RESUMO
PURPOSE: Electrical stimulation of the whole hypoglossal nerve (HGp-ES) has been demonstrated to enlarge the pharynx and improve pharyngeal stability and patency to airflow in all animals studied, but not in humans. The present study was undertaken to better understand the effect of HGp-ES on the human pharynx. METHODS: Eight patients with obstructive sleep apnea who had implanted stimulators with electrodes positioned proximally on the main truck of the hypoglossus were studied under propofol sedation. Pharyngoscopy and air flow measurements at multiple levels of continuous positive airway pressure (CPAP) were performed before and during Hgp-ES. RESULTS: HGp-ES that activates both tongue protrusors and retractors narrowed the pharyngeal lumen at the site of collapse (velopharynx in all subjects) from 1.38 ± 0.79 to 0.75 ± 0.44 cm2, p < 0.05 (measured at mid-range of CPAP levels) and lowered airflow (from 8.88 ± 2.08 to 6.69 ± 3.51 l/min, p < 0.05). Changes in critical pressure (Pcrit) and velopharyngeal compliance were not significant, but oropharyngeal compliance decreased (from 0.43 ± 0.18 to 0.32 ± 0.13 cm2/cmH2O, p < 0.05). No correlation was found between the pattern of change in luminal shape (determined as the ratio of a-p vs. lateral diameter when lowering CPAP) or changes in cross-sectional area and airflow during Hgp-ES. CONCLUSIONS: Our findings indicate that human retractors dominate when stimulated together with the protrusors during HGp-ES. While co-activation of retractors may be beneficial, it should be limited. We speculate that exercises that augment protrusor force may improve the response to hypoglossal stimulation. The exclusion of patients with concentric pharyngeal obstruction should be re-evaluated.
Assuntos
Estimulação Elétrica , Nervo Hipoglosso/fisiopatologia , Apneia Obstrutiva do Sono/fisiopatologia , Adulto , Pressão Positiva Contínua nas Vias Aéreas , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
The difficult airway constitutes a continuous challenge for anesthesiologists. Guidelines and algorithms are key to preserving patient safety, by recommending specific plans and strategies that address predicted or unexpected difficult airway. However, there are currently no "gold standard" algorithms or universally accepted standards. The aim of this article is to present a synthesis of the recommendations of the main guidelines and difficult airway algorithms.
Assuntos
Manuseio das Vias Aéreas/normas , Manuseio das Vias Aéreas/métodos , Algoritmos , Anestesia Geral , Humanos , Intubação Intratraqueal , Guias de Prática Clínica como AssuntoRESUMO
Serious complications secondary to Venturi jet ventilation used during microlaryngoscopy are rare, but when they occur, they may pose a life-threatening emergency. We report the case of a 45-year-old woman, previously treated with 70 Gy of irradiation for a T1 laryngeal carcinoma, who developed pneumomediastinum and subcutaneous emphysema after the use of Venturi jet ventilation. Keeping in mind the histologic changes to the irradiated structures, we suggest more caution when using Venturi jet ventilation in patients who have recently undergone neck irradiation therapy.
Assuntos
Carcinoma de Células Escamosas/patologia , Carcinoma de Células Escamosas/radioterapia , Neoplasias Laríngeas/patologia , Neoplasias Laríngeas/radioterapia , Enfisema Mediastínico/etiologia , Procedimentos Cirúrgicos Otorrinolaringológicos/métodos , Respiração Artificial/efeitos adversos , Biópsia , Feminino , Humanos , Enfisema Mediastínico/diagnóstico , Enfisema Mediastínico/diagnóstico por imagem , Microcirurgia , Pessoa de Meia-Idade , RadiografiaRESUMO
Hunter's syndrome is due to recessively inherited mucopolysaccharide storage diseases. The anaesthetic complications in this syndrome are related to the organs involved in the disease, but pertain especially to upper airway obstruction problems. We report a patient with Hunter's syndrome who, while under general anaesthesia for a simple procedure (the introduction of bilateral grommets), suffered a fatal outcome.
Assuntos
Obstrução das Vias Respiratórias/etiologia , Anestesia Geral , Complicações Intraoperatórias , Ventilação da Orelha Média , Mucopolissacaridose II/cirurgia , Adolescente , Evolução Fatal , Humanos , MasculinoRESUMO
We present a case of microlaryngoscopy in a patient with an unexpectedly difficult airway. The airway was managed by using an oesophageal-tracheal Combitube (Kendall-Sheridan, Argyle, NY) (ETC) and a fibre-optic bronchoscope (Pentax-Japan-5 mm).
