Ética, nuevas formas de morir y donación de órganos / Ethics, new ways of dying and organ donation

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Less postoperative nausea and vomiting after propofol + remifentanil versus propofol + fentanyl anaesthesia during plastic surgery.

BACKGROUND: The effect of different opioids on postoperative nausea and vomiting (PONV) has not been conclusively determined yet, thus the aim of this study was to compare the incidence of PONV in propofol-anaesthetized patients receiving either fentanyl or remifentanil as opioid supplement. METHODS: Sixty ASA physical status I and II patients scheduled for plastic surgery gave their written informed consent for this prospective, randomized, double-blind study. Anaesthesia was induced with propofol, rocuronium and fentanyl (n = 30; 2 microg kg(-1)) or remifentanil (n = 30; 1 microg kg(-1)). After tracheal intubation, anaesthesia was maintained with propofol, oxygen in air and an infusion of the opioid studied, which was modified according to clinical criteria. Baseline postoperative analgesia was achieved with intravenous propacetamol + metamizol. Intravenous morphine was given if visual analogic scale (VAS) for pain was > or = 4 (scale 0-10) and metoclopramide was administered if a patient presented > or = 2 PONV episodes (nausea or vomiting) in less than 30 min. Postoperatively (2, 12 and 24 h), we registered VAS, rescue morphine consumption, number of patients with episodes of PONV and number of patients requiring metoclopramide. P < 0.05 was considered significant. RESULTS: There were no significant differences between groups in the demographic parameters, ASA physical status, propofol dose, VAS, and rescue morphine requirements. Fourteen patients in the fentanyl group and four in the remifentanil group presented PONV episodes 2-12 h postoperative hours' interval; (P < 0.05). Ten patients in the fentanyl group and four in the remifentanil group presented vomiting episodes in the same period (P < 0.05); and eight patients in the fentanyl group and one in the remifentanil group required metoclopramide; (P < 0.05). The number of postoperative PONV episodes were low, both in the 0-2-h period (n = 2 vs. n = 1, fentanyl and remifentanil, respectively) and in the 12-24-h period (n = 3 vs. n = 1). CONCLUSION: Propofol + fentanyl anaesthesia resulted in a higher incidence of PONV and requirements of antiemetic drugs in the period between 2 and 12 postoperative hours compared with propofol + remifentanil, in patients undergoing plastic surgery.

[Fentanyl or remifentanil to potentiate a single dose of rocuronium in patients anesthetized with propofol with evaluation by accelerometry]. / Potenciación de una dosis única de rocuronio por fentanilo o remifentanilo en pacientes anestesiados con propofol. Evaluación por acelerometría.

OBJECTIVE: To compare the increase in potency of a single dose of rocuronium during anesthesia with propofol combined with either fentanyl or remifentanil. PATIENTS AND METHODS: Forty patients scheduled for plastic surgery were distributed in 2 groups of 20 according to the opioid drug assigned: fentanyl or remifentanil. Induction with propofol was accomplished by computer-controlled infusion, with response measured in the adductor pollicis muscle. After calibration, a dose of 0.6 mg/Kg of rocuronium was infused. Anesthesia was maintained with propofol, oxygen in air, and an equipotent dose of either fentanyl or remifentanil, which was modified to maintain heart rate and systolic arterial pressure within 30% above or below baseline levels. Patient characteristics recorded were age, sex, height, weight, ASA class, type of surgery, and the propofol and opioid doses consumed. Intubation conditions and time to onset of action of rocuronium (T1), of recovery of the first response in a train of four (RT1), and of recovery of 25% of the first response or clinical duration. RESULTS: The groups were statistically similar in terms of demographic variables, type of surgery, propofol and opioid consumption, intubation conditions, and rocuronium T1 and RT1. Clinical duration of anesthesia was longer (p<0.05) in the remifentanil group (33.1 +/- 10 minutes) than in the fentanyl group (27.1 +/- 7.4 minutes). CONCLUSIONS: Remifentanil administered in combination with propofol for anesthesia does not affect time of onset of a single dose of 0.6 mg/Kg dose of rocuronium, but clinical duration of anesthesia is longer with remifentanil and propofol than with the fentanyl and propofol combination. The surgical and intubation conditions achieved with both combinations are adequate and similar.

