Tratamiento del dolor anticipatorio en los niños antes de la retirada de la vía endovenosa: efectividad de la utilización de la distracción mediante las pompas de jabón / Anticipatory pain treatment in children after intravenous catheter remove: effectiveness of distraction with soap bubbles

La colocación de la vía venosa en niños antes de la cirugía se realiza después de la inducción anestésica, cuando el niño ya está inconsciente en la mesa quirúrgica. El niño no experimenta, en este caso, dolor a la colocación de la vía, ya que está inconsciente, pero al despertar siente dolor debajo del apósito. La reacción de los niños a la retirada de la vía endovenosa está poco estudiada; sin embargo, el niño vive este procedimiento como de dolor anticipatorio, ya que siente en la mano el dolor que le ha causado la aguja. Es importante mitigar en lo posible esta situación, ya que la memoria de una experiencia dolorosa puede tener consecuencias a largo plazo, ya sea en futuras reacciones a los eventos dolorosos o en la aceptación del personal sanitario en futuros encuentros. El manuscrito pretende mostrar, con un ejemplo visual mediante fotografías, la eficacia en la utilización de la distracción para la retirada del catéter venoso en niños (AU)

The placement of the intravenous catheter in children before surgery is performed after induction of anesthesia, when the child is unconscious on the operating table. The child has not experience, in this case, the placement of the road, as he is unconscious, but when he awake in pain beneath the dressing. The reaction of children to the withdrawal of the intravenous catheter is poorly studied; however, the child lives this procedure as anticipatory pain because it feels in her hand the pain that has caused by the needle. It is important to mitigate as far as possible this situation, as the memory of a painful experience can have long-term consequences, either in future reactions to painful events or acceptance of health personnel in future meetings The manuscript is intended to show a visual example by photographs, efficiency in the use of distraction for removal of the venous catheter in children (AU)

Anesthetic Considerations of Stiff-Person Syndrome: A Case Report.

Stiff-person syndrome (SPS) is a neurologic disorder characterized by painful involuntary episodes of severe muscle rigidity affecting the axial muscles and extremities. Although the etiology of SPS is unknown, it is suspected to involve the synthesis of γ-aminobutyric acid (GABA). Symptoms of SPS are precipitated by sudden unexpected movements, noises, and stress. Additionally, SPS has been linked with various autoimmune disorders, including diabetes mellitus, thyroid disease, pernicious anemia, and certain cancers. Because of the effect of SPS and SPS medications, inhalational agents and neuromuscular blockers have the potential to cause prolonged hypotonia following anesthesia, resulting in respiratory failure despite full reversal of neuromuscular blockade. In documented case reports, the outcomes of using general anesthesia with inhalational agents and neuromuscular blockers in patients with SPS varied. This case report highlights the anesthetic management of a 56-year-old woman with diagnosed SPS undergoing a hemicolectomy for a colon mass using total intravenous anesthesia.

Unknown Pseudocholinesterase Deficiency in a Patient Undergoing TIVA with Planned Motor Evoked Potential Monitoring: A Case Report.

Pseudocholinesterase abnormalities are a genetic cause of aberrant metabolism of the depolarizing muscle relaxant succinylcholine. This article examines a case where succinylcholine was chosen to facilitate intubation due to its ultra short duration and the request of the surgeon to monitor motor evoked potentials. Following succinylcholine administration the neurophysiologist was unable to obtain motor evoked potentials. This case study highlights the intraoperative and postoperative management of an elderly patient with an unknown pseudocholinesterase deficiency.

Experiences of military CRNAs with service personnel who are emerging from general anesthesia.

