Anestesia neuroaxial en pacientes portadores de dispositivos de derivación de líquido cefalorraquídeo: revisión descriptiva / Neuraxial anaesthesia in patients with cerebrospinal fluid shunts: A descriptive review

La anestesia neuroaxial en pacientes portadores de dispositivos de derivación de líquido cefalorraquídeo (LCR) se ha asociado clásicamente a un alto riesgo de complicaciones. Con el fin de recabar toda la evidencia disponible, se realizó una búsqueda estructurada de los trabajos publicados en usuarios portadores de estos dispositivos, sometidos a algún tipo de técnica neuroaxial para procedimientos obstétricos o quirúrgicos no relacionados con el mismo, valorando la eficacia de la técnica y las complicaciones perioperatorias. Solo se encontraron series de casos y casos clínicos (n = 72). Se identificó uno de insuficiente cobertura anestésica, que precisó una modificación de la técnica, así como una complicación intraoperatoria con compromiso de seguridad para el sujeto. No se describió ningún caso de infección ni disfunciones posoperatorias del dispositivo relacionadas con el método anestésico. La evidencia hallada es escasa y de baja calidad, lo que no permite establecer conclusiones significativas, aunque los pacientes podrían beneficiarse de una valoración individualizada. (AU)

Neuraxial anesthesia in patients with cerebrospinal fluid (CSF) shunt devices has traditionally been associated with a high risk of complications. In order to gather all available evidence, a structured search was conducted to include published studies involving users of these devices, undergoing any form of neuraxial technique for obstetric or surgical procedures unrelated to them. Effectiveness of the technique and perioperative complications were assessed. Only case series and case reports (n = 72) were identified. One patient was found to have insufficient anesthetic coverage, necessitating a modification of the technique, and another one had an intraoperative complication which compromised the subject's safety. No infection events or postoperative device dysfunction related to the anesthetic method were described. The evidence found is scarce and of low quality, preventing the establishment of significant conclusions. Nevertheless, patients may obtain benefit from an individualized evaluation. (AU)

Neuraxial anaesthesia in patients with cerebrospinal fluid shunts: A descriptive review.

Neuraxial anesthesia in patients with cerebrospinal fluid (CSF) shunt devices has traditionally been associated with a high risk of complications. In order to gather all available evidence, a structured search was conducted to include published studies involving users of these devices, undergoing any form of neuraxial technique for obstetric or surgical procedures unrelated to them. Effectiveness of the technique and perioperative complications were assessed. Only case series and case reports (n = 72) were identified. One patient was found to have insufficient anesthetic coverage, necessitating a modification of the technique, and another one had an intraoperative complication which compromised the subject's safety. No infection events or postoperative device dysfunction related to the anesthetic method were described. The evidence found is scarce and of low quality, preventing the establishment of significant conclusions. Nevertheless, patients may obtain benefit from an individualized evaluation.

Manejo anestésico versus seguridad del paciente en tiempos de COVID-19 / Anesthetic management vs patient safety in times of COVID-19

Resumen: La pandemia del COVID-19 ha tenido un impacto significativo en los servicios sanitarios de todo el mundo. Desde el punto de vista anestésico, algunos de los retos clínicos son el alto riesgo del paciente de sufrir complicaciones pulmonares durante el período perioperatorio y el de infección del personal sanitario por la manipulación de la vía aérea y los aerosoles. Se describe la conducta anestésica realizada a una paciente oncológica con PCR para COVID-19 positiva que deseaba preservar su fertilidad antes de comenzar tratamiento oncológico adyuvante y que, según los protocolos establecidos en el momento del caso, se debían demorar las intervenciones no urgentes hasta la negativización de la PCR, lo que conllevaría a retrasar la intervención sin poder comenzar el tratamiento médico para el proceso tumoral, escogiéndose la técnica anestésica más fiable para evitar complicaciones a la paciente y al personal sanitario.

