Presentación de un caso y revisión de literatura: anestesia total intravenosa en cirugía de estesioneuroblastoma / Presentation of a case and literature review: total intravenous anesthesia in estesioneuroblastoma surgery

Resumen: El estesioneuroblastoma es una neoplasia de las células del neuroepitelio olfatorio. Tiene una baja incidencia de 0.4 por cada millón de habitantes. Se caracteriza por síntomas como sinusitis, epistaxis, cefalea, discapacidad visual, obstrucción nasal, hiposmia y rinorrea. En este reporte se presenta el caso de un paciente masculino de 29 años con estesioneuroblastoma estadio Kadish C, quien fue programado para resección quirúrgica bajo anestesia total intravenosa con resultados satisfactorios durante el procedimiento quirúrgico.

Abstract: Esthesioneuroblastoma is a neoplasm of the olfactory neuroepithelium cells, it has a low incidence of 0.4 per million inhabitants. It is characterized by symptoms such as sinusitis, epistaxis, headache, visual impairment, nasal obstruction, hyposmia, and rhinorrhea. We present the case of a 29-year-old male patient with Kadish C stage esthesioneuroblastoma, who was scheduled for surgical resection under total intravenous anesthesia with satisfactory results during the surgical procedure.

Resultados de la anestesia total intra venosa (TIVA) con perfusión controlada por objetivo (TCI) en pacientes sometidos a trasplante renal / Outcomes of Total Intravenous Anesthesia (TIVA) with Goal Controlled Perfusion (TCI) in Kidney Transplant Patients

Introducción: La anestesia total intravenosa (TIVA) con perfusión controlada por objetivo (TCI) es una técnica de anestesia general que usa una combinación de fármacos administrados exclusivamente por vía intravenosa sin usar fármacos por vía inhalatoria. Objetivos: Determinar los resultados del uso de TIVA TCI en los pacientes sometidos a trasplante renal, donantes y receptores, entre noviembre de 2014 y julio de 2018, en el Hospital de Clínicas. Pacientes y métodos: Estudio observacional, analítico transversal, con muestreo no probabilístico a criterio. La serie se agrupó en donantes y receptores. Los datos se expresan en medias y proporciones, se analizó el Odds Rattio y el R2. Se consideró una p< 0,05 como significativa. Resultados: se incluyeron a 198 intervenciones anestésicas, 131 (66,2%) fueron receptores. El rango de edad fue de entre 5 y 66 años (35,8±13 años) y 114 (57%) fueron masculinos. En el post operatorio inmediato, el tiempo en despertar, la PAS, PAD, PAM, frecuencia cardiaca y saturación de oxígeno no tuvieron diferencias significativas, en la comparación de los grupos (donante y receptor). Se observó cefalea en 3 (1,5%) del grupo de donantes y ninguna en los receptores. La diuresis fue tardía en 18 (9,1%) pacientes (p= 0,084 R2=29). Conclusión: La TIVA TCI demostró ser una técnica muy efectiva en el trasplante renal, con pronta recuperación y despertar inmediato tras la extubación, con lucidez absoluta en todos los pacientes.

Introduction: Total intravenous anesthesia (TIVA) with goal-controlled perfusion (TCI) is a general anesthesia technique that uses a combination of drugs administered exclusively intravenously without using inhalational drugs. Objectives: To determine the results of the use of TIVA TCI in kidney transplant patients, donors and recipients, between November 2014 and July 2018, at the Hospital de Clínicas. Patients and methods: Observational, cross-sectional analytical study, with non-probabilistic sampling at the discretion. The series was grouped into donors and recipients. The data is expressed in means and proportions, the Odds Rattio and the R2 were analyzed. A p<0.05 was considered significant. Results: 198 anesthetic interventions were included, 131 (66.2%) were recipients. The age range was between 5 and 66 years (35.8±13 years) and 114 (57%) were male. In the immediate postoperative period, time to awakening, SBP, DBP, MAP, heart rate and oxygen saturation did not show significant differences when comparing the groups (donor and recipient). Headache was observed in 3 (1.5%) of the donor group and none in the recipients. Diuresis was late in 18 (9.1%) patients (p= 0.084 R2=29). Conclusion: TIVA TCI proved to be a very effective technique in kidney transplantation, with prompt recovery and immediate awakening after extubation, with absolute clarity in all patients.

Anestesia total intravenosa libre de opioides guiada por qCON y qNOX en paciente obesa / Total Intravenous anesthesia in patients with intestinal occlusive syndrome

Introducción: En los últimos años la anestesia libre de opioides ha constituido una alternativa más a las técnicas tradicionales de anestesia general. Con la exclusión de este grupo de fármacos se evitan los múltiples efectos adversos y complicaciones asociados al mismo. A pesar de que la anestesia libre de opioides tiene sus indicaciones y que ha demostrado sus beneficios en cierto grupo de pacientes, existen aún controversias en relación con su utilidad en el paciente obeso. Características como la obesidad hacen que los modelos multimodales empleados para programar la anestesia libre de opioides sean cada vez más complejos. Objetivos: Describir un caso clínico realizado con la técnica de anestesia libre de opioides que constituye la primera experiencia en Ecuador. Presentación del caso: Se presenta el caso de una paciente obesa intervenida de colecistectomía laparoscópica mediante infusión de propofol, ketamina, lidocaína, sulfato de magnesio, y dexmedetomidina. La titulación de estos fármacos se realizó mediante cálculo de concentraciones plasmáticas a través de modelos farmacocinéticos y guiada por monitorización de profundidad anestésica y analgésica, con lo cual se logró optimizar el consumo de fármacos, disminuir las complicaciones y una evolución clínica favorable. Hasta donde se conoce a nivel local y de país (Ecuador) es la primera experiencia que se reporta con esta técnica. Conclusiones: La anestesia libre de opioides puede resultar una elección en el paciente obeso ya que asegura una adecuada recuperación sin efectos adversos asociados(AU)

