Influencia de la anestesia general sobre el tronco encefálico / Influence of general anaesthesia on the brainstem

El papel que desempeña el tronco encefálico en el control del funcionamiento basal del organismo y los detalles sobre cómo la anestesia general puede influir sobre este aún no está completamente definido. Sin embargo, en cada anestesia general el anestesiólogo debe ser consciente de la interacción de los fármacos anestésicos y la función del tronco encefálico en relación con la homeostasis del organismo. Como resultado de esta interacción habrá cambios en el nivel de consciencia, los reflejos protectores del organismo, el ritmo respiratorio, la frecuencia cardíaca, la temperatura o la presión arterial entre otros. La función del tronco encefálico puede ser explorada usando 3 enfoques diferentes: a través de la exploración clínica, analizando los cambios en la actividad eléctrica del cerebro o mediante el uso de técnicas de neuroimagen. El presente artículo de formación continuada trata de la influencia de los efectos de los fármacos anestésicos sobre la función del tronco encefálico. Para ello se estudia la exploración clínica de los nervios craneales y de diversos arcos reflejos afectados, el análisis de las señales eléctricas, tales como los cambios electroencefalográficos, y lo que se sabe acerca del tronco encefálico a través del uso de técnicas de imagen, más concretamente a través de imágenes obtenidas por resonancia magnética funcional. El objetivo es proporcionar al anestesiólogo clínico una visión global de la interacción entre los cambios inducidos por los anestésicos relacionados con la función del tronco encefálico (AU)

The exact role of the brainstem in the control of body functions is not yet well known and the same applies to the influence of general anaesthesia on brainstem functions. Nevertheless in all general anaesthesia the anaesthesiologist should be aware of the interaction of anaesthetic drugs and brainstem function in relation to whole body homeostasis. As a result of this interaction there will be changes in consciousness, protective reflexes, breathing pattern, heart rate, temperature or arterial blood pressure to name a few. Brainstem function can be explored using three different approaches: clinically, analyzing changes in brain electric activity or using neuroimaging techniques. With the aim of providing the clinician anaesthesiologist with a global view of the interaction between the anaesthetic state and homeostatic changes related to brainstem function, the present review article addresses the influence of anaesthetic drug effects on brainstem function through clinical exploration of cranial nerves and reflexes, analysis of electric signals such as electroencephalographic changes and what it is known about brainstem through the use of imaging techniques, more specifically functional magnetic resonance imaging (AU)

Hypnosis closed loop TCI systems in outpatient surgery. / Sistemas de TCI en circuito cerrado para la hipnosis en cirugía ambulatoria.

OBJECTIVE: Determine the influence of general anaesthesia with closed-loop systems in the results of outpatient varicose vein surgery. PATIENTS AND METHODS: Retrospective observational study including data from 270 outpatients between 2014 and 2015. The patients were divided into 2 groups according to the type of general anaesthesia used. The CL Group included patients who received propofol in closed-loop guided by BIS and remifentanil using TCI, and the C Group received non-closed-loop anaesthesia. Age, sex, surgical time, discharge time and failure of outpatient surgery were recorded. Quantitative data were checked for normal distribution by the method of Kolmogorov-Smirnov-Lilliefors. Differences between groups were analysed by a Student-t-test or Mann-Whitney-Wilcoxon test, depending on their distribution. Categorical data were analysed by a Chi-squared test. We used Kaplan-Meier estimator and the effect size (calculated by Cohen's d) to study the discharge time. Statistical analysis was performed using R 3.2.3 binary for Mac OS X 10.9. RESULTS: There were no significant differences in age, sex and surgical time and failure of outpatient surgery. Discharge time was different in both groups: 200 (100) vs. 180 (82.5) minutes, C Group and CL Group, respectively (data are median and interquartile rank); P=.005. CONCLUSION: The use of closed-loop devices for the hypnotic component of anaesthesia hastens discharge time. However, for this effect to be clinically significant, some improvements still need to be made in our outpatient surgery units.

Anesthetic Management for Pediatric Awake Tracheostomy.