Assuntos
Complicações Intraoperatórias , Doenças da Laringe/cirurgia , Laringoscopia/métodos , Prega Vocal/cirurgia , Idoso , Broncoscopia/métodos , Feminino , Tecnologia de Fibra Óptica , Humanos , Intubação Intratraqueal/instrumentaçãoRESUMO
STUDY OBJECTIVE: To examine the influence of spinal anesthesia on postoperative pain and postoperative opioid requirements. DESIGN: Prospective randomized study. SETTING: Bnai-Zion Medical Center, Haifa, Israel-a government hospital. MEASUREMENTS AND MAIN RESULTS: 30 ASA physical status I and II unpremedicated women undergoing elective total abdominal hysterectomy were randomly allocated into two groups of 15 patients each using a sealed envelope technique. Patients in Group 1 were given a subarachnoid injection of 12 mg hyperbaric bupivacaine and after 10 minutes general anesthesia was induced. Patients in Group 2 received only general anesthesia. Anesthesia was induced with midazolam and maintained with oxygen, N2O, isoflurane, and pancuronium. No opioids were given intraoperatively. Postoperatively patient-controlled analgesia (PCA) with morphine was initiated in both groups (1 mg x mL(-1), bolus dose 1 mg, lockout interval 10 minutes, and background infusion 1 mg x mL(-1)) at patient first request for analgesic. Pain was assessed over 24 hours by cumulative morphine dose and visual analog score (VAS). Postoperative PCA morphine consumption at 2, 6, and 24 hours following patient first request for analgesic for Groups 1 and 2 were: 3.1 +/- 1 mg versus 7.2 +/- 3 mg (p = 0.04), 13.4 +/- 2 mg versus 17.2 +/- 4 mg (p = 0.03) and 35.9 +/- 8 mg versus 47.7 +/- 8 mg in Group 2 (p = 0.04). VAS scores at 4, 6, 12, and 24 hours postoperatively were not significantly different between the two groups. CONCLUSIONS: Preoperative neural blockade may reduce postoperative analgesic requirements.
Assuntos
Raquianestesia , Dor Pós-Operatória/prevenção & controle , Adulto , Analgesia Controlada pelo Paciente , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/uso terapêutico , Anestesia Geral , Feminino , Humanos , Histerectomia , Pessoa de Meia-Idade , Morfina/administração & dosagem , Morfina/uso terapêutico , Medição da Dor , Fatores de TempoAssuntos
Obstrução das Vias Respiratórias/etiologia , Osso Hioide/anormalidades , Intubação Intratraqueal , Laringe/anormalidades , Traqueia/anormalidades , Adulto , Humanos , Osso Hioide/diagnóstico por imagem , Laringe/diagnóstico por imagem , Dor Lombar/cirurgia , Masculino , Cartilagem Tireóidea/anormalidades , Cartilagem Tireóidea/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Traqueia/diagnóstico por imagem , Traqueostomia , Resultado do TratamentoAssuntos
Anestesia Obstétrica , Laringoscópios , Feminino , Humanos , Hipertensão , Intubação , GravidezRESUMO
La vía aérea difícil constituye un continuo desafío para el anestesiólogo y su tratamiento es una de las tareas de mayor exigencia al representar un riesgo vital. Las guías y algoritmos juegan un papel clave en la preservación de la seguridad del paciente al recomendar planes y estrategias específicos para abordar la vía aérea difícil prevista o inesperada. Sin embargo, no existen actualmente algoritmos «de referencia», ni estándares universalmente aceptados. El objetivo de este artículo es presentar una síntesis de las recomendaciones de las principales guías y algoritmos de la vía aérea difícil (AU)
The difficult airway constitutes a continuous challenge for anesthesiologists. Guidelines and algorithms are key to preserving patient safety, by recommending specific plans and strategies that address predicted or unexpected difficult airway. However, there are currently no "gold standard" algorithms or universally accepted standards. The aim of this article is to present a synthesis of the recommendations of the main guidelines and difficult airway algorithms (AU)
Assuntos
Humanos , Obstrução das Vias Respiratórias/prevenção & controle , Manuseio das Vias Aéreas/métodos , Anestesia/métodos , Procedimentos Cirúrgicos Operatórios/métodos , Complicações Pós-Operatórias/prevenção & controle , Guias de Prática Clínica como Assunto , Algoritmos , Traqueia/anatomia & histologia , BroncoscopiaRESUMO
