Damage control surgery in the era of damage control resuscitation.

Damage control surgery (DCS) is a concept of abbreviated laparotomy, designed to prioritize short-term physiological recovery over anatomical reconstruction in the seriously injured and compromised patient. Over the last 10 yr, a new addition to the damage control paradigm has emerged, referred to as damage control resuscitation (DCR). This focuses on initial hypotensive resuscitation and early use of blood products to prevent the lethal triad of acidosis, coagulopathy, and hypothermia. This review aims to present the evidence behind DCR and its current application, and also to present a strategy of overall damage control to include DCR and DCS in conjunction. The use of DCR and DCS have been associated with improved outcomes for the severely injured and wider adoption of these principles where appropriate may allow this trend of improved survival to continue. In particular, DCR may allow borderline patients, who would previously have required DCS, to undergo early definitive surgery as their physiological derangement is corrected earlier.

Duration of analgesic effectiveness after the posterior and lateral transversus abdominis plane block techniques for transverse lower abdominal incisions: a meta-analysis.

BACKGROUND: Both posterior and lateral transversus abdominis plane (TAP) block techniques provide effective early (0-12 h) postoperative analgesia after transverse incision surgery. However, whether either technique produces prolonged analgesia lasting beyond 12 h remains controversial. This meta-analysis examines the duration of analgesia associated with posterior and lateral TAP blocks in the first 48 h after lower abdominal transverse incision surgery. METHODS: We retrieved randomized controlled trials (RCTs) investigating the analgesic effects of TAP block compared with control in patients undergoing lower abdominal transverse incision surgery. Outcomes sought included interval postoperative i.v. morphine consumption and also rest and dynamic pain scores at 12, 24, 36, and 48 h postoperatively. Opioid-related side-effects and patient satisfaction at 24 and 48 h were also assessed. The 12-24 h interval morphine consumption was designated as a primary outcome. RESULTS: Twelve RCTs including 641 patients were analysed. Four trials examined the posterior technique and eight assessed the lateral technique. Compared with control, the posterior TAP block reduced postoperative morphine consumption during the 12-24 h and 24-48 h intervals by 9.1 mg (95% CI: -16.83, -1.45; P=0.02) and 5 mg (95% CI: -9.54, -0.52; P=0.03), respectively. It also reduced rest pain scores at 24, 36, and 48 h, and also dynamic pain scores at 12, 24, 36, and 48 h. Differences were not significant with the lateral TAP block. CONCLUSION: Based on the comparisons with control, the posterior TAP block appears to produce more prolonged analgesia than the lateral TAP block. Future RCTs comparing these two techniques are required to confirm our findings.

Hypercapnia and surgical site infection: a randomized trial.

BACKGROUND: Tissue oxygenation is a strong predictor of surgical site infection (SSI). Mild intraoperative hypercapnia increases peripheral, gastrointestinal, and splanchnic tissue oxygenation and perfusion. Hypercapnia also has anti-inflammatory effects. However, it is unknown whether hypercapnia reduces SSI risk. We tested the hypothesis that mild intraoperative hypercapnia reduces the risk of SSI in patients having colon resection surgery. METHODS: With institutional review board approval and subject consent, patients having elective colon resection (e.g. hemicolectomy and low-anterior resection) expected to last >2 h were randomly assigned to intraoperative normocapnia (PE'CO2 ≈ 35 mm Hg; n=623) or hypercapnia ( PE'CO2 ≈ 50 mm Hg; n=592). Investigators blinded to group assignment evaluated perioperative SSI (Center for Disease Control criteria) for 30 postoperative days. SSI rates were compared. RESULTS: Patient and surgical characteristics were comparable among the groups. The SSI rate for normocapnia was 13.3%, and for hypercapnia, it was 11.2% (P=0.29). The Executive Committee stopped the trial after the first a priori determined statistical assessment point because of much smaller actual effect compared with the projected. However, because the actual difference found in the SSI rates (15-16%) were within the 95% confidence intervals (CIs) of the projected relative difference of 33% (95% CI -43 to +24%), our results cannot be considered as 'no difference', and cannot exclude a Type II error. Time to first bowel movement was half-a-day shorter in the hypercapnia group. CONCLUSIONS: Mild hypercapnia appears to have little or-possibly-no ability to prevent SSI after colon resection. Other strategies for reducing SSI risk should thus take priority.

Plasma ropivacaine concentrations during bilateral transversus abdominis plane infusions.

BACKGROUND: The transversus abdominis plane (TAP) block is a regional anaesthetic technique that blocks abdominal wall somatic afferent nerves. We conducted a prospective observational study to evaluate the venous plasma concentrations of ropivacaine during a continuous TAP infusion. METHODS: Twenty patients who were planned to undergo intra-abdominal cavity surgery requiring a mid-line laparotomy incision were enrolled. Patients were excluded if they had a history of chronic pain, opioid tolerance, renal or hepatic impairment, or contraindication to study medications. Subjects received a standardized general anaesthetic, and at the completion of surgery, ultrasound-guided subcostal or posterior TAP blocks and catheters. A TAP infusion of 2 mg ml(-1) ropivacaine was administered for 72 h after operation. Data collection during the 72 h included morphine requirements, pain scores, and plasma ropivacaine levels. RESULTS: TAP blocks and catheters were successfully inserted in all recruited subjects. The fourth subject experienced neurological symptoms attributed to local anaesthetic toxicity, but did not have high plasma ropivacaine concentrations. However, the protocol was amended for the subsequent 16 subjects, to a weight-based dosing regimen. The range of total plasma ropivacaine concentrations was 0.98-3.41 mg litre(-1) for posterior infusions and 0.96-3.48 mg litre(-1) for subcostal infusions. Four subjects had total ropivacaine levels >3.4 mg litre(-1). The range of unbound plasma ropivacaine concentrations was 0.022-0.135 mg litre(-1) for posterior infusions and 0.031-0.120 mg litre(-1) for subcostal infusions. CONCLUSION: Given the potential for high plasma concentrations from a bilateral TAP infusion technique, attention should be paid to individualized dosing strategies.

Uso do tramadol venoso e subcutâneo em herniorrafia inguinal: estudo comparativo / Intravenous and subcutaneous tramadol for inguinal herniorrhaphy: comparative study / Uso del tramadol venoso y subcutáneo en herniorrafía inguinal: estudio comparativo

JUSTIFICATIVA E OBJETIVOS: A herniorrafia inguinal é uma das cirurgias mais realizadas no homem. O bloqueio do neuroeixo é a técnica anestésica comumente utilizada e, na maioria das vezes, o paciente se encontra em condições para alta domiciliar algumas horas após o procedimento, desde que apresente analgesia satisfatória e ausência de náuseas e vômitos. O tramadol é um fármaco analgésico que pode ser utilizado para a analgesia pós-operatória, porém apresenta, como importantes efeitos colaterais, a presença de náuseas e vômitos, cuja incidência pode variar de 0 por cento a 50 por cento associada ao seu uso. O objetivo deste estudo foi comparar a incidência de náuseas e vômitos e a qualidade da analgesia pósoperatória do tramadol pela via subcutânea e endovenosa em pacientes submetidos à herniorrafia inguinal. METÓDO: Estudo prospectivo com 30 pacientes submetidos à herniorrafia inguinal. Foram divididos em dois grupos: Grupo C (n = 15) recebeu Tramadol 1,5 mg.kg-1 subcutâneo e Grupo V (n = 15) recebeu Tramadol 1,5 mg.kg-1 endovenoso. Para todos os pacientes, fez-se anestesia peridural contínua com levobupivacaína a 0,5 por cento. Foram registrados os dados antropométricos, qualidade de analgesia e ocorrência de náuseas e vômitos nas primeiras 8 horas do pós-operatório. RESULTADOS: Não houve diferença estatística entre os grupos com relação aos dados antropométricos, qualidade da analgesia e ocorrência de náuseas e vômitos. CONCLUSÕES: Conclui-se, neste estudo, que não existe diferença estatisticamente significante quanto à incidência de náuseas e vômitos e à qualidade da analgesia quando se utiliza o tramadol por via venosa e subcutânea.

