Structure of the Anesthesia Intensive Care Units: Recommendations of the Intensive Care Section of the Spanish Society of Anaesthesiology. / Estructura de las unidades de cuidados intensivos de anestesia: recomendaciones de la Sección de Cuidados Intensivos de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR).

BACKGROUND AND OBJECTIVE: In this article, the Intensive Care Section of the Spanish Society of Anesthesiology (SCI-SEDAR) establishes new recommendations based on the standards published by the Ministry of Health, Consumer Affairs and Social Welfare and aligned with the principle international guidelines, and develops a tool to improve quality and efficiency. MATERIALS AND METHOD: Over a 12-month period (2018), 3 members of the SCI-SEDAR defined the methodology, developed the recommendations and selected the panel of experts. Due to the limited evidence available for many of the recommendations and the significant structural differences between existing anesthesia intensive care units, we chose a modified Delphi approach to determine the degree of consensus. RESULTS: The panel consisted of 24 experts from 21 institutions. The group put forward 175 recommendations on 8 sections, including 129 with strong consensus and 46 with weak consensus. CONCLUSIONS: The SCI-SEDAR has established a series of structural recommendations that should be used when renovating or creating new anesthesia intensive care units.

The beneficial effect of spinal cord stimulation in a patient with severe cerebral ischemia and upper extremity ischemic pain.

Spinal cord stimulation (SCS) is used in the treatment of chronic pain, ischemia because of obstructive arterial disease, and anginal pain. Recently, a number of studies have described the effects of the high cervical SCS, including increased cerebral blood flow, although the underlying mechanisms are unknown. This case report describes a patient with a severe complex ischemic condition affecting both cerebral and upper limb blood flow with an associated complex regional pain syndrome in upper limb. While all previous clinical treatments proved ineffective, cervical SCS afforded satisfactory results. Possible mechanisms underlying the cervical SCS effect are discussed.

[Patient satisfaction with spinal cord stimulation for failed back surgery syndrome]. / Satisfacción del paciente con síndrome de dolor de raquis postquirúrgico portador de un sistema de neuroestimulación medular.

INTRODUCTION: The incidence of failed back surgery syndrome is about 40%. We studied the efficacy of and patient satisfaction with use of a spinal cord stimulator to treat this syndrome. MATERIAL AND METHODS: A period of 72 months of experience with implanted spinal cord stimulators was analyzed in this observational, descriptive study of patients who were included retrospectively. Patients met criteria for failed back surgery syndrome according to the taxonomy of the International Association for the Study of Pain. A chi2 test was used to compare qualitative variables. Results for quantitative variables were compared by analysis of variance. Statistical significance was set at P < 0.05. RESULTS: Thirty-four patients were studied. Both lumbar back and radicular pain assessed on a visual analog scale (VAS) decreased significantly from the mean overall score of 6. As time passed, fewer patients felt the system met their expectations. More patients said the system met their expectations in the first months after implantation (73.5%) than at a later interview (55.9%). Seventeen complications were reported, the most common being mechanical difficulties with the implanted stimulator. None of the complications were serious. Use of additional medication to control pain decreased in 38.2% of the cases. A total of 73.5% of the patients considered the implanted stimulator to be beneficial and 67.6% would have a spinal cord stimulator implanted again. CONCLUSIONS: Spinal cord stimulation improves lumbar back pain in patients with failed back surgery syndrome and reduces the amount of additional medication taken to control pain. It is important for patients to adjust their expectations about the implanted stimulator.

[Ketamine for subarachnoid anesthesia during hypovolemia: preliminary study in pigs]. / Utilización de ketamina para anestesia subaracnoidea durante hipovolemia. Estudio experimental preliminar en cerdos.