Introduction: In recent years, opioid-free anesthesia has become another alternative in front of traditional general anesthesia techniques. The exclusion of this group of drugs avoids the numerous adverse effects and complications associated with its usage. Although opioid-free anesthesia has its indications and has showed its benefits in a certain group of patients, there is still controversy regarding its usefulness in the obese patient. Characteristics such as obesity make the multimodal models used to program opioid-free anesthesia increasingly complex. Objectives: To describe a clinical case involving the opioid-free anesthesia technique, which is the first experience in Ecuador. Case presentation: The case is presented of a female obese patient who underwent laparoscopic cholecystectomy by infusion of propofol, ketamine, lidocaine, magnesium sulfate and dexmedetomidine. Titration of these drugs was carried out by calculating plasma concentrations through pharmacokinetic models and guided by monitoring of anesthetic and analgesic depth, thus optimizing drug consumption, reducing complications and achieving a favorable clinical evolution. As far as known locally and in the country (Ecuador), this is the first reported experience with this technique. Conclusions: Opioid-free anesthesia may be a choice in the obese patient, since it ensures adequate recovery without associated adverse effects(AU)

Anestesia total intravenosa en pacientes con síndrome oclusivo intestinal / Total Intravenous anesthesia in patients with intestinal occlusive syndrome

Introducción: La anestesia total intravenosa es una técnica de anestesia general en la que se administran los fármacos exclusivamente por vía endovenosa, en ausencia de agentes inhalatorios. Objetivo: Describir los resultados que se observaron en el empleo de la anestesia total intravenosa en los pacientes con diagnóstico de síndrome oclusivo para tratamiento quirúrgico. Métodos: Se desarrolló una investigación observacional descriptiva, longitudinal en el Hospital General Docente "Abel Santamaría Cuadrado", de enero de 2014 a enero de 2017. De un universo de 417 pacientes, se seleccionó una muestra de 205 casos que cumplieron con los criterios de inclusión y exclusión. Las variables fueron presión arterial media, frecuencia cardíaca, saturación de oxígeno, complicaciones, tiempo de recuperación, nivel de sedación y respuesta analgésica. Resultados: El 95,61 por ciento de los casos se mantuvieron normotensos y el 96,10 por ciento con frecuencia cardíaca normal. Se constataron signos clínicos de superficialidad anestésica en el 1,46 por ciento de los individuos. La mayoría de los casos se recuperaron entre 10 y 20 min para un 92,19 por ciento. Se observó un nivel de sedación insuficiente en 189 pacientes (92,19 por ciento). No se evidenciaron complicaciones posoperatorias en el 96,58 por ciento. La respuesta analgésica fue adecuada en el 95,12 por ciento de los casos. Conclusiones: La aplicación de la anestesia total intravenosa para cirugía por oclusión intestinal demostró resultados satisfactorios como método anestésico(AU)

Introduction: Total intravenous anesthesia is a general anesthesia technique in which drugs are administered exclusively intravenously, in the absence of inhalation agents. Objective: To describe the outcomes observed in the use of total intravenous anesthesia in patients diagnosed with occlusive syndrome for surgical treatment. Methods: A descriptive, longitudinal and observational research was carried out in Abel Santamaría Cuadrado General Teaching Hospital of Pinar del Río, Cuba, from January 2014 to January 2017. From a universe of 417 patients, a sample of 205 cases that met the inclusion and exclusion criteria was selected. The variables were mean arterial pressure, heart rate, oxygen saturation, complications, recovery time, level of sedation, and analgesic response. Results: 95.61 percent of the cases remained normotensive and 96.10 percent kept a normal heart rate. Clinical signs of sedation were found in 1.46 percent of the individuals. Most of the cases recovered between 10 and 20 minutes, accounting for 92.19 percent. Insufficient sedation was observed in 189 patients (92.19 percent). No postoperative complications were observed in 96.58 %. Analgesic response was adequate in 95.12 percent of cases. Conclusions: The application of total intravenous anesthesia for intestinal occlusion surgery showed satisfactory outcomes as an anesthetic method(AU)

Anestesia total intravenosa en la cirugía oncológica de mama / Total intravenous anesthesia in oncologist breast surgery

Introducción: El cáncer es la principal causa de muerte. Cada año se diagnostican millones de mujeres con cáncer de mama que necesitan tratamiento quirúrgico, para lo cual la anestesia total intravenosa parece ser una excelente opción. Objetivo: Describir los resultados de la aplicación de la anestesia total intravenosa en las pacientes a las que se les efectuó cirugía oncológica de mama. Métodos: Se realizó un estudio observacional, descriptivo, longitudinal, prospectivo, en el Servicio de Anestesiología del Hospital General Docente "Abel Santamaría Cuadrado" en el período comprendido entre enero de 2013 y enero de 2015. Se estudió una población accesible de 111 pacientes seleccionados mediante criterios de inclusión y exclusión. Para el análisis estadístico se utilizaron distribuciones de frecuencias, cálculo de medidas de tendencia central y de dispersión. Algunas de las variables fueron tensión arterial, frecuencia cardíaca, saturación de oxígeno, complicaciones, tiempo de recuperación, nivel de sedación, respuesta analgésica. Resultados: Se logró gran estabilidad hemodinámica en más del 95 por ciento de las pacientes. Se detectó superficialidad anestésica en 1,80 por ciento de los casos. El 92,80 por ciento de los casos se recuperaron entre 10 y 20 min. Se presentó sedación adecuada en 106 pacientes. Las principales complicaciones fueron las náuseas y los vómitos en 9,01 por ciento. Existió una adecuada respuesta analgésica en 93,69 por ciento de los casos. Conclusiones: La aplicación de la anestesia total intravenosa para cirugía oncológica de mama arrojó resultados muy satisfactorios como método anestésico(AU)

