RESUMEN
This article deals with anesthesia for patients receiving ECT for a variety of mood disorders. It includes indications, contraindications, patient selection, workflow, anesthetic management, and postprocedure complications of electroconvulsive therapy.
Asunto(s)
Anestesia/métodos , Terapia Electroconvulsiva/métodos , Manejo de la Vía Aérea , Anestesia/efectos adversos , Anestésicos/farmacología , Humanos , Trastornos del Humor/fisiopatología , Trastornos del Humor/terapia , Cuidados PosoperatoriosRESUMEN
PURPOSE OF REVIEW: Procedures are increasingly being performed in the acute care setting, outside of the operating rooms (OR). This article aims to review the current literature on out-of-OR procedural sedation with a focus on the ICU and emergency department, highlighting the following topics: multidisciplinary team approach, choice of pharmacologic agent, sedation scales, current safety guidelines, anticipating complications, appropriate monitoring and necessary resources. RECENT FINDINGS: Subjective assessment of sedation using sedation scales is controversial. Addition of ketamine and dexmedetomidine to propofol for sedation improves patient and proceduralist satisfaction. The short-acting benzodiazepine remimazolam shows promise in initial phase 2 trials. Use of capnography for monitoring during sedation is being challenged by new literature from the emergency department setting. Hypoxia is the most common adverse event with procedural sedation, and the risk of pulmonary aspiration is low. SUMMARY: Multimodal/synergistic sedation under a multidisciplinary team provides the best patient satisfaction. Collection and analysis of physiological data and outcomes of patients undergoing procedural sedation is necessary to maintain compliance with regulatory bodies. There is a paucity of comprehensive guidelines for conducting research in procedural sedation; therefore, it is being currently addressed by the Sedation Consortium.
Asunto(s)
Sedación Consciente/métodos , Cuidados Críticos/métodos , Servicios Médicos de Urgencia/métodos , Servicio de Urgencia en Hospital/organización & administración , Unidades de Cuidados Intensivos/organización & administración , Sedación Consciente/efectos adversos , Humanos , Cuidados IntraoperatoriosRESUMEN
Glucagon is well acknowledged as a sphincter of Oddi relaxant for both diagnostic and therapeutic uses in choledocholithiasis, and an empiric treatment for ß-blocker overdose. Although it has been implicated in inducing cardiovascular crises in patients with asymptomatic pheochromocytoma, adverse effects in other patient populations have not been characterized. This case report describes a patient with hypertension controlled on ß blockers who, after glucagon administration during an intraoperative cholangiography, experienced hypertensive emergency despite adequate pain control. Nitroglycerin acted as a key agent to decrease the patient's blood pressure as well as a secondary relaxant of the sphincter of Oddi. The patient had no radiographic evidence of pheochromocytoma. As out-of-operating room and intraoperative uses of glucagon continue to increase, perioperative physicians should be aware of its potential hemodynamic effects even in healthy populations.
Asunto(s)
Fármacos Gastrointestinales/efectos adversos , Glucagón/efectos adversos , Hipertensión/inducido químicamente , Antihipertensivos/uso terapéutico , Urgencias Médicas , Femenino , Humanos , Hidralazina/uso terapéutico , Hipertensión/tratamiento farmacológico , Labetalol/uso terapéutico , Persona de Mediana Edad , Nitroglicerina/uso terapéutico , Vasodilatadores/uso terapéuticoRESUMEN
Administration of carbon monoxide derived from carbon monoxide-releasing molecules has been demonstrated to enhance coagulation in vitro at small concentrations (100-200âµmol/l) in human and rabbit plasma. We sought to determine if carbon monoxide-releasing molecule-2 [tricarbonyldichlororuthenium (II) dimer, CORM-2] would improve coagulation in rabbit plasma in vitro via thrombelastography and in an in vivo preclinical rabbit model of ear bleeding time following administration of clopidogrel (20âmg/kg) with aspirin (10âmg/kg) via gavage. Addition of 100âµmol/l CORM-2 to rabbit plasma significantly improved coagulation. This procoagulant effect was blocked by pre-exposure of plasma to an agent that converts hemefibrinogen to methemefibrinogen in human plasma, preventing carbon monoxide binding and enhancement of coagulation. Rabbit ear bleeding time was 5.8â±â1.1âmin 2-3âh after clopidogrel/aspirin administration. Bleeding time significantly decreased to 2.6â±â0.6âmin, 5âmin after administration of CORM-2 (10âmg/kg; 279âµmol/l 'best-case' instantaneous concentration) intravenously. CORM-2 enhances plasmatic coagulation in a manner similar to that of human plasma in vitro, and plasmatic coagulation is enhanced in vivo by CORM-2 as well. Additional preclinical investigation of the effects of CORM-2 on coagulopathy (e.g. heparin or hemodilution mediated) utilizing this rabbit model is planned.
Asunto(s)
Coagulación Sanguínea/efectos de los fármacos , Monóxido de Carbono/metabolismo , Hemorragia/sangre , Compuestos Organometálicos/farmacología , Plasma/metabolismo , Administración Oral , Animales , Aspirina/farmacología , Tiempo de Sangría , Coagulación Sanguínea/fisiología , Clopidogrel , Fibrinolíticos/farmacología , Hemorragia/tratamiento farmacológico , Inyecciones Intravenosas , Masculino , Compuestos Organometálicos/metabolismo , Inhibidores de Agregación Plaquetaria/farmacología , Conejos , Tromboelastografía , Ticlopidina/análogos & derivados , Ticlopidina/farmacologíaRESUMEN
Children < or =18 years with malignant proptosis enrolled in ophthalmic tumor clinic at a tertiary cancer center from July 2003 to December 2006 were retrospectively analyzed. The incidence of proptosis among the pediatric cancer patients was 4.9%. Secondary tumors accounted for majority of cases (n=62, 59.6%) with retinoblastoma (51%) being the commonest cause of proptosis. Fourteen (13.5%) patients presented with bilateral proptosis; all but one had metastatic tumor as underlying cause. Metastatic malignancies had significantly lower hemoglobin and platelet count and higher white blood count. Therefore, careful analysis of symptomatology, hemogram, and those with bilateral proptosis warrant a hematologic work-up before imaging studies and invasive orbital biopsy.