[Comparison of anesthetic maintenance and recovery with propofol versus sevoflurane combined with remifentanil in craniotomy for supratentorial neoplasm]. / Estudio comparativo de remifentanilo combinado con propofol o sevofluorano para el mantenimiento y recuperación de la anestesia en craneotomía por neoplasia supratentorial.

OBJECTIVE: To compare the effectiveness of propofol versus sevoflurane associated with remifentanil on the maintenance of anesthesia and on recovery in patients undergoing elective supratentorial craniotomy. PATIENTS AND METHODS: Prospective randomized trial enrolling 90 patients scheduled for excision of a brain neoplasm. All received an infusion of remifentanil at a dose of 0.5 microg x Kg(-1) x min(-1) until tracheal intubation and then 0.25 microg x Kg(-1) x min(-1) during surgery. Induction was achieved with propofol and anesthesia was maintained with either sevoflurane at a maximum alveolar concentration of 0.4 (45 patients) or propofol by target controlled infusion at a concentration of 2.5 microg x mL(-1) (45 patients, group P). Variables assessed were hemodynamic stability during anesthesia and times and quality of recovery from anesthesia (eye opening, initiation of spontaneous ventilation, extubation, cough reflex, and temporal and spacial orientation 3 minutes after extubation. During the first 24 hours after surgery, pain intensity was evaluated on a verbal visual analog scale (VAS) and the incidence of nausea and vomiting was recorded. RESULTS: Times until eye opening upon request and until extubation were significantly shorter in the sevoflurane group than in the propofol group: 3.7 (SD, 1.2) minutes vs 5 (3.1) minutes, respectively, for eye opening and 6.6 (1.2) minutes vs 8.1 (3.3) minutes for extubation (P<0.01). The incidence of nausea and vomiting was significantly higher in the sevoflurane group (40% vs 13%, respectively, P<0.01). CONCLUSIONS: Combining remifentanil with propofol or with sevoflurane provides satisfactory anesthesia during elective supratentorial craniotomy to remove a brain neoplasm. Hemodynamic stability is appropriate and recovery from anesthesia is rapid.

Estudio comparativo de remifentanilo combinado con propofol o sevofluorano para el mantenimiento y recuperación de la anestesia en craneotomía por neoplasia supratentorial / Comparison of anesthetic maintenance and recovery with propofol versus sevoflurane combined with remifentanil in craniotomy for supratentorial neoplasm

OBJETIVO. Comparar el uso de propofol o sevofluoranoasociados a remifentanilo para el mantenimiento yrecuperación de la anestesia en pacientes sometidos acraneotomía supratentorial electiva.PACIENTES Y MÉTODOS. Estudio prospectivo y aleatoriosobre 90 pacientes programados para exéresis deneoplasia cerebral. Todos recibieron remifentanilo a 0,5µg Kg-1 min-1 hasta la intubación traqueal seguido de0,25 µg Kg-1 min-1 durante la cirugía. Inducción con propofoly mantenimiento con sevoflurano 0,4 CAM (45pacientes, grupo S) o propofol con TCI (target controlinfusion) a 2,5 µg mL-1 (45 pacientes, grupo P). Se valoróla estabilidad hemodinámica durante la anestesia, lostiempos y calidad de la recuperación tras la anestesia:apertura de los ojos, inicio de la ventilación, extubación,capacidad para toser y orientación temporoespacial a los3 minutos de la extubación. Durante las primeras 24horas del postoperatorio se evaluó la intensidad deldolor mediante la escala de valoración verbal (EVS) y seregistró la incidencia de náuseas y vómitos (NVPO).RESULTADOS. Los tiempos de apertura de los ojos pororden y de extubación fueron significativamente menoresen el grupo S (3,7 ± 1,2 min frente 5 ± 3,1 min y 6,6± 1,2 min frente 8,1 ± 3,3 min (p<0,01 respectivamente).La incidencia de NVPO fue significativamente superioren el grupo S (40% frente 13%, p<0,01).CONCLUSIONES. La combinación de remifentanilo conpropofol o con sevoflurano proporcionan una anestesiasatisfactoria durante la craneotomía supratentorial electivapor neoplasia cerebral, consiguiendo la estabilidadhemodinámica apropiada y la recuperación rápida de laanestesia