Diagnóstico diferencial de meningitis postoperatoria tras anestesia subaracnoidea / Differential diagnosis of postoperative meningitis following subaracnoid anesthesia

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[Prolonged neuromuscular block after a single dose of vecuronium in a patient with undiagnosed polyneuropathy and steroid myopathy]. / Bloqueo neuromuscular prolongado tras dosis única de vecuronio en un paciente con polineuropatía y miopatía esteroide no diagnosticadas.

We report the case of a patient who had been receiving long-term corticoid therapy with undiagnosed polyneuropathy and steroid-related myopathy before experiencing prolonged neuromuscular blockade (lasting longer than 4 hours) after administration of a single dose of 0.08 mg/kg of vecuronium. Neuromuscular function was monitored by accelerometry with four-stimuli series. Many of the circumstances present in this case -such as prior administration of succinylcholine, the use of an inhaled anesthetic, kidney insufficiency and cyclosporin therapy- have been associated with increased duration of blockade induced by neuromuscular blockers, although durations reported have been shorter than that experienced by our patient. After electromyography and muscle biopsy, polyneuropathy and steroid-related myopathy were diagnosed. We conclude that neuromuscular blockers should be administered with extreme caution to patients with polyneuropathy and those undergoing long-term corticoid therapy, in order to prevent prolonged neuromuscular blockade.

[Comparison of sevoflurane and propofol in the maintenance of and recovery from anesthesia]. / Comparación entre sevoflurano y propofol en el mantenimiento y recuperación de la anestesia.

OBJECTIVE: To compare the recovery of patients after anesthesia with sevoflurane or propofol during open urological surgery or lumbar column surgery of intermediate duration. PATIENTS AND METHODS: Thirty-six ASA I, II or II patients were enrolled prospectively and randomly assigned to two groups to receive either sevoflurane (n = 19) or proporol (n = 17). Anesthetic induction was accomplished with thiopental, fentanil and vecuronium. During anesthetic maintenance a mixture of 60% nitrous oxide in oxygen plus the drug under study was adjusted to keep blood pressure and/or heart rate within +/- 20% of baseline. After surgery we recorded time until eye opening, spontaneous breathing, extubation, orientation, and identification of parts of the body. Side effects were likewise recorded. In the postanesthetic recovery ward patient condition was assessed using the Aldrete scale, the Newman-Trieger test and a visual analog scale for postoperative pain. Consumption of analgesic during the first 24 h after surgery was monitored. RESULTS: No significant differences were found in demographic data; duration of anesthesia; anesthetic doses; or time until spontaneous breathing, extubation, orientation or identification of parts of the body. Only time until eye opening was shorter in the sevoflurane group than in the propofol group (6.9 +/- 3.3 vs 11.5 +/- 4.8 min; p < 0.05). No differences were recorded on scales reflecting intermediate-term recovery. Analgesic consumption and the incidence of side effects were similar in both groups. CONCLUSIONS: Sevoflurane and propofol are comparable for anesthetic maintenance in urological and neurological procedures of intermediate duration.

Compartment syndrome with severe rhabdomyolysis in the postoperative period following major vascular surgery.

We report a case of compartment syndrome with marked rhabdomyolysis in the immediate postoperative period following major vascular surgery. Early and aggressive treatment, based on intravenous fluids, sodium bicarbonate, mannitol and fasciotomy, resulted in satisfactory management of the patient and prevented the onset of severe complications, such as acute renal failure in a patient who presented several factors that predisposed him to this disorder.

[Cardiovascular effects of a single dose of propofol in coronary patients with good ventricular function]. / Efectos cardiovasculares de una dosis única de propofol en enfermos coronarios con buena función ventricular.