OBJECTIVES: To assess whether subarachnoid ketamine has fewer hemodynamic effects than lidocaine in normal and hypovolemic pigs and to determine whether or not the effects of ketamine are dose-dependent. METHODS: Thirty pigs were randomly allocated to receive subarachnoid administration of lidocaine 2 mg x kg(-1), ketamine 1 mg x kg(-1) or ketamine 2 mg x kg(-1), in a situation of either normal or reduced blood volume. The pigs were assigned to six groups: group L2 (2% lidocaine 2 mg x kg(-1), normovolemia), group L2H (2% lidocaine 2 mg x kg(-1), hypovolemia), group K1 (ketamine 1 mg x kg(-1), normovolemia), group K1H (ketamine 1 mg x kg(-1), hypovolemia), group K2 (ketamine 2 mg.kg(-', normovolemia), and group K2H (ketamine 2 mg x kg(-1), hypovolemia). To induce hypovolemia 30% of the calculated blood volume was withdrawn from each pig. The subarachnoid space was catheterized, and invasive measurements of hemodynamic variables (derived from arterial, central venous and pulmonary artery catheter monitoring) were obtained. Variables were recorded at baseline and 5 and 15 min after drug injection in the normovolemic groups, and at baseline after inducing hypovolemia and 5 and 15 min after drug injection in the hypovolemic groups. RESULTS: In the normovolemic pigs no significant differences were detected between groups. In hypovolemic pigs differences were observed in heart rate and arterial pressure between the ketamine 1 mg x kg(-1) and lidocaine 2 mg x kg(-1) groups (P < 0.05). The decreases in heart rate and arterial pressure were less marked in the ketamine group. Mixed venous oxygen saturation and cardiac index deteriorated to a lesser degree in both ketamine groups than in the lidocaine groups (P < 0.05). CONCLUSIONS: Racemic ketamine administered by subarachnoid injection in hypovolemic pigs produces less deterioration in hemodynamic variables than does lidocaine. Hemodynamic changes caused by ketamine were not dose-dependent. These findings may be of interest, given the increased use of ketamine in neuroaxial anesthesia and analgesia and perhaps the possible use of neuroaxial ketamine in hypovolemic patients.

Use of botulinum toxin in the treatment of chronic myofascial pain.

BACKGROUND: Myofascial pain syndrome (MPS) is defined as acute or chronic pain with sensory or motor autonomic symptoms, referred from active myofascial triggering points with associated dysfunction. Previous studies have suggested the usefulness of botulinum toxin A (BTX-A) in the treatment of MPS since it is capable of controlling muscular spasms, as well as other alternative mechanisms of action. OBJECTIVES: To analyze the efficacy of BTX-A treatment and its effect on daily life activities assessing pain reduction using a visual analogue scale (VAS); degree of improvement in physical impairment and disability scoring in the Oswestry low back pain questionnaire; and psychologic status using the Hospital Anxiety and Depression Scale (HAD), in patients suffering from MPS. METHOD: An open-label interventional prospective trial was conducted in 77 patients diagnosed of refractory MPS (defined as the presence of muscle spasm with pain on mobilization or stretching, plus the existence of trigger points with associated referred pain), resistant to both conservative management and to physical therapy. The BTX-A dosages for the different muscles were chosen according to a standardized protocol. Electromyographic guidance was used to localize the motor end plate prior to injection in superficial muscles; while fluoroscopic guidance was employed to evidence intramyofascial spread of the contrast solution within deep muscles. The assessment of treatment efficacy was based on a pain VAS applied before enrollment, at 15, 30, and 90 days and upon completion of the study; the Lattinen test to establish a relationship between pain intensity and its corresponding impact on daily living; and the HAD scale to assess psychologic stress, performed both before treatment and at the end of the study; and the Oswestry Questionnaire was used to evaluate patients' ability to carry out daily life activities according to their degree of physical impairment and disability scores. RESULTS: The global analysis revealed a positive correlation between the VAS score prior to treatment and the scoring at 15, 30, and 90 days. This correlation was maintained when analyzing independently for superficial or deep muscles. The correlation coefficients for HAD scores and the Lattinen test values showed a significant association between pre- and post-treatment findings. No adverse events were recorded for 83.1% of the cases. CONCLUSIONS: The results of this study are consistent with other studies showing the efficacy of BTX-A for treating pain in MPS. The evaluation of the psychologic dimension of this disorder and its associated disability can provide valuable information for the adequate management of these patients and for assessing treatment outcome.

Application of a psychological decision algorithm for the selection of patients susceptible to implantation of neuromodulation systems for the treatment of chronic pain. A proposal.

