Réplica al artículo: "Comparación de bolus de fentanilo con perfusión de remifentanilo en el control de la respuesta hemodinámica a la laringoscopia e intubación orotraqueal: estudio prospectivo, randomizado y doble ciego". Respuesta / No disponible

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[Bolus administration of fentanyl vs continuous perfusion of remifentanil for control of hemodynamic response to laryngoscopy and orotracheal intubation: a randomized double-blind trial]. / Comparación de bolus de fentanilo con perfusión de remifentanilo en el control de la respuesta hemodinámica a la laringoscopia e intubación orotraqueal: estudio prospectivo, randomizado y doble ciego.

OBJECTIVES: To compare the efficacy and safety of fentanyl and remifentanil in the prevention of hemodynamic responses to direct laryngoscopy and orotracheal intubation, and to compare the effects of these techniques on peripheral blood oxyhemoglobin saturation in normotensive women undergoing scheduled gynecologic surgery. MATERIAL AND METHODS: Prospective clinical trial in ASA 1-2 patients undergoing gynecologic surgery. The patients were randomized to 2 groups: the remifentanil group received a perfusion of 1 microg x kg(-1) x min(-1) until intubation whereas the fentanyl group received a bolus dose of 2 microg x kg(-1). Etomidate (0.3 mg x kg(-1)) and rocuronium bromide (0.6 mg x kg(-1)) were used for anesthetic induction. Seven serial measurements of systolic, diastolic, and mean arterial pressure were recorded in addition to heart rate and peripheral blood oxyhemoglobin saturation at the following times: baseline, denitrogenation, postinduction, and 3 more times at consecutive 2-minute intervals. RESULTS: Fifty-four patients were enrolled. A statistically significant attenuation of the postintubation hemodynamic response was observed in the remifentanil group. The effect was evident on arterial pressure (P=.0001) and heart rate (P=.031) with respect to baseline values. That protective effect was not seen in the fentanyl group. No differences in peripheral blood oxyhemoglobin saturation were observed. CONCLUSIONS: Remifentanil provides greater hemodynamic control than fentanyl at the doses utilized. No adverse effects attributable to these opioids were observed in either group.

[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.

Comparación de bolus de fentanilo con perfusión de remifentanilo en el control de larespuesta hemodinámica a la laringoscopia e intubación orotraqueal: estudioprospectivo, randomizado y doble ciego / Bolus administration of fentanyl vs continuous perfusion of remifentanil for control of hemodynamic response to laryngoscopy and orotracheal intubation: a randomized double-blind trial

OBJETIVOS: Comparar la eficacia y seguridad del fentanilocon remifentanilo en la prevención de la respuestahemodinámica asociada a la laringoscopia directa eintubación orotraqueal, y su repercusión sobre la saturaciónperiférica de oxígeno en mujeres normotensasprogramadas para cirugía ginecológica.MATERIAL Y MÉTODO: Estudio clínico prospectivo enpacientes ASA I-II sometidas a cirugía ginecológica. Sedistribuyeron de forma aleatoria en dos grupos: grupoR, remifentanilo 1 μg Kg–1 min–1 hasta la intubación ygrupo F, fentanilo 2 μg Kg–1. Para la inducción anestésicautilizamos etomidato (0,3 mg Kg–1) y bromuro derocuronio (0,6 mg Kg–1). Se realizaron siete medicionesseriadas de la presión arterial sistólica, diastólica ymedia, frecuencia cardiaca y saturación periférica deoxígeno durante los periodos: control, desnitrogenación,postinducción, postintubación y posteriormente cada dosminutos tres determinaciones consecutivas.RESULTADOS: Se incluyeron 54 pacientes. El grupo R mostróun efecto estadísticamente significativo de atenuación dela respuesta hemodinámica postintubación tanto en la presiónarterial (p = 0,0001), como en la frecuencia cardiaca(p = 0,031) respecto de su valor basal. Sin embargo, con elgrupo del fentanilo (grupo F), no se observó dicho efecto protector.No se observaron diferencias en la saturación periféricade oxígeno en ambos grupos durante el estudio.CONCLUSIONES: A las dosis utilizadas, el remifentanilocomparativamente con el fentanilo, ofrece mayor controlhemodinámico. No se observaron efectos secundarios enambos grupos atribuibles a los opiáceos(AU)

