La anestesia subaracnoidea no produce disfunción ventricular izquierda transitoria en pacientes mayores de 60 años sin enfermedad cardiovascular / Spinal anesthesia does not cause left ventricular dysfunction in patients older than 60 years without cardiovascular disease

Objetivos: Evaluar la función sistólica ventricular izquierda por ecocardiograma transtorácico en pacientes mayores de 60 años, sin enfermedad cardiovascular, bajo anestesia subaracnoidea instaurada. Pacientes y métodos: Estudio observacional prospectivo con un total de 54 pacientes mayores de 60 años sin enfermedad cardiovascular, a quienes, tras la instauración de una anestesia subaracnoidea con bupivacaína hiperbárica al 0,5% con bloqueo sensitivoT10 o mayor, se les midió la función sistólica ventricular izquierda a partir del movimiento sistólico del anillo mitral (mitral anular plane systolic excursion [MAPSE].) Además, se midió el índice de colapsabilidad de vena cava inferior (ICVCI), la integral velocidad tiempo del tracto de salida del ventrículo izquierdo (ITTSVI) y del gasto cardiaco (GC). Los valores a los 5min del bloqueo se compararon con los obtenidos previamente al mismo. Resultados: Se evidenció una disminución del 3,3% del MAPSE y una ligera disminución del IVTTSVI y GC, en ningún caso con significación estadística ni clínica. El 14,8% de los pacientes presentó presión arterial media (PAM) igual o inferior a 60mmHg. La comparación de los cambios ecocardiográficos entre estos pacientes y los que no presentaron hipotensión no fueron estadísticamente significativos ni clínicamente relevantes. Discusión: Se demuestra que la anestesia subaracnoidea con nivel anestésico T10 o superior en pacientes mayores de 60 años sin enfermedad cardiovascular, es una técnica segura ya que no altera de forma significativa parámetros ecocardiográficos de medición de la función sistólica ventricular izquierda.(AU)

Background: Elderly patients are undergoing surgery more frequently than ever. In this population, spinal anesthesia, which is known to cause sympathetic blockade associated with arterial vasodilation, is proposed as an excellent option. However, its effects on left ventricular systolic function have not been studied. Objectives: To evaluate left ventricular systolic function by transthoracic echocardiography in patients older than 60 years, without prior cardiovascular disease, under spinal anesthesia. Patients and methods: Prospective observational study with a total of 54 patients older than 60 years without prior cardiovascular disease, in whom, after the completion of subarachnoid anesthesia with hyperbaric 0.5% bupivacaine with sensory block equal to or greater than T10, left ventricular systolic function was measured using MAPSE. In addition, CI-IVC, LVOT-VTI and CO were measured. Values at 5 minutes after the blockade were compared with those obtained previously. Results: A 3.3% decrease in MAPSE and a slight decrease in LVOT-VTI and CO were found, with no statistical or clinical significance. The 14.8% of the patients presented MAP equal to or less than 60mmHg. Comparison of echocardiographic changes between hypotensive and non-hypotensive patients was not statistically significant or clinically relevant. Discussion: Our study shows that spinal anesthesia with anesthetic level T10 or higher in patients older than 60 years without cardiovascular disease is a safe technique since it does not significantly alter echocardiographic parameters measuring left ventricular systolic function.(AU)

Spinal anesthesia does not cause left ventricular dysfunction in patients older than 60 years without cardiovascular disease.

BACKGROUND: Elderly patients are undergoing surgery more frequently than ever. In this population, spinal anesthesia, which is known to cause sympathetic blockade associated with arterial vasodilation, is proposed as an excellent option. However, its effects on left ventricular systolic function have not been studied. OBJECTIVES: To evaluate left ventricular systolic function by transthoracic echocardiography in patients older than 60 years, without prior cardiovascular disease, under spinal anesthesia. PATIENTS AND METHODS: Prospective observational study with a total of 54 patients older than 60 years without prior cardiovascular disease, in whom, after the completion of subarachnoid anesthesia with hyperbaric 0.5% bupivacaine with sensory block equal to or greater than T10, left ventricular systolic function was measured using MAPSE. In addition, CI-IVC, LVOT-VTI and CO were measured. Values at 5 min after the blockade were compared with those obtained previously. RESULTS: A 3.3% decrease in MAPSE and a slight decrease in LVOT-VTI and CO were found, with no statistical or clinical significance. 14.8% of the patients presented MAP equal to or less than 60 mmHg. Comparison of echocardiographic changes between hypotensive and non-hypotensive patients was not statistically significant or clinically relevant. DISCUSSION: Our study shows that spinal anesthesia with anesthetic level T10 or higher in patients older than 60 years without cardiovascular disease is a safe technique since it does not significantly alter echocardiographic parameters measuring left ventricular systolic function.

