RESUMEN
BACKGROUND AND PURPOSE: International recommendations advocate that carotid endarterectomy (CEA) should be performed within 2 weeks from the index event in symptomatic carotid artery stenosis (sCAS) patients. However, there are controversial data regarding the safety of CEA performed during the first 2 days of ictus. The aim of this international, multicenter study was to prospectively evaluate the safety of urgent (0-2 days) in comparison to early (3-14 days) CEA in patients with sCAS. METHODS: Consecutive patients with non-disabling (modified Rankin Scale scores ≤2) acute ischaemic stroke or transient ischaemic attack due to sCAS (≥70%) underwent urgent or early CEA at five tertiary-care stroke centers during a 6-year period. The primary outcome events included stroke, myocardial infarction or death during the 30-day follow-up period. RESULTS: A total of 311 patients with sCAS underwent urgent (n = 63) or early (n = 248) CEA. The two groups did not differ in baseline characteristics with the exception of crescendo transient ischaemic attacks (21% in urgent vs. 7% in early CEA; P = 0.001). The 30-day rates of stroke did not differ (P = 0.333) between patients with urgent (7.9%; 95% confidence interval 3.1%-17.7%) and early (4.4%; 95% confidence interval 2.4%-7.9%) CEA. The mortality and myocardial infarction rates were similar between the two groups. The median length of hospitalization was shorter in urgent CEA [6 days (interquartile range 4-6) vs. 10 days (interquartile range 7-14); P < 0.001]. CONCLUSIONS: Our findings highlight that urgent CEA performed within 2 days from the index event is related to a non-significant increase in the risk of peri-procedural stroke. The safety of urgent CEA requires further evaluation in larger datasets.
Asunto(s)
Isquemia Encefálica/cirugía , Estenosis Carotídea/cirugía , Endarterectomía Carotidea/efectos adversos , Accidente Cerebrovascular/cirugía , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/etiología , Estenosis Carotídea/complicaciones , Femenino , Humanos , Masculino , Persona de Mediana Edad , Accidente Cerebrovascular/etiología , Centros de Atención Terciaria , Factores de Tiempo , Resultado del TratamientoRESUMEN
This study aimed to assess the effects of sugammadex and neostigmine/atropine on postoperative cognitive dysfunction (POCD) in adult patients after elective surgery. A randomised, double-blind controlled trial was carried out on 160 American Society of Anesthesiologists physical status I to III patients who were >40 years. The Mini-Mental State Evaluation, clock-drawing test and the Isaacs Set test were used to assess cognitive function at three timepoints: 1) preoperatively, 2) one hour postoperatively, and 3) at discharge. The anaesthetic protocol was the same for all patients, except for the neuromuscular block reversal, which was administered by random allocation using either sugammadex or neostigmine/atropine after the reappearance of T2 in the train-of-four sequence. POCD was defined as a decline ≥1 standard deviation in ≥2 cognitive tests. The incidence of POCD was similar in both groups at one hour postoperatively and at discharge (28% and 10%, in the neostigmine group, 23% and 5.4% in the sugammadex group, P=0.55 and 0.27 respectively). In relation to individual tests, a significant decline of clock-drawing test in the neostigmine group was observed at one hour postoperatively and at discharge. For the Isaacs Set test, a greater decline was found in the sugammadex group. These findings suggest that there are no clinically important differences in the incidence of POCD after neostigmine or sugammadex administration.
Asunto(s)
Atropina/administración & dosificación , Disfunción Cognitiva/epidemiología , Neostigmina/administración & dosificación , Complicaciones Posoperatorias/epidemiología , gamma-Ciclodextrinas/administración & dosificación , Adulto , Disfunción Cognitiva/etiología , Método Doble Ciego , Procedimientos Quirúrgicos Electivos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Antagonistas Muscarínicos/administración & dosificación , Bloqueo Neuromuscular/métodos , Parasimpaticomiméticos/administración & dosificación , SugammadexRESUMEN
BACKGROUND: Sevoflurane exerts effects on pulmonary cells that could protect against lung injury. We evaluated the potential of pretreatment with sevoflurane to attenuate lipopolysaccharide (LPS)-induced lung injury. METHODS: LPS was administered intratracheally in Wistar rats to induce lung injury. Sevoflurane was administered for 30 min at 0.25, 0.5 or 1.0 MAC 15 min before LPS or for 30 min at 0.5 MAC 24 hours before LPS. After initial analysis of bronchoalveolar lavage fluid (BALF) cells and total protein, the group of 0.5 MAC 15 min before LPS was further analyzed for surfactant aggregates subfractions, plasma malondialdehyde levels and lung histology. RESULTS: LPS instillation resulted in neutrophils sequestration in the lungs, loss of alveolar macrophages, increased BALF total protein and decreased large surfactant aggregates. Only inhalation of sevoflurane for 30 min at 0.5 MAC 15 min before LPS installation effectively reduced neutrophil accumulation, preserved alveolar epithelial cells and reduced total protein content in BALF. This regimen also reduced plasma malondialdehyde levels and increased large surfactant aggregates, despite the application of mechanical ventilation. This effect was preserved after LPS instillation and the favorable composition of surfactant was maintained. CONCLUSION: Pretreatment with sevoflurane effectively attenuates direct severe lung injury, possibly by inhibition of neutrophil accumulation and alteration of the surfactant composition.
