Observational study of nonogenarians undergoing emergency, non-trauma surgery.

BACKGROUND: Nonagenarian population is growing, and so is the number of them needing emergency surgery. Yet, their treatment is often based on the outcomes of younger patients: although old age is known to be a risk factor for surgery, its level is not clear. This is a prospective, observational study to describe the population. It is aimed at providing quantified scientific evidence of the current procedures and their outcomes. METHODS: All non-traumatic nonagenarians who underwent surgery between July 2006 and September 2010 in our University Hospital were recruited and followed up over a month after discharge. A descriptive statistical analysis was performed. RESULTS: Of the approximately 12 660 surgical emergencies, 102 were nonagenarians: 69.6% were women, who mostly had an ASA score III (62.7%). Perioperative morbidity and mortality rates of 61.6% [95% confidence interval (CI): 52.33-71.19%] and 35.3% (95% CI: 26.01-44.57%), respectively, were found statistically associated with preoperative neoplasms. The most frequent causes of surgery were acute limb arterial thrombosis (20), incarcerated hernia (17), and bowel occlusion (14). Confusion, renal failure, and abdominal problems accounted for the most frequent causes of morbidity. Among them, abdominal complications, cardiogenic pulmonary oedema, aspiration, stroke, and renal failure were associated with mortality. CONCLUSIONS: The study gave scientific support and actual figures to many intuitive beliefs: morbidity and mortality are high and are associated with many preoperative comorbidities. All this, combined with an already reduced life expectancy, and a presumably low physiological reserve makes these patients particularly vulnerable to emergency surgery.

[Neuromuscular block management during general anesthesia in a cohort of 1545 patients: a multicenter study]. / Estudio multicéntrico sobre el manejo del bloqueo neuromuscular durante la anestesia general en una cohorte de 1.545 pacientes.

BACKGROUND AND OBJECTIVE: Neuromuscular blockers (NMBs) have traditionally been thought to increase the risk of respiratory complications, although drawing conclusions in this respect would require complex studies in large patient samples. The aim of this study was to analyze data from the ARISCAT study to obtain an overall picture of how NMBs are being used and blocks are reversed in Catalonia, Spain. MATERIAL AND METHODS: NMB use as reflected in data from the ARISCAT study was analyzed. Case information from the database was organized into 4 groups: for patients not receiving a NMB (No-NMB), patients whose NMB block was performed with succinylcholine alone (SC), patients who received a single dose of a nondepolarizing NMB (SD-NMB), and patients who received additional doses of a nondepolarizing NMB or a continuous perfusion (AD-NMB). We analyzed patient characteristics, clinical and surgical characteristics, and complications during and after surgery in each of the groups. Variables were also analyzed according to whether the NMB effect had to be reversed. RESULTS: Of the 2991 patients included in the ARISCAT study, 1545 received general or combined anesthesia. Of the 1545 patients, 1267 (89%) received a NMB and the block was reversed with an anticholinesterase agent in 54%. The group distribution was as follows: No-NMB, 103 patients; SC, 31; SD-NMB, 527; and AD-NMB, 709. The highest rate of comorbidity, longest duration of surgery, highest rate of complications during and after surgery, and the longest hospital stays were observed in the last of the 4 groups (AD-NMB). Reversion was required significantly more often after cardiothoracic and upper abdominal surgical procedures; the complication rates after those 2 types of surgery were statistically similar. CONCLUSIONS: Nondepolarizing NMBs are used in combination with general anesthesia often in Catalonia; their use is associated with duration and type of surgery. A reversal drug is administered relatively more often in Catalonia than in other geographic areas.

[Fetoscopic tracheal occlusion for the treatment of severe congenital diaphragmatic hernia: preliminary results]. / Oclusión traqueal fetoscópica (FETO) para el tratamiento de la hernia diafragmática congénita severa: resultados preliminares.