BACKGROUND AND OBJECTIVES: Inguinal herniorrhaphy is one of the most common surgeries in men. Neuroaxis block is the anesthetic technique used more often and in the majority of the cases the patient is ready to be discharged from the hospital a few hours after the procedure, as long as satisfactory analgesia is present and nausea and vomiting are absent. Tramadol is an analgesic drug that can be used in postoperative analgesia, but it has important side effects, such as nausea and vomiting whose incidence can range from 0 percent to 50 percent. The objective of the present study was to compare the incidence of nausea and vomiting and the quality of postoperative analgesia of subcutaneous and intravenous tramadol in patients undergoing inguinal herniorrhaphy. METHODS: This is a prospective study with 30 patients undergoing inguinal herniorrhaphy. Patients were divided into two groups: Group C (n = 15) received 1.5 mg.kg-1 of subcutaneous Tramadol, and Group V (n = 15) received 1.5 mg.kg-1 of intravenous Tramadol. All patients underwent continuous epidural anesthesia with 0.5 percent levobupivacaine. Anthropometric data, quality of analgesia, and the development of postoperative nausea and vomiting in the first eight hours were recorded. RESULTS: Statistically significant differences were not observed between both groups for anthropometric data, quality of analgesia, and the development of nausea and vomiting. CONCLUSIONS: The present study demonstrates the absence of statistically significant differences regarding the incidence of nausea and vomiting and quality of analgesia when using intravenous and subcutaneous Tramadol.

JUSTIFICATIVA Y OBJETIVOS: La herniorrafía inguinal es una de las cirugías más realizadas en el hombre. El bloqueo del neuro eje es la técnica anestésica más utilizada y en la mayoría de los casos, el paciente está en condiciones de recibir el alta algunas horas después del procedimiento, siempre que presente analgesia satisfactoria y la ausencia de náuseas y vómitos. El tramadol es un fármaco analgésico que puede ser utilizado para la analgesia postoperatoria, pero que presenta, como importantes efectos colaterales, náuseas y vómitos, y su incidencia puede variar de 0 por ciento a 50 por ciento, dependiendo del uso. El objetivo de este estudio fue comparar la incidencia de náuseas y vómitos y la calidad de la analgesia postoperatoria del tramadol por la vía subcutánea y endovenosa en pacientes sometidos a la herniorrafía inguinal. MÉTODOS: Estudio prospectivo con 30 pacientes sometidos a la herniorrafía inguinal. Se dividieron en dos grupos: Grupo C (n = 15) que recibió Tramadol 1,5 mg.kg-1 subcutáneo y el Grupo V (n = 15) que recibió Tramadol 1,5 mg.kg-1 endovenoso. A todos los pacientes se les practicó la anestesia epidural continua con levobupivacaína a 0,5 por ciento. Fueron registrados los datos antropométricos, la calidad de la analgesia y la incidencia de náuseas y vómitos en el postoperatorio (en las primeras ocho horas). RESULTADOS: No hubo diferencia estadística entre los grupos con relación a los datos antropométricos, calidad de la analgesia e incidencia de náuseas y vómitos. CONCLUSIONES: En este estudio llegamos a la conclusión de que no existe diferencia estadísticamente significante cuanto a la incidencia de náuseas y vómitos y a la calidad de la analgesia cuando se utiliza el tramadol por vía venosa y subcutánea.

Raquianestesia contínua com altas doses de anestésicos locais / Continuous spinal anesthesia with high dose of local anesthetics / Raquianestesia continua con altas dosis de anestésicos locales

JUSTIFICATIVA E OBJETIVOS: A maior vantagem da raquianestesia contínua é o melhor controle de nível, intensidade e duração da analgesia espinal. Com o advento dos cateteres intermediários (cateter por foral da agulha) e sua baixa incidência de cefaleia e sintomas neurológicos, a técnica vem ganhando credibilidade. O objetivo de caso é relatar a possível segurança do uso do novo cateter com grande dose de bupivacaína hiperbárica a 0,5 por cento com glicose a 1,6 por cento associada à lidocaína 2 por cento hiperbárica com glicose a 1,6 por cento. RELATO DO CASO: Paciente do sexo masculino, 78 anos, 85 kg, 168 cm, estado físico ASA III, hipertenso, coronariopata e insuficiência renal crônica. Candidato à cirurgia de volumosas hérnias inguinal bilateral e umbilical, sendo submetido por uma semana a pneumoperitôneo para criar espaço. Após venóclise com cateter 18G, monitoração com cardioscópio, pressão arterial não invasiva e oximetria de pulso, foi sedado com 1 mg de midazolam e fentanil 100 µg por via venosa e colocado em decúbito lateral esquerdo. Submetido à raquianestesia contínua por via mediana em L3-L4, com conjunto de agulha cortante 27G e cateter 22G. A dose total de anestésico utilizada no procedimento foi 25 mg de bupivacaína 0,5 por cento (hiperbárica com glicose a 1,6 por cento) e 160 mg de lidocaína 2 por cento (hiperbárica com glicose a 1,6 por cento) e morfina (100 µg). Paciente acompanhado até o 30º dia sem queixa neurológica. CONCLUSÕES: Recentemente, a má distribuição do anestésico local através de microcateter foi atribuída como causa de síndrome de cauda equina. Este relato de caso mostrou que, com a administração de altas doses de anestésicos hiperbáricos através do novo cateter, não houve má distribuição nem risco de síndrome de cauda equina.

BACKGROUND AND OBJECTIVES: Better control of the level, intensity, and duration of spinal analgesia represents the greatest advantages of continuous spinal anesthesia. With the advent of intermediate catheters (over-the-needle catheter) and its low incidence of headaches and neurological symptoms, the technique has been gaining credibility. The objective of this paper is to report the possible safety of the new catheter with a large dose of hyperbaric 0.5 percent bupivacaine with 1.6 percent glucose associated with hyperbaric 2 percent lidocaine with 1.6 percent glucose. CASE REPORT: Male patient, 78 years old, 85 kg, 168 cm, physical status ASA III, with hypertension, coronary artery disease, and chronic renal failure. The patient was candidate for surgery for huge bilateral inguinal and umbilical hernias, being submitted to preoperative pneumoperitoneum for one week to stretch abdominal cavity. After venoclysis with an 18G catheter, he was monitored with cardioscope, non-invasive blood pressure, and pulse oximetry; he was sedated with 1 mg of midazolam and 100 µg of fentanyl intravenously, and placed in left lateral decubitus. He underwent continuous spinal anesthesia by a median puncture in L3-L4 with a set with a 27G cut-bevel needle and 22G catheter. The total dose of anesthetic used was 25 mg of 0.5 percent bupivacaine (hyperbaric, with 1.6 percent glucose), 160 mg of 2 percent lidocaine (hyperbaric, with 1.6 percent glucose), and morphine (100 µg). The patient was followed-up until the 30th postoperative day without neurological complaints. CONCLUSIONS: Recently, the poor distribution of the local anesthetic through the microcatheter was attributed as the cause of cauda equina syndrome. This case report showed that, with the administration of high doses of hyperbaric anesthetics through the new catheter, poor distribution or risk of cauda equina syndrome were not observed.