We conducted this qualitative study to understand the experiences of military Certified Registered Nurse Anesthetists (CRNAs) working with service personnel who have traumatic brain injury (TBI) and/or posttraumatic stress disorder (PTSD) and are emerging from general anesthesia. This study is important because there are no studies in the literature that describe the experiences of anesthetists working with patients with these specific problems. The leading questions were: "Out of all the anesthesia cases both abroad and stateside (post 9/11/2001), have you noticed service members wake from general anesthesia (not utilizing total intravenous anesthesia (TIVA), in a state of delirium? If so, can you tell me your experiences and thought processes as to why it was occurring?" Five themes emerged: (1) Emergence delirium (ED) exists and to a much higher degree in the military than in the general population. (2) ED was much more prevalent in the younger military population. (3) TIVA was a superior anesthetic for patients thought to have TBI and/or PTSD. (4) Talking to all patients suspected of having TBI and/or PTSD before surgery and on emergence was vital for a smooth emergence. (5) There is something profound happening in regard to ketamine and PTSD and TBI.

[An established anesthesia team-care model: over 12000 cases in a digestive endoscopy unit]. / Consolidación de un modelo asistencial basado en un equipo de anestesia: experiencia en más de 12.000 casos en una Unidad de Endoscopia Digestiva.

BACKGROUND AND OBJECTIVE: The growing demand for digestive and other endoscopic procedures outside the operating room, both in terms of type of endoscopy and number of patients, requires reorganization of the anesthesiology department's workload. We describe 2 years of our hospital digestive endoscopy unit's experience with a now well-established care model involving both anesthesiologists and nurse anesthetists. MATERIAL AND METHODS: After previously reviewing the medical records of outpatients and conducting a telephone interview about state of health, nurse anesthetists administered a combination of propofol and remifentanil through a target-controlled infusion system under an anesthesiologist's direct supervision. RESULTS: The ratio of anesthesiologists to nurses ranged from 1:2 to 1:3 according to the complexity of the examination procedure. Over 12000 endoscopies (simple to advanced) in a total of 11853 patients were performed under anesthesia during the study period. Airway management maneuvers were required by 4.9% of the patients; 0.18% required bag ventilation for respiratory depression, and 0.084% required bolus doses of a vasopressor to treat hypotension or atropine to treat bradycardia. The procedure had to be halted early in 9 patients (0.07%). No patient required orotracheal intubation and none died. Nor were any complications related to sedation recorded. CONCLUSION: The results suggest that this care model can safely accommodate a large caseload in anesthesia at an optimum level of quality.

¿Qué opinan las enfermeras sobre el dolor asociado a las punciones vasculares? / What do nurses on pain associated With vascular functions?

Una de las técnicas más frecuentemente utilizadas por las enfermeras en el desempeño de su práctica clínica es la punción vascular, asociada comúnmente a un dolor soportable por el paciente en mayor o menor medida. Desde hace unos años ha ido apareciendo en la industria farmacéutica una serie de anestésicos locales que pueden ser utilizados durante la punción vascular para minimizar o mitigar este dolor. El interés creciente de las enfermeras en este campo queda demostrado por los cada vez más numerosos artículos científicos publicados en esta disciplina, englobada en la terapia intravenosa. Durante el IV Congreso Nacional de la Asociación de Equipos de Terapia Intravenosa, celebrado en 2010 en Valencia, se pasó a los congresistas una encuesta con el objetivo de evaluar sus conocimientos e inquietudes sobre el control del dolor en las punciones y la utilización de anestésicos locales (AU)

One of the most common techniques used by nurses in carrying out their clinical practice is the vascular puncture, commonly associated with pain bearable for the patient to a greater or lesser extent. For the past few years have been appearing in the pharmaceutical industry a series of local anesthetics can be used for vascular puncture to minimize or alleviate the pain. The increasing interest by nurses in this field is evidenced by the growing number of scientific articles published in this discipline, included in the Intravenous Therapy. During the Fourth National Congress of the Association of Intravenous Therapy Teams held in 2010 in Valencia went over to the Congress a survey to assess their knowledge and concerns about pain control in the punctures and the use of local anesthetics in the same (AU)

Use of dexmedetomidine and ketamine infusions during scoliosis repair surgery with somatosensory and motor-evoked potential monitoring: a case report.

