Asunto(s)
Analgesia Epidural/efectos adversos , Analgesia Obstétrica/efectos adversos , Enfermedades de los Nervios Craneales/etiología , Hematoma Subdural/etiología , Adulto , Enfermedades de los Nervios Craneales/diagnóstico , Femenino , Hematoma Subdural/diagnóstico , Humanos , Imagen por Resonancia Magnética , EmbarazoRESUMEN
BACKGROUND: Scoliosis repair is a major orthopaedic surgery associated with severe post-operative pain. Ketamine and magnesium have an established efficacy as morphine-sparing agents. Our purpose was to evaluate the morphine-sparing effect of both magnesium and ketamine given simultaneously compared with ketamine alone during scoliosis surgery. METHODS: Fifty patients scheduled for posterior instrumentation were randomised in a prospective double-blind study. The Gr (K + Mg) received, after induction, an intravenous (IV) bolus of ketamine 0.2 mg/kg and magnesium 50 mg/kg, followed by continuous infusion of ketamine (0.15 mg/kg/h) and magnesium (8 mg/kg/h) until extubation. The Gr (K) received the same dose of ketamine associated with bolus and continuous infusion of normal saline. All patients received multimodal analgesia associated with IV morphine administered via patient-controlled analgesia pump. Morphine consumption, visual analogue scale (VAS) pain scores and occurrence of side effects were followed until 48 h post-operatively. Sleep quality and patient satisfaction were also followed. P < 0.05 was considered statistically significant. RESULTS: The average cumulative morphine consumption was significantly lower in the Gr (K + Mg) compared with the Gr (K) at post-operative hours 4, 8, 12, 18, 30, 36 and 48. The relative difference in the post-operative morphine consumption was 29.5%: Gr (K + Mg) 51.53 mg vs. Gr (K) 73.16 mg. VAS scores were not statistically different between the two groups. However, qualities of sleep and satisfaction scores on the first night were significantly better in the Gr (K + Mg) (P = 0.027 and P = 0.016, respectively). CONCLUSION: Ketamine and magnesium association reduces the post-operative morphine consumption after scoliosis surgery. It seems to provide a better sleep quality and improves patient satisfaction.
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Analgésicos/uso terapéutico , Ketamina/uso terapéutico , Sulfato de Magnesio/uso terapéutico , Morfina/administración & dosificación , Dolor Postoperatorio/prevención & control , Escoliosis/cirugía , Fusión Vertebral/efectos adversos , Adolescente , Analgesia Controlada por el Paciente , Niño , Método Doble Ciego , Quimioterapia Combinada , Femenino , Humanos , Hiperalgesia/inducido químicamente , Hiperalgesia/fisiopatología , Hiperalgesia/prevención & control , Infusiones Intravenosas , Fijadores Internos , Complicaciones Intraoperatorias/prevención & control , Masculino , Dolor Postoperatorio/tratamiento farmacológico , Satisfacción del Paciente , Piperidinas/efectos adversos , Náusea y Vómito Posoperatorios/etiología , Estudios Prospectivos , Implantación de Prótesis , Remifentanilo , Sueño/efectos de los fármacosRESUMEN
INTRODUCTION: Hip fractures are a reliable indicator of osteoporosis. Despite their importance, few studies have assessed their epidemiology in Lebanon and the Middle East. HYPOTHESES: Hip fracture incidence rates in Lebanon approximate those of Northern countries, and show the same characteristics, particularly the exponential increase with age, higher incidence in women, and a recent trend of rate leveling in women but not in men. MATERIALS AND METHODS: A national database of hip fracture cases admitted to hospitals in Lebanon in 2007 was created. Crude and age-adjusted incidence rates were calculated at 5-year intervals for individuals over age 50. These rates were also standardized to the 2000 United States population, and compared to those of other countries. Projected incidence rates in Lebanon in 2020 and 2050 were also calculated. RESULTS: A total of 1199 patients were included in the study. The crude annual incidence rate in individuals over 50 was 147 per 100,000 individuals, 132 per 100,000 males and 160 per 100,000 females, with a female-to-male ratio of 1.2. The age-standardized annual incidence rates (per 100,000) were 180 in males and 256 in females. Assuming unchanged healthcare parameters, the projected crude incidence rates for people over 50 are expected to reach 174 and 284 per 100,000 in 2020 and 2050 respectively. CONCLUSIONS: Lebanese hip fracture rates are lower than Northern countries, but show many similar characteristics such as an exponential increase with age, a higher incidence in women, and clues of a leveling of rates in women but not in men. Numbers are expected to increase substantially in the coming decades. LEVEL OF EVIDENCE: Level IV. Epidemiological study.
