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1.
Rev Med Liege ; 76(7-8): 614-619, 2021 Jul.
Artigo em Francês | MEDLINE | ID: mdl-34357714

RESUMO

Intracerebroventricular (ICV) infusion of morphine is a well-known technique to relieve intractable neoplasic pain when conventional analgesic strategies reach their limits. Through this case report, we present indications, assets, and drawbacks of this procedure in such conditions. We also describe the adaptation of the systemic analgesic treatment to allow discharge from the hospital to home settings. Thanks to the ICV infusion of a mixture of morphine, bupivacaine and clonidine, the patient was weaned from oral opioid medications and reached an acceptable level of comfort. This allowed him to be discharged from the hospital to go back home with a specific setting of mobile palliative care structure. The patient's family followed training about the device to prevent any technical trouble and to react in case of unwanted events.


Assuntos
Clonidina , Dor Intratável , Analgésicos Opioides/uso terapêutico , Bupivacaína/uso terapêutico , Clonidina/uso terapêutico , Humanos , Infusões Intraventriculares , Masculino , Morfina/uso terapêutico , Dor Intratável/tratamento farmacológico , Dor Pós-Operatória , Cuidados Paliativos
2.
Br J Anaesth ; 121(5): 1084-1096, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30336853

RESUMO

BACKGROUND: Impaired consciousness has been associated with impaired cortical signal propagation after transcranial magnetic stimulation (TMS). We hypothesised that the reduced current propagation under propofol-induced unresponsiveness is associated with changes in both feedforward and feedback connectivity across the cortical hierarchy. METHODS: Eight subjects underwent left occipital TMS coupled with high-density EEG recordings during wakefulness and propofol-induced unconsciousness. Spectral analysis was applied to responses recorded from sensors overlying six hierarchical cortical sources involved in visual processing. Dynamic causal modelling (DCM) of induced time-frequency responses and evoked response potentials were used to investigate propofol's effects on connectivity between regions. RESULTS: Sensor space analysis demonstrated that propofol reduced both induced and evoked power after TMS in occipital, parietal, and frontal electrodes. Bayesian model selection supported a DCM with hierarchical feedforward and feedback connections. DCM of induced EEG responses revealed that the primary effect of propofol was impaired feedforward responses in cross-frequency theta/alpha-gamma coupling and within frequency theta coupling (F contrast, family-wise error corrected P<0.05). An exploratory analysis (thresholded at uncorrected P<0.001) also suggested that propofol impaired feedforward and feedback beta band coupling. Post hoc analyses showed impairments in all feedforward connections and one feedback connection from parietal to occipital cortex. DCM of the evoked response potential showed impaired feedforward connectivity between left-sided occipital and parietal cortex (T contrast P=0.004, Bonferroni corrected). CONCLUSIONS: Propofol-induced loss of consciousness is associated with impaired hierarchical feedforward connectivity assessed by EEG after occipital TMS.


Assuntos
Anestésicos Intravenosos/efeitos adversos , Córtex Cerebral/fisiopatologia , Propofol/efeitos adversos , Estimulação Magnética Transcraniana/métodos , Inconsciência/induzido quimicamente , Adulto , Anestesia Geral/efeitos adversos , Teorema de Bayes , Biorretroalimentação Psicológica/efeitos dos fármacos , Causalidade , Eletroencefalografia , Potenciais Evocados/efeitos dos fármacos , Feminino , Lobo Frontal/fisiopatologia , Humanos , Masculino , Lobo Parietal/fisiopatologia
3.
Br J Anaesth ; 119(4): 664-673, 2017 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-29121278