Síndrome de cauda equina posterior a la administración por vía subaracnoidea de bupivacaina hiperbárica al 0, 75 % / Cauda equina syndrome following subarachnoid administration of hyperbaric bupivacaine 0. 75 %

El síndrome de cauda equina es una patología poco frecuente en el área de anestesiología. Esta se caracteriza por presentar un conjunto de signos y síntomas que involucran: dolor, disminución o abolición de la fuerza muscular, disfunción de esfínteres e hipoestesia de silla de montar. El objetivo del presente trabajo es presentar y discutir el caso clínico de una paciente con diagnóstico de síndrome de cauda equina posterior a la administración por vía subaracnoidea de bupivacaina al 0,75 % hiperbárica. Se trata de paciente femenina de 42 años a quien se le realizó cesárea segmentaria y salpingectomia bilateral con bloqueo anestésico subaracnoideo; y quien posteriormente a las dieciséis horas del posoperatorio presentó: disminución de la fuerza muscular de miembros inferiores e hipoestesia de región de silla de montar, reflejo rotuliano: 0/4 bilateral y retención urinaria. Se le inicia tratamiento farmacológico y fisiátrico inmediatamente establecido el diagnóstico de síndrome de cauda equina. La paciente fue dada de alta el día diez del posoperatorio, con disminución significativa de la clínica antes descrita, evidenciándose posteriormente retención urinaria por lo que requirió sondaje vesical intermitente. Una vez establecido el diagnostico se instaló inmediatamente tratamiento farmacológico y fisiátrico para dar una oportuna resolución de la patología(AU)

Cauda equina syndrome is a rare pathology in the area of anesthesiology. This is characterized by presenting a set of signs and symptoms that involve: pain, decrease or abolition of muscle strength, sphincter dysfunction and saddle hypoesthesia. The objective of this work is to present and discuss the clinical case of a patient with a diagnosis of cauda equina syndrome after the administration of hyperbaric 0.75% bupivacaine via the subarachnoid route. This is a 42-year-old female patient who underwent segmental cesarean section and bilateral salpingectomy with subarachnoid anesthetic block; and who subsequently at sixteen hours postoperatively presented: decreased muscle strength, lower limbs and hypoesthesia of the saddle region, knee jerk reflex: bilateral 0/4 and urinary retention. Pharmacological and physical treatment was started immediately, the diagnosis of cauda equina syndrome was established. The patient was discharged on postoperative day 10, with a significant decrease in the symptoms described above, later evidence of urinary retention, requiring intermittent bladder catheterization. Once the diagnosis was established, pharmacological and physiatric treatment was immediately installed to give a timely resolution of the pathology(AU)

Anaesthetic management of C-section in Brugada syndrome: When less is more. / Manejo anestésico del síndrome de Brugada para cesárea: cuando menos es más.

Brugada Syndrome (BrS) is a rare and high risk condition, seldom encountered in the delivery room. Pregnant patients with BrS benefit from the lowest possible doses of arrhythmogenic drugs such as local anesthetics. Based on this premise, the following case report exposes how a subarachnoid approach might be a desirable technique in C-section procedures for BrS patients. Pain and anxiety management are priorities in this specific population. Peri-partum planning, with a previous anesthesiology appointment and mutidisciplinary care in tertiary hospital facilities are crucial to avoid complications.

Falla o resistencia en la anestesia espinal para cesárea / Failure or resistance in spinal anesthesia for cesarean section

Introducción: La anestesia regional es la más empleada en la cesárea obstétrica. En particular, el uso de la anestesia intratecal tiene sus ventajas. Aunque la tasa de falla es baja, la aparición de este evento genera dificultades que merecen atención. Objetivo: Describir la conducta anestésica en una paciente obstétrica en la que falla la anestesia regional intratecal. Caso clínico: Paciente femenina, de 20 años a la que se le administró anestesia intratecal por el especialista. No hubo errores en la punción lumbar, esta se realizó con trócar 25 punta Whitacre. No se constató bloqueo sensitivo, motor ni simpático, por lo que se realizó anestesia general endotraqueal, la cual transcurrió sin dificultades. En el posoperatorio inmediato se observa hiperlaxitud articular lo que llevó a sospechar el diagnóstico. Este fue positivo conjuntamente con el servicio de Neurología, se determinó Síndrome de Ehlers danlos tipo III. Conclusiones: El índice de falla es muy bajo en anestesia suaracnoidea pero si se presenta un paciente de este tipo, debe descartarse por completo. Existen pocos casos documentados de resistencia a la anestesia local; pero si así fuera, debe estudiarse exhaustivamente para buscar estrategias que permitan un acto anestésico óptimo(AU)