Asunto(s)
Lesión Pulmonar Aguda/prevención & control , Anestésicos por Inhalación/uso terapéutico , Éteres Metílicos/uso terapéutico , Lesión Pulmonar Aguda/inducido químicamente , Animales , Líquido del Lavado Bronquioalveolar , Lipopolisacáridos , Masculino , Ratas , Ratas Wistar , Sevoflurano , Sustancias Reactivas al Ácido Tiobarbitúrico/metabolismoAsunto(s)
Androstanoles/antagonistas & inhibidores , Hepatopatías/complicaciones , Fármacos Neuromusculares no Despolarizantes/antagonistas & inhibidores , Derivación Portosistémica Intrahepática Transyugular/métodos , gamma-Ciclodextrinas , Adulto , Androstanoles/metabolismo , Periodo de Recuperación de la Anestesia , Síndrome de Budd-Chiari/complicaciones , Femenino , Hepatitis C/complicaciones , Humanos , Cirrosis Hepática/complicaciones , Hepatopatías/metabolismo , Pruebas de Función Hepática , Masculino , Persona de Mediana Edad , Monitoreo Intraoperatorio , Fármacos Neuromusculares no Despolarizantes/metabolismo , Rocuronio , SugammadexRESUMEN
INTRODUCTION: Intrathecal baclofen therapy using implantable pumps is an established treatment for spasticity. The pumps occasionally experience serious malfunction. CASE REPORT: A 12-year-old girl suffering from spastic diplegia was implanted with a Medtronic SynchroMed II pump (Medtronic Inc., Minneapolis, Minn., USA). During a refill at 3 months 19 ml of baclofen were still in the pump. It was assumed that there was a lumbar catheter obstruction and a revision was performed. At 11 months she was receiving 180 microg/day. When she presented for refill, there were again 19 ml of baclofen in the reservoir. The pump was refilled, stopped and restarted at a lower dose. Ten minutes after restart the patient was complaining that she could not move her legs. Within the next 50 min she lapsed into coma, from a presumed baclofen overdose. She was intubated and ventilated. The reservoir was emptied of baclofen and the pump stopped. Seventeen hours after the baclofen overdose, the patient woke up gradually with no new neurological deficits. The pump was removed a week later. Medtronic laboratories examined the pump and reported no technical fault. DISCUSSION: The implanted Medtronic SynchroMed II pump suffered an unusual malfunction. It is postulated that the pump had suffered a motor stall, and when it was restarted, it gave an unusually high, potentially lethal, dose to the patient. CONCLUSION: Physicians who implant pumps for intrathecal baclofen administration need to be aware that these devices may suffer unheralded catastrophic failure that can lead to potentially lethal overdose administration.