Dexmedetomidine and ketamine infusions were the main anesthetic for a 15-year-old girl, who underwent scoliosis repair surgery with intraoperative wake-up test, somatosensory evoked potential (SSEP), and motor-evoked potential (MEP) monitoring. To achieve maintenance of anesthesia, dexmedetomidine and ketamine were administered concomitantly. The dexmedetomidine dose ranged from 0.9 to 1.2 microg/kg per hour throughout the case, and the ketamine dose ranged from 0.4 to 0.6 mg/kg per hour. The analgesic properties of dexmedetomidine and ketamine were complimented by the continuous fentanyl infusion at 1 to 2 microg/kg per hour. The sympatholytic properties of dexmedetomidine were balanced with the sympathomimetic properties of ketamine, and the patient required minimal vasoactive support (only 250 microg of phenylephrine was administered over the course of 12 hours of anesthetic care). This anesthetic regimen, as well as 60% nitrous oxide and 40% oxygen, provided satisfactory conditions for the intraoperative neurophysiologic monitoring. This case report discusses the use of dexmedetomidine and ketamine infusions as an alternative to propofol-based total intravenous anesthesia during scoliosis repair surgery with intraoperative SSEP and MEP monitoring.

Use of propofol and emergence agitation in children: a literature review.

Emergence agitation (EA) is an important issue in pediatric anesthesia. This phenomenon arises more frequently with the use of inhalational agents. Three commonly used general anesthesia techniques in children were evaluated as to the associated incidence of emergence reactions. An extensive literature review was performed to evaluate these anesthetic practices and the occurrence of EA in young children. Relevant literature was obtained from multiple sources, including professional journals, professional websites, and textbooks. Three categories of anesthesia techniques were reviewed: sevoflurane inhalational general anesthetic, Emerpropofol as an adjunct to sevoflurane general anesthetic, and propofol total intravenous anesthesia (TIVA) techniques. Several variables within each category were evaluated with respect to the outcome of EA: prevention, intraoperative adjuncts, type of surgery, and patient-related factors. According to the literature evidence base, there is an advantage to either propofol TIVA or adjunctive propofol with sevoflurane (compared with sevoflurane alone). We conclude, based on the current evidence, that the use of propofol is associated with a reduction in the incidence of emergence agitation.

Rapid sequence induction anaesthesia: a guide for nurses in the emergency department.

Emergency rapid sequence induction (RSI) anaesthesia is the cornerstone of emergency airway management performed on patients in the emergency department (ED). The Royal College of Anaesthetists has stated that anaesthesia should not proceed without a skilled, dedicated assistant. It is essential that ED nurses are educated, skilled and competent to assist with RSI in the ED.

Heart block and prolonged Q-Tc interval following muscle relaxant reversal: a case report.

Heart block and Q-Tc interval prolongation have been reported with several agents used in anesthesia, and the US Food and Drug Administration mandates evaluation of the Q-T interval with new drugs. Drug-induced Q-T interval prolongation may precipitate life-threatening arrhythmias, is considered a precursor for torsades de pointes, and may predict cardiovascular complications. In the patient described in this article, heart block occurred and the Q-Tc interval became prolonged after muscle relaxant reversal with neostigmine; both were considered to be related to the combination of agents used in the case, as well as to other predisposing factors such as morbid obesity. The agents used that affected cardiac conduction were neostigmine, desflurane, droperidol, dolasetron, and dexmedetomidine. Although the heart block was resolved after 2 doses of atropine, prolonged P-R and Q-Tc intervals persisted into the immediate postoperative period but returned to baseline within 4 hours. Clinical implications of this report include increasing awareness of the multitude of factors affecting Q-T interval prolongation during anesthesia.

Airway management in a child with penetrating pharyngeal wall foreign body injury: a case report.

