Influencia de las anomalías faringolaríngeas diagnosticadas mediante laringoscopia indirecta en la predicción de la dificultad de intubación / Influence of pharyngolaryngeal anomalies diagnosed through indirect laryngoscopy in the prediction of difficult intubation

Objetivo: Detectar anomalías faringolaríngeas no valoradas habitualmente en la evaluación de la vía aérea difícil mediante la realización en el preoperatorio de una laringoscopia indirecta con el laringoscopio rígido e investigar su influencia en la predicción de la dificultad de intubación traqueal (DIT). Métodos: Estudio observacional prospectivo en 300 pacientes consecutivos sometidos a intervenciones quirúrgicas programadas bajo anestesia general. Además de evaluar los predictores demográficos y clínicos comunes de la vía aérea difícil, les fue practicada en el preoperatorio una laringoscopia indirecta con el laringoscopio rígido para diagnosticar las anomalías faringolaríngeas. Después, bajo anestesia general y laringoscopia directa comprobamos en qué pacientes existía DIT. Se investigó la asociación de todas las variables anteriores con la DIT, se confeccionó un modelo de regresión logística con fines predictivos y su poder de discriminación se consiguió valorando el área bajo la curva ROC obtenida. Resultados: Se contabilizaron 46 anomalías: 31 alteraciones de la epiglotis (22 epiglotis abarquilladas, 9 epiglotis flácidas o hipertrofiadas), 6 amígdalas linguales hipertróficas, 3 tumores en la vía aérea superior y 6 alteraciones de la lengua. Se encontró DIT en 14 casos (4,66%). El modelo elaborado y sus coeficientes para confeccionarlo fueron: f(x) = 1,322 + (2,173 distancia tiromentoniana < 6,5 cm) + (1,813 epiglotis abarquillada) - (1,310* cm abertura boca). El poder global de discriminación era 0,83 (IC 95%: 0,70-0,95). Conclusiones: La laringoscopia indirecta permitió el diagnóstico de las anomalías faringolaríngeas, y de ellas la epiglotis abarquillada fue una de las variables incluidas en el modelo de regresión logística (AU)

Objective: To determine the pharyngolaryngeal anomalies not usually included in the evaluation of difficult airway, in order to investigate the influence of these anomalies in the prediction of difficult intubation. To do this, indirect laryngoscopy with a 70° rigid laryngoscope was performed on all patients during the preoperative period. Methods: This is an observational, prospective study on 300 consecutive patients who were scheduled for endotracheal intubation under general anesthesia. In addition to assessing the airway in the preoperative period by demographic and clinical predictors of difficult airway, rigid indirect laryngoscopy was performed to diagnose pharyngolaryngeal anomalies. Later, under general anesthesia and direct laryngoscopy it was checked to see if there was difficulty in intubating the larynx, and its association with all previous variables was investigated. A logistic regression model for prediction purposes was developed, and its power of discrimination was achieved by assessing the area under the curve. Results: During the examination by indirect laryngoscopy 46 anomalies were found, which were as follows: 31 abnormalities of the epiglottis (22 omega epiglottis, 9 flaccid or hypertrophic epiglottis); 6 findings of hypertrophic lingual tonsils, 3 cases of upper airway tumors, and 6 patients with tongue disorders. Intubation difficulty was found in 14 cases (4.66%). The regression model found, and its coefficients to develop it were: f(x) = 1.322 + (2.173 thyromental distance < 6.5 cm) + (1.813 omega epiglottis) - (1.310*cm opening mouth). Global power of discrimination was 0.83, with a 95% confidence interval from 0.709 to 0.952). Conclusion: Indirect laryngoscopy allowed pharyngolaryngeal anomalies to be diagnosed, including omega epiglottis, which was one of the variables included in the logistic regression model (AU)

Influence of pharyngolaryngeal anomalies diagnosed through indirect laryngoscopy in the prediction of difficult intubation.