JUSTIFICATIVA Y OBJETIVOS: La mayor ventaja de la raquianestesia continua es el mejor control del nivel de intensidad y duración de la analgesia espinal. Con el advenimiento de los catéteres intermediarios (catéter por fuera de la aguja) y por su baja incidencia de cefalea y síntomas neurológicos, la técnica ha venido ganando credibilidad. El objetivo de este caso es relatar la posible seguridad del uso del nuevo catéter con una gran dosis de bupivacaína hiperbárica al 0,5 por ciento con glucosa al 1,6 por ciento asociada a la lidocaína al 2 por ciento hiperbárica y con glucosa al 1,6 por ciento. RELATO DEL CASO: Paciente masculino, de 78 años, 85 kg, 168 cm, estado físico ASA III, hipertenso, con coronariopatía e insuficiencia renal crónica. Candidato a cirugía de voluminosas hernias inguinales bilateral y umbilical, siendo sometido durante una semana a neumoperitoneo para crear espacio. Posteriormente a la venoclisis con catéter 18G, monitorización con cardioscopio, presión arterial no invasiva y oximetria de pulso, fue sedado con 1 mg de midazolam y fentanil 100 µg por vía venosa y colocado en decúbito lateral izquierdo. Sometido a la raquianestesia continua por vía mediana en L3-L4, y conjunto de aguja cortante 27G con catéter 22G. La dosis total de anestésico utilizada en el procedimiento fue 25 mg de bupivacaína al 0,5 por ciento (hiperbárica con glucosa al 1,6 por ciento) y 160 mg de lidocaína al 2 por ciento (hiperbárica con glucosa al 1,6 por ciento) y morfina (100 µg). Paciente con seguimiento hasta el 30º día sin quejidos neurológicos. CONCLUSIONES: Recientemente, la mala distribución del anestésico local a través de microcatéter, se atribuyó a una causa del síndrome de cola de caballo. Este relato de caso mostró que, con la administración de altas dosis de anestésicos hiperbáricos a través del nuevo catéter, no hubo una mala distribución ni el riesgo de síndrome de cola de caballo.

Anestesia para colecistectomia videolaparoscópica em paciente portador de doença de Steinert: relato de caso e revisão de literatura / Anesthesia for videolaparoscopic cholecystectomy in a patient with Steinert disease: case report and review of the literature / Anestesia para colecistectomía videolaparoscópica en oaciente oortador de enfermedad de Steinert: relato de caso y revisión de la literatura

JUSTIFICATIVA E OBJETIVOS: As distrofias miotônicas são doenças neuromusculares de transmissão autossômica dominante. Dentre elas, a distrofia miotônica tipo 1 (DM1), ou doença de Steinert, é a mais comum no adulto e, além do envolvimento muscular, apresenta manifestações sistêmicas importantes. A DM1 representa um desafio para o anestesiologista. Os pacientes apresentam maior sensibilidade às drogas anestésicas e complicações, principalmente cardíacas e pulmonares. Além disso, há a possibilidade de apresentarem hipertermia maligna e crise miotônica. Descreveu-se o caso de um paciente que teve complicação pulmonar importante após ser submetido à anestesia geral. RELATO DO CASO: Paciente de 39 anos, portador de DM1, foi submetido à anestesia geral para colecistectomia videolaparoscópica. A anestesia foi venosa total com propofol e remifentanil e rocurônio. O procedimento cirúrgico de 90 minutos não apresentou intercorrências, mas após a extubação o paciente apresentou insuficiência respiratória e crise miotônica, que tornou a intubação traqueal impossível. Utilizou-se a máscara laríngea, que possibilitou a oxigenação adequada, e a ventilação mecânica foi mantida até a recuperação total da atividade respiratória. Evolução ocorreu sem outras complicações. CONCLUSÕES: A DM1 é uma doença que apresenta várias peculiaridades para o anestesiologista. O conhecimento minucioso do seu envolvimento sistêmico, associado à ação diferenciada das drogas anestésicas nesses pacientes, proporcionará um ato anestésicocirúrgico mais seguro.

BACKGROUND AND OBJECTIVES: Myotonic dystrophies are autosomal dominant neuromuscular diseases. Among them, myotonic dystrophy type 1 (MD1), or Steinert disease, is the most common in adults, and besides muscular involvement it also has important systemic manifestations. Myotonic dystrophy type 1 poses a challenge to the anesthesiologist. Those patients are more sensitive to anesthetics and prone to cardiac and pulmonary complications. Besides, the possibility of developing malignant hyperthermia and myotonic episodes is also present. CASE REPORT: This is a 39-year old patient with DM1 who underwent general anesthesia for videolaparoscopic cholecystectomy. Total intravenous anesthesia with propofol, remifentanil, and rocuronium was the technique chosen. Intercurrences were not observed in the 90-minute surgical procedure, but after extubation, the patient developed respiratory failure and myotonia, which made tracheal intubation impossible. A laryngeal mask was used, allowing adequate oxygenation, and mechanical ventilation was maintained until full recovery of the respiratory function. The patient did not develop further complications. CONCLUSIONS: Myotonic dystrophy type 1 presents several particularities to the anesthesiologist. Detailed knowledge of its systemic involvement along with the differentiated action of anesthetic drugs in those patients will provide safer anesthetic-surgical procedure.

JUSTIFICATIVA Y OBJETIVOS: Las distrofias miotónicas son enfermedades neuromusculares de transmisión autosómica dominante. Entre ellas está la distrofia miotónica tipo 1 (DM1), o enfermedad de Steinert, que es la más común en el adulto y además de la involucración muscular, presenta manifestaciones sistémicas importantes. La DM1 representa un reto para el anestesiólogo. Los pacientes presentan una mayor sensibilidad a los fármacos anestésicos y complicaciones, principalmente cardíacas y pulmonares. Además de eso, existe la posibilidad de presentar hipertermia maligna y crisis miotónica. Se ha descrito el caso de un paciente que tuvo una complicación pulmonar importante después de haber sido sometido a la anestesia general. RELATO DEL CASO: Paciente de 39 años, portador de DM1, sometido a la anestesia general para colecistectomía videolaparoscópica. La anestesia fue venosa total con propofol y remifentanil y rocuronio. El procedimiento quirúrgico de 90 minutos no presentó intercurrencias, pero después de la extubación, el paciente presentó insuficiencia respiratoria y crisis miotónica, que hizo la intubación traqueal imposible. Se utilizó la máscara laríngea, que posibilitó la oxigenación adecuada, y la ventilación mecánica se mantuvo hasta la recuperación total de la actividad respiratoria. Evolucionó sin otras complicaciones. CONCLUSIONES: La DM1 es una enfermedad que presenta varias peculiaridades para el anestesiólogo. El conocimiento minucioso de su involucración sistémica, asociado a la acción diferenciada de los fármacos anestésicos en esos pacientes, proporcionará un acto anestésico-quirúrgico más seguro.

Uso do bloqueio combinado raqui-peridural durante cirurgia de cólon em paciente de alto risco: relato de caso / Uso del bloqueo combinado raquiepidural durante cirugía de colon en paciente de alto riesgo: relato de caso / Combined spinal epidural anesthesia during colon surgery in a high-risk patient: case report

Justificativa e objetivos: O bloqueio combinado raqui-peridural (BCRP) oferece vantagens sobre a anestesia peridural ou subaracnóidea com injeção única. O objetivo deste relato foi apresentar um caso onde a anestesia subaracnóidea segmentar pode ser técnica efetiva para intervenção cirúrgica gastrintestinal...

Background and objectives: Combined spinal epidural anesthesia (CSEA) has advantages over single injection epidural or subarachnoid blockades. The objective of this report was to present a case in which segmental subarachnoid block can be an effective technique for gastrointestinal surgery...

Justificativa y objetivos: El bloqueo combinado raquiepidural (BCRE), tiene ventajas sobre la anestesia epidural o subaracnoidea con inyección única. El objetivo de este relato, fue presentar un caso donde la anestesia subaracnoidea segmentaria, puede ser una técnica efectiva para la intervención quirúrgica gastrointestinal...