Abstract: The COVID-19 pandemic has had a significant impact on healthcare services worldwide. From the anesthetic point of view, some of the clinical challenges are the high patient risk of pulmonary complications during the perioperative period and the risk of infection of healthcare personnel due to airway and aerosol handling. We describe the anesthetic management of an oncological patient with positive PCR for COVID-19 who wished to preserve her fertility before starting adjuvant oncological treatment and that, according to the protocols established at the time of the case, non-urgent interventions should be delayed until the PCR was negative, which would lead to delaying the intervention without being able to start medical treatment for the tumor process, choosing the most reliable anesthetic technique to avoid complications for the patient and the health personnel.

Analgesia obstétrica en la paciente con síndrome de Stickler: un reporte de caso y revisión de la literatura / Obstetric analgesia in the patient with Stickler syndrome: a case report and review of the literature

Resumen: El síndrome de Stickler tiene una incidencia de uno en 7,500-9,000 recién nacidos. Es una enfermedad del tejido conectivo con patrón de herencia autosómico dominante en la mayoría de los casos, aunque también con patrón recesivo, por afección patogénica de genes procolágeno como COL2A1, COL11A1, entre otros. Cursa con manifestaciones multisistémicas craneofaciales, oculares, auditivas, esqueléticas/articulares y se ha asociado a prolapso de la válvula mitral. Se diferencian tres tipos: tipo I (el más frecuente, 75%) o síndrome de Stickler completo, tipo II o síndrome de Stickler ocular y el tipo III u oto-espóndilo-displasia megaepifisaria. El diagnóstico se realiza al probar las manifestaciones o al demostrar una variante genética patogénica. Respecto al manejo anestésico en la paciente obstétrica, se recomienda evitar la anestesia general. Se presenta el caso de una paciente de 26 años con diagnóstico de síndrome de Stickler tipo I, con embarazo a término y su relación con la anestesia neuroaxial. A pesar de su incidencia, no existe literatura médica acerca del manejo de la anestesia neuroaxial en este tipo de pacientes.

Abstract: Stickler syndrome has an incidence of 1/7.500-9.000 in newborns. It is a connective tissue disease with an autosomal dominant inheritance pattern in most cases, but also with a recessive pattern, due to the pathogenic involvement of procollagen genes such as COL2A1, COL11A1, among others. It is characterized by craniofacial, ocular, auditory and skeletal/joint multisystemic signs and symptoms, and has been associated with prolapse of the mitral valve. Three types are differentiated: type I (the most frequent, 75%) or complete Stickler syndrome, type II or ocular Stickler syndrome and type III or oto-espondilo-megaepiphyseal dysplasia. The diagnosis is made by confirming the signs and symptoms or by verifying the presence of a pathogenic genetic variant. With respect to the anesthetic management in the obstetric patient, it is recommended to avoid general anesthesia. The article illustrates the case of a female patient of 26 years with Stickler syndrome type I and full-term pregnancy, and associated implications for neuroaxial anesthesia. Despite its incidence, there is no medical literature on the management of neuraxial anesthesia in this type of patients.

Motor deficit in the puerperium. Is neuroaxial analgesia the most frequent cause? / Déficit motor en el puerperio. ¿Es la analgesia neuroaxial la causa más frecuente?

Motor deficits of lower limbs during pregnancy and the puerperium are relatively frequent. They are usually attributed to complications which are associated with neuroaxial techniques performed by the anesthesiologist. But there are other possible causes, such as transient osteoporosis of the hips. Transient osteoporosis of pregnancy is a rare and self-limited pathology of unknown etiology. The most severe complication that can occur are pathological fractures, mainly in the load joints. This pathology usually occurs in the third trimester of pregnancy and is showed up with pain and functional impotence of the lower limb affected. We present the case of a 35-year-old woman, 40+3 weeks of pregnancy who starts labour. Normally functioning epidural catheter is placed and finally cesarean section is decided because failure to progress; 48h later the patient begins with functional impotence and pain in the lower left limb. MRI is performed, epidural hematoma is ruled out and osteopenia of the hips is proved. The patient is diagnosed with transient osteoporosis of pregnancy.