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Accidentes por Caídas/estadística & datos numéricos , Fracturas de Cadera/epidemiología , Osteoporosis/epidemiología , Distribución por Edad , Anciano , Anciano de 80 o más Años , Bases de Datos Factuales , Femenino , Curación de Fractura/fisiología , Fracturas de Cadera/diagnóstico , Fracturas de Cadera/cirugía , Humanos , Incidencia , Líbano/epidemiología , Masculino , Persona de Mediana Edad , Osteoporosis/diagnóstico por imagen , Vigilancia de la Población , Pronóstico , Radiografía , Estudios Retrospectivos , Medición de Riesgo , Distribución por Sexo , Estados Unidos/epidemiologíaRESUMEN
INTRODUCTION: Neurotoxic fish poisoning appears to be a recent phenomenon in the Mediterranean Sea. We report a case of deep non-reactive reversible coma after ingestion of Mediterranean fish innards. CASE REPORT: An 80 year-old man, heavy smoker who had a previous cerebral infarct in the posterior territory, was admitted for rapid deterioration of his neurological condition. He started having perioral tingling, then dysarthria, then became quadriparetic, then developed respiratory and hemodynamic failure and within 3-4h, entered a state of deep non-reactive coma with absence of all brainstem reflexes. He started to improve after 20 h and recovered his neurological baseline within 36 h. Later on, he stated that all his symptoms started after he ingested the gonads of a toxic fish, Lagocephalus scleratus. DISCUSSION: Tetrodotoxin blocks voltage-gated sodium channels and inhibits the production and propagation of action potentials. This toxin is highly concentrated in the liver, gonads, intestines and skin of this fish that is well-known in Japan (where it is considered as a delicacy) and South-East Asia and seems to have migrated recently to the Mediterranean Sea. There is no known antidote to tetrodotoxin but intensive supportive treatment can be life-saving.
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Coma/inducido químicamente , Coma/etiología , Enfermedades Transmitidas por los Alimentos/complicaciones , Carne , Síndromes de Neurotoxicidad/complicaciones , Tetraodontiformes , Tetrodotoxina/envenenamiento , Anciano de 80 o más Años , Animales , Tronco Encefálico/fisiología , Infarto Cerebral/etiología , Femenino , Humanos , Masculino , Mar Mediterráneo , Examen Neurológico , Ovario/química , Cuadriplejía/etiología , Fumar/efectos adversosRESUMEN
INTRODUCTION: The American College of Cardiology/American Heart Association (ACC/AHA) guidelines stratify perioperative cardiac risk according to clinical markers, functional capacity, and type of surgery. They help determining which patients are candidates for preoperative cardiac testing and optimizing the cost-effectiveness of the evaluation strategy. Auditing our preoperative anaesthetic screening practice revealed an exceedingly high rate of referrals to the cardiologists. A small pocket-size reminder was created in order to improve the adhesion of the anaesthesiologists to the recommendations of the ACC/AHA, and confirm or obviate the need for a formal preoperative specialized cardiology consultation. Another audit was conducted 1 year later in order to evaluate the effectiveness of this reminder. METHODS: The second audit was conducted over a period of 1 month. Recorded data included demographic characteristics, clinical predictors of cardiovascular risk, surgical risk, and the reasons for the cardiac evaluation by a cardiologist (as reported by the senior or junior anaesthesiologist). Results of this second audit were compared to those of the audit conducted a year earlier. RESULTS: During the first audit, a total of 654 patients were seen in the preoperative unit. Fifty-two patients were referred to a cardiologist during the study period (7.9%). Guidelines for cardiac assessment were respected in 7/52 patients (13.5%). During the second audit, 30 out of 787 patients (3.8%) screened in preoperative anaesthetic consultation unit were referred to the cardiologist. According to the ACC/AHA guidelines, 27/30 patients (90%) objectively needed a cardiology consultation due to the existence of a known previous heart disease. DISCUSSION: The use of the pocket reminder concerning the ACC/AHA recommendations significantly reduced both the total number of cardiology referrals, and the number of unjustified referrals. The use of a pocket guide may help in reducing both the cost and the postponement of scheduled surgery.