RESUMO

Background: The isolated forearm test (IFT) is the gold standard test of connected consciousness (awareness of the environment) during anaesthesia. The frontal alpha-delta EEG pattern (seen in slow wave sleep) is widely held to indicate anaesthetic-induced unconsciousness. A priori we proposed that one responder with the frontal alpha-delta EEG pattern would falsify this concept. Methods: Frontal EEG was recorded in a subset of patients from three centres participating in an international multicentre study of IFT responsiveness following tracheal intubation. Raw EEG waveforms were analysed for power-frequency spectra, depth-of-anaesthesia indices, permutation entropy, slow wave activity saturation and alpha-delta amplitude-phase coupling. Results: Volitional responses to verbal command occurred in six out of 90 patients. Three responses occurred immediately following intubation in patients (from Sites 1 and 2) exhibiting an alpha-delta dominant (delta power >20 dB, alpha power >10 dB) EEG pattern. The power-frequency spectra obtained during these responses were similar to those of non-responders (P>0.05) at those sites. A further three responses occurred in (Site 3) patients not exhibiting the classic alpha-delta EEG pattern; these responses occurred later relative to intubation, and in patients had been co-administered ketamine and less volatile anaesthetic compared with Site 1 and 2 patients. None of the derived depth-of-anaesthesia indices could robustly discrimate IFT responders and non-responders. Conclusions: Connected consciousness can occur in the presence of the frontal alpha-delta EEG pattern during anaesthesia. Frontal EEG parameters do not readily discriminate volitional responsiveness (a marker of connected consciousness) and unresponsiveness during anaesthesia. Clinical trial registration: NCT02248623.


Assuntos
Anestesia Geral/métodos , Estado de Consciência/efeitos dos fármacos , Eletroencefalografia/efeitos dos fármacos , Monitorização Intraoperatória/métodos , Adulto , Estudos de Coortes , Eletroencefalografia/métodos , Feminino , Antebraço , Humanos , Masculino , Estudos Prospectivos , Adulto Jovem
4.
Br J Anaesth ; 119(4): 674-684, 2017 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-29121293

RESUMO

Background: We used functional connectivity measures from brain resting state functional magnetic resonance imaging to identify human neural correlates of sedation with dexmedetomidine or propofol and their similarities with natural sleep. Methods: Connectivity within the resting state networks that are proposed to sustain consciousness generation was compared between deep non-rapid-eye-movement (N3) sleep, dexmedetomidine sedation, and propofol sedation in volunteers who became unresponsive to verbal command. A newly acquired dexmedetomidine dataset was compared with our previously published propofol and N3 sleep datasets. Results: In all three unresponsive states (dexmedetomidine sedation, propofol sedation, and N3 sleep), within-network functional connectivity, including thalamic functional connectivity in the higher-order (default mode, executive control, and salience) networks, was significantly reduced as compared with the wake state. Thalamic functional connectivity was not reduced for unresponsive states within lower-order (auditory, sensorimotor, and visual) networks. Voxel-wise statistical comparisons between the different unresponsive states revealed that thalamic functional connectivity with the medial prefrontal/anterior cingulate cortex and with the mesopontine area was reduced least during dexmedetomidine-induced unresponsiveness and most during propofol-induced unresponsiveness. The reduction seen during N3 sleep was intermediate between those of dexmedetomidine and propofol. Conclusions: Thalamic connectivity with key nodes of arousal and saliency detection networks was relatively preserved during N3 sleep and dexmedetomidine-induced unresponsiveness as compared to propofol. These network effects may explain the rapid recovery of oriented responsiveness to external stimulation seen under dexmedetomidine sedation. Trial registry number: Committee number: 'Comité d'Ethique Hospitalo-Facultaire Universitaire de Liège' (707); EudraCT number: 2012-003562-40; internal reference: 20121/135; accepted on August 31, 2012; Chair: Prof G. Rorive. As it was considered a phase I clinical trial, this protocol does not appear on the EudraCT public website.


Assuntos
Encéfalo/efeitos dos fármacos , Encéfalo/fisiologia , Dexmedetomidina/farmacologia , Imageamento por Ressonância Magnética/métodos , Propofol/farmacologia , Sono/fisiologia , Adolescente , Adulto , Anestésicos Intravenosos/farmacologia , Mapeamento Encefálico/métodos , Estado de Consciência , Feminino , Humanos , Hipnóticos e Sedativos/farmacologia , Processamento de Imagem Assistida por Computador , Masculino , Vias Neurais/efeitos dos fármacos , Adulto Jovem
6.
Obes Surg ; 27(3): 716-729, 2017 03.
Artigo em Inglês | MEDLINE | ID: mdl-27599985