Introduction: Cancer is the leading cause of death worldwide. Every year millions of women are diagnosed with breast cancer and they need surgical treatment, for which total intravenous anesthesia seems to be an excellent option. Objective: Describe the results of the application of total intravenous anesthesia in patients undergoing oncological breast surgery. Methods: An observational, descriptive, longitudinal, prospective study was conducted in the Anesthesiology Service of "Abel Santamaría Cuadrado" Hospital in the period between January 2013 and January 2015. An accessible population of 111 patients selected using inclusion and exclusion criteria was studied. For the statistical analysis, frequency distributions, calculation of measures of central tendency and dispersion were used. Some of the variables were blood pressure, heart rate, oxygen saturation, complications, recovery time, level of sedation, analgesic response. Results: High hemodynamic stability was achieved in more than 95 percent of the patients. Anesthetic superficiality was detected in 1.80 percent of cases. 92.80 percent of the cases recovered after 10 to 20 minutes. Adequate sedation was present in 106 patients. The main complications were nausea and vomiting in 9.01 percent There was an adequate analgesic response in 93.69 percent of the cases. Conclusions: The application of total intravenous anesthesia for oncological breast surgery yielded very satisfactory results as an anesthetic method(AU)

Factores pronósticos de complicaciones en pacientes con cardiopatía isquémica sometidos a anestesia total intravenosa en cirugía electiva / Total intravenous anethesia in ischemic coronary patients: Prognosis factors

A prospective longitudinal cohort study was conducted in patients with ischemic heart disease undergoing total intravenous anesthesia in elective surgery at the "Carlos Manuel de Céspedes Bayamo Provincial Hospital, from the Cauto region during the period from January 1, 2015 to March 30, 2017; with the aim of identifying the risk factors hypothetically related to the prognosis of the appearance of anesthetic complications. The exposed cohort consisted of 47 patients who developed complications in the study period and met the inclusion criteria. To assess the association between the variables, the Mantel Chi-square test was used. The magnitude of the associations was estimated by calculating the relative risks (RR) of complications. The consumption of to- bacco as a toxic habit, the non-use of beta-blockers and statins were the surgical risk factors depending on the patient associated with the prognosis of the appearance of anesthetic complications; not so age. Comorbidity in patients with ischemic heart disease of diabetes mellitus, heart failure and arrhythmias, were associated with the appearance of anesthetic complications. The ASA III-IV classification and high-risk surgical procedures were the surgical risk factors based on the surgery related to the prognosis of anesthetic complications.

Se realizó un estudio longitudinal prospectivo de cohorte en pacientes con cardiopatía isquémica sometidos anestesia total intravenosa en cirugía electiva en el Hospital provincial "Carlos Manuel de Céspedes de Bayamo, procedentes de la región del Cauto durante el período comprendido desde el 1r de enero del 2015 hasta 30 de marzo de 2017. El objetivo era identificar los factores de riesgo hipotéticamente relacionados con el pronóstico de aparición de complicaciones anestésicas. La cohorte expuesta estuvo constituida por 47 pacientes que desarrollaron complicaciones en el período de estudio y cumplieron con los criterios de inclusión. Para valorar la asociación entre las variables, se empleó el test de Ji al Cuadrado de Mantel. La magnitud de las asociaciones se estimó mediante el cálculo de los riesgos relativos (RR) de complicaciones. El consumo de tabaco como hábito tóxico, el no uso de beta-bloqueadores y estatinas se constituyeron en los factores de riesgo quirúrgico en función del enfermo, asociados con el pronóstico de aparición de complicaciones anestésicas; no así la edad. La comorbilidad en los pacientes con cardiopatía isquémica de diabetes mellitus, insuficiencia cardíaca y las arritmias, se asociaron a la aparición de complicaciones anestésicas. La clasificación ASA III-IV y los procedimientos quirúrgicos de alto riesgo fueron los factores de riesgo quirúrgico en función de la cirugía relacionados con el pronóstico de aparición de complicaciones anestésicas.

Multimodal anesthesia associated with regional block in a dog who underwent corrective surgery for persistent right aortic arch: case report / Anestesia multimodal associada a bloqueio loco-regional em cão submetido a cirurgia corretiva para persistência de arco aórtico direito: relato de caso

The persistence of the fourth right aortic arch (PRAA) is a congenital malformation that affects the heart base's main vessels. Surgical treatment is recommended and should be advocated as a matter of urgency. In this context, efficient anesthesia planning is necessary, with satisfactory analgesia, associating multimodal techniques with regional blocks. The present work aims to report the anesthetic procedure during corrective surgery for PRAA in a dog. Neuroleptanalgesia was intramuscularly performed, using acepromazine (0.015 mg.kg-1) and methadone (0.3 mg.kg-1) in pre-anesthetic medication. Ketamine (1 mg.kg-1) and propofol (3 mg.kg-1) were administered at induction, both intravenously, followed by maintenance using total intravenous anesthesia with propofol (initial rate of 0.4 mg.kg-1 .minute) and remifentanil, (0.2 mcg.kg.-1.minute). In addition, ultrasound-guided regional intercostal block was performed, with 5% bupivacaine without vasoconstrictor (0.05ml.kg-1). Ketamine infusion was postoperatively maintained for one hour. The instituted protocol proved to be satisfactory in controlling trans and postoperative pain, maintaining all parameters stable during and after the procedure, without any intercurrence. Thus, the protocol provided quality recovery to the patient.(AU)

A persistência do quarto arco aórtico direito é uma má formação congênita, afetando os principais vasos da base cardíaca. O tratamento cirúrgico é recomendado e preconiza-se um planejamento anestésico eficiente, associando-se técnicas multimodais a bloqueios regionais. O presente trabalho objetiva relatar a anestesia durante cirurgia corretiva de PDA em cão. Na medicação pré-anestésica, instituiu-se neuroleptonalgesia, utilizando-se acepromazina (0,015 mg.kg-1) e metadona (0,3 mg.kg-1), por via intramuscular. Na indução, foi administrada cetamina (1mg.kg -1) e propofol (3 mg.kg-1). Para manutenção, utilizou--se propofol (taxa inicial de 0,4 mg.kg-1.minuto) e remifentanil, (0,2 mcg.kg-1.minuto). Além disso, foi realizado bloqueio regional intercostal guiado por ultrassom com bupivacaína sem vasoconstritor a 5% (0,05ml.kg-1). O paciente permaneceu em infusão analgésica de cetamina por uma hora, no pós operatório. O protocolo estabelecido demonstrou ser satisfatório no controle de dor trans e pós-operatória, mantendo todos os parâmetros estáveis, sem nenhuma intercorrência, proporcionando qualidade de recuperação ao paciente.(AU)

