Consideraciones anestésicas en un paciente en tratamiento con disulfiram y naltrexona por alcoholismo crónico / No disponible

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Doppler transcraneal, BIS y entropía como medición indirecta del flujo cerebral durante la anestesia total intravenosa en pacientes pediátricos / Transcranial Doppler ultrasound, bispectral index, and electroencephalographic monitoring of entropy during pediatric total intravenous anesthesia

OBJETIVOS: El Doppler transcraneal (DTC) es una técnica de monitorización no invasiva de la velocidad del flujo sanguíneo cerebral en las principales arterias intracraneales, especialmente las arterias del polígono de Willis. Nuestro propósito es analizar mediante Eco-Doppler pulsado, si durante la anestesia en pediatría, las alteraciones del flujo sanguíneo cerebral (FSC), se corresponden con modificaciones en los valores medidos de índice biespectral (BIS) y entropía [Estado (ES) y Respuesta (ER)]. MATERIAL Y MÉTODOS: Estudio observacional prospectivo y ciego, en 36 pacientes de 5 a 11 años, con anestesia general total intravenosa, para cirugía general menor. Se realizó inducción con propofol y fentanilo. Para el mantenimiento se utilizó propofol y remifentanilo en perfusión continua y cisatracurio. Se monitorizó el patrón hemodinámico y respiratorio, gases administrados, temperatura, patrón de hipnosis (BIS y entropía - ES y ER-), y patrón de FSC estimado (sonografía Doppler pulsada) en la arteria cerebral media. Se realizó un suavizamiento estadístico para el bruto de datos. Se obtuvieron los parámetros de índice de resistencia, índice de pulsatilidad, velocidad media y flujo sanguíneo estimado. Se determinaron correlaciones para los valores de BIS, ES, ER, índice de pulsatilidad, índice de resistencia, velocidad media, flujo sanguíneo estimado, CO2 espirado y temperatura obtenidos. Se determinó la existencia de modelos de regresión. RESULTADOS: La inducción presentó un patrón de alta resistencia (velocidades medias bajas, índices de pulsatilidad elevados) hasta obtener el valor más bajo de BIS y entropía ES (31 y 29). Durante el mantenimiento se presentó un patrón de sonografía más enlentecido (normalización de índice de pulsatilidad, índice de resistencia y velocidad media), existiendo correlación estadística y concordancia entre las modificaciones de flujo y los valores absolutos de Entropía y BIS (–Pearson– r >= ± 0,91. Concordancia Doppler-BIS de 95,6%); coincidentes con valores de BIS y ES de 35-45; y en el despertar, las velocidades de flujo se acercaron a cifras basales cuando los valores de BIS y ES ascendieron (90-98). Se detectaron modificaciones puntuales del FSC estimado coincidentes con elevación o descenso casi concomitante de BIS (r > 0,95), que presentó un ligero retraso no superior al minuto, y que no fueron detectadas de igual modo por entropía. CONCLUSIONES: Proporcionamos los patrones sonográficos durante la anestesia para propofol. Los sistemas de monitorización de hipnosis podrían ser considerados como sistemas indirectos de medición de flujo cerebral (siendo BIS el de mayor sensibilidad). El DTC permitiría objetivar modificaciones de flujo durante la anestesia relacionados con la profundidad de la hipnosis(AU)

BACKGROUND AND OBJECTIVE: Transcranial Doppler ultrasound is a noninvasive technique for monitoring the velocity of blood flow in the main intracranial arteries, particularly those in the circle of Willis. Our aim was to assess whether changes in cerebral arterial blood flow in anesthetized pediatric patients detected by pulsed Doppler ultrasound correlate with changes in the bispectral (BIS) index and electroencephalographic state and response entropy (ES and ER, respectively). MATERIAL AND METHODS: Prospective, blinded observational study of 36 pediatric patients (age range, 5 to 11 years) under total intravenous anesthesia for minor surgical procedures. Propofol and fentanyl were used for induction; propofol and remifentanil in continuous perfusion and a single dose of cisatracurium were used for maintenance. In all patients we monitored hemodynamic and respiratory patterns, gases, temperature, and hypnosis (BIS, ES and ER) as well as cerebral blood flow estimated by pulsed Doppler ultrasound in the middle cerebral artery. Raw data were subjected to statistical smoothing. The resistance index, pulsatility index, mean velocity, and estimated baseline cerebral blood flow were calculated from the Doppler sonogram. We then studied the correlations between the Doppler-derived values and BIS, ES, ER, fraction of end-tidal carbon dioxide, and temperature. The variables were entered into logistic regression. RESULTS: The pattern at induction indicated high resistance (low mean velocities and high pulsatility indexes) until the lowest BIS and ES values of 31 and 29, respectively, were reached. During maintenance, the Doppler sonogram pattern was slower (normalization of the pulsatility index, the resistance index, and mean velocity). Changes in flow and absolute entropy and BIS values were statistically correlated (Pearson’s r values >= 0.91); there was 95.6% agreement between Doppler values and BIS and agreement between BIS and ES values of 35-45. On awakening, flow velocities approached baseline values when BIS and ES rose to between 90 and 98. The estimated cerebral blood flow underwent fluctuations coinciding with an approximately concomitant increase or decrease in BIS (r > 0.95); the response of BIS was slightly delayed by no more than a minute but there was no corresponding response of entropy measurements. CONCLUSIONS:We report Doppler ultrasound patterns during anesthesia with propofol. Systems for monitoring hypnosis could be considered indirect measurements of cerebral blood flow; BIS measurements are more sensitive to flow change. Transcranial Doppler ultrasound facilitates the observation of changes in blood flow that occur at different levels of hypnosis during anesthesia(AU)