OBJECTIVE: To determine the pharyngolaryngeal anomalies not usually included in the evaluation of difficult airway, in order to investigate the influence of these anomalies in the prediction of difficult intubation. To do this, indirect laryngoscopy with a 70° rigid laryngoscope was performed on all patients during the preoperative period. METHODS: This is an observational, prospective study on 300 consecutive patients who were scheduled for endotracheal intubation under general anesthesia. In addition to assessing the airway in the preoperative period by demographic and clinical predictors of difficult airway, rigid indirect laryngoscopy was performed to diagnose pharyngolaryngeal anomalies. Later, under general anesthesia and direct laryngoscopy it was checked to see if there was difficulty in intubating the larynx, and its association with all previous variables was investigated. A logistic regression model for prediction purposes was developed, and its power of discrimination was achieved by assessing the area under the curve. RESULTS: During the examination by indirect laryngoscopy 46 anomalies were found, which were as follows: 31 abnormalities of the epiglottis (22 omega epiglottis, 9 flaccid or hypertrophic epiglottis); 6 findings of hypertrophic lingual tonsils, 3 cases of upper airway tumors, and 6 patients with tongue disorders. Intubation difficulty was found in 14 cases (4.66%). The regression model found, and its coefficients to develop it were: f(x)=1.322+(2.173 thyromental distance <6.5 cm)+(1.813 omega epiglottis)-(1.310*cm opening mouth). Global power of discrimination was 0.83, with a 95% confidence interval from 0.709 to 0.952). CONCLUSION: Indirect laryngoscopy allowed pharyngolaryngeal anomalies to be diagnosed, including omega epiglottis, which was one of the variables included in the logistic regression model.

El hallazgo de glucosa en el fluido obtenido por el catéter epidural después de su inserción durante la anestesia combinada intradural-epidural realizada con bupivacaína hiperbara es un suceso habitual / The finding of glucose in the fluid obtained by epidural catheter after its insertion during combined intradural-epidural anaesthesia with hyperbaric bupivacaine is a usual occurrence

Objetivos. Evaluar si la aparición de glucosa en el fluido obtenido espontáneamente del catéter epidural tras su inserción, durante la anestesia combinada intradural-epidural realizada con bupivacaína hiperbara, es un suceso habitual. Pacientes y métodos. Estudio observacional prospectivo en 34 pacientes con anestesia combinada intradural-epidural a los que después de localizar el espacio epidural con solución salina, insertar la aguja espinal e inyectar bupivacaína hiperbara, se les introdujo un catéter epidural. Tras observar si goteaba espontáneamente algún fluido por él, se determinó si este contenía glucosa. Retirada la aguja epidural y lavada su luz con solución salina, se comprobó si en el lavado existía glucosa. Las muestras se analizaron con un glucómetro. Cuando desapareció el bloqueo motor se administró una dosis de anestésico local por el catéter epidural. Se valoró la asociación de los parámetros demográficos con el goteo espontáneo por el catéter epidural. Resultados. En 22 pacientes se produjo goteo espontáneo por el catéter epidural tras su inserción. Todas las muestras obtenidas contenían glucosa. En 9 de 34 muestras del lavado de aguja epidural existía glucosa. Ningún paciente sufrió bloqueo sensitivomotor excesivo. Se encontró asociación estadísticamente significativa (p<0,05) de la edad con el goteo espontáneo por el catéter (a más edad, más goteo). Conclusión. El hallazgo de glucosa en el fluido obtenido por el catéter epidural es un suceso frecuente y sin significación clínica. Proponemos que pudo deberse a fuga de líquido cefalorraquídeo por el agujero de punción dural durante o después de la administración de la bupivacaína hiperbara y al derrame de esta en el espacio epidural(AU)

Objectives. To determine whether the appearance of glucose in the fluid spontaneously obtained by the epidural catheter after its insertion during combined intradural-epidural anaesthesia with hyperbaric bupivacaine is a usual occurrence. Patients and methods. A prospective, observational study was conducted on 34 patients with combined intradural-epidural anaesthesia in whom an epidural catheter was introduced, after locating the epidural space with a saline solution, inserting a spinal needle and injecting hyperbaric bupivacaine. After observing whether any fluid was spontaneously dripping from it, it was determined if this contained glucose. Withdrawal of the needle and washing its lumen with saline solution, it was checked whether there was glucose in washout. The samples were analysed using a glucose meter. When the motor block disappeared a dose of local anaesthetic was administered through the epidural catheter. The relationship of the demographic parameters with the spontaneous dripping of the epidural catheter was evaluated. Results. Spontaneous dripping by the epidural catheter after its insertion was observed in 22 patients. All the samples obtained contained glucose. There was glucose in 9 out of 34 epidural needle wash samples. None of the patients suffered from excessive motor-sensory block. There was a statistically significant relationship between patient age (P<.05) and spontaneous dripping by the catheter (the higher the age, more dripping). Conclusion. The finding of glucose in the fluid obtained by the epidural catheter is a frequent occurrence and is of no clinical significance. We propose that it could be due to a leak of cerebrospinal fluid by the dural puncture needle during or after the administering of the hyperbaric bupivacaine and the spillage of this into the epidural space(AU)

[The finding of glucose in the fluid obtained by epidural catheter after its insertion during combined intradural-epidural anaesthesia with hyperbaric bupivacaine is a usual occurrence]. / El hallazgo de glucosa en el fluido obtenido por el catéter epidural después de su inserción durante la anestesia combinada intradural-epidural realizada con bupivacaína hiperbara es un suceso habitual.