Oxigenación apnéica para extracción de cuerpo extraño en vía aérea / Apneic oxygenation for extracting a foreign body in the airway

La oxigenación apnéica consiste en la administración de flujos altos de oxígeno a través de algún dispositivo supraglótico mientras el paciente se mantiene en apnea. Se explica por qué el alveolo desnitrogenizado con una composición en su mayor parte de oxígeno, permite la difusión alveolo capilar y genera una presión subatmosférica capaz de arrastrar el flujo de oxigeno existente en el árbol traqueobronquial hasta el mismo alveolo, siempre y cuando no hubiera obstrucción mecánica de la vía aérea. El tiempo aumenta considerablemente hasta que la saturación de oxígeno disminuya, lo que se conoce como tiempo de apnea segura. Se presenta la experiencia de emplear esta técnica en un escolar de 5 años sin antecedentes patológicos, que ingirió un cuerpo extraño (semilla de girasol), la cual se localizaba en vía aérea bronquio principal derecho. Este se extrajo por fibrobroncoscopía bajo anestesia total intravenosa, priorizando la ventilación espontánea hasta localizarlo, y luego, debido a la dificultad que presentó su extracción, se empleó relajación muscular y apnea para optimizar las condiciones de la extracción. Durante este periodo, se empleó la técnica de oxigenación apnéica, la cual se mantuvo durante 12 min. La saturación pulsátil de oxigeno fue mayor al 92 por ciento, tiempo suficiente para culminar la extracción con éxito y sin complicaciones(AU)

Apneic oxygenation consists in the administration of high flows of oxygen through a supraglottic device while the patient remains in apnea. It is explained because the alveolus with low nitrogen concertation/accumulation, with a composition mostly of oxygen, allows capillary alveolus to diffuse, as well as it generates a subatmospheric pressure capable of dragging the oxygen flow existing in the tracheobronchial tree to the alveolus itself, as long as there is no mechanical airway obstruction. The time increases considerably until oxygen saturation decreases, which is known as the safe apnea time. The experience of using this technique is presented is it was used with a five-year-old boy with no pathological history and who swallowed a foreign body (sunflower seed), which was located in the airway, specifically the right main bronchus. The foreign body was extracted by fiberoptic bronchoscopy under total intravenous anesthesia, prioritizing spontaneous ventilation until it was located; and then, due to the difficulty for its extraction, muscle relaxation and apnea were used to optimize the extraction conditions. During this period, the apneic oxygenation technique was used and maintained for twelve minutes. Pulsatile oxygen saturation was greater than 92 percent, enough time to complete the extraction successfully and without complications(AU)

Infusiones controladas por objetivo y sistemas de circuito cerrado. Límites en expansión / Target-controlled infusions and closed-loop systems: expansion limits

Introducción: La administración manual en bolo ha evolucionado desde la infusión volumétrica basada en regímenes farmacológicos estandarizados, hasta los sistemas de infusión controlada por objetivo y los más sofisticados sistemas de circuito cerrado. Objetivo: Describir los principios tecnológicos y aplicaciones clínicas extendidas de la infusión controlada por objetivo y los sistemas de circuito cerrado. Métodos: Se realizó una revisión no sistemática de la literatura, en bases de datos científicas como Cochrane Database of Systematic Reviews, Pubmed/Medline, EMBASE, Scopus, Web of Science, EBSCOhost, Science Direct, OVID y el buscador académico Google Scholar, en el mes de septiembre del año 2020. Desarrollo: La disponibilidad y portabilidad de dispositivos electrónicos con capacidad de procesamiento avanzado a precios relativamente accesibles, el perfeccionamiento del aprendizaje automático e inteligencia artificial aplicado a las decisiones médicas, y las iteraciones tecnológicas complejas incorporadas en los sistemas de circuito abierto y cerrado, desarrollados originalmente en el campo de la Anestesiología, han posibilitado su expansión a otras especialidades y entornos clínicos tan disímiles como el tratamiento de la diabetes mellitus, administración de fármacos antineoplásicos, ventilación mecánica, control de las variables hemodinámicas y la terapia antimicrobiana en pacientes críticos. Conclusiones: La infusión controlada por objetivo y los sistemas de circuito cerrado se han convertido en tecnologías maduras, seguras y viables, aplicadas clínicamente en múltiples naciones y escenarios, con un desempeño superior a los sistemas manuales tradicionales(AU)

Introduction: Manual bolus administration has evolved from volumetric infusion based on standardized pharmacological regimens to target-controlled infusion systems and the most sophisticated closed-loop systems. Objective: To describe the technological principles and extended clinical applications of target-controlled infusion and closed-loop systems. Methods: A nonsystematic review of the literature was carried out, during September 2020, in scientific databases such as Cochrane Database of Systematic Reviews, Pubmed/Medline, EMBASE, Scopus, Web of Science, EBSCOhost, Science Direct, OVID and the academic search engine Google Scholar. Development: The availability and portability of electronic devices with advanced processing capacity at relatively affordable prices, the refinement of machine learning and artificial intelligence applied to medical decisions, as well as the complex technological iterations incorporated into open and closed-loop systems, originally developed in the field of anesthesiology, have enabled their expansion to other specialties and clinical settings so diverse as treatment of diabetes mellitus, administration of antineoplastic drugs, mechanical ventilation, control of hemodynamic variables and antimicrobial therapy in critical patients. Conclusions: Target-controlled infusion and closed-loop systems have become mature, safe and viable technologies, applied clinically in multiple nations and settings, with superior performance compared to traditional manual systems(AU)

Impacto de la anestesia intravenosa en cirugía robótica para paciente de alto riesgo sometido a cirugía oncológica de larga duración en el Centro Médico Naval / Impact of intravenous anesthesia in robotic surgery for high-risk patient undergoing long-term oncologic surgery at the Naval Medical Center