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Anestesia , Adhesión a Directriz , Pruebas de Función Cardíaca , Auditoría Médica , Cuidados Preoperatorios , HumanosRESUMEN
INTRODUCTION: Postoperative pain relief in Lebanon is a public health problem because its coverage is insufficient. STUDY DESIGN: A survey was performed with a questionnaire distributed to anaesthesiologists during the Lebanese national meeting of anaesthesia in May 2006. RESULTS: A total of 106 out of the 230 distributed questionnaires were collected. The coverage of the postoperative pain is different in the university hospitals and others. A preoperative information and postoperative evaluation of pain are only performed by 26% of anesthesiologists. A multimodal analgesia is begun in the operative room or in postanaesthesist care unit for 92% of the patients. Only 71% of the anaesthesiologists have pumps for patient-controlled analgesia. Written protocols for postoperative analgesia are available in only 58% of the centres. Among anaesthesiologists, only 36% have an initial and/or continuous formation to treat the postoperative pain. The major obstacle for improvement of postoperative pain is the cost of such treatments, which must be supported by the patients. CONCLUSION: Even if there is a good awareness of the importance to relieve the postoperative pain, important efforts must be done in this domain in Lebanon.
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Dolor Postoperatorio/terapia , Adulto , Analgesia Controlada por el Paciente/instrumentación , Analgesia Controlada por el Paciente/estadística & datos numéricos , Anestesia , Anestesiología/instrumentación , Femenino , Encuestas de Atención de la Salud , Humanos , Líbano , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Dolor Postoperatorio/economía , Encuestas y Cuestionarios , Recursos HumanosAsunto(s)
Anestesia General/métodos , Anestésicos Generales/farmacología , Hidroxizina/administración & dosificación , Administración Oral , Adulto , Femenino , Humanos , Nervio Mandibular/patología , Enfermedades del Sistema Nervioso Periférico , Inducción de Remisión , Temperatura , Traumatismos del Sistema Nervioso , Resultado del Tratamiento , Traumatismos del Nervio TrigéminoRESUMEN
Freeman-Sheldon syndrome, or distal arthrogryposis type 2A, is a rare congenital myopathy and dysplasia characterised by multiple contractures, abnormalities of the head and face, defective development of the hands and feet and skeletal malformations. The facial muscle contracture produces the typical 'whistling face' appearance. Anaesthetic issues include difficult intravenous access, difficult airway and postoperative pulmonary complications. Although an association with malignant hyperthermia has been suggested, this has not been confirmed. We report the management of a seven-year-old girl with Freeman-Sheldon syndrome undergoing anterior and posterior spinal surgery and describe a successful anaesthetic regimen based on a total intravenous anaesthesia technique with remifentanil and propofol without neuromuscular blocking agents. The child had an uneventful anaesthetic and postoperative course. We believe the presence of the myopathy warranted the use of a 'non-triggering' anaesthetic, as suxamethonium and volatile agents may be associated with significant complications such as muscle rigidity and rhabdomyolysis in myopathic patients, even in the absence of malignant hyperthermia.
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Anomalías Múltiples/cirugía , Anestesia General , Anomalías Craneofaciales/complicaciones , Procedimientos Ortopédicos , Escoliosis/cirugía , Columna Vertebral/cirugía , Anestésicos Intravenosos , Artrogriposis/complicaciones , Presión Sanguínea/fisiología , Niño , Electroencefalografía , Femenino , Frecuencia Cardíaca/fisiología , Humanos , Monitoreo Intraoperatorio , Dolor Postoperatorio/diagnóstico , Dolor Postoperatorio/tratamiento farmacológico , Piperidinas , Propofol , Remifentanilo , Respiración Artificial , Escoliosis/complicaciones , SíndromeRESUMEN
BACKGROUND AND OBJECTIVE: Controlled hypotension is frequently used for obtaining better exposure during tympanoplasty. The aim of this study was to compare dexmedetomidine, a selective, short-acting, central alpha2-adrenergic agonist with remifentanil, an ultra-short-acting opioid with properties similar to other mu-specific agonists, regarding their effects in achieving controlled hypotension and improving surgical field exposure and surgeon's satisfaction during tympanoplasty. METHODS: In this prospective, double-blind pilot study, 24 consecutive patients scheduled for elective tympanoplasty were randomly assigned to receive either dexmedetomidine 1 microg kg(-1) over 10 min at anaesthesia induction followed by 0.4-0.8 microg kg(-1) h(-1) infusion during maintenance or remifentanil 1 microg kg(-1) over 1 min at anaesthesia induction followed by 0.2-0.4 microg kg(-1) min(-1) infusion during maintenance. Mean arterial pressure and heart rate were recorded before induction, at incision, 30, 60, 90 and 120 min after incision and 10 min after stopping the infusion. Surgical field exposure condition and satisfaction scores were assessed by the surgeon, blinded to the study drugs. RESULTS: Mean arterial pressure and heart rate were significantly lower in the remifentanil group compared with the dexmedetomidine group at all times (P = 0.03 and 0.036, respectively). Surgical field exposure condition (3 +/- 0.01 vs. 2.3 +/- 0.7; P = 0.039) and surgeons' satisfaction (3 +/- 0.01 vs. 2.25 +/- 0.87; P = 0.039) scores were significant after remifentanil compared with dexmedetomidine. CONCLUSIONS: Infusion of dexmedetomidine, at the doses used in this study, was less effective than remifentanil in achieving controlled hypotension, good surgical field exposure condition and surgeons' satisfaction during tympanoplasty.
