[Analysis of organ failure and mortality in sepsis due to secondary peritonitis]. / Análisis de la insuficiencia de órganos y mortalidad en la sepsis por peritonitis secundaria.

OBJECTIVES: To identify the organs most susceptible to develop multiorgan dysfunction syndrome (MODS) in patients with sepsis due to secondary peritonitis, and to determine the outcome and mortality predicting utility of the SOFA (Sequential Organ Failure Assessment) system. DESIGN: A prospective, observational cohort study was made. SETTING: The resuscitation unit of a third-level university hospital. PATIENTS: A prospective, observational cohort study was made of 102 patients with sepsis of abdominal origin and failure of at least one organ related to the infection. The demographic characteristics were documented, along with the abdominal origin of sepsis, mortality after 28 days, and the daily SOFA score. RESULTS: The mortality rate after 28 days was 55%. A total of 53% of the patients presented failure of two or more organs on the first day of admission. The mean daily SOFA score was significantly higher among the patients that died after day 4 of admission. The variables showing a statistically significant correlation to increased mortality were: MODS (P=.000), central nervous system failure (P=.000) and SOFA score on day 4 of admission (P=.012). The area under the ROC curve showed the mortality predicting capacity of the SOFA score on day 4 of admission to be 0.703 (95%CI 0.538-0.853; P=.026). The maximum discriminating capacity was recorded for MODS, with an area under the ROC curve of 0.776 (95%CI 0.678-0.874; P=.000). CONCLUSIONS: Organ failure outcome as predicted by the SOFA score showed high precision - the mean SOFA score on day 4 of admission being a good mortality predictor. MODS was the main cause of death, while central nervous system, renal and respiratory failure were identified as the mortality risk factors.

[Cranial nerve block with bupivacaine for postoperative analgesia following supratentorial craniotomy]. / Bloqueo craneal con bupivacaína para analgesia postoperatoria en craneotomía supratentorial.

OBJECTIVE: To assess the effectiveness of analgesia by cranial nerve block with bupivacaine in the first 24 hours following elective supratentorial craniotomy. PATIENTS AND METHODS: A prospective, randomized, double-blind study was performed in 30 patients who underwent craniotomy for excision of a tumor. The cranial nerve block was performed using saline (control group, n=15) or 0.25% bupivacaine with epinephrine at 1:200 000 (bupivacaine group, n=15). Morphine (2 mg, intravenous bolus) was used for rescue analgesia. Pain was assessed on a visual analog scale (VAS) at 2, 4, 8, 12, 16, and 24 hours following the cranial nerve block. The following data were recorded: time elapsed until appearance of pain, use of rescue analgesia, and incidence of adverse effects. RESULTS: The use of morphine was significantly lower in the group of patients who received a cranial nerve block with bupivacaine than in the control group (mean [SD], 3.7 [1.6] mg vs 172 [2.5] mg). The mean time to the first requirement for rescue analgesia was longer in the bupivacaine group than in the control group (731 [247] minutes vs 80 [71] minutes). The VAS score during the first 16 hours was significantly lower in the bupivacaine group than in the control group. The incidence of nausea and vomiting was significantly higher in the control group (67% vs 13%). CONCLUSIONS: Cranial nerve block with 0.25% bupivacaine following supratentorial craniotomy improves postoperative analgesia, reduces the requirement for morphine, and contributes to reducing nausea and vomiting.

[Postoperative delirium in patient neurosurgical: evaluation by means of the Abbreviated Mental Test]. / Delirio postoperatorio en pacientes neuroquirúrgicos: evaluación mediante el Test Mental Abreviado.

OBJECTIVES: To assess the incidence and characteristics of postoperative changes in the higher cerebral functions after elective intracranial surgery under general anesthesia. PATIENTS AND METHODS: This is a prospective study of 60 patients, aged 18-81 years, submitted to neurosurgical operations, allocated into two groups of 30 patients each: intracranial surgery group, patients submitted to craniotomy, and extracranial surgery group or control group, patients submitted to spinal procedures. All patients were given the Abbreviated Mental Test (AMT) on the day before to the operation, and then 2 and 24 hours after the end of the procedure. All individuals were managed with the same anesthetic technique. RESULTS: No differences in regard to demographics, duration of the operation, ASA physical state, and habits were found between the two groups. No differences in the pre-surgical and post-surgical AMT mean score were encountered between patients submitted to intracranial 9.87 +/- 0.35 or to spinal surgeries 9.80 +/- 0.41. Similarly, there were no significant differences between the two groups in the results of the AMT performed at 2 and 24 hours after the end of the surgeries. Only two subjects undergoing spinal procedures had a score of < or = 8 in the AMT performed 2-hours after the operation, while none showed a decrease in the 24-hour test score. CONCLUSIONS: Patients submitted to intracranial surgery did not show any changes in cognitive or attention functions during the first postoperative 24 hours as assessed by the AMT.