Introduction: Regional anesthesia is the most used in obstetric caesarean section. In particular, the use of intrathecal anesthesia has its advantages. Although the failure rate is low, the onset of this event generates difficulties that deserve attention. Objective: To describe the anesthetic management in an obstetric patient with failure of regional intrathecal anesthesia. Clinical case: Female patient, aged 20 years, who was administered intrathecal anesthesia by the specialist. There were no errors in the lumbar puncture, this was done with a trocar 25 of Whitacre tip. No sensory, motor or sympathetic block was observed, so general endotracheal anesthesia was performed, which went on smoothly. In the immediate postoperative period, joint hypermobility was observed, leading to suspicion of the diagnosis. This was positive in conjunction with the Neurology service, Ehlers-Danlos syndrome type 3 was determined. Conclusions: The failure rate is very low for subarachnoid anesthesia. However, for a patient of this type, it should be completely ruled out. There are few documented cases of resistance to local anesthesia. If it were the case, it should be studied exhaustively to look for strategies that allow an optimal anesthetic management(AU)

Fentanil y bupivacaína al 0, 5 porciento en ancianos con fractura de cadera operados con anestesia subaracnoidea / Fentanyl and 0, 5 percent bupivacaine in elderly patients with hip fracture operated on under subarachnoid anesthetic

Fundamento: el paciente anciano tiene mayor riesgo de presentar inestabilidad hemodinámica y complicaciones anestésicas durante el perioperatorio. Objetivo: describir la estabilidad hemodinámica en los ancianos operados de fractura de cadera utilizando anestesia subaracnoidea, en el hospital Ernesto Guevara de la Serna, entre enero- diciembre de 2015. Métodos: se realizó un estudio longitudinal, prospectivo, en el lugar y período señalados. El universo de estudio estuvo constituido por todos los pacientes ancianos con fractura de cadera, a los cuales se les practicó cirugía para corrección de la misma, y la muestra por 47 pacientes con estado físico ASA II y III, operados utilizando anestesia subaracnoidea con dosis de bupivacaína 0,5 por ciento 8 mg más fentanil 25 mcg. Se utilizó la estadística descriptiva a través del análisis porcentual. Resultados: predominaron los pacientes del sexo femenino en el 70,21 por ciento, el 63,82 por ciento pertenecieron al grupo de edad entre 76 y 85 años; fueron más frecuentes los pacientes con estado físico ASA II con el 68,1 por ciento; el 87,23 por ciento presentó estabilidad de la tensión arterial, la frecuencia cardiaca se mantuvo normal en el 83 por ciento, el efecto secundario más frecuente fue el prurito leve, el cual se presentó en el 100 por ciento de los casos, seguido de la somnolencia en el 74,4 por ciento. Conclusiones: la mayoría de los pacientes ancianos que fueron operados de fractura de cadera con anestesia subaracnoidea, utilizando la asociación de fentanil 25 mcg más bupivacaína al 0,5 por ciento 8 mg, mostraron estabilidad hemodinámica en cuanto a tensión arterial y frecuencia cardíaca. La totalidad de los casos refirieron prurito facial leve como efecto adverso(AU)

Background: the elderly patient is at a greater risk of hemodynamic instability and anesthetic complications during the perioperative period. Objective: to describe the hemodynamic stability in the elderly operated on for hip fracture using subarachnoid anesthetic, at the Ernesto Guevara de la Serna Hospital from January through December 2015. Methods: a prospective longitudinal study was carried out at the place and during the period herein mentioned. The study universe consisted of all the elderly patients with hip fracture, who underwent surgery to correct it. The sample was made up of 47 patients with ASA 2 and 3 physical statuses, who were operated on using subarachnoid anesthetic with doses of bupivacaine, 0,5 percent 8 mg plus fentanyl, 25 mcg. Descriptive statistics was used by means of percentage analysis. Results: female patients prevailed in 70,21 percent; 63,82 percent belonged to the 76 to 85 age group; patients with ASA 2 physical status were more frequent with 68,1 percent; 87,23 percent showed stability of blood pressure; heart rate remained normal in 83 percent; the most common side effect was mild pruritus, which occurred in 100 percent of the cases, followed by drowsiness in 74,4 percent. Conclusions: most of the elderly patients who were operated on for hip fracture under subarachnoid anesthetic using the combination of fentanyl, 25 mcg plus 0,5 percent bupivacaine, 8 mg showed hemodynamic stability in terms of blood pressure and heart rate. All cases reported mild facial pruritus as an adverse effect(AU)

Is there any benefit in associating neuraxial anesthesia to general anesthesia for coronary artery bypass graft surgery? / Existe algum benefício em associar a anestesia neuroaxial à anestesia geral para revascularização miocárdica?

