Uso tópico de sevoflurano en heridas complejas de miembro inferior / Topical use of sevoflurane in complex lower limb wounds

El dolor crónico asociado a heridas de larga evolución en miembros inferiores constituye una situación de conflicto con características angustiantes que compromete seriamente la calidad de vida e interfiere en el proceso de reparación tisular, estableciendo un cuadro propio en el cual la herida se transforma en un componente más de esta compleja condición y no el motivo en sí de la consulta. Dadas las limitaciones y efectos negativos de las terapias usuales para el alivio del dolor crónico en heridas, se establece una apertura a nuevas propuestas adyuvantes. Motivo de ello es el propósito del presente trabajo, a través del uso de sevoflurano tópico para evaluar el incremento de la analgesia en una población con úlceras en miembro inferior de diverso origen etiológico.

Application Value of Sevoflurane Combined with Brachial Plexus Block in Children with Humeral Fracture Surgery and its Effect on Hemodynamics: A Clinical and Anatomical Study

SUMMARY: To observe the effect of sevoflurane combined with brachial plexus block (BPB) in children with humeral fracture surgery and its effect on hemodynamics. 84 children who received surgical treatment of humeral fracture in our hospital from September 2019 to September 2022 were selected. According to different anesthesia methods, the children were divided into control group and study group. The control group only received laryngeal mask sevoflurane; the study group received laryngeal mask sevoflurane combined with BPB. The operation situation, hemodynamic indexes, stress level, pain and adverse reactions of children was observed. The postoperative awakening time in the study group was lower than control group, the postoperative pain onset time in the study group was higher than control group (P0.05). Postoperative 2h, the levels of serum cortisol, b-endorpin, norepinephrine and epinephrine in the study group were lower than control group (P0.05). Sevoflurane combined with BPB is helpful to shorten the postoperative awakening time of children with humeral fracture, reduce the degree of postoperative pain, improve hemodynamics, and reduce stress response, and has good safety.

El objetivo fue observar el efecto del sevoflurano combinado con bloqueo del plexo braquial (BPB) en niños con cirugía de fractura de húmero y su efecto sobre la hemodinámica. Se seleccionaron 84 niños que recibieron tratamiento quirúrgico de fractura de húmero en nuestro hospital desde septiembre de 2019 hasta septiembre de 2022. Según diferentes métodos de anestesia, los niños se dividieron en grupo control y grupo de estudio. El grupo control solo recibió sevoflurano en mascarilla laríngea; el grupo de estudio recibió sevoflurano con mascarilla laríngea combinado con BPB. Se observó la situación operatoria, índices hemodinámicos, nivel de estrés, dolor y reacciones adversas de los niños. El tiempo hasta el despertar postoperatorio en el grupo de estudio fue menor que el del grupo control, el tiempo de aparición del dolor postoperatorio en el grupo de estudio fue mayor que el del grupo control (P0,05). A las 2 horas postoperatorias, los niveles séricos de cortisol, β-endorfina, norepinefrina y epinefrina en el grupo de estudio fueron más bajos que los del grupo control (P 0,05). El sevoflurano combinado con BPB es útil para acortar el tiempo de despertar del posoperatorio de los niños con fractura de húmero, reduce el grado de dolor postoperatorio, mejora la hemodinámica y reduce la respuesta al estrés, además de tener buena seguridad.

Minimal fresh gas flow sevoflurane anesthesia and postoperative acute kidney injury in on-pump cardiac surgery: a randomized comparative trial

Abstract Background Compound A is generated by sevoflurane when it reacts with carbon dioxide absorbers with strong bases at minimal fresh gas flow (FGF) and is nephrotoxic in animals. No conclusive data has shown increased risk in humans. The aim of this study was to investigate if minimal FGF promotes an increase in the incidence of acute kidney injury (AKI) when compared to high FGF in patients undergoing on-pump cardiac surgery under sevoflurane anesthesia. Methods Two hundred and four adult patients scheduled for on-pump cardiac surgery under sevoflurane anesthesia were randomly allocated to two groups differentiated by FGF: minimal FGF (0.5 L.min−1) or high FGF (2.0 L.min−1). Baseline creatinine measured before surgery was compared daily to values assayed on the first five postoperative days, and 24-hour urinary output was monitored, according to the KDIGO (Kidney Disease Improving Global Outcomes) guideline to define postoperative cardiac surgery-associated acute kidney injury (CSA-AKI). Creatinine measurements were also obtained 20 and 120 days after hospital discharge. Results Postoperative AKI occurred in 55 patients, 26 patients (29.5%) in the minimal FGF group and 29 patients (31.5%) in the high FGF group (p= 0.774). Twenty days after discharge, 11 patients (6.1%) still had CSA-AKI and 120 days after discharge only 2 patients (1.6%) still had CSA-AKI. Conclusions When compared to high FGF, minimal FGF sevoflurane anesthesia during on-pump cardiac surgery is not associated with increased risk of postoperative AKI in this population at high risk for renal injury.