OBJECTIVES: To determine whether the appearance of glucose in the fluid spontaneously obtained by the epidural catheter after its insertion during combined intradural-epidural anaesthesia with hyperbaric bupivacaine is a usual occurrence. PATIENTS AND METHODS: A prospective, observational study was conducted on 34 patients with combined intradural-epidural anaesthesia in whom an epidural catheter was introduced, after locating the epidural space with a saline solution, inserting a spinal needle and injecting hyperbaric bupivacaine. After observing whether any fluid was spontaneously dripping from it, it was determined if this contained glucose. Withdrawal of the needle and washing its lumen with saline solution, it was checked whether there was glucose in washout. The samples were analysed using a glucose meter. When the motor block disappeared a dose of local anaesthetic was administered through the epidural catheter. The relationship of the demographic parameters with the spontaneous dripping of the epidural catheter was evaluated. RESULTS: Spontaneous dripping by the epidural catheter after its insertion was observed in 22 patients. All the samples obtained contained glucose. There was glucose in 9 out of 34 epidural needle wash samples. None of the patients suffered from excessive motor-sensory block. There was a statistically significant relationship between patient age (P<.05) and spontaneous dripping by the catheter (the higher the age, more dripping). CONCLUSION: The finding of glucose in the fluid obtained by the epidural catheter is a frequent occurrence and is of no clinical significance. We propose that it could be due to a leak of cerebrospinal fluid by the dural puncture needle during or after the administering of the hyperbaric bupivacaine and the spillage of this into the epidural space.

Alteración de la actividad de la butirilcolinesterasa en pacientes con enfermedad de Alzheimer tratados con inhibidores de la acetylcolinesterasa / Changes in butyrylcholinesterase activity in patients with Alzheimer disease treated with acetylcholinesterase inhibitors

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[Use of a rigid laryngoscope and a flexible nasal fiberoptic scope to assess the difficult airway: description of 3 cases]. / Utilización del laringoscopio rígido y el nasofibroscopio flexible en la valoración de la vía aérea difícil: descripción de 3 casos.

Indirect inspection of the airway using a 70 degrees rigid laryngoscope plus a flexible nasal fiberoptic scope can provide additional information when the anesthesiologist foresees that airway management will be difficult. These devices are useful for detecting structural abnormalities, they can be attached to the same visualization system, and they do not require topical anesthesia or sedation of the patient. We report on 3 patients diagnosed with difficult airway. Inspection with a rigid laryngoscope during the preanesthetic assessment visit revealed abnormalities that prevented visualization of the glottis. In the first case, the epiglottis was absent, as it had been removed with a surrounding tumor; in the second and third cases, an epiglottic deformity and hypertrophy of the base of the tongue were found. A flexible nasal fiberoptic scope gave an unobstructed view of the glottis in these cases, making it easier to choose an intubation method.

Utilización del laringoscopio rígido y el nasofibroscopio flexible en la valoración de la vía aérea difícil: descripción de 3 casos / Use of a rigid laryngoscope and a flexible nasal fiberoptic scope to assess the difficult airway: description of 3 cases

La exploración de los pacientes con criterios de dificultaden el manejo de la vía aérea puede ser ampliadacon la realización de una laringoscopia indirecta utilizandoel laringoscopio rígido de 70º y el nasofibroscopioflexible. Son útiles para detectar anomalías estructurales,se acoplan al mismo sistema de visualización y noprecisan anestesia tópica ni sedación de los pacientes.Presentamos 3 pacientes diagnosticados de vía aéreadifícil, a los que se les realizó en la consulta de valoraciónpreanestésica una laringoscopia con el laringoscopiorígido. Se observó en el primero la falta de epiglotis,en el segundo una deformidad epiglótica y en el tercerouna hipertrofia de la base de la lengua, anormalidadesque impedían la visión de la glotis. Se les practicó unalaringoscopia con el nasofibroscopio flexible que permitióobservar la glotis sin obstáculos. La visión completade la vía aérea facilitó la elección del método de intubación(AU)