Penetrating foreign bodies of the oropharynx are encountered in children of all ages, although more frequently between the ages of 3 to 5 years. A thorough preanesthetic evaluation of these patients, including type and extent of injury, must be performed if time allows. As a result of the often emergent nature of these cases, poor patient cooperation, and great potential for airway compromise, special considerations are given to management of the airway. The use of nontraditional equipment may greatly facilitate laryngoscopy and intubation.

The ins and outs of I. V. anesthetics.

With a strong knowledge of the pharmacologic measures that work side-by-side with anesthesia, nurses can keep patients safe while preventing negative consequences.

Gorham disease: an intraoperative case study.

Gorham disease is a rare chronic disorder that is characterized by the abnormal proliferation of thin-walled capillaries and small lymphatic vessels that results in the massive osteolysis of adjacent bone. Clinical manifestations are determined by the area of involvement, which may include the chest and ribs. The case presented involves a 47-year-old man with Gorham disease complicated by unilateral chylothorax who was treated with thoracic duct ligation. The anesthetic implications associated with Gorham disease are discussed, and nonsurgical primary and adjunctive treatments for chylothorax are summarized.

Practical considerations of intravenous sedation for the perioperative nurse.

There has been a recent increase in the number and types of cases performed with conscious sedation in the operating room and in minor operative suites (endoscopy, plastics, etc.), with nurse administering conscious sedation to healthy, uncomplicated patients under the direction of a physician. The literature is replete with articles which proffer guidelines, discuss the basics of conscious sedation, the role of the nurse, training and competency issues, and policy development. This article provides perioperative nurses with some practical, hands-on information to aid them in providing safe, quality care to their patients. There are detailed sections which address required equipment, perioperative patient assessment and monitoring, and information on commonly used medications and their side effects. The author offers this information based on literature review, education, and experience, and does not reflect the official position of any one organization.

Physiology of respiratory system related to anesthesia.

All inhalational anesthetic agents depress respiratory function. They also depend largely on the respiratory system to facilitate an induction and emergence from anesthesia. The other anesthetic agents, such as intravenous agents, also depress respiration. Much of the morbidity and mortality that occurs in the perioperative period can be attributed to an alteration in lung mechanics and dysfunctions in airway dynamics. In fact, it is postulated that 70% to 80% of the morbidity and mortality occurring in the perioperative period is associated with some form of respiratory dysfunction. Consequently, a detailed discussion of the many facets of respiratory anatomy and physiology will be presented. If the CRNA incorporates this information into anesthesia practice, care of the surgical patient will be enhanced.

Anesthetic management of arteriovenous malformation: a case report.

This case illustrates the anesthetic management of radiographically assisted embolization and surgical excision of a large arteriovenous malformation (AVM). Excision resulted in significant blood loss and cerebral edema. This prompted the use of cerebral protection and induced hypotension. The patient was kept in a barbiturate coma postoperatively. On emergence from the barbiturates, the patient demonstrated elevated intracranial pressure and resolving deficits. She was discharged 3 weeks after surgery for rehabilitation. Arteriovenous malformations can compromise the cerebral parenchyma by mass effect, by hemorrhage, and by "stealing" blood from adjacent tissue. Subarachnoid hemorrhage (SAH) can result in sympathetic stimulation, hydrocephalus, meningeal irritation, fluid and electrolyte disturbances, and cerebral vasospasm. Excision may result in massive cerebral hemorrhage and edema as arterial pressures are abruptly normalized. Anesthetic management is guided by a full evaluation of the patient's pathophysiology and medical management. The anesthetist must understand the total impact of the AVM, compensatory responses, and the hazard of surgery and anesthesia. The goal is to achieve a balance in oxygen supply and demand at a pressure sufficient to perfuse the brain tissue without exceeding the pressure limits of compromised vasculature. This must be done while providing optimal brain relaxation for excision with minimal bleeding.