[Postoperative analgesia in cardiac surgery: spinal versus intravenous morphine]. / Analgesia postoperatoria en cirugía cardiaca: comparación de morfina intratecal versus morfina intravenosa.

OBJECTIVE: To compare the effects of spinal and intravenous administration of morphine to supplement anesthesia with remifentanil in terms of analgesia during early postoperative recovery and considering time until extubation. MATERIAL AND METHODS: This prospective, randomized, blinded trial enrolled 59 patients scheduled for cardiac surgery. The patients were assigned to receive either a spinal infusion of morphine (15 microg x Kg(-1)) or an intravenous infusion (0.3 mg x Kg(-1)). Anesthesia was maintained with 0.15 to 0.50 microg x Kg(-1) x min(-1) of remifentanil and 2 to 4 mg x Kg(-1) x h(-1) of propofol in perfusion. After the period of extracorporeal circulation, all patients were given an intravenous infusion of 30 mg of ketorolac. Later intravenous ketorolac was ministered at a dose of 30 mg per 8 hours; intravenous morphine (bolus dose of 3 mg) was also administered until pain was relieved. RESULTS: The same quality of postoperative analgesia and anesthetic recovery was achieved with both spinal and intravenous administration. The incidence of side effects was also similar. Likewise, the extubation times were similar in the 2 groups (spinal infusion group: 294.5 [SD, 150.5] minutes; intravenous group: 325.0 [139.9] minutes; P>0.05). Less postoperative intravenous morphine was administered in the first 24 hours to patients in the spinal morphine group (P<0.05) and fewer patients in that group required intravenous morphine boluses (P<0.05). CONCLUSIONS: Our study suggests that spinal morphine does not offer advantages over intravenous morphine with regard to postoperative analgesia, hemodynamic stability and respiratory parameters, time until extubation, or adverse effects.

[Evaluation of antibiotic prophylaxis in surgery]. / Evaluación de la profilaxis antibiótica en cirugía.

OBJECTIVE: To evaluate the level of compliance with antibiotic prophylaxis during surgery in a university referral hospital. PATIENTS AND METHODS: A descriptive study of 257 patients undergoing clean or clean-contaminated elective surgery was carried out in 2001. Data were gathered prospectively by three anesthesiologists in the operating room. Prophylaxis was considered to have been administered correctly if the first dose was given before the skin incision, if a second dose was given during operations lasting longer than 240 minutes, and if the antibiotic prescribed was of a wide enough spectrum to cover the type of surgical procedure performed. RESULTS: Prophylaxis was administered incorrectly to 132 patients (51.4%). The causes were administration after incision in 21.8%, long-duration surgery without a second dose in 15.6%, administration after incision plus long-duration surgery without a second dose in 3.1%, inadequate-spectrum antibiotic in 4.7%, administration after incision plus inadequate dose in 2.7%, inadequate dose in 1.9%, inadequate-spectrum antibiotic plus administration after incision in 0.8%, late second dose in 0.4%, long-duration surgery without a second dose plus inadequate dose in 0.4%. DISCUSSION: The rates of late administration of an antibiotic or failure to administer a second dose during long-duration surgery is high. CONCLUSION: To improve the low level of compliance and avoid late administration of antibiotics, we propose that the anesthetist be responsible for giving antibiotic prophylaxis and for directly monitoring compliance errors in the operating room.

Analgesia postoperatoria en cirugía cardíaca: comparación de morfina intratecal versus morfina intravenosa / Postoperative analgesia in cardiac surgery: spinal versus intravenous morphine

OBJETIVOS: Comparar, en pacientes intervenidos decirugía cardiaca, el efecto de la morfina intratecal (IT)frente a la morfina intravenosa (IV), como suplemento ala anestesia con remifentanilo. Se valoran el tiempo deextubación y la analgesia durante el postoperatorio inmediato.MATERIAL Y MÉTODOS: Estudio prospectivo, randomizadoy ciego, en el que se incluyen 59 pacientes programadospara cirugía cardiaca. Los pacientes fueron asignadosal grupo MIT (15 µg Kg-1 de morfina intratecal) oal grupo MIV (0,3 mg Kg-1 de morfina intravenosa). Laanestesia fue mantenida con 0,15-0,50 µg Kg-1min-1 deremifentanilo y 2-4 mg Kg-1h-1 de propofol en perfusión.Después del periodo de circulación extracorpórea, atodos se les administró 30 mg IV de ketorolaco. Posteriormentese administró ketorolaco IV (30 mg/8 horas) ybolus de morfina IV de 3 mg hasta el alivio del dolor.RESULTADOS: Con las dos pautas analgésicas (morfinaIT y morfina IV) se alcanzó el mismo nivel de analgesiapostoperatoria, recuperación anestésica y efectos secundarios.Los tiempos de extubación fueron similares en losdos grupos (Grupo MIT: 294,5 ± 150,5 minutos; grupoMIV: 325,0 ± 139,9 minutos, p < 0,05). La dosis de morfinaIV administrada durante las primeras 24 horas fuemenor (p<0,05) en el grupo MIT, en este grupo menospacientes precisaron bolos de morfina IV (p<0,05).CONCLUSIONES: Nuestro estudio sugieren que la morfinaIT no ofrece ventajas sobre la administración de morfinaIV con respecto a la analgesia postoperatoria, parámetroshemodinámicos y respiratorios, tiempo deextubación o efectos adversos