Indirect inspection of the airway using a 70° rigidlaryngoscope plus a flexible nasal fiberoptic scope canprovide additional information when the anesthesiologistforesees that airway management will be difficult. Thesedevices are useful for detecting structural abnormalities,they can be attached to the same visualization system, andthey do not require topical anesthesia or sedation of thepatient. We report on 3 patients diagnosed with difficultairway. Inspection with a rigid laryngoscope during thepreanesthetic assessment visit revealed abnormalities thatprevented visualization of the glottis. In the first case, theepiglottis was absent, as it had been removed with asurrounding tumor; in the second and third cases, anepiglottic deformity and hypertrophy of the base of thetongue were found. A flexible nasal fiberoptic scope gavean unobstructed view of the glottis in these cases, makingit easier to choose an intubation method(AU)

Bispectral index changes in carotid surgery.

BACKGROUND: Intraoperative monitoring of cerebral ischemia with shunting during carotid endarterectomy (CEA) remains controversial. Our objective was to evaluate the sensitivity and specificity of BIS changes during carotid clamping in relation to shunted patients in awake CEA. METHODS: Eighty CEAs under cervical block were included. There were two patient groups: with clinical signs of cerebral ischemia (shunted patients) and without signs of cerebral ischemia (nonshunted patients). Data were based on bispectral index (BIS) values and neurological monitoring at different surgery time points, with special attention paid during carotid clamping. BIS values were compared between shunted and nonshunted patients. Sensitivity and specificity, along with positive and negative predictive values of a percentage BIS value decrease during carotid clamping from baseline BIS values, were calculated in both patient groups. RESULTS: Shunting was performed in 11 patients with cerebral ischemia at carotid clamping. Mean BIS values were 82.82+/-11.98 in shunted patients and 92.31+/-5.42 in nonshunted patients at carotid clamping (p<0.001). Relative decreased BIS values in relation to basal BIS values were 13.57% in shunted patients and 3.68% in nonshunted patients (p<0.05). The percentage decrease in BIS was 14%, sensitivity was 81.8% (95% CI 49.9-96.8), and specificity was 89.7% (95% CI 79.3-95.4). CONCLUSION: BIS monitoring during carotid clamping is an easy, noninvasive method which correlates with cerebral ischemia in patients undergoing CEA. A decrease>or=14% from the basal BIS value presents a high negative predictive value, and ischemia is unlikely without a decrease. Nonetheless, a decrease may not always indicate cerebral ischemia with a low positive predictive value.

[Quantitative test to distinguish spinal fluid from saline solution in combined spinal-epidural anesthesia]. / Método cuantitativo para distinguir el líquido cefalorraquídeo de la solución salina en la anestesia combinada intradural-epidural.

OBJECTIVES: To validate the use of a digital blood glucose meter for detecting the presence of spinal fluid during combined spinal-epidural anesthesia in terms of specificity, positive and negative predictive values, and likelihood ratios. PATIENTS AND METHODS: Validation was studied in 30 patients scheduled for surgery under combined spinal-epidural anesthesia. A positive finding, defined as detection of spinal fluid return or aspiration by the epidural or spinal needle, was compared with results of standard reference tests (the pattern of sensory or motor block after administration of the local anesthetic). After locating the epidural space with saline solution, the test was performed and 3 mL of local anesthetic was administered. If no sensory or motor blockade was evident, the test was considered a true negative. Spinal puncture was then performed, the test was repeated, and 2 to 3 mL of local anesthetic was injected. The test was considered a true positive if sensory or motor blockade was evident. These findings entered into the validation analyses. RESULTS: Sensitivity was 100%, specificity 94%, positive predictive value 93%, negative predictive value 100%, the positive likelihood ratio 15.5, and negative likelihood 0. CONCLUSION: Blood glucose meter readings provide a valid quantitative measure for distinguishing spinal fluid from saline solution during combined spinal-epidural anesthesia. The method, which uses a readily available device, is easy to use to rule out the presence of spinal fluid.

