Brazilian Journal of Anesthesiology (Edicion en Espanol)最新文献

Background and objectives

Postoperative bleeding has a great clinical importance and can contribute to increased mortality and morbidity in patients undergoing coronary artery bypass graft surgery. In this prospective, randomized, double-blind study, we evaluated the effect of prophylactic administration of fibrinogen concentrate on post-coronary artery bypass graft surgery bleeding.

Methods

A total of 60 patients undergoing coronary artery bypass surgery were randomly divided into two groups. Patients in the fibrinogen group received 1 g of fibrinogen concentrate 30 min prior to the operation, while patients in the control group received placebo. Post-operative bleeding volumes, prothrombin time, partial thromboplastin time, INR, hemoglobin and transfused blood products in both groups were recorded. A strict red blood cell transfusion protocol was used in all patients.

Results

There were no significant differences between intra-operative packed red blood cells infusion in the studied groups (1.0 ± 1.4 in fibrinogen group, and 1.3 ± 1.1 in control group). Less postoperative bleeding was observed in the fibrinogen group (477 ± 143 versus 703 ± 179, p = 0.0001). Fifteen patients in the fibrinogen group and 21 in the control group required post-op packed red blood cells infusion (p = 0.094). No thrombotic event was observed through 72 h after surgery.

Conclusion

Prophylactic fibrinogen reduces post-operative bleeding in patients undergoing coronary artery bypass graft.

A 2-year-old boy with acute lymphoblastic leukemia was presented with peripherally inserted central catheter dysfunction. Radiological examinations revealed a catheter remnant in the right atrium extending into pulmonary vein. The catheter remnant was successfully removed from the right atrium by percutaneous endovascular intervention without any complications.

Background and objectives

This is a prospective, randomized, single-blind study. We aimed to compare the tracheal intubation conditions and hemodynamic responses either remifentanil or a combination of remifentanil and lidocaine with sevoflurane induction in the absence of neuromuscular blocking agents.

Methods

Fifty intellectually disabled, American Society of Anesthesiologists I–II patients who underwent tooth extraction under outpatient general anesthesia were included in this study. Patients were randomized to receive either 2 μg kg⁻¹ remifentanil (Group 1, n = 25) or a combination of 2 μg kg⁻¹ remifentanil and 1 μg kg⁻¹ lidocaine (Group 2, n = 25). To evaluate intubation conditions, Helbo-Hansen scoring system was used. In patients who scored 2 points or less in all scorings, intubation conditions were considered acceptable, however if any of the scores was greater than 2, intubation conditions were regarded unacceptable. Mean arterial pressure, heart rate and peripheral oxygen saturation (SpO₂) were recorded at baseline, after opioid administration, before intubation, and at 1, 3, and 5 min after intubation.

Results

Acceptable intubation parameters were achieved in 24 patients in Group 1 (96%) and in 23 patients in Group 2 (92%). In intra-group comparisons, the heart rate and mean arterial pressure values at all-time points in both groups showed a significant decrease compared to baseline values (p = 0.000).

Conclusion

By the addition of 2 μg/kg remifentanil during sevoflurane induction, successful tracheal intubation can be accomplished without using muscle relaxants in intellectually disabled patients who undergo outpatient dental extraction. Also worth noting, the addition of 1 mg/kg lidocaine to 2 μg/kg remifentanil does not provide any additional improvement in the intubation parameters.

Background and objectives

S-(+)-ketamine is an intravenous anaesthetic and sympathomimetic with properties of local anaesthetic. It has an effect of an analgetic and local anaesthetic when administered epidurally, but there are no data whether low doses of S-(+)-ketamine have sympathomimetic effects. The aim of this study was to determine whether low doses of S-(+)-ketamine, given epidurally together with local anaesthetic, have any effect on sympathetic nervous system, both systemic and below the level of anaesthetic block.