Neuraxial anesthesia in patients with multiple sclerosis - a systematic review / Anestesia neuraxial em pacientes com esclerose múltipla - uma revisão sistemática

Abstract Background and objectives: Current guidelines for neuraxial analgesia in patients with multiple sclerosis are ambiguous and offer the clinician only a limited basis for decision making. This systematic review examines the number of cases in which multiple sclerosis has been exacerbated after central neuraxial analgesia in order to rationally evaluate the safety of these procedures. Methods: A systematic literature search with the keywords "anesthesia or analgesia" and "epidural, peridural, caudal, spinal, subarachnoid or intrathecal" in combination with "multiple sclerosis" was performed in the databases PubMed and Embase, looking for clinical data on the effect of central neuraxial analgesia on the course of multiple sclerosis. Results and conclusions: Over a period of 65 years, our search resulted in 37 reports with a total of 231 patients. In 10 patients multiple sclerosis was worsened and nine multiple sclerosis or neuromyelitis optica was first diagnosed in a timely context with central neuraxial analgesia. None of the cases showed a clear relation between cause and effect. Current clinical evidence does not support the theory that central neuraxial analgesia negatively affects the course of multiple sclerosis.

Resumo Justificativa e objetivos: As diretrizes atuais para analgesia neuraxial em pacientes com esclerose múltipla (EM) são ambíguas e oferecem ao clínico apenas uma base limitada para a tomada de decisão. Esta revisão sistemática examina o número de casos nos quais a EM foi exacerbada após analgesia neuraxial central para avaliar racionalmente a segurança desses procedimentos. Métodos: Uma busca sistemática da literatura com as palavras-chave "anestesia ou analgesia" e "epidural, peridural, caudal, espinhal, subaracnóideo ou intratecal" em combinação com multiple sclerosis foi feita nas bases de dados PubMed e Embase à procura de dados clínicos sobre a efeito da analgesia neuraxial central sobre o curso da esclerose múltipla. Resultados e conclusões: Durante um período de 65 anos, nossa busca resultou em 37 relatos com um total de 231 pacientes. Em 10 pacientes, a esclerose múltipla foi agravada e, em nove, a esclerose múltipla ou neuromielite óptica foi diagnosticada pela primeira vez em momento concomitante com a analgesia neuraxial central. Nenhum dos casos apresentou uma clara relação entre causa e efeito. A evidência clínica atual não sustenta a teoria de que a analgesia neuraxial central afeta negativamente o curso da esclerose múltipla.

[Neuraxial anesthesia in patients with multiple sclerosis - a systematic review]. / Anestesia neuraxial em pacientes com esclerose múltipla ­ uma revisão sistemática.

BACKGROUND AND OBJECTIVES: Current guidelines for neuraxial analgesia in patients with multiple sclerosis are ambiguous and offer the clinician only a limited basis for decision making. This systematic review examines the number of cases in which multiple sclerosis has been exacerbated after central neuraxial analgesia in order to rationally evaluate the safety of these procedures. METHODS: A systematic literature search with the keywords "anesthesia or analgesia" and "epidural, peridural, caudal, spinal, subarachnoid or intrathecal" in combination with "multiple sclerosis" was performed in the databases PubMed and Embase, looking for clinical data on the effect of central neuraxial analgesia on the course of multiple sclerosis. RESULTS AND CONCLUSIONS: Over a period of 65 years, our search resulted in 37 reports with a total of 231 patients. In 10 patients multiple sclerosis was worsened and nine multiple sclerosis or neuromyelitis optica was first diagnosed in a timely context with central neuraxial analgesia. None of the cases showed a clear relation between cause and effect. Current clinical evidence does not support the theory that central neuraxial analgesia negatively affects the course of multiple sclerosis.

Pain after major elective orthopedic surgery of the lower limb and type of anesthesia: does it matter? / Dor após cirurgia eletiva ortopédica de grande porte em membro inferior e o tipo de anestesia: isso importa?