OBJECTIVE: To compare the effectiveness of propofolversus sevoflurane associated with remifentanil on themaintenance of anesthesia and on recovery in patientsundergoing elective supratentorial craniotomy.PATIENTS AND METHODS: Prospective randomized trialenrolling 90 patients scheduled for excision of a brainneoplasm. All received an infusion of remifentanil at adose of 0.5 µg·Kg-1·min-1 until tracheal intubation andthen 0.25 µg·Kg-1·min-1 during surgery. Induction wasachieved with propofol and anesthesia was maintainedwith either sevoflurane at a maximum alveolar concentrationof 0.4 (45 patients) or propofol by target controlledinfusion at a concentration of 2.5 µg·mL-1 (45patients, group P). Variables assessed were hemodynamicstability during anesthesia and times and qualityof recovery from anesthesia (eye opening, initiation ofspontaneous ventilation, extubation, cough reflex, andtemporal and spacial orientation 3 minutes after extubation.During the first 24 hours after surgery, pain intensitywas evaluated on a verbal visual analog scale (VAS)and the incidence of nausea and vomiting was recorded.RESULTS: Times until eye opening upon request anduntil extubation were significantly shorter in the sevofluranegroup than in the propofol group: 3.7 (SD, 1.2)minutes vs 5 (3.1) minutes, respectively, for eye openingand 6.6 (1.2) minutes vs 8.1 (3.3) minutes for extubation(P<0.01). The incidence of nausea and vomiting was significantlyhigher in the sevoflurane group (40% vs 13%,respectively, P<0.01).CONCLUSIONS: Combining remifentanil with propofolor with sevoflurane provides satisfactory anesthesiaduring elective supratentorial craniotomy to remove abrain neoplasm. Hemodynamic stability is appropriateand recovery from anesthesia is rapid

[Infant boy with propionic acidemia: anesthetic implications]. / Implicaciones anestésicas en un niño afecto de acidemia propiónica.

A 12-month-old boy diagnosed with propionic acidemia underwent gastrostomy. The patient's general state was good and he was alert, but with reduced muscular tone (unstable when seated with support, floppy head) and with dystonic movements in all extremities. An electroencephalogram showed slightly slowed brain activity. The patient was being treated with a low protein diet, phenobarbital, L-carnitine, L-isoleucine, and biotin. Surgery was carried out in satisfactory conditions with general anesthesia without opioids combined with infiltration of the surgical wound with local anesthetic. Recovery from anesthesia was rapid and free of complications. Propionic acidemia is caused by mitochondrial propionyl coenzyme carboxylase deficiency. Most patients have episodes of severe metabolic ketoacidosis as a result of excessive protein intake, delayed development, vomiting, gastroesophageal reflux, lethargy, hypotonia, and convulsions. The anesthetic approach involves avoiding triggers of metabolic acidosis (such as fasting, dehydration, hypoxemia, and hypotension) and preventing airway complications. Agents that metabolize propionic acid (such as succinylcholine, benzylisoquinoline neuromuscular blocking agents, and propofol) are not used, as they can exacerbate acidemia. We also believe that using local or regional anesthesia in combination with general anesthesia without opiates is safe and effective for controlling pain during surgery and postoperative recovery, as that combination avoids respiratory depression in these patients, who are highly sensitive to opiates.

Implicaciones anestésicas en un niño afecto de acidemia propiónica / Infant boy with propionic acidemia: anesthetic implications

Un niño de 12 meses de edad con diagnóstico de acidemia propiónica fue intervenido para gastrostomía. El paciente presentaba buen estado general y sensorio despejado, tono muscular disminuido, sedestación inestable con apoyo, sostén cefálico incompetente y movimientos distónicos de las cuatro extremidades. El EEG mostraba una actividad bioeléctrica cerebral discretamente enlentecida. El paciente estaba siendo tratado con dieta hipoproteica, fenobarbital, L-carnitina, L-isoleucina y biotina. La cirugía fue realizada bajo anestesia general sin opioides combinada con infiltración de la herida quirúrgica con anestésico local, que proporcionó condiciones quirúrgicas satisfactorias y una recuperación de la anestesia rápida y sin complicaciones. La acidemia propiónica se produce como consecuencia de la actividad deficiente de la enzima mitocondrial propionilCo-A carboxilasa. La mayoría de los pacientes presentan episodios de cetoacidosis metabólica severa secundaria a la excesiva ingesta proteica, retraso del desarrollo, vómitos, reflujo gastroesofágico, letargia, hipotonía y crisis convulsivas. La conducta anestésica se dirige a evitar los precipitantes de acidosis metabólica (ayuno, deshidratación, hipoxemia e hipotensión arterial) y las complicaciones de la vía aérea, así como no utilizar agentes anestésicos que se metabolizan a ácido propiónico como la succinilcolina, bloqueantes neuromusculares bencilisoquinoleínicos y el propofol, ya que pueden contribuir a la acidemia. Además, consideramos que el empleo de anestesia locorregional combinada con anestesia general sin opioides es segura y efectiva para el control del dolor durante la intervención y en el postoperatorio, ya que evitaría la depresión respiratoria en estos pacientes con elevada sensibilidad a los opioides

A 12-month-old boy diagnosed with propionic acidemia underwent gastrostomy. The patient's general state was good and he was alert, but with reduced muscular tone (unstable when seated with support, floppy head) and with dystonic movements in all extremities. An electroencephalogram showed slightly slowed brain activity. The patient was being treated with a low protein diet, phenobarbital, L-carnitine, L-isoleucine, and biotin. Surgery was carried out in satisfactory conditions with general anesthesia without opioids combined with infiltration of the surgical wound with local anesthetic. Recovery from anesthesia was rapid and free of complications. Propionic acidemia is caused by mitochondrial propionyl coenzyme carboxylase deficiency. Most patients have episodes of severe metabolic ketoacidosis as a result of excessive protein intake, delayed development, vomiting, gastroesophageal reflux, lethargy, hypotonia, and convulsions. The anesthetic approach involves avoiding triggers of metabolic acidosis (such as fasting, dehydration, hypoxemia, and hypotension) and preventing airway complications. Agents that metabolize propionic acid (such as succinylcholine, benzylisoquinoline neuromuscular blocking agents, and propofol) are not used, as they can exacerbate acidemia. We also believe that using local or regional anesthesia in combination with general anesthesia without opiates is safe and effective for controlling pain during surgery and postoperative recovery, as that combination avoids respiratory depression in these patients, who are highly sensitive to opiates