Methods

The study was conducted on two groups of patients to whom epidural anaesthesia was administered to. Local anaesthesia (0.5% bupivacaine) was given to one group (control group) while local anaesthesia and S-(+)-ketamine were given to other group. Age, height, weight, systolic, diastolic and mean arterial blood pressure were measured. Non-competitive enzyme immunochemistry method (Cat Combi ELISA) was used to determine the concentrations of catecholamines (adrenaline and noradrenaline). Immunoenzymometric determination with luminescent substrate on a machine called Vitros Eci was used to determine the concentration of cortisol. Pulse transit time was measured using photoplethysmography. Mann–Whitney U-test, Wilcoxon test and Friedman ANOVA were the statistical tests. Blood pressure, pulse, adrenaline, noradrenaline and cortisol concentrations were measured in order to estimate systemic sympathetic effects.

Results

40 patients in the control group were given 0.5% bupivacaine and 40 patients in the test group were given 0.5% bupivacaine with S-(+)-ketamine. Value p < 0.05 has been taken as a limit of statistical significance.

Conclusions

Low dose of S-(+)-ketamine administered epidurally had no sympathomimetic effects; it did not change blood pressure, pulse, serum hormones or pulse transit time. Low dose of S-(+)-ketamine administered epidurally did not deepen sympathetic block. Adding 25 mg of S-(+)-ketamine to 0.5% bupivacaine does not deprive sympathetic tonus below the level of epidural block at the moment of most expressed sympathetic block and has no effect on sympathetic tonus above the block level.

Objective

Central blockage provided by spinal anaesthesia enables realization of many surgical procedures, whereas hemodynamic and respiratory changes influence systemic oxygen delivery leading to the potential development of series of problems such as cerebral ischemia, myocardial infarction and acute renal failure. This study was intended to detect potentially adverse effects of hemodynamic and respiratory changes on systemic oxygen delivery using cerebral oxymetric methods in patients who underwent spinal anaesthesia.

Methods

Twenty-five ASA I–II Group patients aged 65–80 years scheduled for unilateral inguinal hernia repair under spinal anaesthesia were included in the study. Following standard monitorization baseline cerebral oxygen levels were measured using cerebral oximetric methods. Standardized Mini Mental Test (SMMT) was applied before and after the operation so as to determine the level of cognitive functioning of the cases. Using a standard technique and equal amounts of a local anaesthetic drug (15 mg bupivacaine 5%) intratechal blockade was performed. Mean blood pressure (MBP), maximum heart rate (MHR), peripheral oxygen saturation (SpO₂) and cerebral oxygen levels (rSO₂) were preoperatively monitored for 60 min. Pre- and postoperative haemoglobin levels were measured. The variations in data obtained and their correlations with the cerebral oxygen levels were investigated.

Results

Significant changes in pre- and postoperative measurements of haemoglobin levels and SMMT scores and intraoperative SpO₂ levels were not observed. However, significant variations were observed in intraoperative MBP, MHR and rSO₂ levels. Besides, a correlation between variations in rSO₂, MBP and MHR was determined.

Conclusion

Evaluation of the data obtained in the study demonstrated that post-spinal decline in blood pressure and also heart rate decreases systemic oxygen delivery and adversely effects cerebral oxygen levels. However, this downward change did not result in deterioration of cognitive functioning.