ABSTRACT BACKGROUND AND OBJECTIVES: The use of neuraxial anesthesia in cardiac surgery is recent, but the hemodynamic effects of local anesthetics and anticoagulation can result in risk to patients. OBJECTIVE: To review the benefits of neuraxial anesthesia in cardiac surgery for CABG through a systematic review of systematic reviews. CONTENT: The search was performed in Pubmed (January 1966 to December 2012), Embase (1974 to December 2012), The Cochrane Library (volume 10, 2012) and Lilacs (1982 to December 2012) databases, in search of articles of systematic reviews. The following variables: mortality, myocardial infarction, stroke, in-hospital length of stay, arrhythmias and epidural hematoma were analyzed. CONCLUSIONS: The use of neuraxial anesthesia in cardiac surgery remains controversial. The greatest benefit found by this review was the possibility of reducing postoperative arrhythmias, but this result was contradictory among the identified findings. The results of findings regarding mortality, myocardial infarction, stroke and in-hospital length of stay did not show greater efficacy of neuraxial anesthesia.

RESUMO JUSTIFICATIVA E OBJETIVOS: O uso da anestesia neuroaxial em cirurgia cardíaca é recente, porém os efeitos hemodinâmicos dos anestésicos locais e a anticoagulação podem trazer riscos aos pacientes. OBJETIVO: Revisar os benefícios da anestesia neuroaxial em cirurgia cardíaca para revascularização miocárdica por meio de uma revisão sistemática de revisões sistemáticas. CONTEÚDO: Foi feita pesquisa nas bases de dados Pubmed (de janeiro de 1966 a dezembro de 2012), Embase (1974 a dezembro 2012), The Cochrane Library (volume 10, 2012) e Lilacs (1982 a dezembro de 2012) em busca de artigos de revisões sistemáticas. Foram analisadas as seguintes variáveis: mortalidade, infarto do miocárdio, acidente vascular cerebral, tempo de internação hospitalar, arritmias e hematoma peridural. CONCLUSÕES: O uso da anestesia neuroaxial para revascularização miocárdica permanece controverso. O maior benefício encontrado por meio desta revisão foi a possibilidade de redução das arritmias pós-operatórias, porém esse resultado foi contraditório entre as evidências identificadas. Os resultados das evidências encontradas referentes à mortalidade, ao infarto do miocárdio, ao acidente vascular cerebral e ao tempo de internação hospitalar não mostraram maior efetividade da anestesia neuroaxial.

Is there any benefit in associating neuraxial anesthesia to general anesthesia for coronary artery bypass graft surgery?

BACKGROUND AND OBJECTIVES: The use of neuraxial anesthesia in cardiac surgery is recent, but the hemodynamic effects of local anesthetics and anticoagulation can result in risk to patients. OBJECTIVE: To review the benefits of neuraxial anesthesia in cardiac surgery for CABG through a systematic review of systematic reviews. CONTENT: The search was performed in Pubmed (January 1966 to December 2012), Embase (1974 to December 2012), The Cochrane Library (volume 10, 2012) and Lilacs (1982 to December 2012) databases, in search of articles of systematic reviews. The following variables: mortality, myocardial infarction, stroke, in-hospital length of stay, arrhythmias and epidural hematoma were analyzed. CONCLUSIONS: The use of neuraxial anesthesia in cardiac surgery remains controversial. The greatest benefit found by this review was the possibility of reducing postoperative arrhythmias, but this result was contradictory among the identified findings. The results of findings regarding mortality, myocardial infarction, stroke and in-hospital length of stay did not show greater efficacy of neuraxial anesthesia.

Single shot spinal anaesthesia with hypobaric bupivacaine for hip fracture repair surgery in the elderly. Randomized, double blinded comparison of 3.75 mg vs. 7.5 mg.

BACKGROUND: Arterial hypotension is the most frequent adverse effect of subarachnoid anaesthesia in the elderly sustaining a femoral proximal fracture. Decreasing the local anaesthetic dose reduces the incidence of hypotension but shortens sensory block duration that could be insufficient in some surgical procedures. Sensory block duration could be prolonged using hypobaric local anaesthetics. We evaluated whether low hypobaric bupivacaine doses were adequate for this type of surgery while maintaining the haemodynamic stability. METHODS: A prospective, randomized, double blinded study was designed. Patients over 65 years old, sustaining traumatic hip fracture, were assigned to one of two groups: B0.5 group, hypobaric bupivacaine 7.5mg 5mg/ml (control group), and B0.25 group, hypobaric bupivacaine 3.75 mg 2.5mg/ml (study group). After subarachnoid injection, sensory level and motor blockade degree were registered, as were blood pressure, and heart rate at basal time and at 2, 5, 10, 15, 20 and 30 min after injection. The doses of vasopressor needed were registered as well. Surgical conditions and the duration of the surgical procedure-whether rescue analgesia or anaesthesia was needed-and sensory level regression to T12, were registered as well. RESULTS: Sixty four patients was the calculated sample size. The study was stopped in an interim analysis because an elevated number of patients in the B0.25 group needed iv rescue anaesthesia. In the analyzed cases, blood pressure was significantly lower in the B0.5 group at the 15 and 30 min measurements. Vasopressor drugs needs were similar between groups [ephedrine accumulated mean (SD) doses 11.4 (5.2) mg vs. 9.1 (2.7) mg, p=0.045)]. Sensory block regression to T12 was faster in the B0.25 group, [(mean (SD) 68.2 (29.0) min vs. 112.8 (17.3) min in the B0.5 group, p<0.05]. Five out of 19 patients in the B0.25 group needed intravenous anaesthesia rescue before surgery started. CONCLUSION: Lowering hypobaric bupivacaine dose to 3.75 mg in subarachnoid anaesthesia for hip fracture repair surgery in elderly patients decrease intraoperative blood pressure, but in an important number of patients intravenous anaesthesia rescue was needed and preclude recommendation.

