Anestesia libre de opioides para cistectomía radical laparotómica en obesidad mórbida / Opioid-free anesthesia for open radical cystectomy in morbid obesity

El estudio de la técnica anestésica libre de opioides aporta evidencias de su efectividad y seguridad. Sin embargo, aún no están bien definidos todos sus riesgos y beneficios, ni en qué pacientes o intervenciones puede ser superior a la técnica anestésica convencional basada en opioides. Las cirugías intensivas y/o duraderas plantean dudas para la utilización de esta técnica por la respuesta a cambios hemodinámicos bruscos, al no producir la simpaticolisis a través de la actuación sobre el receptor μ y haber poca experiencia de uso. Una paciente con obesidad mórbida fue sometida a cistectomía radical con derivación urinaria tipo Bricker mediante laparotomía infraumbilical, consiguiéndose una adecuada estabilidad hemodinámica y una analgesia óptima en el postoperatorio sin emplear opioides intraoperatorios. La anestesia libre de opioides está en expansión con una evidencia creciente. No obstante, es necesario seguir investigando sobre sus posibilidades de utilización, las distintas combinaciones de fármacos que se puedan emplear y la resolución de complicaciones que puedan ocurrir.(AU)

Opioid-free anaesthesia shows evidence about its efectivity and security, even though its risks and benefits are not well defined. Neither are the patient profile or sort of surgery where it could be superior to the conventional opioid-based anaesthetic technique. Aggressive and/or long-lasting surgeries set out several queries on this technique regarding sudden hemodynamic changes, as it does not produce sympatholysis through μ receptor and there is modest experience in this technique. A morbidly obese patient received open radical cystectomy with Bricker-type urinary diversion using infraumbilical incision under OFA protocol, maintaining an adequate hemodynamic stability and excellent analgesia in postoperatory care without using any intraoperative opioids. Opioid-free anaesthesia technique is developing its evidence. However, it is necessary to keep on researching its clinical applications, different drug combinations and solutions to its expected complications.(AU)

Opioid-free anesthesia for open radical cystectomy in morbid obesity.

Opioid-free anaesthesia shows evidence about its efectivity and security, even though its risks and benefits are not well defined. Neither are the patient profile or sort of surgery where it could be superior to the conventional opioid-based anaesthetic technique. Aggressive and/or long-lasting surgeries set out several queries on this technique regarding sudden hemodynamic changes, as it does not produce sympatholysis through µ receptor and there is modest experience in this technique. A morbidly obese patient received open radical cystectomy with Bricker-type urinary diversion using infraumbilical incision under OFA protocol, maintaining an adequate hemodynamic stability and excellent analgesia in postoperatory care without using any intraoperative opioids. Opioid-free anaesthesia technique is developing its evidence. However, it is necessary to keep on researching its clinical applications, different drug combinations and solutions to its expected complications.

Opioid-free anesthesia for open radical cystectomy in morbid obesity. / Anestesia libre de opioides para cistectomía radical laparotómica en obesidad mórbida.

Opioid-free anaesthesia shows evidence about its efectivity and security, even though its risks and benefits are not well defined. Neither are the patient profile or sort of surgery where it could be superior to the conventional opioid-based anaesthetic technique. Aggressive and/or long-lasting surgeries set out several queries on this technique regarding sudden hemodynamic changes, as it does not produce sympatholysis through µ receptor and there is modest experience in this technique. A morbidly obese patient received open radical cystectomy with Bricker-type urinary diversion using infraumbilical incision under OFA protocol, maintaining an adequate hemodynamic stability and excellent analgesia in postoperatory care without using any intraoperative opioids. Opioid-free anaesthesia technique is developing its evidence. However, it is necessary to keep on researching its clinical applications, different drug combinations and solutions to its expected complications.

Preservation of renal function in cardiac surgery patients with low cardiac output syndrome: levosimendan vs beta agonists.

BACKGROUND: Some studies have been performed to assess the effects of levosimendan on cardiac function when administered to cardiac surgery patients with low cardiac output syndrome (LCOS) in the immediate postoperative period. Levosimendan is an inotropic agent for the treatment of low cardiac output syndrome that seems to have a protective effect on renal function. METHODS: It is a quasi-experimental study. A total of 100 patients with LCOS received either beta-agonists or levosimendan. We assessed the incidence of postoperative kidney failure in cardiac surgery patients. In patients who had kidney failure at diagnosis of LCOS, we examined whether differences existed in the evolution of kidney failure based on the treatment administered for LCOS. The parameters measured included haemodynamics, oxygen supply, and renal function as assessed by the AKI scale. ANOVA, Student's t-test and Wilcoxon or Friedman tests were used. RESULTS: Up to 30% of cardiac surgery patients had kidney failure at diagnosis of LCOS. Kidney failure at discharge from the ICU was more frequent in patients who received beta-agonist drugs as compared to those who received levosimendan (p < 0.05). CONCLUSION: The incidence of kidney failure decreased with the postoperative administration of levosimendan to cardiac surgery patients with LCOS, as compared to beta-agonists. TRIAL REGISTRATION: Current Controlled Trials ISRCTN 46058317. Date of registration: 7/10/2019. Retrospectively registered.