RESUMO

BACKGROUND: Severe obstructive sleep apnea (OSA) is an independent risk factor for perioperative complications. Clinical scores such as Snoring, Tiredness, Observed apnea, high blood Pressure, Body Mass Index (BMI) higher than 35 kg m-2, Age older than 50 years, Neck circumference larger than 40 cm, and male gender (STOP-Bang), perioperative sleep apnea prediction (P-SAP), and OSA50 have been proposed for detecting OSA. We recently proposed a new score based on morphological metrics only, the DES-OSA score. This study compared the DES-OSA score to the three other ones with regard to their ability to detect OSA. Obese patients are particularly at risk of OSA. METHODS: Following informed consent and institutional review board (IRB) approval, 1584 consecutive adults were. Should the STOP-Bang be indicative of increased risk of severe OSA, the patient was referred to complementary polysomnography (PSG). Eventual already existing recent PSG data were also collected. The abilities of the four scores to predict OSA severity were compared using sensitivity, specificity, Cohen's kappa coefficient (CKC), and area under ROC curve (AUROC) analysis. RESULTS: PSG was performed in 150 patients. For detecting severe OSA, OSA50 had the highest sensitivity [value (95 % CI) 0.98 (0.90-1)]. STOP-Bang was significantly less sensitive than P-SAP and OSA50. In that respect, DES-OSA was significantly more specific than the three other ones [0.75 (0.65-0.83)]. The AUROC of DES-OSA was significantly the largest [0.9 (0.84-0.95)]. The highest CKC at detecting severe OSA was 0.62 (0.49-0.74) for DES-OSA. Similar results were obtained for moderate to severe OSA prediction. CONCLUSIONS: DES-OSA, which is the only exclusively morphological score available, appears to surpass the three other scores in their ability to predict moderate to severe and severe OSA, at least in our setting and in our screened population. CLINICAL TRIAL REGISTRATION: ClinicalTrial.gov NCT02051829.


Assuntos
Cuidados Pré-Operatórios/métodos , Apneia Obstrutiva do Sono/diagnóstico , Adolescente , Adulto , Idoso , Índice de Massa Corporal , Fadiga/etiologia , Feminino , Humanos , Hipertensão/etiologia , Masculino , Programas de Rastreamento/métodos , Pessoa de Meia-Idade , Obesidade/complicações , Obesidade Mórbida/complicações , Polissonografia/métodos , Valor Preditivo dos Testes , Fatores de Risco , Sensibilidade e Especificidade , Índice de Gravidade de Doença , Apneia Obstrutiva do Sono/complicações , Ronco/epidemiologia , Adulto Jovem
7.
J Physiol Pharmacol ; 67(4): 617-624, 2016 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-27779482

RESUMO

Postoperative development or worsening of obstructive sleep apnea is a potential complication of anesthesia. The objective of this study was to study the effects of a premedication with alprazolam on the occurrence of apneas during the immediate postoperative period. Fifty ASA 1 - 2 patients undergoing a colonoscopy were recruited. Patients with a history of obstructive sleep apnea (OSA) were excluded. Recruited patients were randomly assigned to one of two groups: in Group A, they received 0.5 mg of alprazolam orally one hour before the procedure; and in Group C, they received placebo. Anesthesia technique was identical in both groups. Patients were monitored during the first two postoperative hours to establish their AHI (apnea hypopnea index, the number of apneas and hypopneas per hour). Nine patients were excluded (4 in group A and 5 in group C) due to technical problems or refusal. Interestingly, premedication by alprazolam did not change intra-operative propofol requirements. During the first two postoperative hours, the AHI was significantly higher in group A than in group C (Group A: 20.33 ± 10.97 h-1, C: 9.63 ± 4.67 h-1). These apneas did not induce significant arterial oxygen desaturation, or mandibular instability. Our study demonstrates that a premedication with 0.5 mg of alprazolam doesn't modify intra-operative anesthetic requirements during colonoscopy, but is associated with a higher rate of obstructive apneas during at least three and a half hours after ingestion. No severe side effects were observed in our non-obese population. Our results must be confirmed on a larger scale.


