¿Qué debemos hacer hoy y qué hacemos en CMA de oftalmología? / No disponible

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[Anesthesia for ophthalmic surgery]. / Anästhesie bei ophthalmologischen Operationen - eine Standortbestimmung.

The majority of ophthalmic interventions can be done today under locoregional anesthesia using "Monitored Anesthesia Care" (MAC). General anesthesia techniques are mostly reserved for the pediatric segment and for patients with specific comorbidity and/or lengthy procedure. Cataract surgery in predominantly geriatric patients belongs to the field of the so-called "high volume-surgery": Given the low perioperative risk in this patient group, adapted and optimized processes are indicated. A focused premedication and informing these patients ensures good perioperative compliance. Preoperative tests are be conducted in this patient population only as a function of relevant comorbidity. Premedication usually takes place as a classical anesthesia consultation, but new methods such as an internet-based premedication for healthy patients offers a new option. The intraoperative anesthesia method depends on the needs of the surgeon and the expectations and possibilities of cooperation of the patient.

[The premedication visit--suggestions for a patient-friendly design]. / Das Prämedikationsgespräch--Anregungen zu einer patientenfreundlichen Gestaltung.

The premedication visit is often a difficult situation for the anaesthetist. On the one hand the patient needs to be informed in detail, but on the other he must not be alienated unnecessarily. Furthermore, a hospital stay represents an exceptional situation for the patient in which he behaves differently than in everyday life and shows a limited ability to process information. Following certain communication strategies allows to convey information to the patient in a comprehensible manner and to describe his individual anaesthesiological risk without needlessly creating fear.

Pre-emptive local analgesia in video-assisted thoracic surgery sympathectomy.

OBJECTIVE: Our goal is to determine whether infiltration with a short-acting local anaesthetic such as lidocaine before the surgical incision has a pre-emptive effect on postoperative pain intensity and on incidence of paraesthesia in patients undergoing standard thoracoscopic sympathectomy for palmar hyperhidrosis. MATERIAL AND METHODS: This prospective study includes a consecutive series of 18 patients undergoing bilateral standard thoracoscopic sympathectomy for palmar hyperhidrosis during January 2005-December 2007. Each patient enrolled in the study was randomised to receive pre-incisional lidocaine with epinephrine infiltration of the wounds on the one side, and normal saline solution on the other. The identical surgery was performed on each side to allow patients to act as their own controls. Then, the side which received local analgesia was compared with the control side with regard to pain control and paraesthesia after 4, 24 and 168 h postoperatively. The patients and investigators were both blinded concerning the side randomised to receive pre-emptive local analgesia (PLA). RESULTS: We found that patients reported significantly less pain on the side treated with pre-emptive local anaesthesia in contrast to the control side 4 and 24h after surgery (p=0.001 and p=0.004, respectively). However, that difference decreased with time and was no longer significant 168 h following surgery (p=0.156). Regarding the paraesthesia, the incidence was higher in the control side than the PLA side at 4, 24 and 168 h postoperatively, but the difference was not statistically significant. A total of 17 of 18 (94%) patients noted a change in palmar hyperhidrosis status after surgery. CONCLUSION: Our study shows that the pre-injection of local anaesthetic before standard thoracoscopic sympathectomy suppresses the local pain mediators, hence resulting in significantly less pain in the first postoperative 24 h but not thereafter. The clinical impact of the procedure is the possibility of early discharge to home and early return to work with potential economical benefits. However, because of the small number of patients, further studies are needed to corroborate our results.

Relaxing music as pre-medication before surgery: a randomised controlled trial.

INTRODUCTION: Patients who await surgery often suffer from fear and anxiety, which can be prevented by anxiolytic drugs. Relaxing music may be an alternative treatment with fewer adverse effects. This randomised clinical trial compared pre-operative midazolam with relaxing music. METHOD: Three hundred and seventy-two patients scheduled for elective surgery were randomised to receive pre-operative prevention of anxiety by 0.05-0.1 mg/kg of midazolam orally or by relaxing music. The main outcome measure was the State Trait Anxiety Inventory (STAI X-1), which was completed by the patients just before and after the intervention. RESULTS: Of the 177 patients who completed the music protocol, the mean and (standard deviation) STAI-state anxiety scores were 34 (8) before and 30 (7) after the intervention. The corresponding scores for the 150 patients in the midazolam group were 36 (8) before and 34 (7) after the intervention. The decline in the STAI-state anxiety score was significantly greater in the music group compared with the midazolam group (P<0.001, 95% confidence interval range -3.8 to -1.8). CONCLUSION: Relaxing music decreases the level of anxiety in a pre-operative setting to a greater extent than orally administrated midazolam. Higher effectiveness and absence of apparent adverse effects makes pre-operative relaxing music a useful alternative to midazolam for pre-medication.