OBJETIVES: To compare the efficacy and safety offentanyl and remifentanil in the prevention ofhemodynamic responses to direct laryngoscopy andorotracheal intubation, and to compare the effects ofthese techniques on peripheral blood oxyhemoglobinsaturation in normotensive women undergoingscheduled gynecologic surgery.MATERIAL AND METHODS: Prospective clinical trial inASA 1-2 patients undergoing gynecologic surgery. Thepatients were randomized to 2 groups: the remifentanilgroup received a perfusion of 1 μg·kg-1·min-1 untilintubation whereas the fentanyl group received a bolusdose of 2 μg·kg-1. Etomidate (0.3 mg·kg-1) and rocuroniumbromide (0.6 mg·kg-1) were used for anesthetic induction.Seven serial measurements of systolic, diastolic, and meanarterial pressure were recorded in addition to heart rateand peripheral blood oxyhemoglobin saturation at thefollowing times: baseline, denitrogenation, postinduction,and 3 more times at consecutive 2-minute intervals.RESULTS: Fifty-four patients were enrolled. Astatistically significant attenuation of the postintubationhemodynamic response was observed in the remifentanilgroup. The effect was evident on arterial pressure(P=.0001) and heart rate (P=.031) with respect tobaseline values. That protective effect was not seen in thefentanyl group. No differences in peripheral bloodoxyhemoglobin saturation were observed.CONCLUSIONS: Remifentanil provides greaterhemodynamic control than fentanyl at the doses utilized.No adverse effects attributable to these opioids wereobserved in either group(AU)

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

Analgesia domiciliario con infusores subcutáneos / Analgesia unit subcutaneous pumas at home

OBJETIVO: Evaluar la efectividad y seguridad del uso de un sistema de bomba elastomérica con una solución de Ketorolaco 270 mg y Tramadol 300 mg en suero fisiológico por vía subcutánea a 1 ml/hora en el tratamiento del dolor postoperatorio moderado-severo en Cirugía Ambulatoria Ortopédica. MATERIAL Y MÉTODOS: Se realiza un estudio retrospectivo sobre 250 pacientes sometidos a diversas intervenciones de Cirugía Ortopédica Ambulatoria. Después de la intervención son conectados al infusor subcutáneo Multitrate 2C1154K (Baxter®) con la pauta propuesta durante tres días. Los parámetros analizados son: Score Telefónico basado en estado general, dolor, sangrado, tolerancia, cumplimiento del tratamiento, fiebre > a 38º C y estado de la herida. Según el Score Telefónico obtenido la evolución se clasifica en Grupo I: evolución normal, correcto nivel de analgesia y buen estado general del paciente; Grupo II: necesidad de nueva llamada y Grupo III: necesita atención médica. Se evalúa la necesidad de analgesia de rescate y la descripción de los efectos secundarios. RESULTADOS: Llamadas del Grupo I: 95,2%; Grupo II: 4%; llamadas del Grupo III: 0,8%. Necesidad de analgesia de rescate: 12,2%. Efectos secundarios: mareo: 1,7%; cefalea 1,4%; vómitos: 1,4%; náuseas: 0,8%; picor: 0,8%; sueño: 0,8%; arrancado 0,5%; no efectos secundarios: 92,6%. CONCLUSIONES: El uso de analgesia invasiva domiciliaria por vía subcutánea, mediante una infusión de 1 ml/hora de una mezcla de Ketorolaco y Tramadol es eficaz y seguro para el control del dolor moderado-severo en Cirugía Ortopédica Ambulatoria (AU)