[Intraoperative anaphylaxis in a patient with undiagnosed latex sensitivity]. / Anafilaxia intraoperatoria en un paciente con sensibilización al látex desconocida.

Latex allergy is a cause of anaphylactic reactions during general anesthesia. It is currently the second most common cause of anaphylaxis during anesthesia and should be considered in all cases in which signs develop during surgery. Clinical manifestations are highly variable and depend on the type and amount of exposure to the allergen as well as on individual sensitivity. Cardiovascular collapse is the most common presentation in anesthetized patients, and the second most common manifestations are skin rash and bronchospasm. Latex gloves are implicated in most allergic reactions triggered by latex. Individuals allergic to latex are also sensitive to certain fruits (latex-fruit syndrome) because the presence of specific proteins common in both causes a phenomenon known as cross reactivity. A 34-year-old man with acute abdomen underwent emergency exploratory laparoscopy, which was converted to laparotomy based on findings in the surgical field. Coinciding with surgical manipulation, the patient developed severe hypotension, tachycardia, bronchospasm, and arterial desaturation, which responded favorably to intravenous fluids and medication. After all other possible causes of the events were ruled out, intraoperative anaphylactic reaction was suspected and later confirmed by tests, including allergy tests. When the patient was stable and the surgical environment was latex-free, the procedure was carried out with no complications and the postoperative course was uneventful.

Anafilaxia intraoperatoria en un paciente con sensibilización al látex desconocida / Intraoperative anaphylaxis in a patient with undiagnosed latex sensitivity

La alergia al látex es causa de reacciones anafilácticas durante la anestesia general. Debe tenerse en cuenta en todo paciente que sufre un cuadro de anafilaxia intrao- peratoria, ya que el látex representa actualmente la segunda causa más importante de anafilaxia durante la anestesia. Las manifestaciones clínicas son muy variables, dependiendo de la vía de exposición, la cantidad del alergeno contactado y la susceptibilidad personal. En los pacientes anestesiados el colapso cardiovascular es la forma más frecuente de presentación clínica seguida por el rash cutáneo y broncoespasmo, estando implicados, en la mayoría de las reacciones alérgicas mediadas por el látex, los guantes del látex. Las personas alérgicas al látex lo son también a determinadas frutas (síndrome látex-frutas),debido a la existencia de proteínas comunes, fenómeno conocido como reactividad cruzada. Un varón de 34 años de edad se somete a laparoscopia exploradora de urgencias por un cuadro de abdomen agudo. Debido a los hallazgos en el campo quirúrgico, se decide la reconversión en laparotomía. Coincidiendo con la manipulación quirúrgica, el paciente desarrolló un cuadro de hipotensión severa, taquicardia,broncoespasmo y desaturación arterial, el cual respondió favorable- mente a la administración intravenosa de fluidos y agentes farmacológicos. Tras excluir otras posibles causas etiológicas que pudiesen justificar el cuadro clínico se sospechó una reacción anafiláctica intraoperatoria al látex, que posteriormente fue confirmada mediante pruebas de laboratorio y estudio alergológico. Después de estabilizar al paciente y disponer un ambiente quirúrgico exento de látex, el procedimiento quirúrgico, así como la evolución del paciente transcurrió sin incidencias

Latex allergy is a cause of anaphylactic reactions during general anesthesia.It is currently the second most common cause of anaphylaxis during anesthesia and should be considered in all cases in which signs develop during surgery. Clinical manifestations are highly variable and depend on the type and amount of exposure to the allergen as well as on individual sensitivity. Cardiovascular collapse is the most common presentation in anesthetized patients, and the second most common manifestations are skin rash and bronchospasm. Latex gloves are implicated in most allergic reactions triggered by latex. Individuals allergic to latex are also sensitive to certain fruits (latex-fruit syndrome)because the presence of specific proteins common in both causes a phenomenon known as cross reactivity. A 34-year-old man with acute abdomen underwent emergency exploratory laparoscopy, which was converted to laparotomy based on findings in the surgical field. Coinciding with surgical manipulation, the patient developed severe hypotension, tachycardia, bronchospasm, and arterial desaturation, which responded favorably to intravenous fluids and medication. After all other possible causes of the events were ruled out, intraoperative anaphylactic reaction was suspected and later confirmed by tests, including allergy tests. When the patient was stable and the surgical environment was latex-free, the procedure was carried out with no complications and the postoperative course was uneventful