OBJECTIVES: To evaluate survival and lung growth in fetuses with severe congenital diaphragmatic hernia (CDH) treated with fetoscopic tracheal occlusion (FETO) compared with control fetuses and to analyze possible complications of the anesthetic techniques used. PATIENTS AND METHODS: This prospective study was performed on fetuses with CDH. FETO was undertaken before the 29th week of gestation on fetuses with a lung-to-head ratio (LHR) less than 1. FETO was not performed on fetuses with an LHR between 1.0 and 1.5 or those with an LHR less than 1 where consent was not given. Lung growth was monitored by means of LHR. FETO was performed under fetal intramuscular anesthesia and maternal epidural anesthesia and sedation with remifentanil. RESULTS: Seventeen fetuses were included in the study. FETO was performed on 11 fetuses and was effective in 9. The median percentage difference between LHR at diagnosis and prior to FETO was 1.15% (P=.183); between diagnosis and before removing the balloon, the difference was 130.5% (P=.003); and between diagnosis and before delivery, 90.18% (P=.003). In the control group (n=6), the median percentage difference between LHR at diagnosis and before delivery was 49.25% (P=.028). No significant hemodynamic or respiratory changes occurred in either mother or fetus during fetoscopy. All the fetuses in the control group died; 45.5% of those in the FETO group survived. CONCLUSIONS: The use of FETO in cases of CDH appears to increase survival and lung growth. Fetal anesthesia in association with maternal epidural anesthesia and sedation makes it possible to place and remove the endotracheal balloon via fetoscopy with acceptable maternal comfort and without notable complications.

[Anesthetic management of sacroiliac-vertebral echinococcosis]. / Manejo anestésico de la hidatidosis sacroilíaca-vertebral.

Bone echinococcosis affects the spine and pelvis in 60% of cases. Bone lesions may be silent for between 10 and 20 years. The capsules progress aggressively through the medullary canal and replace the trabecular bone without forming cysts, as occurs in the organs, thus making anaplylaxis rare. The combination of chemotherapy and surgery facilitates anesthetic management and reduces the incidence of anaphylactic events and disease recurrence.

Manejo anestésico de la hidatidosis sacroilíaca-vertebral / Anesthetic management of sacroiliac-vertebral echinococcosis

La hidatidosis afecta a la columna y a la pelvis en un60% de los casos, las lesiones en el hueso pueden estarsilentes de 10 a 20 años. Las vesículas progresan agresivamentepor el canal endomedular y sustituyen a las trabéculasóseas sin formar quistes como en las vísceras,por lo que la posibilidad de anafilaxia es rara. La combinaciónde quimioterapia y cirugía facilita el manejoanestésico, reduciendo la incidencia de reacciones anafilácticasy las recidivas de la enfermedad (AU)

Bone echinococcosis affects the spine and pelvis in60% of cases. Bone lesions may be silent for between 10and 20 years. The capsules progress aggressivelythrough the medullary canal and replace the trabecularbone without forming cysts, as occurs in the organs, thusmaking anaplylaxis rare. The combination ofchemotherapy and surgery facilitates anestheticmanagement and reduces the incidence of anaphylacticevents and disease recurrence (AU)

Oclusión traqueal fetoscópica (FETO) para el tratamiento de lahernia diafragmática congénita severa: resultados preliminares / Fetoscopic tracheal occlusion for the treatment of severe congenital diaphragmatic hernia: preliminary results

