Time course and train-of-four fade of mivacurium block during sevoflurane and intravenous anaesthesia.

BACKGROUND AND OBJECTIVE: Volatile anaesthetics inhibit nicotinic acetylcholine receptors at clinically relevant concentrations with higher affinity for the neuronal nicotinic receptor. The inhibitory effects of propofol on nicotinic receptors have only been documented at supraclinical concentrations. The aim of this study was to determine recovery properties and train-of-four (TOF) fade of mivacurium during sevoflurane and propofol anaesthesia, in order to examine any differences both in the enhancement of the neuromuscular block (postjunctional effects) and in TOF fade (prejunctional effects). METHODS: Twenty ASA I-II adult patients were randomly allocated to maintenance of anaesthesia with sevoflurane (end-tidal concentration 2%) or propofol. Neuromuscular block was assessed by acceleromyography and a single dose of mivacurium (0.15 mg kg(-1)) was administered (in the sevoflurane group after 30 min of exposure to sevoflurane). We measured time for recovery of the first twitch of the TOF (T1) from 25-75%, time from 25% recovery of T1 to achieving a TOF ratio (TOFR) of 0.8, TOFR at 50%, 75% and 90% recovery of T1, and height of T1 at TOFR of 0.7 and 0.9. Data were tested using t-test for independent samples. RESULTS: Recovery times (mean (95% confidence interval, CI)) of mivacurium in the sevoflurane group (T1 25-75%, 11.3 (8.1-14.5) min; T1 25%-TOFR0.8, 19.1 (15.7-22.5) min) were significantly longer (P < 0.05) than in the propofol group (T1 25-75%, 6.5 (5.2-7.7) min; T1 25%-TOFR0.8, 11.3 (7.8-10.3) min). No differences were found in the relations between TOFR and T1 or vice versa, between the groups. CONCLUSIONS: Recovery times after a single dose of mivacurium were prolonged by sevoflurane compared with propofol but no differences in TOF fade were observed between the two anaesthetics.

[Acute lung injury related to transfusion of fresh frozen plasma]. / Lesión pulmonar aguda relacionada con la transfusión de plasma fresco congelado.

A 23-year-old woman with no relevant medical history required transfusion of 2 units of fresh frozen plasma before diagnostic laparoscopy. Following transfusion, serious bilateral pulmonary edema with hypoxia developed and resolved with 48 hours of mechanical ventilation. Immunological testing of blood from the 2 donors and the patient revealed the presence of anti-HLA DR-52 antibodies in the plasma of a donor and the presence of the corresponding antigen in the patient, confirming the diagnosis of fresh frozen plasma transfusion-related acute lung injury. Transfusion-related acute lung injury associated with plasma-containing blood products has an incidence of 1:5000 transfused units and a mortality rate of up to 10% of cases. Clinical suspicion should remain high in making the diagnosis and ruling out other causes of pulmonary edema, given that a firm diagnosis will come only after immunological testing. Transfusion-related acute lung injury is considered an under-diagnosed syndrome and must be included in the differential diagnosis of respiratory distress when a transfusion has been given.

Lesión pulmonar aguda relacionada con la transfusión de plasma fresco congelado / Acute lung injury related to transfusion of fresh frozen plasma

Una mujer de 23 años, sin antecedentes patológicos de interés, precisó la transfusión de dos unidades de plasma fresco congelado (PFC) previa a una laparoscopia diagnóstica. Tras la transfusión desarrolló un edema pulmonar bilateral con hipoxemia grave que requirió para su resolución 48 horas de ventilación mecánica. El estudio inmunohematológico de los dos donantes y de la paciente puso de manifiesto la presencia de un anticuerpo antiHLA DR-52 en el plasma de uno de los donantes y la presencia del antígeno correspondiente en la paciente, lo que confirmó el diagnóstico de lesión pulmonar aguda relacionada con la transfusión (LPART) de PFC. La LPART es una reacción transfusional asociada a derivados sanguíneos contenedores de plasma, con una incidencia de 1/5000 unidades transfundidas y que presenta una mortalidad de hasta el 10 por ciento de los casos. Su diagnóstico se establece por un alto grado de sospecha y al descartar otras causas de edema pulmonar, pues el diagnóstico de certeza se realiza a posteriori tras estudio inmunológico. La LPART se considera un síndrome infradiagnosticado y debe incluirse en el diagnóstico diferencial de un distrés respiratorio en el contexto de una transfusión (AU)

[Effect of sevoflurane on the neuromuscular blockade produced by continuous mivacurium infusion ]. / Efecto de sevoflurano sobre el bloqueo neuromuscular de mivacurio en infusión continua.