El marcapasos (MP) es un sistema que consiste en un generador de impulso y un electrodo o electrodos que conducen el impulso eléctrico hacia el corazón del paciente. Se han creado códigos de MP y de desfibrilador automático implantables para describir el tipo de cada uno. El Colegio Norteamericano de Cardiólogos han descrito indicaciones para la implantación de MP y de desfibrilador automático implantable. Algunos MP tienen interruptores de circuitos magnéticos incorporados, sin embargo, la aplicación magnética puede causar efectos adversos graves; por tanto, los dispositivos deben ser considerados programables, salvo que se tenga un conocimiento diferente. Cuando un paciente portador de dispositivo se somete a cualquier procedimiento (con o sin anestesia), se deben tomar precauciones especiales, incluyendo historial/examen físico dirigidos; preguntas sobre el MP antes y después del procedimiento, uso de medicamentos de urgencia/estimulación y desfibrilación temporales; reprogramación del MP e inhabilitación de ciertas funciones del mismo, si fuere preciso; monitorización de los trastornos metabólicos y electrolíticos y evitar ciertos medicamentos y equipos que puedan interferir con la función del MP. Si hay alguna previsión de interacción con el dispositivo, considerar la suspensión del procedimiento hasta que la fuente de la interferencia haya sido eliminada o controlada. Se deben tomar todas las medidas correctivas para garantizar el funcionamiento adecuado del MP. Después del procedimiento, la frecuencia y el ritmo cardíacos deben ser monitorizados continuamente, y deben estar preparados los medicamentos y equipos de urgencia; y si fuera necesario, consultar con un cardiólogo o con el servicio de MP- desfibrilador automático implantable.

La compresión de la vena cava inferior es un problema común al final del embarazo. También puede ocurrir debido a la compresión de la vena cava inferior por tumores abdominales o pélvicos. Relatamos un caso de compresión iatrogénica aguda de la vena cava inferior debido al exceso de taponamiento durante una cirugía intraabdominal.

Justificación y objetivos

la anemia es un hallazgo clínico común en las UCI. La transfusión de hematíes es la principal forma de tratamiento, a pesar de los riesgos que están asociados a ella. Así, nos propusimos evaluar el perfil transfusional de los pacientes en diferentes UCI.

Métodos

análisis prospectivo de los pacientes ingresados en las UCI de un hospital universitario terciario con indicación de transfusión de concentrado de hematíes. Se recolectaron características demográficas y el perfil transfusional, haciéndose el análisis univariado considerando como significativos los resultados con p ≤ 0,05.

Resultados

se analizaron 408 transfusiones en 71 pacientes. La concentración promedio de hemoglobina en el ingreso fue de 9,7 ± 2,3 g/dL y la concentración pretransfusional de 6,9 ± 1,1 g/dL. Las principales indicaciones de transfusión fueron la concentración de hemoglobina (49%) y el sangrado activo (32%). El número intermedio de unidades transfundidas por episodio fue 2 (1-2) y la mediana del tiempo de almacenaje fue de 14 (7-21) días. El número de pacientes transfundidos con hemoglobina por encima de 7 g/dL y el número de bolsas transfundidas por episodio fueron significativamente diferentes entre las UCI. Los pacientes que recibieron 3 o más transfusiones tuvieron más tiempo de ventilación mecánica y de permanencia en la UCI y una mayor mortalidad en 60 días. Hubo una asociación de la mortalidad con la gravedad de la enfermedad, pero no así con las características transfusionales.

Conclusiones

la práctica transfusional de hemocomponentes estuvo parcialmente a tono con las directrices preconizadas, aunque exista una diferencia de conducta entre los diferentes perfiles de UCI. Pacientes transfundidos evolucionaron con resultados desfavorables. Pese a la escasez de sangre en los bancos de sangre, el tiempo promedio de almacenaje de las bolsas fue alto.

La anemia de Fanconi es un síndrome hereditario autosómico recesivo raro, caracterizado por deficiencia de la médula ósea y por anomalías congénitas y hematológicas. La literatura sobre el manejo anestésico de esos pacientes es limitada. El manejo de una displasia del desarrollo de la cadera fue descrito en un paciente con anemia de Fanconi. Debido a la naturaleza heterogénea, un paciente con anemia de Fanconi debe ser sometido a la evaluación preoperatoria para diagnosticar las características clínicas. En conclusión, el bloqueo caudal fue nuestra elección para ese paciente con anemia de Fanconi sin trombocitopenia para evitar el N₂O, reducir la cantidad de anestésico, microcefalia existente, hipotiroidismo y aumento de las enzimas hepáticas, proporcionar analgesia postoperatoria y reducir la cantidad de analgésico usado en el postoperatorio.