Single shot spinal anesthesia with very low hyperbaric bupivacaine dose (3.75 mg) for hip fracture repair surgery in the elderly. A randomized, double blinded study.

PURPOSE: Single shot spinal anesthesia is used worldwide for hip fracture repair surgery in the elderly. Arterial hypotension is a frequent adverse effect. We hypothesized that lowering local anesthetics dose could decrease the incidence of arterial hypotension, while maintaining quality of surgical anesthesia. METHODS: In a randomized double blinded study, 66 patients over the age of 65 years, with hip fracture needing surgical repair, were assigned to B0.5 group 7.5mg hyperbaric bupivacaine 5mg/ml (control group), and B0.25 group 3.75mg hyperbaric bupivacaine 2.5mg/ml (study group). Sensory and motor block level, and hemodynamic parameters including blood presure, heart rate and vasopressor dose administration were registered, along with rescue anesthesia needs, the feasibility of surgery, its duration, and regression time of sensory anesthesia to T12. RESULTS: After exclusions, 61 patients were included in the final analysis. Arterial hypotension incidence was lower in the B0.25 group (at the 5, 10, and 15min determinations), and a lower amount of vasopressor drugs was needed (mean accumulated ephedrine dose 1.6mg vs. 8.7mg in the B0.5 group, p<0.002). Sensory block regression time to T12 was shorter in the B0.25 group, mean 78.6±23.6 (95% CI 51.7-110.2)min vs. 125.5±37.9 (95% CI 101.7-169.4)min in the B0.5 group, p=0.033. All but one patient in the B0.25 group were operated on under the anesthetic procedure first intended. No rescue anesthesia was needed. CONCLUSION: Lowering bupivacaine dose for single shot spinal anesthesia for hip fracture repair surgery in elderly patients was effective in decreasing the occurrence of arterial hypotension and vasopressor use, while intraoperative quality remained.

[Spinal anesthesia versus general anesthesia in the surgical treatment of inguinal hernia. Cost-effectiveness analysis]. / Anestesia subaracnoidea y anestesia general en el tratamiento quirúrgico de la hernia inguinal en pacientes ambulatorios. Análisis comparativo de coste-efectividad.

OBJECTIVE: To compare the costs related to the clinical effectiveness of general anesthesia versus spinal anesthesia in inguinal hernioplasty ambulatory surgery. MATERIAL AND METHODS: An observational, retrospective cohort study measurement and analysis of cost-effectiveness, in the ambulatory surgery unit of a general hospital. All patients over 18 years of age diagnosed with primary inguinal hernia and scheduled for unilateral hernioplasty between January 2010 and December 2011 were included. Duration of anesthetic induction, length of stay in both the operating room, and in the post-anesthesia care unit, the anesthetic effectiveness (the incidence of adverse effects and the patient's comfort level), and variable economic costs associated with the use of drugs, as well as the use of human resources, were compared. RESULTS: The final analysis included 218 patients, 87.2% male, with a mean age of 53 years (range: 18-85 years). Of these, 139 (63.76%) received subarachnoid anesthesia and 79,(36.2%) general anesthesia. The length of time a patient remained in the post-anesthesia care unit was 337.6±160.2min in the subarachnoid anesthesia group, and 210.0±97.5min for the general anesthesia group (P<.001). Costs of drugs for general anesthesia were higher than that for subarachnoid anesthesia (86.2±8.3 vs. 18.7±7.2). The total cost difference between the 2 techniques was €115.8 more for subarachnoid anesthesia (P<.001). CONCLUSIONS: Both techniques showed similar effectiveness. The overall costs for subarachnoid anesthesia were greater than for the general. The cost-effectiveness of general anesthesia is better for outpatient inguinal hernia repair surgery.

[Hypobaric metameric subarachnoid anaesthesia for anaesthetic management in vertebral reinforcement techniques. Our experience in 6 cases]. / Anestesia subaracnoidea hipobárica metamérica para las técnicas de refuerzo vertebral. Experiencia en 6 casos.