OBJECTIVE: To evaluate the effect of sevoflurane on a neuromuscular block from mivacurium in continuous infusion. PATIENTS AND METHODS: Fourteen ASA I-II patients receiving general anesthesia for orthopedic procedures on the knee. The neuromuscular block was monitored by acceleromyography in the adductor pollicis muscle after stimulation of the cubital nerve. Anaesthesia was induced with propofol and remifentanil. After orotracheal intubation, mivacurium was given in continuous infusion adjusted to obtain a stable submaximal block defined as a variation in the block of 3% more or less for 10 minutes (first response on a train of four [T1] between 40% and 60% of the calibrated value). Values for T1, the T4/T1 ratio (TR) and temperature over the thenar eminence were recorded at 3 moments: control moment (infusion of mivacurium and sevoflurane at an expired fraction of 1.5% for 30 minutes) and post-sevoflurane moment (perfusion of mivacurium and sevoflurane at an expired fraction of 0% for 15 minutes). Statistical analysis was by analysis of variance and post-hoc contrast (Tukey). RESULTS: Results are expressed as means with standard error between parentheses. We found that values at T1(%) and TR(%) were significantly lower at the sevoflurane moments (T1 = 43.11 [1]; TR = 25.68 [1]) and the post-sevoflurane moment (T1 = 36.29 [2]; TR = 25.06 [2]) than at the control moment (T1 = 53.18 [1]; TR = 38.93 [1]) (P < .05). T1 was significantly lower at the post-sevoflurane moment than at the sevoflurane moment (P < .05) but TR did not differ significantly. CONCLUSION: Sevoflurane causes a significant increase in the neuromuscular block maintained by mivacurium in continuous infusion and the increase lasts at least 15 minutes after the halogenated agent is cleared from blood.

Efecto de sevoflurano sobre el bloqueo neuromuscular de mivacurio en infusión continua / Effect of sevoflurane on a neuromuscular block from mivacurium in continuous infusion

OBJETIVO: Evaluar el efecto de sevoflurano sobre un bloqueo neuromuscular inducido por mivacurio en infusión continua. PACIENTES Y MÉTODOS: Fueron estudiados 14 pacientes ASA I-II sometidos a anestesia general para procedimientos de cirugía ortopédica de rodilla. El bloqueo neuromuscular se monitorizó en el aductor del pulgar, tras estimulación del nervio cubital, mediante acelerometría. La inducción anestésica se llevó a cabo con propofol y remifentanilo. Tras la intubación orotraqueal se procedió a la administración de mivacurio en infusión continua, ajustándola hasta obtener un bloqueo estable submáximo definido como variación del mismo menor de ñ 3 por ciento durante 10 minutos [1ª respuesta del tren de cuatro (T1) entre el 40 por ciento y 60 por ciento del valor obtenido en la calibración]. Se analizaron los valores de T1, T4/T1 ratio (TR) y temperatura a nivel de la eminencia tenar en 3 periodos: Control (perfusión estable de mivacurio sin sevoflurano), Sevo (perfusión de mivacurio y sevoflurano fracción espiratoria (FE) 1,5 por ciento durante 30 minutos) y Postsevo (perfusión de mivacurio y sevoflurano FE 0 por ciento durante 15 minutos). El análisis estadístico se realizó mediante el análisis de la varianza y contrastes post-hoc (Tukey). RESULTADOS: Encontramos valores (mediañerror típico) de T1( por ciento) y TR( por ciento) significativamente descendidos (p<0,05) en los periodos Sevo (T1=43,11ñ1; TR=25,98ñ1) y Postsevo (T1=36,29ñ2; TR=25,06ñ2) al compararlos con el control (T1=53,18ñ1; TR=38,93ñ1). El T1 fue significativamente menor (p<0,05) en el periodo Postsevo frente al Sevo, sin encontrar diferencias en el valor TR. CONCLUSIÓN: Sevoflurano produce un aumento significativo del bloqueo neuromuscular inducido por mivacurio en infusión continua, aumento que se prolonga en el tiempo al menos 15 minutos una vez se ha eliminado el agente halogenado de la sangre (AU)

Neumomediastino y enfisema subcutáneo como complicación precoz postoperatoria de histerectomía / Pneumomediastinum and subcutaneous emphysema as an early postoperaive complication of hysterectomy

Se presenta el caso de una mujer de 51 años que, en el postoperatorio inmediato tras una histerectomía total y doble anexectomía por útero polimiomatoso, desarrolló un enfisema subcutáneo y neumomediastino debido a los vómitos (AU)

[Pneumococcal bacteremia in patients aged over 65 years. A study of 161 cases]. / Bacteriemia neumocócica en pacientes mayores de 65 años. Estudio de 161 casos.

