Colecistectomía laparoscópica con manejo ambulatorio ultracorto / Laparoscopic cholecystectomy with ultra short hospital stay

Introducción. La colecistectomía laparoscópica es la técnica de elección para el tratamiento de la enfermedad biliar benigna. El manejo ambulatorio en este tipo de procedimientos podría ofrecer ahorros económicos y una mayor disponibilidad de camas. Objetivo. El propósito del presente estudio es mostrar nuestra experiencia al practicar colecistectomías laparoscópicas con manejo ambulatorio menor de seis horas. Materiales y métodos. Se llevó a cabo un estudio de cohortes en pacientes sometidos a colecistectomía laparoscópica en la Clínica Gestión Salud de Cartagena de Indias, Colombia, entre el 1° de octubre de 2009 y el 31 de agosto de 2013. Resultados. Se practicaron 1.260 colecistectomías laparoscópicas. Se cumplieron los criterios para manejo ambulatorio en 1.207 (95,8 %) casos. El tiempo promedio de hospitalización hasta el alta hospitalaria, fue de 4,18 horas (rango: 3 a 10). De los 1.207 pacientes que cumplieron criterios para manejo ambulatorio, 23 (1,9 %) requirieron ser hospitalizados y la primera causa de hospitalización fue el diagnóstico intraoperatorio de enfermedad biliar aguda. El porcentaje de reingreso de pacientes dados de alta, fue del 0,6 %. Conclusiones. En esta serie, la colecistectomía laparoscópica se pudo practicar con manejo ambulatorio ultracorto para el tratamiento de la enfermedad biliar benigna en pacientes seleccionados, sin que esto atentara contra la seguridad del paciente ni se tradujera en altos índices de reingreso o consulta.

Background: At the introduction of laparoscopic cholecystectomy it was usual to have a one-day hospital stay (overnight) after surgery. Refinement of the surgical and anesthetic techniques has resulted in the discharge of patients on the same day of the operation. The aim of this study was to present our experience with laparoscopic cholecystectomy as an ambulatory procedure, with a hospital stay of less than six hours. Methods: A cohort study was carried out including all patients submitted to laparoscopic cholecystectomy. Inclusion criteria were: ages between 17 and 75 years, benign gallbladder disease (polyps and cholelithiasis), elective surgery, 1 and 2 ASA classification, residence at less than 20 kilometer distance, available telephone contact and the ambulatory regime informed consent. The same two surgeons operated on all patients. All patients were given general anesthesia with local anesthetic infiltration at the port sites. Results: A total of 1260 laparoscopic cholecystectomies were performed. 1207 (95,8%) had criteria to be included in the ambulatory regime. Only 23 (1.9%) out of the 1207 patients required hospitalization. Average time for hospital discharge was 4.18 hours (r: 3-10) and readmission percentage was 0.6%. Conclusions: In our series an ultra-short ambulatory laparoscopic cholecystectomy regime was implemented for the treatment of the benign biliary disease in selected patients with no negative incidence on the patients safety, and very low readmission rate and postoperative consultations.

Anestesia en embarazada para traqueostomía urgente por hemangioma sangrante en lengua / Anesthesia for emergency tracheostomy due to bleeding hemangioma of the tongue in a pregnant patient

Paciente embarazada de 20 años de edad con diagnóstico de hemangioma cavernoso en lengua, labios y cuello, con sangrado activo. Fue programada para traqueostomía de emergencia bajo anestesia general. La inducción anestésica fue planeada con intubación despierta con fibrobroncoscopio acorde a los algoritmos de vía aérea difícil de ASA, siendo la vía aérea manejada con tubo endotraqueal número 5,5 Fr bajo infusión de remifentanilo a 0,02-0,05 µg/kg/min para sedación y se aplicó anestesia local en la vía aérea superior para disminuir el dolor y el reflejo nauseoso, mientras respiraba espontáneamente. La intubación traqueal fue realizada exitosamente. Posterior a una hora de cirugía con 200 cc de pérdidas sanguíneas, la paciente fue trasladada a la sala de cuidados posoperatorios. Su vía aérea fue manejada con tubo número 7,5 Fr y se realizó traqueostomía sin lesionar el hemangioma en cuello. Posteriormente fue programada para embolectomía de los vasos del hemangioma y luego será programará para escisión quirúrgica. En este caso la intubación en paciente despierto con fibrobroncoscopia bajo infusión con remifentanilo fue segura y útil para el abordaje del paciente con hemangioma sangrante en vía aérea.