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Agonistas alfa-Adrenérgicos/farmacología , Presión Sanguínea/efectos de los fármacos , Dexmedetomidina/farmacología , Frecuencia Cardíaca/efectos de los fármacos , Hipotensión Controlada/métodos , Timpanoplastia , Adulto , Analgésicos Opioides/farmacología , Anestesia General , Sedación Consciente/estadística & datos numéricos , Métodos Epidemiológicos , Femenino , Humanos , Infusiones Intravenosas , Masculino , Proyectos Piloto , Piperidinas/farmacología , Remifentanilo , Factores de TiempoRESUMEN
We report the case of a 60-year-old woman who underwent mitral valve replacement and tricuspid valve repair. Following surgery she developed rapid onset of ascitis and secondary abdominal compartmental syndrome with low cardiac output and oliguria. Following drainage of the ascitis, the abdominal pressure dropped with a spectacular improvement of both the cardiac ant the urine output.
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Abdomen , Síndromes Compartimentales/etiología , Enfermedades de las Válvulas Cardíacas/cirugía , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Femenino , Humanos , Persona de Mediana EdadRESUMEN
INTRODUCTION: The epileptogenic potential of quinolones differs from one product to the other. The rare epileptic seizures induced by gatifloxacin were seen with the intravenous route. PATIENTS: We report two old ladies presenting with generalized status epilepticus after being treated orally with normal doses of gatifloxacin, with a good recovery. Past medical history of convulsion was the only factor found. Brain MR imaging was unremarkable. In one patient, EEG showed continuous bilateral paroxysmal discharges, predominantly frontal. CONCLUSION: Caution is warranted when using quinolones in elderly patients, especially those suffering from epilepsy.
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Antiinfecciosos/efectos adversos , Fluoroquinolonas/efectos adversos , Estado Epiléptico/inducido químicamente , Anciano , Femenino , Gatifloxacina , HumanosRESUMEN
BACKGROUND: Arterial oxygenation may be compromised in morbidly obese patients undergoing bariatric surgery. The aim of this study was to evaluate the effect of a vital capacity manoeuvre (VCM), followed by ventilation with positive end-expiratory pressure (PEEP), on arterial oxygenation in morbidly obese patients undergoing open bariatric surgery. METHODS: Fifty-two morbidly obese patients (body mass index >40 kg m-2) undergoing open bariatric surgery were enrolled in this prospective and randomized study. Anaesthesia and surgical techniques were standardized. Patients were ventilated with a tidal volume of 10 mL kg-1 of ideal body weight, a mixture of oxygen and nitrous oxide (FiO2 = 40%) and respiratory rate was adjusted to maintain end-tidal carbon dioxide at a level of 30-35 mmHg. After abdominal opening, patients in Group 1 had a PEEP of 8 cm H2O applied and patients in Group 2 had a VCM followed by PEEP of 8 cm H2O. This manoeuvre was defined as lung inflation by a positive inspiratory pressure of 40 cm H2O maintained for 15 s. PEEP was maintained until extubation in the two groups. Haemodynamics, ventilatory and arterial oxygenation parameters were measured at the following times: T0 = before application of VCM and/or PEEP, T1 = 5 min after VCM and/or PEEP and T2 = before abdominal closure. RESULTS: Patients in the two groups were comparable regarding patient characteristics, surgical, haemodynamic and ventilatory parameters. In Group 1, arterial oxygen partial pressure (PaO2) and arterial haemoglobin oxygen saturation (SaO2) were significantly increased and alveolar-arterial oxygen pressure gradient (A-aDO2) decreased at T2 when compared with T0 and T1. In Group 2, PaO2 and SaO2 were significantly increased and A-aDO2 decreased at T1 and T2 when compared with T0. Arterial oxygenation parameters at T1 and T2 were significantly improved in Group 2 when compared with Group 1. CONCLUSION: The addition of VCM to PEEP improves intraoperative arterial oxygenation in morbidly obese patients undergoing open bariatric surgery.
