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1.
Anaesthesist ; 69(12): 886-889, 2020 12.
Artigo em Alemão | MEDLINE | ID: mdl-32980949

RESUMO

This is a case report of a 29-year-old female patient who developed unilateral mydriasis following the use of a scopolamine patch for the prevention of postoperative nausea and vomiting (PONV).Given a medical history showing multiple risk factors for PONV, a preauricular scopolamine patch was applied prior to the induction of anesthesia. General anesthesia was induced with 150 mg propofol and 25 µg sufentanil and maintained with total intravenous anesthesia, using propofol (5 mg/kg per h) and remifentanil (2-3 µg/kg per h).Following an uneventful surgery of 90min duration, the patient was extubated and transferred to the recovery room, where the patch was removed. During the orthopedic ward round the following day, the clinical examination revealed anisocoria of the left eye in the form of unilateral mydriasis. In order to determine the cause of this clinical presentation, further neurological and ophthalmological examinations and investigations were carried out. In addition, magnetic resonance imaging was conducted to rule out a central nervous cause. The results of the investigations were negative and no pathology was identified. In addition, the symptoms resolved within 24 h of onset without any therapeutic intervention. Therefore, a suspected diagnosis of a pharmacologically induced anisocoria from the scopolamine patch was made, whereby the substance accidentally reached the affected left eye.Previous studies showed that scopolamine patches may reduce early emetic symptoms. Case reports describing the occurrence of anisocoria following the application of scopolamine patches have been previously published. In all of these cases the patches were used to prevent PONV and each case was comprehensively investigated using various diagnostic and clinical tools. It should be noted, however, that a dysfunctional accommodation is listed as a common side effect of the drug, affecting more than 1 in 10 patients.Even though the efficacy of scopolamine patches for the prevention of PONV is proven, clinicians should be aware of the common ophthalmological side effect. Particularly with respect to various surgical disciplines, where anisocoria may indicate an underlying surgery-related complication, the application of scopolamine patches should be well- considered.


Assuntos
Antieméticos , Propofol , Adulto , Anisocoria/induzido quimicamente , Anisocoria/prevenção & controle , Feminino , Humanos , Náusea e Vômito Pós-Operatórios/prevenção & controle , Remifentanil , Escopolamina/efeitos adversos
2.
Anaesthesist ; 69(9): 632-638, 2020 09.
Artigo em Alemão | MEDLINE | ID: mdl-32671428

RESUMO

BACKGROUND: In the case of a poor peripheral venous status the use of conventional approaches is associated with several failed attempts, delay of treatment, increased pain and escalation to more invasive techniques. Ultrasound-guided venous access has become increasingly popular for difficult venous access; however, in German-speaking countries it has not yet become as popular as in English-speaking countries. First attempt success rates are high, but the factors contributing to the time needed for ultrasound-guided venous access are not well investigated. It is hypothesized that body mass index (BMI), vein diameter and depth contribute to the time needed for successfully establishing a peripheral vein access in patients with a difficult venous status. METHODS: This study included 68 patients with a poor venous status. After written consent was obtained patient characteristics were documented and upper extremity veins eligible for access were scanned with ultrasound with the aim of performing an ultrasound-guided venous access. The following time periods were documented: 1) first skin contact with the ultrasound probe, 2) time to identify an accessible vein, 3) time for venous access. RESULTS: Of the patients 67 were successfully punctured by ultrasound-guided venous access, 65 at the first attempt and 2 at the second attempt. In one patient conventional venous access was obtained at the same time. A higher BMI was associated with a significantly shorter total puncture time (+1 BMI point ≙ -2.25 s) and a shorter vein identification time (+1 BMI point ≙ -1.82 s). A greater vein diameter correlated with a shorter total time (-14.23 s/mm) and a greater depth correlated with an increased total time (+1.65 s/mm). CONCLUSION: A greater vein diameter and a higher BMI contribute to a shorter time period for ultrasound-guided venous access. Obese patients with difficult venous access may benefit from ultrasound-guided venous access, which could be explained by the imaging contrast with a higher proportion of subcutaneous fatty tissue.


Assuntos
Cateterismo Venoso Central/métodos , Ultrassonografia de Intervenção/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Humanos , Pessoa de Meia-Idade
3.
Int J Sports Med ; 38(2): 85-91, 2017 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-27454133

RESUMO

Prolonged breath-hold causes complex compensatory mechanisms such as increase in blood pressure, redistribution of blood flow, and bradycardia. We tested whether apnea induces an elevation of catecholamine-concentrations in well-trained apneic divers.11 apneic divers performed maximal dry apnea in a horizontal position. Parameters measured during apnea included blood pressure, ECG, and central, in addition to peripheral hemoglobin oxygenation. Peripheral arterial hemoglobin oxygenation was detected by pulse oximetry, whereas peripheral (abdominal) and central (cerebral) tissue oxygenation was measured by Near Infrared Spectroscopy (NIRS). Exhaled O2 and CO2, plasma norepinephrine and epinephrine concentrations were measured before and after apnea.Averaged apnea time was 247±76 s. Systolic blood pressure increased from 135±13 to 185±25 mmHg. End-expiratory CO2 increased from 29±4 mmHg to 49±6 mmHg. Norepinephrine increased from 623±307 to 1 826±984 pg ml-1 and epinephrine from 78±22 to 143±65 pg ml-1 during apnea. Heart rate reduction was inversely correlated with increased norepinephrine (correlation coefficient -0.844, p=0.001). Central (cerebral) O2 desaturation was time-delayed compared to peripheral O2 desaturation as measured by NIRSabdominal and SpO2.Increased norepinephrine caused by apnea may contribute to blood shift from peripheral tissues to the CNS and thus help to preserve cerebral tissue O2 saturation longer than that of peripheral tissue.