Guía de actuación ante una lesión periférica tras un bloqueo nervioso en CMA / No disponible

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Pharmacological interventions and concepts of fast-track perioperative medical care for enhanced recovery programs.

BACKGROUND: Improving perioperative efficiency and tightly maintaining the patient's homeostasis in order to improve rehabilitation and well-being are key factors in the increasing popularity of fast-track recovery programs. Although the pharmacological contribution should not be overestimated, the use of up-to-date pharmacological agents with predictable duration of action and minimal side effects is mandatory to allow for a fast and gentle recovery process. METHODS: A literature review of about 160 peer-reviewed publications provides the basis for this review of pharmacological interventions for optimizing recovery following anesthesia. RESULTS: The choice of anesthetic technique and pharmacological agents should be tailored to the needs of the patient as well as the type of procedure being performed as fast-track surgery. The universally applicable goals valid for every class of intervention are that they should be easy to use, have minimal side effects, maintain homeostasis, allow for a predictable on- and offset, and give minimal impairment of recovery and function. CONCLUSIONS: The pivotal role played by the anesthesiologist in facilitating the recovery process following surgical procedures has assumed increased importance in the concept of enhanced recovery programs. Although the interdisciplinary approach common to all parties involved (surgeons, anesthesiologists, nurses, physiotherapists) is the true enabler of fast-track surgery, the choice of anesthetic drugs and concomitant medication can all influence the ability to fast-track patients after surgery and should therefore considered mandatory in fast-track programs.

The efficacy comparison of ibuprofen, acetaminophen-codeine, and placebo premedication therapy on the depth of anesthesia during treatment of inflamed teeth.

The purpose of this study was to elucidate whether premedication therapy with acetaminophen-codeine or ibuprofen is able to increase the depth of anesthesia in inflamed teeth. Sixty patients with the diagnosis of irreversible pulpitis in 1 mandibular tooth requiring root canal therapy (RCT) were selected. Two other teeth in the same quadrant were selected as controls. An electric pulp tester (EPT) was used to evaluate pulp sensitivity at the baseline and after drug administration and anesthesia injection. The subjects were divided into 3 groups randomly, and in each group 1 of the 3 drugs including acetaminophen-codeine, ibuprofen, and placebo were administered 1 hour before anesthesia delivery. After 1 hour, anesthesia was injected and after a waiting period, the EPT measurement was recorded. The reversed EPT scale was used to evaluate the depth of anesthesia achieved during RCT. Data were analyzed to statistically compare the results before and after intervention in cases and controls of each group and among different groups. Significanly lower tooth sensitivity levels (TSLs) were observed after intervention in acetaminophen-codeine and ibuprofen groups, which was more significant in the ibuprofen group. The comparison of inflamed teeth TSLs in the acetaminophen-codeine group and the placebo group after anesthesia and drug administration showed significant differences (P = .001). This comparison between ibuprofen and placebo groups also showed significant differences (P approximately 0). Also, significantly lower TSL of inflamed teeth was observed in the ibuprofen group in comparison with the acetaminophen-codeine group (P = .002). This study reflected preoperative administration of ibuprofen, if not contraindicated, as a drug of choice 1 hour before local anesthesia injection as an effective method for achieving a deep anesthesia during RCT of teeth with irreversible pulpitis.

[A method for potentiation of local anesthesia for tooth removal and pulp extirpation]. / Sposob potentsiirovaniia mestnoi anestezii pri udalenii zuba i ékstirpatsii pul'py.

Local anesthesia can be considered adequate in 22% cases, which is explained by the absence of inhibitory effect on allogens, persistence of psychoemotional tension, and effector reactions. Therefore it is recommended to potentiate local anesthesia by a drug complex including analgesic ketrodole, tranquilizer diazepam, and alpha-adrenoagonist clofelin, used transbuccally 8-10 min before anesthesia. This pretreatment 3-fold increased the adequacy of local anesthesia for tooth removal and pulp extirpation.