Sevoflurane attenuates myocardial ischemia/reperfusion injury by up-regulating microRNA-99a and down-regulating BRD4

Purpose: It has been explored that sevoflurane (Sevo) is cardioprotective in myocardial ischemia/reperfusion injury (MI/RI) and mediates microRNA (miRNA) expression that control various physiological systems. Enlightened by that, the work was programmed to decode the mechanism of Sevo and miR-99a with the participation of bromodomain-containing protein 4 (BRD4). Methods: MI/RImodel was established on mice. MI/RI modeled mice were exposed to Sevo or injected with miR-99a or BRD4-related vectors to identify their functions in cardiac function, pathological injury, cardiomyocyte apoptosis, inflammation, and oxidative stress in MI/RI mice. MiR-99a and BRD4 expression in myocardial tissues were tested, and their relation was further validated. Results: MiR-99a was down-regulated, and BRD4 was up-regulated in MI/RI mice. Sevo up-regulated miR-99a to inhibit BRD4 expression in myocardial tissues of MI/RI mice. Sevo improved cardiac function, relieved myocardial injury, repressed cardiomyocyte apoptosis, and alleviated inflammation and oxidative stress in mice with MI/RI. MiR-99a restoration further enhanced the positive effects of Sevo on mice with MI/RI. Overexpression of BRD4 reversed up-regulation of miR-99a-induced attenuation of MI/RI in mice. Conclusions: The work delineated that Sevo up-regulates miR-99a to attenuate MI/RI by inhibiting BRD4.

Neuroprotective potential of sevoflurane against isoflurane induced cognitive dysfunction in rats via anti-inflammatory and antioxidant effect

Purpose: Intravenous anesthetics have excellent analgesic activity without inducing the side effect in the respiratory system. The aim and objective of the current experimental study was to access the neuroprotective effect of sevoflurane against isoflurane induced cognitive dysfunction in rats. Methods: Isoflurane was used for induction the neurodysfunction in the rats, and rats received the oral administration of sevoflurane (2.5, 5 and 10 mg/kg). Morris water test was carried out for the estimation of cognitive function. Neurochemical parameters, antioxidant parameters and pro-inflammatory cytokines were also estimated. Results: Sevoflurane significantly (P < 0.001) altered the neurochemical parameters such as anti-choline acetyltransferase, acetylcholine esterase, acetylcholine, protein carbonyl, choline brain-derived neurotrophic factor, and amyloid ß; antioxidant parameters such as glutathione, superoxide dismutase, and malondialdehyde; pro-inflammatory cytokines include interleukin (IL-2, IL-10, IL-4, IL-6, IL-10, IL-1ß), and tumor necrosis factor-α. Sevoflurane significantly reduced the activity of caspase-3. Conclusions: Sevoflurane exhibited the neuroprotection against the cognitive dysfunction in rats via anti-inflammatory and antioxidant mechanism.

Pain management & opioid dose reduction with topical sevoflurane instillations in intractable venous ulcers: a case report

Abstract Vascular ulcers (VU) constitute a major cause of pain and disability, and significantly compromise quality of life. VU have a natural tendency to become chronic and in many cases exhibit anunsatisfactoryresponse to many of the standard therapeutic options.The case of a 73 year-old Caucasian female with severe pain and poorly-controlled pain (Visual Analogic Scale-VAS- of 8-9) due to three lower leg long-standing VUs is reported and discussed herein. The patient was treated with topical instillations of undiluted sevoflurane as per institutional off-label protocol (starting doses of 1mL/cm2 twice a day, and up-titrated according to response to a maximum of 7 mL twice daily). The VAS score dropped to 0-1 shortly after initiation of therapy and remained stable throughout treatment up until the closure of the observations. Subsequently, opioid therapy was gradually tapered down and ultimately abandoned.Sevoflurane application resulted on adequate and sustained pain management of refractory VU, with no significant side effects. On account of its beneficial effectivity and safety profiles, topical sevoflurane emerges as an add-on alternative for the long-term management of VU, and potentially other painful conditions.

Efecto epitelizante y analgésico del sevoflurano tópico en el tratamiento de las úlceras por presión grado I-III no infectadas Hospital Obrero N°1 de La Paz Bolivia / Epithelializing and analgesic effect of topical sevoflurane in the treatment by pressure of uninfected grade I-III ulcers Hospital Obrero (workers´ Hospital) N°1 of La Paz Bolivia

