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Monitoreo intraoperatorio con BIS y tiempo de extubación después de cirugía cardiaca. Análisis secundario de un estudio randomizado

Septiembre 18, 2015. No. 2089

Monitoreo intraoperatorio con BIS y tiempo de extubación después de cirugía cardiaca. Análisis secundario de un estudio randomizado Intraoperative bispectral index monitoring and time to extubation after cardiac surgery: secondary analysis of a randomized controlled trial. Vance JL, Shanks AM1, Woodrum DT. BMC Anesthesiol. 2014 Sep 18;14:79. doi: 10.1186/1471-2253-14-79. eCollection 2014. PDF Monitoreo cerebral con electroencefalografía y el electroencefalograma derivado del BIS durante cirugía cardiaca Brain monitoring with electroencephalography and the electroencephalogram-derived bispectral index during cardiac surgery. Kertai MD1, Whitlock EL, Avidan MS. Anesth Analg. 2012 Mar;114(3):533-46. doi: 10.1213/ANE.0b013e31823ee030. Epub 2012 Jan 17. Abstract Cardiac surgery presents particular challenges for the anesthesiologist. In addition to standard and advanced monitors typically used during cardiac surgery, anesthesiologists may consider monitoring the brain with raw or processed electroencephalography (EEG). There is strong evidence that a protocol incorporating the processed EEG bispectral index (BIS) decreases the incidence intraoperative awareness in comparison with standard practice. However, there is conflicting evidence that incorporating the BIS into cardiac anesthesia practice improves "fast-tracking," decreases anesthetic drug use, or detects cerebral ischemia. Recent research, including many cardiac surgical patients, shows that a protocol based on BIS monitoring is not superior to a protocol based on end-tidal anesthetic concentration monitoring in preventing awareness. There has been a resurgence of interest in the anesthesia literature in limited montage EEG monitoring, including nonproprietary processed indices. This has been accompanied by research showing that with structured training, anesthesiologists can glean useful information from the raw EEG trace. In this review, we discuss both the hypothesized benefits and limitations of BIS and frontal channel EEG monitoring in the cardiac surgical population. PDF   El impacto del BIS versus la concentración anestésica al final de la espiración sobre el tiempo de extubación traqueal en cirugía cardiaca ¨fast-track¨ The impact of bispectral index versus end-tidal anesthetic concentration-guided anesthesia on time to tracheal extubation in fast-track cardiac surgery. Villafranca A, Thomson IA, Grocott HP, Avidan MS, Kahn S, Jacobsohn E. Anesth Analg. 2013 Mar;116(3):541-8. doi: 10.1213/ANE.0b013e31827b117e. Epub 2013 Feb 11. Abstract BACKGROUND: Bispectral Index (BIS)-guided anesthesia administration has been reported to reduce the time to tracheal extubation. However, no trials have compared the ability of BIS guidance to promote earlier tracheal extubation relative to guidance by end-tidal anesthetic concentration (ETAC). We hypothesized that BIS-guided anesthesia would result in earlier tracheal extubation compared with ETAC-guided anesthesia in fast-track cardiac surgery patients. METHODS: This study consisted of patients at a single institution who were enrolled in the larger, multicenter BIS or Anesthesia Gas to Reduce Explicit Recall (BAG-RECALL) clinical trial that compared rates of postoperative awareness for patient whose anesthetic was guided by BIS versus ETAC. Patients undergoing cardiac surgery were randomized to BIS (n = 361) or ETAC (n = 362) guided anesthesia. Volatile anesthetic was titrated either to maintain a BIS value of 40 to 60 (BIS group), or an age-adjusted minimum alveolar concentration of 0.7 to 1.3 (ETAC group). In the ETAC group, anesthesiologists were blinded to the BIS values. In this substudy, time to tracheal extubation was compared between groups. Cox regression identified predictors affecting the instantaneous probability of tracheal extubation. RESULTS: Time to tracheal extubation was not significantly different between groups (odds ratio 1.04, 95% confidence interval, 0.88-1.23, P = 0.643). In addition, group assignment did not influence the instantaneous probability of tracheal extubation (P = 0.433). Predictors decreasing the instantaneous probability of tracheal extubation included higher body mass index (P = 0.001), higher logistic EuroSCORE (P = 0.015), complex surgery type (P = 0.034), and surgery completion in the evening (P = 0.03). CONCLUSIONS: Compared with management based on ETAC, anesthetic management based on BIS guidance does not strongly increase the probability of earlier tracheal extubation in patients undergoing fast-track cardiac surgery. The decision to extubate the trachea is more influenced by patient characteristics and perioperative course than the assignment to BIS or ETAC monitoring. PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015