Influência da medicação pré-anestésica com midazolam e clonidina no nível de hipnose após indução anestésica com propofol e alfentanil em crianças: monitorização pelo Índice bispectral / Influence of midazolam and clonidine premedication on hypnosis level after anesthetic induction with propofol and alfentanil in children: bispectral index monitoring / Influencia de la medicación pré-anestésica con midazolam y clonidina en el nivel de hipnosis después de inducción anestésica con propofol y alfentanil en niños: monitorización por el índice bispectral

Justificativa e Objetivos - A medicação pré-anestésica (MPA) é equivalente da anestesia e diminui tanto a necessidade de concentrações elevadas de anestésicos como a ansiedade perioperatória, produzindo amnésia e contribuindo para estabilidade hemodinâmica. Dentre as drogas administradas na MPA de crianças, encontram-se o midazolam e a clonidina. O objetivo desta pesquisa foi avaliar se a MPA com midazolam e clonidina exerce influência no nível de hipnose, avaliado pelo BIS, em crianças após indução anestésica com propofol e alfentanil. Método - Participaram do estudo 30 pacientes, com idades entre 2 e 12 anos, estado físico ASA I, submetidos a cirurgias eletivas, que foram distribuídos em 3 grupos: G1 - sem MPA, G2 - midazolam (0,5 mg.kgðû) e G3 - clonidina (4 µg.kgðû), por via oral, 60 minutos antes da cirurgia. Todos os pacientes receberam alfentanil (30 µg.kgðû), propofol (3 mg.kgðû) e atracúrio (0,5 mg.kgðû). Avaliou-se o valor derivado do BIS antes da indução da anestesia (M1) e após a intubação (M2). O método estatístico utilizado foi a análise de variância para idade, peso e altura, e análise de perfil para o BIS, sendo o valor de p < 0,05 considerado significativo. Resultados - Quando se comparou o mesmo momento (M1 ou M2) entre os três grupos, não foram observadas diferenças estatisticamente significativas. Quando se compararam os dois momentos de um mesmo grupo, M1 foi maior que M2 nos três grupos. Conclusões - A medicação pré-anestésica com midazolam e clonidina não influenciou o nível de hipnose em crianças induzidas com propofol e alfentanil

Does anaesthetic technique affect the outcome after transurethral resection of the prostate?

OBJECTIVE: To determine if the choice of anaesthetic (spinal or general) has any influence on outcomes after transurethral resection of the prostate (TURP). PATIENTS AND METHODS: The records of 261 patients undergoing TURP between October 1995 and July 1998 were selected for a matched-cohort study. There were 87 complete datasets for cases performed under general anaesthesia and each was matched to two patients (174) from those undergoing spinal anaesthesia. The cohorts were matched by age, physical status score and date of operation. The primary outcome measures were length of stay in the recovery room and satisfaction with postoperative analgesia. RESULTS: There were no significant differences in major outcomes. There was a higher incidence of some minor adverse events in the group having general anaesthesia. Back pain was more common after spinal anaesthesia. CONCLUSION: Spinal anaesthesia was not associated with an improved outcome after TURP. The choice of anaesthesia should be made by the patient, surgeon and anaesthetist on the basis of the known risks of particular adverse events.

Infusion rates and levels of premedication in tumescent liposuction.

BACKGROUND: Tumescent liposuction has proven to be an extremely safe and effective method of liposuction. However, the infusion of tumescent anesthesia can take 1 hour or more to complete. OBJECTIVE: To document the types, dosages, and routes of administration of premedication utilized by four experienced tumescent liposuction surgeons. To determine if infusion rates for tumescent anesthesia are affected by types of premedication. METHODS: Four experienced liposuction surgeons were asked to review their most recent 100 tumescent liposuction patients with respect to types and dosages of premedication and routes of administration. Data were also provided on corresponding infusion pump settings and infusion rates. Volumes of tumescent anesthesia and corresponding volumes of fat aspirated were also collected on the same 400 patients. RESULTS: Infusion of tumescent anesthesia could be performed more rapidly in patients who were given greater amounts of premedication. Volumes of tumescent anesthesia infused were generally two or more times the volume of fat aspirated. Patients could be infused with less premedication if slow infiltration was employed. CONCLUSION: Infusion rates for tumescent anesthesia can be increased of greater amounts of premedication are given. However, this must be balanced against the safety of the premedication.