Assuntos
Apneia/sangue , Suspensão da Respiração , Epinefrina/sangue , Hipóxia/sangue , Norepinefrina/sangue , Adulto , Pressão Sanguínea , Dióxido de Carbono/análise , Mergulho/fisiologia , Feminino , Frequência Cardíaca , Hemoglobinas , Humanos , Masculino , Pessoa de Meia-Idade , Oximetria , Oxigênio/sangue , Espectroscopia de Luz Próxima ao Infravermelho
4.
Acta Anaesthesiol Scand ; 60(6): 723-33, 2016 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-26869241

RESUMO

BACKGROUND: Ultrasound of the inferior vena cava provides rapid and non-invasive assessment of fluid responsiveness. We hypothesized that the extensibility of the internal jugular vein (IJV) as well reflects intravascular volume state. We assessed IJV dimensions together with pulse pressure variation (PPV) as dynamic index for fluid responsiveness in mechanically ventilated patients. METHODS: Of 50 patients after cardiac surgery were assessed. Ultrasound of IJV dimensions as well as collection of hemodynamic data were performed in 30° and horizontal (0°) position, and the ventilator- and position-induced IJV extensibilities (E-IJV) were calculated. RESULTS: Mean ventilator-induced E-IJV in 30° position was 56%, and mean PPV in 30° position was 13.7%. Changing the patient's position from 30° to 0° significantly reduced ventilator-induced E-IJV as well as PPV. Pearson's correlation test revealed significant association between ventilator-induced E-IJV and fluid responsiveness deduced from PPV in 0° position (r = 0.43, P < 0.005). An E-IJV threshold >5% identified patients with significantly elevated PPV values. CONCLUSION: Ultrasound of the IJV and PPV as a dynamic index for fluid responsiveness can be associated under certain defined conditions. Whether or not ultrasound of the IJV can be useful to predict patient intravascular volume state should be further studied using invasive cardiac output monitoring.


Assuntos
Hidratação , Veias Jugulares/diagnóstico por imagem , Veias Jugulares/fisiopatologia , Complicações Pós-Operatórias/diagnóstico por imagem , Respiração Artificial , Ultrassonografia , Adulto , Idoso , Idoso de 80 Anos ou mais , Pressão Sanguínea , Procedimentos Cirúrgicos Cardíacos , Feminino , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/fisiopatologia , Volume Sistólico , Resultado do Tratamento
5.
Anaesthesist ; 64(5): 373-80, 2015 May.
Artigo em Alemão | MEDLINE | ID: mdl-25986408

RESUMO

BACKGROUND: The origin of emergence agitation in children remains unclear; however, an association between surgical procedure, patient age and anesthetic regimen and the incidence of postoperative agitation has been described in the literature. AIM: The aim of this survey performed between February and April 2014 was to collect data from the daily clinical practice by experienced pediatric anesthesiologists regarding documentation, premedication, anesthesia regimen and postoperative treatment with respect to children with emergence agitation. MATERIAL AND METHODS: An online questionnaire with 33 items was developed and sent to all 525 members of the scientific committee of pediatric anesthesia (WAKKA) of the German Society of Anesthesiology and Intensive Care (DGAI). Members were asked to respond within a time period of 1 month but no reminders were sent out via email or telephone. RESULTS: A total of 156 members participated in the survey and of these 143 questionnaires were fully completed and included in the final evaluation (27 %). Of the participants 77 % had more than 6 years professional experience in the field of pediatric anesthesia and for 87 % emergence agitation remains a relevant clinical problem. The estimated incidence of emergence agitation was given as 1-10 % and as high as 11-20 % by 56% and 20 % of the participants, respectively. The incidence of postoperative agitation is documented by only 11 % of the participants with a validated score, such as the pediatric anesthesia emergence delirium (PEAD) scale and 89 % of the participants use midazolam for premedication. As a preemptive intervention total intravenous anesthesia is performed by 56 % whereas clonidine is used as first line prevention by 30 %. Postoperative pharmacological treatment is performed by a bolus administration of propofol (56 %) and clonidine (26 %). Postoperative parental presence was considered beneficial by 82 %. CONCLUSION: Emergence agitation is still seen as a relevant clinical problem by experienced pediatric anesthesiologists. Propofol is first choice when it comes to pharmacological prevention and treatment of emergence agitation. Postoperative parental presence was considered beneficial by the majority of anesthesiologists.