Awake tracheostomy is indicated for acute upper airway obstruction, when other methods of securing the airway, such as intubation and cricothyrotomy, have failed or are inappropriate. This option is rarely considered in pediatrics because of the concerns of patient cooperation and safety and has not been described in the literature. We describe the anesthetic management of an awake tracheostomy performed on a 7-year-old girl, with a large supraglottic mass obstructing the laryngeal introitus.

Dialysis Access Surgery: Does Anesthesia Type Affect Maturation and Complication Rates?

BACKGROUND: Creation of an arteriovenous fistula (AVF) is the preferred method of establishing long-term dialysis access. There are multiple anesthetic techniques used for patients undergoing this surgery including general endotracheal intubation, laryngeal mask airway, regional anesthesia with nerve blocks, and monitored anesthesia care with local infiltration. It is unclear what effect the method of anesthesia has on AVF creation success rate. It is our objective to determine if anesthesia type affects success of these surgeries defined by complication and maturation rates. METHODS: A retrospective review was performed in a single institution, single surgeon study of 253 patients who underwent AVF creation between January 2003 and December 2010. Patients were cross analyzed between 3 anesthesia types (General Endotracheal Intubation, Laryngeal Mask Airway and Local Infiltration with Monitored Anesthesia Care) and AVF creation surgeries (radiocephalic, brachiocephalic, and basilic vein transposition). No patients had regional anesthesia performed. Demographic data including comorbidities and risk factors were stratified among all categories. Analysis of variance, chi-squared testing, and Fisher's exact P testing was performed across all anesthesia types and specific operations and measured according to success of fistula maturation and complication rates (including death within 30 days, myocardial infarction within 30 days, respiratory insufficiency, venous hypertension, wound infections, neuropathy, and vascular steal syndrome). RESULTS: There were no significant differences in maturation rate in terms of all 3 anesthesia types for radiocephalic (P = 0.191), brachiocephalic (P = 0.191), and basilic vein transposition surgeries (P = 0.305). In addition, there were no differences in complication rates between the surgeries and the 3 types of anesthesia (P = 0.557). CONCLUSIONS: Our study shows that despite anesthesia type, outcomes in terms of maturation and complication rate are not statistically different in AVF creation surgeries. The use of monitored anesthesia care with local anesthesia may improve operative efficiency in terms of time in the operating room and in the recovery unit and therefore may be the preferred method of anesthesia. This recommendation may also parallel the preference to avoid general anesthesia in a patient population with more medical comorbidities. It is our conclusion that dialysis access surgery should therefore be performed under local anesthesia with monitored anesthesia care.

[The Origins of the Words : Zenshin Masui and Kyokusho Masui.]

In 1850, Seikei Sugita coined the word "Masui" to describe a physical condition induced by ether inhala- tion. Therefore, the word"Masui"initially meant general anesthesia. After physical methods to produce local numbness were introduced to Japan, it was necessary to make a new phrase to express the methods and the physical condition produced by them, and "Kyokusho Masui" was made, in which "kyokusho" means local. Then,"Zenshin Masui", indicating general anesthesia, was made to form a set of "Kyokusho Masui" and "Zenshin Masui". It was 1876 when Tadanori Ishiguro published "Geka Tsujutsu", in which he described a clear definition of "Kyokusho Masui" and "Zenshin Masui". This is one of the earliest uses of "Kyokusho Masui" together with "Zenshin Masui" in Japan.

Tratamiento quirúrgico ambulatorio del cáncer de mama. Experiencia en el Hospital General de Ciudad Real / Breast cancer ambulatory surgery. Experience at General Hospital in Ciudad Real

Objetivo. Describir la casuística de pacientes con diagnóstico de cáncer de mama intervenidas en el Hospital General Universitario de Ciudad Real mediante un programa de cirugía mayor ambulatoria (CMA). Pacientes y método. Estudio descriptivo retrospectivo donde se presenta la serie de pacientes del Hospital General de Ciudad Real con diagnóstico de cáncer de mama e intervenidas quirúrgicamente en el periodo comprendido entre el 1 de enero de 2010 y el 1 de febrero de 2011. Resultados. Se intervinieron un total de 130 pacientes; de ellas, un 20% se consideraron larga estancia, un 32,3% corta estancia y un 47,7%, CMA. En el 69,4% de los casos, las técnicas quirúrgicas más asociadas a CMA fueron cirugías conservadoras. Conclusiones. La cirugía del cáncer de mama es factible en programas de cirugía mayor ambulatoria, con criterios establecidos de selección de pacientes. Las técnicas conservadoras fueron las más empleadas en nuestro programa (AU)