BACKGROUND AND OBJECTIVE: Several studies showed that single analgesic modality management can attenuate perioperative stress, but little is known about the effect of multimodal analgesia on catecholamine responses to surgical trauma in children. METHODS: Fifty children (American Society of Anesthesiologists Grade I or II) were randomly allocated to one of two groups: one received general anaesthesia and a caudal block (control group), and one group was given general anaesthesia, caudal block and intravenous (i.v.) fentanyl 2 microg kg(-1) (fentanyl group). Plasma epinephrine and norepinephrine concentrations were measured three times during the perioperative period: at induction time (T(0)), at the end of surgery (T(1)) and when the children were fully awake in the postanaesthesia care unit (T(2)). RESULTS: There was a significant reduction in the catecholamine levels in the two groups when (T(1)) and (T(2)) were compared with T(0). When plasma epinephrine levels (at T(0), T(1) and T(2)) between the two groups were compared, a statistically significant reduction at T(2) was obtained in the fentanyl group, when compared with the control group. However, plasma norepinephrine levels showed no statistically significant difference between the two groups (at T(0), T(1) and T(2)). CONCLUSION: These findings suggest that the multimodal analgesic approach of adding i.v. low-dose fentanyl to a caudal block may decrease the plasma epinephrine release in children undergoing inguinal herniotomy.
Assuntos
Analgesia/métodos , Anestésicos Combinados/uso terapêutico , Catecolaminas/sangue , Fentanila/uso terapêutico , Hérnia Inguinal/cirurgia , Bloqueio Nervoso/métodos , Anestesia Geral/métodos , Anestésicos Combinados/administração & dosagem , Anestésicos Intravenosos/administração & dosagem , Anestésicos Intravenosos/uso terapêutico , Pressão Sanguínea/efeitos dos fármacos , Dióxido de Carbono/sangue , Pré-Escolar , Quimioterapia Combinada , Procedimentos Cirúrgicos Eletivos/métodos , Epinefrina/sangue , Fentanila/administração & dosagem , Frequência Cardíaca/efeitos dos fármacos , Humanos , Monitorização Fisiológica/métodos , Norepinefrina/sangue , Resultado do TratamentoRESUMO
BACKGROUND: During surgery, damage occurs to muscles in the area of the operation. The few studies that have examined creatine phosphokinase (CK) values after surgery have been in adults. The only study in children was after cardiac surgery. Understanding the normal enzyme pattern of change may help to differentiate malignant hyperthermia, anaesthesia-induced rhabdomyolysis and elevated CK values resulting from inherited muscle disease in cases in which these are suspected. The aim of this study was to delineate the normal rise of CK after minor and major surgery in children. METHODS: A total of 71 patients aged 1 month-17 yr were studied. From the cohort of 71 patients, 46 underwent elective surgery (14 major, 32 minor) and in 25 the surgery was designated as an emergency surgery (21 major, 4 minor). The anaesthesia protocol was similar for both groups with halothane induction and isoflurane maintenance. Owing to its possible effect on CK, succinylcholine was avoided during the study. RESULTS: The mean values of CK concentration before and after surgery were 63.1 iu litre(-1) and 151.5 iu litre(-1), respectively. The median CK elevation (range) for the major and minor surgery groups was 43 iu litre(-1) (4-647) and 10 iu litre(-1) (-28 to 122), respectively (P<0.0001). CONCLUSIONS: CK concentrations in the major surgery group were significantly higher than the minor surgery group. This profile can contribute to the evaluation of patients who present with the possibility of malignant hyperthermia, anaesthesia-induced rhabdomyolysis and underlying muscle disease. Any rise of CK concentration above what is expected should prompt further investigation.