[Transcranial Doppler ultrasound, bispectral index, and electroencephalographic monitoring of entropy during pediatric total intravenous anesthesia]. / Doppler transcraneal, BIS y entropía como medición indirecta del flujo cerebral durante la anestesia total intravenosa en pacientes pediátricos.

BACKGROUND AND OBJECTIVE: Transcranial Doppler ultrasound is a noninvasive technique for monitoring the velocity of blood flow in the main intracranial arteries, particularly those in the circle of Willis. Our aim was to assess whether changes in cerebral arterial blood flow in anesthetized pediatric patients detected by pulsed Doppler ultrasound correlate with changes in the bispectral (BIS) index and electroencephalographic state and response entropy (ES and ER, respectively). MATERIAL AND METHODS: Prospective, blinded observational study of 36 pediatric patients (age range, 5 to 11 years) under total intravenous anesthesia for minor surgical procedures. Propofol and fentanyl were used for induction; propofol and remifentanil in continuous perfusion and a single dose of cisatracurium were used for maintenance. In all patients we monitored hemodynamic and respiratory patterns, gases, temperature, and hypnosis (BIS, ES and ER) as well as cerebral blood flow estimated by pulsed Doppler ultrasound in the middle cerebral artery. Raw data were subjected to statistical smoothing. The resistance index, pulsatility index, mean velocity, and estimated baseline cerebral blood flow were calculated from the Doppler sonogram. We then studied the correlations between the Doppler-derived values and BIS, ES, ER, fraction of end-tidal carbon dioxide, and temperature. The variables were entered into logistic regression. RESULTS: The pattern at induction indicated high resistance (low mean velocities and high pulsatility indexes) until the lowest BIS and ES values of 31 and 29, respectively, were reached. During maintenance, the Doppler sonogram pattern was slower (normalization of the pulsatility index, the resistance index, and mean velocity). Changes in flow and absolute entropy and BIS values were statistically correlated (Pearson's r values > or = 0.91); there was 95.6% agreement between Doppler values and BIS and agreement between BIS and ES values of 35-45. On awakening, flow velocities approached baseline values when BIS and ES rose to between 90 and 98. The estimated cerebral blood flow underwent fluctuations coinciding with an approximately concomitant increase or decrease in BIS (r > 0.95); the response of BIS was slightly delayed by no more than a minute but there was no corresponding response of entropy measurements. CONCLUSIONS: We report Doppler ultrasound patterns during anesthesia with propofol. Systems for monitoring hypnosis could be considered indirect measurements of cerebral blood flow; BIS measurements are more sensitive to flow change. Transcranial Doppler ultrasound facilitates the observation of changes in blood flow that occur at different levels of hypnosis during anesthesia.

Manejo anestésico de un paciente con displasia arritmogénica de ventrículo derecho, ascitis y colitis ulcerosa para una cirugía abdominal mayor / Patient with right ventricular arrhythmogenic dysplasia, ascites and ulcerative colitis: anesthetic management during major abdominal surgery

Presentamos el caso de un varón de 43 años con colitis ulcerosa y displasia arritmogénica de ventrículo derecho con deterioro de la función ventricular y portador de un desfibrilador automático implantable programado para pancolectomía por transformación adenomatosa de pólipos de colon. Se discuten aspectos básicos sobre la displasia arritmogénica de ventrículo derecho, su manejo y monitorización de cara a una cirugía mayor abdominal y el manejo perioperatorio de un enfermo con un desfibrilador automático implantable, con especial atención a la influencia de las interferencias electromagnéticas que pueden alterar su funcionamiento en un contexto quirúrgico. Por último se detallan los datos de la historia de un enfermo asintomático que deben hacer sospechar la presencia de una displasia arritmogénica de ventrículo derecho

A 43-year-old man with ulcerative colitis was scheduled for pancolectomy owing to adenomatous transformation of polyps. The patient had right ventricular arrhythmogenic dysplasia, with deteriorating ventricular function, and carried an automatic implantable defibrillator. We discuss the general features of arrhythmogenic right ventricular dysplasia and its implications for management and monitoring during major abdominal surgery. Perioperative management of a patient with an implantable defibrillator is also discussed, with special attention to the influence of electromagnetic interference that can affect how the device functions during surgery. Finally, we list signs that should lead to suspicion of arrhythmogenic right ventricular dysplasia in an asymptomatic patient

[Assessing preoperative use of medicinal plants during preanesthetic interviews]. / Valoración del consumo preoperatorio de plantas medicinales en la consulta preanestésica.