[Comparison of anesthetic maintenance and recovery with propofol versus sevoflurane combined with remifentanil in craniotomy for supratentorial neoplasm]. / Estudio comparativo de remifentanilo combinado con propofol o sevofluorano para el mantenimiento y recuperación de la anestesia en craneotomía por neoplasia supratentorial.

OBJECTIVE: To compare the effectiveness of propofol versus sevoflurane associated with remifentanil on the maintenance of anesthesia and on recovery in patients undergoing elective supratentorial craniotomy. PATIENTS AND METHODS: Prospective randomized trial enrolling 90 patients scheduled for excision of a brain neoplasm. All received an infusion of remifentanil at a dose of 0.5 microg x Kg(-1) x min(-1) until tracheal intubation and then 0.25 microg x Kg(-1) x min(-1) during surgery. Induction was achieved with propofol and anesthesia was maintained with either sevoflurane at a maximum alveolar concentration of 0.4 (45 patients) or propofol by target controlled infusion at a concentration of 2.5 microg x mL(-1) (45 patients, group P). Variables assessed were hemodynamic stability during anesthesia and times and quality of recovery from anesthesia (eye opening, initiation of spontaneous ventilation, extubation, cough reflex, and temporal and spacial orientation 3 minutes after extubation. During the first 24 hours after surgery, pain intensity was evaluated on a verbal visual analog scale (VAS) and the incidence of nausea and vomiting was recorded. RESULTS: Times until eye opening upon request and until extubation were significantly shorter in the sevoflurane group than in the propofol group: 3.7 (SD, 1.2) minutes vs 5 (3.1) minutes, respectively, for eye opening and 6.6 (1.2) minutes vs 8.1 (3.3) minutes for extubation (P<0.01). The incidence of nausea and vomiting was significantly higher in the sevoflurane group (40% vs 13%, respectively, P<0.01). CONCLUSIONS: Combining remifentanil with propofol or with sevoflurane provides satisfactory anesthesia during elective supratentorial craniotomy to remove a brain neoplasm. Hemodynamic stability is appropriate and recovery from anesthesia is rapid.

[Precurarization with rocuronium prevents fasciculations and biochemical changes after succinylcholine administration]. / La precurarización con rocuronio previene las fasciculaciones y los cambios bioquímicos tras la administración de succinilcolina.

OBJECTIVE: To determine the efficacy of rocuronium to prevent fasciculations and biochemical changes after succinylcholine administration. PATIENTS AND METHODS: Prospective, randomized double-blind trial enrolling 60 ASA I-II patients scheduled for elective surgery under general anesthesia. The patients were assigned to 2 groups to receive either 0.06 mg x Kg(-1) of rocuronium or physiological saline solution 90 seconds before administration of 1.5 mg x Kg(-1) of succinylcholine. The incidence and severity of fasciculations and serum concentrations of potassium before anesthesia and 3, 5, and 20 minutes after succinylcholine administration were recorded. Other serum concentrations recorded were myoglobin, creatinine phosphokinase and lactate before anesthesia and 20 minutes after succinylcholine administration. RESULTS: The increases in potassium levels at 3 and 5 minutes (0.3 +/- 0.3 and 0.2 +/- 0.4 mmol x L(-1)) and in myoglobin levels at 20 minutes (38.9 +/- 31.7 ng x mL(-1)) were attenuated by precurarization with rocuronium. The incidence of fasciculations was significantly lower (p<0.001) and their severity significantly less (p<0.001) in patients who received rocuronium before administration of succinylcholine. CONCLUSIONS: Precurarization with rocuronium 90 seconds before succinylcholine administration reduces the incidence and severity of fasciculations and prevents increases in serum potassium and myoglobin concentrations.