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Cirugía Bariátrica/métodos , Obesidad Mórbida/cirugía , Oxígeno/sangre , Respiración con Presión Positiva/métodos , Capacidad Vital , Adulto , Analgésicos no Narcóticos/administración & dosificación , Análisis de los Gases de la Sangre/métodos , Presión Sanguínea/fisiología , Dióxido de Carbono/sangre , Femenino , Frecuencia Cardíaca/fisiología , Humanos , Intubación Intratraqueal/métodos , Masculino , Óxido Nitroso/administración & dosificación , Estudios Prospectivos , Pruebas de Función Respiratoria/métodos , Factores de TiempoRESUMEN
Moya Moya is a rare disease of uncertain origin, characterised by stenosis of one or both of the internal carotid arteries and responsible of several neurological signs. We present the case of a boy with Moya Moya disease who was scheduled for an epiphisiodesis of the lateral malleola and had a spinal anaesthesia with hyperbaric bupivacaine 0.5% 10 mg without any perioperative complications. Any anaesthetic method could be used, provided special attention is given to avoid changes of capnea and blood pressure to preserve cerebral blood flow and palliate to cerebral flow steal.
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Anestesia Raquidea , Enfermedad de Moyamoya/complicaciones , Adolescente , Anestésicos Locales , Presión Sanguínea/fisiología , Bupivacaína , Dióxido de Carbono/sangre , Circulación Cerebrovascular/fisiología , Peroné/cirugía , Humanos , Masculino , Procedimientos OrtopédicosRESUMEN
Malignant hyperthermia (MHS) is a rare potentially fatal complication of general anesthesia. Anesthetic agents most frequently incriminated are succinylcholine and halogenated agents. Respiratory acidosis is the most specific and sensitive sign. Hyperthermia per se may occur secondarily or may stay totally absent. Tachycardia and/or arrhythmias often develop due to hyperkalemia and metabolic acidosis. Muscle rigidity whenever present is pathognomonic The "gold standard" test for the diagnosis of MHS is the halothane-caffeine contracture test. Dantrolene is the treatment of choice and prognosis depends on the early administration of this agent.
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Hipertermia Maligna , Dantroleno/uso terapéutico , Diagnóstico Diferencial , Femenino , Humanos , Hipertermia Maligna/diagnóstico , Hipertermia Maligna/terapia , Persona de Mediana Edad , Relajantes Musculares Centrales/uso terapéuticoRESUMEN
Hemodynamic effects of pressure support ventilation (PSV) were assessed in 33 patients, after cardiac surgery. The patients, selected for their stable left ventricular and respiratory functions, underwent uncomplicated coronary artery bypass grafting. They all underwent the same anesthetic protocol, and an invasive hemodynamic monitoring. Eight to ten hours postoperatively, while all patients were fully awake, normothermic and hemodynamically stable, controlled ventilation (CV) was replaced by 3 levels of PSV (20, 10, 5 cm H2O). These levels were applied consecutively for 20 minutes each, before extubation. Hemodynamic and gas exchange data were recorded on CV, on each level of PSV, and on spontaneous breathing. The results were analyzed using ANOVA and Bonfferoni methods. No statistical significance could be noted between the five modes of ventilation as to hemodynamic parameters, arterial and mixed venous blood gases, and oxygen consumption (VO2). The only 2 parameters that reached statistical significance were central venous pressure and respiratory rate. Our study demonstrates that patients with stable cardiovascular and respiratory function can adapt to different levels of PSV without hemodynamic modifications or an increase in their VO2.
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Puente de Arteria Coronaria , Respiración con Presión Positiva , Función Ventricular Izquierda , Adulto , Anciano , Análisis de Varianza , Anestesia Intravenosa , Dióxido de Carbono/sangre , Presión Venosa Central , Femenino , Hemodinámica , Humanos , Intubación Intratraqueal , Masculino , Persona de Mediana Edad , Monitoreo Fisiológico , Oxígeno/sangre , Consumo de Oxígeno , Respiración con Presión Positiva/métodos , Cuidados Posoperatorios , Intercambio Gaseoso Pulmonar , RespiraciónRESUMEN
Bilateral superior vena cava is a congenital anomaly of which the anaesthesiologist and intensivist should be aware in order to not mistake catheters placed in the left superior vena cava as being malpositioned outside of the venous circulation. These malpositions generally require catheter removal and reinsertion. This anomaly although rare is not-so-unusual. It is generally well tolerated.