Anestesia en neurorradiología intervencionista / Anesthesia in interventional neuroradiology

Los procedimientos que se realizan en neurorradiologíaintervencionista son cada vez más complejos por loque deben estar bien planificados y coordinados. Elanestesiólogo junto con el radiólogo, técnicos y enfermerasjuega un papel fundamental. Con esta revisión sepretende analizar el papel del anestesiólogo en estos procedimientosdesde el inicio hasta su manejo en el postoperatorioinmediato. En primer lugar debe garantizar laseguridad en el transporte, mantener la vía aérea, conseguirla inmovilidad del paciente, controlar la estabilidadhemodinámica, manejar la anticoagulación y la antiagregacióny asegurar un despertar rápido para valorarneurológicamente al paciente in situ. Así mismo, deberátratar las posibles complicaciones cerebrales durante losprocedimientos que pueden llegar a ser emergencias (AU)

Interventional neuroradiology procedures havebecome increasingly complex, requiring planning andcoordination. Key roles are played by the anesthesiologistand the radiologist, as well as by technicians and nurses.This review aims to analyze the anesthesiologist’s part inmanaging these procedures, from the start of theintervention through the immediate postoperativeperiod. First concerns are to assure patient safety duringtransfer, maintain the airway, keep the patient immobileand hemodynamically stable, and manage anticoagulantand antiplatelet treatments. Rapid awakening must alsobe assured so that the patient’s neurologic status can beassessed in situ. The anesthesiologist should treat anyneurologic complications that develop and that mightlead to emergency situations during the procedures (AU)

Sedación profunda con propofol y alfentanilo en punción folicular vía transvaginal para técnicas de fecundación in vitro / Deep sedation with Propofol and Alfentanyil in transvaginal oocyte retrieval for in vitro fertilization techniques

INTRODUCCIÓN Y OBJETIVO: Se han utilizado múltiples técnicas anestésicas para la punción folicular vía transvaginal guiada por ecografía. Se han asociado diferentes riesgos a este procedimiento y a su tratamiento anestésico. El propósito del estudio es evaluar tiempos de recuperación e incidencia de complicaciones postoperatorias, principalmente náuseas y vómitos, tras el uso de la sedación profunda con Propofol y Alfentanilo. MATERIAL Y MÉTODOS: Cincuenta y seis mujeres, ASA I-II, se sometieron a anestesia i.v. usando Alfentanilo 0,5-1 mg y Propofol 2-2,5 mg para la inducción y Propofol en bolus de 0,5 mg/kg para el mantenimiento. Se registraron episodios de náuseas y vómitos postoperatorios (antes del alta y durante 24h), requerimientos analgésicos, tiempo de recuperación y otras complicaciones. RESULTADOS: Ninguna de las pacientes presentó espisodios eméticos y se registraron náuseas en el 3,57%. El 42,9% de las pacientes no precisó analgesia postoperatoria y solamente 2 pacientes (3,6%) necesitario 3 fármacos para controlar el dolor. El tiempo medio de estancia (ingreso-alta) fue de 1h 59 min. No existieron otras complicaciones postoperatorias. CONCLUSIONES: La sedación profunda con propofol y alfentanilo parece segura para la técnica de punción folicular bajo control por ecógrafo transvaginal, sin complicaciones mayores y con un muy bajo índice de náuseas y vómitos postoperatorios, resultando unas estancias medias adecuadas para el proceso (AU)

INTRODUCTION AND OBJECTIVES: Different types of anaesthetic techniques have been described for ultrasound guided trans-vaginal oocyte retrieval. Different factors are associated with this surgery and its anaesthetic management. The purpose of this study was to evaluate the recovery time and the incidence of postoperative complications, mainly nausea and vomiting, after administration of Propofol and Alfentanyl in these procedures. MATERIAL AND METHODS: Fifty six women, ASA I-II, underwent i.v. anaesthesia using 0,5-1 mg Alfentanyl and 2-2.5 mg/Kg Propofol for induction and 0.5mg/Kg Propofol bolus for maintenance. Postoperative episodes of nausea and vomiting (before discharge and during the first 24h), analgesia requirements, recovery time and other complications were recorded. RESULTS: No episodes of vomiting were recorded and nausea occurred only in two cases (3.57%). 42.9% of the patients did not require an a further analgesia, and only two patients (3.57%) needed three analgesics for pain control. Time from admission until discharge was 1h 59 min. No further complications were registered in the study. DISCUSSION: Deep sedation with propofol and alfentanyl seems to be safe for trans-vaginal oocyte retrieval, without important complications, with a very low index of nausea and vomiting episodes and a short post-operative stay for the procedure (AU)