Raquianestesia contínua em paciente submetido à gastrectomia parcial: relato de caso / Raquianestesia continua en paciente sometido a la gastrectomía parcial: relato de caso / Continuous spinal block in a patient undergoing partial gastrectomy: case report

JUSTIFICATIVA E OBJETIVOS: Devido à alta incidência de complicações técnicas e neurológicas, a raquianestesia contínua foi abandonada por muitos anos. Com o surgimento dos cateteres intermediários, a técnica vem ressurgindo e ganhando simpatia no arsenal anestesiológico. O objetivo deste relato foi resgatar a utilidade da técnica como alternativa viável para procedimento de médio a grande porte. RELATO DO CASO: Paciente feminina, 58 anos, 62 kg, estado físico ASA I, com relato de enxaqueca, lombalgia e procedimentos cirúrgicos prévios sob raquianestesia sem intercorrências. Candidata à laparotomia exploradora por provável tumor pélvico. Após venóclise com cateter 18G, monitorização com cardioscópio, pressão arterial-não invasiva e oximetria de pulso, foi sedada com midazolam 2 mg e fentanil 100 »g e colocada em decúbito lateral esquerdo. Foi submetida à raquianestesia contínua por via mediana em L3-L4. Foram injetados 9 mg de bupivacaína hiperbárica a 0,5 por cento e 120 »g de sulfato de morfina. Após inspeção da cavidade, verificou-se que o tumor era proveniente do estroma gástrico, sendo necessária ampliação da incisão e realização de gastrectomia parcial. Todo o procedimento foi realizado com pequena dose de solução hiperbárica e completa estabilidade hemodinâmica. Não houve necessidade de UTI no pós-operatório e a paciente evoluiu sem queixas e com alto grau de satisfação. Recebeu alta hospitalar após 72 horas sem nenhuma intercorrência. CONCLUSÕES: Os cateteres intermediários utilizados em raquianestesia contínua mostram-se promissores em tornar a técnica bastante atraente e de grande utilidade em operações de médio a grande porte, podendo inclusive ser alternativa eficaz no manuseio de pacientes em estado crítico, em que grandes repercussões hemodinâmicas podem ser deletérias.

BACKGROUND AND OBJECTIVES: Due to the high incidence of technical and neurological complications, continuous spinal blocks were not performed for several years. With the advent of intermediate catheters the technique has been used more often and gaining acceptance among anesthesiologists. The objective of this report was to demonstrate the usefulness of the technique as a viable alternative for medium and major size surgeries. CASE REPORT: This is a 58 years old female patient, weighing 62 kg, physical status ASA I, with a history of migraines, low back pain, and prior surgeries under spinal block without intercurrence. The patient was scheduled for exploratory laparotomy for a probable pelvic tumor. After venoclysis with an 18G catheter, monitoring with cardioscope, non-invasive blood pressure and pulse oximetry was instituted; she was sedated with 2 mg of midazolam and 100 »g of fentanyl, and placed in left lateral decubitus. The patient underwent continuous spinal block through the median approach in L3-L4; 9 mg of 0.5 percent hyperbaric bupivacaine and 120 »g of morphine sulfate were administered. Inspection of the abdominal cavity revealed a gastric stromal tumor that required an increase in the incision for a partial gastrectomy. A small dose of hyperbaric solution was required for the entire procedure, which was associated with complete hemodynamic stability. Postoperative admission to the ICU was not necessary; the patient presented a good evolution without complaints and with a high degree of satisfaction. She was discharged from the hospital after 72 hours without intercurrence. CONCLUSIONS: Intermediate catheters used in continuous spinal blocks have shown the potential to turn it an attractive and useful technique in medium and large size surgeries and it can even be an effective alternative in the management of critical patients to whom hemodynamic repercussions can be harmful.

JUSTIFICATIVA Y OBJETIVOS: A causa de la elevada incidencia de las complicaciones técnicas y neurológicas, la raquianestesia continua fue abandonada durante muchos años. Con el surgimiento de los catéteres intermediarios, la técnica ha venido evolucionando nuevamente y obteniendo la simpatía en el arsenal anestesiológico. El objetivo de este relato, fue rescatar la utilidad de la técnica como una alternativa viable para el procedimiento de medio y gran porte. RELATO DEL CASO: Paciente femenina, 58 años, 62 kg, estado físico ASA I, con relato de jaqueca, lumbago y procedimientos quirúrgicos previos, bajo raquianestesia sin intercurrencias. Candidata a laparotomía exploradora por un probable tumor pélvico. Después de efectuada la venoclisis con catéter 18G, monitorización con cardioscopio, presión arterial no invasiva, y la oximetría de pulso, se le sedó con midazolam 2 mg y fentanil 100 »g y se le puso en decúbito lateral izquierdo. Se le sometió a la raquianestesia continua por vía mediana en L3-L4. Se le inyectaron 9 mg bupivacaína hiperbárica a 0,5 por ciento y 120 »g de sulfato de morfina. Después de la inspección de la cavidad, se verificó que el tumor era proveniente del estroma gástrico, siendo necesaria la ampliación de la incisión y la realización de gastrectomía parcial. Todo el procedimiento fue realizado con una pequeña dosis de solución hiperbárica y una completa estabilidad hemodinámica. No hubo necesidad de UCI en el postoperatorio y la paciente evolucionó sin quejarse y con un alto grado de satisfacción. Recibió el alta después de 72 horas sin ningún problema. CONCLUSIONES: Los catéteres intermediarios utilizados en la raquianestesia continua parecen ser promisorios en hacer con que la técnica sea bastante atractiva y de gran utilidad en operaciones de medio y gran porte, y puede incluso ser una alternativa eficaz en el manejo de pacientes en estado crítico, donde las grandes repercusiones hemodinámicas pueden ser perjudiciales.

Controle de temperatura em intervenção cirúrgica abdominal convencional: comparação entre os métodos de aquecimento por condução e condução associada à convecção / Control de temperatura en intervención quirúrgica abdominal convencional: comparación entre los métodos de calentamiento por conducción y conducción asociada a la convección / Temperature control in conventional abdominal surgery: comparison between conductive and the association of conductive and convective warming

JUSTIFICATIVA E OBJETIVOS: Hipotermia intra-operatória é complicação frequente, favorecida por operação abdominal. A eficácia da associação dos métodos de aquecimento por condução e convecção na prevenção de hipotermia e seus efeitos no período de recuperação pós-operatória foram os objetivos deste estudo. MÉTODO: Quarenta e três pacientes de ambos os sexos de 18 a 88 anos de idade, submetidos à laparotomia xifopúbica sob anestesia geral e monitorização da temperatura esofágica, foram distribuídos de modo aleatório em dois grupos de aquecimento: COND (n = 24), com colchão de circulação de água a 37ºC no dorso e COND + CONV (n = 19), com a mesma condição associada à manta de ar aquecido a 42ºC sobre o tórax e membros superiores. Analisados peso, sexo, idade, duração da operação e anestesia, temperaturas na indução anestésica (Mi), horas consecutiva (M1, M2), final da operação (Mfo) e anestesia (Mfa), entrada (Me-REC) e saída (Ms-REC) da recuperação pós-anestésica (SRPA), além das incidências de tremores e queixas de frio no pós-operatório. RESULTADOS: Os grupos foram semelhantes em todas as variáveis analisadas, exceto nas temperaturas em M2, M3, M4, Mfo e Mfa. O grupo COND reduziu a temperatura a partir da segunda hora da indução anestésica, mas o grupo COND + CONV só na quarta hora. Em COND, observou-se hipotermia na entrada e saída da SRPA. CONCLUSÕES: Associar métodos de aquecimento retardou a instalação e diminui a intensidade da hipotermia intra-operatória, mas não reduziu a incidência das queixas de frio e tremores.