Método cuantitativo para distinguir el líquido cefalorraquídeo de la solución salina en la anestesia combinada intradural-epidural / Quantitative test to distinguish spinal fluid from saline solution in combined spinalepidural anesthesia

OBJETIVOS: Proponer la utilización de un glucómetrodigital como método cuantitativo sencillo para detectarlíquido cefalorraquídeo durante la técnica de anestesiacombinada epidural-intradural y determinar su validez,a través de la sensibilidad, especificidad, valores predictivosy cocientes de probabilidad.PACIENTES Y MÉTODOS: Se realizó el estudio de validezdel test en 30 pacientes programados para cirugía conanestesia combinada intradural-epidural. Se consideróun resultado positivo si había glucosa en el líquido querefluía o se aspiraba a través de la aguja epidural eintradural, y se contrastaba con un patrón de referencia(las características del bloqueo sensitivo o motor tras laadministración de anestésico local). Tras localizar elespacio epidural con solución salina, se realizaba el testy se administraban 3 mL de anestésico local. Si no habíabloqueo sensitivo o motor, el test se consideraba verdaderonegativo. Se realizaba la punción dural, se realizabael test y se administraban 2-3 mL de anestésico local.En este caso si había bloqueo sensitivo o motor el test seconsideraba verdadero positivo. Con todo ello se realizóel análisis de validez.RESULTADOS: La sensibilidad del test fue del 100%, suespecificidad del 94%, el valor predictivo positivo de93%, y el valor predictivo negativo de 100%, la razón deprobabilidad positiva de 15,5 y la negativa de 0.CONCLUSIÓN: El glucómetro utilizado es un métodocuantitativo válido para diferenciar líquido cefalorraquídeode solución salina durante la anestesia combinada,de uso sencillo y fácilmente disponible, con una granutilidad para confirmar o descartar la presencia delíquido cefalorraquídeo(AU)

OBJECTIVES: To validate the use of a digital bloodglucose meter for detecting the presence of spinal fluidduring combined spinal-epidural anesthesia in terms ofspecificity, positive and negative predictive values, andlikelihood ratios.PATIENTS AND METHODS: Validation was studied in 30patients scheduled for surgery under combined spinalepiduralanesthesia. A positive finding, defined asdetection of spinal fluid return or aspiration by theepidural or spinal needle, was compared with results ofstandard reference tests (the pattern of sensory or motorblock after administration of the local anesthetic). Afterlocating the epidural space with saline solution, the testwas performed and 3 mL of local anesthetic wasadministered. If no sensory or motor blockade wasevident, the test was considered a true negative. Spinalpuncture was then performed, the test was repeated, and2 to 3 mL of local anesthetic was injected. The test wasconsidered a true positive if sensory or motor blockadewas evident. These findings entered into the validationanalyses.RESULTS: Sensitivity was 100%, specificity 94%,positive predictive value 93%, negative predictive value100%, the positive likelihood ratio 15.5, and negativelikelihood 0.CONCLUSION: Blood glucose meter readings provide avalid quantitative measure for distinguishing spinal fluidfrom saline solution during combined spinal-epiduralanesthesia. The method, which uses a readily availabledevice, is easy to use to rule out the presence of spinalfluid(AU)

Utilización del BIS como predictor de la amnesia anterógradaproducida por el midazolam intranasal administradocomo premedicación / The bispectral index as a predictor of anterograde amnesia caused by premedication with intranasal midazolam

OBJETIVOS: Determinar la capacidad del índice biespectral(BIS) como predictor de amnesia anterógrada para loseventos que ocurren desde la llegada a quirófano de lospacientes hasta la inducción anestésica, después de premedicarloscon 10 mg de midazolam intranasal.PACIENTES Y MÉTODOS: Pacientes intervenidos paracualquier intervención quirúrgica programada con anestesiageneral, después de monitorizarlos con el índice biespectraly administrarles 10 mg de midazolam por víaintranasal. Se observó el BIS hasta que empezó a bajar demanera continua y mantenida por debajo del valor de 90,se anotó el tiempo transcurrido y se les trasladó a quirófano.Todos los pacientes fueron sometidos a seis maniobrasrutinarias antes de la inducción. Finalizada la intervenciónse les interrogó sobre los recuerdos de las maniobras realizadas.Se estudiaron los valores de sensibilidad, especificidady valores predictivos; para obtener la cifra de BISque presenta una mejor combinación de sensibilidad yespecificidad, se trazó una curva ROC.RESULTADOS: Incluímos 55 pacientes, el tiempo mediotranscurrido en descender el valor de BIS fue 5,93 ± 2,93minutos. La sensibilidad total de la prueba es de 0,96 y laespecificidad de 0,60, el valor predictivo positivo de 0,91 yel valor predictivo negativo de 0,75. El valor global de laprueba es del 89,1%. El mejor valor de corte de la curvaROC es 83.CONCLUSIONES: La disminución del BIS por debajo delvalor de 90 se puede usar como predictor de amnesia anterógradatras la administración de 10 mg de midazolamintranasal (AU)

