[Influence of neostigmine on the course of neuromuscular blockade with rocuronium or cisatracurium: a randomized, double-blind trial]. / Influencia de la neostigmina en la evolución clínica del bloqueo neuromuscular de rocuronio y cisatracurio. Estudio aleatorizado doble ciego.

OBJECTIVES: To compare the time-course of neuromuscular blockade with rocuronium or cisatracurium during intravenous anesthesia, in terms of both the time to spontaneous recovery or time to reversal after administration of neostigmine. MATERIAL AND METHODS: Patients classified as ASA 1-2 were randomized to receive blinded administration of a single injection of twice the 95% effective dose of rocuronium or cisatracurium for general anesthesia, and then neostigmine plus atropine at recovery of the first train-of-4 (TOF) twitch at 5% or 25%, or normal saline solution as placebo at recovery of the first TOF twitch at 25%. The neuromuscular blockade was monitored by acceleromyography. Intergroup comparisons were carried out by Student t test and analysis of variance. RESULTS: Sixty patients were enrolled. Mean (SD) time to onset was faster with rocuronium at (1.04 [0.32] minutes) compared with cisatracurium at (2.58 [0.81] minutes) and duration was shorter: time to the first twich at 5% was 30 (6.4) minutes with rocuronium and 38.1 (9.7) minutes with cisatracurium. The total duration of blockade (time to the 80% TOF ratio) was also shorter with rocuronium when the neuromuscular blockade was reversed, but there were no differences in the time to block reversal when neostigmine was not used: 62 (18.9) minutes to recovery from the rocuronium blockade vs 66.96 (15.9) minutes to recover from a cisatracurium blockade. A high percentage of patients had less than an 80% TOF ratio at 60 and 90 minutes of administration of the neuromuscular blockerswhen reversal was not used (patients receiving rocuronium, 60% at 60 minutes, and 20% at 90 minutes; patients receiving cisatracurium, 80% at 60 minutes, and 40% at 90 minutes). CONCLUSION: Not antagonizing a rocuronium- or cisatracurium-induced neuromuscular blockade in surgical procedures lasting less than 90 minutes can lead to a high percentaje of residual blockade (TOF ratio <80%).

Influencia de la neostigmina en la evolución clínica del bloqueo neuromuscular de rocuronio y cisatracurio. Estudio aleatorizado doble ciego / Influence of neostigmine on the course of neuromuscular blockade with rocuronium or cisatracurium: a randomized, double-blind trial

OBJETIVOS: Comparar la evolución y la recuperación,tanto espontánea como tras reversión con neostigmina,del bloqueo neuromuscular (BNM) de rocuronio y cisatracuriodurante una anestesia intravenosa.MATERIAL Y MÉTODO: Pacientes ASA 1-2 fueron randomizadosde forma ciega para recibir una dosis única2ED95% de rocuronio o de cisatracurio durante una anestesiageneral intravenosa, y recibir neostigmina más atropinaa la recuperación de la primera respuesta del TOF(T1) del 5% o del 25%, o recibir placebo (suero fisiológico)a T1 25%. La monitorización del BNM se llevó a cabomediante aceleromiografía. La comparación entre gruposse realizó mediante las pruebas T student y ANOVA.RESULTADOS: Se incluyeron 60 pacientes en el estudio.Rocuronio presentó unos tiempos de instauración(1,04±0,32 vs 2,58±0,81 min) y duración Dosis-T1 5%(30±6,4 vs 38,1±9,7 min) significativamente inferiores acisatracurio. La duración total del bloqueo (Dosis-TOFratio 80%) también fue inferior para rocuroniocuando se usó reversión del BNM, pero no observamosdiferencias cuando no se utilizó reversión con neostigmina(62 ±18,9 min rocuronio vs 66,96±15,9 min cisatracurio).Para ambos fármacos, cuando no se utilizó reversióndel BNM, un alto porcentaje de pacientes mantuvoun TOFratio<80% a los 60 y 90 min de administrado elbloqueante (Rocuronio TOFratio<80%: 60% 60 min,20% 90 min; Cisatracurio TOFratio<80%: 80% 60 min,40% 90 min).CONCLUSIÓN: No revertir el BNM de rocuronio o cisatracurioen procesos anestésico-quirúrgicos inferiores a90 min puede llevarnos a un alto porcentaje de pacientescon BNM residual (TOFratio<80%) (AU)

OBJECTIVES: To compare the time-course of neuromuscular blockade with rocuronium or cisatracurium during intravenous anesthesia, in terms of both the time to spontaneous recovery or time to reversal after administration of neostigmine. MATERIAL AND METHODS: Patients classified as ASA 1-2 were randomized to receive blinded administration of a single injection of twice the 95% effective dose of rocuronium or cisatracurium for general anesthesia, and then neostigmine plus atropine at recovery of the first train-of-4 (TOF) twitch at 5% or 25% or normal saline solution as placebo at recovery of the first TOF twitch at 25%. The neuromuscular blockade was monitored by acceleromyography. Intergroup comparisons were carried out by Student t test and analysis of variance. RESULTS: Sixty patients were enrolled. Mean (SD) time to onset was faster with rocuronium at (1.04-0.32 minutes) compared with cisatracurium at (2.58-0.81 minutes) and duration was shorter: time to the first twich at 5% was 30 (6.4) minutes with rocuronium and 38.1 (9.7) minutes with cisatracurium. The total duration of blockade (time to the 80% TOF ratio) was also shorter with rocuronium when the neuromuscular blockade was reversed, but there were no differences in the time to block reversal when neostigmine was not used: 62 (18.9) minutes to recovery from the rocuronium blockade vs 66.96 (15.9) minutes to recover from a cisatracurium blockade. A high percentage of patients had less than an 80% TOF ratio at 60 and 90 minutes of administration of the neuromuscular blockerswhen reversal was not used (patients receiving rocuronium, 60% at 60 minutes, and 20% at 90 minutes; patients receiving cisatracurium, 80% at 60 minutes, and 40% at 90 minutes). CONCLUSION: Not antagonizing a rocuronium- or cisatracurium-induced neuromuscular blockade in surgical procedures lasting less than 90 minutes can lead to a high percentaje of residual blockade (TOF ratio <80%) (AU)