JUSTIFICATIVA Y OBJETIVOS: La Hipotermia intraoperatoria es una complicación frecuente, favorecida por la operación abdominal. La eficacia de la asociación de los métodos de calentamiento por conducción y convección en la prevención de hipotermia y sus efectos en el período de recuperación postoperatoria, fueron los objetivos de este estudio. MÉTODO: Cuarenta y tres pacientes de los dos sexos, entre 18 y 88 años de edad, sometidos a la laparotomía xifopúbica bajo anestesia general y monitorización de la temperatura esofágica, aleatoriamente distribuidos en dos grupos de calentamiento: COND (n = 24) colchón de circulación de agua a 37,0ºC en el dorso y COND + CONV (n = 19) la misma condición asociada a la manta de aire calentado a 42ºC sobre el tórax y los miembros superiores. Se analizó el peso, sexo, edad, duración de la operación y anestesia, temperaturas en la inducción anestésica (Mi), horas consecutiva (M1, M2), final de la operación (Mfo) y anestesia (Mfa), entrada (Me-REC) y salida (Ms-REC) de la recuperación postanestésica (SRPA), además de las incidencias de temblores y quejidos de frío en el postoperatorio. RESULTADOS: Los grupos fueron similares en todas las variables analizadas, excepto en las temperaturas en M2, M3, M4, Mfo y Mfa. El Grupo COND redujo la temperatura a partir de la segunda hora de la inducción anestésica, pero el grupo COND + CONV sólo en la cuarta hora. En COND se observó una hipotermia en la entrada y en la salida de la SRPA. CONCLUSIONES: El asociar métodos de calentamiento, retardó la instalación y redujo la intensidad de la hipotermia intraoperatoria, pero no redujo la incidencia de los quejidos de frío y los temblores.

BACKGROUND AND OBJECTIVES: Intraoperative hypothermia is a common complication, and its development is favored by abdominal surgeries. The efficacy of the association of conductive and convective warming methods in the prevention of hypothermia, and its effects during postoperative recovery were the objectives of this study. METHODS: Forty-three patients of both genders, ages 18 to 88 years, undergoing xyphopubic laparotomy under general anesthesia and monitoring of the esophageal temperature were randomly divided in two groups, according to the warming method: COND (n = 24), circulating-water mattress at 37º C on the back, and COND + CONV (n = 19), circulating-water mattress associated with warm air blanket at 42º C over the thorax and upper limbs. Weight, gender, age, duration of surgery and anesthesia, temperature on anesthetic induction (Mi), consecutive hours (M1, M2), end of surgery (Mes) and anesthesia (Mea), and admission (Ma-REC) and discharge (Md-REC) from the post-anesthetic recovery room (PARR), besides the postoperative incidence of tremors and complaints of cold, were analyzed. RESULTS: Both groups were similar regarding all parameters analyzed, except temperatures on M2, M3, M4, Mes, and Mea. The temperature of patients in the COND group decreased from the second hour of anesthetic induction on, but in the COND + CONV group it only happened in the fourth hour. Patients in the COND group presented hypothermia upon admission and discharge from the PARR. CONCLUSIONS: The association of different warming methods delayed the beginning and reduced the severity of intraoperative hypothermia, but it did not reduce the complaints of feeling cold and tremors.

Anestesia em anã acondroplásica obesa mórbida para gastroplastia redutora / Anestesia en enana acondroplásica obesa mórbida para gastroplastia reductora / Anesthesia for bariatric surgery in an achondroplastic dwarf with morbid obesity

JUSTIFICATIVA E OBJETIVOS: A acondroplasia é a forma mais comum entre os diversos tipos de osteocondrodisplasias causadoras do nanismo. O anão pode ser acometido de obesidade com relativa frequência e o tratamento cirúrgico tem demonstrado maior eficácia tanto para a perda efetiva de peso quanto para a sua manutenção a longo prazo. O objetivo deste trabalho foi apresentar um caso de gastroplastia redutora com derivação intestinal em Y-de-Roux em anão acondroplásico obeso mórbido. Foram analisadas as diversas dificuldades encontradas no manuseio anestésico deste paciente e a maneira pela qual foram abordadas, objetivando a diminuição da morbimortalidade no intra-operatório. RELATO DO CASO: Paciente de 29 anos, feminina, anã com acondroplasia e obesidade mórbida desde a infância. Suas medidas eram de 123 cm de altura e peso corporal de 144 kg. Com índice de massa corporal (IMC) de 95,18 kg.m-2, apresentava várias doenças associadas, sobretudo dos sistemas respiratório e osteoarticular. Após longo período de acompanhamento com dieta, exercícios físicos e apoio psicológico, a paciente melhorou sua condição clínica, sendo encaminhada para a realização da operação proposta: gastroplastia redutora à Capella-Fobi. Na anestesia houve dificuldade na intubação traqueal acordada sob laringoscopia direta, sendo necessária a utilização do broncofibroscópio. Transcurso intra-operatório sem complicações, sendo mantida sob anestesia geral venosa total com infusão contínua de remifentanil e propofol. Extubada ao final do procedimento na sala cirúrgica. CONCLUSÕES: As comorbidades simultâneas da acondroplasia e da obesidade mórbida podem dificultar o manuseio anestésico, sobretudo em relação às vias aéreas. É necessário uma avaliação pré-anestésica bem conduzida para antecipar condutas e minimizar esses riscos, otimizando, assim, a condução da anestesia.

JUSTIFICATIVA Y OBJETIVOS: La acondroplasia es la forma más común entre los diversos tipos de osteocondrodisplasias causadoras del enanismo. El enano puede ser acometido de obesidad con una relativa frecuencia, y el tratamiento quirúrgico ha demostrado una mayor eficacia, tanto para la pérdida efectiva de peso como para a su mantenimiento a largo plazo. El objetivo de este trabajo fue presentar un caso de gastroplastia reductora con derivación intestinal en Y-de-Roux en enano acondroplásico obeso mórbido. Se analizaron las diversas dificultades encontradas en el manejo anestésico de este paciente y la manera a través de la cual se abordaron, objetivando la disminución de la morbi mortalidad en el intraoperatorio. RELATO DEL CASO: Paciente de 29 años, femenina, enana, con acondroplasia y obesidad mórbida desde la infancia. Sus medidas eran de 123 cm de altura y peso corporal de 144 kg, al momento de la entrada en el servicio de Cirugía Bariátrica. Con un índice de masa corporal (IMC) de 95,18 kg.m-2, presentaba varias enfermedades asociadas, principalmente del sistema respiratorio y osteoarticular. Después de un largo período de acompañamiento con dieta, ejercicios físicos y apoyo psicológico, la paciente mejoró su condición clínica, siéndole intervenida con la operación propuesta: gastroplastia reductora a la Capella-Fobi. En la anestesia, hubo dificultad en la intubación traqueal con la paciente despierta y bajo laringoscopía directa, siendo necesaria utilización del broncofibroscopio. Transcurso intraoperatorio sin complicaciones, siendo mantenida bajo anestesia general venosa total con infusión continua de remifentanil y propofol. Extubada al final del procedimiento en la sala de operaciones. CONCLUSIONES: Las comorbidades simultáneas de la acondroplasia y de la obesidad mórbida pueden dificultar el manejo anestésico, principalmente con relación a las aéreas. Es necesario una evaluación preanestésica bien conducida para anticipar conductas...