OBJETIVE: To determine the ability of the bispectralindex (BIS) to predict anterograde amnesia for eventsoccurring between the arrival of patients in the operatingtheater and anesthetic induction, following premedicationwith 10 mg of intranasal midazolam.PATIENTS AND METHODS: We enrolled patients scheduledfor any type of surgery under general anesthesia. Patientswere first monitored using the BIS and administered 10mg of intranasal midazolam. The BIS was monitored untilit began to fall steadily and remained below a value of 90;the elapsed time was recorded and the patient was takento the theater. All patients underwent 6 routine maneuversbefore induction. After surgery, patients were asked abouttheir memory of the maneuvers performed. Sensitivity,specificity, and predictive values were studied to obtain theBIS value that provided the best combination of sensitivityand specificity, and a receiver operating characteristic(ROC) curve was drawn.RESULTS: We enrolled 55 patients. The mean (SD) timetaken for the BIS value to fall was 5.93 (2.93) minutes. Thesensitivity of the test was 0.96 and specificity was 0.60. Thepositive predictive value was 0.91 and the negativepredictive value was 0.75. The test classified 89.1% of thepatients correctly. The ROC curve showed the best cutoffto be 83.CONCLUSIONS: A fall in the BIS to below 90 can be usedas a predictor for anterograde amnesia followingadministration of 10 mg of intranasal midazolam (AU)

[Comparison of 2 devices to measure spinal fluid glucose concentration in hyperbaric spinal anesthesia]. / Comparación de dos sistemas de medida de las concentraciones de glucosa en líquido cefalorraquídeo en la anestesia intradural hiperbara.

OBJECTIVES: To compare spinal fluid glucose measurements recorded by the laboratory analyzer Synchron LX20 Pro and the glucometer Ascensia Elite XL during continuous spinal anesthesia after injection of 10 mg of hyperbaric bupivacaine, in order to assess the reliability and speed of the 2 devices for monitoring changes in glucose concentration. PATIENTS AND METHODS: Prospective study of 34 patients under continuous spinal anesthesia administered through a 22-gauge catheter; 9 samples of spinal fluid were extracted from each patient for glucose level measurement. The first extraction was before administration of the anesthetic and the remaining ones were during spinal anesthesia until the end of complete motor block. Correlation was assessed with the Pearson test and agreement with the Bland-Altman method. RESULTS: A total of 241 pairs of measurements were obtained. The correlation was r = 0.96 (P < .01). The mean (SD) difference in measurements from the 2 devices was -1.06 (34.82 mg x dL(-1)). The percentage of variation (systematic error) was -1.9% (11.8%), placing the 95% confidence interval between -25% and 21.2%. CONCLUSIONS: Measurements from the 2 devices are highly correlated. The absolute and percentage systematic error (bias) is negligible. Finding that 95% of measurements are within 23% of the mean seems a fair percentage of error to us. We therefore believe the percentage variation, or systematic error, is clinically acceptable and that either device can be used.

Comparación de dos sistemas de medida de las concentraciones de glucosa en líquido cefalorraquídeo en la anestesia intradural hiperbara / Comparison of 2 devices to measure spinal fluid glucose concentration in hyperbaric spinal anesthesia

OBJETIVOS: Comparar las mediciones de glucorraquia realizadas en el Laboratorio con el autoanalizador Synchron LX20 PRO(R) (Beckman Coulter) con las realizadas con un glucómetro Ascensia EliteXL&Elite(R) durante la anestesia espinal, después de administrar 10 mg de bupivacaína hiperbara para así disponer de un método rápido y fiable al medir las cifras de glucorraquia durante una anestesia espinal continua y seguir su evolución. PACIENTES Y MÉTODOS: Estudio prospectivo de 34 pacientes bajo anestesia espinal continua con un catéter 22 G a través del cual se extrajeron 9 muestras por paciente de líquido cefalorraquídeo para determinar la glucorraquia, la primera antes de la administración del anestésico y los siguientes durante la anestesia espinal hasta el final del bloqueo motor completo. La correlación se midió con el test de Pearson y el grado de concordancia con el método de Bland-Altman. RESULTADOS: Se obtuvieron 241 pares de medidas. El coeficiente de correlación fue de r = 0,96 (p < 0,01). La diferencia media entre los dos métodos fue de –1,06 ± 34,82 mg dL–1. El porcentaje de variación (error sistemático) fue de –1,9 ± 11,8%, situándose el intervalo de confianza del 95% entre el –25% y el 21,2%. CONCLUSIONES: Se obtiene una buena correlación entre ambos métodos. El error sistemático absoluto y porcentual (bias), es despreciable. Encontrar el 95% de los valores con un margen de un 23% sobre la media del error porcentual nos parece razonable, por lo que consideramos la variación porcentual del error sistemático clínicamente aceptable para poder intercambiar ambos métodos de medida

