martes, 30 de junio de 2015

Propofol / Imagen del Mes/ Image of the month

Mujer de 65 años, 86.6 kg, talla 252 cm, ASA 2, obesa, con la pared abdominal péndula, que se sometió a abdominoplastia de pubis hasta xifoides. La analgesia se proporciona con 3 litros de solución tumescente (lidocaína 500 mg + 1000 mg de epinefrina/litro. Lidocaína total 1500 mg igual a 17.3 mg/kg) y 50 mg i.v. de ketamina. La paciente se fue monitorizada con ECG, presión arterial no invasiva, oximetría de pulso y BIS/EMG. Una bolsa de 1000 mL de solución i.v. se colocó bajo los hombros para aumentar la tensión en el músculo geniogloso y facilitar el mantenimiento de la vía aérea. Se utilizaron oxígeno nasal 2 litros/min y ketamina i.v. 50 mg 3 minutos antes de la infiltración de la pared abdominal. El nivel estable cerebral de propofol pre-ketamina fue facilitado con inducción de propofol con incrementos de 50 µg/kg titulados a 60 <BIS <75 con la línea base EMG. (Ver You Tube Going under with Goldilocks anesthesia). La sedación se continuó con propofol en bomba de infusión ajustado a 50 µg/kg/min) para tener 60 <BIS <75. Los picos en el EMG fueron tratados con 400 µg/kg de propofol hasta que el EMG regresó a la línea de base. La analgesia postoperatoria con 25 mL de bupivacaína 0.25% inyectada a través de cada uno de los tubos de drenaje, total de 125 mg (50 mL).
Imágenes cortesía del Dr. Barry Friedberg 

Women 65 years old, 191lbs, ASA 2, obese, with pendulous abdominal wall, which underwent pubis to xiphoid abdominoplasty. Analgesia was provided with 3 liters tumescent solution (lidocaine 500 mg + 1000 µg epinephrine/each liter. Total lidocaine 1500 mg equal to 17.3 mg/kg) and 50 mg i.v. ketamine. She was monitored with ECG, NIBP, pulse oximetry and BIS/EMG. A 1000 mL i.v. solution bag was placed under her shoulders to increase tension in the genioglossus muscle and facilitate the maintenance of the airway. Nasal oxygen 2 L/min and i.v. ketamine 50 mg 3 minutes prior to infiltration of the abdomen wall were used. Stable pre-ketamine propofol brain level was facilitated by incremental propofol induction @ 50 mcg/kg titrated to 60<BIS<75 with baseline EMG. (See You Tube Going under with Goldilocks) Sedation was continued with infusion pump propofol set to 50 mcg /kg/min) to have 60<BIS<75. EMG spikes were treated with 400 mcg/kg propofol until EMG returned to baseline. Postoperative analgesia with bupivacaine 0.25% 25 mL injected through each drain, total 125 mg (50 mL).
Images courtesy of Barry Firedberg MD. 

Propofol en cirugía Plástica "de consultorio"
Propofol in office-based plastic surgery.
Friedberg BL.
Semin Plast Surg. 2007 May;21(2):129-32. doi: 10.1055/s-2007-979214.
Propofol is the nearly ideal agent for office-based plastic surgery. Among all anesthetic agents, only propofol has the ability to elicit happiness in this special group of patients. Cosmetic surgery patients will tolerate discomfort in preference to postoperative nausea and vomiting. Propofol is a powerful antiemetic agent. Patient safety will not be optimized unless the person responsible for the administration of propofol has airway management skills. Dedicated anesthesia providers are highly skilled in airway management. Although the short half-life of propofol is seductive for a fast-acting, rapid emerging anesthetic, interindividual differences in propofol response make measurement of the target organ (i.e., the brain) with a bispectral index (BIS) monitor very important. BIS levels < 45 for > 1 hour are associated with increased 1-year anesthesia mortality thought to be associated with an inflammatory response. The only currently available way to avoid overmedicating with propofol is to monitor with a level of consciousness monitor like BIS.
KEYWORDS: BIS monitor; Propofol; anesthesia; ketamine; office-based plastic surgery

Anestesia disociativa para cirugía plástica en el ¨consultorio¨
Dissociative anesthesia in an office-based plastic surgery practice.
Vinnik CA.
Semin Plast Surg. 2007 May;21(2):109-14. doi: 10.1055/s-2007-979211.
In 1974, the author began to use ketamine in association with diazepam for cosmetic and reconstructive procedures. Since then, through courses in the United States and abroad, well over a thousand plastic surgeons have been taught the technique. Ketamine, by itself, ablates sensory input of pain at the thalamic level but has been associated with hallucinations, bad dreams, and other untoward effects. These can be prevented by the use of benzodiazepines, which "bracket" the use of ketamine. If the patient is sedated and awakens under the influence of these agents, there is no adverse ketamine effect. Specific techniques and adjunct agents are described.
KEYWORDS: Ketamine; Robinul®; Valium®; Versed®; dissociative anesthesia; fentanyl; midazolam

Protocolo con ketamina-diazepam para sedación intravenosa. Experiencia en el hospital de cirugía estética.
Ketamine-diazepam protocol for intravenous sedation: The cosmetic surgery hospital experience.
Quttainah A, Carlsen L, Voice S, Taylor J.
Can J Plast Surg. 2004 Fall;12(3):141-3.
Rising hospital costs and operating room scheduling difficulties have influenced plastic surgeons to rely more often on intravenous sedation in office surgical settings. The use of ketamine as an intravenous sedation agent has enjoyed some popularity, but this has been far from universal. Its reputation for producing psychological sequelae such as nightmares, flashbacks and schizophrenic-like reactions have made many anesthesiologists and plastic surgeons reluctant to use this drug. The authors' experience using a ketamine/diazepam protocol with approximately 11,400 patients since 1971 at the Cosmetic Surgery Hospital in Woodbridge, Ontario is presented. The methodology consists of intravenous diazepam followed with low-dose ketamine (0.5 mg/kg to a maximum of 40 mg) 2 min later. This provides the surgeon with a period of profound amnesia to allow for infiltration of the local anesthetic. It is this local anesthetic delivered during the dissociative state that provides prolonged analgesia throughout thesurgery. The patient is maintained throughout the procedure with increments of diazepam and midazolam. This protocol is found to be effective, reliable and reproducible, and the experience of the patient and plastic surgeon has been overwhelmingly favourable.
KEYWORDS: Intravenous sedation; Ketamine; Office anesthesia

Procedimientos de sedación y analgesia para la cirugía de mama fuera del hospital: una visión general de la técnica de sedación y analgesia.
Procedural sedation and analgesia for out-of-hospital breast surgery: an overview of the procedural sedation and analgesia technique
Louw AJ,
South Afr J Anaesth Analg 2014;20(1):89-92
Out-of-hospital surgical procedures are a rapidly growing market. This has led to surgical procedures that were previously limited to the hospital operating room, with general anaesthesia being performed outside the hospital with sedation and regional anaesthesia. Breast surgery, whether cosmetic, reconstructive or diagnostic, also follows this trend. The aim of this refresher course is to give an overview of the nerve supply to the breast, to explain the type of blocks used and to provide an overview of the sedation technique. The audience should have a better acceptance of performing procedural sedation and analgesia (PSA) for this type of surgery out of hospital after this overview. The author will also provide an overview during the presentation of his own current practice of performing these procedures.

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Barry Friedberg

Videoclips sobre propofol y anestesia
Videos on propofol and anesthesia
Anestesia y Medicina del Dolor
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