Resumen: La práctica de cirugía robótica es un proceso complejo que implica desarrollo y tecnología no sólo en el campo de la cirugía, sino también en el campo de la anestesiología. Implica un proceso multifactorial, ya que ha generado un cambio drástico multidisciplinario basado en tecnología de punta que pretende ofrecer mejores condiciones durante el manejo perioperatorio en cirugía robótica. La anestesia total intravenosa cumple objetivos específicos en relación a la posición del paciente, relajación cerebral, neuroprotección, hemodinamia, pérdida y recuperación de la conciencia, parálisis neuromuscular, parámetros ventilatorios, etc. Ofrece seguridad y calidad al paciente durante el procedimiento con una mínima interferencia con el monitoreo electrofisiológico y permite modular la profundidad anestésica desde una neurosedación hasta una anestesia general, de acuerdo a las diferentes etapas de la cirugía. Un factor atribuible a la anestesia moderna para el éxito de la cirugía robótica es usar diferentes agentes anestésicos que promuevan inducción, mantenimiento y emersión anestésica más rápida y suave, a fin de reducir el tiempo de recuperación del estado de conciencia, funciones básicas y psicomotoras como la anestesia general multimodal.

Abstract: The practice of robotic surgery is a complex process, involving development and technology; not only in the surgery field but also in the anesthesiology field. It implies a multifactorial process since it has generated a drastic multidisciplinary change based on state-of-the-art technology; which aims to offer better conditions during perioperative management in robotic surgery. Intravenous Total Anesthesia accomplishes specific objectives in relation to patient position, brain relaxation, neuroprotection, hemodynamics, loss and recovery of consciousness, neuromuscular paralysis, ventilatory parameters, providing safety and quality during the procedure; with minimal intervention during electrophysiological monitoring and enabling anesthetic depth to be modulated from neurosedation to general anesthesia, according to the different stages of the surgery. A factor attributable to modern anesthesia for robotic surgery success is to employ different anesthetic agents promoting induction, maintenance of general anesthesia, smother and faster anesthetic emersion, for the purpose of reducing recovery time of the state of consciousness), basic and psychomotor functions; as is the general multimodal anesthesia.

Comparison of Propofol or Isoflurane Anesthesia Maintenance, Combined with a Fentanyl-Lidocaine-Ketamine Constant-Rate Infusion in Goats Undergoing Abomasotomy.

This study aimed to compare, first, the anesthetic and cardiopulmonary effects of propofol or isoflurane anesthetic maintenance in goats receiving a fentanyl-lidocaine-ketamine infusion undergoing abomasotomy and, secondly, to compare the quality of the recovery from anesthesia. Two groups were used: propofol (TIVA) and isoflurane (PIVA). Goats were premedicated with fentanyl (10 µg/kg intravenously [IV]), lidocaine (2 mg/kg, IV), and ketamine (1.5 mg/kg, IV). Anesthesia was induced with propofol and maintenance consisted of fentanyl (10 µg/kg/h, IV), lidocaine (50 µg/kg/min, IV), and ketamine (50 µg/kg/min, IV) as constant-rate infusions (CRIs), combined with either CRI of propofol at initial dose of 0.3 mg/kg/min, IV (TIVA), or isoflurane with initial end-tidal (FE'Iso) concentration of 1.2% partial intravenous anesthesia (PIVA). The mean effective propofol dose for maintenance was 0.44 ± 0.07 mg/kg/min, while the mean FE'Iso was 0.81 ± 0.2%. Higher systolic arterial pressure (SAP) values were observed in total intravenous anesthesia (TIVA) during some time points. Recovery was smooth in PIVA, while restlessness, vocalizations, and paddling were observed in TIVA. Both protocols produced a satisfactory quality of anesthesia during surgery, with minimal impact on cardiopulmonary function. Nevertheless, recovery after anesthesia in TIVA might be of poor quality.

Obstrução esofágica torácica por corpo estranho em cão: relato de caso

Corpos estranhos (CE) esofágicos são objetos inanimados que podem causar obstrução total ou parcial do lúmen esofágico, comumente causam disfagia, regurgitação e vômito. A casuísta de obstrução por CE esofágico é elevada na clínica de pequenos animais. O tratamento constitui na remoção do CE e correção de possíveis alterações secundárias. Dessa forma, o objetivo do presente trabalho foi relatar um caso de obstrução por CE em porção de esôfago torácico, tendo como fim aprofundar conhecimentos a respeito de obstrução esofágica de forma geral, desde as manifestações clínicas, achados aos exames complementares, diagnóstico e terapêutica.

Esophageal foreign bodies (FB) are inanimate objects that can cause total or partial obstruction of the esophageal lumen, commonly causing dysphagia, regurgitation and vomiting. The number of esophageal FB obstruction is high in the small animal clinic. Treatment consists of removing the FB and correcting secondary changes. Thus, the objective of the present study was to report a case of obstruction by a FB in a group of thoracic esophagus, with the purpose of deepening the knowledge about esophageal obstruction in general, from clinical manifestations, findings to complementary exams, diagnosis and technical.

Technical and clinical evaluation of a closed loop TIVA system with SEDLineTM spectral density monitoring: Multicentric prospective cohort study.