OBJECTIVES: To compare spinal fluid glucose measurements recorded by the laboratory analyzer Synchron LX20 Pro and the glucometer Ascensia Elite XL during continuous spinal anesthesia after injection of 10 mg of hyperbaric bupivacaine, in order to assess the reliability and speed of the 2 devices for monitoring changes in glucose concentration. PATIENTS AND METHODS: Prospective study of 34 patients under continuous spinal anesthesia administered through a 22-gauge catheter; 9 samples of spinal fluid were extracted from each patient for glucose level measurement. The first extraction was before administration of the anesthetic and the remaining ones were during spinal anesthesia until the end of complete motor block. Correlation was assessed with the Pearson test and agreement with the Bland-Altman method. RESULTS: A total of 241 pairs of measurements were obtained. The correlation was r=0.96 (P<.01). The mean (SD) difference in measurements from the 2 devices was –1.06 (34.82 mg·dL-1). The percentage of variation (systematic error) was –1.9% (11.8%), placing the 95% confidence interval between -25% and 21.2%. CONCLUSIONS: Measurements from the 2 devices are highly correlated. The absolute and percentage systematic error (bias) is negligible. Finding that 95% of measurements are within 23% of the mean seems a fair percentage of error to us. We therefore believe the percentage variation, or systematic error, is clinically acceptable and that either device can be used

[Relation between glucose concentrations in cerebrospinal fluid and sensory and motor block during spinal anesthesia with hyperbaric bupivacaine]. / Relación de los niveles de la glucorraquia con el bloqueo sensitivo y motor durante la anestesia raquídea con bupivacaína hiperbara.

OBJECTIVE: To study the relation between cerebrospinal fluid (CSF) glucose levels, the highest level of sensory block, and the duration of motor block after intrathecal injection of 2 mL of hyperbaric bupivacaine. To determine CSF glucose levels upon recovery from motor block. PATIENTS AND METHODS: A prospective study of 34 patients administered a spinal anesthetic in continuous infusion through a 22-gauge catheter. CSF samples were extracted through the catheter 5, 10, 15, 20, 30, 45, and 60 minutes after start of infusion and upon motor recovery. After each extraction the intensity of the motor block was assessed; the intensity of the sensory block was assessed after each extraction up to 20 minutes. RESULTS: Glucose concentrations in CSF tended to decrease from 5 minutes (1027.07 [SD 349.04] mg dL(-1)) until full motor recovery (247.50 [20.39] mg dL(-1)). The probability of finding a motor block at a CSF glucose concentration of 287.5 mg dL(-1) or higher was less than 5%. We identified a positive correlation between the highest level of sensory block and the duration of full motor block (r=0.62, P<0.01) and between CSF glucose levels at the moment of greatest sensory block and upon full motor recovery (r=0.50, P<0.01). CONCLUSIONS: After continuous spinal anesthesia with hyperbaric bupivacaine, glucose concentrations in CSF are directly related to the highest level of sensory block, the course of the blockade, and its reversal.

Relación de los niveles de la glucorraquia con el bloqueo sensitivo y motor durante la anestesia raquídea con bupivacaína hiperbara / Relation between glucose concentrations in cerebrospinal fluid and sensory and motor block during spinal anesthesia with hyperbaric bupivacaine