Assuntos
Anestesia/efeitos adversos , Complicações Pós-Operatórias/psicologia , Agitação Psicomotora/psicologia , Criança , Pré-Escolar , Delírio/epidemiologia , Delírio/etiologia , Delírio/psicologia , Feminino , Alemanha/epidemiologia , Inquéritos Epidemiológicos , Humanos , Incidência , Lactente , Masculino , Pediatria , Cuidados Pós-Operatórios , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Medicação Pré-Anestésica , Agitação Psicomotora/epidemiologia , Agitação Psicomotora/prevenção & controle , Inquéritos e Questionários
6.
Br J Anaesth ; 112(4): 695-702, 2014 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-24305645

RESUMO

BACKGROUND: Electroconvulsive therapy (ECT) is a highly effective and established treatment for depression. Magnetic seizure therapy (MST) has recently been developed and seems equally effective while associated with fewer side-effects. Both require general anaesthesia, which could be quantified using the bispectral index (BIS). We compared ECT and MST with respect to recovery times, left-sided BIS, and left-right differences in BIS. METHODS: In this prospective, observational study, we enrolled 10 successive patients receiving ECT and 10 patients undergoing MST. Anaesthesia was performed with propofol and monitored with a bilateral BIS sensor. The seizure was elicited when the BIS was within a range from 50 to 60. The time to eye opening was measured and bilateral BIS were recorded for 10 min after seizure induction. RESULTS: A comparable anaesthetic depth was observed in the ECT and MST groups at baseline [mean (standard deviation, sd) BIS values of 94.1 (4.1) and 95.5 (3.0), respectively] and before seizure induction [mean (sd) BIS values of 52.3 (9.6) and 55.2 (10.3), respectively]. Post-ictally, MST patients opened their eyes significantly earlier than ECT patients [3.0 (1.0) vs 6.7 (1.3) min, P<0.001]. They showed a significantly higher BIS at 2 min after seizure induction [69.2 (10.1) vs 50.9 (15.9), P=0.003], and this difference was still present at 10 min after seizure induction [BIS 81.5 (6.5) vs 68.0 (16.4), P<0.001]. Significant differences between the left and right BIS were observed in neither the ECT nor the MST group. CONCLUSIONS: At a comparable anaesthetic depth, MST is superior to ECT in terms of post-ictal recovery, which is correctly reflected by higher post-ictal BIS values. Unilateral BIS monitoring is sufficient to monitor anaesthetic depth in ECT and MST patients. TRIAL REGISTRY NUMBER: NCT 01318018.


Assuntos
Transtorno Depressivo/terapia , Eletroconvulsoterapia/métodos , Eletroencefalografia/métodos , Estimulação Magnética Transcraniana/métodos , Adulto , Idoso , Período de Recuperação da Anestesia , Anestesia Intravenosa/métodos , Anestésicos Intravenosos/farmacologia , Monitores de Consciência , Dominância Cerebral/fisiologia , Eletroencefalografia/efeitos dos fármacos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica/métodos , Propofol/farmacologia , Estudos Prospectivos , Processamento de Sinais Assistido por Computador , Adulto Jovem
7.
Anaesthesiologie ; 71(8): 626-630, 2022 08.
Artigo em Alemão | MEDLINE | ID: mdl-35420328

RESUMO

This is a case report of a 45-year-old patient, 39 weeks of gestation, who was intubated via rapid sequence induction (RSI) for an emergency cesarean. The indication for emergency cesarean was a pathological cardiotocography during the ejection phase following labor induction.Despite the primary use of a video laryngoscope, there was difficulty aligning the laryngeal axis. Therefore, an internal stylet was used to heavily angulate the endotracheal tube (ETT) to a hockey stick shape to enter the larynx.Postoperative dyspnea and extensive facial swelling were initially diagnosed as an allergic reaction. Only 22 h later the diagnosis of tracheal rupture was confirmed following computer tomography.We hypothesized that the mechanism of injury was due to excessive pressure transmitted to the tip of the ETT. This probably occurred due to a leverage effect caused by the withdrawal of the heavily bent stylet from the ETT, forcing an intratracheal cranial movement of the ETT.By conducting an experiment on a pig's trachea, we were able to visualize this mechanism of injury. In addition, we were able to demonstrate that bending the stylet to a similar angle as the laryngoscope blade led to minimal movement of the tip of the ETT.Therefore, when using a stylet during intubation, we recommend bending the ETT and stylet to the shape of the used laryngoscope blade and retracting the stylet at a similar angle to avoid complications, such as tracheal rupture.