INTRODUCTION: Closed loop total intravenous anesthesia is a technique in which the patient's hemodynamic and anesthetic depth variables are monitored, and based on this information, a computer controls the infusion rate of drugs to keep them within pre-established clinical parameters. OBJECTIVE: To describe the technical and clinical performance of a closed loop system for total intravenous anesthesia with propofol and remifentanil, using the SEDLineTM monitor. DESIGN: Multicentric prospective cohort study. SETTING: Surgery room. PATIENTS: ASA I-II undergoing elective surgery. MEASUREMENTS: The authors designed a closed loop system that implements a control algorithm based on anesthetic depth monitoring and the Patient State Index (PSITM) of the SEDLine monitor for propofol, and on hemodynamic variables for remifentanil. The measurement of clinical performance was made based on the percentage of PSITM maintenance time in the range 20-50. Precision analysis was evaluated by measuring median performance error (MDPE) can be defined as the median difference between actual and desired values, which refers to the degree of precision in which the controller is able to maintain the control variable within the objective set by the anesthesiologist; it represents the direction (over-prediction or under-prediction) of performance error (PE) rather than size of errors, which is represented by MDAPE, median absolute percentage error, Wobble index, which is used for measuring the intrasubject variability in performance error. RESULTS: Data were obtained from 93 patients in three healthcare centers. The percentage of PSITM maintenance time in the 20-50 range was 92% (80.7-97.0). MDPE was 10.7 (- 11.0-18.0), MDAPE 21.0 (14.2-26.8) and wobble 10.7 (7.0-16.9). No adverse surgical or anesthetic events were found. CONCLUSIONS: The closed loop total intravenous anesthesia system with SEDLine developed by the authors was used without major complication and appear to be feasible its use in clinical performance.

Anestesia total intravenosa libre de opioides en un paciente con síndrome de Joubert: caso clínico / Opioid free total intravenous anesthesia in Joubert syndrome: Case report

Joubert syndrome (JS) is a rare autosomal recessive disorder characterized by abnormal eye movements, respiratory pattern abnormalities, anatomical airway alterations, mental retardation and hypoplasia/aplasia of the cerebellar vermis confirmed by magnetic resonance imaging. This case report describes the successful management of a patient with JS operated of cholesteatoma under 100% opioid-free total intravenous general anaesthesia. We also provide a brief review of JS, its anaesthetic implications and opioid-free anaesthesia (OFA) technique.

El síndrome de Joubert (SJ) es una enfermedad autosómica recesiva poco frecuente caracterizada por trastornos oculares, respiratorios, alteraciones anatómicas de la vía aérea, retraso mental e hipoplasia/aplasia del vermis cerebeloso constatada mediante resonancia magnética. Presentamos un caso exitoso de paciente con SJ operado de colesteatoma bajo anestesia general endovenosa total 100% libre de opioides. Asimismo, realizamos una breve revisión del SJ, sus implicaciones anestésicas y de la técnica de anestesia libre de opioides.

Anestesia total intravenosa en cirugía oncológica de mama / Total intravenous anesthesia in breast oncology surgery

Introducción: La anestesia total intravenosa se caracteriza por estabilidad hemodinámica, profundidad anestésica, recuperación rápida y predecible, menor cantidad de medicamentos y menor toxicidad. Objetivo: Describir los resultados de la anestesia total intravenosa en cirugía oncológica de mama. Método: Se realizó un estudio descriptivo, longitudinal en el Hospital Clínico Quirúrgico Hermanos Ameijeiras, entre enero de 2016 a diciembre 2016, en 100 pacientes a las que se les administró anestesia total intravenosa con midazolam y fentanilo para proceder quirúrgico oncológico de mama. En ellas se determinó la repercusión hemodinámica, el nivel de sedación, analgesia, la recuperación y complicaciones. Resultados: La media de la edad de las pacientes fue 58,99 ± 12,5 años. De las pacientes en estudio 92 por ciento no presentó signos clínicos de superficialidad. Solo 21 pacientes presentaron complicaciones. Las variaciones de la tensión arterial fueron las más frecuentes (16 por ciento), seguidas de la bradicardia o taquicardia en solo cuatro casos. De forma inmediata se recuperó 74 por ciento de los casos y 26 por ciento restante lo hizo de manera mediata. El nivel de sedación fue adecuado en 50 por ciento y excesivo en 4 por ciento. Del total de los casos, 99 por ciento experimentaron respuesta analgésica sin dolor. Conclusiones: Los resultados del uso de anestesia total intravenosa fueron buenos, con adecuada respuesta analgésica y escasas complicaciones(AU)

Introduction: Total intravenous anesthesia is characterized by hemodynamic stability, anesthetic depth, rapid and predictable recovery, less medication and less toxicity. Objective: To describe the outcomes of total intravenous anesthesia in breast cancer surgery. Method: A descriptive, longitudinal study was carried out in Hermanos Ameijeiras Clinical-Surgical Hospital, from January 2016 to December 2016, in 100 patients who were administered total intravenous anesthesia with midazolam and fentanyl for breast oncology surgery. The patients were determined hemodynamic repercussion, the level of sedation, analgesia, recovery and complications. Results: The mean age of the patients was 58.99±12.5 years. Among the patients under study, 92 percent did not present clinical signs of superficiality. Only 21 patients presented complications. Variations in blood pressure were the most frequent (16 percent), followed by bradycardia or tachycardia in only four cases. Immediately, 74 percent of the cases were recovered and the remaining 26 percent did so timely. The level of sedation was adequate in 50 percent and excessive in 4 percent. Among the total number of cases, 99 percent experienced analgesic response without pain. Conclusions: The outcomes of total intravenous anesthesia usage were good, with adequate analgesic response and few complications(AU)

Sufentanil during anesthetic induction of remifentanil-based total intravenous anesthesia: a randomized controlled trial / Sufentanil durante a indução da anestesia intravenosa total à base de remifentanil: ensaio clínico randômico

Abstract Background Postoperative pain represents an important concern when remifentanil is used for total intravenous anesthesia because of its ultrashort half-life. Longer acting opioids, such as sufentanil, have been used during induction of remifentanil-based total intravenous anesthesia as a means to overcome this shortcoming. However, the effectiveness and safety of such strategy still lacks evidence from randomized clinical trials. Hence, we aimed to assess the postoperative analgesic efficacy and safety of a single dose of sufentanil administered during the induction of remifentanil-based total intravenous anesthesia. Methods Forty patients, scheduled for elective open abdominal surgery, were randomized to receive remifentanil-based total intravenous anesthesia with or without a single dose of sufentanil upon induction. We assessed the postoperative morphine consumption administered through a patient-controlled analgesia pump. Self-reported pain scores and the occurrence of nausea, vomiting, pruritus, agitation, somnolence and respiratory depression were also assessed up to 2 days after surgery. Results The mean difference between the sufentanil and control groups regarding morphine consumption in the post-anesthetic care unit and at 12, 24 and 48 h after surgery were -7.2 mg (95%CI: -12.5 to -2.1, p < 0.001), -3.9 mg (95%CI: -11.9 to 4.7, p = 0.26), -0.6 mg (95%CI: (-12.7 to 12.7, p = 0.80), and -1.8 mg (95%CI: (-11.6 to 15.6, p = 0.94), respectively. Neither self-reported pain nor the incidence of adverse events were significantly different between groups at any time point. Conclusion Our findings suggest that the administration of sufentanil during induction of remifentanil-based total intravenous anesthesia is associated with decreased early postoperative opioid consumption.