Objective. To describe the series of patients diagnosed with breast cancer that went to the operation room in the Ambulatory Surgery Program in the University General Hospital of Ciudad Real. Patients and methods. Retrospective descriptive study of patients diagnosed of breast cancer in University General Hospital of Ciudad Real and had been operated between 01-01-2010 to 01-02-2011. Results. 130 patients were analyzed. 20% were considered long stay more than 72 hours, 32,3% were short stay and 47,7% were ambulatory surgery. Conservative surgery were performed in 69,4% of all the cases included. Conclusion. Breast cancer surgery is feasible in ambulatory surgery programs with patients selection criteria. Conservative techniques were the most common surgery in our program (AU)

Effects of various anesthesia maintenance on serum levels of selenium, copper, zinc, iron and antioxidant capacity / Efeitos da manutenção de várias anestesias sobre os níveis séricos de selênio, cobre, zinco e ferro e a capacidade antioxidante / Efectos del mantenimiento de varias anestesias sobre los niveles séricos de selenio, cobre, cinc y hierro y la capacidad antioxidante

BACKGROUND AND OBJECTIVES: In this study, we aimed to investigate the effects of sevoflurane, desflurane and propofol maintenances on serum levels of selenium, copper, zinc, iron, malondialdehyde, and glutathion peroxidase measurements, and antioxidant capacity. METHODS: 60 patients scheduled for unilateral lower extremity surgery which would be performed with tourniquet under general anesthesia were divided into three groups. Blood samples were collected to determine the baseline serum levels of selenium, copper, zinc, iron, malondialdehyde and glutathion peroxidase. Anesthesia was induced using 2-2.5 mg kg-1 propofol, 1 mg kg-1 lidocaine and 0.6 mg kg-1 rocuronium. In the maintenance of anesthesia, under carrier gas of 50:50% O2:N2O 4 L min-1, 1 MAC sevoflorane was administered to Group S and 1 MAC desflurane to Group D; and under carrier gas of 50:50% O2:air 4 L min-1 6 mg kg h-1 propofol and 1 µg kg h-1 fentanyl infusion were administered to Group P. At postoperative blood specimens were collected again. RESULTS: It was observed that only in Group S and P, levels of MDA decreased at postoperative 48th hour; levels of glutathion peroxidase increased in comparison to the baseline values. Selenium levels decreased in Group S and Group P, zinc levels decreased in Group P, and iron levels decreased in all three groups, and copper levels did not change in any groups in the postoperative period. CONCLUSION: According to the markers of malondialdehyde and glutathion peroxidase, it was concluded that maintenance of general anesthesia using propofol and sevoflurane activated the antioxidant system against oxidative stress and using desflurane had no effects on oxidative stress and antioxidant system. .

JUSTIFICATIVA E OBJETIVOS: Investigar os efeitos da manutenção de sevoflurano, desflurano e propofol sobre nos níveis séricos de selênio, cobre, zinco, ferro e malondialdeído, as mensurações de glutationa peroxidase e a capacidade antioxidante. MÉTODOS: Foram alocados em três grupos 60 pacientes agendados para cirurgia unilateral de membros inferiores, feita com torniquete sob anestesia geral. Amostras de sangue foram coletadas para determinar os níveis séricos basais de selênio, cobre, zinco, ferro, malondialdeído e glutationa peroxidase. A anestesia foi induzida com 2-2,5 mg kg-1 de propofol, 1 mg kg-1 de lidocaína e 0,6 mg kg-1 de rocurônio. Na manutenção da anestesia, sob gás de transporte de 50% O2 e 50% N2O (4 L min-1), sevoflurano a 1 CAM foi administrado ao Grupo S e desflurano a 1 CAM ao Grupo D e, sob gás de transporte em mistura de 50% O2 e 50% ar (4 L min-1), 6 mg kg h-1 de propofol e 1 mg kg h-1 de fentanil foram administrados ao Grupo P. No pós-operatório, amostras de sangue foram novamente coletadas. RESULTADOS: Apenas nos grupos S e P os níveis de MDA diminuíram em 48 horas de pós-operatório; os níveis de glutationa peroxidase aumentaram em comparação com os valores basais. Os níveis de selênio diminuíram no Grupo S e no Grupo P, os níveis de zinco diminuíram no Grupo P, os níveis de ferro diminuíram em todos os grupos e não houve alteração nos níveis de cobre em nenhum grupo no período pós-operatório. CONCLUSÃO: De acordo com os marcadores de malondialdeído e glutationa peroxidase, concluímos que a manutenção da anestesia geral com propofol e sevoflurano ativou o sistema antioxidante contra o estresse oxidativo e o uso de desflurano não teve efeitos sobre o estresse oxidativo e o sistema antioxidante. .