Assuntos
Laringoscópios , Laringe , Humanos , Intubação Intratraqueal/efeitos adversos , Ruptura/etiologia , Traqueia/diagnóstico por imagem
8.
Br J Anaesth ; 105(2): 172-8, 2010 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-20587537

RESUMO

BACKGROUND: The patient state index (PSI) and the bispectral index (BIS) quantify anaesthetic depth based on the EEG using different algorithms. We compared both indices with regard to the prediction of the depth of propofol anaesthesia. METHODS: In 17 patients, propofol was infused until burst suppression occurred and stopped thereafter until BIS recovered to values above 60. This was repeated; afterwards, patients were intubated, for subsequent surgery. Without surgical stimulus, PSI and BIS were measured simultaneously and compared with the estimated effect-site concentrations of propofol. These were derived from simultaneous pharmacokinetic and -dynamic modelling in an individual two-stage and a population-based NONMEM approach. RESULTS: A close sigmoid relationship was observed between the propofol effect-site concentration and both PSI [coefficient of determination rho(2)=0.91 (sd 0.05)] and BIS [rho(2)=0.92 (0.03)], which was significantly steeper for PSI [gamma=2.2 (0.6)] than for BIS [gamma=1.8 (0.4)], and reached significantly lower values for PSI [E(max)=0.3 (1.1)] than for BIS [E(max)=5.3 (6.7)] at maximal propofol concentrations. A significantly smaller k(e0) was obtained for PSI [0.09 (0.03) min(-1)] compared with BIS [0.10 (0.02) min(-1)]. PSI and BIS correlated significantly with each other (rho(2)=0.866) and predicted propofol effect-site concentration with a comparable probability [P(K)=0.87 (0.05) and 0.86 (0.05), respectively]. NONMEM revealed E(0)=89.3 and 92.3, E(max)=1.9 and 8.6, C(e50)=1.38 and 1.92 microg ml(-1), gamma=1.6 and 1.48, and k(e0)=0.103 and 0.131 min(-1) as typical values for PSI and BIS, respectively. CONCLUSIONS: The PSI and the BIS monitors performed equally well in predicting depth of propofol anaesthesia. However, PSI was lower than BIS by approximately 10-15 points at high propofol concentrations.


Assuntos
Anestésicos Intravenosos/farmacologia , Eletroencefalografia/efeitos dos fármacos , Monitorização Intraoperatória/métodos , Propofol/farmacologia , Processamento de Sinais Assistido por Computador , Adolescente , Adulto , Idoso , Anestésicos Intravenosos/administração & dosagem , Anestésicos Intravenosos/sangue , Relação Dose-Resposta a Droga , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Otorrinolaringológicos , Propofol/administração & dosagem , Propofol/sangue , Reprodutibilidade dos Testes , Adulto Jovem
9.
Am J Obstet Gynecol ; 199(6): 673.e1-6, 2008 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-19084099

RESUMO

OBJECTIVE: The objective of the study was to compare the outcomes of hysterectomies performed by residents under supervision of a teaching physician with those performed by attendings alone. STUDY DESIGN: This was a retrospective cohort analysis of hysterectomies performed at the Greater Baltimore Medical Center from 2004 to 2006. RESULTS: Of 159 nonteaching and 265 teaching cases, there was no significant difference in any of the surgical outcomes, except mean operating room time in minutes (94.8 [+/- 47.0] vs 107.4 [+/- 42.4]; P = .005), seromas (2.5% vs 0%; P = .02), and others (5% vs 0.8%; P = .007) in nonteaching vs teaching cases, respectively. The demographics and comorbidities were similar. The mean operating room time difference of 13 minutes was not clinically significant. CONCLUSION: Although teaching hysterectomies take a bit longer to perform, there were no greater adverse outcomes.


Assuntos
Competência Clínica , Histerectomia/métodos , Internato e Residência/métodos , Corpo Clínico Hospitalar , Adulto , Estudos de Coortes , Educação de Pós-Graduação em Medicina , Feminino , Seguimentos , Procedimentos Cirúrgicos em Ginecologia/educação , Pesquisas sobre Atenção à Saúde , Hospitais de Ensino , Humanos , Histerectomia/efeitos adversos , Tempo de Internação/tendências , Pessoa de Meia-Idade , Organização e Administração , Avaliação de Resultados em Cuidados de Saúde , Complicações Pós-Operatórias/epidemiologia , Probabilidade , Estudos Retrospectivos , Medição de Risco , Resultado do Tratamento
10.
Neuroscience ; 119(2): 323-33, 2003.
Artigo em Inglês | MEDLINE | ID: mdl-12770549

RESUMO

Status epilepticus (S.E.) is known to lead to a large number of changes in the expression of voltage-dependent ion channels and neurotransmitter receptors. In the present study, we examined whether an episode of S.E. induced by pilocarpine in vivo alters functional properties and expression of voltage-gated Na(+) channels in dentate granule cells (DGCs) of the rat hippocampus. Using patch-clamp recordings in isolated DGCs, we show that the voltage-dependent inactivation curve is significantly shifted toward depolarizing potentials following S.E. (half-maximal inactivation at -43.2+/-0.6 mV) when compared with control rats (-48.2+/-0.8 mV, P<0.0001). The voltage-dependent activation curve is significantly shifted to more negative potentials following S.E., with half-maximal activation at -28.6+/-0.8 mV compared with -25.8+/-0.9 mV in control animals (P<0.05). The changes in voltage dependence resulted in an augmented window current due to increased overlap between the activation and inactivation curve. In contrast to Na(+) channel voltage-dependence, S.E. caused no changes in the kinetics of fast or slow recovery from inactivation. The functional changes were accompanied by altered expression of Na(+) channel subunits measured by real-time reverse transcription-polymerase chain reaction in dentate gyrus microslices. We investigated expression of the pore-forming alpha subunits Na(v)1.1-Na(v)1.3 and Na(v)1.5-Na(v)1.6, in addition to the accessory subunits beta(1) and beta(2). The Na(v)1.2 and Na(v)1.6 subunit as well as the beta(1) subunit were persistently down-regulated up to 30 days following S.E. The beta(2) subunit was transiently down-regulated on the first and third day following S.E. These results indicate that differential changes in Na(+) channel subunit expression occur in concert with functional changes. Because coexpression of beta subunits is known to robustly shift the voltage dependence of inactivation in a hyperpolarizing direction, we speculate that a down-regulation of beta-subunit expression may contribute to the depolarizing shift in the inactivation curve following S.E.