OBJETIVO: Estudiar la relación de la glucorraquia conel nivel más alto del bloqueo sensitivo y con la duracióndel bloqueo motor después de la administración intratecalde 2 mL de bupivacaína hiperbara. Averiguar lascifras de glucorraquia al finalizar el bloqueo motor.PACIENTES Y MÉTODOS: Estudio prospectivo de 34pacientes bajo anestesia espinal continua con un catéter22 G, a través del cual se extraen muestras de líquidocefalorraquídeo para determinar la glucorraquia a los 5,10, 15, 20, 30, 45, 60 minutos y al final del bloqueomotor. Después de cada extracción se valora el grado delbloqueo motor y durante los primeros 20 minutos elnivel del bloqueo sensitivo.RESULTADOS: Se observa una tendencia descendente delos niveles de glucorraquia desde los 5 minutos (1027,07 ±349,04 mg dL-1), hasta el final del bloqueo motor completo(247,50 ± 20,39 mg dL-1). La probabilidad de no encontrarbloqueo motor con cifras de glucorraquia de 287,5 mgdL-1 o superiores es menor del 5%. Identificamos unacorrelación positiva entre el nivel más alto de bloqueo sensitivoy la duración del bloqueo motor completo (r = 0,62,p < 0,01) y entre las glucorraquias obtenidas en el momentodel nivel más alto de bloqueo sensitivo y al final del bloqueomotor completo (r = 0,50, p <0,01).CONCLUSIÓN: Después de una anestesia espinal continuacon bupivacaína hiperbara, la glucorraquia guardauna relación directa con el nivel más alto de bloqueosensitivo, la evolución y el final del bloqueo motor

OBJECTIVE: To study the relation between cerebrospinalfluid (CSF) glucose levels, the highest level of sensoryblock, and the duration of motor block after intrathecalinjection of 2 mL of hyperbaric bupivacaine. Todetermine CSF glucose levels upon recovery from motorblock.PATIENTS AND METHODS: A prospective study of 34patients administered a spinal anesthetic in continuousinfusion through a 22-gauge catheter. CSF samples wereextracted through the catheter 5, 10, 15, 20, 30, 45, and60 minutes after start of infusion and upon motor recovery.After each extraction the intensity of the motorblock was assessed; the intensity of the sensory blockwas assessed after each extraction up to 20 minutes.RESULTS: Glucose concentrations in CSF tended todecrease from 5 minutes (1027.07 [SD 349.04] mg dL-1)until full motor recovery (247.50 [20.39] mg dL-1). Theprobability not to find a motor block at a CSF glucoseconcentration of 287.5 mg dL-1 or higher was less than5%. We identified a positive correlation between the highestlevel of sensory block and the duration of full motorblock (r=0.62, P<0.01) and between CSF glucose levels atthe moment of greatest sensory block and upon fullmotor recovery (r=0.50, P<0.01).CONCLUSIONS: After continuous spinal anesthesia withhyperbaric bupivacaine, glucose concentrations in CSFare directly related to the highest level of sensory block,the course of the blockade, and its reversal

[Interaction of donepezil and muscular blockers in Alzheimer's disease]. / Interacción entre donepezilo y bloqueantes musculares en la enfermedad de Alzheimer.

A 75-years-old man with Alzheimer's disease, treated with the cholinesterase inhibitor donepezil for 14 months, was scheduled for left colectomy under general anesthesia. During the procedure, succinylcholine-induced relaxation was prolonged and the effect of atracurium besylate was inadequate even at higher doses than those indicated for the patient's weight. Cholinesterase blood tests performed 10 months, 1 month and 10 days before surgery had demonstrated a gradual decrease in the duration of activity of the enzyme. Such an effect, which has been described for cholinesterase inhibitors like neostigmine and donepezil, would explain the prolonged effect of succinylcholine. After ruling out other causes for resistance to atracurium, we conclude that donepezil or its metabolites acted on muscle plaque, blocking acetylcholine hydrolysis and antagonizing atracurium.

Interacción entre donepezilo y bloqueantes musculares en laenfermedad de Alzheimer / Interaction of donepezil and muscle blockers in Alzheimer's disease

Un paciente de 75 años que padecía enfermedad de Alzheimer, por lo que estaba en tratamiento desde hacía 14 meses con donepezilo (inhibidor de la acetilcolinesterasa) fue programado para intervención de colectomía izquierda bajo anestesia general, y presentó en el transcurso de la misma un alargamiento del tiempo de relajación por succinilcolina, así como una relajación posterior inadecuada por besilato de atracurio que requirió una dosificación mayor de la prevista por su peso.Al paciente se le habían realizado tres tipificaciones de colinesterasa diez meses, un mes y una semana previas a la intervención, que mostraban una disminución progresiva en el tiempo de la actividad total de la enzima, esto que ya ha sido descrito como una acción de los inhibidores de la colinesterasa como la neostigmina, también es un efecto del donepezilo y explicaría el alargamiento de la acción de la succinilcolina. La resistencia al atracurio, después de descartar otras causas, creemos que fue debida a un efecto del donepezilo o sus metabolitos sobre la placa muscular, en la que actuó bloqueando la hidrólisis de la acetilcolina y antagonizando el efecto del atracurio. (AU)