Impacto de un programa de educación estructurado sobre el nivel de ansiedad preoperatoria de pacientes pediátricos y de sus padres / Impact of a structured education program on preoperative anxiety level in pediatric patients and their parents

Introducción: los pacientes pediátricos y sus padres sienten ansiedad antes de una cirugía, síntoma que afecta la inducción anestésica, el dolor y el comportamiento postoperatorio. El objetivo fue evaluar el efecto de la educación preoperatoria estructurada en el nivel de ansiedad de niños sometidos a cirugía electiva y de sus padres. Métodos: estudio prospectivo, aleatorio, doble ciego, en niños de 2-12 años, ASA I-II. Los participantes fueron aleatorizados en grupo control (información habitual) y grupo experimental (información estructurada). Se registraron variables demográficas, nivel de ansiedad en unidad preoperatoria y en pabellón en niños y padres; se evaluó el comportamiento de los niños durante la inducción anestésica. Análisis estadístico: t-test, x2; valores expresados en media y desviación estándar; significancia p ≤ 0,05. Resultados: se reclutaron 34 pacientes, 18 en grupo control y 16 en grupo experimental. Los valores ansiedad en niños pre-pabellón fueron 37,7 ± 21,4 en grupo control y 31,9 ± 11,5 en grupo experimental (p= 0,35); durante pre-inducción fue 43,2 ± 25,3 y 36 ± 15,5 respectivamente (p= 0,33). Los niveles de ansiedad en padres pre-pabellón fueron 42,5 ± 15,5 para grupo control y 37,6 ± 6,9 en grupo experimental (p= 0,25), y al retirarse del pabellón fueron de 45,1 ± 16,6 y 43,9 ± 9,8 respectivamente (p= 0,82). No hubo diferencias en el comportamiento durante la inducción anestésica entre ambos grupos (p= 0,24). Conclusiones: no fue posible demostrar efectos de información estructurada en niveles de ansiedad en niños que van a ser operados y en sus padres.

Introduction: Pediatric patients and their parents experience anxiety before surgery, a symptom that affects anesthetic induction, pain and postoperative behavior. The objective was to evaluate the effect of structured preoperative education on the anxiety level in children undergoing elective surgery and their parents. Methods: A prospective, randomized, double-blind study in children aged 2-12 years, ASA I-II. Patients were randomized into a control group (usual preoperative information) and an experimental group (structured information). Demographic variables, anxiety level in the preoperative unit and in operating room in children and parents were recorded; the behavior of children during anesthetic induction was evaluated. Statistical analysis: t-test, x2; values expressed as mean and standard deviation; significance p ≤ 0.05. Results: 34 patients were recruited, 18 in the control group and 16 in the experimental group. The anxiety levels in children in preoperative unit were 37.7 ± 21 and 31.9 ± 11.5.4 in control and experimental group, respectively (p = 0.35), and in operating room were 43.2 ± 25.3 and 36 ± 15.5 respectively (p = 0.33). Parental anxiety levels in preoperative unit were 42.5 ± 15.5 in control group and 37.6 ± 6.9 in experimental group (p = 0.25), and when they leaving operating room were 45.1 ± 16.6 and 43.9 ± 9.8 respectively (p = 0.82). There were no differences in the behavior during anesthetic induction between both groups (p = 0.24). Conclusions: It was not possible to demonstrate effects of structured information on anxiety levels in children undergoing surgery and in their parents.

Biomarkers as predictors of renal damage in neonates undergoing cardiac surgery.