Assuntos
Alprazolam/administração & dosagem , Hipnóticos e Sedativos/administração & dosagem , Apneia Obstrutiva do Sono/induzido quimicamente , Adulto , Idoso , Alprazolam/uso terapêutico , Analgésicos/uso terapêutico , Anestésicos Intravenosos/uso terapêutico , Colonoscopia , Método Duplo-Cego , Esquema de Medicação , Feminino , Humanos , Hipnóticos e Sedativos/uso terapêutico , Ketamina/uso terapêutico , Masculino , Pessoa de Meia-Idade , Propofol/uso terapêutico
8.
Acta Anaesthesiol Belg ; 67(2): 81-85, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-29444393

RESUMO

BACKGROUND: Sevoflurane induction in chil- dren is performed using different techniques. Constricted, centered, and symmetrical pupils (CCSP) are classically the endpoint to be achieved before laryngoscopy is performed. OBJECTIVES: We investigated whether two different inhalation induction techniques with the same clinical end- point provided similar intubating conditions and comparable depth of anesthesia as assessed by the Bispectral Index (BIS). METHODS: Following IRB approval, and informed parental consent, 20 children were recruited. They were sched- uled for general anesthesia with tracheal intubation, and randomly assigned to Group 1, where the practitioner used 6% inspired sevoflurane in 50% 02/N20, and no manually assisted ventilation, or Group 2, where inspired sevoflurane was 8% in 50% 02/N20, and ventilation was manually supported upon loss of consciousness. BIS values were blinded. Laryngoscopy was performed after CCSP. Intubation conditions scoring was based on jaw relaxation (mobile = 1, partially mobile = 2, fixed = 3), position of vocal cords (open = 1, half-closed = 2, closed = 3), and cough (no cough = 1, 1 or 2 coughing efforts = 2, persistent coughing = 3). A total score > 3 corresponded to non-optimal conditions. RESULTS: Upon CCSP, BIS values were significantly lower in Group 1 [mean (SD) : 30 (8) - 48 (18), p <0.001], despite significantly higher end-tidal sevoflurane concentration in Group 2 [mean (SD) : 5.0 (0.7) - 6.2 (0.5) ; p <0.001]. Time to CCSP was slightly shorter in Group 2. Intubation conditions were always optimal except for one patient of Group 1. DISCUSSION: Both induction techniques achieve good intubating conditions. Possible explanations for the between-group BIS difference include variable appreciation of the CCSP endpoint, different induction lengths or sevoflurane equilibration times, or sevoflurane-induced increase in electroencephalogram power. A better indicator of the best time to intubate is needed to avoid too deep anesthesia in children.


Assuntos
Anestesia por Inalação/métodos , Intubação Intratraqueal/métodos , Máscaras , Criança , Pré-Escolar , Monitores de Consciência , Método Duplo-Cego , Eletroencefalografia , Humanos , Éteres Metílicos/farmacologia , Sevoflurano
9.
Acta Anaesthesiol Belg ; 67(3): 143-147, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-29873470

RESUMO

We report the case of a 70-year-old man, with increased anesthetic risk, who beneficiated from a lumbar laminarthrectomy from lumbar vertebra 4 (L4) to sacral 1 (S1). A dural tear facing L5-S 1 levels occurred during surgery and was repaired intra-operatively. Postoperatively, back and radicular pain symptoms appeared along with a pseudo-meningocele. Successful treatment was only achieved after performing an epidural blood patch and closed subarachnoid drainage. This well-known but infrequent management was undertaken after a first epidural blood patch attempt, and after two unsuccessful surgical choking procedures. Management is here described, and discussed at the light of existing literature.