JUSTIFICACIÓN Y OBJETIVOS: Investigar los efectos del mantenimiento de sevoflurano, desflurano y propofol sobre los niveles séricos de selenio, cobre, cinc, hierro y malondialdehído, las medidas de glutatión peroxidasa y la capacidad antioxidante. MÉTODOS: Fueron ubicados en 3 grupos 60 pacientes programados para cirugía unilateral de miembros inferiores, realizada con torniquete bajo anestesia general. Fueron recogidas muestras de sangre para determinar los niveles séricos basales de selenio, cobre, cinc, hierro, malondialdehído y glutatión peroxidasa. La anestesia fue inducida con 2-2,5 mg/kg-1 de propofol, 1 mg/kg-1 de lidocaína y 0,6 mg/kg-1 de rocuronio. En el mantenimiento de la anestesia, bajo gas portador de 50% de O2 y 50% de N2O (4 L/min-1), sevoflurano a 1 CAM fue administrado al grupo S; y desflurano a 1 CAM al grupo D y bajo gas portador en mezcla de 50% O2 y 50% aire (4 L/min-1), 6 mg/kg/h-1 de propofol y 1 µg/kg/h-1 de fentanilo fueron administrados al grupo P. En el postoperatorio se recogieron de nuevo muestras de sangre. RESULTADOS: Solamente en los grupos S y P los niveles de malondialdehído disminuyeron en las 48 h del postoperatorio; los niveles de glutatión peroxidasa aumentaron en comparación con los valores basales. Los niveles de selenio disminuyeron en el grupo S y en el grupo P, los niveles de cinc disminuyeron en el grupo P, los de hierro disminuyeron en todos los grupos y no hubo alteración en los niveles de cobre en ningún grupo en el período postoperatorio. CONCLUSIÓN: De acuerdo con los marcadores de malondialdehído y glutatión peroxidasa, llegamos a la conclusión de que el mantenimiento de la anestesia general con propofol y sevoflurano activó el sistema antioxidante contra el estrés oxidativo y el uso de desflurano no tuvo efectos sobre el estrés oxidativo y el sistema antioxidante. .

Neumoencéfalo como causa de descenso del índice biespectral / Pneumocephalus as a cause of a decrease in the bispectral index

En un paciente sometido a extirpación de un tumor epidermoide del ángulo pontocerebeloso por vía retrosigmoidea derecha con anestesia general, se observó un descenso brusco de los valores del índice biespectral (BIS) con elevación de la tasa de supresión, que probablemente fue debido a la aparición de neumoencéfalo a nivel frontal. No se observó clínica neurológica simultánea, y el paciente fue extubado en la sala de reanimación sin incidencias después de que las cifras del BIS volvieran a elevarse. Se optó por el tratamiento conservador contando con la reabsorción y redistribución del aire (AU)

A sharp decrease in the values of the bispectral index (BIS), along with an increase in suppression rate, was observed in a patient after the removal of an epidermoid tumor in the cerebellopontine angle by right retrosigmoid access under general anesthesia. This was probably related to a frontal pneumocephalus. No accompanying neurological signs were observed. The patient was extubated in the Recovery Room with no further incidents, as the BIS increased again. The neurosurgeons chose conservative treatment, relying on the reabsorption and redistribution of the air (AU)

Phonological outcome of laryngeal framework surgery by different anesthesia protocols: a single-surgeon experience.