BACKGROUND: Acute Kidney Injury is a complication in children with heart disease undergoing cardiac surgery with cardiopulmonary bypass. The aim of this study is to describe the behavior of KIM-1 (Kidney Injury Molecule) and NGAL (Neutrophil Gelatinase Associated Lipocalin) as early predictors of renal damage, comparing them with serum creatinine and creatinine clearance, in neonates undergoing cardiac surgery. METHODS: Twenty-one (21) neonates, under 4 kg, with complex congenital heart diseases, RACHS-1 > 3, without preoperative renal failure, were studied. Serum creatinine and creatinine clearance were measured preoperatively and at 24, 48, 72, 96 hours postoperatively. Urinary samples of KIM-1(pg/ml) and NGAL (ng/ml) were collected after induction of anesthesia at 24 and 48 hours post-operatively. RESULTS: nRIFLE criteria were used to divide cohorts in "NO AKI" (12 patients) and "AKI" (nine patients). In the AKI group, serum creatinine increased significantly and creatinine clearance decreased significantly at 24, 48, and 72 hours compared with their respective baseline values. There was no difference in KIM-1 and NGAL values between patients who developed AKI and those who did not at any measured time. CONCLUSIONS: The deterioration of renal function continues to be one of the most frequent complications in this population. In our study, biomarkers did not show any correlation with the appearance of AKI. It remains to be seen whether this behavior of the biomarkers is linked with the non-consistent release of these types of molecules in immature kidneys. It is likely that a larger panel of biomarkers together with other glomerular filtration rate assessment methods will provide more information about AKI diagnosis.

Effect-Site Target-Controlled Infusion in the Obese: Model Derivation and Performance Assessment.

BACKGROUND: The aim of this study is to derive a propofol pharmacokinetic (PK) pharmacodynamic (PD) model to perform effect-site target-controlled infusion (TCI) in obese patients, and to analyze its performance along with that of other available PK models. METHODS: In the first step of the study, a 3-compartment PK model linked to a sigmoidal inhibitory Emax PD model by a first-order rate constant (keo) was used to fit propofol concentration-bispectral index (BIS) data. Population modeling analysis was performed by nonlinear mixed effects regression in NONMEM (ICON, Dublin, Ireland). PK data from 3 previous studies in obese adult patients (n = 47), including PD (BIS) data from 1 of these studies (n = 20), were pooled and simultaneously analyzed. A decrease in NONMEM objective function (ΔOBJ) of 3.84 points, for an added parameter, was considered significant at the 0.05 level. In the second step of the study, we analyzed the predictive performance (median predictive errors [MDPE] and median absolute predictive errors [MDAPE]) of the current model and of other available models using an independent data set (n = 14). RESULTS: Step 1: The selected PKPD model produced an adequate fit of the data. Total body weight resulted in the best size scalar for volumes and clearances (ΔOBJ, -18.173). Empirical allometric total body weight relationships did not improve model fit (ΔOBJ, 0.309). A lag time parameter for BIS response improved the fit (ΔOBJ, 89.593). No effect of age or gender was observed. Step 2: Current model MDPE and MDAPE were 11.5% (3.7-25.0) and 26.8% (20.7-32.6) in the PK part and 0.4% (-10.39 to 3.85) and 11.9% (20.7-32.6) in the PD part. The PK model developed by Eleveld et al resulted in the lowest PK predictive errors (MDPE = <10% and MDAPE = <25%). CONCLUSIONS: We derived and validated a propofol PKPD model to perform effect-site TCI in obese patients. This model, derived exclusively from obese patient's data, is not recommended for TCI in lean patients because it carries the risk of underdosing.

Eficacia analgésica y complicaciones a corto plazo de catéteres peridurales lumbares y torácicos en pacientes pediátricos: una evaluación retrospectiva / Analgesic efficacy and short-term complications of lumbar peridural catheters and thoracic in pediatric patients: a retrospective evaluation