Assuntos
Giro Denteado/metabolismo , Pilocarpina , Canais de Sódio/fisiologia , Estado Epiléptico/patologia , Animais , Condutividade Elétrica , Estimulação Elétrica , Corantes Fluorescentes/farmacocinética , Regulação da Expressão Gênica/efeitos dos fármacos , Técnicas In Vitro , Masculino , Análise por Pareamento , Potenciais da Membrana , Agonistas Muscarínicos , Neurônios/fisiologia , Técnicas de Patch-Clamp/métodos , Subunidades Proteicas/química , Subunidades Proteicas/genética , RNA Mensageiro/biossíntese , Ratos , Ratos Wistar , Reação em Cadeia da Polimerase Via Transcriptase Reversa/métodos , Rodaminas/farmacocinética , Canais de Sódio/genética , Estado Epiléptico/induzido quimicamente , Sinaptofisina/química , Sinaptofisina/genética , Fatores de Tempo
11.
Obstet Gynecol ; 93(1): 38-40, 1999 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-9916953

RESUMO

OBJECTIVE: When cancer strikes a patient, it has a major impact on the family. Whereas many health care providers deal with the family while the patient is living, few have any long-term interactions after she has died. The purpose of this study is to interface with family members and reflect upon the impact ovarian cancer had on them. METHODS: A retrospective chart review was conducted of 222 patients who had been diagnosed and treated for ovarian carcinoma between the years 1990 and 1994 at Maine Medical Center, a tertiary care medical center. Of these, 34 patients who had been deceased for longer than 1 year were selected on the basis of specific criteria. The families of these individuals were each mailed a questionnaire comprising seven questions tailored to evaluate one family member's impressions and experiences of coping with a loved one who had died from ovarian cancer. Candid responses of any length were invited. RESULTS: Written responses were received from 32 of the 34 families that were mailed questionnaires. Of those responding, 65% were spouses, 22% were children, and 13% were siblings of the deceased. Each questionnaire was answered by only one relative, and the majority of questions posed received multiple detailed answers. According to the vast majority of respondents, the worst part of treatment was continuing chemotherapy. The most common emotion expressed by family members at the time of diagnosis was one of something having gone wrong. Both travel and living longer appeared to be the most treasured aspects of the patient's life once the diagnosis had been made. Watching their loved one suffer and the overwhelming sense of helplessness were the worst aspects of the disease process. The loved one was most often thought of on her birthday, and 90.6% of the respondents thought another female in their family was likely to get ovarian cancer. CONCLUSION: This study attempted to define those concerns and thoughts that remain important to family members whose loved ones had died from ovarian cancer. Common emotions expressed by family members years after the death of their loved one include their sense of surprise at the diagnosis, their sense of helplessness during the progression of the disease, and their pain in watching their loved one suffer. For them, the worst part of their loved one's treatment was continued chemotherapy, and a common unfounded fear was that another female family member would likely die from ovarian cancer. The responses encourage us as health care providers to remain in touch with these families even after the death of their loved one and to address the misconceptions, fears, and anxieties that our patients and their families may have.


Assuntos
Família/psicologia , Pesar , Neoplasias Ovarianas , Feminino , Humanos , Inquéritos e Questionários , Fatores de Tempo
12.
Surg Oncol Clin N Am ; 7(2): 399-416, 1998 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-9537984

RESUMO

The management of gynecological malignancies is dictated by the stage and nature of the disease. Often, the optimal treatment requires radical pelvic surgery. This is especially true in cervical, ovarian, and vulvar carcinoma. Radical hysterectomy, exenterative procedures and tumor debulking comprise the armamentarium of gynecological oncologists. This article attempts to review the different surgical strategies with attention to their respective indications, potential complications, and overall efficacy.