[False low oximetry reading caused by patent blue vital dye during breast surgery]. / Falsa desaturación provocada por colorante durante la cirugía de mama.

Patent blue vital (patent blue V; Laboratoire Guerbet, France) is used to identify the sentinel node during surgery for invasive breast cancer. Detecting the sentinel node that first drains the primary tumor reduces the need for total breast and wide axillary node removal, with the problems that such radical surgery involves. Like other dyes, patent blue V can interfere with accurate pulse oximeter reading, leading to underestimation of real values. We report the case of a 31-year-old woman who underwent lumpectomy and removal of the sentinel node. After intradermal injection of patent blue V dye into the left breast (100 mg administered because the sentinel node was difficult to locate) a drop in peripheral oxyhemoglobin saturation from 99% to 93% was detected by the pulse oximeter. When arterial blood gas analysis showed normal values and other causes were ruled out, the diagnosis was false low oximetry reading due to patent blue V dye.

Bloqueo paravertebral torácico: una excelente alternativa en analgesia regional / Thoracic paravertebral block: an excellent alternative for regional analgesia

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[Obstetrical anesthesia in 15 women with myasthenia gravis]. / Anestesia en 15 gestantes afectadas de miastenia grave.

OBJECTIVES: To report our experience in managing anesthesia during obstetric delivery of women with myasthenia gravis (MG) and to review the anesthetic technique of choice for vaginal or cesarean delivery in such cases. PATIENTS AND METHODS: Fifteen pregnancies in 12 patients were recorded between 1980 and 1996; 14 cases were documented. Disease course during pregnancy, delivery and postpartum, the course of pregnancy, the presence of severe neonatal myasthenia and anesthetic treatment during vaginal or cesarean delivery were analyzed. RESULTS: Improvement in MG was observed in 6 cases. No change was seen in 4 patients and 3 worsened. In one woman generalized MG debuted 15 days after delivery. Two neonates were premature and a third suffered severe neonatal myasthenia. Six vaginal deliveries were aided by forceps; 8 deliveries were by cesarean and 1 fetus was aborted. Lumbar epidural anesthesia was employed in 73.33% (5 vaginal deliveries and 6 cesareans) and general anesthesia in 26.66% (1 abortion, 1 vaginal delivery and 2 cesareans). CONCLUSIONS: Continuous lumbar epidural anesthesia is the technique of choice for vaginal as well as cesarean deliveries. The combination of opioids and local anesthetics is considered particularly beneficial for patients, as it allows the motor blockade to be decreased. General anesthesia is only indicated when there is bulbar involvement. Short-acting non depolarizing agents, among them atracurium Besilate, are the muscle relaxants of choice. Succinylcholine is contraindicated. Thanks to current optimization of anesthetic and recovery techniques and administration of non depolarizing muscle relaxants with neuromuscular monitoring, the prognosis for pregnant MG patients has improved considerably.

Continuous infusion is superior to bolus doses with thoracic paravertebral blocks after thoracotomies.