CONCLUSION: Similar to combined arytenoid adduction and medialization laryngoplasty (i.e. combined surgery) under local anesthesia, general anesthesia by intubation or by the laryngeal mask airway (LMA) method significantly improves phonological outcome. Thus, laryngeal framework surgery under general anesthesia is a promising surgical approach for selected patients with unilateral vocal cord paralysis (UVCP). OBJECTIVE: The advantages of laryngeal framework surgery under local anesthesia have been described, but no studies exist concerning the difference in phonological outcome of laryngeal framework surgery performed under general anesthesia. To add new information, we retrospectively investigated the phonological outcome of the combined surgery performed under three different anesthesia protocols. METHODS: Thirty-nine consecutive patients with severe UVCP underwent the combined surgery under three anesthesia protocols performed by a single surgeon: (1) under general anesthesia by intubation, (2) under general anesthesia using LMA, and (3) under local anesthesia. RESULTS: Under all anesthesia protocols, the vocal cords of most patients could be positioned such that the best vocal outcome could be expected. Statistical analyses demonstrated improved maximum phonation time and mean airflow rate, and grade, roughness, breathiness, asthenia, and strain (GRBAS) scale in all patients, regardless of their anesthesia protocol. Furthermore, of the three protocols, local anesthesia had the shortest operation time.

Experiencia y tratamiento anestésico en el implante transcatéter de la prótesis valvular aórtica autoexpandible CoreValve ® / Anesthetic management and experience in the transcatheter implantation of the CoreValve ® self-expanding aortic valve

Objetivo. Analizar la experiencia y el tratamiento anestésico perioperatorio en la implantación transcatéter de la válvula aórtica autoexpandible CoreValve® en un hospital universitario terciario. Material y métodos. Estudio observacional analítico con revisión de datos incorporados a una base mantenida de forma prospectiva de 142 pacientes diagnosticados de estenosis aórtica severa, a los que se implantó una válvula aórtica autoexpandible CoreValve® entre diciembre de 2007 y diciembre de 2012. Resultados. La media de edad de los pacientes fue de 82,5 ± 6,1 años y el EuroSCORE logístico de 14,9 ± 11,2. En 107 pacientes (75,3%) se utilizó anestesia general, y en 35 (24,6%), anestesia local con sedación. La anestesia local con sedación se asoció con un menor requerimiento de fármacos vasoactivos (p = 0,003) durante el implante. No encontramos diferencias estadísticamente significativas entre ambas técnicas anestésicas en el tiempo de duración del procedimiento, en la estancia hospitalaria ni en la morbimortalidad. La tasa de éxito fue del 97,1%. La complicación más frecuente fueron los trastornos de la conducción, que precisaron la implantación de marcapasos definitivo en 46 pacientes (32,3%). No hubo ningún exitus intraoperatorio, la mortalidad por cualquier causa a los 30 días fue del 6,3% y la supervivencia al año estimada por el método de Kaplan-Meier fue de 83,1%. Conclusiones. Este estudio confirma que en pacientes con estenosis aórtica severa y alto riesgo quirúrgico la sustitución valvular aórtica transcatéter es una alternativa efectiva y segura. Tanto la anestesia general como la local con sedación son opciones válidas, dependiendo de la experiencia del equipo (AU)

Hiperpirexia maligna / Malignant hyperpyrexia

Se revisa el tema de la hiperpirexia maligna y otros síndromes hipertérmicos. Tras una descripción de la fisiopatología se proponen pautas de diagnóstico, diagnóstico diferencial y tratamiento ante un aumento de la temperatura de un paciente. Dentro de esta entidad es fundamental el diagnóstico precoz y el tratamiento inmediato, el cual puede ser instaurado siguiendo una protocolización estricta, que incluye una distribución de las tareas entre varios componentes del equipo anestesicoquirúrgico, incluyendo la enfermería. La colaboración de varios profesionales es imprescindible. Se destaca la ausencia de seguimiento y apoyo a nivel nacional, y se aporta una dirección de correo electrónico para ayuda (AU)

This article reviews malignant hyperpyrexia and other hyperthermic syndromes. The physiopathology of these syndromes is described and strategies for their diagnosis, differential diagnosis and treatment are proposed. Early diagnosis and immediate treatment are essential. The latter can be initiated by following a strict protocol, which includes the distribution of tasks among the various components of the anesthesiology-surgical care team, including nurses. The collaboration of various professionals is essential. The lack of follow-up and national support is highlighted and an e-mail address for support is provided (AU)

Type I gore-tex laryngoplasty for glottic incompetence in mobile vocal folds.