Assuntos
Neoplasias dos Genitais Femininos/cirurgia , Carcinoma/cirurgia , Feminino , Neoplasias dos Genitais Femininos/patologia , Humanos , Histerectomia , Excisão de Linfonodo , Invasividade Neoplásica , Estadiamento de Neoplasias , Neoplasias Ovarianas/cirurgia , Exenteração Pélvica , Pelve/cirurgia , Complicações Pós-Operatórias , Procedimentos de Cirurgia Plástica , Resultado do Tratamento , Derivação Urinária , Neoplasias do Colo do Útero/cirurgia , Neoplasias Vulvares/cirurgia
13.
Anaesth Intensive Care ; 38(1): 159-66, 2010 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-20191792

RESUMO

This study was designed to investigate the impact of the Entropy Module and Bispectral Index (BIS) monitoring on drug consumption and recovery times compared with standard anaesthetic practice in patients undergoing orthopaedic surgery using a combination of regional and general anaesthesia as performed by an experienced anaesthesiologist. We hypothesised that electroencephalogram monitoring would lead to a lower drug consumption as well as shorter recovery times. With institutional review board approval and written informed consent, 90 adult patients undergoing surgery to the upper or lower extremity received regional anaesthesia for post- and intraoperative pain control and were randomised to receive general anaesthesia by propofol/remifentanil infusion controlled either solely by clinical parameters or by targeting Entropy or BIS values of 50. Recovery times and drug consumption were recorded. Data from 79 patients were analysed. Compared with standard practice, patients with Entropy or BIS monitoring showed a similar propofol consumption (standard practice 101 +/- 22 microg/kg/minute, Entropy 106 +/- 24 microg/kg/minute, BIS 104 +/- 20 microg/kg/minute) and showed similar Aldrete scores (10/10) one minute after extubation: 9.1 +/- 0.3, 9.2 +/- 0.6 and 9.3 +/- 0.5, respectively. Time points of extubation were 7.3 +/- 2.9 minutes, 9.2 +/- 3.9 minutes and 6.8 +/- 2.9 minutes, respectively, demonstrating a significant difference between Entropy and BIS (P = 0.023). Compared with standard practice, targeting an Entropy or BIS value of 50 did not result in a reduction of propofol consumption during general anaesthesia combined with regional anaesthesia as performed by an experienced anaesthesiologist in orthopaedic patients.


Assuntos
Anestesia por Condução , Anestesia Intravenosa/estatística & dados numéricos , Anestésicos Intravenosos , Eletroencefalografia/métodos , Eletroencefalografia/estatística & dados numéricos , Monitorização Intraoperatória/métodos , Piperidinas , Propofol , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Período de Recuperação da Anestesia , Anestesia Geral , Interpretação Estatística de Dados , Entropia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Monitorização Intraoperatória/estatística & dados numéricos , Procedimentos Ortopédicos , Propofol/administração & dosagem , Sala de Recuperação , Remifentanil , Adulto Jovem
14.
Female Pelvic Med Reconstr Surg ; 16(4): 238-41, 2010 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-22453349

RESUMO

OBJECTIVES: : To compare perioperative outcomes of a retropubic synthetic midurethral Gynecare TVT slings (Gynecare Worldwide, division of Ethicon Inc, NJ) performed by urogynecologists, urologists, and general gynecologists. METHODS: : This is a retrospective, cohort study of retropubic synthetic midurethral Gynecare TVT sling outcomes performed between 2001 and 2007 at a single institution. Other synthetic and nonsynthetic slings, or slings performed with concurrent surgeries were excluded. The primary outcomes were mean sling operating room (OR) time in minutes (min) and estimated blood loss in milliliters (mL). All variables were stratified by the surgeon's specialty: urogynecology (URO-GYN), urology (URO), and general gynecology (GYN). RESULTS: : Of 279 Gynecare TVT sling procedures, 126 were performed by URO-GYN, 30 by URO, and 123 by GYN. Mean sling OR time was 38.8 ± 8.5 minutes for URO-GYN, 42.6 ± 11.2 minutes for URO, and 39.8 ± 14.3 minutes for GYN, P = 0.30. Estimated blood loss was 56.6 ± 68.3 mL for URO-GYN, 69.7 ± 82.6 mL for URO, and 68.8 ± 73.4 mL for GYN, P = 0.37. The intraoperative complications (bladder, urethral perforations, and hemorrhage) were similar among the specialties. In the postoperative period, there was no difference in subsequent need for urethrolysis (cutting or removal of the sling), return to OR, and readmission to the hospital after the procedure among all 3 specialties. CONCLUSIONS: : All 3 specialties (urogynecologist, urologists, and general gynecologists) had similar major perioperative outcomes in performing retropubic synthetic midurethral Gynecare TVT slings.