Abstract Background and objectives: Total knee arthroplasty and total hip arthroplasty are associated with chronic pain development. Of the studies focusing on perioperative factors for chronic pain, few have focused on the differences that might arise from the anesthesia type performed during surgery. Methods: This was a prospective observational study performed between July 2014 and March 2015 with patients undergoing unilateral elective total knee arthroplasty (TKA) or total hip arthroplasty (THA) for osteoarthritis. Data collection and pain evaluation questionnaires were performed in three different moments: preoperatively, 24 hours postoperatively and at 6 months after surgery. To characterize pain, Brief Pain Inventory (BPI) was used and SF-12v2 Health survey was used to further evaluate the sample's health status. Results: Forty and three patients were enrolled: 25.6% men and 74.4% women, 51,2% for total knee arthroplasty and48.8% for total hip arthroplasty, with a mean age of 68 years. Surgeries were performed in 25.6% of patients under general anesthesia, 55.8% under neuraxial anesthesia and 18.6% under combined anesthesia. Postoperatively, neuraxial anesthesia had a better pain control. Comparing pain evolution between anesthesia groups, neuraxial anesthesia was associated with a decrease in “worst”, “medium” and “now” pain at six months. Combined anesthesia was associated with a decrease of “medium” pain scores at six months. Of the three groups, only those in neuraxial group showed a decrease in level of pain interference in “walking ability”. TKA, “worst” pain preoperatively and general were predictors of pain development at six months. Conclusions: Patients with gonarthrosis and severe pain preoperatively may benefit from individualized pre- and intraoperative care, particularly preoperative analgesia and neuraxial anesthesia.

Resumo Justificativa e objetivos: A artroplastia total de joelho e a artroplastia total de quadril estão associadas ao desenvolvimento de dor crônica. Dentre os estudos que avaliam os fatores perioperatórios para a dor crônica, poucos abordam as diferenças que podem surgir do tipo de anestesia feita durante a cirurgia. Métodos: Estudo observacional, prospectivo, feito entre julho de 2014 e março 2015 com pacientes submetidos à ATJ unilateral eletiva ou ATQ para a osteoartrite. A coleta de dados e a avaliação da dor por meio de questionários foram feitas em três momentos distintos: no pré-operatório, em 24 horas de pós-operatório e aos seis meses após a cirurgia. O Inventário Breve da Dor (IBD) foi usado para caracterizar a dor o e o Questionário SF-12v2 foi usado para avaliar melhor o estado de saúde da amostra. Resultados: Foram inscritos 43 pacientes: 25,6% homens e 74,4% mulheres, 51,2% para ATJ e 48,8% ATQ, com média de 68 anos. A cirurgia foi feita em 25,6% dos pacientes sob anestesia geral, em 55,8% sob anestesia neuroaxial e em 18,6% sob anestesia combinada. No pós-operatório, a anestesia neuraxial apresentou melhor controle da dor. Na comparação da evolução da dor entre os grupos, a anestesia neuraxial foi associada a uma diminuição de “pior”, “médio” e “sem” dor em seis meses. A anestesia combinada foi associada a uma diminuição do escore “médio” de dor em seis meses. Dos três grupos, apenas aqueles no grupo neuraxial apresentaram uma diminuição do nível de interferência da dor na “capacidade de caminhar”. ATJ, “pior” dor no pré-operatório e anestesia geral foram preditivos de desenvolvimento de dor aos seis meses. Conclusões: Os pacientes com gonartrose e dor intensa no pré-operatório podem obter benefício de cuidados individualizados no pré e intraoperatório, particularmente de analgesia no pré-operatório e anestesia neuraxial.

Pain after major elective orthopedic surgery of the lower limb and type of anesthesia: does it matter?