Assuntos
Repouso em Cama , Placa de Sangue Epidural , Dura-Máter/lesões , Dura-Máter/cirurgia , Complicações Intraoperatórias/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Coluna Vertebral/cirurgia , Idoso , Vazamento de Líquido Cefalorraquidiano , Descompressão Cirúrgica , Dura-Máter/diagnóstico por imagem , Humanos , Complicações Intraoperatórias/líquido cefalorraquidiano , Complicações Intraoperatórias/diagnóstico por imagem , Imageamento por Ressonância Magnética , Masculino , Estenose Espinal/cirurgia , Espaço Subaracnóideo/cirurgia , Sucção
10.
Yearb Med Inform ; 10(1): 95-101, 2015 Aug 13.
Artigo em Inglês | MEDLINE | ID: mdl-26293855

RESUMO

OBJECTIVE: The aim of this paper is to review existing technologies for the nociception / anti-nociception balance evaluation during surgery under general anesthesia. METHODS: General anesthesia combines the use of analgesic, hypnotic and muscle-relaxant drugs in order to obtain a correct level of patient non-responsiveness during surgery. During the last decade, great efforts have been deployed in order to find adequate ways to measure how anesthetic drugs affect a patient's response to surgical nociception. Nowadays, though some monitoring devices allow obtaining information about hypnosis and muscle relaxation, no gold standard exists for the nociception / anti-nociception balance evaluation. Articles from the PubMed literature search engine were reviewed. As this paper focused on surgery under general anesthesia, articles about nociception monitoring on conscious patients, in post-anesthesia care unit or in intensive care unit were not considered. RESULTS: In this article, we present a review of existing technologies for the nociception / anti-nociception balance evaluation, which is based in all cases on the analysis of the autonomous nervous system activity. Presented systems, based on sensors and physiological signals processing algorithms, allow studying the patients' reaction regarding anesthesia and surgery. CONCLUSION: Some technological solutions for nociception / antinociception balance monitoring were described. Though presented devices could constitute efficient solutions for individualized anti-nociception management during general anesthesia, this review of current literature emphasizes the fact that the choice to use one or the other mainly relies on the clinical context and the general purpose of the monitoring.


Assuntos
Anestésicos Gerais/farmacologia , Monitorização Intraoperatória/instrumentação , Nociceptividade , Anestesia Geral , Resposta Galvânica da Pele , Humanos , Monitorização Intraoperatória/métodos , Manejo da Dor , Fotopletismografia
12.
Minerva Anestesiol ; 81(9): 960-7, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-25479468

RESUMO

BACKGROUND: Obstructive Sleep Apnea (OSA) increases the perioperative risk of complications. Chronic use of Continuous Positive Airway Pressure (CPAP) by patients decreases the importance of comorbidities caused by the OSA. However, many patients do not adhere to the treatment. Given the postoperative complications, it is important for the anesthesiologist to identify non-adherent patients. This prospective study was designed to identify factors that would predict patient adherence. METHODS: Ninety patients who were treated by CPAP for more than one year were recruited. Among them, and based on objective criteria such as length of use of CPAP during the night, 75 were considered as being adherent to CPAP, while the other 15 were not. Sixty-two potential causes of non-adherence were investigated (some have not been tested before), and further divided into five categories. Those categories included cultural, intellectual, or economic factors, OSA comorbidities, patient belief about health, ENT-related problems, and pathophysiological features estimating the degree of improvement afforded by CPAP introduction. RESULTS: Multivariate binary logistic regression analysis identified one criterion of non-adherence to treatment, namely the feeling of breathlessness, and three criteria of adherence, namely awareness of the risk of complications, awareness of treatment efficacy, and feeling of being less tired with CPAP therapy. CONCLUSIONS: These four new criteria should preoperatively be sought, in order to detect non-adherent patients more efficiently.


Assuntos
Pressão Positiva Contínua nas Vias Aéreas , Cooperação do Paciente/estatística & dados numéricos , Apneia Obstrutiva do Sono/terapia , Idoso , Anestesia , Pressão Positiva Contínua nas Vias Aéreas/efeitos adversos , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Período Perioperatório , Cuidados Pré-Operatórios , Estudos Prospectivos , Fatores Socioeconômicos
13.
Rev Med Liege ; 69 Spec No: 31-5, 2014.
Artigo em Francês | MEDLINE | ID: mdl-25796795

RESUMO

Electroencephalography (EEG) records brain electrical activity at the scalp level. As a functional and non invasive witness of brain activity, EEG has long raised the interest of researchers and practitioners, notably in the domain of anesthesia. Thanks to technical advances, this complex signal can now be dissected, and a huge amount of information can be extracted from it. This information gives the opportunity to quantify theeffects of general anesthesia on the brain, and provides a better understanding of the underlying mechanisms.


