathological analysis showed clear cell renal adenocarcinoma and pheochromocytoma. Postoperative evaluation showed dopamine, adrenaline, noradrenaline and vanilmandelic acid were normal. A 131 MIBG scan was normal. CONCLUSION: Although an adrenal mass may appear to be clinically irrelevant, a careful study should be performed to discard a functioning tumor and to avoid the serious complications that might arise during surgery.

[Core and cutaneous thermal changes in the upper limb after anesthesia induction]. / Cambios térmicos centrales y cutáneos en el miembro superior después de la inducción anestésica.

OBJECTIVES: To describe and compare the core-cutaneous thermal and photoplethysmographic time-course effects after induction of general anesthesia with propofol, fentanyl and vecuronium. PATIENTS AND METHODS: We measured digital blood flow, core temperature and skin temperature in the upper limb (fingertip, forearm and upper arm) in 20 patients (10 men and 10 women, ASA-I) before anesthetic induction and 5, 10, 15 and 20 min after induction. Skin temperature changes were recorded with disposable thermocouples. Blood flow was recorded by digital photoplethysmography (PhPl) in the thumb. Anesthesia was provided without premedication, using propofol (3 mg.kg-1), fentanyl (0.1 mg) and vecuronium (0.1 mg.kg-1). After endotracheal intubation, anesthesia was maintained with oxygen-nitrous oxide and 0.1 mg of intravenous fentanyl at the tenth minute, without inhaled anesthetics. RESULTS: All patients showed intense, abrupt vasodilatation in the thumb with marked increases in PhPl (PhPl = 10.4 +/- 5.0 mV/V, at 5 min, p < 0.001) and fingertip temperature (TFingertip = 6.2 +/- 2.0 C, at 10 min, p < 0.001). However, skin temperature changes in the upper arm and forearm were moderate and slower (TForearm = 2.1 +/- 1.4 C, p < 0.01 and TUpper arm = 1.1 +/- 1.2 C, p < 0.01; at 20 min in both cases). A significant correlation was found only between PhPl and TFingertip (r = 0.55, p < 0.001). CONCLUSIONS: Anesthetic induction with propofol, fentanyl and vecuronium produces cutaneous vasodilatation in the upper limb unequally: the greatest increase in skin temperature occurs at the fingertip, while forearm and upper arm temperatures increase less. We think that skin vasodilatation in peripheral distal areas may play an important role in redistributing core heat during anesthesia.

Exagerada respuesta cardiovascular durante la escisión de un hipernefroma / Exaggerated cardiovascular response during excision of a hypernephroma

No disponible

Cambios térmicos centrales y cutáneos en el miembro superior después de la inducción anestésica / Core and cutaneous thermal changes in the upper limb after anesthetic induction

Objetivos. Describir y comparar los cambios térmicos (centrales y cutáneos en el miembro superior) y fotopletismográficos después de la inducción anestésica con fentanilo, propofol y vecuronio. Pacientes y métodos. Hemos medido las variaciones de la temperatura central y cutáneas del miembro superior (dedo, antebrazo y brazo), así como las variaciones del flujo sanguíneo digital, en 20 pacientes adultos, ASA-I (10 varones y 10 mujeres), cada 5 min durante los 20 min iniciales de la anestesia general. La temperatura se midió con termosondas desechables (esofágicas y cutáneas) conectadas a un termómetro digital y el flujo sanguíneo digital mediante fotopletismografía digital. La anestesia se realizó sin premedicación con: propofol (3 mg - kg-1), fentanilo 0,1 mg y vecuronio 0,1 mg - kg-1. El mantenimiento anestésico se realizó con: N2O-O2 (75/35 por ciento) y fentanilo 0,1 mg a los 10 min, sin anestésicos inhalatorios. Resultados. La inducción anestésica se asoció con vasodilatación digital intensa y rápida, con un incremento marcado de la amplitud de la onda fotopletismográfica (AOFP) ( AOFP = 10,4 ñ 5,0 mV/V, a los 5 min; p < 0,001) y de la temperatura cutánea del dedo ( Tdedo = 6,2 ñ 2,0 °C, a los 10 min; p < 0,001). Sin embargo, los cambios de la temperatura cutánea en el brazo y antebrazo fueron moderados y lentos ( Tantebrazo = 2,1 ñ 1,4 °C; p < 0,01 y Tbrazo = 1,1 ñ 1,2 °C; p < 0,01; en ambos casos a los 20 min). Solamente encontramos una correlación significativa entre la AOFP y la Tdedo: r = 0,55 (p < 0,001).Conclusiones. La inducción anestésica con propofol, fentanilo y vecuronio produce vasodilatación cutánea en el miembro superior, pero distribuida de forma desigual; el mayor incremento de la temperatura cutánea sucede en los dedos, mientras que el brazo y el antebrazo presentan variaciones térmicas menores. Creemos que la vasodilatación de las áreas periféricas distales puede tener un papel importante en la redistribución del calor central durante la anestesia (AU)