Objective. The application of a decision algorithm is described here for the inclusion of patients in a protocol of therapeutic intervention by the use of an implantable neuromodulation system. This algorithm is based on the assessment of the psychological profiles of the patients and their environment. Materials and methods. This algorithm was applied to patients in the Multidisciplinary Unit for Pain Treatment at the General University Hospital of Valencia (Spain) by means of a clinical interview performed by the Psychology Department prior to the therapeutic decision. It was applied to two samples. The first sample was made up of patients psychologically assessed prior to implantation; the second sample was made up of implanted patients to whom the algorithm was applied retrospectively, by reviewing their clinical medical history. Results. In the first sample, pain relief of 50% or higher was obtained by 80% of the subjects studied, while in the second the percentage decreased to 63%. While the rate of implants removed in sample 1 was 4.2%, the rate of implants removed in sample 2 was 7.5% due to lack of efficacy. In a third sample, made up of implanted patients from sample 1 and sample 2, a discriminant analysis was performed using a pooled variable. Conclusion. The results of the application of the pooled analysis confirm the need for considering the psychological profile as a variable predicting an optimum result in the therapeutic treatment of chronic pain.

Subarachnoid anesthesia in young patients: a comparative analysis of two needle bevels.

BACKGROUND AND OBJECTIVES: This prospective, randomized, double-blind study compares the efficacy of two spinal needles in terms of their performance characteristics and associated perioperative complaints in young patients. METHODS: ASA I and II patients aged from 20 to 40 years undergoing lower limb orthopedic surgery were included during a 12-month period. After application of the protocol, 158 patients were recruited. The patients were randomized to two groups: group I: 26-gauge Atraucan (n = 79) and Group II: 27-gauge Whitacre (n = 79). A study was made of the demographic parameters, technical characteristics, and peri- and postoperative complications. RESULTS: No significant differences were found in the technical handling of the needles, number of attempts made to achieve the puncture, or the time required to perform the technique. No technical failures (spinal anesthesia inadequate for the planned surgery) were reported, and the frequency of complications during the procedure was identical in both groups. Frequency of postdural puncture headache (3.8%) or severity and duration showed no difference between the two groups. The overall assessment of postoperative complications revealed similar scores for both needles. CONCLUSIONS: Technical handling (ease with which block was performed) of the needles analyzed was extremely easy, showing a high success rate which associated with the similar incidence of complications. Type of bevel does not appear to be a determining factor in the quality or morbidity associated with subarachnoid block when fine-gauge needles are used in young patients.

Continuous spinal anesthesia: a comparative study of standard microcatheter and Spinocath.

BACKGROUND AND OBJECTIVES: This prospective, randomized study evaluated the advantages and disadvantages of a new subarachnoid catheter. METHODS: Sixty ASA I-IV patients aged 40-70 years, scheduled for total knee arthroplasty, were randomly distributed into group 1 (Spinocath; Braun Melsungen, Germany) and group 2 (Intralong; Pajunk, Germany). The study tabulated details of subarachnoid catheter insertion, dural puncture, time to free cerebrospinal fluid (CSF) flow, anesthesia onset time, surgery anesthesia time, the upper level of sensory block reached, the anesthesiologist-evaluated degree of difficulty with the technique, and the quality of analgesia obtained and complications. At the end of surgery, all the catheters were removed, and their patency was checked. RESULTS: Spinocath insertion required 6.3 +/- 3.2 minutes in group 1 versus 3.9 +/- 1.2 minutes in group 2 (P < .01) with similar difficulties with catheter introduction. Perception of dural puncture was better in group 1 (P < .05). There were significant intergroup differences in time to free flow of CSF through the catheter. In group 2, correct catheter positioning had to be confirmed by aspiration in 80% of cases (P < .05). At the end of surgery, the catheters were removed, and there were no significant differences between groups. The anesthetic blocks were similar with both systems. Patient opinion of the technique did not differ between groups, and regression analysis did not show any differences between groups or correlation to any incident during performance of the technique. Globally, the anesthesiologists participating in the study considered both systems to be easy to use and adequate for continuous spinal anesthesia. With respect to the advantage afforded by a directional needle in orientating the catheter within the spinal canal, the Spinocath system-with a longer technique performance time than the standard approach-involves a success rate and incidence of technical problems similar to that of the conventional technique.