Vertebral reinforcement techniques, such as percutaneous vertebroplasty and kyphoplasty, are minimally invasive procedures used in the treatment of fractured or collapsed vertebras. The anaesthetic techniques employed during these procedures are diverse and with variable results. We report 6 cases, vertebroplasty and kyphoplasty using subarachnoid metameric anaesthesia with a hypobaric technique. Haemodynamic stability and analgesia were satisfactory in all of them.

Black esophagus (acute esophageal necrosis) after spinal anesthesia.

Acute esophagic necrosis or black esophagus is an uncommon clinical entity that owes its name to the endoscopic view of the necrotic esophageal mucosa. It is always related with a critical medical condition and usually has an ischemic etiology. We report the first case of acute esophageal necrosis after a spinal anesthetic for partial hip joint arthroplasty. We discuss the underlying pathophysiological mechanisms.

Spinal anaesthesia in a patient with post-spine surgery dural ectasia.

Dural sac ectasia is a very infrequent anatomical abnormality, usually caused by connective tissue diseases, as Marfan syndrome. Very few cases have been described being a consequence of a previous spine surgical procedure. We describe the case of an elderly patient who should be operated on twice due to sub-occlusive colon disease. Surgery was performed under spinal anaesthesia. A dural sac ectasia was suspected after the first procedure and the abdominal X-ray was reviewed. The characteristics of the anatomical alteration and the course of both anaesthetic procedures were described. X-ray and CT images were provided.

Analgesia postoperatoria con el uso de morfina liofilizada / Postoperative analgesia with the use of lyophilized morphine

Introducción: la anestesia subaracnoidea morfínica es poco empleada para el alivio del dolor agudo postoperatorio durante las intervenciones quirúrgicas tanto electiva como de urgencia. Objetivo: describir la repercusión cardiorrespiratoria de la anestesia subaracnoidea morfínica en pacientes intervenidos quirúrgicamente. Métodos: se realizó un estudio descriptivo, prospectivo y longitudinal en una muestra aleatoria de 500 pacientes operados por el Servicio de Cirugía en el Hospital Militar de Holguín en el periodo comprendido de agosto del 2009 y octubre del 2012; quienes recibieron anestesia subaracnoidea con 150 mg de lidocaína hiperbárica más 0.4 mg de morfina liofilizada. Como variables se monitorizó la tensión arterial sistólica y diastólica, frecuencia cardiaca, frecuencia respiratoria, saturación pulsátil de oxígeno de la hemoglobina, intensidad del dolor postoperatorio, tiempo de analgesia postoperatoria, dosis de analgesia de rescate y efectos adversos. Resultados: la media del tiempo de analgesia postoperatoria se prolongó a más de 30 horas y la mayoría de los pacientes no demandaron analgesia de rescate en las primeras 48 horas. Predominaron el prurito y las náuseas y vómitos como efectos adversos. Conclusiones: la prolongación significativa de la analgesia con escasa demanda de analgesia de rescate y un estable comportamiento cardiorrespiratorio con una incidencia de efectos adversos menores, convierten a la anestesia subaracnoidea morfínica en un método útil y seguro para pacientes intervenidos quirúrgicamente, tanto electiva como de urgencia.

Background: anesthesia with subarachnoid Morphine is not very used to alleviate acute postoperative pain during either elective or emergency surgical interventions. Objective: to describe cardiorespiratory repercussion of anesthesia with subarachnoid Morphine in patients who have undergone surgery. Methods: a longitudinal prospective descriptive study was conducted in a random sample of 500 patients who underwent surgery in the Surgical Service of Military Hospital of Holguín during the period from August 2009 to October 2012, who received subarachnoid anesthesia with 150 mg of hyperbaric lidocaine and 0.4 mg of lyophilized morphine. Variables such as systolic and diastolic blood pressures, cardiac frequency, respiratory frequency, oxygen saturation of hemoglobin, intensity of postoperative pain, time of postoperative analgesia, doses of rescue analgesia and adverse effects were monitored. Results: The mean time of postoperative analgesia was prolonged to more than 30 hours and the majority of patients didn't demand rescue analgesia during the first 48 hours. Pruritus, nausea, and vomiting predominated as adverse effects. Conclusions: The significant extension of analgesia with scarce demand of rescue analgesia and a stable cardiorespiratory behavior with an incidence of minor adverse effects convert anesthesia with subarachnoid Morphine into a useful and safe method for patients who have undergone either elective or emergency surgery.