No disponible

Estudio de la eritropoyetina sérica en pacientes con cáncer colorrectal / Serum erythropoietin response in patients with colorectal cancer

Introducción. Los pacientes con tumores sólidos avanzados desarrollan frecuentemente anemia. El mecanismo más importante en la patogenia de la anemia es el descenso de la eritropoyesis. Ésta puede ser debida a un descenso de la síntesis de eritropoyetina, una menor actividad de ésta sobre la médula ósea o una respuesta disminuida de la médula ósea a la eritropoyetina. El objetivo de este estudio es analizar la tasa de eritropoyetina en pacientes con cáncer colorrectal poco avanzado, comparándola con un grupo control. Pacientes y métodos. Hemos estudiado a 20 pacientes con cáncer colorrectal, que fueron diagnosticados por estudio radiológico y/o endoscópico con biopsia, y a un grupo control de 20 sujetos sanos. Tras el diagnóstico se determinaron los siguientes parámetros séricos: hemoglobina, hematócrito, hematíes y eritropoyetina. El análisis estadístico se realizó con el test de la t de Student y las correlaciones entre las variables con el test de Pearson (r). Resultados. Los parámetros hematológicos fueron inferiores en el grupo del cáncer colorrectal, aunque se hallaban dentro de la normalidad. La tasa de eritropoyetina en este grupo se encontraba significativamente aumentada (p < 0,01), existiendo una correlación entre la eritropoyetina y la hemoglobina (r = 0,59; p < 0,01), y entre la eritropoyetina y el hematócri-to (r = 0,61; p < 0,01).Conclusiones. Las concentraciones de eritropoyetina están muy elevadas en los pacientes con cáncer colorrectal, a pesar de no presentar una anemia evidente, pudiendo deberse este incremento a otras causas (factores tumorales, citocinas, etc.) (AU)

Effect of clozapine on the oxygen, glucose uptake and oxidative phosphorylation of rat brain in vitro.

Clozapine, a neuroleptic drug isostere of the phenothiazines, at a dose of 10(-3) M decreased the oxygen consumption of rat brain slices and homogenates. However, this effect was not potentiated when brain slices were incubated with 100 mM potassium or in a calcium-free medium, the uncoupling of brain mitochondrial oxidative phosphorylation by 10(-3) M clozapine can also be rulled out.

Effect of dibenzepin hydrochloride on the oxygen, glucose uptake and oxidative phosphorylation of rat brain in vitro.

Dibenzepin hydrochloride (10(-3) M) decreases the oxygen uptake of whole brain homogenates and uncouples brain mitochondrial oxidative phosphorylation. At the same concentration this drug inhibits oxygen uptake of rat brain slices when calcium is absent in the incubation or then contains an excess of potassium.

[Effect of dextropoxyphene on oxidative phosphorylation in brain and liver of rat (author's transl)]. / Efecto del dextropropoxifeno sobre el consumo de oxígeno y fosforilización oxidativa de cerebro e higado de rata in vitro.

Dextropropoxyphene hydrochloride increases significantly oxygen uptake in whole rat brain homogenates at concentrations of 10(-4), 10(-5), 10(-6) M when using sucrose 0.25 M pH 7.4 as incubation medium. If substrate and cofactors are added to the sucrose, this drug decreases oxygen uptake at 10(-3) M concentration in brain and liver rat homogenates, and it also decreases significantly the P:O quotient of mitochondria in both organs by uncoupling the oxidative phosphorylation.