Resumo Justificativa A dor pós-operatória é uma grande preocupação quando o remifentanil é usado para anestesia intravenosa total devido à sua meia-vida ultracurta. Os opioides de ação mais longa, como o sufentanil, têm sido usados durante a indução de anestesia intravenosa total à base de remifentanil como um meio de superar essa deficiência. Porém, a eficácia e segurança de tal estratégia ainda precisam de evidências advindas de ensaios clínicos randômicos. Portanto, objetivamos avaliar a eficácia analgésica e a segurança pós-operatória de uma dose única de sufentanil administrada durante a indução de anestesia intravenosa total à base de remifentanil. Métodos Quarenta pacientes eletivamente agendados para cirurgia abdominal aberta foram randomizados para receber anestesia intravenosa total à base de remifentanil, com ou sem uma dose única de sufentanil, após a indução da anestesia. Avaliamos o consumo de morfina no pós-operatório, administrado através de uma bomba de analgesia controlada pelo paciente. Os escores de dor autorrelatados e a ocorrência de náusea, vômito, prurido, agitação, sonolência e depressão respiratória também foram avaliados até dois dias após a cirurgia. Resultados A diferença média entre os grupos sufentanil e controle em relação ao consumo de morfina em sala de recuperação pós-anestesia e após 12, 24 e 48 horas da cirurgia foi de -7,2 mg (IC 95%: -12,5 a -2,1, p < 0,001), -3,9 mg (IC 95%: -11,9 a 4,7, p = 0,26), -0,6 mg (IC 95%: (-12,7 a 12,7, p = 0,80) e -1,8 mg (IC 95%: -11,6 para 15,6, p = 0,94), respectivamente. Não houve diferença significativa tanto nos escores de dor autorrelatados, quanto na incidência de eventos adversos entre os grupos. Conclusão Nossos achados sugerem que a administração de sufentanil durante a indução de anestesia intravenosa total à base de remifentanil está associada à redução do consumo de opioides no pós-operatório imediato.

[Sufentanil during anesthetic induction of remifentanil-based total intravenous anesthesia: a randomized controlled trial]. / Sufentanil durante a indução da anestesia intravenosa total à base de remifentanil: ensaio clínico randômico.

BACKGROUND: Postoperative pain represents an important concern when remifentanil is used for total intravenous anesthesia because of its ultrashort half-life. Longer acting opioids, such as sufentanil, have been used during induction of remifentanil-based total intravenous anesthesia as a means to overcome this shortcoming. However, the effectiveness and safety of such strategy still lacks evidence from randomized clinical trials. Hence, we aimed to assess the postoperative analgesic efficacy and safety of a single dose of sufentanil administered during the induction of remifentanil-based total intravenous anesthesia. METHODS: Forty patients, scheduled for elective open abdominal surgery, were randomized to receive remifentanil-based total intravenous anesthesia with or without a single dose of sufentanil upon induction. We assessed the postoperative morphine consumption administered through a patient-controlled analgesia pump. Self-reported pain scores and the occurrence of nausea, vomiting, pruritus, agitation, somnolence and respiratory depression were also assessed up to 2 days after surgery. RESULTS: The mean difference between the sufentanil and control groups regarding morphine consumption in the post-anesthetic care unit and at 12, 24 and 48h after surgery were -7.2mg (95%CI: -12.5 to -2.1, p<0.001), -3.9mg (95%CI: -11.9 to 4.7, p=0.26), -0.6mg (95%CI: (-12.7 to 12.7, p=0.80), and -1.8mg (95%CI: (-11.6 to 15.6, p=0.94), respectively. Neither self-reported pain nor the incidence of adverse events were significantly different between groups at any time point. CONCLUSION: Our findings suggest that the administration of sufentanil during induction of remifentanil-based total intravenous anesthesia is associated with decreased early postoperative opioid consumption.

Factores de riesgo de complicaciones respiratorias en cirugía oncológica de mama con anestesia total intravenosa / Risk factors of respiratory complications in breast cancer surgery with total intravenous anesthesia

A prospective longitudinal cohort study was performed in patients with breast cancer operated surgically with the use of total intravenous anesthesia in the provincial hospital Carlos Manuel de Céspedes de Bayamo, from the Cauto region during the period from January 1 from 2014 to December 31, 2016, with the aim of identifying the risk factors hypothetically related to the appearance of respiratory complications. It was established that the exposed cohort was constituted by 79 patients who developed complications during the study period and met the inclusion criteria. The diagnosis of respiratory complications was made during the entire surgical procedure and finished. The magnitude of the associations was estimated by calculating the relative risks (RR) of complications. The age of the patient equal to or greater than 65 years, and smoking were the surgical risk factors depending on the patient related to the onset of respiratory complications in breast cancer surgery with total intravenous anesthesia, not alcoholism. Anemia, obesity, low weight and recent respiratory tract infection were surgical risk factors dependent on associated diseases related to the appearance of respiratory complications. The ASA III-IV classification and the surgical time of more than three hours were surgical risk factors related to surgery related to the appearance of respiratory complications.