BACKGROUND AND OBJECTIVES: Achondroplasia is the most common form among the different types of osteochondrodysplasia that cause dwarfism. Dwarves develop obesity quite frequently, and surgical treatment has shown greater efficacy, both for effective weight loss and long term maintenance. The objective of this report was to present the case of bariatric surgery with Y-en-Roux gastric bypass in an achondroplastic dwarf with morbid obesity. The different difficulties in the anesthetic management of this patient and the way they were dealt with were discussed in order to decrease intraoperative morbidity and mortality. CASE REPORT: This is a 29 years old female dwarf with achondroplasia and morbid obesity since childhood. She was 123 cm tall and weighed 144 kg at the time of admission to the Bariatric Surgery service. With a body mass index (BMI) of 95.18 kg.m-2, she had several associated diseases especially of the respiratory system and osteoarticular system. After a long follow-up with diet, exercises, and psychological support, her clinical condition improved and she was referred for surgery: Y-en-Roux gastroplasty using the technique of Capella-Fobi. Intubation of the awake patient under direct laryngoscopy was difficult and a bronchofibroscope had to be used. Surgery was uneventful and the patient was maintained under total intravenous anesthesia with continuous infusion of remifentanil and propofol. She was extubated at the end of the surgery still in the operating room. CONCLUSIONS: The simultaneous comorbidities of achondroplasia and morbid obesity can hinder the anesthetic management, especially regarding the airways. A thorough pre-anesthetic evaluation is necessary to anticipate the conducts and minimize risks, therefore optimizing the evolution of anesthesia.

Remifentanil versus Sufentanil em infusão contínua em intervenções cirúrgicas videolaparoscópicas: estudo comparativo / Continuous infusion of remifentanil versus sufentanil in videolaparoscopic surgeries: a comparative study

JUSTIFICATIVA E OBJETIVOS: A infusão contínua (IC) de remifentanil na técnica de anestesia venosa total é prática comum. Já o sufentanil em IC para cirurgias de curta/média duração tem sido pouco utilizado. O objetivo desse estudo foi comparar duas técnicas de anestesia venosa total, utilizando remifentanil ou sufentanil em IC, quanto ao comportamento anestésico no intra-operatório e às características da recuperação anestésica em pacientes submetidos à videolaparoscopia. MÉTODO: Participaram desse estudo 60 pacientes divididos em 2 grupos iguais (GR e GS). O GR foi induzido com remifentanil IC e o GS com sufentanil em bolus associado à IC. A IC de remifentanil era desligada ao fim da cirurgia, enquanto a IC de sufentanil, 20 minutos antes. Os pacientes receberam no intra-operatório cetoprofeno e dipirona. Como analgésico de resgate na sala de recuperação pós-anestésica (SRPA) foi utilizado tramadol. Foram analisados as variações da pressão arterial média (PAM) e freqüência cardíaca (FC), o tempo de despertar, o consumo de propofol, as intercorrências na SRPA e o tempo de permanência na SRPA. RESULTADOS: A média da PAM foi maior no GS em relação ao GR (91,9 × 77,6, p < 0,0001). A incidência de dor foi significativamente maior no GR em relação ao GS (22 × 1 paciente, p < 0,0001). A incidência de NVPO foi maior no GR em relação ao GS (10 × 2 pacientes, p = 0,0098). A média do tempo de permanência na SRPA foi maior no GR em relação ao GS (76 × 49 min, p < 0,0001). CONCLUSÕES: O controle hemodinâmico foi satisfatório nos grupos. A IC de sufentanil promoveu melhor controle da dor no pós-operatório com menor consumo de analgésico de resgate; conseqüentemente, houve menor incidência de NVPO e menor tempo de permanência na SRPA.

BACKGROUND AND OBJECTIVES: Continuous infusion (CI) of remifentanil is common in total intravenous anesthesia. On the other hand, CI of sufentanil for short/medium-term surgeries has not been widely used. The objective of this study was to compare two techniques of total intravenous anesthesia, using CI of remifentanil or sufentanil, regarding their intraoperative behavior and characteristics of recovery of patients undergoing videolaparoscopic surgeries. METHODS: Sixty patients, equally divided in 2 groups (RG and SG), participated in this study. Continuous infusion of remifentanil was used for anesthetic induction in RG, while a bolus of sufentanil associated with CI of this drug was used in SG. The CI of remifentanil was discontinued at the end of the surgery, while the CI of sufentanil was discontinued 20 minutes before the end of the surgery. Patients received ketoprofen and dypirone intraoperatively. Tramadol was used for rescue analgesia in the recovery room. Variations of mean arterial pressure (MAP) and hard reate (HR), time for awakening, propofol consumption, intercurrences in the recovery room, and time of stay in the recovery room were analyzed. RESULTS: Mean MAP was greater in SG than in RG (91.9 × 77.6, p < 0.0001). The incidence of pain was significantly greater in RG than on SG (22 × 1 patient, p < 0.0001). The incidence of postoperative nausea and vomiting (PONV) was greater in RG than in SG (10 × 2 patients, p < 0.0098). The mean time of stay in the recovery room was greater in RG than in SG (76 × 49 min, p < 0.0001). CONCLUSIONS: Hemodynamic control was satisfactory in both groups. Continuous infusion of sufentanil promoted better postoperative pain control with decreased consumption of rescue analgesic and, consequently, reduced incidence of PONV and reduced time of stay in the recovery room.

JUSTIFICATIVA Y OBJETIVOS: La infusión continua (IC) de remifentanil en la técnica de anestesia venosa total es una práctica común. Ya el sufentanil en IC para cirugías de corta/media duración ha sido poco utilizado. El objetivo de este estudio fue el de comparar dos técnicas de anestesia venosa total, utilizando remifentanil o sufentanil en IC, en cuanto al comportamiento anestésico en el intraoperatorio y en cuanto a las características de la recuperación anestésica en pacientes sometidos a la videolaparoscopía. MÉTODO: Participaron en el estudio 60 pacientes divididos en 2 grupos iguales (GR y GS). El GR fue inducido con remifentanil IC y el GS con sufentanil en bolus asociado a IC. La IC de remifentanil se desconectaba al final de la cirugía, mientras que la IC de sufentanil 20 minutos antes. Los pacientes recibieron en el intraoperatorio cetoprofeno y dipirona. Como analgésico de rescate en la sala de recuperación pos anestésica (SRPA) se usó el tramadol. Fueron analizadas las variaciones de la PAM y FC, tiempo de despertar, consumo de propofol, intercurrencias en la SRPA y tiempo de permanencia en la SRPA. RESULTADOS: El promedio de la PAM fue mayor en el GS con relación al GR (91,9 × 77,6, p < 0,0001). La incidencia de dolor fue significativamente mayor en el GR con relación al GS (22 × 1 paciente, p < 0,0001). La incidencia de NVPO fue mayor en el GR con relación al GS (10 × 2 pacientes, p = 0,0098). El promedio del tiempo de permanencia en la SRPA fue mayor en el GR en con relación al GS (76 × 49 min, p < 0,0001). CONCLUSIONES: El control hemodinámico fue satisfactorio en los grupos. La IC de sufentanil generó un mejor control del dolor en el pos operatorio con menor consumo de analgésico de rescate, por lo tanto, se registró una menos incidencia de NVPO y un menor tiempo de permanencia en la SRPA.

Avaliação da aplicação do índice de tobin no desmame da ventilação mecânica após anestesia geral / Evaluating the use of the tobin index when weaning patients from mechanical ventilation after general anesthesia

JUSTIFICATIVA E OBJETIVO: O índice preditivo de descontinuação da ventilação mecânica é parâmetro de prognóstico de desmame. O objetivo deste estudo foi avaliar a aplicação do índice de Tobin antes da extubação traqueal em pacientes submetidos à anestesia geral. MÉTODO: Foram analisados 80 pacientes, 40 (50 por cento) homens e 40 (50 por cento) mulheres submetidos a colecistectomia sob anestesia geral. A média de idade foi 57,7 ± 12,4 (33 a 82 anos) e a média do peso corpóreo foi 70,85 ± 11,07 (48 a 90 kg). Trinta e sete (46,2 por cento) pacientes eram tabagistas. O índice de Tobin foi obtido pela relação entre freqüência respiratória e volume corrente em ciclos/litro/minuto (c.L-1.min-1). Foram estudadas as variáveis: idade, peso, tabagismo, risco anestésico-cirúrgico, duração do procedimento, volume corrente expirado e freqüência respiratória pós-operatória, tempo de permanência na recuperação pós-anestésica, ocorrências clínicas intra-operatórias e gravidade das ocorrências clínicas após extubação. Foram utilizados testes estatísticos paramétricos e não-paramétricos, e análise de regressão logística univariada e múltipla. RESULTADOS: A idade (p = 0,019), peso corpóreo (p = 0,006), tabagismo (p = 0,014), risco anestésico (p = 0,0001), volume corrente (p < 0,0001), freqüência respiratória (p < 0,0001), tempo de permanência na recuperação pós-anestésica (p < 0,0001) e ocorrências clínicas pós-extubação (p < 0,0001) influenciaram de forma significativa o índice de Tobin. As variáveis independentes com risco de insucesso do desmame ventilatório foram idade avançada e o peso corpóreo elevado (p = 0,023). CONCLUSÕES: O desmame ventilatório pós-operatório com índice de Tobin > 80 c.L-1.min-1 e < 100 c.L-1.min-1 apresentou risco elevado de ocorrências clínicas pós-extubação traqueal. Nos pacientes com índice de Tobin > 80 c.L-1.min-1, a idade avançada e o peso corpóreo elevado constituíram variáveis independentes de risco para...

