[Intraoperative transesophageal echocardiography and systolic anterior motion of the mitral valve: findings during noncardiac surgery]. / Ecocardiografía transesofágica intraoperatoria y movimiento sistólico anterior de válvula mitral: hallazgo intraoperatorio durante cirugía no cardíaca.

Systolic anterior motion is an under-recognized cause of acute systemic hypotension during noncardiac surgery. This dynamic event has come to light with the introduction of intraoperative transesophageal echocardiography, which provides anatomic and functional images in real time. The cause of this abnormal motion is still uncertain, although it is thought that changes in the shape and function of the left ventricle allow displacement of the mitral valve annulus so that 1 or more leaflets can be pulled toward the outflow tract and obstruct it during the systole. It is important to recognize and diagnose this phenomenon as a cause of hypotension during noncardiac surgery because it can be treated with volume replacement and beta-blockers. The results of such measures can be monitored on intraoperative echocardiographic images. Volume replacement should increase the size of the ventricle and the beta-blockers should decrease the hyperdynamic state. We report a case of abnormal systolic motion during noncardiac surgery that was managed with the help of echocardiography.

Ecocardiografía transesofágica intraoperatoria y movimiento sistólico anterior de válvula mitral: hallazgo intraoperatorio durante cirugía no cardíaca / Intraoperative transesophageal echocardiography and systolic anterior motion of the mitral valve: findings during noncardiac surgery

El fenómeno de movimiento sistólico anormal de la válvulamitral es una entidad clínica poco reconocida comocausa de hipotensión arterial sistémica aguda intraoperatoriadurante cirugía no cardíaca. Con el advenimiento dela ecocardiografía transesofágica intraoperatoria que permiteobtener imágenes anatómicas y funcionales cardíacasen tiempo real, este fenómeno dinámico se ha hecho evidente.Su etiología aunque poco clara, se piensa que sedebe a cambios morfológicos y funcionales del ventrículoizquierdo que permiten el desplazamiento del anillo valvularmitral lo que facilita que uno o ambos velos sean arrastradosdurante la sístole hacia el tracto de salida del ventrículoizquierdo, obstruyéndolo. La importancia que tienesu diagnóstico y reconocimiento como causa de hipotensióndurante el intraoperatorio de una cirugía no cardíacaes que su tratamiento se basa en el aporte de volumen y ala utilización preferente de betabloqueantes. La ecocardiografíaintraoperatoria permite la monitorización y visualizaciónde los resultados de esta terapia. Con el aporte devolumen aumenta el tamaño ventricular y con el uso debetabloqueantes se logra disminuir el estado hiperdinámico.Se presenta el siguiente caso clínico ocurrido duranteuna cirugía no cardíaca donde el manejo y la evolucióndependieron de las imágenes diagnósticas de movimientosistólico anormal realizadas con ecocardiografía

Systolic anterior motion is an under-recognized cause of acute systemic hypotension during noncardiac surgery. This dynamic event has come to light with the introduction of intraoperative transesophageal echocardiography, which provides anatomic and functional images in real time. The ;;cause of this abnormal motion is still uncertain, although it ;;is thought that changes in the shape and function of the left ;;ventricle allow displacement of the mitral valve annulus so ;;that 1 or more leaflets can be pulled toward the outflow ;;tract and obstruct it during the systole. It is important to ;;recognize and diagnose this phenomenon as a cause of ;;hypotension during noncardiac surgery because it can be ;;treated with volume replacement and Beta-blockers. The ;;results of such measures can be monitored on intraoperative ;;echocardiographic images. Volume replacement should ;;increase the size of the ventricle and the Beta-blockers should ;;decrease the hyperdynamic state. We report a case of ;;abnormal systolic motion during noncardiac surgery that ;;was managed with the help of echocardiography

Efficacy of oral rofecoxib versus intravenous ketoprofen as an adjuvant to PCA morphine after urologic surgery.

BACKGROUND: Adjunctive use of nonsteroidal anti-inflammatory drugs has become increasingly popular in the perioperative period because of their opioid-sparing effects. This randomized, controlled, double-dummy study was designed to evaluate the cost-effectiveness of using oral rofecoxib as an alternative to intravenous ketoprofen for pain management in patients undergoing urologic surgery. METHODS: Seventy patients were randomly assigned to receive either a placebo (Control) or rofecoxib 50 mg po (Rofecoxib) 1 h prior to surgery. After a standardized spinal anesthetic, patients in the Control group received ketoprofen 100 mg IV q 8 h for 24 h, while the Rofecoxib group received an equivolume of saline at 8-h intervals for 24 h. Both groups were allowed to self-administer morphine (1 mg IV boluses) using a PCA delivery system. The need for 'rescue' analgesic medication, as well as pain scores [using an 11-point verbal rating scale (VRS) (0 = none to 10-severe)], were recorded at 1, 2, 6, 12, and 24-h intervals after surgery. In addition, the incidences of side-effects were recorded at the end of the study period. RESULTS: Total amount of morphine required in the initial 24-h postoperative period was nonsignificantly reduced in the Rofecoxib group (29 +/- 2 vs. 37 +/- 4 mg). More importantly, the percentage of patients reporting moderate-to-severe pain (VRS score > or =4) during the study period was lower in the Rofecoxib group (12 vs. 22%, P < 0.05). The daily cost of rofecoxib (USD 1.14 for 50-mg dose) was also significantly less than ketoprofen (USD 3.06 for three 100-mg doses). CONCLUSION: Premedication with oral rofecoxib (50 mg) is a cost-effective alternative to the parenteral nonselective NSAID, ketoprofen (100 mg q 8 h), when used as an adjuvant to PCA morphine for pain management after urologic surgery.