Assuntos
Anestesia , Eletroencefalografia , Monitorização Neurofisiológica Intraoperatória/métodos , Humanos
14.
Acta Anaesthesiol Belg ; 65(4): 137-49, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25622379

RESUMO

Preeclampsia was formerly defined as a multisystemic disorder characterized by new onset of hypertension (i.e. systolic blood pressure (SBP) ≥ 140 mmHg and/or diastolic blood pressure (DBP) ≥ 90 mmHg) and proteinuria (> 300 mg/24 h) arising after 20 weeks of gestation in a previously normotensive woman. Recently, the American College of Obstetricians and Gynecologists has stated that proteinuria is no longer required for the diagnosis of preeclampsia. This complication of pregnancy remains a leading cause of maternal morbidity and mortality. Clinical signs appear in the second half of pregnancy, but initial pathogenic mechanisms arise much earlier. The cytotrophoblast fails to remodel spiral arteries, leading to hypoperfusion and ischemia of the placenta. The fetal consequence is growth restriction. On the maternal side, the ischemic placenta releases factors that provoke a generalized maternal endothelial dysfunction. The endothelial dysfunction is in turn responsible for the symptoms and complications of preeclampsia. These include hypertension, proteinuria, renal impairment, thrombocytopenia, epigastric pain, liver dysfunction, hemolysis-elevated liver enzymes-low platelet count (HELLP) syndrome, visual disturbances, headache, and seizures. Despite a better understanding of preeclampsia pathophysiology and maternal hemodynamic alterations during preeclampsia, the only curative treatment remains placenta and fetus delivery. At the time of diagnosis, the initial objective is the assessment of disease severity. Severe hypertension (SBP ≥ 160 mm Hg and/or DBP ≥ 110 mmHg), thrombocytopenia < 100.000/µL, liver transaminases above twice the normal values, HELLP syndrome, renal failure, persistent epigastric or right upper quadrant pain, visual or neurologic symptoms, and acute pulmonary edema are all severity criteria. Medical treatment depends on the severity of preeclampsia, and relies on antihypertensive medications and magnesium sulfate. Medical treatment does not alter the course of the disease, but aims at preventing the occurrence of intracranial hemorrhages and seizures. The decision of terminating pregnancy and perform delivery is based on gestational age, maternal and fetal conditions, and severity of preeclampsia. Delivery is proposed for patients with preeclampsia without severe features after 37 weeks of gestation and in case of severe preeclampsia after 34 weeks of gestation. Between 24 and 34 weeks of gestation, conservative management of severe preeclampsia may be considered in selected patients. Antenatal corticosteroids should be administered to less than 34 gestation week preeclamptic women to promote fetal lung maturity. Termination of pregnancy should be discussed if severe preeclampsia occurs before 24 weeks of gestation. Maternal end organ dysfunction and non-reassuring tests of fetal well-being are indications for delivery at any gestational age. Neuraxial analgesia and anesthesia are, in the absence of thrombocytopenia, strongly considered as first line anesthetic techniques in preeclamptic patients. Airway edema and tracheal intubation-induced elevation in blood pressure are important issues of general anesthesia in those patients. The major adverse outcomes associated with preeclampsia are related to maternal central nervous system hemorrhage, hepatic rupture, and renal failure. Preeclampsia is also a risk factor for developing cardiovascular disease later in life, and therefore mandates long-term follow-up.


Assuntos
Pré-Eclâmpsia/terapia , Analgesia Obstétrica , Anestesia Obstétrica , Anti-Hipertensivos/uso terapêutico , Feminino , Hidratação , Humanos , Pré-Eclâmpsia/etiologia , Gravidez , Fatores de Risco
15.
Ann Fr Anesth Reanim ; 33(2): 135-7, 2014 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-24365153

RESUMO

Deciding to cease treatment in intensive care unit patients whose prognosis is hopeless allows programming the moment of death, and hence, post mortem transplantable organ donation. Such organ donations are more frequent in Anglo-Saxon countries. In the context of growing organ needs, they have significantly increased the number of organs that are available for transplant. Progressive experience has shown that crystal-clear procedures must be set up in order to avoid lack of understanding, opposition, or even conflict between involved medical teams and immediate relatives of potential donors. The decision of organ transplantation must totally be separated from the decision of treatment cessation. Supportive treatment cessation must be done according to previously established procedures. Medications that are compatible with organ transplantation must be listed. Finally, the needs of patient relatives must be met.