OBJECTIVES: To determine the cardiovascular effects of a single dose of propofol in coronary patients with good ventricular function. PATIENTS AND METHODS: Propofol 2 mg/kg-1 was administered to twenty coronary patients during dissection of the internal mammary artery in myocardial revascularization surgery. Heart rate (HR), systolic and diastolic systemic and pulmonary arterial pressure (SAP, DAP, SPAP and DPAP), central venous pressure, pulmonary capillary wedge pressure, cardiac output (CO), right ventricular ejection fraction, systemic and pulmonary vascular resistances (SVR and PVR), right and left ventricular stroke work index (RVSWI and LVSWI), rate-pressure product (RPP) and pressure-rate quotient (PRQ) were recorded prior to (baseline) and at 1, 3, 5, 10, 15, 20 and 30 min after administration of the drug. RESULTS: One minute after administration of the drug there was a maximum decrease in SAP (-26%), DAP (-17%), SVR (-22%), RVSWI (-23%), RPP (-24%) and PRQ (-22%) (p < 0.001 in all cases) and this continued to be significant throughout the study for SAP, DAP and RPP, and for SVR, RVSWI and PRQ at times 15, 3 and 10, respectively. There were no significant changes in HR, CO, ventricular filling pressures and the remaining variables during the study. CONCLUSIONS: Propofol produces the greatest decrease in systemic arterial pressure 1 min after administration and this decrease was maintained during the 30 min that our study lasted, due to a decrease in SVR but not in CO or in ventricular filling pressures.

Haemodynamic effects of propofol during coronary artery bypass surgery.

We have studied the haemodynamic effects of a bolus injection of propofol 2 mg kg-1 in 20 patients with good ventricular function undergoing aortocoronary bypass surgery. Heart rate and systolic and diastolic systemic (SAP, DAP) and pulmonary arterial pressures, central venous pressure, pulmonary artery wedge pressure, cardiac output (CO), right ventricular ejection fraction, systemic (SVR) and pulmonary vascular resistances and left ventricular stroke work index (LVSWI) were measured before and at 1, 3, 5, 10, 20 and 30 min after the administration of propofol. At 1 min, maximum decreases were detected in SAP (-26%, P < 0.001), DAP (-17%, P < 0.001), SVR (-22% P < 0.001) and LVSWI (-23%, P < 0.001). The other variables studied showed no significant variations at any time during the study. We conclude that propofol reduces systemic arterial pressure by a decrease in SVR, but not in CO or ventricular filling pressures.

Effects of propofol on mean arterial pressure and systemic vascular resistance during cardiopulmonary bypass.

This study was designed to evaluate the effects of propofol on mean arterial pressure (MAP) and systemic vascular resistance (SVR) during cardiopulmonary bypass (CPB). Twenty patients were divided randomly for administration of 2 mg.kg-1 propofol (group Propofol, n = 10) or 0.9% saline solution (group Control, n = 10) during CPB. The two groups were comparable with respect to sex, age, height, type of surgery (valvular or coronary), arterial hypertension and preoperative antihypertensive treatment. Only their weight and body surface area were significantly different (control group vs propofol group, respectively: 78.5 +/- 14.4 vs 64.7 +/- 7.7 kg, P < 0.05; and 1.85 +/- 0.2 vs 1.68 +/- 0.13 m2, P < 0.05). MAP, SVR and SVR index were significantly lower in the propofol group than in the control group at 10, 15 and 20 min of study, suggesting that the hypotensive effect of a bolus injection of propofol is due, at least in part, to a direct decrease in the SVR.

[Plasma histamine levels after the administration of atracurium or pancuronium in patients undergoing general anesthesia]. / Niveles plasmáticos de histamina tras la administración de atracurio o pancuronio en pacientes sometidos a anestesia general.

OBJECTIVES: To compare the release of histamine induced by atracurium and pancuronium. MATERIAL AND METHODS: We studied 20 patients ASA III undergoing vascular surgery under etomidate anesthesia. Patients were randomly treated with either 0.5 mg/kg of atracurium or 0.1 mg/kg of pancuronium as muscle relaxant agents. Plasma histamine concentration, heart rate, arterial blood pressure, PaO2, and PaCO2 were measured at the basal state and 1.2 and 5 min after administration of the muscle relaxant drug. RESULTS: Plasma histamine concentration at baseline were 0.691 +/- 0.6 ng/ml in the atracurium group and 0.756 +/- 0.612 ng/ml in the pancuronium group. These levels raised up to 2.748 +/- 6.278 ng/ml (atracurium) and 2.553 +/- 5.454 ng/ml (pancuronium). These differences were not statistically significant. The course of the remaining parameters studied in these patients was also comparable between the two groups. There were no clinical manifestations associated with the release of histamine. CONCLUSIONS: Plasma levels of histamine after administration of atracurium were not significantly different from those induced by pancuronium.