Se realizó un estudio longitudinal prospectivo de cohorte en pacientes con cáncer de mama intervenidos quirúrgicamente con el empleo de anestesia total intravenosa en el hospital provincial "Carlos Manuel de Céspedes de Bayamo, procedentes de la región del Cauto durante el período comprendido desde el 1ro de enero de 2014 hasta 31 de diciembre de 2016, con el objetivo de identificar los factores de riesgo hipotéticamente relacionados con la aparición de complicaciones respiratorias. Se estableció que la cohorte expuesta estuvo constituida por 79 pacientes que desarrollaron complicaciones en el período de estudio y cumplieron con los criterios de inclusión. La evaluación del diagnóstico de complicaciones respiratorias se realizó durante todo el procedimiento quirúrgico y terminado éste. La magnitud de las asociaciones se estimó mediante el cálculo de los riesgos relativos (RR) de complicaciones. La edad de la paciente igual o superior a 65 años, y el tabaquismo fueron los factores de riesgo quirúrgico en función del enfermo relacionados con la aparición de complicaciones respiratorias en cirugía oncológica de mama con anestesia total intravenosa, no así el alcoholismo. La anemia, la obesidad, bajo peso y la infección reciente del tracto respiratorio fueron los factores de riesgo quirúrgico dependiente de enfermedades asociadas relacionados con la aparición de complicaciones respiratorias. La clasificación ASA III-IV y un tiempo quirúrgico superior a tres horas se constituyeron en los factores de riesgo quirúrgico en función de la cirugía relacionados con la aparición de complicaciones respiratorias.

Variante de cálculo de infusión de ketamina en la TIVA manual / A Variant for calculating ketamine infusion in manual total intravenous anesthesia

Introducción: Un requisito en la conducción de la anestesia intravenosa total, en modo manual, radica en la necesidad de realizar ajustes de dosificación temporales para evitar la acumulación plasmática del fármaco. Desde hace algunos años existe el interés de emplear otros fármacos como la ketamina. Objetivos: Comparar la variación temporal de la concentración plasmática de ketamina al aplicar una variante de cálculo de decrecimiento de la velocidad de infusión (Vinf) con una velocidad de infusión invariable. Métodos: Se realizó un estudio analítico que describe el cálculo de dosificación para TIVA manual, la simulación farmacocinética del comportamiento de la concentración plasmática de la ketamina en caso de administrarse invariablemente con esos regímenes de dosificación, en un paciente virtual, de 70 Kg, según el modelo de Domino y el análisis de la variante de cálculo de decrecimiento de la Vinf del medicamento. Se estimó una significación estadística de un 95 por ciento (p<0.05). Resultados: la variante de cálculo de decrecimientode la velocidad de infusión: Vinf (tn) = Vinf (tn-1) _ [(Vinf (tn-1) x e(1 + 1/t)t)/100] = Vinf (t n-1) x 0,85 permitió valores más estables de la concentración plasmática, aproximadas a la del modelo ideal (p>0,05), por espacio de 6 h. Conclusiones: es probable que el decrecimiento de la dosis de ketamina, establecido por la variante de cálculo e infusión propuesta, posibilite una mejor estabilidad de la concentración plasmática(AU)

Introduction: A requirement in the manual conduction of total intravenous anesthesia is the need to make temporary dosage adjustments to avoid drug accumulation in plasma. For some years there has been interest in using other drugs such as ketamine. Objectives: To compare the temporal variation of ketamine concentration in plasma when applying a variant for calculating the decrease in the infusion rate (Vinf) with an invariable infusion rate. Methods: An analytical study was carried out describing the dosage calculation for manual total intravenous anesthesia, the pharmacokinetic simulation of the behavior of ketamine concentration in plasma in case of being invariably administered with these dosing regimens, in a virtual patient, of 70 kg, according to the Domino model and the analysis of the variant for calculating the decrease of ketamine infusion rate. A statistical significance of 95 percent was estimated (p<0.05). Results: The variant for calculating the decrease of the infusion rate: Vinf (tn) = Vinf (tn-1) _ [(Vinf (tn-1) x e (1+1/t) t)/100] = Vinf (tn -1) x 0.85 allowed more stable values of plasma concentration, which approximate that of the ideal model (p>0.05), for a time of 6 hours. Conclusions: Probably, the decrease of the ketamine dose, established by the proposed calculation and infusion variant, allows better stability of plasma concentration(AU)

Propofol pharmacokinetic and pharmacodynamic profile and its electroencephalographic interaction with remifentanil in children.

BACKGROUND: Propofol and remifentanil are commonly combined during total intravenous anesthesia. The impact of remifentanil in this relationship is poorly quantified in children. Derivation of an integrated pharmacokinetic and pharmacodynamic propofol model, containing remifentanil pharmacodynamic interaction information, enables propofol effect-site target-controlled infusion in children with a better prediction of its hypnotic effect when both drugs are combined. AIMS: We designed this study to derive an integrated propofol pharmacokinetic-pharmacodynamic model in children and to describe the pharmacodynamic interaction between propofol and remifentanil on the electroencephalographic bispectral index effect. METHODS: Thirty children (mean age: 5.45 years, range 1.3-11.9; mean weight: 23.5 kg, range 8.5-61) scheduled for elective surgery with general anesthesia were studied. After sevoflurane induction, maintenance of anesthesia was based on propofol and remifentanil. Blood samples to measure propofol concentration were collected during anesthesia maintenance and up to 6 hours in the postoperative period. Bispectral index data were continuously recorded throughout the study. A pharmacokinetic-pharmacodynamic model was developed using population modeling. The Greco model was used to examine the pharmacokinetic-pharmacodynamic interaction between propofol and remifentanil for BIS response RESULTS: Propofol pharmacokinetic data from a previous study in 53 children were pooled with current data and simultaneously analyzed. Propofol pharmacokinetics were adequately described by a three-compartment distribution model with first-order elimination. Theory-based allometric relationships based on TBW improved the model fit. The Greco model supported an additive interaction between propofol and remifentanil. Remifentanil showed only a minor effect in BIS response. CONCLUSION: We have developed an integrated propofol pharmacokinetic-pharmacodynamic model that can describe the pharmacodynamic interaction between propofol and remifentanil for BIS response. An additive interaction was supported by our modeling analysis.