Subarachnoid ketamine in swine--pathological findings after repeated doses: acute toxicity study.

BACKGROUND AND OBJECTIVES: The purpose of this study was to investigate whether 5% ketamine with and without preservative, administered intrathecally to swine, produced a clinical anesthetic effect and caused direct subacute neurotoxicity. METHODS: Twenty pigs were used. Under general anesthesia, a subarachnoid catheter was placed at L5-L6 or L6-S1 spinal interspace. Five animals were used for initial clinical evaluation of the anesthetic effects of subarachnoid ketamine (12.5 and 25.0, and 500 mg). Two animals were excluded because of bloody taps, two served as controls (catheterization without drug administration), four received ketamine racemate (25.0 mg/d), four received ketamine racemate preservative free (25.0 mg/d), and three received benzethonium chloride, the ketamine excipient (0.05 mg/d). All drugs were administered for 7 days. The catheters were withdrawn at the end of the treatment period. After 35 days, the pigs were euthanized and the spinal cord removed and preserved for histopathologic study with hematoxilyn-eosin and luxol-fast blue myelin staining. Histopathologic effects were defined as absent/minimal, mild, or severe by a pathologist, unaware of group allocation, by evaluating the presence and intensity of peripheral and/or central chromatolysis, spongiosis, neuronal loss, perivascular neuroglia, neuronolysis, and myelin degeneration. RESULTS: All doses of ketamine produced immediate cutaneous anesthesia and motor block; benzethonium chloride did not. Histopathologic examination showed no neurotoxic effect of ketamine without preservative; ketamine with preservative showed a discrete neurotoxic effect, and the preservative alone produced a moderate neurotoxic effect. CONCLUSIONS: Clinically, in swine, subarachnoid ketamine without preservative is a safe and effective anesthetic and did not show significant neurotoxic effects. However, ketamine with preservative produces minimal changes, and benzethonium chloride alone produces moderate neurotoxic effects.

[Cardiocirculatory effects of intravenous anesthetic induction in an experimental model of acute hypovolemia]. / Efectos cardiocirculatorios de la inducción anestésica intravenosa en un modelo experimental de hipovolemia aguda.

OBJECTIVE: To evaluate the cardiovascular effects of ketamine, midazolam, thiopentone and propofol in acutely hypovolemic pigs and to determine whether the association of ketamine and midazolam offers any advantage. PATIENTS AND METHODS: Twenty-two Landrace-Large-White pigs. After monitoring was begun, acute hypovolemia was induced by means of rapid exsanguination of 30% of calculated volume. Hemodynamic variables were measured: a) at baseline; b) after exsanguination; c) 2 min after anesthetic induction; d) 10 min after anesthetic induction, and e) after reinfusion of the exsanguinated volume. RESULTS: All pressures, cardiac output, cardiac index, and mixed venous oxygen saturation fell significantly with the induction of hypovolemia. Heart rate, systemic vascular resistances and arteriovenous oxygen differential increased. Ten min after anesthetic induction, heart rate in the midazolam group was significantly lower than in the ketamine-midazolam group. Arterial pressures decreased significantly after anesthetic induction with all drugs. The decrease in systolic arterial pressure was smaller in thiopenthal-anesthetized pigs than in pigs receiving either midazolam or propofol at the 10 min recording. The decrease in mean arterial and diastolic pressure after 10 min was smaller with thiopental than with any other drug. The decrease in mean arterial pressure was less in the thiopental and ketamine-midazolam groups than in the others after reinfusion. Diastolic arterial pressure at 10 min and after reinfusion had decreased less in the thiopental and ketamine-midazolam groups than in the propofol group. After anesthetic induction, the post-hypovolemic figures for cardiac output and cardiac index held steady or changes were slightly accentuated, with no statistically significant differences among the groups. CONCLUSIONS: The intravenous anesthetics evaluated were detrimental to cardiovascular function in acute hypovolemic pigs. Low-dose thiopental and ketamine plus midazolam may be the anesthetics of choice in this setting. Propofol caused the greatest degree of hemodynamic instability.