Assuntos
Creatina Quinase/sangue , Procedimentos Cirúrgicos Operatórios , Adolescente , Biomarcadores/sangue , Criança , Pré-Escolar , Diagnóstico Diferencial , Humanos , Lactente , Recém-Nascido , Masculino , Hipertermia Maligna/diagnóstico , Procedimentos Cirúrgicos Menores , Doenças Musculares/diagnóstico , Doenças Musculares/genética , Complicações Pós-Operatórias/diagnóstico , Período Pós-Operatório , Valores de ReferênciaRESUMO
This study compares the anti-emetic effect of acupuncture with that of ondansetron and a placebo. Ninety children undergoing dental treatment under general anaesthesia were randomly allocated to one of the three equal groups, to receive acupuncture needle insertion, intravenous ondansetron 0.15 mg x kg(-1) or a placebo. Parental satisfaction scores and the incidence of emetic episodes were recorded. A significant difference was found in the number of patients who vomited and the total number of the emetic episodes when comparing the two treatment groups with the placebo group (p < 0.0001). A significant difference was also found between the treatment groups and the placebo group with respect to parental satisfaction score (p < 0.03). We conclude that traditional Chinese acupuncture is a valid non-pharmacological alternative anti-emetic treatment that can be recommended as a prophylactic technique in children undergoing dental surgery under general anaesthesia.
Assuntos
Analgesia por Acupuntura , Antieméticos/uso terapêutico , Restauração Dentária Permanente , Ondansetron/uso terapêutico , Náusea e Vômito Pós-Operatórios/prevenção & controle , Anestesia Dentária , Anestesia Geral , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Estudos ProspectivosRESUMO
This study examined the relationship between the EEG (spectral edge frequency 90-SEF90) and the occurrence of awareness defined for the purpose of this study as responsiveness to verbal commands. Fifty women undergoing general anaesthesia for elective Caesarean section were examined. Responsiveness to verbal commands was detected every minute in the period from the induction of anaesthesia to the delivery of the newborn using the Tunstall isolated forearm technique and correlated with the SEF90 value. The patients were assigned by a randomized code to receive either thiopentone (4 mg.kg-1) or ketamine (1 mg.kg-1) for induction of anaesthesia. Before the administration of succinylcholine a tourniquet was applied to the free arm, and inflated to 200 mmHg, to maintain motor function to one arm. The EEG recordings started five minutes before induction and were recorded throughout anaesthesia. The incidence of responsiveness to verbal commands was lower in the ketamine group (24%) where the average SEF90 was 12.0 +/- 3 Hz, than in the thiopentone group (52%), where the average SEF90 was 18.09 +/- 3 Hz (P = 0.01). The results suggest that SEF values of < or = 8.6 Hz were sufficient to avoid responsiveness to verbal commands.
Assuntos
Anestesia Geral , Conscientização , Cesárea , Eletroencefalografia , Processamento de Sinais Assistido por Computador , Adulto , Anestesia Intravenosa , Percepção Auditiva , Procedimentos Cirúrgicos Eletivos , Feminino , Antebraço/inervação , Análise de Fourier , Humanos , Recém-Nascido , Ketamina/administração & dosagem , Monitorização Intraoperatória , Neurônios Motores/efeitos dos fármacos , Movimento , Gravidez , Succinilcolina/administração & dosagem , Tiopental/administração & dosagemRESUMO
The incidence of inguinal hernia is higher in premature infants, particularly in low birth weight neonates. This latter group may also incur increased postoperative respiratory complications and inpatient admissions. The purpose of this study was to compare the effects of general and spinal anaesthesia on postoperative respiratory morbidity and on the length of hospital stay in high-risk infants undergoing inguinal herniorrhaphy. Forty patients, all high-risk infants who underwent unilateral or bilateral herniorrhaphies, were randomly assigned to receive general anaesthesia (n = 20) or spinal anaesthesia (n = 20). There was a significant difference in respiratory morbidity between the two groups, as well as a significant difference in the inpatient hospital stay. The present study suggests that spinal anaesthesia can be used safely for high-risk infants, preterm or formerly preterm, undergoing inguinal hernia repair.
Assuntos
Anestesia Geral/efeitos adversos , Raquianestesia/efeitos adversos , Apneia/etiologia , Hérnia Inguinal/cirurgia , Doenças do Prematuro/cirurgia , Bradicardia/etiologia , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Tempo de Internação , Complicações Pós-Operatórias , Fatores de RiscoRESUMO
Hemodynamic changes were studied in 10 patients with severe coronary disease during routine transurethral prostatectomy (TURP) when performed in the lithotomy position with and without elevation of the legs. The patients undergoing the procedure in the lithotomy position with elevation of the legs exhibited significant hemodynamic changes as compared with those undergoing the procedure without elevation of the legs. This leads us to conclude that performing TURP in the lithotomy position without elevation of the legs benefited the patient by stabilizing hemodynamic factors.
