Dosis de carga de Dexdor® y nivel óptimo de sedación durante procedimientos de cirugía oral y maxilofacial en régimen ambulatorio: un estudio observacional / Loading dose of Dexdor® and optimal sedation during oral and maxillofacial ambulatory surgery procedures: an observational study

Introducción. El objetivo de este estudio fue evaluar el efecto de diferentes dosis de carga de dexmedetomidina (formulación Dexdor®) en el tiempo para lograr y mantener un nivel óptimo de sedación, y su repercusión hemodinámica. Material y métodos. Estudio observacional aprobado por el CEIC-Navarra en pacientes programados para cirugía oral y maxilofacial ambulatoria con dexmedetomidina en la Clínica Universidad de Navarra entre febrero de 2013 y noviembre de 2014. En función de la dosis de carga los pacientes fueron agrupados en 3 categorías:<0,5; 0,5; y>0,5μg/kg. El nivel óptimo de sedación se definió como un índice biespectral<85. Los datos se analizaron utilizando técnicas de análisis de supervivencia. Los requerimientos de fármacos vasoactivos fueron evaluados mediante regresión logística exacta. Resultados. Ochenta y un pacientes fueron evaluados. La hazard ratio de alcanzar un índice biespectral<85 para los pacientes de los grupos de 0,5 y>0,5μg/kg fue de 1,5 (IC 95% 0,9; 2,6) y 1,8 (IC 95% 0,8; 3,9), respectivamente, en comparación con el grupo inferior. Cinco pacientes (6,2%) precisaron de atropina. Los pacientes en el grupo de>0,5μg/kg mostraron mayor riesgo de requerir atropina respecto al grupo de<0,5μg/kg (odds ratio 2,2; IC 95% 0,03; 183). Conclusión. Una dosis de carga de Dexdor®>0,5μg/kg parece reducir el tiempo necesario para alcanzar y mantener un nivel óptimo de sedación durante los primeros 60min de procedimiento. La posible relación entre la dosis de carga y los requerimientos de atropina precisa una investigación más exhaustiva (AU)

Introduction. Dexdor® do not include the possibility of loading dose, which could increase time to achieve adequate sedation for ambulatory procedures. The objective of this study was to evaluate the effect of several loading dose of dexmedetomidine in the time to achieve and maintain an optimal level of sedation and its clinical hemodynamic repercussion. Material and methods. The IRB approved this observational study for patients that underwent oral and maxillofacial ambulatory surgery under dexmedetomidine at the University of Navarra Clinic from February 2013 to November 2014. According to the loading dose the patients were grouped into 3 categories:<0.5, 0.5, and>0.5μg/kg. Optimal level of sedation was defined as bispectral index<85. Data were analyzed using survival analysis techniques. Vasoactive drugs requirements was evaluated using exact logistic regression. Results. Eighty-one patients were evaluated. Hazard ratios for patients in 0.5 and >0.5μg/kg loading dose categories for achieving a bispectral index<85 were 1.5 (95% CI 0.9, 2.6) and 1.8 (95% CI 0.8, 3.9), respectively, compared with the lowest category. Five patients (6.2%) required atropine for bradycardia. Patients in the group>0.5μg/kg showed greater risk of requiring atropine compared with the group<0.5μg/kg (odds ratio 2.2; 95% CI 0.03, 183). Conclusion. Loading dose of dexmedetomidine>0.5μg/kg appears minimize the time to achieve and maintain an optimal level of sedation during the first 60min of procedure. Further investigation to elucidate the association between loading dose of dexmedetomidine and subsequent atropine requirements may be warranted (AU)

Loading dose of Dexdor® and optimal sedation during oral and maxillofacial ambulatory surgery procedures: An observational study. / Dosis de carga de Dexdor® y nivel óptimo de sedación durante procedimientos de cirugía oral y maxilofacial en régimen ambulatorio: un estudio observacional.