Assuntos
Doadores de Tecidos/classificação , Obtenção de Tecidos e Órgãos/ética , Suspensão de Tratamento , Atitude do Pessoal de Saúde , Atitude Frente a Morte , Morte Encefálica , Cuidados Críticos , Morte , Tomada de Decisões , Dissidências e Disputas , Comissão de Ética , França , Parada Cardíaca , Humanos , Internacionalidade , Futilidade Médica , Equipe de Assistência ao Paciente , Relações Profissional-Família , Prognóstico , Assistência Terminal/legislação & jurisprudência , Coleta de Tecidos e Órgãos , Obtenção de Tecidos e Órgãos/legislação & jurisprudência , Obtenção de Tecidos e Órgãos/normas , Isquemia Quente , Suspensão de Tratamento/legislação & jurisprudência
16.
Arch Ital Biol ; 150(2-3): 155-63, 2012.
Artigo em Inglês | MEDLINE | ID: mdl-23165875

RESUMO

This paper reviews the current knowledge about the mechanisms of anesthesia-induced alteration of consciousness. It is now evident that hypnotic anesthetic agents have specific brain targets whose function is hierarchically altered in a dose-dependent manner. Higher order networks, thought to be involved in mental content generation, as well as sub-cortical networks involved in thalamic activity regulation seems to be affected first by increasing concentrations of hypnotic agents that enhance inhibitory neurotransmission. Lower order sensory networks are preserved, including thalamo-cortical connectivity into those networks, even at concentrations that suppress responsiveness, but cross-modal sensory interactions are inhibited. Thalamo-cortical connectivity into the consciousness networks decreases with increasing concentrations of those agents, and is transformed into an anti-correlated activity between the thalamus and the cortex for the deepest levels of sedation, when the subject is non responsive. Future will tell us whether these brain function alterations are also observed with hypnotic agents that mainly inhibit excitatory neurotransmission. The link between the observations made using fMRI and the identified biochemical targets of hypnotic anesthetic agents still remains to be identified.


Assuntos
Anestesia Geral/métodos , Mapeamento Encefálico , Encéfalo/irrigação sanguínea , Estado de Consciência/fisiologia , Imageamento por Ressonância Magnética , Anestésicos/farmacologia , Encéfalo/efeitos dos fármacos , Estado de Consciência/efeitos dos fármacos , Lateralidade Funcional , Humanos , Processamento de Imagem Assistida por Computador , Oxigênio/sangue
18.
Acta Anaesthesiol Scand ; 56(6): 787-96, 2012 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-22288889

RESUMO

BACKGROUND: The Surgical Pleth Index (SPI), derived from pulse amplitude and heartbeat interval, is proposed to monitor anti-nociception during anaesthesia. Its response to noxious stimulation can be affected by the intravascular volume status. This study investigated the effect of a fluid challenge (FC) on SPI during steady-state conditions. METHODS: After Institutional Review Board approval, 33 consenting patients undergoing neurosurgery received a 4 ml/kg starch FC over less than 5 min under stable surgical stimulation conditions and stable propofol (Ce(PPF) ) and remifentanil (Ce(REMI) ) effect-site concentrations as estimated by target-controlled infusion systems. Intravascular volume status was assessed using the Delta Down (DD). We looked at the SPI response to FC according to DD, Ce(PPF) , and Ce(REMI) . RESULTS: Following FC, SPI did not change in 16, increased in 12, and decreased in 3 patients. Ce(REMI) poorly affected the SPI response to FC. In normovolaemic patients, the probability of an SPI change after FC was low under common Ce(PPF) (0.9 to 3.9 µg/ml). A decrease in SPI was more probable with worsening hypovolaemia and lowering Ce(PPF) , while an increase in SPI was more probable with increasing Ce(PPF) . SPI changes were only attributable to modifications in pulse wave amplitude and not in heart rate. CONCLUSIONS: During stable anaesthesia and surgery, SPI may change in response to FC. The effect of FC on SPI is influenced by volaemia and Ce(PPF) through pulse wave amplitude modifications. These situations may confound the interpretation of SPI as a surrogate measure of the nociception-anti-nociception balance.