Introducción: la analgesia peridural postoperatoria en niños es efectiva con catéteres insertados al nivel del sitio quirúrgico. Objetivo:comparar la eficacia y las complicaciones de catéteres insertados a nivel lumbar y torácico para analgesia postoperatoria. Método:revisamos la base de datos del Servicio de dolor agudo. Extrajimos información de pacientes de 0-18 años, con analgesia peridural postoperatoria. Los pacientes fueron divididos en grupo lumbar y torácico y, en cada grupo, por edades. Recopilamos información de: variables demográficas, tipo de cirugía, nivel de inserción del catéter peridural, solución de anestésico local administrada, analgésicos sistémicos, coadyuvantes peridurales, dolor postoperatorio y complicaciones. Dividimos las complicaciones según gravedad. Resultados: se analizaron 221 pacientes, 123 con catéter lumbar y 98 con catéter torácico. Catéteres peridurales lumbares y torácicos fueron principalmente insertados en niños de 1-3 años y mayores de 4 años respectivamente. Se utilizó bupivacaína 0,1-0,125 por ciento. Las cirugías fueron urológicas, intraabdominales, ortopédicas, torácicas y cardiovasculares. Los niños con catéteres torácicos tuvieron más dolor (mediana (rango): 3 (0-6) vs. 2 (0-4)) y necesitaron sus catéteres por más días (promedio (DE): 2,96 (1,06) vs. 2,53 (1,09) que aquellos con catéter lumbar. Los requerimientos analgésicos fueron similares en ambos grupos. Hubo 60 complicaciones (27,1 por ciento), principalmente menores (92 por ciento), sin diferencias entre los grupos lumbar y torácica (30 por ciento vs 23 por ciento) ni entre las diferentes edades. Conclusión: los catéteres peridurales insertados en relación al sitio quirúrgico, a nivel lumbar o torácico, proporcionarían analgesia postoperatoria clínicamente aceptable y comparable, con similar incidencia de complicaciones.(AU)

Introduction: postoperative epidural analgesia in children is effective with catheters inserted at the level of the surgical site. Objective: compare the efficacy and complications of epidural catheters inserted at the lumbar and thoracic level for postoperative analgesia in this population. Methods: we review the Acute Pain Service Database. We extracted information of patient from 0 to 18 years with postoperative epidural analgesia. Patients were divided into lumbar and thoracic groups and, in each group, by age. Collected data included: demographic, type of surgery, details of epidural catheters insertion, the local anesthetic administered, systemic analgesics and epidural adjuvant used, postoperative pain and complications. We divide complications according severity. Results: 221 patients were analyzed, 123 with lumbar and 98 with thoracic epidurals catheters. Lumbar and thoracic epidural catheters were mainly placed in patients 1-3 years and older than four years respectively. Bupivacaine 0.1-0.125 percent was the analgesic solution used. Performed surgeries were urological, intraabdominal, orthopedic, thoracic and cardiovascular. Children with thoracic catheters had more pain (median (IQR): 3 (0-6) vs. 2 (0-4)) and needed their catheters more days (mean (SD): 2.96 (1.06) vs. 2.53 (1.09)) than children with lumbar catheters.Analgesic requirements were similar between both groups. There were 60 complications (27.1 percent), mainly minors (92 percent), with no differences between lumbar and thoracic groups (30 percent vs. 23 percent respectively), and among age categories. Conclusion: the epidural catheters inserted about the surgical site, at the lumbar or the thoracic level would provide clinically acceptable and comparable postoperative analgesia with a similar rate of complications.(AU)

Evaluación de competencia de pacientes antes de la cirugía / Assessment of mental competency of patients, before surgery

Resumen Objetivo: Evaluar las alteraciones de la competencia en pacientes entre 18 y 65 años programados a cirugía general en el Hospital Clínico UC-Christus. Se estudiaron las alteraciones en habilidades cognitivas asociadas a la competencia de los pacientes, en distintos momentos previos a una cirugía electiva, bajo la hipótesis de que la capacidad de tomar decisiones varía o fluctúa antes de una intervención quirúrgica. Material y métodos: Estudio observacional, de carácter transversal. Fueron evaluados 85 pacientes, 44 en la unidad preoperatoria y 41 en el pabellón quirúrgico, por medio del test Montreal cognitive asessment tool (MoCA). Resultados: No hubo diferencias significativas entre la evaluación en la unidad preoperatoria y en el pabellón quirúrgico (p = 0,19). Ni tampoco en cuanto a porcentaje de pacientes con puntaje MoCA menor a puntaje de corte de 26 puntos en ambos lugares (30 vs. 26%; p = 0,61). Discusión: Variables como edad y nivel educacional pueden estar asociadas a alteraciones en la competencia de los pacientes. El momento de evaluación de los pacientes no influye significativamente en los resultados del test MoCA. Conclusiones: No fue posible concluir que existan diferencias en la capacidad de consentir de los pacientes, evaluada según puntaje en escala MoCA, en momentos próximos a una intervención quirúrgica.