[Prolonged coma due to fat embolism syndrome after fracture of the femur]. / Coma prolongado por síndrome de embolia grasa tras fractura de fémur.

A 24-year-old male came to the emergency department with a diaphyseal fracture of the femur resulting from a motorcycle accident. Neurological deterioration was progressive, although a computed tomography scan was normal. Endotracheal intubation for mechanical ventilation was necessary. His condition progressed to sepsis and multiorgan failure before resolving. Magnetic resonance images of the brain suggested a fat embolism. The presence of a patent foramen ovale was investigated. The patient remained in a state of coma vigil for 3 months after the accident. After ruling out other more likely causes of neurological deterioration after trauma with fractures, fat embolism should be suspected. The prognosis for the neurological manifestations of fat embolism syndrome are generally good. Severe cases suggest massive (paradoxical) embolization of the brain and are associated with a patent foramen ovale. Early diagnosis will identify the patient at high surgical risk. A favorable course and outcome have been reported with preoperative closure of the foramen ovale.

Coma prolongado por síndrome de embolia grasa tras fractura de fémur / Prolonged coma due to fat embolism syndrome after fracture of the femur

Un varón de 24 años presentó, tras sufrir fracturadiafisaria de fémur por accidente de moto, un deterioroneurológico progresivo con tomografía computerizadacerebral normal, que obligó a la intubación endotraqueale instauración de ventilación mecánica. Evolucionóhacia un cuadro de sepsis y disfunción multiorgánica,que se resolvió. La resonancia magnética cerebralmostró imágenes sugestivas de embolismo graso y seinvestigó la presencia de foramen oval permeable. Elpaciente permanecía en estado de coma vigil tres mesesdespués del accidente.Tras descartar otras causas más probables, el deterioroneurológico tras un traumatismo con fracturas, debehacernos sospechar un embolismo graso. Las manifestacionesneurológicas del síndrome de embolia grasa tienen,por lo general, buen pronóstico. Los casos gravessugieren una embolización cerebral (paradójica) masivay se asocian a la existencia de un foramen oval permeable.El diagnóstico precoz permite identificar al pacientecomo de alto riesgo para el tratamiento quirúrgico definitivo.Se ha descrito una evolución positiva con el cierrepreoperatorio del foramen oval

A 24-year-old male came to the emergency departmentwith a diaphyseal fracture of the femur resultingfrom a motorcycle accident. Neurological deteriorationwas progressive, although a computed tomography scanwas normal. Endotracheal intubation for mechanicalventilation was necessary. His condition progressed tosepsis and multiorgan failure before resolving. Magneticresonance images of the brain suggested a fat embolism.The presence of a patent foramen ovale was investigated.The patient remained in a state of coma vigil for 3months after the accident.After ruling out other more likely causes of neurologicaldeterioration after trauma with fractures, fat embolismshould be suspected. The prognosis for the neurologicalmanifestations of fat embolism syndrome aregenerally good. Severe cases suggest massive (paradoxical)embolization of the brain and are associated with apatent foramen ovale. Early diagnosis will identify thepatient at high surgical risk. A favorable course and outcomehave been reported with preoperative closure of theforamen ovale

Chronic pain in the spinal cord injured: statistical approach and pharmacological treatment.

We include in this article the results of a postal inquiry into chronic pain in SCI patients in Valencia (Spain), and our experience with their management. A mailed questionnaire including lesion and chronic pain data was sent to all of the 380 SCI patients who live in the region of Valencia. We received 202 answers, with 145 questionnaires being accurately answered and these were analysed for this study. The results show that chronic pain (that is, lasting more than 6 months) is very common (65.5%). The most frequent type was deafferentation pain (phantom pain), described as burning or a painful numbness. Since 1988 we have been treating a sample of 33 patients suffering from resistant pain according to the following therapies: 1 amitriptyline + clonazepam+NSAID (nonsteroidal antiinflammatory drugs); 2 amitriptyline + clonazepam + 5-OH-tryptophane + TENS (transcutaneous electrical nerve stimulation); 3 amitriptyline + clonazepam + SCS (spinal cord stimulation); 4 morphine, by continuous intrathecal infusion. After almost 4 years using these therapies we can affirm that the results regarding analgesia reached 80% in all cases, and that morphine used by intrathecal route is very safe and useful in selected patients.

[A classic case of Ludwig's angina]. / Un caso clásico de angina de Ludwig.

The AA. have the chance to review the etiology, the clinic and the management of this risky process, through a characteristic Ludwig's angina of their own practice. A middle age man carrying an odontogenic inflammation developed a spreading infection into the deep neck tissues. The problem was successfully resolved with antibiotherapy and surgical drainage.