Analgesia postoperatoria con el uso de morfina liofilizada / Postoperative analgesia with the use of lyophilized morphine

Introducción: la anestesia subaracnoidea morfínica es poco empleada para el alivio del dolor agudo postoperatorio durante las intervenciones quirúrgicas tanto electiva como de urgencia. Objetivo: describir la repercusión cardiorrespiratoria de la anestesia subaracnoidea morfínica en pacientes intervenidos quirúrgicamente.Métodos: se realizó un estudio descriptivo, prospectivo y longitudinal en una muestra aleatoria de 500 pacientes operados por el Servicio de Cirugía en el Hospital Militar de Holguín en el periodo comprendido de agosto del 2009 y octubre del 2012; quienes recibieron anestesia subaracnoidea con 150 mg de lidocaína hiperbárica más 0.4 mg de morfina liofilizada. Como variables se monitorizó la tensión arterial sistólica y diastólica, frecuencia cardiaca, frecuencia respiratoria, saturación pulsátil de oxígeno de la hemoglobina, intensidad del dolor postoperatorio, tiempo de analgesia postoperatoria, dosis de analgesia de rescate y efectos adversos. Resultados: la media del tiempo de analgesia postoperatoria se prolongó a más de 30 horas y la mayoría de los pacientes no demandaron analgesia de rescate en las primeras 48 horas. Predominaron el prurito y las náuseas y vómitos como efectos adversos. Conclusiones: la prolongación significativa de la analgesia con escasa demanda de analgesia de rescate y un estable comportamiento cardiorrespiratorio con una incidencia de efectos adversos menores, convierten a la anestesia subaracnoidea morfínica en un método útil y seguro para pacientes intervenidos quirúrgicamente, tanto electiva como de urgencia(AU)

Background: anesthesia with subarachnoid Morphine is not very used to alleviate acute postoperative pain during either elective or emergency surgical interventions. Objective: to describe cardiorespiratory repercussion of anesthesia with subarachnoid Morphine in patients who have undergone surgery. Methods: a longitudinal prospective descriptive study was conducted in a random sample of 500 patients who underwent surgery in the Surgical Service of Military Hospital of HolguÝn during the period from August 2009 to October 2012, who received subarachnoid anesthesia with 150 mg of hyperbaric lidocaine and 0.4 mg of lyophilized morphine. Variables such as systolic and diastolic blood pressures, cardiac frequency, respiratory frequency, oxygen saturation of hemoglobin, intensity of postoperative pain, time of postoperative analgesia, doses of rescue analgesia and adverse effects were monitored. Results: The mean time of postoperative analgesia was prolonged to more than 30 hours and the majority of patients didn't demand rescue analgesia during the first 48 hours. Pruritus, nausea, and vomiting predominated as adverse effects. Conclusions: The significant extension of analgesia with scarce demand of rescue analgesia and a stable cardiorespiratory behavior with an incidence of minor adverse effects convert anesthesia with subarachnoid Morphine into a useful and safe method for patients who have undergone either elective or emergency surgery(AU)

[Prophylaxis and treatment of arterial hypotension during caesarean with spinal anaesthesia]. / Profilaxis y tratamiento de la hipotensión arterial en la cesárea con anestesia subaracnoidea.

Caesarean section is one of the most common surgical procedures worldwide. Arterial hypotension is the most prevalent adverse effect after spinal anaesthesia. Various methods have been used to prevent or treat hypotension. Since there is no treatment 100% effective by itself, a multimodal management is required to achieve an optimum balance and avoidance of hemodynamic imbalance. Strategies to avoid this side effect are analyzed on the basis of the best evidence available so far, summarized as mechanical factors, anesthetics, fluids and vasopressors. After spinal anaesthesia for caesarean section, the best strategy available for prevention of hypotension appears to be the combination of crystalloids along with an alpha 1 agonist vasopressor.

Anestesia subaracnoidea con ropivacaína hiperbárica versus bupivacaína hiperbárica asociadas a fentanilo para operación cesárea de urgencia.: Ensayo clínico controlado con asignación aleatoria

RESUMEN Introducción: se comparó la anestesia subaracnoidea con ropivacaína hiperbárica y bupivacaína hiperbárica ambas asociadas a fentanilo en pacientes sometidas a operación cesárea de urgencia. Se utilizaron dosis menores a las estudiadas hasta el momento, pero más adecuadas a las recomendadas en la actualidad. Objetivos: se buscó comparar los dos tipos de anestésico local analizando su incidencia en el bloqueo motor, como en el comportamiento hemodinámico intraoperatorio posterior a la administración subaracnoidea de las soluciones en estudio, y describir la frecuencia de efectos adversos asociados al procedimiento. Método: el estudio realizado es un ensayo clínico controlado con asignación aleatoria, multicéntrico, en pacientes embarazadas de término (37 a 41 semanas de embarazo), ASA I o II, entre 18 y 40 años que recibieron bupivacaína hiperbárica 10 mg más fentanilo 20 mg (grupo 1) o ropivacaína hiperbárica 15 mg más fentanilo 20 mg (grupo 2), por vía intratecal. Todas las drogas utilizadas en el presente protocolo se encuentran aprobadas por la ANMAT. Evaluando bloqueo motor, hemodinamia y efectos adversos. Resultados: no hubo diferencias significativas en cuanto a edad, talla, peso, edad gestacional y tiempo quirúrgico. La ropivacaína -suministrada en dosis equipotentes en relación con la bupivacaína- mostró un menor potencial en la prolongación del bloqueo motor. El grupo bupivacaína enseñó una mayor incidencia de hipotensión -con una significación de p= 0,02- en relación con la ropivacaína. Estos hallazgos se confirman a través de las diferencias en cuanto a la administración de efedrina requerida para cada uno de los grupos: más de 25% mayor para el grupo bupivacaína. Otros efectos adversos no presentaron significancia estadística. Conclusión: tanto la ropivacaína como la bupivacaína proporcionan seguridad y calidad en pacientes sometidas a operación cesárea de urgencia. Sin embargo, la ropivacaína presenta mayor eficiencia debido a la menor incidencia de complicaciones hemodinámicas y a una recuperación más rápida del bloqueo motor.