Abstract Objective: To evaluate competence related alterations, in patients between 18 and 65 years old, scheduled to surgery in the Hospital Clínico UC-Christus. Alteration of cognitive skills associated to patients competence were observed in the preoperatory service, and in the surgical theatre. The underlying hypothesis was than the skills related to decision making fluctuates in the previous moments to a surgical intervention. Material and methods: Observational study. A total of 85 patients were evaluated, 44 in the preoperatory room and 41 in the surgical theatre, using the Montreal Cognitive Asessment Tool (MoCA). Results: There were no differences between evaluations in the preoperatory room and the surgical theatre (P=.19). Neither were differences between the percentage of patients who achieved less than 26 points (the cutoff of the test) in both evaluated places (30 vs. 26%, P=.61). Discussion: Other associated variables, such as age and educational level, could be related to competence related alterations in patients. The patient evaluation moment does not influences the results of the MoCA test. Conclusions: It is not possible to conclude than there are no differences in the patients ability to consent, evaluated by the MoCA tool, in the moments prior to a surgical intervention.

¿Existe relación entre la concentración de inducción anestésica de sevofluorano y la incidencia de agitación postanestésica en niños? / Is there a relationship between the concentration of sevofluoran anesthetic induction and the incidence of post-anesthetic agitation in children?

Introducción. La inducción anestésica con sevofluorano se asocia con agitación postanestésica (APA) en niños. Concentraciones de sevofluorano mayores a 6% producen actividad cerebral epileptiforme, la que podría estar relacionada a APA. El propósito de este estudio fue comparar el efecto de dos diferentes concentraciones de inducción anestésica con sevofluorano sobre la incidencia de APA, en niños sometidos a cirugía infraumbilical. Método. Estudio prospectivo y doble ciego, en pacientes de 2 a 7 años, operados de fimosis o hernia inguinal con anestesia general y bloqueo epidural caudal. Los pacientes fueron aleatorizados para recibir sevofluorano 5 por ciento (grupo S5) o sevofluorano 8 por ciento (grupo S8). Se registraron variables demográficas, signos vitales, profundidad anestésica utilizando índice biespectral (BIS) y respuesta motora durante distintos momentos de la anestesia. Se evaluó la presencia de agitación en pabellón y recuperación utilizando la escala de APA pediátrica (PAED). Análisis estadístico: t-test o Mann-Whitney y test Chi-cuadrado o Fisher, p < 0,05 considerada significativa. Resultados. Se reclutaron 33 pacientes, 16 en el grupo S5 y 17 en el grupo S8. Ambos grupos fueron comparables en cuanto a variables demográficas, signos vitales, respuesta motora y valores de BIS. No hubo diferencias significativas en la incidencia de APA en pabellón (S5: 31,3 por ciento y S8: 35,3 por ciento) y en recuperación (S5: 43,8 por ciento y S8: 41,2 por ciento), entre los grupos. Conclusión. No habría relación entre la concentración de inducción anestésica de sevofluorano y la incidencia de APA en niños sometidos a cirugía infraumbilical con anestesia general y bloqueo caudal. (AU)