BACKGROUND AND OBJECTIVES: Total knee arthroplasty and total hip arthroplasty are associated with chronic pain development. Of the studies focusing on perioperative factors for chronic pain, few have focused on the differences that might arise from the anesthesia type performed during surgery. METHODS: This was a prospective observational study performed between July 2014 and March 2015 with patients undergoing unilateral elective total knee arthroplasty (TKA) or total hip arthroplasty (THA) for osteoarthritis. Data collection and pain evaluation questionnaires were performed in three different moments: preoperatively, 24 hours postoperatively and at 6 months after surgery. To characterize pain, Brief Pain Inventory (BPI) was used and SF-12v2 Health survey was used to further evaluate the sample's health status. RESULTS: Forty and three patients were enrolled: 25.6% men and 74.4% women, 51,2% for total knee arthroplasty and48.8% for total hip arthroplasty, with a mean age of 68 years. Surgeries were performed in 25.6% of patients under general anesthesia, 55.8% under neuraxial anesthesia and 18.6% under combined anesthesia. Postoperatively, neuraxial anesthesia had a better pain control. Comparing pain evolution between anesthesia groups, neuraxial anesthesia was associated with a decrease in "worst", "medium" and "now" pain at six months. Combined anesthesia was associated with a decrease of "medium" pain scores at six months. Of the three groups, only those in neuraxial group showed a decrease in level of pain interference in "walking ability". TKA, "worst" pain preoperatively and general were predictors of pain development at six months. CONCLUSIONS: Patients with gonarthrosis and severe pain preoperatively may benefit from individualized pre- and intraoperative care, particularly preoperative analgesia and neuraxial anesthesia.

[Pain after major elective orthopedic surgery of the lower limb and type of anesthesia: does it matter?] / Dor após cirurgia eletiva ortopédica de grande porte em membro inferior e o tipo de anestesia: isso importa?

BACKGROUND AND OBJECTIVES: Total knee arthroplasty and total hip arthroplasty are associated with chronic pain development. Of the studies focusing on perioperative factors for chronic pain, few have focused on the differences that might arise from the anesthesia type performed during surgery. METHODS: This was a prospective observational study performed between July 2014 and March 2015 with patients undergoing unilateral elective total knee arthroplasty (TKA) or total hip arthroplasty (THA) for osteoarthritis. Data collection and pain evaluation questionnaires were performed in three different moments: preoperatively, 24hours postoperatively and at 6 months after surgery. To characterize pain, Brief Pain Inventory (BPI) was used and SF-12v2 Health survey was used to further evaluate the sample's health status. RESULTS: Forty and three patients were enrolled: 25.6% men and 74.4% women, 51,2% for total knee arthroplasty and48.8% for total hip arthroplasty, with a mean age of 68 years. Surgeries were performed in 25.6% of patients under general anesthesia, 55.8% under neuraxial anesthesia and 18.6% under combined anesthesia. Postoperatively, neuraxial anesthesia had a better pain control. Comparing pain evolution between anesthesia groups, neuraxial anesthesia was associated with a decrease in "worst", "medium" and "now" pain at six months. Combined anesthesia was associated with a decrease of "medium" pain scores at six months. Of the three groups, only those in neuraxial group showed a decrease in level of pain interference in "walking ability". TKA, "worst" pain preoperatively and general were predictors of pain development at six months. CONCLUSIONS: Patients with gonarthrosis and severe pain preoperatively may benefit from individualized pre- and intraoperative care, particularly preoperative analgesia and neuraxial anesthesia.

Effectiveness of combined regional-general anesthesia for reducing mortality in coronary artery bypass: meta-analysis / Efetividade da associação da anestesia regional à anestesia geral na redução da mortalidade em revascularização miocárdica: metanálise

ABSTRACT BACKGROUND AND OBJECTIVES: Neuraxial anesthesia (NA) has been used in association with general anesthesia (GA) for coronary artery bypass; however, anticoagulation during surgery makes us question the viability of benefits by the risk of epidural hematoma. The aim of this study was to perform a meta-analyzes examining the efficacy of NA associated with GA compared to GA alone for coronary artery bypass on mortality reduction. METHODS: Mortality, arrhythmias, cerebrovascular accident (CVA), myocardial infarction (MI), length of hospital stay (LHS), length of ICU stay (ICUS), reoperations, blood transfusion (BT), quality of life, satisfaction degree, and postoperative cognitive dysfunction were analyzed. The weighted mean difference (MD) was estimated for continuous variables, and relative risk (RR) and risk difference (RD) for categorical variables. RESULTS: 17 original articles analyzed. Meta-analysis of mortality (RD = -0.01, 95% CI = -0.03 to 0.01), CVA (RR = 0.79, 95% CI = 0.32-1.95), MI (RR = 0.96, 95% CI = 0.52-1.79) and LHS (MD = -1.94, 95% CI = -3.99 to 0.12) were not statistically significant. Arrhythmia was less frequent with NA (RR = 0.68, 95% CI = 0.50-0.93). ICUS was lower in NA (MD = -2.09, 95% CI = -2.92 to -1.26). CONCLUSION: There was no significant difference in mortality. Combined NA and GA showed lower incidence of arrhythmias and lower ICUS.