INTRODUCCIÓN: las úlceras por presión constituyen un importante problema de salud por su frecuencia, carácter crónico, costes económicos y una merma en la calidad de vida en pacientes internados en las unidades de cuidados especiales. MATERIAL Y MÉTODOS: el objetivo del estudio fue evaluar el efecto epitelizante y analgésico del sevoflurano aplicado tópicamente en úlceras por presión grado I-III no infectadas de pacientes internados. El tipo de estudio fue Ensayo clínico aleatorizado. Un total de 16 pacientes fueron incluidos en el estudio y fueron divididos aleatoriamente en 2 grupos: grupo A (8 pacientes), en los que se realizó la curación con sevoflurano tópico más povidona yodada y, grupo B (8 pacientes) curación solo con yodopovidona. La valoración de la evolución de la úlcera se realizó mediante la Escala PUSH, que valora superficie, cantidad de exudado y tipo de tejido del lecho. RESULTADOS: durante la realización de la curación, el dolor manifestado por los integrantes del Grupo A (1.6 ± 0.7), fue mucho menor que el observado el Grupo B (7.2 ± 1). No se encontró diferencias significativas en la superficie de la úlcera y en la cantidad de exudado; si se encontró una diferencia significativa en el tipo de tejido existente en el lecho ulceroso, en los pacientes del Grupo A se evidenció la presencia de tejido de granulación y epitelial a partir de la tercera semana de tratamiento, lo cual, en los pacientes del Grupo B, se observó a partir de la cuarta semana.

INTRODUCTION: pressure ulcers constitute an important health problem due to their frequency, chronic nature, economic costs and a reduction in the quality of life in patients hospitalized in special care units. MATERIAL AND METHODS: the aim of the study was to evaluate the epithelializing and analgesic effect of sevoflurane applied topically in uninfected grade I-III pressure ulcers of hospitalized patients. The type of study was Randomized Clinical Trial. A total of 16 patients were included in the study and were randomly divided into 2 groups: group A (8 patients), in which the cure was performed with topical sevoflurane plus povidone iodine, and group B (8 patients) only with povidone iodine. The evaluation of the evolution of the ulcer was performed using the PUSH Scale, which assesses surface area, amount of exudate and type of bed tissue. RESULTS: during the healing, the pain manifested by the members of Group A (1.6 ± 0.7), was much lower than that observed in Group B (7.2 ± 1). No significant differences were found on the surface of the ulcer and in the amount of exudate; If a significant difference was found in the type of tissue existing in the ulcer bed, in Group A patients the presence of epithelial and granulation tissue was evidenced starting the third week of treatment, which, in Group A patients B, was observed starting the fourth week.

Analgesic effectiveness and improvement in quality of life after using topical sevoflurane for an extremely painful anal fissure / Eficácia analgésica e melhoria da qualidade de vida com o uso tópico de sevoflurano em fissura anal extremamente dolorosa

Painful anal fissures could be distressing conditions that severely impair the patients' quality of life. The analgesic effectiveness of topical drugs, such as calcium-antagonists and nitrates is quite variable. The inhalational anesthetic sevoflurane is being repurposed as a topical analgesic for painful chronic wounds.We report a pioneer experience treating a painful chronic anal fissure with topical sevoflurane. A young adult male was suffering from an extremely painful chronic anal fissure, which severely affected his quality of life. The topical treatment with nitroglycerine and diltiazem gels failed. The patient agreed to the treatement with topical sevoflurane as an off-label medication, and it produced an immediate, intense, and long-lasting analgesic effect. An intense but rapidly transient burning sensation, as well as persistent but well-tolerated flatulence were the only adverse effects. The quality of life was greatly improved, and the cost of the treatment was affordable. Therefore, the off-label use of topical sevoflurane appears to be an effective alternative for the symptomatic treatment of painful anal fissures (AU)

As fissuras anais dolorosas podem ser condições angustiantes que prejudicam gravemente a qualidade de vida dos pacientes. A eficácia analgésica de medicamentos tópicos, como antagonistas de cálcio e nitratos, é bastante variável. O anestésico inalatório sevoflurano está sendo reaproveitado como analgésico tópico para feridas crônicas dolorosas. Relatamos uma experiência pioneira de tratamento com sevoflurano tópico em fissura anal crônica dolorosa. Umjovemadulto do sexomasculino sofria de uma fissura anal crônica extremamente dolorosa, que afetava gravemente sua qualidade de vida. O tratamento tópico com nitroglicerina e géis de diltiazem foi ineficaz. O paciente concordou com o tratamento com sevoflurano tópico como medicamento off-label, ou seja, com uso diferente do aprovado embula. O sevoflurano tópico produziu um efeito analgésico imediato, intenso e duradouro. Uma sensação de ardência intensa, mas transitória, e flatulência persistente, embora bem tolerada, foram os únicos efeitos adversos. A qualidade de vidamelhorou significativamente, e o custo do tratamento revelou-se acessível. Portanto, o uso off-label de sevoflurano tópico pode ser uma alternativa analgésica eficaz em casos de fissuras anais dolorosas. (AU)

Bloqueo caudal más anestesia general balanceada en un paciente con pentalogía de Cantrell, presentación de un caso clínico / Caudal block plus inhaled general anesthesia in a patient with pentalogy of Cantrell, presentation of a clinical case

The pentalogy of Cantrell is a disorder characterized by congenital abnormalities in the abdominal wall, lower sternum, anterior diaphragm, diaphragmatic pericardium, and cardiac anomalies. It is a rare disease with 250 cases registered around the world. The anesthetic implications will require a specialized management given the ventilatory mechanics and cardiac function which are compromised by the disease in the newborn. We present the case of a female patient with pentalogy of Cantrell without prenatal diagnosis, who had an operative procedure to correct patent ductus arteriosus and abdominal mesh placement under balanced general anesthesia with sevoflurane and fentanyl plus caudal block. This case is reported to provide our experience in the anesthetic management of this type of patients.