[Effects of sevoflurane on mid-latency auditory evoked potentials and the 95% spectral frequency limit]. / Efectos del sevoflurano sobre los potenciales evocados auditivos de latencia media y límite de frecuencia espectral 95%.

OBJECTIVES: To investigate the effects of sevoflurane on mid-latency auditory evoked potentials (MLAEP) and compare them to changes in the encephalographic 95% spectral edge frequency (SEF95). PATIENTS AND METHODS: The effect of sevoflurane on MLAEP and SEF95 was studied in 15 patients. Anesthetic induction was carried out with propofol, remifentanil, and cisatracurium. After anesthetic induction, the patients were ventilated to achieve different expired concentrations of sevoflurane (1%, 1.5%, and 2%) during 3 consecutive 10-minute periods before the start of surgery. SEF95 and the amplitude and latency of the Na, Pa and Nb MLAEP waves were recorded. All the parameters were measured at baseline and during the different expired fractions of sevoflurane. RESULTS: The increase in sevoflurane concentration was accompanied by a significant decrease in amplitude and a statistically significant increase in latency of the Na, Pa and Nb waves. Likewise, SEF95 decreased significantly. A linear relation was demonstrated between sevoflurane concentration and the variables Na, Pa, Nb and SEF95. CONCLUSIONS: Our results indicate that the effect of sevoflurane on the MLEAP of Na, Pa and Nb is similar to that of other anesthetic gases. Even though the amplitude of the Na, Pa and Nb waves decreased in a dose-dependent way, SEF95 correlated more strongly with sevoflurane concentration.

[Puerperal cardiomyopathy and pulmonary edema after cesarean section]. / Miocardiopatía periparto y edema pulmonar tras cesárea.

A 26-year-old woman in the thirty-second week of her fifth pregnancy was admitted with diffuse sudden-onset abdominal pain. Examination revealed cervical dilation to 8 cm, a ruptured uterine cerclage and transverse presentation of the fetus, indicating a need for emergency cesarean section, which was performed under uneventful spinal anesthesia. Three days after surgery the patient presented signs consistent with acute pulmonary edema coinciding with blood transfusion. Echocardiography demonstrated left ventricular systolic dysfunction with an ejection fraction of 35%. The diagnosis was peripartum myocardiopathy with acute respiratory insufficiency due to heart failure. Furosemide and captopril were prescribed and the outcome was satisfactory. The discharge echocardiogram showed a left ventricle of normal size and thickness, and the ejection fraction was 55%. Peripartum myocardiopathy is a type of heart failure that develops during the third trimester or during the first six months after delivery, in the absence of signs of ventricular dysfunction or previous heart disease. Based on clinical presentation and echocardiographic findings, we believe that peripartum myocardiopathy was the cause of acute pulmonary edema in this patient.

[Pulse oximetry reduces the unnecessary administration of oxygen in the postanesthesia recovery period]. / La pulsioximetría reduce la administración innecesaria de oxígeno en el período de recuperación postanestésica.

OBJECTIVES: To investigate whether patients admitted to the postanesthesia recovery unit (PRU) need routine oxygen supplementation in the immediate postoperative period, by measuring changes in arterial oxygen saturation (SpO2) with a pulse oximeter. MATERIAL AND METHODS: Two hundred ninety-nine patients were admitted to the PRU after surgery. All breathed room air after their operations. During transfer to and time in the PRU, SpO2 was recorded. We administered oxygen through a face mask to patients whose SpO2 fell below 94% and to patients whose SpO2 levels fell below baseline, when baseline values were less than 94%. We recorded patient data, physical status (ASA), type of anesthesia, duration of surgery, Aldrete score upon admission to the PRU and SpO2 before and after surgery while the patient breathed room air. RESULTS: General anesthesia was used in 82.3% of the patients and local-regional anesthesia with sedation in 17.7%. PRU stay was 75.6 +/- 92.4 min. Twenty-five percent of the patients were treated with oxygen after surgery and 75% did not require supplemental oxygen. Time until the appearance of desaturation was 3.3 +/- 2.8 min. The coefficient of multiple correlation between postoperative SpO2 while breathing room air (dependent variable) and preoperative SpO2, age and duration of surgery was R = 0.522 (p < 0.001). CONCLUSIONS: Our results are sufficient to demonstrate the validity of pulse oximetry for avoiding indiscriminate oxygen supplementation in patients admitted to the PRU.