OBJETIVOS: Evaluar la supervivencia y crecimientopulmonar de fetos con hernia diafragmática congénitasevera (HDCs) tratados con oclusión traqueal fetoscópica(FETO) comparado con aquellos en que no se realizóy analizar posibles complicaciones de las técnicas anestésicas.PACIENTES Y MÉTODOS: Estudio prospectivo en fetoscon HDCs. FETO fue realizada antes de la 29 SG a fetoscon un lung head ratio (LHR) < 1. No se realizó FETO alos pacientes con LHR entre 1,0 y 1,5 o con LHR<1 queno dieron consentimiento. El crecimiento pulmonar fuemonitorizado con el LHR. Las fetoscopias se realizaronbajo anestesia intramuscular fetal asociada a anestesiaepidural y sedación materna con remifentanilo.RESULTADOS: Se incluyeron 17 fetos. En 11 se realizóFETO que fue efectiva en 9, la mediana de la diferenciade porcentajes del LHR respecto al diagnóstico fue1,15% (p = 0,183) previamente FETO, 130,5% (p =0,003) antes de retirar el balón y 90,18% (p = 0,003)antes del parto. En los “no FETO” (n=6) la diferencia deporcentajes del LHR antes del parto respecto al diagnósticofue 49,25% (p = 0,028). Durante las fetoscopiasno se produjeron cambios significativos hemodinámicoso respiratorios maternos ni fetales. En el grupo "FETO" 45,5% sobrevivieron mientras que en el "no FETO" todos murieron. CONCLUSIONES: FETO en la HDCs parece aumentar lasupervivencia y el crecimiento pulmonar. La anestesiafetal asociada a anestesia epidural y sedación maternapermiten colocar y retirar el balón endotraqueal fetoscópicamentecon buena confortabilidad materna sin complicacionesimportantes (AU)

OBJECTIVES: To evaluate survival and lung growth infetuses with severe congenital diaphragmatic hernia(CDH) treated with fetoscopic tracheal occlusion(FETO) compared with control fetuses and to analyzepossible complications of the anesthetic techniques used.PATIENTS AND METHODS: This prospective study wasperformed on fetuses with CDH. FETO was undertakenbefore the 29th week of gestation on fetuses with a lungto-head ratio (LHR) less than 1. FETO was notperformed on fetuses with an LHR between 1.0 and 1.5or those with an LHR less than 1 where consent was notgiven. Lung growth was monitored by means of LHR.FETO was performed under fetal intramuscularanesthesia and maternal epidural anesthesia andsedation with remifentanil.RESULTS: Seventeen fetuses were included in thestudy. FETO was performed on 11 fetuses and waseffective in 9. The median percentage difference betweenLHR at diagnosis and prior to FETO was 1.15%(P=.183); between diagnosis and before removing theballoon, the difference was 130.5% (P=.003); andbetween diagnosis and before delivery, 90.18% (P=.003).In the control group (n=6), the median percentagedifference between LHR at diagnosis and before deliverywas 49.25% (P=.028). No significant hemodynamic orrespiratory changes occurred in either mother or fetusduring fetoscopy. All the fetuses in the control groupdied; 45.5% of those in the FETO group survived. CONCLUSIONS: The use of FETO in cases of CDHappears to increase survival and lung growth. Fetalanesthesia in association with maternal epidural anesthesiaand sedation makes it possible to place and remove theendotracheal balloon via fetoscopy with acceptablematernal comfort and without notable complications (AU)

[Comparison of the effect of desflurane with isoflurane in patients over 65 years of age: multicenter study]. / Comparación de los efectos del desflurano con el isoflurano en los pacientes mayores de 65 años: estudio multicéntrico.

OBJECTIVE: To compare the effects of desflurane (DES) and isoflurane (ISO) in patients over 65 years of age based on recovery, hemodynamic variables, need for additional drugs and postoperative rates of nausea and vomiting. PATIENTS AND METHODS: Ninety-eight patients were anesthetized with DES (n = 51) at an inspired concentration of 3% or ISO (n = 47) at a concentration of 0.5%, both combined with 60% nitrous oxide. Anesthetic concentration was later adjusted to maintain hemodynamic variables within 20% above or below baseline. Analgesia was provided with fentanyl and neuromuscular relaxation with atracurium. After surgery, anesthetic gases were withdrawn. We then recorded variables related to anesthetic recovery, postoperative analgesia and the rates of nausea and vomiting. RESULTS: Mean time (+/- SD) until eye opening was 7.6 +/- 5.5 minutes for patients anesthetized with DES and was significantly less than the 14.4 +/- 8.9 minutes taken by patients anesthetized with ISO (p < 0.01). Patients anesthetized with DES spent 23 minutes less time in the recovery room than did patients anesthetized with ISO (p < 0.05). There were no significant differences in need for fentanyl, atracurium, postoperative analgesia, hemodynamic variables or rates of nausea or vomiting. CONCLUSIONS: Patients over 65 years of age anesthetized with DES recovered in half the time of patients anesthetized with ISO. DES is a safe anesthetic for elderly patients and may offer clinical advantages.