We present the case of a 20-year-old pregnant patient diagnosed with cavernous hemangioma in her tongue, lips and neck with active bleeding. An emergency tracheostomy under general anesthesia was scheduled. Anesthesia was planned for conscious intubation with a fibrobronchoscope suited for the difficult airway management ASA algorithms. The airway was managed with a number 5.5 Fr. endotracheal tube under 0.02-0.05µg/kg/min remifentanyl infusion. The patient was sedated and given local anesthesia in the upper airway to reduce pain and gag reflex during spontaneous breathing. Intubation was successful. Having a total blood loss of 200 cc, the patient was taken to the postoperative care room hour after surgery. The airway was managed with a tracheostomy procedure using a number 7.5 Fr tube and without damaging the hemangioma. She was then scheduled for a vessel embolectomy and surgical removal. In this case, conscious intubation with remifentanyl was safe and adequate for the approach of the patient with bleeding airway hemagioma.

La metoclopramida no disminuye la incidencia de náusea y vómito postoperatorios cuando se asocia a dexametasona en pacientes ambulatorios llevados a procedimientos otorrinolaringológicos / Metoclopramide do not reduce the incide of postoperative nausea and vomiting, associated to dexamethasone in ambulatory patients undergoing ambulatory ear, nose and thorat surgery

Objetivo: evaluar el efecto profiláctico antiemético de la combinación dexametasona – metoclopramida en pacientes llevados a procedimientos otorrinolaringológicos. Materiales y Métodos: En este estudio doble ciego y placebo controlado, 208 pacientes ambulatorios anestesiados con una técnica anestésica convencional, fueron aleatorizados para recibir dexametasona 8 mg durante la inducción anestésica y metoclopramida, 10 mg al final de la cirugía (Grupo A), dexametasona, 8 mg durante la inducción anestésica y placebo al final de la cirugía (Grupo B), placebo durante la inducción anestésica y metoclopramida, 10 mg al final de la cirugía (Grupo C) o placebo durante la inducción anestésica y al final de la cirugía (Grupo D). La ausencia de vómito y de náusea moderada y no solicitud de administración de medicación antiemética de rescate, se consideraron componentes de la respuesta completa al tratamiento antiemético. Resultados: Durante el período pre-alta del hospital, el número de pacientes que experimentaron respuesta completa al tratamiento profiláctico fue significativamente mayor en los grupos B (90.4%) y A (86.5%) al compararlos con los grupos D (55.8%) y C (75%). A las 24 horas, la proporción de pacientes con una respuesta completa fue significativamente mayor en el grupo A (96.2%) en comparación con los grupo C (67.3%) y D (78.8%) y de igual forma en el grupo B (88%) en comparación con el grupo C (67.3%). Conclusiones: La combinación de dexametasona con metoclopramida no es significativamente más efectiva que la administración de dexametasona sola en la profilaxis de náusea y vómito postoperatorios.

Objective: The aim of this study was to evaluate the prophylactic antiemetic effects of the combination dexamethasone – metoclopramide in patients undergoing ear-nose-throat procedures. Materials and methods: In this placebo-controlled, double-blind study, 208 outpatients under standardized anesthetic were randomized to receive dexamethasone 8 mg before anesthesia induction and metoclopramide, 10 mg at the end of surgery (Group A), dexamethasone 8 mg before anesthesia induction and placebo at the end of surgery (Group B), placebo before anesthesia induction and metoclopramide, 10 mg at the end of surgery (Group C) or placebo before anesthesia induction and at the end of surgery (Group D). Complete response to prophylactic antiemetic medication was defined as no vomiting no sustained moderate nausea and no requesting of antiemetic drug. Results: During predischarge period, the number of patients with complete response to prophylactic antiemetic medication was significantly higher in groups B (90.4%) and A (86.5%) in comparison with groups D (55.8%) and C (75%). At the 24 h follow-up evaluation, complete response was higher in group A (96.2%) in comparison with groups C (67.3%) and D (78.8%). Conclusions: combination dexamethasone-metoclopramide is not more effective than administration of dexamethasone alone in the posoperative profylaxis of nausea and vomiting.