La pentalogía de Cantrell es una enfermedad caracterizada por anormalidades congénitas de la pared abdominal supraumbilical, esternón inferior, diafragma, pericardio diafragmático y anomalías cardiacas. Se trata de una enfermedad rara con 250 casos registrados alrededor del mundo. Las implicaciones anestésicas requieren de un manejo especializado debido a la mecánica ventilatoria y función cardíaca que se encuentran comprometidas en el recién nacido. Se presenta el caso de una recién nacida portadora de pentalogía de Cantrell, no diagnosticada prenatalmente, quien fue sometida a corrección de ductus arterioso persistente y colocación de malla abdominal bajo anestesia general balanceada con sevofluorano y fentanilo más bloqueo caudal. Se reporta el presente caso para brindar nuestra experiencia en el manejo anestésico de este tipo de pacientes.

lncRNA KCNQ1OT1 reverses the effect of sevoflurane on hepatocellular carcinoma progression via regulating the miR-29a-3p/CBX3 axis

Sevoflurane (SEVO) is widely applied as an anesthetic, which exerts antitumor capacity in various cancers, including hepatocellular carcinoma (HCC). Previous studies indicated that long non-coding RNA KCNQ1 opposite strand/antisense transcript 1 (KCNQ1OT1) was upregulated, while microRNA-29a-3p (miR-29a-3p) was downregulated in HCC. Thus, we aimed to explore the roles of KCNQ1OT1 and miR-29a-3p in HCC cells exposed to SEVO. Cell proliferation, apoptosis, migration, and invasion were assessed by the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay, flow cytometry, and transwell assays, respectively. The levels of genes were determined by quantitative real-time polymerase chain reaction (qRT-PCR) or western blot. Furthermore, the interaction between miR-29a-3p and KCNQ1OT1 or chromebox protein homolog 3 (CBX3) was predicted by Starbase or Targetscan, and then confirmed by dual-luciferase reporter assay. We found that the levels of KCNQ1OT1 and CBX3 were decreased, while miR-29a-3p was increased in SEVO-treated HCC cells. KCNQ1OT1 overexpression weakened the inhibitory effects of SEVO on HCC cell proliferation, apoptosis, migration, and invasion. Interestingly, KCNQ1OT1 bound to miR-29a-3p, and miR-29a-3p targeted CBX3. KCNQ1OT1 upregulated CBX3 level by repressing miR-29a-3p expression. Furthermore, KCNQ1OT1 exerted tumor promotion in HCC cells via suppressing miR-29a-3p to regulate CBX3 expression. Collectively, our findings demonstrated that KCNQ1OT1 regulated the antitumor effects of SEVO on HCC cells through modulating the miR-29a-3p/CBX3 axis, providing a theoretical basis for the treatment of HCC.

Síndrome de hipertermia maligna: una patología infrecuente / Malignant hyperthermia syndrome: A rare entity

Resumen Introducción: El síndrome de hipertermia maligna es un trastorno farmacogenético del músculo esquelético de carácter hereditario, que se caracteriza por un estado hipermetabólico relacionado con la exposición a anestésicos inhalatorios o relajantes musculares despolarizantes. Se trata de una afección infrecuente en individuos genéticamente predispuestos, con una incidencia muy baja en pediatría (1 de cada 10,000-15,000 procedimientos anestésicos). Caso clínico: Se presenta un caso de hipertermia maligna relacionado con la exposición a sevoflurano durante una cirugía de adenoidectomía en un paciente de sexo femenino de 6 años de edad. La paciente presentó taquicardia, hipercapnia e hipertermia, que precisaron la administración de dos dosis sucesivas de dantroleno sódico. La evolución posterior fue buena. Conclusiones: El síndrome de hipertermia maligna es un cuadro poco frecuente en la edad pediátrica. Se debe sospechar de forma precoz, ya que es fundamental su detección temprana para iniciar el tratamiento.

Abstract Background: Malignant hyperthermia syndrome is a hereditary pharmacogenetic disorder of skeletal muscle characterized by hypermetabolic state related to the exposure of volatile anesthetic gases or depolarizing muscle relaxants. It is an infrequent entity that occurs in genetically predisposed individuals, with a very low incidence in pediatrics (1 in 10,000-15,000 anesthetic procedures). Case report: We report a case of malignant hyperthermia related to exposure to sevoflurane during adenoidectomy surgery in a 6-year-old female. The patient presented with tachycardia, hypercapnia, and hyperthermia, requiring two successive doses of dantrolene sodium administration, with an adequate response to the treatment. Conclusions: Malignant hyperthermia syndrome is a rare condition in pediatric patients that should be detected in early stages since it is essential to initiate the treatment as soon as possible.