BACKGROUND: Here we present the results from a prospective analysis of pneumococcal bacteremia in patients older than 65 years, highlighting its differences with regard to patients aged from 15 to 64 years. PATIENTS AND METHOD: We performed a prospective follow-up study (1988-1999) of patients older than 14 years whohad blood cultures positive for Streptococcus pneumoniae(S. pneumoniae). S. pneumoniae was identified using standard techniques. The antimicrobial sensitivity was analysed using the broth midrodilution technique and the serotype was studied in a reference laboratory. Statistical analyses were performed by means of the SPSS program, version 9.0. RESULTS: 161 out of 321 bacteremias occurred in 154 patients older than 65 years (86 males). Most frequent underlying diseases were chronic obstructive pulmonary disease (COPD), diabetes and neoplasia. Most patients had pneumonia, 29.7% with ilfiltrates involving at least two lung lobes. 9.4% of bacteremias were nosocomial. Among patients older than 65 years, 32.5% of strains were resistant to penicillin, compared to 21.7% in patients younger than 65 years(p = 0.034). Mortality in patients over 65 years was higher than in younger patients (25.3% vs 11.5%; p = 0.002) and mortality predictive factors in a multivariate analysis were age, nosocomial bacteremia and multi-lobe involvement (in patients with pneumonia). CONCLUSIONS: There is a high incidence of pneumococcal bacteremia in patients over 65 years of age. These patients have a higher rate of resistance to penicillin and a higher mortality rate than younger patients. Mortality predictive factors are age, nosocomial bacteremia and multi-lobe involvement.

Video-laparoscopic staging of gastric cancer. A prospective multicenter comparison with noninvasive techniques.

BACKGROUND: The high proportion of gastric carcinomas present in an unresectable stage, together with the emergence of multimodal treatments, increases the usefulness of objective staging methods that avoid unnecessary laparotomies. METHODS: A prospective evaluation of the accuracy of laparoscopy in the staging of 71 patients with gastric adenocarcinoma is presented. Serosal infiltration, retroperitoneal fixation, metastasis to lymph nodes, peritoneal and liver metastasis, and ascites were determined in the staging workup. Sensitivity, specificity, and predictive values were calculated and compared with those obtained with ultrasonography (US) and computed tomography (CT). RESULTS: The diagnostic accuracy of laparoscopy in the determination of resectability was 98.6%. Consequently, over 40% of patients were spared unnecessary laparotomies. Laparoscopy yielded diagnostic indices superior to US and CT for all the tumoral attributes studied. Our technique permits accurate assessment and pathologic verification of liver and the peritoneal and retroperitoneal extent of tumor invasion in the majority of patients. CONCLUSIONS: Laparoscopy in gastric adenocarcinoma is a reliable technique that provides accurate assessment of resectability and stage, thus avoiding unnecessary laparotomies in patients in whom surgical palliation is not indicated. A stepwise diagnostic workup combining imaging and minimally invasive techniques is proposed.

[Antiemetic prophylaxis after laparoscopic cholecystectomy: comparative study of dehydrobenzperidol, metoclopramide, ondansetron and placebo]. / Profilaxis antiemética tras la colecistectomía laparoscópica: estudio comparativo de dehidrobenzoperidol, metoclopramida, ondansetrón y placebo.

OBJECTIVES: To compare the efficacy of ondansetron to that of metoclopramide, dehydrobenzperidol and placebo for the prevention of postoperative nausea and vomiting (PONV) after laparoscopic cholecystectomy in a double-blind random study. PATIENTS AND METHOD: A total of 100 ASA I, II and III patients undergoing scheduled laparoscopic cholecystectomy were divided into 4 groups according to whether they received one of the following intravenously just prior to anesthetic induction: 1.25 mg dehydrobenzperidol (group D), 10 mg metoclopramide (group M), 4 mg ondansetron (group O) or 2 ml of saline (group P). All received general anesthesia with induction by thiopental, analgesia with fentanyl, muscle relaxation with atracurium and maintenance with oxygen-air and isoflurane. Episodes of nausea and/or vomiting during the first 24 h after surgery were recorded. Treatment was considered effective if no episodes occurred during this period. RESULTS: Nine of the 100 patients were excluded from the study. There were no significant differences in demographic variables among the 4 groups. The incidence of PONV was significantly greater in group P than in any of the other groups. There were no significant differences in PONV among groups D, M and O. CONCLUSIONS: Ondansetron provides safe, effective prophylaxis for PONV after laparoscopic cholecystectomy, but it is not superior to the antiemetic drugs usually used. Its use may be justified in patients in whom dehydrobenzperidol or metoclopramide are contraindicated.