OBJECTIVE: To determine the effectiveness of gore-tex medialization thyroplasty for the management of glottic incompetence (GI) in patients with mobile vocal folds. METHODS: Twenty patients with glottic incompetence (GI) and mobile vocal folds were retrospectively analyzed after gore-tex medialization laryngoplasty. Pre- and postoperative outcome measures including grade, roughness, breathiness, asthenia, strain of the voice (GRBAS), glottal function index (GFI), and voice-related quality of life (VRQOL) were compared to detect surgical effectiveness. Two anesthetic subgroups were identified and compared: general anesthesia, via laryngeal mask airway (LMA) anesthetic, and local anesthesia. RESULTS: Statistically significant differences were identified between pre- and postoperative VRQOL (P<0.0001), GFI (P<0.01), and composite GRBAS (P<0.0001) after a mean follow-up time of 7.8 months. Both the LMA and the local anesthetic subgroups demonstrated similar significance across these measures. GFI and VRQOL scores demonstrate a moderate correlation (ρ=0.71). Perceptual voice quality (GRBAS) correlates slightly better with VRQOL scores (ρ=-0.6; P<0.01) than qualitative measures of glottal function (GFI) (ρ=0.43). CONCLUSION: Gore-tex thyroplasty provides reliable medium-term improvement in both perceptual and subjective voice parameters in the setting of GI with mobile vocal folds.

Chemical restraint, anesthesia, and analgesia for camelids.

This article covers techniques used to provide chemical restraint, injectable or inhalation anesthesia, and analgesia in camelid patients. Understanding the information presented improves safety and efficacy when using the techniques presented in the article. This article focuses primarily on llama and alpaca patients. Of the techniques that have been used on camels, the dosing protocols provided have proven effective.

[A comparison of the effectiveness of transtracheal heating and humidification system in maintaining body temperature during general anesthesia with low flow gases].

We evaluated the effectiveness of transtracheal heating and humidification system in maintaining body temperature during general anesthesia with low flow gases in 12 gastric cancer patients. Patients were divided into two group; Control group A in which a hot-water circulating system was used and group B in which a transtracheal heating and humidification system by ANAMED HUMITUBE was used, during gastric cancer operation. Compared to the hot-water circulating system, the transtracheal heating and humidification system is more effective for maintaining body temperature and humidification after abdominal lavage by warm saline water. But there was no difference between the two groups about awakening from general anesthesia. We concluded that transtracheal heating and humidification system by ANAMED HUMITUBE is effective in maintaining body temperature under general anesthesia with low flow gases.

Patients' desire for information about anaesthesia: Danish attitudes.

BACKGROUND: Patients' desire for information about anaesthesia has been examined in a number of Commonwealth countries but not in Scandinavia. A questionnaire was distributed to form a basis for giving Danish patients more appropriate preoperative information. METHODS: 201 preoperative patients in Denmark were asked to complete a questionnaire. The patients were divided into subgroups according to: age, gender, residential origin, ASA group, educational level, type of anaesthesia planned and number of previous anaesthetics. RESULTS: Patients from a city area required significantly more information than patients from a rural/urban area about premedication drugs, drips/catheters, pain/pain relief and complications. Men more than women preferred to know about dangerous complications. Information about pain/pain relief, duration of anaesthesia, and influence of anaesthesia on daily activities such as eating, drinking, mobilisation was given the highest priority, while unpleasant information such as about complications and needles was given the lowest priority. Meeting the anaesthetist and information about alternative methods of anaesthesia and premedication drugs were given only moderate priority. Ranking information in Denmark was significantly correlated with Scotland, Canada and Australia, despite profound differences in priority. More often than Danish patients, Australian patients felt they had right to know, and especially about complications. CONCLUSION: Patients from a city area required more information than patients from a rural/urban area. Information about the influence on daily activities was preferred to unpleasant information. Ranking information in Denmark was correlated with a number of Commonwealth countries.