RESUMO INTRODUÇÃO E OBJETIVOS: A anestesia neuroaxial (AN) vem sendo utilizada em associação com a anestesia geral (AG) para revascularização miocárdica, entretanto a anticoagulação durante a cirurgia torna questionável a viabilidade dos benefícios mediante o risco de hematoma de espaço peridural. O objetivo deste estudo foi executar metanálises analisando a efetividade da AN associada à AG comparada à AG isolada para a cirurgia de revascularização miocárdica relativa à redução da mortalidade. MÉTODOS: Foram analisados mortalidade, arritmias, acidente vascular cerebral (AVC), infarto miocárdico (IM), tempo de internação hospitalar (TIH), tempo de internação em unidade de terapia intensiva (TUTI), reoperações, transfusão sanguínea (TS), qualidade de vida, grau de satisfação e disfunção cognitiva pós-opertória. A diferença média (DM) ponderada foi estimada para as variáveis contínuas e risco relativo (RR) e a diferença de risco (DR) para variáveis categóricas. RESULTADOS: Analisados 17 artigos originais. Metanálise da mortalidade (DR = -0,01; IC 95% = -0,03 a 0,01), AVC (RR = 0,79; IC 95% = 0,32 a 1,95), IM (RR = 0,96; IC 95% = 0,52 a 1,79) e TIH (DM = -1,94; IC 95% = -3,99 a 0,12) não demonstraram significância estatística. Arritmia foi menos frequente com AN (RR = 0,68; IC 95% = 0,50 a 0,93). O TUTI foi menor no com AN (DM = -2,09; IC 95% = -2,92 a -1,26). CONCLUSÃO: Não se observaram diferenças estatisticamente significantes quanto a mortalidade. A combinação de AN e AG mostrou menor incidência de arritmias e menor TUTI.

Effectiveness of combined regional-general anesthesia for reducing mortality in coronary artery bypass: meta-analysis.

BACKGROUND AND OBJECTIVES: Neuraxial anesthesia (NA) has been used in association with general anesthesia (GA) for coronary artery bypass; however, anticoagulation during surgery makes us question the viability of benefits by the risk of epidural hematoma. The aim of this study was to perform a meta-analyzes examining the efficacy of NA associated with GA compared to GA alone for coronary artery bypass on mortality reduction. METHODS: Mortality, arrhythmias, cerebrovascular accident (CVA), myocardial infarction (MI), length of hospital stay (LHS), length of ICU stay (ICUS), reoperations, blood transfusion (BT), quality of life, satisfaction degree, and postoperative cognitive dysfunction were analyzed. The weighted mean difference (MD) was estimated for continuous variables, and relative risk (RR) and risk difference (RD) for categorical variables. RESULTS: 17 original articles analyzed. Meta-analysis of mortality (RD=-0.01, 95% CI=-0.03 to 0.01), CVA (RR=0.79, 95% CI=0.32-1.95), MI (RR=0.96, 95% CI=0.52-1.79) and LHS (MD=-1.94, 95% CI=-3.99 to 0.12) were not statistically significant. Arrhythmia was less frequent with NA (RR=0.68, 95% CI=0.50-0.93). ICUS was lower in NA (MD=-2.09, 95% CI=-2.92 to -1.26). CONCLUSION: There was no significant difference in mortality. Combined NA and GA showed lower incidence of arrhythmias and lower ICUS.

[Effectiveness of combined regional-general anesthesia for reducing mortality in coronary artery bypass: meta-analysis]. / Efetividade da associação da anestesia regional à anestesia geral na redução da mortalidade em revascularização miocárdica: metanálise.