OBJECTIVES: To assess the use of medicinal plant preparations in preanesthetic interviews at a Spanish university hospital. MATERIALS AND METHODS: A total of 500 questionnaires were randomly distributed over a period of 3 months to patients attending a preanesthetic assessment interview. RESULTS: Of the 431 valid questionnaires returned, 154 (35.73%) were from patients who reported consumption of some type of herbal remedy and 55 (12.76%) were from patients who used a medicinal plant considered in the literature to be potentially toxic. Consumption was higher among women (64.28%) (P < 0.001). Among users of these plants, 137 (88.96%) reported that they did not consider them to be medications and 141 (91.55%) would not have told the anesthesiologist about their use during a routine clinical interview. CONCLUSION: There is considerable use of medicinal herbs with potentially adverse interactions with various drugs used during the perioperative period. Anesthesiologists need to be familiar with such herbs and their effects and to ask specific questions about their use during the preanesthetic interview.

Valoración del consumo preoperatorio de plantas medicinales en la consulta preanestésica / Assesing preoperative use of medicinal plants during preanesthetic interviews

OBJETIVOS: Valorar el consumo de plantas medicinales en la consulta preanestésica de un hospital universitario español. MATERIAL Y MÉTODOS: Durante tres meses se llevaron a cabo un total de 500 encuestas repartidas de forma aleatoria en pacientes que acudían a consulta para valoración preanestésica RESULTADOS: De las 431 encuestas válidas, 35,73 % (154) de los pacientes encuestados afirmaron estar consumiendo algún tipo de planta medicinal y el 12,76% (55) afirmaron estar consumiendo alguna planta medicinal recogida en la bibliografía consultada como potencialmente tóxica. El consumo fue mayor en mujeres 64,28% (P<0,001). De los consumidores, 88,96% (137) no consideraban a las plantas medicinales como medicamentos y el 91,55% (141) no habría informado al anestesiólogo de su consumo durante una entrevista clínica rutinaria. CONCLUSIÓN: En la muestra estudiada el consumo de plantas medicinales con potenciales efectos adversos e interacciones farmacológicas con distintos fármacos utilizados habitualmente durante el periodo perioperatorio es importante. Es necesario que los anestesiólogos conozcan dichas plantas medicinales y sus efectos, e interroguen de forma específica sobre su consumo durante la consulta preanestésica

OBJECTIVES: To assess the use of medicinal plant preparations in preanesthetic interviews at a Spanish university hospital. MATERIALS AND METHODS: A total of 500 questionnaires were randomly distributed over a period of 3 months to patients attending a preanesthetic assessment interview. RESULTS: Of the 431 valid questionnaires returned, 154 (35.73%) were from patients who reported consumption of some type of herbal remedy and 55 (12.76%) were from patients who used a medicinal plant considered in the literature to be potentially toxic. Consumption was higher among women (64.28%) (P<0.001). Among users of these plants, 137 (88.96%) reported that they did not consider them to be medications and 141 (91.55%) would not have told the anesthesiologist about their use during a routine clinical interview. CONCLUSION: There is considerable use of medicinal herbs with potentially adverse interactions with various drugs used during the perioperative period. Anesthesiologists need to be familiar with such herbs and their effects and to ask specific questions about their use during the preanesthetic interview

[Patient with right ventricular arrhythmogenic dysplasia, ascites and ulcerative colitis: anesthetic management during major abdominal surgery]. / Manejo anestésico de un paciente con displasia arritmogénica de ventrículo derecho, ascitis y colitis ulcerosa para una cirugía abdominal mayor.

A 43-year-old man with ulcerative colitis was scheduled for pancolectomy owing to adenomatous transformation of polyps. The patient had right ventricular arrhythmogenic dysplasia, with deteriorating ventricular function, and carried an automatic implantable defibrillator. We discuss the general features of arrhythmogenic right ventricular dysplasia and its implications for management and monitoring during major abdominal surgery. Perioperative management of a patient with an implantable defibrillator is also discussed, with special attention to the influence of electromagnetic interference that can affect how the device functions during surgery. Finally, we list signs that should lead to suspicion of arrhythmogenic right ventricular dysplasia in an asymptomatic patient.