Intra-articular analgesia after arthroscopic knee surgery: comparison of three different regimens.

One hundred and three patients ASA grades I-II, 16-80 years of age scheduled for arthroscopic meniscectomy were prospectively studied, and randomly allocated to one of four groups: group 1 (n = 25): 0.25% bupivacaine (50 mg) intra-articular (IA), group 2 (n = 27): 1 mg of 0.1% preservative free morphine chloride in saline, group 3 (n = 26): 1 mg of 0.1% preservative free morphine chloride in 0.25% bupivacaine and group 4 (n = 25): normal saline (0.9%). The volume given was always 20 mL. Ketorolac [Toradol, 30 mg intramuscularly (i.m.)] was used as rescue medication; analgesia was assessed using a visual analogue scale (VAS), a verbal rating scale (VRS), supplemental analgesic consumption post-operatively (SAC) and the presence of side effects. Verbal rating scale and visual analogue scale scores showed better pain control in group 1, 20 min after surgery, and in groups 1 and 2 at 4 h and 10 h as well as in the global VAS. In multifactorial analysis no significant differences among groups or side effects was found, pH analysis of the substances used showed no alterations in the basal pH range. The analgesic efficacy of 20 mL of bupivacaine 0.25% is similar to that of 1 mg of morphine in 20 mL of saline 0.9%. The morphine-bupivacaine mixture was no more efficacious than bupivacaine or morphine alone.

Predictors of patient satisfaction with regional anesthesia.

BACKGROUND AND OBJECTIVES: The practice and success of regional anesthesia (RA) are influenced by a number of factors. The aim of this study was to evaluate patients' attitudes toward RA--perhaps the aspect least evaluated in anesthesia practice--and the factors influencing it. METHODS: A total of 154 patients (59 male, 95 female) aged 13 to 96 years were subjected to different RA techniques for orthopedic and trauma surgery. On the following day, a nurse not belonging to the surgical area and not aware of the anesthesia technique gave a questionnaire to the patient. RESULTS: After application of the study protocol, 110 patients were evaluated (40 male, 70 female), aged 13 to 96 years (mean, 66 +/- 12). Of these, 15.5% had undergone RA previously. Patient attitude toward RA was mostly either favorable (46.4%) or indifferent (45.5%)--only 6.4% showed a negative attitude. Inconveniences of RA were mentioned by 24.6% of patients, and the most common complaint was the needle puncture involved in the technique (18.1%). Advantages of RA were cited by 82.7% of patients (two or more quoted in 75.3%): the possibility of speaking with relatives during the immediate postoperative period (72.7%), staying awake (71.8%), and the absence of pain during the immediate postoperative interval (37.3%). Regression analysis showed the complaint of needle puncture to be the greatest negative factor. CONCLUSION: The performance of RA and consequently the knowledge of it acquired by the patients led to an increase in demand among those individuals who previously had expressed doubts about the technique. Previously positive attitudes remained unchanged. The combination of adequate sedation and the correct anesthetic procedure may favor patient acceptance of RA.

[Analysis of knowledge about the anesthesiology specialty among a population of medical students]. / Análisis de los conocimientos de la especialidad de anestesiología en una población de estudiantes de medicina.

OBJECTIVES: To analyze the knowledge of anesthesiology possessed by a group of medical students representative of medically trained individuals who have not yet worked in a hospital. MATERIAL AND METHOD: Students in their fifth year of medical studies at the University of Valencia were invited to voluntarily and anonymously answer a questionnaire with dichotomous and multiple choice responses covering general and specific aspects of anesthesiology. The survey also collected personal and epidemiological data. One hundred eighty-five questionnaires were returned. RESULTS: The results obtained were analyzed for correlations with epidemiological and personal data (sex, information received, prior anesthesia); no significant correlations were found between these data and correct response. It was believed by 78.4% that the anesthesiologist's function during surgery does not go beyond warning the surgeon of changes in vital signs. Nevertheless, 76.2% asserted that the anesthesiologist's function is to protect the patient during the perioperative period. CONCLUSION: In comparison with the general population, medical students' training has left them with inadequate understanding of anesthesiology.