SUMMARY Introduction: we compared hyperbaric ropivacaine with hyperbaric bupivacaine in subarachnoid anesthesia, both associated to fentanyl, in patients subject to urgent cesarean section. The doses used were lower than those studied so far but more adequate than those currently recommended. Objectives: we compared the two types of local anesthesia and analyzed their effect on motor block and on hemodynamic performance during the surgery after the subarachnoid administration of the solutions under study; at the same time we described the frequency of adverse effects associated to this procedure. Method: the study performed consisted of a multicenter randomized controlled clinical trial, in term pregnant patients (37 to 41 weeks pregnant), ASA I or II, between 18 and 40 years of age, who received intrathecal hyperbaric bupivacaine 10 mg plus 20 mcg fentanyl (Group 1) or intrathecal hyperbaric ropivacaine 15 mg plus 20 mcg fentanyl (Group 2). All drugs used in this protocol are approved by the A.N.M.A.T (National Administration of Drugs, Foods and Technology). Motor block, hemodynamics and adverse effects were evaluated. Results: there were no significant differences in terms of age, size, weight gestational age and surgical time. Ropivacaine -administered in equipotent doses in relation with bupivacaine- showed a lower potential in the prolongation of motor block. The bupivacaine group evidenced a higher incidence of hypotension - with a significant p= 0,02- compared to ropivacaine. These findings are confirmed by the differences in the administration of ephedrine required for each group: more than 25% higher for the bupivacaine group. Other adverse effects were not statistically significant. Conclusion: both ropivacaine and bupivacaine provide safety and quality in patients undergoing urgent cesarean section. However, ropivacaine proves to be more efficient due to lower incidence of hemodynamic complications and a rapid recovery from motor block.

RESUMO Introdução: comparou-se a anestesia subaracnóidea com ropivacaína hiperbárica e bupivacaína hiperbárica ambas associadas à fentanil em pacientes que foram à cesariana de urgência. Utilizaram-se doses menores as estudadas até o momento, porêm mais adequadas às recomendadas na atualidade. Objetivos: procurou-se comparar os dois tipos de anestésicos locais analisando o bloqueio motor, comportamento hemodinâmico intra-operatório posterior a administração subaracnóidea das soluções em estudo e descrever a frequência de efeitos adversos associados ao procedimento. Método: O estudo realizado é um ensaio clinico controlado e aleatório, multicêntrico, em pacientes grávidas a termo (37 a 41 semanas de gravidez), ASA I ou II, dentre 18 e 40 anos que receberam bupivacaina hiperbarica 10 mg + fentanil 20 µg (Grupo 1) ou ropivacaina hiperbarica 15 mg + fentanil 20 µg (Grupo 2), por via intratecal. Todas as drogas usadas no presente protocolo se encontram aprovadas pela A.N.M.A.T. avaliando o bloqueio motor, hemodinâmica e efeitos adversos. Resultados: não houve diferenças significativas quanto à idade, estatura, peso, idade gestacional e tempo cirúrgico. A ropivacaina (administrada em dose equipotente em relação a bupivacaina), mostrou um menor potencial no tempo de bloqueio motor. O grupo bupivacaina apresentou maior hipotensão (p =0.02) em relação a ropivacaina. Estes resultados se confirmam através da diferença de administração de efedrina requerida para cada um dos grupos: mais de 25 % a mais para o grupo bupivacaina. Outros efeitos adversos não aprestaram significância estatística. Conclusão: as duas soluções, ropivacaina e bupivacaina, proporcionaram segurança e qualidade em pacientes em que se realizou cesarianas de urgência. Entretanto, a ropivacaina apresentou maior eficiência devido à menor incidência de complicações hemodinâmicas e uma recuperação mais rápida do bloqueio motor.