Sufentanil reduces emergence delirium in children undergoing transthoracic device closure of vsd after sevoflurane-based cardiac anesthesia

Abstract Objective: The aim of this study was to evaluate whether sufentanil can reduce emergence delirium in children undergoing transthoracic device closure of ventricular septal defect (VSD) after sevoflurane-based cardiac anesthesia. Methods: From February 2019 to May 2019, 68 children who underwent transthoracic device closure of VSD at our center were retrospectively analyzed. All patients were divided into two groups: 36 patients in group S, who were given sufentanil and sevoflurane-based cardiac anesthesia, and 32 patients in group F, who were given fentanyl and sevoflurane-based cardiac anesthesia. The following clinical data were recorded: age, sex, body weight, operation time, and bispectral index (BIS). After the children were sent to the intensive care unit (ICU), pediatric anesthesia emergence delirium (PAED) and face, legs, activity, cry, consolability (FLACC) scale scores were also assessed. The incidence of adverse reactions, such as nausea, vomiting, drowsiness and dizziness, was recorded. Results: There was no significant difference in age, sex, body weight, operation time or BIS value between the two groups. Extubation time (min), PEAD score and FLACC scale score in group S were significantly better than those in group F (P<0.05). No serious anesthesia or drug-related side effects occurred. Conclusions: Sufentanil can be safely used in sevoflurane-based fast-track cardiac anesthesia for transthoracic device closure of VSD in children. Compared to fentanyl, sufentanil is more effective in reducing postoperative emergence delirium, with lower analgesia scores and greater comfort.

Variability of anesthetic depth in total intravenous anesthesia vs balanced anesthesia using entropy indices: a randomized, crossover, controlled clinical trial / Variabilidad de la profundidad anestésica en anestesia total intravenosa vs. anestesia general balanceada usando índices de entropía. Un ensayo clínico aleatorizado, cruzado y controlado

Abstract Introduction: Total intravenous anesthesia (TIVA) and balanced anesthesia (BA) are the most commonly used anesthetic techniques. The differences are the variability of the depth of anesthesia between these techniques that might predict which one is safer for patients and presents a lower risk of intraoperative awakening. Objective: To determine whether a difference exists in the variability of depth of anesthesia obtained by response entropy (RE). Methods: A crossover clinical trial was conducted on 20 healthy patients receiving upper or lower limb ambulatory orthopedic surgery. Patients were randomly assigned to (a) target-controlled infusion of propofol using the Schnider model at a target concentration of 2.5 µg/mL for 15 minutes and a 10-minute washout, followed by sevoflurane administration at 0.8 minimal alveolar concentration (MAC) for the reminder of the surgery, or (b) the reverse sequence. Differences in the variability of the depth of anesthesia using RE were evaluated using paired t-test. Results: The treatment effect showed no significant difference in the average values of RE, during TIVA = 97.23 vs BA 97.04 (P = 0.39). Carry Over (-4.98 vs 4.08) and Period (100.3 vs 94.68) effects were not significantly different. Conclusion: The present study suggests that both anesthetic techniques are equivalent in terms of the stability of the depth of anesthesia. It is important to keep testing the determinants of the efficacy of different populations because the individual behaviors of patients might ultimately tip the scale.

Resumen Introducción: La anestesia total intravenosa (TIVA, por sus siglas en inglés) y la anestesia balanceada (AB) son las técnicas anestésicas más comúnmente utilizadas. La diferencia está en la variabilidad de la profundidad de la anestesia entre estas dos técnicas, lo cual pudiera predecir cuál es más segura para los pacientes y representar un menor riesgo de despertar intraoperatorio. Objetivo: Determinar si existe alguna diferencia en la variabilidad de la profundidad de la anestesia obtenida según los índices de entropía de respuesta (ER). Métodos: Se llevó a cabo un estudio clínico cruzado en 20 pacientes sanos que se sometieron a cirugía ortopédica ambulatoria de miembros superiores o inferiores. Los pacientes se asignaron aleatoriamente así: a) infusión controlada por objetivo (TCI, por sus siglas en inglés) de propofol, utilizando el modelo Schnider a una concentración objetivo de 2,5 µg/mL durante 15 min y un período de lavado de 10 minutos, seguido de la administración de sevoflurano a 0,8 de concentración alveolar mínima (CAM) durante el tiempo restante de la cirugía; o b) la secuencia inversa. Las diferencias en la variabilidad de la profundidad de la anestesia utilizando entropía de respuesta se evaluaron utilizando la prueba t pareada. Resultados: El efecto del tratamiento no mostró ninguna diferencia significativa en los valores promedio de entropía de respuesta (ER) durante TIVA = 97,23 vs. AB 97,04 (P = 0,39). Los efectos de arrastre (-4,98 vs. 4,08) y período (100,3 vs. 94,68) no fueron significativamente diferentes. Conclusiones: El presente estudio sugiere que ambas técnicas anestésicas son equivalentes en términos de estabilidad de la profundidad de la anestesia. Es importante continuar probando los factores determinantes de eficacia en las distintas poblaciones, ya que el comportamiento individual de cada paciente pudiera finalmente inclinar la balanza.