Anestesia para craneotomías con resecciones volumétricas en áreas elocuentes guiadas por estereotaxia. Sedación Consciente vs. Anestesia General / Anesthesia for craniotomies with volumetric resections in eloquent areas guided by stereotaxis. Conscious Sedation vs. General anesthesia

El tratamiento quirúrgico actual de las lesiones cerebrales y sobre todo de aquellas ubicadas en áreas elocuentes o de difícil acceso, implican la utilización de métodos estereotacticos y neurofisiologicos multimodales que incluyen Cráneotomias (CT), resecciones volumétricas guiadas por estereotaxia, mapeos funcionales corticales (MFC) y despertares intraoperatorios (DI)1.

Agreement between percentage pain reductions calculated from numeric rating scores of pain intensity and those reported by patients with acute or cancer pain.

The use of percentage pain reduction is increasingly used to evaluate the effectiveness of pain treatments, but the degree of agreement between calculated percentage pain reduction (CPPR) as calculated from pre- and post-treatment levels of pain intensity and those reported directly by patients is unknown. Lack of agreement between these two measures could lead to errors in the determination of treatment effectiveness. We aimed to determine the agreement between CPPR and patient-reported percentage pain reduction (PRPPR). Patients with acute or cancer pain were asked to rate their pain intensity on a 0-10 verbal numerical rating scale (NRS) and to estimate the percent pain reduction from baseline pain after analgesic administration. They then received analgesics every 10 min until pain intensity declined to 4/10 or less. To evaluate agreement between CPPR and PRPPR, we computed the concordance correlation coefficient (CCC), which measures both accuracy and precision, and estimated the 95% limits of agreement for the differences between these two measures. 761 adult patients were enrolled. Female, healthy patients with acute pain of severe intensity and high levels of education predominated in the sample. The mean difference between CPPR and PRPPR was -2.6% (95% limits of agreement -12 to 17%). The CCC was 0.56 (accuracy was 0.9 and precision was 0.6). Although CPPR appeared to underestimate PRPPR in the higher range, this trend was not clinically important. The agreement between percentage pain reductions calculated from NRS scores and those estimated by patients did not vary according to gender or age. The good overall agreement between percentage pain reductions calculated from NRS scores and those estimated by patients suggests that these indices may be used interchangeably. The findings of this study extend existing patient-centered pain research and may be applied for the evaluation and comparison of pain treatments.

What decline in pain intensity is meaningful to patients with acute pain?

Despite widespread use of the 0-10 numeric rating scale (NRS) of pain intensity, relatively little is known about the meaning of decreases in pain intensity assessed by means of this scale to patients. We aimed to establish the meaning to patients of declines in pain intensity and percent pain reduction. Upon arrival to the postanesthesia care unit, postsurgical patients rated their baseline pain intensity on both a 0-10 NRS and on a 4-point verbal scale. Patients whose NRS was higher than 4/10 received intravenous opioids until their pain intensity declined to 4/10 or lower. During opioid titration, patients were asked every 10 min to rate pain intensity on a NRS and to indicate the degree of pain improvement on a 5-point Likert scale from 'no improvement' to 'complete pain relief'. Seven hundred adult patients were enrolled. For patients with moderate pain, a decrease of 1.3 units (20% reduction) corresponded to 'minimal' improvement, a decrease of 2.4 (35% reduction) to 'much' improvement, a decrease of 3.5 units (45% reduction) corresponded to 'very much' improvement. For patients with severe pain, the decrease in NRS pain score and the percentage of pain relief had to be larger to obtain similar degrees of pain relief. The change in pain intensity that is meaningful to patients increases as the severity of their baseline pain increases. The present findings are applicable in the clinical setting and research arena to assess treatment efficacy.

Acidosis metabólica inducida por metanol administrado por vía cutánea en un niño de 9 meses de edad / Metabolic acidosis induced by methanol administered per cutaneous acoute in a 9 month infant

Se presenta el caso de un niño de 9 meses de edad con intoxicación accidental por metanol. El paciente desarrolló las siguientes alteraciones clínicas y bioquímicas: Hiperventilación, convulsiones, acidosis metabólica y aumento del anion gap. Fue tratado con infusión de bicarbonato, ventilación mecánica y etanol. Se revisa la fisiopatología, diagnóstico y tratamiento de esta intoxicación