Assuntos
Doença das Coronárias/fisiopatologia , Hemodinâmica/fisiologia , Postura , Prostatectomia , Doenças Prostáticas/cirurgia , Idoso , Idoso de 80 Anos ou mais , Cateterismo de Swan-Ganz , Doença das Coronárias/complicações , Humanos , Masculino , Pessoa de Meia-Idade , Doenças Prostáticas/complicaçõesRESUMO
UNLABELLED: The aim of this study was to compare fiberoptic-guided airway exchange of the esophageal-tracheal Combitube (ETC, Kendall-Sheridan Catheter Corp., Argyle, NY) with an endotracheal tube in spontaneously breathing versus mechanically ventilated patients. Forty patients with Mallampati score III and IV scheduled for elective surgery were randomly allocated into two groups (n = 20 each): nonparalyzed, spontaneously breathing or paralyzed, mechanically ventilated patients. After anesthetic induction and insertion of the ETC, a fiberoptic bronchoscope threaded into an armored endotracheal tube was passed transnasally into the larynx. Endotracheal intubation was successful in 18 spontaneously breathing patients and in 15 patients during controlled ventilation. Successful airway exchange was completed in significantly less time (P < 0.05) in spontaneously breathing patients (9+/-3 min; mean +/- SD) than in mechanically ventilated patients (13+/-4 min). Both methods allowed for continuous airway control and maintenance of ventilation and oxygenation. The described method is a means of replacing the ETC with an endotracheal tube without interruption of airway control or ventilation. Replacing the ETC with an endotracheal tube using this method is more readily accomplished during spontaneous ventilation than during controlled ventilation. IMPLICATIONS: We describe the replacement of the Combitube by an endotracheal tube by the aid of fiberoptic bronchoscopy and without interruption of airway control or ventilation. The performance of this technique was facilitated by spontaneous ventilation compared with mechanical ventilation.
Assuntos
Anestesia Geral/métodos , Tecnologia de Fibra Óptica , Intubação Intratraqueal/métodos , Respiração Artificial/métodos , Respiração , Adulto , Idoso , Feminino , Humanos , Intubação Intratraqueal/instrumentação , Masculino , Pessoa de Meia-Idade , Troca Gasosa PulmonarRESUMO
This article describes the implementation and utilization of a continuous quality improvement (CQI) program in the identification, analysis, and correction of a rate-based event in anesthesia, in this case, intraoperative hypertension. A CQI program was implemented based on voluntary, handwritten, anonymous reports of intraoperative and postanesthesia care unit events. This CQI program detected a high incidence of intraoperative hypertension, indicated major causal factors, suggested a set of corrective measures, and allowed for measurement of their efficacy.
Assuntos
Anestesiologia/normas , Hospitais de Ensino/normas , Hipertensão/epidemiologia , Cuidados Intraoperatórios/normas , Cuidados Pós-Operatórios/normas , Gestão da Qualidade Total/métodos , Educação Continuada , Hospitais com 300 a 499 Leitos , Humanos , Incidência , Indicadores de Qualidade em Assistência à Saúde , Valores de Referência , Gestão de Riscos , Vigilância de Evento SentinelaRESUMO
We evaluated the effect of adding fentanyl to bupivacaine, compared with bupivacaine alone, on the stress response. The effect was evaluated by determining blood levels of epinephrine (E) and norepinephrine (NE) in pediatric patients receiving caudal epidural blocks. Sixty children, 1-8 yr of age, scheduled for elective herniorrhaphy, were randomly allocated to two groups of 30 patients each. Group A received inhaled anesthesia and caudal epidural block with bupivacaine 0.25% alone, 1.0 mL/kg. Group B received identical anesthesia; however, fentanyl 1 microg/kg was added to the bupivacaine in the caudal block. Blood samples for E and NE plasma levels were drawn at induction time (H(0)), at the end of surgery (H(1)), and in the postanesthesia care unit (H(2)). In both groups, there was a significant decrease in the E and NE plasma levels, when comparing H(1) and H(2) with H(0) within the same group (P < 0.001). There were no significant differences in the E and NE plasma levels between the two groups at H(0), H(1), and H(2) (P = 0.5, P = 0.12, P = 0.5, respectively). Pain scores (modified Children's Hospital of Eastern Ontario Pain Score) were also similar in both groups (P = 0. 19). This study suggests that adding fentanyl 1 microg/kg to bupivacaine in the caudal epidural block in children does not influence plasma levels of E and NE, nor does it improve the analgesic intensity of the caudal block.