BACKGROUND AND OBJECTIVES: The predictive index for discontinuing mechanical ventilation is a prognostic parameter. The objective of this study was to evaluate the use of the Tobin index before tracheal extubation in patients undergoing general anesthesia. METHODS: Eighty patients, 40 (50 percent) men and 40 (50 percent) women undergoing cholecystectomy under general anesthesia were analyzed. The mean age of the patients was 57.7 ± 12.4 (33 to 82 years) and mean body weight was 70.85 ± 11.07 (48 to 90 kg). Thirty-seven patients (46.2 percent) were smokers. The Tobin index was obtained through the relationship between respiratory rate and tidal volume in cycles/Liter/minute (c.L-1.min-1). Age, weight, smoking, anesthetic-surgical risk, duration of the procedure, expired tidal volume, and postoperative respiratory rate, length of time in the recovery room, intraoperative clinical intercurrences and severity of the clinical intercurrences after extubation were studied. Parametric and non-parametric statistical tests, and analysis of univariate and multiple logistic regression were used. RESULTS: Age (p = 0.019), body weight (p = 0.006), smoking (p = 0.014), anesthetic risk (p = 0.0001), tidal volume (p < 0.0001), respiratory rate (p < 0.0001), length of time in the recovery room (p < 0.0001), and post-extubation clinical intercurrences (p < 0.0001) had a significant influence in the Tobin index. The independent variables with risk of failure to wean included advanced age and elevated body weight (p = 0.023). CONCLUSIONS: Weaning patients off mechanical ventilation in the postoperative period with a Tobin Index > 80 c.L-1.min-1 and < 100 c.L-1.min-1 was associated with elevated risk of postoperative clinical intercurrences after extubation. Patients with a Tobin index > 80 c.L-1.min, advanced age and increased body weight were independent variables of risk of failure to discontinue mechanical ventilation.

JUSTIFICATIVAS Y OBJETIVOS: El índice de predicción de descontinuación de la ventilación mecánica es parámetro de pronóstico de destete. El objetivo de este estudio fue evaluar la aplicación del índice de Tobin antes de la extubación traqueal en pacientes sometidos a la anestesia general. MÉTODO: Fueron analizados 80 pacientes, 40 (50 por ciento) hombres y 40 (50 por ciento) mujeres sometidos a colecistectomía bajo anestesia general. El promedio de edad fue 57,7 ± 12,4 (33 a 82 años) y la media del peso corporal fue 70,85 ± 11,07 (48 a 90 kg). Treinta y siete (46,2 por ciento) pacientes eran tabaquistas. El índice de Tobin se obtuvo por la relación entre frecuencia respiratoria y volumen corriente en ciclos/litro/minuto (c.L-1.min-1). Fueron estudiadas las variables edad, peso, tabaquismo, riesgo anestésico-quirúrgico, duración del procedimiento, volumen corriente expirado y frecuencia respiratoria postoperatoria, tiempo de permanencia en la recuperación post anestésica, incidencias clínicas intraoperatorias y gravedad de las incidencias clínicas después de la extubación. Fueron utilizados pruebas estadísticas paramétricos y no paramétricos, y análisis de regresión logística variada y múltiple. RESULTADOS: La edad (p = 0,019), peso corpóreo (p = 0,006), tabaquismo (p = 0,014), riesgo anestésico (p = 0,0001), volumen corriente (p < 0,0001), frecuencia respiratoria (p < 0,0001), tiempo de permanencia en la recuperación post anestésica (p < 0,0001) e incidencias clínicas pos extubación (p < 0,0001) influyeron significativamente en el índice de Tobin. Las variables independientes con riesgo de fracaso del destete por ventilación fueron edad avanzada y el peso corpóreo elevado (p = 0,023). CONCLUSIONES: El destete por ventilación postoperatorio con índice de Tobin > 80 c.L-1.min-1 y < 100 c.L-1.min-1 presentó riesgo elevado de incidencias clínicas después de la extubación traqueal. En los pacientes con índice de Tobin...

The Effect of Morphine on Pain and Bowel Function after Colonic Surgery:Epidural Bupivacaine-morphine Versus Intravenous Patient-controlled Analgesia with Morphine / 대한마취과학회지

BACKGROUND:Gastrointestinal paralysis after abdominal surgery has long troubled both patients and surgeons. Gastrointestinal side effects still constitute a major drawback in the acute use of opioids. Choice of postoperative analgesia may affect the rate of recovery of gastrointestinal function. The purpose of the present study was to investigate the influence of intravenous and epidural morphine on recovery of bowel function and pain by measuring intestinal motility and the visual analogue scale after colon surgery. METHODS: Twenty patients undergoing colon surgery used postoperative pain contol. Patients were allocated to receive either IV PCA (patient-controlled analgesia) with morphine or CEA (continuous epidural analgesia) with 0.1% bupivacaine-0.04% morphine. Patients were assessed for pain with a visual analogue scale, and for side effects at 1, 6, 12, 24, 48 hours postoperatively. Arterial blood samples for the measurement of blood gas and plasma concentration of morphine were taken. The time to first postoperative passage of flatus and feces, length of nasogastric therapy, time to liquid, soft and solid food intake, daily and total morphine requirement and length of hospital stay were recorded. RESULTS: There were no significant differences in bowel movement outcome except in length of nasogastric therapy, but the CEA group had significantly lower pain scores and required fewer days of nasogastric therapy when compared with the IV PCA group. CONCLUSIONS: These observations indicate that IV PCA with morphine and CEA can be used to relieve postoperative pain without prolonging the recovery of bowel movements, but CEA with bupivacaine and morphine constitutes an effective means of analgesia.

The Effects of Combined Epidural-General Anesthesia and Postoperative Epidural Analgesia on Recovery of Bowel Function and Complications in Colon Surgery / 대한마취과학회지

BACKGROUND: The combination of epidural opioids and local anesthetics provides synergistic analgesia and appears to provide superior analgesia with activity. But the effects of both drugs on bowel motility are oppositional. The object of this study is to evaluate the effect of combined epidural-general anesthesia and postoperative epidural analgesia on the recovery of bowel function and on complications in colon surgery. METHODS: 84 patients were allocated to three groups. 29 patients received intraoperative epidural- general anesthesia and continuous epidural analgesia with local anesthetic-opioid for 48 hours postoperatively (Group I). Group II (n = 25) and Group III (n = 30) received intraoperative general anesthesia alone with postoperative epidural analgesia with an intramuscular injection of analgesics, respectively. We compared the pain score and side effects of these analgesic methods, recovery of bowel movements, postoperative complications and postoperative hospital stay among groups. RESULTS: Groups I and II showed better analgesic effects at rest and upon coughing when compared with Group III (P<0.05). There were no significant differences in the incidences of nausea and vomiting, pruritus, motor blockade and the recovery time of bowel movement and postoperative hospital stay among groups. The incidences of ileus/wound complication and dysrhythmia were not different, but the incidence of pulmonary complication in group I (0%) was significantly lower than in group II (12%) and III (20%) (P<0.05). CONCLUSIONS: Combined epidural-general anesthesia and postoperative epidural analgesia results in decreases in the pain score and in the incidence of pulmonary complication. Moreover, epidural analgesia using local anesthetic and opioid does not affect side effects, recovery time of bowel motility, incidences of ileus/wound and dysrhythmia complications.