Mechanisms of Cardioprotection of Halogenated Agents During Extracorporeal Circulation in Cardiac Surgery.

The implementation of cardioprotective strategies involving pre-, intra-, and postoperative interventions is key during cardiac surgery requiring extracorporeal circulation (ECC). The primary goal of this study was to review the physiopathology and protection strategies against myocardial damage secondary to ECC during cardiac surgery. The administration halogenated anesthetics for cardiac anesthesia is common place due to their well-known cardioprotective effects and their capacity to ensure hypnosis. An optimal myocardial protection strategy requires that a comprehensive approach should be adopted to cover pre-, intra-, and post-operative interventions. Pre-conditioning and post-conditioning share numerous pathways, mainly based on mitochondrial signaling, antiapoptotic pathways, and reduced inflammatory mediators. However, volatile anesthetic can also be administered during ECC, in which mechanism of action has been scantly investigated, during this period and its biology is still unknown.

Cardioprotective efficacy of sevoflurane vs. propofol during induction and/or maintenance in patients undergoing coronary artery revascularization surgery without pump: A randomized trial.

PURPOSE: Pre and post-operative administration of sevoflurane in myocardial revascularization surgery provides enhanced cardioprotective effects exerted by pharmacologic pre- and post-conditioning, as compared to propofol. The identification of the enzymes involved in conditioning mechanisms is crucial to the understanding of the effects of sevoflurane in cardiac surgery patients. The impact of sevoflurane on another crucial target organ-the kidney-was also assessed. METHODS: Ninety patients undergoing off-pump myocardial revascularization surgery were allocated to receive either intra- and postoperative sevoflurane (SS), intraoperative sevoflurane and postoperative propofol (SP), or intra- and postoperative propofol (PP)). Troponin I and hemodynamic parameters were monitored during the first 48 postoperative hours; blood and urine samples were collected at baseline and at 24h to determine Akt, ERK1/2, PKG, iNO, bradykinin receptor, caspase 3, NT proBNP and urinary NGAL. RESULTS: The enzymes were overexpressed in the SS group, remained unchanged in the SP group, and decreased in the PP group. Renal function was best preserved in the SS group. CONCLUSIONS: The overexpression of enzymes induced by intraoperative anesthesia and postoperative sedation with sevoflurane reduces myocardial damage and improves renal function in patients undergoing off-pump myocardial revascularization surgery.

Prolonged sevoflurane administration in the off-pump coronary artery bypass graft surgery: beneficial effects.

PURPOSE: The benefits of intraoperative administration of halogenated agents in patients undergoing cardiac surgery have been shown by numerous studies. The mechanisms of preconditioning and postconditioning appear to be the cause of these benefits. The possibility of maintaining the early postoperative sedation with halogenated agents, after its intraoperative administration, can increase their benefits. PATIENTS AND METHODS: This is a prospective trial with 60 patients undergoing coronary artery bypass graft surgery divided into 3 groups according to the administration of hypnotic drugs in the intraoperative and postoperative periods (sevoflurane, sevoflurane: SS, sevoflurane-propofol: SP, propofol-propofol: PP). For the first 48 hours, hemodynamic parameters, the need for inotropic drugs, N-terminal pro-brain natriuretic peptide, and troponin I plasmatic concentrations were obtained. RESULTS: There were significant differences between group SS and the other 2 groups in the levels of N-terminal pro-brain natriuretic peptide (SS [501±280 pg/mL] compared with SP [1270±498 pg/mL] and PP [1775±527 pg/mL] [P<.05]) and troponin I (SS [0.5±0.4 ng/mL] compared with SP [1.61±1.30 ng/mL] and PP [2.27±1.5 ng/mL] [P<.05]) and a lower number of inotropic drugs. CONCLUSION: Sevoflurane administration in patients undergoing off-pump coronary artery bypass graft, in the operating room and the intensive care unit, decreases myocardial injury markers compared with patients who only received sevoflurane in the intraoperative period, but both were a better option to decrease levels of myocardial markers when compared with the propofol group.