15.
Br J Anaesth ; 97(5): 666-75, 2006 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-16928699

RESUMO

BACKGROUND: Automated indices derived from mid-latency auditory evoked potentials (MLAEP) have been proposed for monitoring the state of anaesthesia. The A-Line ARX index (AAI) has been implemented in the A-Line monitor (Danmeter, V1.4). Several studies have reported variable and, in awake patients, sometimes surprisingly low AAI values. The purpose of this study was to reproduce these findings under steady-state conditions and to investigate their causes. METHODS: Ten awake unmedicated volunteers were studied under steady-state conditions. For each subject, the raw EEG and the AAI were recorded with an A-Line monitor (V1.4) during three separate sessions of 45.0 (1.6) min duration each. MATLAB (Mathworks) routines were used to derive MLAEP responses from EEG data and to calculate maximal MLAEP amplitudes. RESULTS: The AAI values ranged from 15 to 99, while 11.4% fell below levels which, according to the manufacturer, indicate an anaesthetic depth suitable for surgery. Inter-individual and intra-individual variation was observed despite stable recording conditions. The amplitudes of the MLAEP varied from 0.8 to 42.0 microV. The MLAEP amplitude exceeded 2 microV in 75.3% of readings. The Spearman's rank correlation coefficient between the MLAEP amplitude and the AAI value was r=0.89 (P<0.0001). CONCLUSIONS: The version of the A-Line monitor used in this study does not exclude contaminated MLAEP signals. Previous publications involving this version of the A-Line monitor (as opposed to the newer A-Line/2 monitor series) should be reassessed in the light of these findings. Before exclusively MLAEP-based monitors can be evaluated as suitable monitors of depth of anaesthesia, it is essential to ensure that inbuilt validity tests eliminate contaminated MLAEP signals.


Assuntos
Potenciais Evocados Auditivos , Monitorização Intraoperatória/métodos , Estimulação Acústica/métodos , Adulto , Artefatos , Conscientização/fisiologia , Eletroencefalografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/instrumentação , Reprodutibilidade dos Testes , Processamento de Sinais Assistido por Computador
16.
Acta Anaesthesiol Scand ; 50(10): 1244-9, 2006 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-17067324

RESUMO

BACKGROUND: Several studies have shown a reduction in anaesthetic drug consumption with Bispectral Index (BIS) titration compared with standard clinical practice. However, the amount of reduction varied widely between 1% and 40%. We investigated the correlation between reduction in anaesthetic drug consumption and mean titrated BIS values. METHODS: An analysis upon randomized controlled trials cited until January 2006 in MEDLINE and other databases investigating the potential reduction in anaesthetic (hypnotic) drug consumption with BIS titration was performed. Investigations with a marked difference (> 15%) in opioid drug consumption between the BIS group and the standard practice group were excluded. Correlations between amount of reduction in hypnotic drug use and the mean titrated BIS value were analysed with linear regression. RESULTS: Fourteen manuscripts covering 2582 patients were included into the analysis. The mean BIS value in the standard clinical practice group averaged over all studies was 43.6 +/- 3.2 and the mean BIS value in the BIS-titrated group was 49.9 +/- 5.4. The amount of reduction in hypnotic drug use correlated significantly with the mean BIS values in the BIS-titrated groups (r =0.68) and with the differences between the mean BIS value in the BIS-titrated group and the mean BIS value in the standard clinical practice group (r = 0.70). Every point of BIS difference between the two groups resulted in a reduced hypnotic drug use of approximately 2%. CONCLUSION: Despite differences in the study designs and in the drugs used, a linear correlation between the mean titrated BIS value and the hypnotic drug saving potential was found.


Assuntos
Anestésicos/uso terapêutico , Período Intraoperatório , Relação Dose-Resposta a Droga , Eletroencefalografia/efeitos dos fármacos , Humanos , Seleção de Pacientes , Ensaios Clínicos Controlados Aleatórios como Assunto
17.
Am J Obstet Gynecol ; 192(5): 1677-81, 2005 May.
Artigo em Inglês | MEDLINE | ID: mdl-15902176

RESUMO

OBJECTIVE: This study was undertaken to compare the objective and subjective long-term surgical outcomes in patients receiving Tutoplast fascia lata allograft slings with those receiving autograft slings for the treatment of stress urinary incontinence (SUI). STUDY DESIGN: We reviewed all patients (n = 71) undergoing suburethral sling with either autologous fascia lata (n = 39) or Tutoplast fascia lata (n = 32) for urodynamic stress incontinence (USI) from October 1, 1998, to August 1, 2001. RESULTS: Of the original 71 patients, 47 were evaluated by objective and/or subjective means at a minimum of 2 years after surgery. Subjective quality of life measures, subjective continence, maximum urethral closure pressure, and bladder neck mobility were not different between the 2 groups. USI was demonstrated in 41.7% of allograft patients compared with no autograft patients (P = .007). CONCLUSION: Although patient reported cure of SUI is high for both sling types, USI recurs at a significantly higher rate in Tutoplast slings compared with autologous slings.


Assuntos
Fascia Lata/transplante , Incontinência Urinária por Estresse/cirurgia , Idoso , Desidratação , Feminino , Humanos , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Solventes , Transplante Autólogo/estatística & dados numéricos , Transplante Homólogo/estatística & dados numéricos , Resultado do Tratamento , Incontinência Urinária por Estresse/fisiopatologia , Urodinâmica
18.
Drugs Today (Barc) ; 39(7): 513-40, 2003 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-12973401

RESUMO

Voiding dysfunction may be defined as difficulty in the volitional emptying of the bladder in an efficient and controlled manner that can extend from a spectrum of minor irritative symptoms to complete retention. Resolution of symptoms can be accomplished by correctly identifying the underlying pathology and directing therapy appropriately to restore function and anatomy. Causes and treatments of obstructive voiding dysfunction tend to be gender specific. In approximately one-half of women, the causes of obstructive voiding dysfunction are prior anti-incontinence surgery and pelvic organ prolapse, which will usually lead to a surgical intervention. For men, benign prostate disease is the overwhelming cause of obstructive voiding. Due to its increasing prevalence in the aging male population, a variety of treatments--pharmacological and operative--have been developed, with more on the horizon. This review addresses a wide variety of treatments for the numerous conditions causing obstructive voiding dysfunction in men and women, all of them with the goal in mind of resolve the patient's symptoms without creating de novo pathology.