Short term olfactory memory and olfactory function after inhalation anesthetic agents: a randomized clinical trial / Memória olfativa de curta duração e função olfativa após anestésicos inalatórios: estudo clínico randomizado

Abstract Background and objectives: This clinical trial aimed to evaluate the effects of two different inhalation anesthetic agents on postoperative olfactory memory and olfactory function in patients who underwent micro laryngeal surgery. Methods: This randomized prospective controlled study consisted of 102 consecutive patients with a voice disorder. The patients underwent micro laryngeal surgery for voice disorders under general anesthesia. Patients who did not meet inclusion criteria and/or declined to participate (n = 34) were excluded from the study. Patients were divided into two groups. Four patients from Group 1 and four patients from Group 2 were lost to follow-up. Group 1 (n = 30) received sevoflurane, and Group 2 (n = 30) received desflurane during anesthesia. We compared the results by performing the pre-op and post-op Connecticut Chemosensory Clinical Research Center Olfactory test. Results: Thirty-three patients (55%) were male and 27 (45%) were female. The mean age was 48.18 ± 13.88 years (range: 19‒70 years). Preoperative and postoperative olfactory functions did not show a significant difference within the groups postoperatively (p > 0.05). Preoperative and postoperative olfactory memory showed a significant decrease 3 hours after the surgery (p < 0.05). Conclusions: Olfactory functions and memory were not affected by desflurane in the early postoperative period. Although sevoflurane did not affect olfactory functions, it had a temporary negative effect on olfactory memory in the early postoperative period.

Resumo Introdução e objetivos: O estudo avaliou o efeito pós-operatório de dois agentes anestésicos inalatórios distintos na memória olfativa de curta duração e na função olfativa em pacientes submetidos à microcirurgia de laringe. Método: O estudo prospectivo controlado randomizado avaliou, consecutivamente, 102 pacientes com alteração vocal submetidos à microcirurgia de laringe sob anestesia geral. Trinta e quatro pacientes não obedeceram aos critérios de inclusão e/ou não aceitaram participar do estudo e foram excluídos. Os pacientes foram divididos em dois grupos. Quatro pacientes do Grupo 1 e quatro do Grupo 2 foram perdidos durante o seguimento. O Grupo 1 (n = 30) recebeu sevoflurano durante a anestesia e o Grupo 2 (n = 30), desflurano. Comparamos resultados pré e pós-operatórios de memória olfativa e funções olfativas, realizando o Connecticut Chemosensory Clinical Research Center Olfactory test. Resultados: Foram incluídos um total de 33 (55%) homens e 27 (45%) mulheres. A idade média foi 48,18 ± 13,88 anos (variação: 19-70 anos). As funções olfativas pré e pós-operatórias não apresentaram diferença estatisticamente significante dentro dos grupos no pós-operatório (p > 0,05). A memória olfativa pré e pós-operatória não mostrou diminuição estatisticamente significante quando avaliada três horas após a cirurgia (p< 0,05). Conclusões: Memória e funções olfativas não foram alteradas pelo desflurano no pós-operatório imediato. Embora o sevoflurano não tenha alterado as funções olfativas, causou efeito temporário negativo na memória olfativa no pós-operatório imediato.

Anestesia para reparación antenatal de mielomeningocele: Presentación de un caso / Anesthesia for myelomenigocele antenatal repair: Case report

INTRODUCTION: The advance in the methods of prenatal diagnosis and surgical techniques have allowed the development of fetal surgery, achieving identification and early treatment of anomalies invalidating extrauterine life. Myelomeningocele (MMC) is the most frequent neural tube defect and its intrauterine correction has demonstrated benefits. OBJECTIVE: To publicize the anesthetic management of a prenatal correction of MMC performed in a public hospital in Chile. CASE REPORT: 31-year-old woman, pregnancy of 25 weeks of gestational age, fetus carrying MMC lumbosacral, who underwent open correction. Procedure performed with incidents under general anesthesia with remifentanil and sevoflorane MAC in 2 and tocolytic prophylaxis. At 48 hours post operative, he presented an acute pulmonary edema compatible (EPA), which was successfully resolved with depletive therapy for 24 hours in the Intensive Care Unit, without the need for mechanical ventilation or use of vasoactive drugs. Discharged one week later in good condition, with interruption of pregnancy by elective caesarean section at 37 weeks, with a newborn without stigmas of neurological sequelae. CONCLUSIONS: The mother-fetus binomial is a challenge for the anesthetist. In intrauterine surgery the need for knowledge about the pharmacology of tocolytics, placental uterine physiology and the complications of the procedure are added.