OBJECTIVES: This study was designed to determine whether a continuous thoracic paravertebral infusion of bupivacaine (continuous TPVI) offers a higher quality of analgesia than a bolus regimen after thoracotomy. DESIGN: A prospective and randomized study. SETTING: It was conducted by an anesthesiology and pain clinic department in a university hospital. PARTICIPANTS: Thirty patients were included in this study. INTERVENTIONS: As postoperative analgesia, the patients received either 20 mL of 0.375% bupivacaine every 6 hours (n = 15; bolus group), or a loading dose of 15 mL of 0.375% bupivacaine, plus an infusion of 5 mL of 0.25% bupivacaine every hour (n = 15; infusion group). MEASUREMENTS AND MAIN RESULTS: Pain intensity was assessed at rest and on movement (coughing) at 0, 1, 4, 10, 20, and 48 hours by means of the visual analog scale. The need for additional rescue analgesia, bupivacaine plasma concentration in the infusion group, blockade level (pinprick), and vital signs were also recorded. There were no significant differences regarding the additional rescue analgesia, vital signs, and pinprick level. However, the pain scores were significantly higher in the bolus group at rest and on movement (p < 0.01). The bupivacaine plasma concentration was low with a Cmax of 1.841 +/- 0.20 micrograms/mL at 15 hours. No systemic toxicity or other side effects were seen. CONCLUSION: Results suggest that continuous TPVI provides better pain control than the bolus regimen after this kind of surgery.

[Anesthesia for thoracoscopy]. / Anestesia en la toracoscopia.

The thoracoscopy is used both for diagnosis and treatment of pleural and lung diseases. We describe our experience in managing anesthesia for such procedures, the number of which is increasing thanks to technical advances. We review 82 thoracoscopic procedures, 48 of which were video assisted. Sixty-two were performed under balanced general anesthesia (GA) with isoflurane, fentanyl and atracurium. Local anesthesia (LA) with fractionated doses of propofol and fentanyl was used in 20 cases. The mean age of patients receiving LA (63 +/- 17 years) was significantly greater (p < 0.05) than those receiving GA (49 +/- 13 years). ASA IV patients were given LA and sedation. Selective bronchial intubation was performed in 46 cases. Complications during surgery were severe hypoxemia (SpO2 < 85%) requiring suspension of selective lung ventilation in 8 cases, moderate hypoxemia (spO2 < 90% and > 85%) in 1 case, coughing in 3 cases and agitation in 1 case. Video-thoracoscopy is a safe technique that is less invasive than conventional thoracotomy. The number of applications is increasing, although its future place in thoracic surgery must still be determined.

Aprotinin versus desmopressin for patients undergoing operations with cardiopulmonary bypass. A double-blind placebo-controlled study.

BACKGROUND: Aprotinin reduces blood loss in operations done with cardiopulmonary bypass, whereas the use of desmopressin remains controversial. We compared aprotinin, desmopressin, and placebo in a double-blind, randomized trial to evaluate bleeding and transfusion requirements. METHODS AND RESULTS: One hundred forty-nine patients (48 received aprotinin, 50 desmopressin, 51 placebo) were included. Blood loss and transfusion requirements were recorded and levels of Factor VIII coagulant activity, von Willebrand's factor, thrombin-antithrombin complexes, and D-dimer were measured. Overall blood loss was 195 +/- 146 ml/m2 in the aprotinin group, 400 +/- 192 ml/m2 in the desmopressin group, and 489 +/- 361 ml/m2 in the placebo group (95% confidence intervals: difference between desmopressin and aprotinin 98 to 312 ml/m2, p < 0.001; difference between placebo and aprotinin 190 to 398 ml/m2, p < 0.001). Twenty-six percent of patients treated with aprotinin, 66% of those treated with desmopressin, and 56% of those treated with placebo were given transfusion (95% confidence intervals: difference between aprotinin versus placebo plus desmopressin 51% to 71%, p < 0.001). Fibrinolytic activation throughout cardiopulmonary bypass was markedly higher with placebo or desmopressin administration. D-dimer level correlated with overall blood loss in patients receiving desmopressin or placebo, but not in those receiving aprotinin. CONCLUSION: Aprotinin administration reduces blood loss and transfusion requirements in cardiopulmonary bypass. This benefit may be explained by a lower activation of fibrinolysis.

[Analgesia of postoperative pain in ambulatory surgery]. / Analgesia del dolor postoperatorio en cirugía ambulatoria.