BACKGROUND AND OBJECTIVES: Neuraxial anesthesia (NA) has been used in association with general anesthesia (GA) for coronary artery bypass; however, anticoagulation during surgery makes us question the viability of benefits by the risk of epidural hematoma. The aim of this study was to perform a meta-analyzes examining the efficacy of NA associated with GA compared to GA alone for coronary artery bypass on mortality reduction. METHODS: Mortality, arrhythmias, cerebrovascular accident (CVA), myocardial infarction (MI), length of hospital stay (LHS), length of ICU stay (ICUS), reoperations, blood transfusion (BT), quality of life, satisfaction degree, and postoperative cognitive dysfunction were analyzed. The weighted mean difference (MD) was estimated for continuous variables, and relative risk (RR) and risk difference (RD) for categorical variables. RESULTS: 17 original articles analyzed. Meta-analysis of mortality (RD=-0.01, 95% CI=-0.03 to 0.01), CVA (RR=0.79, 95% CI=0.32 to 1.95), MI (RR=0.96, 95% CI=0.52 to 1.79) and LHS (MD=-1.94, 95% CI=-3.99 to 0.12) were not statistically significant. Arrhythmia was less frequent with NA (RR=0.68, 95% CI=0.50 to 0.93). ICUS was lower in NA (MD=-2.09, 95% CI=-2.92 to -1.26). CONCLUSION: There was no significant difference in mortality. Combined NA and GA showed lower incidence of arrhythmias and lower ICUS.

[Infusional therapy: an alternative for shouder pain post-laparoscopy]. / Terapia infusional: una alternativa en dolor de hombro post laparoscopia

INTRODUCTION: Neuraxial anesthesia in upper abdominal laparoscopic surgery decreases perioperative morbidity and mortality. However, shoulder pain is common and difficult to control. Use of a major opioid (e.g., fentanyl) for the control of this event may depress respiratory function. This is why we believe that a safe and effective therapeutic control of this disease pain is a multimodal analgesic scheme which we have called infusional therapy. OBJECTIVE: To compare various schemes for controlling shoulder pain secondary to pneumoperitoneum. METHODS: Nonrandomized clinical trial with 56 patients ASA I-II divided into four groups undergoing laparoscopic cholecystectomy. Group I (n= 15) managed with ketorolac 1 mg kg, group II (n = 12) ketoprofen 100 mg, group III (n = 14) ketoprofen 50 mg + 50 mg tramadol, and group IV (n = 15) ketoprofen 100 mg + 100 mg tramadol. The following ariables were analyzed: presence and intensity of pain, analgesia rescue and operative time. RESULTS: Group I had more shoulder pain events compared to other groups (p= 0.002) in the same way the group IV required less rescue analgesia (p= 0.034). CONCLUSION: preemptive analgesia to infusional therapy with ketoprofen-tramadol at doses of 100 mg each is safe for laparoscopic surgery.

Antecedentes: en cirugía laparoscópica del hemiabdomen superior la anestesia neuroaxial disminuye la morbilidad y mortalidad perioperatorias; sin embargo, el dolor de hombro es una afección frecuente de difícil control. Puesto que los fármacos opioides mayores (fentanilo) para el control del dolor deprimen la función respiratoria, consideramos que la terapia infusional es un tratamiento seguro y eficaz. Objetivo: comparar diversos esquemas analgésicos para el control del dolor de hombro secundario al neumoperitoneo. Material y método: ensayo clínico no aleatorizado, efectuado en 56 pacientes ASA I-II en cuatro grupos con colecistectomía laparoscópica. El grupo I (n= 15) se trató con ketorolaco 1 mg/kg, el grupo II (n= 12) con ketoprofeno 100 mg, el grupo III (n= 14) con ketoprofeno 50 mg más tramadol 50 mg, y el grupo IV (n= 15) con ketoprofeno 100 mg más tramadol 100 mg. Las variables analizadas fueron: dolor y su intensidad, analgesia de rescate y tiempo quirúrgico. Resultados: en el grupo I hubo más episodios de dolor de hombro que en el resto de los grupos (p= 0.002); el grupo IV requirió menos analgesia de rescate (p= 0.034). Conclusión: la analgesia preventiva con terapia infusional con ketoprofeno-tramadol, a dosis de 100 mg, es segura para pacientes intervenidos mediante cirugía laparoscópica.