INTRODUCCIÓN: El avance en los métodos de diagnóstico prenatal y las técnicas quirúrgicas han permitido el desarrollo de la cirugía fetal, logrando identificación y tratamiento precoz de anomalías invalidantes para la vida extrauterina. El mielomeningocele (MMC) es el defecto del tubo neural más frecuente y su corrección intrauterina tiene beneficios demostrados. OBJETIVO: Dar a conocer el manejo anestésico de una corrección prenatal de MMC realizada en un hospital público de Chile. CASO CLÍNICO: Mujer de 31 años, embarazo de 25 semanas de edad gestacional, feto portador de MMC lumbosacro, que se sometió a una corrección por vía abierta. Procedimiento realizado con incidentes bajo anestesia general con remifentanilo y sevoflorano MAC en 2 y profilaxis tocolítica. A las 48 horas postoperatorias presentó cuadro compatible con edema pulmonar agudo (EPA), que se resolvió exitosamente con terapia depletiva por 24 horas en Unidad de Cuidados Intensivos, sin necesidad de ventilación mecánica ni uso de drogas vasoactivas. Dada de alta una semana después en buenas condiciones. El embarazo se interrumpió por cesárea electiva a las 37 semanas, con un recién nacido sin estigmas de secuela neurológica. CONCLUSIONES: El binomio madre-feto es un reto para el anestesista. En cirugía intraútero se suma la necesidad de conocimientos sobre la farmacología de los tocolíticos, fisiología útero placentaria y las complicaciones propias del procedimiento.

Malignant hyperthermia in a child after magnetic resonance imaging: a case report / Hipertermia maligna em criança após exame de ressonância magnética: relato de caso

ABSTRACT Objective: To report on a case of malignant hyperthermia in a child after a magnetic resonance imaging of the skull was performed using sevoflurane anesthesia. Case description: A 3-year-old boy admitted to the pediatric intensive care unit after presenting clinical and laboratory findings consistent with unspecified viral meningoencephalitis. While the patient was sedated, a magnetic resonance imaging of the skul was performed using propofol followed by the administration of sevoflurane through a laryngeal mask in order to continue anesthesia. Approximately three hours after the start of the procedure, the patient presented persistent tachycardia, tachypnea, generalized muscular stiffness and hyperthermia. With a diagnostic hypothesis of malignant hyperthermia, dantrolene was then administered, which immediately induced muscle stiffness, tachycardia, tachypnea and reduced body temperature. Comments: Malignant hyperthermia is a rare pharmacogenetic syndrome characterized by a severe hypermetabolic reaction after the administration of halogenated inhalational anesthetics or depolarizing muscle relaxants such as succinylcholine, or both. Although it is a potentially fatal disease, the rapid administration of continued doses dantrolene has drastically reduced the morbidity and mortality of the disease.

RESUMO Objetivo: Relatar um caso de hipertermia maligna em criança após exame de ressonância magnética de crânio realizada sob efeito anestésico de sevoflurano. Descrição do caso: Menino de três anos de idade, admitido na Unidade de Terapia Intensiva Pediátrica (UTIP) após apresentar quadros clínico e laboratorial compatíveis com meningoencefalite viral não especificada. Foi realizado um exame de ressonância magnética de crânio com sedação utilizando, na indução anestésica, o propofol seguido pela administração de sevoflurano por meio de máscara laríngea para manutenção anestésica. Aproximadamente três horas após o início do procedimento, o paciente apresentou taquicardia, taquipneia, rigidez muscular generalizada e hipertermia persistentes. Com hipótese diagnóstica de hipertermia maligna, foi então administrado dantrolene, que fez ceder de forma imediata a rigidez muscular, a taquicardia, a taquipneia e reduziu a temperatura corporal. Comentários: A hipertermia maligna é uma síndrome farmacogenética rara, que se caracteriza por reação hipermetabólica grave após administração de anestésicos inalatórios halogenados e/ou relaxantes musculares despolarizantes, como a succinilcolina. Apesar de ser uma doença potencialmente fatal, a rápida administração de dantrolene, junto às doses de manutenção, tem reduzido drasticamente a morbimortalidade da doença.

Silvoflurano tópico en infección superficial por SARM tras artroplastia de rodilla: caso clínico / Topical sevoflurane for superficial MRSA infection after knee arthroplasty: case report

Intentar el tratamiento retentivo de material protésico ante heridas quirúrgicas infectadas por gérmenes resistentes es objeto de debate, especialmente cuando el agente causal es un Staphylococcus aureus resistente a meticilina (SARM). Una paciente diabética y con obesidad tipo I sufrió infección de la herida quirúrgica tras artroplastia de rodilla que no evolucionó bien con antibioterapia empírica y terapia hiperosmolar. Se planificó una reintervención que fue demorada por motivos extramédicos (falta de terapia de presión negativa para cubrir la herida postoperatoria, pues se preveía no poder realizar cierre primario). Mientras se conseguía este material, y tras obtener el consentimiento de la paciente, se iniciaron irrigaciones de la herida con sevoflurano tópico off-label, pues ese fármaco ha mostrado capacidad antimicrobiana. La evolución clínica fue excelente desde el inicio a pesar de que en el cultivo se aisló un SARM resistente a la antibioterapia empírica, por lo que se desestimó la reintervención y se continuó con sevoflurano tópico junto a la antibioterapia dirigida por antibiograma, lográndose la curación completa de la herida tras 6 semanas. Durante ese tiempo, la paciente no experimentó ningún efecto adverso atribuible al sevoflurano. El sevoflurano tópico aparece como una valiosa nueva opción terapéutica ante heridas postoperatorias infectadas, especialmente cuando los gérmenes causantes son resistentes a los antibióticos convencionales.