[Desflurane: a new inhalation anesthetic]. / Desflurano: un nuevo anestésico inhalatorio.

Desflurane is a new fluoride-only halogenated inhalational anesthetic. It differs from other halogenated anesthetics, in having a lower solubility in all tissues and greater molecular stability in all media. These traits mean, on the one band, that desflurane affords rapid achievement of depth of anesthesia, recovery and management during surgery, and on the other, that its potential toxicity is low and that it is safe for use in low flow circuits. The pharmacodynamic effects of desflurane are similar to those of isoflurane in the blood stream, airways and brain. Sympathetic hyperactivity with increased heart rate and arterial pressure may be triggered when concentration is increased quickly, but this effect is partially abolished when fentanyl is administered. Induction of anesthesia with desflurane causes irritation of the airways, particularly in children, and its use in pediatric surgery is therefore inadvisable. Desflurane potentiates the action of neuromuscular relaxants, much like isoflurane. Desflurane represents a step forward in the search for the ideal anesthetic.

[Orthotopic liver transplant for giant cavernous hemangioma and Kasabach-Merritt syndrome]. / Trasplante hepático ortotópico por hemangioma cavernoso gigante y síndrome de Kasabach-Merritt.

We describe the case of a 42-year-old woman with giant cavernous hemangioma and Kasabach-Merritt syndrome. The patient presented with consumption coagulopathy due to intravascular, intratumoral coagulation as revealed by low platelet levels, fibrinogenopenia and an increase in fibrinolysis with high levels of fibrinogen degradation products. She was scheduled to receive an orthotopic liver transplant because of three factors: respiratory distress caused by compression of the diaphragm by the giant tumor; the risk of bleeding caused by spontaneous rupture or trauma; and the presence of Kasabach-Merritt syndrome due to consumption coagulopathy. Before surgery fibrinogen deficit was corrected with 4 units of cryoprecipitates and low platelet level was treated with 10 units of platelets. Coagulopathy during surgery was corrected with fresh plasma (17 units), cryoprecipitates (6 U), aprotinin (1 x 10(6) U/kg) and antithrombin 3 (2000 U). Blood loss was compensated for with 9 units of packed red blood cells. This report describes the procedures used for anesthesia, for prevention of accidental bleeding during surgery, hemodynamic control and preoperative coagulation testing.

[Comparative study of the efficacy and tolerance of propofol and thiopental in induction and in continuous perfusion with neuroleptanesthesia]. / Estudio comparativo de eficacia y tolerancia de propofol con tiopental en la inducción y en perfusión continua con la neuroleptoanestesia.