Cuidado anestésico monitoreado/Monitored anesthesia care

Cuidado anestésico monitorizado. Una vision general Monitored anesthesia care: An overview. Das S, Ghosh S. J Anaesthesiol Clin Pharmacol. 2015 Jan-Mar;31(1):27-9. doi: 10.4103/0970-9185.150525. PDF  Sedación en endoscopía gastrointestinal: Estudio prospectivo comparando administración de propofol por no-anestesiológos y cuidado anestésico monitorizado Sedation in gastrointestinal endoscopy: a prospective study comparing nonanesthesiologist-administered propofol and monitored anesthesia care. de Paulo GA, Martins FP, Macedo EP, Gonçalves ME, Mourão CA, Ferrari AP. Endosc Int Open. 2015 Feb;3(1):E7-E13. . PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015

Ventilación pulmonar/Lung ventilation

Disfunción pulmonar postoperatoria y ventilación mecánica en cirugía cardiaca Postoperative pulmonary dysfunction and mechanical ventilation in cardiac surgery. Badenes R, Lozano A, Belda FJ. Crit Care Res Pract. 2015;2015:420513. doi: 10.1155/2015/420513. Epub 2015 Feb 3. Abstract Postoperative pulmonary dysfunction (PPD) is a frequent and significant complication after cardiac surgery. It contributes to morbidity and mortality and increases hospitalization stay and its associated costs. Its pathogenesis is not clear but it seems to be related to the development of a systemic inflammatory response with a subsequent pulmonary inflammation. Many factors have been described to contribute to this inflammatory response, including surgical procedure with sternotomy incision, effects of general anesthesia, topical cooling, and extracorporeal circulation (ECC) and mechanical ventilation (VM). Protective ventilation strategies can reduce the incidence of atelectasis (which still remains one of the principal causes of PDD) and pulmonary infections in surgical patients. In this way, the open lung approach (OLA), a protective ventilation strategy, has demonstrated attenuating the inflammatory response and improving gas exchange parameters and postoperative pulmonary functions with a better residual functional capacity (FRC) when compared with a conventional ventilatory strategy. Additionally, maintaining low frequency ventilation during ECC was shown to decrease the incidence of PDD after cardiac surgery, preserving lung function. PDF   Avances recientes en ventilación mecánica en pacientes sin ARDS Recent advances in mechanical ventilation in patients without acute respiratory distress syndrome. Serpa Neto A1, Filho RR2, Rocha LL2, Schultz MJ3. F1000Prime Rep. 2014 Dec 1;6:115. doi: 10.12703/P6-115. eCollection 2014. Abstract While being an essential part of general anesthesia for surgery and at times even a life-saving intervention in critically ill patients, mechanical ventilation has a strong potential to cause harm. Certain ventilation strategies could prevent, at least to some extent, the injury caused by this intervention. One essential element of so-called 'lung-protective' ventilation is the use of lower tidal volumes. It is uncertain whether higher levels of positive end-expiratory pressures have lung-protective properties as well. There are indications that too high oxygen fractions of inspired air, or too high blood oxygen targets, are harmful. Circumstantial evidence further suggests that spontaneous modes of ventilation are to be preferred over controlled ventilation to prevent harm to respiratory muscle. Finally, the use of restrictive sedation strategies in critically ill patients indirectly prevents ventilation-induced injury, as daily spontaneous awakening and breathing trials and bolus instead of continuous sedation are associated with shorter duration of ventilation and shorten the exposure to the injurious effects of ventilation. PDF Daño pulmonary hiperóxico agudo Hyperoxic acute lung injury. Kallet RH, Matthay MA. Respir Care. 2013 Jan;58(1):123-41. doi: 10.4187/respcare.01963. Abstract Prolonged breathing of very high F(IO(2)) (F(IO(2)) ≥ 0.9) uniformly causes severe hyperoxic acute lung injury (HALI) and, without a reduction of F(IO(2)), is usually fatal. The severity of HALI is directly proportional to P(O(2)) (particularly above 450 mm Hg, or an F(IO(2)) of 0.6) and exposure duration. Hyperoxia produces extraordinary amounts of reactive O(2) species that overwhelms natural anti-oxidant defenses and destroys cellular structures through several pathways. Genetic predisposition has been shown to play an important role in HALI among animals, and some genetics-based epidemiologic research suggests that this may be true for humans as well. Clinically, the risk of HALI likely occurs when F(IO(2)) exceeds 0.7, and may become problematic when F(IO(2)) exceeds 0.8 for an extended period of time. Both high-stretch mechanical ventilation and hyperoxia potentiate lung injury and may promote pulmonary infection. During the 1960s, confusion regarding the incidence and relevance of HALI largely reflected such issues as the primitive control of F(IO(2)), the absence of PEEP, and the fact that at the time both ALI and ventilator-induced lung injury were unknown. The advent of PEEP and precise control over F(IO(2)), as well as lung-protective ventilation, and other adjunctive therapies for severe hypoxemia, has greatly reduced the risk of HALI for the vast majority of patients requiring mechanical ventilation in the 21st century. However, a subset of patients with very severe ARDS requiring hyperoxic therapy is at substantial risk for developing HALI, therefore justifying the use of such adjunctive therapies. PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015