Analgesic efficacy and safety of an intraoral lidocaine patch.

The effectiveness of intraoral II-docaine patches was tested by asking participants to rate the pain experienced after insertions of a 25-gauge needle. Needlesticks were performed at baseline and at various time points after patch placement. Each needlestick included contact with the periosteum. Lidocaine patches achieved significantly better analgesia than the placebo within 2.5 to five minutes after placement. Drug-related side effects were minimal and venous blood levels of lidocaine were low, averaging 10 to 14 times less than those achieved with a typical injection of lidocaine plus epinephrine. The authors conclude that the lidocaine patches used in this study are effective and safe in reducing needle insertion pain in adults.

An evaluation of the effect of oral ketamine and standard oral premedication in the sedation of paediatric dental patients.

We compared the effectiveness of ketamine with standard oral premedication (SOP) in 60 children, 2-7 years of age, sedated orally for dental treatment under local anaesthesia. Children were assigned randomly to receive either 12.5 mg/kg ketamine or 0.5 ml/kg of SOP orally 60 min before the dental procedure. Pulse rate, systolic, diastolic and mean arterial pressures, respiratory rates and blood oxygen saturation were recorded prior to drug administration, 60 min thereafter and immediately before the dental procedure. Anxiety levels were measured at the same time intervals. The level of sedation was measured 60 min after drug administration. No significant differences were found in the anxiety levels between the groups 60 min after oral administration. The level of sedation in both groups before surgery was excellent. Operator evaluation for overall effectiveness of treatment showed that sedation was very good in 60 per cent of children in the ketamine group compared with 20 per cent in the SOP group. More children in the ketamine group were better sedated (p < 0.05). Both premedicants produce good sedation and anxiolysis 60 min after premedication and immediately before the surgical procedure.

[Anxiolysis vs. intravenous conscious sedation during maxillary fracture splinting in local anesthesia]. / Anxiolyse versus Analgosedierung bei der Kieferbruchschienung in Lokalanästhesie.

For the conservative treatment of mandibular fractures with arch bars under local anaesthesia we used two forms of premedication in 140 patients: 1. an analgetic sedation with pethidine 1 mg/kg body weight and promethazine 0.5 mg/kg body weight i.m. (n = 70 cases) 2. an anxiolytic sedation with midazolam 0.05-0.1 mg/kg body weight i.v. (n = 70 cases). The effect of the premedication was measured retrospectively by the mean amount of local anaesthetics used during splinting. It could be noted that the mean consumption of local anaesthetics was significantly lower in the midazolam-group than in the pethidine/promethazine-group. The postoperative subjective assessment of the operation by the patients is better under anxiolytic than under analgetic sedation, too.

Midazolam-droperidol premedication for cardiac surgery. A comparison with papaveretum and hyoscine.

A combination of midazolam and droperidol given intramuscularly was compared with papaveretum and hyoscine for premedication of patients about to undergo cardiac surgery. Midazolam and droperidol proved to be a very satisfactory combination, producing superior sedation and anxiolysis with good cardiovascular stability.

Monitored anesthesia care for laparoscopies in oncology patients.

A retrospective chart review was conducted on 241 oncology patients who received monitored anesthesia care for laparoscopy. A review of perioperative analgesic and sedative requirements, and perioperative complications is included. The authors conclude that laparoscopy for diagnostic and staging purposes can be accomplished successfully with monitored anesthesia care.

[Premedication. Pharmacologic preparation prior to regional or general anesthesia]. / Premedikasjon. Medikamentell forberedelse til regional eller generell anestesi.

Patient safety and patient well-being are indications for premedication prior to regional or general anaesthesia. Patient well-being may be improved by anxiolytic acting premedication or analgetic premedication to patients in pain. Side-effects of premedication, as anticholinergic effects or emesis, should be avoided. In outpatient clinics it is important to avoid premedication regimens which may prolong patient recovery after the procedure. The paper discusses the principles of premedication, and includes a survey of the main drugs presently available for this purpose.