We have studied 40 ASA I/II patients aged from 18 to 65 years undergoing otorhinolaryngologic surgery of 40-100 minutes of duration. Patients were randomly assigned to two groups. Anesthesia in group I was induced with thiopental, 4 mg/kg and maintained with N2O at 66% and a variable perfusion of fentanyl. In group II, anesthesia was induced with propofol, 2.5 mg/kg and maintained with a perfusion of 6-12 mg/kg/hour and an initial perfusion of fentanyl, 4 micrograms/kg/hour. Loss of consciousness occurred in 37.49 +/- 9.78 seconds in group I and in 46.25 +/- 12.62 seconds in group II, with no significant differences. Two minutes after induction, propofol group presented a significant decrease in systolic blood pressure of - 12 mm Hg and both groups presented comparable increases in systolic blood pressure and heart rate during intubation. Five minutes later, systolic blood pressure regained normal values. Maintenance in group II was achieved in a proper fashion with a mean propofol consumption of 9.5 +/- 2.6 mg/kg/hour and fentanyl consumption of 4.94 +/- 2.22 micrograms/kg/hour whereas in group II, with N2O at 66%, the amount of fentanyl required was 6.85 +/- 2.95 micrograms/kg/hour, which was significantly higher. Eye opening from the time of interruption of anesthetics was achieved at 6.6 +/- 3.2 minutes in group I and 12.44 +/- 6.34 in group II. Consciousness was regained at 11.25 +/- 3.96 and 16.87 +/- 6.95 minutes, respectively. Pain on injection occurred in 15% with propofol and in 10% with thiopental. No patient presented major complications nor phlebitis after administration of the anesthetic.

[Myasthenia gravis: thymectomy. Muscle relaxation with atracurium besilate]. / Miastenia grave: timectomía. Relajación muscular con besilato de atracurio.

We have carried out a prospective study on the use of the muscle relaxant, atracurium besilate, in 10 patients with myasthenia gravis, seven had type IIB and three had type IIA, who were scheduled for thymectomy, using ED95 0.20 mg/kg, and ten non myasthenic patients undergoing cholecystectomy using ED95 0.50 mg/kg. After monitoring neuromuscular transmission, the time for establishing maximum blockade (EMB), clinical efficacy time (CET), recovery index (RI) and total duration time (TDT) were measured and evaluated comparatively. Results showed that in myasthenics patients, EMB was faster, CET an TDT were more prolonged and RI was higher than in non myasthenic patients. We conclude that atracurium at doses of 0.20 mg/kg is currently the non depolarizing muscle relaxant of choice in myasthenic patients because of the excellent muscle relaxation allowing extubation in the operating room without reverting muscle blockade and not needing ventilatory support during postoperative period.

[Evaluation of the degree of muscle blockade: a comparative study using electromyography of the muscular relaxation induced by pancuronium, atracurium and vecuronium]. / Evaluación del grado de bloqueo muscular: estudio comparativo mediante electromiografía de la relajación muscular provocada por el pancuronio, atracurio y vecuronio.

To compare the muscle relaxing effect of pancuronium, atracurium and vecuronium, 99 patients operated on under neuroleptanesthesia were divided in three groups depending on whether they had received, during induction, pancuronium 0.1 mg/kg, atracurium 0.5 mg/kg, or vecuronium 0.1 mg/kg. One-fourth of the initial dose was repeated if necessary. The electromyographic study of the muscle relaxing effect was carried out with stimulation of the cubital nerve with courses of supramaximal square wave electric stimuli in 'trains of four'. The time to maximal blockade (TMB), the time of clinical effectiveness (TCE), the total duration time (TDT), the time of duration of the maintenance dose (DM 25) and the recovery index (RI) were measured. TMB was 4.3 +/- 1 min for pancuronium, 3.5 +/- 0.8 min for atracurium, and 3.3 +/- 0.98 min for vecuronium. The differences between pancuronium and the other drugs were statistically significant, but they were not so between the latter two. TCE was 67.9 +/- 13.5 min for pancuronium, significantly longer than with vecuronium and atracurium (28.2 +/- 5.7 and 31.5 +/- 4.7, respectively). TDT was 126.2 +/- 19.9 min for pancuronium, 61.2 +/- 11.5 min for atracurium and 55.5 +/- 16.7 for vecuronium. The mean duration of the repeated dose was 52.7 +/- 8.4 min for pancuronium, 19.9 +/- 5 min for vecuronium and 10.9 +/- 5 min for atracurium. RI, which was similar for atracurium and vecuronium (12.7 +/- 1.7 min and 12.8 +/- 3.3 min), was longer for pancuronium (27.7 +/- 4.3 min).