Asunto(s)
Baclofeno/envenenamiento , Parálisis Cerebral/tratamiento farmacológico , Falla de Equipo , Bombas de Infusión Implantables/efectos adversos , Relajantes Musculares Centrales/envenenamiento , Baclofeno/administración & dosificación , Niño , Sobredosis de Droga , Femenino , Humanos , Inyecciones Espinales , Relajantes Musculares Centrales/administración & dosificación , Espasticidad Muscular/tratamiento farmacológicoRESUMEN
The aim of the study is to evaluate the efficacy of post-incisional wound infiltration with levobupivacaine in preventing the postoperative pain associated with inguinal hernia repair in children. Thirty boys, ASA I - II, aged 2 - 12 yrs., undergoing unilateral inguinal hernioplasty under general anaesthesia as day-case patients were allocated randomly to have postoperative analgesia either with post-incisional wound infiltration with levobupivacaine 1.25 mg/kg or with paracetamol 30 mg/kg administered rectally. Postoperative pain was assessed initially in the Post-Anaesthesia Care Unit and on the ward by an observer and afterwards for the next 24 h by the parents, using the Poker Chip Tool for preschoolers and the Visual Analogue Scale for older children, respectively. Postoperative pain was managed by giving paracetamol. The duration of the postoperative analgesia was estimated based on the time when rescue analgesia was first given. Assessment of the quality of postoperative analgesia was based on the children's behaviour. The wound infiltration group showed an increased duration of postoperative analgesia (p < 0.001) and early mobilisation, while the efficacy of postoperative analgesia tended to be more adequate, although no statistically significant difference was noted.
Asunto(s)
Anestésicos Locales/administración & dosificación , Hernia Inguinal/cirugía , Dolor Postoperatorio/prevención & control , Acetaminofén/administración & dosificación , Administración Rectal , Analgésicos no Narcóticos/administración & dosificación , Bupivacaína/administración & dosificación , Bupivacaína/análogos & derivados , Niño , Preescolar , Estudios de Seguimiento , Humanos , Inyecciones , Levobupivacaína , Masculino , Dimensión del Dolor , Resultado del TratamientoRESUMEN
Our study aimed at evaluating the effect of blood transfusion - allogeneic or autologous - on plasma levels of fibronectin during liver resections. Thirty-five patients scheduled for liver resection were randomly allocated to receive autologous (group autologous blood transfusion (ABT), n= 19) or allogeneic (homologous) (homologous blood transfusion (HBT), n= 16) packed red blood cell to maintain serum haemoglobin concentration above 9 g. Serum levels of fibronectin were measured before induction of anaesthesia, at the end of operation and at first, third and sixth postoperative day. Perioperative morbidity and survival rate were also recorded. Serum fibronectin levels were significantly higher (P < 0.05) in the autologous group than in the allogeneic, at the first (134 +/- 49 microg mL(-1) vs. 89 +/- 31 microg mL(-1)) and third (178 +/- 51 microg mL(-1) vs. 96 +/- 41 microg mL(-1)) postoperative day. No differences in survival and complication rate between the two groups were observed. Concentrations of serum fibronectin seem to be adversely affected by allogeneic blood transfusion during liver resection surgery, although this does not seem to affect patients' morbidity and mortality.
Asunto(s)
Transfusión de Sangre Autóloga/efectos adversos , Transfusión de Eritrocitos/efectos adversos , Fibronectinas/sangre , Hepatectomía , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Morbilidad , Periodo Posoperatorio , Análisis de SupervivenciaRESUMEN
BACKGROUND AND OBJECTIVE: We examined the efficacy of intraoperative propofol administration to prevent pruritus induced by epidural morphine. METHODS: Seventy patients ASA I-II undergoing combined epidural and general anaesthesia for hysterectomy were randomly assigned to two groups, Group P where anaesthesia was induced with propofol and fentanyl and maintained with propofol-nitrous oxide and Group S in which anaesthesia was induced with thiopental and fentanyl and maintained with sevoflurane-nitrous oxide. All patients received a ropivacaine epidural bolus with 3 mg morphine 1 h before the end of surgery. The incidence and severity of pruritus were evaluated every 4 h for the first 12 h postoperatively by blinded observers. RESULTS: The total incidence of pruritus was significantly higher (P = 0.024) in Group S (65.6%) compared to Group P (29%) between 4 and 8 h postoperatively. There were also significantly more patients (P = 0.03) reporting severe pruritus in Group S (22%) compared to Group P (0). CONCLUSION: Propofol-based general anaesthesia compared to thiopental-sevoflurane-based anaesthesia reduces the incidence and severity of pruritus induced by a single injection of 3 mg epidural morphine with ropivacaine.