Assuntos
Anestesia Intravenosa , Anestésicos Intravenosos , Volume Sanguíneo/fisiologia , Monitorização Intraoperatória/métodos , Piperidinas , Propofol , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Anestesia Geral , Pressão Sanguínea/fisiologia , Estudos de Coortes , Interpretação Estatística de Dados , Relação Dose-Resposta a Droga , Feminino , Frequência Cardíaca/fisiologia , Humanos , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos , Oxigênio/sangue , Medição da Dor/métodos , Pletismografia , Remifentanil , Adulto Jovem
19.
Acta Anaesthesiol Belg ; 62(3): 161-71, 2011.
Artigo em Inglês | MEDLINE | ID: mdl-22145259

RESUMO

This review aims at defining the link between physiological sleep and general anesthesia. Despite common behavioral and electrophysiological characteristics between both states, current literature suggests that the transition process between waking and sleep or anesthesia-induced alteration of consciousness is not driven by the same sequence of events. On the one hand, sleep originates in sub-cortical structures with subsequent repercussions on thalamo-cortical interactions and cortical activity. On the other hand, anesthesia seems to primarily affect the cortex with subsequent repercussions on the activity of sub-cortical networks. This discrepancy has yet to be confirmed by further functional brain imaging and electrophysiological experiments. The relationship between the observed functional modifications of brain activity during anesthesia and the known biochemical targets of hypnotic anesthetic agents also remains to be determined.


Assuntos
Anestesia Geral , Sono/fisiologia , Nível de Alerta/efeitos dos fármacos , Nível de Alerta/fisiologia , Estado de Consciência , Eletroencefalografia , Humanos , Ketamina/farmacologia , Sono/efeitos dos fármacos
20.
Acta Anaesthesiol Belg ; 62(2): 87-90, 2011.
Artigo em Inglês | MEDLINE | ID: mdl-21919375

RESUMO

The Spectral Entropy proposed to monitor the depth of anesthesia includes the State Entropy (SE) computed from the EEG (0.8-32 Hz frequency band), and the Response Entropy (RE) computed from EEG and facial muscles activity (0.5-47 Hz frequency band). We report an unexpected Entropy response to saline spraying at the end of posterior fossa surgery. Six patients undergoing scheduled functional surgery of the posterior fossa were included in this report. They were anesthetized with propofol and remifentanil using TCI and received an intubation dose of rocuronium. At the end of surgery, saline spraying, performed for hemostatic purpose and wreckage elimination, resulted in a sustained increase in RE and SE without hemodynamic modification in four patients, while no change was observed in the two other ones. In one of the responding patients, 0.1 mg kg(-1) rocuronium attenuated the Entropy response. In the two non responders, repetition of spraying or rocuronium administration did not change Entropy value. Recovery from anesthesia was comparable in all patients and none of them complained from awareness. We conclude that Entropy can increase during posterior fossa surgery in non-paralyzed patients. This response probably reflects an increase in facial muscle activity rather than a change in depth of anesthesia, as far as it can be attenuated by a small dose of rocuronium. While this hypothesis requires further investigation, these observations suggest that saline spraying may confound interpretation of Entropy during posterior fossa surgery.


Assuntos
Encéfalo/cirurgia , Eletroencefalografia/efeitos dos fármacos , Cloreto de Sódio/administração & dosagem , Administração Tópica , Adulto , Androstanóis , Anestésicos Intravenosos , Pressão Sanguínea/efeitos dos fármacos , Encéfalo/efeitos dos fármacos , Entropia , Músculos Faciais/efeitos dos fármacos , Frequência Cardíaca/efeitos dos fármacos , Técnicas Hemostáticas , Humanos , Monitorização Intraoperatória/métodos , Fármacos Neuromusculares não Despolarizantes , Piperidinas , Propofol , Remifentanil , Rocurônio , Volatilização
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