Introduction. Induction of anesthesia with sevoflurane is associated with post-anesthetic agitation (PAA) in children. Sevoflurane concentration greater than 6% produces epileptiform brain activity, which could be related to PAA. The aim of this study was to compare the effect of two different sevoflurane concentrations for anesthesia induction on the incidence of PAA in children undergoing infraumbilical surgery. Method. Prospective, double blind study, performed in patients 2 to 7 years of age, undergoing circumcision or inguinal hernia repair under general anesthesia and epidural caudal block. Patients were randomized to receive sevoflurane 5 percent (S5 group) or sevoflurane 8 percent (S8 group), during anesthesia induction. Demographic variables, vital parameters, anesthesia depth using bispectral index (BIS) and motor responses during different moments of anesthesia were recorded. The presence of agitation in the operating room and recovery room were determined using the pediatric PAA scale (PAED). Statistical analysis: t-test or Mann-Whitney, and Chi-square or Fisher test, p < 0.05 considered significant. Results. Thirty-three patients were enrolled, 16 in the S5 group and 17 in the S8 group. Demographic variables, vital parameters, motor responses and BIS values were comparable between both groups. There were no significant differences in the incidence of PAA in the operating room (S5: 31.3 percent percent and S8: 35.3 percent) or in the recovery room (S5: 43,8 percent and S8: 41.2 percent), between both groups. Conclusion. Sevoflurane concentration used for induction of anesthesia would not be related to the incidence of PAA in children undergoing infraumbilical surgery under general anesthesia and epidural caudal block. (AU)

In vitro fertilization (IVF) in mammals: epigenetic and developmental alterations. Scientific and bioethical implications for IVF in humans.

The advent of in vitro fertilization (IVF) in animals and humans implies an extraordinary change in the environment where the beginning of a new organism takes place. In mammals fertilization occurs in the maternal oviduct, where there are unique conditions for guaranteeing the encounter of the gametes and the first stages of development of the embryo and thus its future. During this period a major epigenetic reprogramming takes place that is crucial for the normal fate of the embryo. This epigenetic reprogramming is very vulnerable to changes in environmental conditions such as the ones implied in IVF, including in vitro culture, nutrition, light, temperature, oxygen tension, embryo-maternal signaling, and the general absence of protection against foreign elements that could affect the stability of this process. The objective of this review is to update the impact of the various conditions inherent in the use of IVF on the epigenetic profile and outcomes of mammalian embryos, including superovulation, IVF technique, embryo culture and manipulation and absence of embryo-maternal signaling. It also covers the possible transgenerational inheritance of the epigenetic alterations associated with assisted reproductive technologies (ART), including its phenotypic consequences as is in the case of the large offspring syndrome (LOS). Finally, the important scientific and bioethical implications of the results found in animals are discussed in terms of the ART in humans.

In vitro fertilization (IVF) in mammals: epigenetic and developmental alterations: scientific and bioethical implications for IVF in humans

The advent of in vitro fertilization (IVF) in animals and humans implies an extraordinary change in the environment where the beginning of a new organism takes place. In mammals fertilization occurs in the maternal oviduct, where there are unique conditions for guaranteeing the encounter of the gametes and the first stages of development of the embryo and thus its future. During this period a major epigenetic reprogramming takes place that is crucial for the normal fate of the embryo. This epigenetic reprogramming is very vulnerable to changes in environmental conditions such as the ones implied in IVF, including in vitro culture, nutrition, light, temperature, oxygen tension, embryo-maternal signaling, and the general absence of protection against foreign elements that could affect the stability of this process. The objective of this review is to update the impact of the various conditions inherent in the use of IVF on the epigenetic profile and outcomes of mammalian embryos, including superovulation, IVF technique, embryo culture and manipulation and absence of embryo-maternal signaling. It also covers the possible transgenerational inheritance of the epigenetic alterations associated with assisted reproductive technologies (ART), including its phenotypic consequences as is in the case of the large offspring syndrome (LOS). Finally, the important scientific and bioethical implications of the results found in animals are discussed in terms of the ART in humans.