Assuntos
Retenção Urinária/terapia , Ensaios Clínicos como Assunto , Feminino , Humanos , Masculino , Hiperplasia Prostática/complicações , Hiperplasia Prostática/tratamento farmacológico , Hiperplasia Prostática/cirurgia , Obstrução Uretral/complicações , Obstrução Uretral/terapia , Bexiga Urinária/fisiopatologia , Obstrução do Colo da Bexiga Urinária/complicações , Obstrução do Colo da Bexiga Urinária/cirurgia , Retenção Urinária/diagnóstico , Retenção Urinária/etiologia , Urodinâmica
19.
Artigo em Inglês | MEDLINE | ID: mdl-14752599

RESUMO

We report a rare case of bladder eversion through a vesicovaginal fistula. The bladder prolapse was almost complete, resulting in ureteral kinking, bilateral hydronephrosis and acute renal failure. After reduction of the bladder eversion, bilateral ureteral stent placement, fistula repair using the Latzko technique and colpocleisis, the patient had rapid resolution of her renal compromise.


Assuntos
Injúria Renal Aguda/etiologia , Doenças da Bexiga Urinária/complicações , Procedimentos Cirúrgicos Urológicos/métodos , Fístula Vesicovaginal/complicações , Fístula Vesicovaginal/patologia , Idoso , Feminino , Humanos , Hidronefrose/etiologia , Prolapso , Ureter/patologia , Doenças da Bexiga Urinária/cirurgia , Fístula Vesicovaginal/cirurgia
20.
J Physiol ; 532(Pt 2): 385-97, 2001 Apr 15.
Artigo em Inglês | MEDLINE | ID: mdl-11306658

RESUMO

1. Fundamental to the understanding of CNS function is the question of how individual neurons integrate multiple synaptic inputs into an output consisting of a sequence of action potentials carrying information coded as spike frequency. The availability for activation of neuronal Na(+) channels is critical for this process and is regulated both by fast and slow inactivation processes. Here, we have investigated slow inactivation processes in detail in hippocampal neurons. 2. Slow inactivation was induced by prolonged (10-300 s) step depolarisations to -10 mV at room temperature. In isolated hippocampal dentate granule cells (DGCs), recovery from this inactivation was biexponential, with time constants for the two phases of slow inactivation tau(slow,1) and tau(slow,2) ranging from 1 to 10 s and 20 to 50 s, respectively. Both (slow,1) and tau(slow,2) were related to the duration of prior depolarisation by a power law function of the form tau(t) = a (t/a)b, where t is the duration of the depolarisation, a is a constant kinetic setpoint and b is a scaling power. This analysis yielded values of a = 0.034 s and b = 0.62 for tau(slow,1) and a = 24 s and b = 0.30 for tau(slow,2) in the rat. 3. When a train of action potential-like depolarisations of different frequencies (50, 100, 200 Hz) was used to induce inactivation, a similar relationship was found between the frequency of depolarisation and both tau(slow,1) and tau(slow,2) (a = 0.58 s, b = 0.39 for tau(slow,1) and a = 3.77 s and b = 0.42 for tau(slow,2)). 4. Using nucleated patches from rat hippocampal slices, we have addressed possible cell specific differences in slow inactivation. In fast-spiking basket cells a similar scaling relationship can be found (a = 3.54 s and b = 0.39) as in nucleated patches from DGCs (a = 2.3 s and b = 0.48) and non-fast-spiking hilar neurons (a = 2.57 s and b = 0.49). 5. Likewise, comparison of human and rat granule cells showed that properties of ultra-slow recovery from inactivation are conserved across species. In both species ultra-slow recovery was biexponential with both tau(slow,1) and tau(slow,2) being related to the duration of depolarisation t, with a = 0.63 s and b = 0.44 for tau(slow,1) and a = 25 s and b = 0.37 for tau(slow,2) for the human subject. 6. In summary, we describe in detail how the biophysical properties of Na(+) channels result in a complex interrelationship between availability of sodium channels and membrane potential or action potential frequency that may contribute to temporal integration on a time scale of seconds to minutes in different types of hippocampal neurons.


Assuntos
Hipocampo/metabolismo , Neurônios/metabolismo , Canais de Sódio/metabolismo , Potenciais de Ação/fisiologia , Animais , Giro Denteado/citologia , Giro Denteado/fisiologia , Eletrofisiologia , Hipocampo/citologia , Humanos , Técnicas In Vitro , Interneurônios/metabolismo , Ratos , Ratos Wistar , Fatores de Tempo
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