AIM: To evaluate the feasibility and security of the use of an elastomeric pump with 270 mg of Ketorolac and 300 mg of Tramadol in a saline solution for subcutaneous administration at a rate of 1 ml/hour for analgesic treatment of moderate pain in Orthopaedic Ambulatory Surgery. MATERIAL AND METHODS: A retrospective study with 250 patients was performed. At the end of surgery, Multitrate 2C1154K (Baxter®) subcutaneous infusor was connected for three days. We analysed a Phone Score based on: general status, pain level, bleeding, diet, treatment fulfillment, fever > 38º C and satisfactory wound evolution. According to the Phone Score obtained we divided the evolution into three groups: Group I: normal evolution, correct level of analgesia and good general state of patient; Group II: new call needed; Group III: medical treatment needed. Supplemental oral analgesia and secondary effects were also evaluated. RESULTS: (95.2%) of calls were in Group I; (4%) were in Group II and (0.8%) in Group III. The need of supplemental oral analgesia was 12.2%. The secondary effects observed were: dizziness: (1.7%); headache: (1.4%); vomiting: (1.4%); nausea: (0.8%); itching: (0.8%); drowsiness: (0.8%); accidental removal: (0.5%); no secondary effects: (92.6%). CONCLUSION: the use of the elastomeric pump Multitrate 2C1154K (Baxter®) for subcutaneous administration of Ketorolac 270 mg and Tramadol 300 mg at 1 ml/hour ratio is useful and safe for moderate postoperative pain control in Orthopaedic Ambulatory Surgery (AU)

[Efficacy of 1% ropivacaine with and without hyaluronidase for peribulbar block]. / Eficacia de la ropivacaína al 1% con y sin hialuronidasa en el bloqueo peribulbar.

OBJECTIVE: To determine whether adding hyaluronidase to 1% ropivacaine without adrenalin enhances peribulbar anesthesia for cataract surgery with phacoemulsification. PATIENTS AND METHODS: Prospective double-blind study of 100 patients (ASA I-III) scheduled for outpatient cataract surgery with peribulbar blockade. The patients were randomized to two groups of 50 to receive either 10 mL of 1% ropivacaine without adrenalin and without hyaluronidase (Group R) or 1% ropivacaine without adrenalin but with 10 U/mL of hyaluronidase (Group RH). We compared the presence of complete akinesia, of adequacy of surgical conditions, and of the need for reinjection. For statistical analysis we used the chi-squared test and a Student t-test for independent samples, with statistical significance at 5%. RESULTS: A block adequate for surgery was obtained in 98% of the patients in Group RH and in 86.7% of the patients in Group R (p = 0.043). Reinjection was necessary for 28.6% of Group R patients and 8.9% of Group RH patients (p = 0.14). Complete akinesia was similar in the two groups. CONCLUSIONS: The greater efficacy of a peribulbar block with the addition of 10 U/mL of hyaluronidase to 1% ropivacaine without adrenalin, in comparison to 1% ropivacaine alone, was demonstrated by a lower rate of reinjection and ocular mobility, even though no statistically significant difference in either ocular or palpebral akinesia was found.

Eficacia de la ropivacaína al 1 por ciento con y sin hialuronidasa en el bloqueo peribulbar / Efficacy of 1 por ciento ropivacaine with and without hyaluronidase for peribulbar blocks

Objetivos: Evaluar si la adición de hialuronidasa a la ropivacaína al 1 por ciento sin adrenalina favorece el bloqueo peribulbar en cirugía de catarata con facoemulsificación. Pacientes y Métodos: Estudio prospectivo, aletaorio y doble ciego en el que se incluyeron 100 pacientes ASA I-III, en dos grupos de 50, programados para cirugía ambulatoria de catarata con bloqueo peribulbar. Los pacientes recibieron 10 ml de ropivacaína al 1 por ciento sin adrenalina y sin hialuronidasa (Grupo R,) o ropivacaína al 1 por ciento sin adrenalina añadiendo 10 U/ml de hialuronidasa (Grupo RH). Se compararon la presencia de aquinesia completa, de un bloqueo quirúrgico que permitiera la cirugía y la necesidad de reinyección. El análisis estadístico se realizó con el test de Chi cuadrado y la t de Student para muestras independientes, con una significación estadística del 5 por ciento. Resultados: Se obtuvo bloqueo quirúrgico en el 98 por ciento de los pacientes del grupo RH y en el 86,7 por ciento de los pacientes del grupo R (p=0,043). Se reinyectó al 28,6 por ciento de los pacientes del grupo R y al 8,9 por ciento de los pacientes del grupo RH (p=0,014). La aquinesia completa fue similar en ambos grupos. Conclusiones: La adición de 10 U/ml de hialuronidasa a la ropivacaína al 1 por ciento sin adrenalina ha demostrado ser más eficaz que la ropivacaína al 1 por ciento sola puesto que disminuye el índice de reinyecciones y la movilidad ocular, aunque no se han encontrado diferencias estadísticamente significativas en cuanto a la aquinesia ocular y palpebral completas. (AU)