Miotonía de Thomsen y embarazo, manejo anestésico: reporte de un caso / Myotonia of Thomsen and pregnancy, anesthetic management: a case report

La miotonía de Thomsen es una enfermedad autosómica dominante que consiste en una marcada hipertrofia muscular a predominio en miembros superiores, que se encuentra asociada a una alteración en los canales de cloruro que intervienen en el potencial de acción del músculo esquelético, dicha enfermedad ha sido vinculada con complicaciones anestésicas como episodios de hipertermia maligna. Se presenta el caso de una paciente de 20 años, IIG, IC, con embarazo de 38 semanas, y diagnóstico de miopatía de Thomsen para resolución obstétrica electiva por vía alta. Se discuten los aspectos clínicos de la enfermedad y su manejo anestésico

Thomsen myotonia is a autosomal dominant disease which consists in marked muscular hypertrophy with dominance in the upper limbs associated with disturbance in the chloride channels involved in the skeletal muscle action potential. This disease has been linked with anesthetic complications such as malignant hyperthermia episodes. Is a patient of 20 years old, IIG, IC, with 38 weeks pregnancy, and diagnosis of myopathy of Thomsen for elective obstetrical resolution by cesarean section. The clinical aspects of the disease and its anaesthetic management are discussed

Incidencia de complicaciones en anestesia neuroaxial en el Hospital Maternologico Germán Urquidi / Incidence of neuroaxial anesthesia complicaions at Hospital Maternológico Germán Urquidi

Resumen En nuestro medio no existen datos estadísticos con respecto a las complicaciones de la anestesia neuroaxial, y específicamente en hospitales con residentes en entrenamiento. Durante el año 2007 se realizaron 4.235 (100%) procedimientos quirúrgicos bajo anestesia en el Hospital Materno Infantil Germán Urquidi, de los cuales el 57,87% (2.451) fueron realizados con anestesia neuroaxial. El presente etudio es descriptivo y retrospectivo, en el cual se registró la incidencia de las complicaciones en anestesial neuroaxial, utilizando un muestréo aleatorio durante el periodo de un año. El 38,63 % (1 .635) de las pacientes que recibieron anestesia neuroaxial presentó algún tipo de complicación. Sólo el 1 ,48% (14) tuvo una complicación mayor reportada como punción dural advertida; de las cuales 4 pacientes presentaron cefalea postpunción. Entre las pacientes) con complicaciones menores 96,51% (1.577) de las pacientes cursaron con hipotensión arterial; 8 pacientes tuvieron bloqueos fallidos y en 11 pacientes se presentaron punciones vasculares reportadas. La incidencia de complicaciones en anestesia neuroaxial en el Hospital Maternológico Germán Urquidi se encuentra por debajo de lo reportado en la literatura, pues el ser un Hospital Universitario no constituye un factor adicional de riesgo que aumente las complicaciones, en procedimientos permanentemente supervisados.

Abstract During the year 2007 were carried out 4.235 (1 00%) surgical procedures under it anesthetizes in the Hospital Maternal Infantile Germán Urquidi, ofthose which 57,87% (2.451) they were carried out with regional anesthesia. In our means statistical data don't exist with regard to the complications of the regional anesthesia, and specifically in hospitals with residents in training. By means of a descriptive and retrospective study oftraverse court he/she registered the incidence ofthe complications in regional anesthesia, using a random sampling during the period of one year. 38,63% (1 .635) ofthe patients that received regional anesthesia it presented some complication type. Only the 1 ,48%(14) he/she had a bigger complication reported as perforation noticed dural punction; of which 4 patients presented migraine postpuntion. Among the patients with complications smaller 96,51 % (1 .577) ofthe patients they studied with arterial hypotension; 8 patients had bankrupt blockades and in 11 patients reported vascular puntions was presented. The incidence of complications in regional anesthesia in the Hospital Maternológico Germán Urquidi is below that reported in the literature, because the being an University Hospital doesn't constitute an additional factor of risk that increases the complications, in permanently supervised procedures.