Asunto(s)
Analgesia Epidural/efectos adversos , Cuidados Intraoperatorios/métodos , Morfina/efectos adversos , Complicaciones Posoperatorias/prevención & control , Propofol/uso terapéutico , Prurito/prevención & control , Analgésicos Opioides/efectos adversos , Anestesia General , Anestésicos por Inhalación/administración & dosificación , Anestésicos Intravenosos/administración & dosificación , Anestésicos Intravenosos/uso terapéutico , Procedimientos Quirúrgicos Electivos , Femenino , Fentanilo/administración & dosificación , Humanos , Histerectomía , Éteres Metílicos/administración & dosificación , Persona de Mediana Edad , Óxido Nitroso/administración & dosificación , Complicaciones Posoperatorias/inducido químicamente , Propofol/administración & dosificación , Prurito/inducido químicamente , Índice de Severidad de la Enfermedad , Sevoflurano , Tiopental/administración & dosificación , Factores de Tiempo , Resultado del TratamientoRESUMEN
The purpose of the study is to evaluate both the efficacy of ring block of the penis with levobupivacaine in preventing intraoperative and postoperative pain associated with circumcision in children and the quality of the recovery. Thirty boys aged 3 - 12 years who underwent circumcision under general anaesthesia as day case patients were allocated randomly to receive either a subcutaneous ring block with levobupivacaine or intravenous fentanyl (2 microg/kg) and paracetamol (30 mg/kg) rectally, after induction of anesthesia but before surgery. The efficacy of intraoperative analgesia was estimated using the heart rate and alterations in blood pressure. The quality of the recovery was assessed based on the Aldrete Scoring System (First Value and Time of Maximum Value were recorded). Postoperative pain was estimated using a four degree scale by nurses in the Postanaesthesia Care Unit and over the next 24 hours by the parents. Paracetamol was given depending on the pain score and the time of first dose given was recorded. The quality of postoperative analgesia was based on the children's activity and mobilisation. The ring block group showed intraoperative cardiovascular stability and a faster and better recovery (p < 0.0005) while the postoperative analgesia tended to be longer and more adequate, although that no statistically significant difference was noted (p < 0.1).
Asunto(s)
Analgesia , Bupivacaína , Circuncisión Masculina , Dolor Postoperatorio/prevención & control , Procedimientos Quirúrgicos Ambulatorios , Bupivacaína/análogos & derivados , Niño , Preescolar , Humanos , Periodo Intraoperatorio , Levobupivacaína , Masculino , Dimensión del DolorRESUMEN
We describe the use of remifentanil in an infant with a partially repaired Shone's syndrome who required tendon lengthening because of congenital clubfoot. Remifentanil has unique properties, making it a potentially useful and predictable agent for infants with significant comorbidity.
Asunto(s)
Analgésicos Opioides , Anestesia/métodos , Pie Equinovaro/cirugía , Cardiopatías Congénitas , Piperidinas , Pie Equinovaro/complicaciones , Cardiopatías Congénitas/complicaciones , Cardiopatías Congénitas/cirugía , Humanos , Lactante , Masculino , Remifentanilo , SíndromeRESUMEN
We describe the case of a 5-year-old boy with phaeochromocytoma of the left adrenal gland, treated surgically by removal of the tumour under general anaesthesia. Phaeochromocytoma is a particularly rare tumour in children and surgical excision is the definitive treatment. We discuss the clinical and laboratory characteristics of the case, the diagnostic approach, the preoperative and intraoperative management and the postoperative course.
Asunto(s)
Neoplasias de las Glándulas Suprarrenales/cirugía , Anestesia General , Feocromocitoma/cirugía , Adyuvantes Anestésicos , Anestésicos por Inhalación , Anestésicos Intravenosos , Preescolar , Fentanilo , Humanos , Isoflurano , Masculino , Fármacos Neuromusculares Despolarizantes , Tiopental , Bromuro de VecuronioRESUMEN
The purpose of the study is to evaluate the efficacy of Intercostal Nerve Block (ICB) with Bupivacaine (BUP) to produce satisfactory analgesia after thoracotomy in children. We studied 20 children aged between 5 and 12 years, scheduled for thoracotomy under general anaesthesia. The children were randomly divided into two groups. In the first group (n = 10) 3 mg/kg BUP 0.5 % with epinephrine 1 : 200 000 was injected by the surgeon under direct vision, into the intercostal space where thoracotomy was performed. In the control group (n = 10) meperidine 1 mg/kg was administered i.v. at the same surgical time, and afterwards the chest was closed. Postoperatively the vital signs, the side effects and the total postoperative analgesic requirements were recorded. The mean duration of postoperative analgesia produced was longer in the BUP group (p < 0.001). None of the children in BUP group suffered from BUP toxicity, while in the control group a high incidence of vomiting and nausea was noticed (p < 0.005). It is concluded that ICB with BUP produces satisfactory and safe analgesia for the early postoperative period after thoracotomy in children.