INTRODUCTION: Dexdor® do not include the possibility of loading dose, which could increase time to achieve adequate sedation for ambulatory procedures. The objective of this study was to evaluate the effect of several loading dose of dexmedetomidine in the time to achieve and maintain an optimal level of sedation and its clinical hemodynamic repercussion. MATERIAL AND METHODS: The IRB approved this observational study for patients that underwent oral and maxillofacial ambulatory surgery under dexmedetomidine at the University of Navarra Clinic from February 2013 to November 2014. According to the loading dose the patients were grouped into 3 categories:<0.5, 0.5, and>0.5µg/kg. Optimal level of sedation was defined as bispectral index<85. Data were analyzed using survival analysis techniques. Vasoactive drugs requirements was evaluated using exact logistic regression. RESULTS: Eighty-one patients were evaluated. Hazard ratios for patients in 0.5 and >0.5µg/kg loading dose categories for achieving a bispectral index<85 were 1.5 (95% CI 0.9, 2.6) and 1.8 (95% CI 0.8, 3.9), respectively, compared with the lowest category. Five patients (6.2%) required atropine for bradycardia. Patients in the group>0.5µg/kg showed greater risk of requiring atropine compared with the group<0.5µg/kg (odds ratio 2.2; 95% CI 0.03, 183). CONCLUSION: Loading dose of dexmedetomidine>0.5µg/kg appears minimize the time to achieve and maintain an optimal level of sedation during the first 60min of procedure. Further investigation to elucidate the association between loading dose of dexmedetomidine and subsequent atropine requirements may be warranted.

Mediastinitis tardía con hidrotórax bilateral tras perforación vascular por catéter venoso central / Late mediastinitis with bilateral hydrothorax after vessel perforation by a central venous catheter

Mujer de 67 años que en el séptimo día postoperatorio precisa de canulación de vía venosa central por yugular interna derecha para nutrición parenteral. Cinco días después desarrolla mediastinitis con hidrotórax bilateral que provoca insuficiencia respiratoria y síndrome de respuesta inflamatoria sistémica (SRIS) secundario a perforación vascular por el catéter (presentamos las imágenes de la perforación vascular). Cuatro factores han sido asociados con un incremento en el riesgo de perforación: rigidez y diámetro del catéter, ángulo formado por la punta del catéter con la estructura vascular, y abordajes izquierdos. Además, han sido descritas tres áreas de seguridad, confirmadas por radiología, para la posición del catéter: vena cava superior, límite entre cava superior y aurícula, y punto medio de la vena innominada. Sin embargo, no podemos olvidar que la radiografía es bidimensional y una misma imagen de la punta del catéter puede corresponderse con muy diversas localizaciones (vena cava superior, vena innominada, extravascular, etc.). Aun con evidencia clínica y radiológica de la posición del catéter, hemos de sospechar perforación vascular en aquellos pacientes con vía central y derrame pleural bilateral que presentan insuficiencia respiratoria e inestabilidad hemodinámica

A central venous catheter was inserted into the right internal jugular vein of a 67-year-old woman to provide parenteral nutrition on the 7th day after surgery. Five days later, mediastinitis with bilateral hydrothorax had developed and was causing respiratory failure and systemic inflammatory response syndrome secondary to documented vascular perforation by the catheter. Four factors have been associated with increased risk of perforation: catheter rigidity and diameter, the angle between the tip of the catheter and the vessel wall, and insertion from the left. Three catheter positions have been described as safe when radiologically confirmed: the superior vena cava, the point where the superior vena cava meets the atrium, and the midpoint of the innominate vein. However, it should not be forgotten that a radiograph is 2-dimensional and a single image of a catheter tip can correspond to a variety of locations (superior vena cava, vena innominata, extravascular location, and more). Even when there is clinical and radiologic evidence of catheter positioning, vascular perforation should be suspected in patients with a central venous catheter and bilateral pleural effusion who present respiratory insufficiency and hemodynamic instability

[Late mediastinitis with bilateral hydrothorax after vessel perforation by a central venous catheter]. / Mediastinitis tardía con hidrotórax bilateral tras perforación vascular por catéter venoso central.

A central venous catheter was inserted into the right internal jugular vein of a 67-year-old woman to provide parenteral nutrition on the 7th day after surgery. Five days later, mediastinitis with bilateral hydrothorax had developed and was causing respiratory failure and systemic inflammatory response syndrome secondary to documented vascular perforation by the catheter. Four factors have been associated with increased risk of perforation: catheter rigidity and diameter, the angle between the tip of the catheter and the vessel wall, and insertion from the left. Three catheter positions have been described as safe when radiologically confirmed: the superior vena cava, the point where the superior vena cava meets the atrium, and the midpoint of the innominate vein. However, it should not be forgotten that a radiograph is 2-dimensional and a single image of a catheter tip can correspond to a variety of locations (superior vena cava, vena innominata, extravascular location, and more). Even when there is clinical and radiologic evidence of catheter positioning, vascular perforation should be suspected in patients with a central venous catheter and bilateral pleural effusion who present respiratory insufficiency and hemodynamic instability.