Although the role of outpatient surgery has become increasingly important in the campaign to reduce waiting lists and health care costs, careful control and treatment of postoperative pain too often receives slight attention. Pain control after surgery must produce high quality analgesia without lengthening the hospital stay or increasing the risk of complications. The risk of side effects must be low, the safety margin wide and administration simple. Anesthesiologists must therefore take preventive measures as well as apply techniques during and after surgery that diminish the intensity of pain and the incidence of nausea or vomiting. Drugs that act in the short term and have few side effects, regional anesthesia (depending on type of operation), non-opioid analgesics and balanced analgesia seem to give good quality control of pain after outpatient surgery.

Heparin-induced thrombocytopenia and heart operation: management with tedelparin.

Anticoagulation for cardiopulmonary bypass in the infrequent clinical setting of thrombocytopenia associated with the use of unfractionated heparin is a very serious problem. We describe a case in which a low-molecular-weight heparin (tedelparin) was selected for this purpose based on a platelet aggregation test, permitting adequate anticoagulation during cardiopulmonary bypass for valve replacement. This case report might help establish an adequate anticoagulation protocol when faced with a patient suffering from this condition.

[Conservative mitral surgery for a tear of the valvular leaflets post-percutaneous mitral commissurotomy]. / Cirugía mitral conservadora por desgarro de velos valvulares poscomisurotomía mitral percutánea.

A case of a 32-year-old woman who developed acute mitral insufficiency after percutaneous mitral dilatation is presented. In spite the fact of having torn both leaflets, successful plastic repair of her valve was performed.

[Thoracic paravertebral blockade: postoperative analgesic effectiveness and plasma concentrations of bupivacaine]. / Bloqueo paravertebral torácico: efectividad analgésica postoperatoria y concentraciones plasmáticas de bupivacaína.

AIMS: To compare the analgesic efficacy of thoracic paravertebral blockade with that of endovenous morphine to measure the plasma levels of bupivacaine and to study the complications derived from both techniques in patients undergoing thoracic or abdominal surgery with unilateral incision. METHODS: Twenty ASA I-II patients allocated to two groups (A and B) of ten patients each were studied. Group A (5 cholecystectomies and 5 thoracotomies) received morphine 0.075 mg/kg i.v. every 3 hours after operation. Group B (5 cholecystectomies and 5 thoracotomies) received thoracic paravertebral blockade 15 ml of 0.37-5% bupivacaine with 1:200.000 adrenaline following tracheal extubation. Analgesia was evaluated according to the visual analogic scale (VAS) with laterality and extension of the blockade being assessed. The plasma levels of bupivacaine were measured by liquid chromatography in 5 patients. Blood pressure, heart rate and respiratory frequency were assessed in both groups. In group B the appearance of pneumothorax or other local complications were noted. The results were statistically analyzed using to the Student's test. RESULTS: The patients in group A presented significantly more pain than those of group B. In these patients analgesia was unilateral. Plasma levels ranged between 0.56 mg/l at 5 minutes of administration and 0.17 mg/l at 240 minutes with a peak of 0.70 mg/l at 10 minutes with all these values being considerably lower those a determined as toxic (2-4 mg/l). No significant differences were found between the values of blood pressure, and cardiac and respiratory frequency of both groups. There were no complications derived from the technique. CONCLUSIONS: Thoracic paravertebral blockade is a very effective postoperative analgesic technique and is superior to that of i.v. morphine in patients undergoing thoracic or unilateral abdominal surgery. Peak plasma levels were much lower than those considered as toxic complications of interest were observed. Therefore, this technique may be considered as an alternative to other blockades such as extradural, interpleural or intercostal.

[Cardiac tamponade: a fatal complication of parenteral nutrition]. / Taponamiento cardíaco: una complicación fatal de la nutrición parenteral.

Several complications are associated with the use of central venous catheters for total parenteral nutrition; cardiac tamponade is one of the most severe. The recent use of flexible materials made of silastic polymeric silicone has great decreased the incidence of this complication, but has not eliminated wholly. We report the case of a patient with fatal cardiac tamponade, while receiving parenteral hyperalimentation trough a silicone central venous catheter placed in the right jugular internal vein, secondary to superior vena cava perforation. The physiopathological mechanisms, precautionary measures and treatment are discussed.