It is challenging to try a retentive treatment of prosthetic material superinfected by resistant microorganisms, especially when the causative agent is a methicillin-resistant Staphylococcus aureus (MRSA). A diabetic, obese female patient suffered from a postoperative wound infection after a knee arthroplasty. Initial treatment with antibiotics and hyperosmolar therapy failed and clinical evolution was no good. Surgery was scheduled, but it was delayed due to nonmedical reasons (lack of negative-pressure therapy to cover the wound since primary wound closure was anticipated to be very improbable to perform). While waiting for this therapy, off-label irrigations with topical sevoflurane were started after obtaining written consent, since this drug has exhibited antimicrobial properties. Clinical evolution turned out to be excellent since the very beginning, even though a MRSA resistant to the antibiotics empirically administered was isolated. Thus, surgery was discarded, and culture-guided antibiotic therapy was added to topical sevoflurane, which was followed by a complete healing of the wound after 6 weeks. Sevoflurane treatment was well tolerated as the patient reported no adverse effects. Therefore, treating postsurgical wounds with topical sevoflurane appears as a valuable new alternative, especially when infections are caused by microorganisms resistant to conventional antibiotics.

Sevoflurano tópico como tratamiento analgésico y antimicrobiano de tenosinovitis piógena de los flexores de la mano. Caso clínico / Topical sevoflurane as analgesic and antimicrobial treatment of pyogenic flexor tenosynovitis of the hand. Case report

Presentamos el caso de un paciente con una tenosinovitis piógena del 5° dedo de la mano, tratado inicialmente con desbridamiento quirúrgico y antibioterapia empírica. La evolución fue desfavorable, pues el dedo presentaba un defecto de cobertura con signos infecciosos en la herida y las curas resultaban muy dolorosas. Al paciente se le ofertaron varias opciones quirúrgicas y, mientras se decidía por alguna, aceptó por escrito iniciar curas con sevoflurano líquido tópico (según protocolo vigente para uso de fármacos fuera de indicación). El efecto analgésico del sevoflurano apareció rápidamente, y la evolución posterior de la herida fue muy favorable, pues los signos infecciosos desaparecieron y el defecto de cobertura se había cerrado tras tres semanas de empleo de sevoflurano tópico, sin necesidad de nuevas cirugías. Este caso ejemplifica que el uso fuera de indicación de sevoflurano tópico para tratar heridas complejas puede evitar actuaciones quirúrgicas, mucho más agresivas para los pacientes.

The clinical case is presented on a patient suffering from pyogenic tenosynovitis affecting the 5th finger of the hand, which was initially treated with surgical debridement and empirical antibiotic treatment. The clinical outcome was unfavourable, since the finger presented with a coverage defect, and the wound seemed to be infected. Wound cleaning and dressings were very painful. The patient was asked to choose between several surgical therapeutic alternatives, but he gave written informed consent to be treated with topical sevoflurane, following an approved protocol for the off-label use of this drug. Pain was accurately controlled after sevoflurane application, and the wound exhibited a very good outcome with disappearance of the clinical signs of infection and complete closure of the defect coverage after three weeks of sevoflurane, with no new surgical procedures. The present clinical case illustrates how the off-label use of topical sevoflurane for the treatment of complicated wounds could be useful to avoid surgical procedures that are more aggressive for patients.

Enriched environment improves sevoflurane-induced cognitive impairment during late-pregnancy via hippocampal histone acetylation

Fetal exposure to sevoflurane induces long-term cognitive impairment. Histone acetylation regulates the transcription of genes involved in memory formation. We investigated whether sevoflurane exposure during late-pregnancy induces neurocognitive impairment in offspring, and if this is related to histone acetylation dysfunction. We determined whether the effects could be reversed by an enriched environment (EE). Pregnant rats were exposed to 2.5% sevoflurane or control for 1, 3, or 6 h on gestational day 18 (G18). Sevoflurane reduced brain-derived neurotrophic factor (BDNF), acetyl histone H3 (Ac-H3), and Ac-H4 levels and increased histone deacetylases-2 (HDAC2) and HDAC3 levels in the hippocampus of the offspring on postnatal day 1 (P1) and P35. Long-term potentiation was inhibited, and spatial learning and memory were impaired in the 6-h sevoflurane group at P35. EE alleviated sevoflurane-induced cognitive dysfunction and increased hippocampal BDNF, Ac-H3, and Ac-H4. Exposure to 2.5% sevoflurane for 3 h during late-pregnancy decreased hippocampal BDNF, Ac-H3, and Ac-H4 in the offspring but had no effect on cognitive function. However, when the exposure time was 6 h, impaired spatial learning and memory were linked to reduced BDNF, Ac-H3, and Ac-H4, which could be reversed by EE.