OBJETIVE: To compare the effects of spinal and intravenousadministration of morphine to supplement anesthesiawith remifentanil in terms of analgesia during early postoperativerecovery and considering time until extubation.MATERIAL AND METHODS: This prospective, randomized,blinded trial enrolled 59 patients scheduled for cardiac surgery.The patients were assigned to receive either a spinalinfusion of morphine (15 µg·Kg-1) or an intravenous infusion(0.3 mg·Kg-1). Anesthesia was maintained with 0.15 to 0.50µg·Kg-1·min-1 of remifentanil and 2 to 4 mg·Kg-1·h-1 of propofolin perfusion. After the period of extracorporeal circulation,all patients were given an intravenous infusion of 30 mgof ketorolac. Later intravenous ketorolac was ministered at adose of 30 mg per 8 hours; intravenous morphine (bolus doseof 3 mg) was also administered until pain was relieved.RESULTS: The same quality of postoperative analgesiaand anesthetic recovery was achieved with both spinal andintravenous administration. The incidence of side effectswas also similar. Likewise, the extubation times were similarin the 2 groups (spinal infusion group: 294.5 [SD,150.5] minutes; intravenous group: 325.0 [139.9] minutes;P>0.05). Less postoperative intravenous morphine wasadministered in the first 24 hours to patients in the spinalmorphine group (P<0.05) and fewer patients in that grouprequired intravenous morphine boluses (P<0.05).CONCLUSIONS: Our study suggests that spinal morphinedoes not offer advantages over intravenous morphinewith regard to postoperative analgesia, hemodynamicstability and respiratory parameters, time until extubation,or adverse effects

Evaluación de la profilaxis antibiótica en cirugía / Evaluation of antibiotic prophylaxis during surgery

OBJETIVO: Evaluar el nivel de cumplimiento de la antibiótico profilaxis en cirugía en un hospital universitario de tercer nivel. PACIENTES Y MÉTODOS: Durante el año 2001 se realizó un estudio descriptivo que incluyó a 257 enfermos sometidos a intervenciones quirúrgicas electivas limpias o limpias contaminadas. La recogida de datos fue realizada en quirófano, de forma prospectiva por tres anestesiólogos. Se consideró que la profilaxis se administró correctamente si la primera dosis fue administrada antes de la incisión de la piel; si se administró una segunda dosis en intervenciones de duración superior a 240 minutos y si se administró un antibiótico de espectro adecuado según el tipo de intervención quirúrgica . RESULTADOS: En 132 pacientes (51,4 por ciento) la profilaxis se realizó incorrectamente. Las causas fueron: 21,8 por ciento administración después de la incisión; 15,6 por ciento cirugía larga sin 2ª dosis; 3,1 por ciento administración después de la incisión y cirugía larga sin 2ª dosis; 4,7 por ciento antibiótico inadecuado; 2,7 por ciento administración después de la incisión y dosis inadecuada; 1,9 por ciento dosis inadecuada; 0,8 por ciento antibiótico inadecuado y administración después de la incisión; 0,4 por ciento 2ª dosis tarde; 0,4 por ciento cirugía larga sin 2ª dosis y dosis inadecuada. DISCUSIÓN: Existe un alto porcentaje de incumplimiento relacionado con la administración tardía del antibiótico y la no administración de una segunda dosis en cirugías de larga duración .CONCLUSIÓN: Para mejorar el bajo nivel de cumplimiento y evitar la administración tardía del antibiótico proponemos al anestesiólogo como responsable de la antibiótico profilaxis, así como la evaluación directa en quirófano para detectar este tipo de error (AU)