Effects of Epidural Analgesia with Morphine and Bupivacaine on Bowel Motility after Gastrectomy / 대한마취과학회지

BACKGROUND: Postoperative ileus is a universal complication after major intraabdominal surgery. Choice of postoperative analgesia may affect the rate of functional recovery of bowel. Epidural analgesia with morphine and bupivacaine is a popular method for pain relief. However little is known about the effects of this regimen on bowel motility. METHODS: Forty patients undergoing partial or total gastrectomy were randomized into two groups. All groups received a standardized general inhalation anesthesia with enflurane. Control group received traditional intramuscular(IM) administration of meperidine for the postoperative analgesia. Experimental group received a bolus of epidural 0.5% bupivacaine 10 ml followed by continuous epidural infusion of 0.21% bupivacaine with 0.01% morphine, started at the end of operation with the basal infusion rate of 1 ml/hours, bolus 1 ml, and ldegrees Ckout interval 30 min during 48 hr. We compared the analgesic effect, side effects and restoration of bowel function(first passage of flatus and feces)between two groups. Postoperative pain was assessed using the 10 cm visual analog pain scale (0=no pain, 10=worst imaginable pain) at rest. Scores were taken at 1, 6 hours after operation and 7 AM, 6 PM of the 1st postoperative day and 7 AM of the 2nd postoperative day. RESULTS: Experimental group revealed superior analgesia(p<0.005) but had a greater incidence of nausea, pruritus and urinary retention. No significant difference was found in restoration of bowel function between two groups. CONCLUSION: There was no superior effect of epidural analgesia with morphine and bupivacaine on bowel motility after gastrectomy than the effect of traditional IM meperidine administration.

There is Some Differences in the Changes of Liver Enzyme Levels among the Type of Surgery under Enflurane Inhalation Anesthesia / 대한마취과학회지

BACKGROUND: There are many factors which cause postoperative hepatic dysfunction. Anesthetic agents are not the most common factor and there aremany other factors such as preoperative condition of the patients, site and duration of the operation, operation per se and so on. The purposeof this study is to evaluate postoperative liver function with respect to different types of surgery. METHOD: Fourty three patients were classified into three groups; 11 patients for tympanoplasty with mastoidectomy (Group 1), 16 patients for total abdominal hysterectomy (Group 2), 15 patients for subtotal gastrectomy (Group 3). All patients were anesthesized with about 2 vol% of enflurane combined with 50% nitrous oxide. Serum glutamic oxalacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT) and alkaline phosphatase (ALP) were measured before anesthesia, 1, 3 and 7 days after surgery in all group, respectively. RESULT: In Group 1 and 2, postoperative SGOT and SGPT levels were maintained with preoperative level during the 7days, but in Group 3, those levels were increased in the 1st day but below upper limit (p<0.05) and decreased thereafter. Alkaline phosphatase level was maintained within the normal range for all the group during the 7 days. CONCLUSION: We consider that postoperative liver functioin may be influenced by different types of surgery, and also may be influenced by anesthetic time.

The Effects of Oral Clonidine on the Cytokines and Stress Hormone Responses in Patients Undergoing Abdominal Hysterectomy / 대한마취과학회지

BACKGROUND: Surgery cause alterations in immune and neuroendocrine responses. Cytokines and stress hormones are importanat mediators which modulate the various immune reactions. The aim of present study is to investigate whether clonidine premedication can affect on the concentrations of cytokines and stress hormones in abdominal hysterectomy patients. METHODS: Twenty two healthy women undergoing abdominal hysterectomy were randomly allocated to two groups: eleven control patients and eleven clonidine(0.15 mg) pretreated patients. Variations in blood cytokines, Interleukin-1beta(IL-1beta), IL-2, IL-6 and tumor necrosis factor-alpha(TNF-alpha), and stress hormones, cortisol and ACTH were studied. Blood sampling were conducted 4 times in each patient: after induction, after incision, after surgery 1 h and 3 h. Cytokines assays were carried out with commercially available ELISA kits, and cortisol with radioimmunoassay and ACTH with immunoradiometric assay. RESULTS: IL-1beta increased early and the concentrations of IL-1beta in clonidine treated group were significantly lower than control. The mean concentrations of IL-2 at 1 and 3 h after surgery were slightly higher than after induction in clonidine treated group. IL-6 increased significantly at 3 h after surgery in both groups. Clonidine lowered IL-6 during the whole period. TNF-alpha, and cortisol and ACTH concentraitons were not affected by clonidin. CONCLUSIONS: Clonidine pretreatment decreased IL-1beta and IL-6 concentrations, but not stress hormones in response to abdominal hysterectomy.

The Effect of Deep Breathing Exercise and Incentive Spirometry to Prevent Postoperative Pulmonary Complications after Abdominal Surgery in Geriatric Patients / 대한마취과학회지

BACKGROUND: The purpose of this clinical study was to evaluate the Incentive Spirometry (IS) and Deep Breathing Exercises (DBE) to prevent postoperative pulmonary complications after abdominal surgery in patients over 60 years of age. METHODS: We prospectively randomized 90 patients into 1 of 3 groups: the control group (30 patients) received no respiratory treatment, the IS group (30 patients) was treated with incentive spirometry 4 times daily and DBE group (30 patients) carried out deep breathing exercises under supervision for 15 min 4 times daily. ABGA was taken at ward, PR (preop.room), RR (recovery room), POD1 day and POD2 day. Roentgenographic changes observed at 24 h. and 48 h. after surgery. Pulmonary complications were defined as the development of 3 or more of 6 new findings: cough, sputum, dyspnea, chest discomfort, temperature greater than 38oC, pulse rate more than 100 beats/min. RESULTS: PaO2 in the DBE group and IS group at PR were significantly increased than the values at ward, and the values of the PaO2 in the DBE group at RR and POD1 day, and those of IS group at PR and POD2 day were significant higher than those of the control group (p<0.05). The frequency of development of pulmonary complications (43.3% in the control group, 20% in the DBE group, 20% in the IS group) and roentgenographic changes were comparable in the 3 groups (26.7%, 16.7%, 20% respectively). The DBE group showed the different incidence of postoperative pulmonary complications between upper and lower abdominal surgery (upper: lower= 35.7: 6.3%). CONCLUSIONS: We concluded that DBE and IS were effective in preventing postoperative pulmonary complications after abdominal surgery and lower abdominal surgery causes lesser postoperative pulmonary complications than upper abdominal surgery.

Pulmonary Thromboembolism Developed in Recovery Period of upper Abdominal Surgery: Case report / 대한마취과학회지

Pulmonary thromboembolism (PTE) is a serious postoperative complication. Prompt diagnosis of PTE is important but it is difficult because clinical manifestations of PTE are not obvious in most cases. A 59 year-old woman received cholecystectomy and choledocholithotomy under general anesthesia. At the 9th postoperative day, syncope, hypoxemia and hypotension were developed suddenly and the patient was transfered to intensive care unit. PTE was suspected with hemodynamic monitoring from pulmonary arterial catheter and echocardiography and diagnosed with lung perfusion scan and venogram of lower extremities. Proper cardiopulmonary support was done and the patient was recovered and discharged in improved condition. In conclusion, if a patient have syncopal attack with shock in postoperative period, PTE must be thought to be an one of possible causes of syncope and thoroughly investigated.