Ventilación mecánica protectiva/Protective mechanical ventilation

No. 2056                                                                                  Agosto 16, 2015

Ventilación protectiva intraoperatoria y riesgo de complicaciones respiratorias postoperatorias. Intraoperative protective mechanical ventilation and risk of postoperative respiratory complications: hospital based registry study. Ladha K, Vidal Melo MF, McLean DJ, Wanderer JP, Grabitz SD, Kurth T, Eikermann M. BMJ. 2015 Jul 14;351:h3646. doi: 10.1136/bmj.h3646. PDF Ventilación protectiva vs convencional en cirugía. Protective versus Conventional Ventilation for Surgery: A Systematic Review and Individual Patient Data Meta-analysis Ary Serpa Neto, M.D., M.Sc., Ph.D.; Sabrine N. T. Hemmes, M.D.; Carmen S. V.  et al Anesthesiology. 2015 May 15. [Epub ahead of print] Abstract This individual patient meta-analysis of 2,127 patients ventilated under general anesthesia for surgery from 15 randomized controlled trials shows that intraoperative ventilation with low tidal volume protects against postoperative pulmonary complications, but further trials are necessary to define the role of intraoperative higher positive end-expiratory pressure to prevent postoperative pulmonary complications after major abdominal surgery. PDF  Ventilación pulmonar protectiva en pacientes obesos Perioperative lung protective ventilation in obese patients. Fernandez-Bustamante A, Hashimoto , Serpa Neto A, Moine P, Vidal Melo MF, Repine JE. BMC Anesthesiol. 2015 May 6;15:56. doi: 10.1186/s12871-015-0032-x. Abstract The perioperative use and relevance of protective ventilation in surgical patients is being increasingly recognized. Obesity poses particular challenges to adequate mechanical ventilation in addition to surgical constraints, primarily by restricted lung mechanics due to excessive adiposity, frequent respiratory comorbidities (i.e. sleep apnea, asthma), and concerns of postoperative respiratory depression and other pulmonary complications. The number of surgical patients with obesity is increasing, and facing these challenges is common in the operating rooms and critical care units worldwide. In this review we summarize the existing literature which supports the following recommendations for the perioperative ventilation in obese patients: (1) the use of protective ventilation with low tidal volumes (approximately 8 mL/kg, calculated based on predicted -not actual- body weight) to avoid volutrauma; (2) a focus on lung recruitment by utilizing PEEP (8-15 cmH2O) in addition to recruitment maneuvers during the intraoperative period, as well as incentivized deep breathing and noninvasive ventilation early in the postoperative period, to avoid atelectasis, hypoxemia and atelectrauma; and (3) a judicious oxygen use (ideally less than 0.8) to avoid hypoxemia but also possible reabsorption atelectasis. Obesity poses an additional challenge for achieving adequate protective ventilation during one-lung ventilation, but different lung isolation techniques have been adequately performed in obese patients by experienced providers. Postoperative efforts should be directed to avoid hypoventilation, atelectasis and hypoxemia. Further studies are needed to better define optimum protective ventilation strategies and analyze their impact on the perioperative outcomes of surgical patients with obesity. PDF  Efecto de la ventilación protectiva sobre las complicaciones pulmonares en pacientes bajo anestesia general Effect of protective ventilation on postoperative pulmonary complications in patients undergoing general anaesthesia: a meta-analysis of randomised controlled trials. Tao T, Bo L, Chen F, Xie Q, Zou Y, Hu B, Li J, Deng X. BMJ Open. 2014 Jun 24;4(6):e005208. doi: 10.1136/bmjopen-2014-005208.   CONCLUSIONS: Intraoperative use of protective ventilation strategies has the potential to reduce the incidence of postoperative pulmonary complications in patients undergoing general anaesthesia. Prospective, well-designed clinical trials are warranted to confirm the beneficial effects of protective ventilation strategies in surgical patients. PDF

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Dexmedetomidina en CAM/Dexmedetomidine in monitored anesthesia care

Agosto 15, 2015. No. 2055

Comparación de dexmedetomidina en cuidado anestésico monitorizado vs anestesia espinal encirugía de várices The comparison of monitored anesthesia care with dexmedetomidine and spinal anesthesia during varicose vein surgery. Moon EJ, Kang KW, Chung JY, Kang JM, Park JH, Joh JH, Park HC, Yi JW. Ann Surg Treat Res. 2014 Nov;87(5):245-52. Abstract PURPOSE: The purpose of this study was to investigate the effectiveness and safety of monitored anesthesia care (MAC) using dexmedetomidine for its sedative and analgesic effect during varicose vein surgery. METHODS: Forty-two patients, who underwent varicose vein surgery, were divided into the MAC group (n = 20) or the spinal anesthesia group (n = 22) for randomized clinical trial. In the MAC group, dexmedetomidine was administered by a loading dose of 1 µg/kg for 10 minutes, followed by a maintenance infusion of 0.2-1.0 µg/kg/hr. Ketamine was used for intermittent injection. In the spinal anesthesia group, midazolam was used for sedation. Intraoperative vital signs, the number of adverse events, and the satisfaction of patients and surgeons concerning the anesthetic condition were compared between the two groups. RESULTS: Systolic blood pressure was intraoperatively significantly different over time between the two groups. The groups had statistical differences in the change in heart rate with regard to time. In the postanesthetic care unit, patients and surgeons in the MAC group had a lower satisfaction score, compared to patients and surgeons in the spinal anesthesia group. However, in the recovery period, patients had a positive perception concerning MAC anesthesia. In addition, without significant adverse events, the MAC group had a shorter time to possible ambulation, which indicated an early recovery. CONCLUSION: We believe that MAC using dexmedetomidine in combination with ketamine may be an alternative anesthetic technique for varicose vein surgery with regard to a patient's preference and medical condition. KEYWORDS: Dexmedetomidine; Monitored anesthesia care; Sedation; Spinal anesthesia PDF  La dexmedetomidina aminora el cuidado anestésico monitorizado Dexmedetomidine ameliorates monitored anaesthesia care. Gupta P, Joshi S, Jethava D, Kumar A. Indian J Anaesth. 2014 Mar;58(2):154-9. doi: 10.4103/0019-5049.130816. Abstract BACKGROUND AND AIMS: Monitored anaesthesia care (MAC) is meant for procedures under local anaesthesia. Various drugs have been used for this purpose. The recently introduced alpha2 agonist, dexmedetomidine provides "conscious sedation" with adequate analgesia and minimal respiratory depression. Hence, the safety and efficacy of two doses of dexmedetomidine for sedation and analgesia were evaluated. METHODS: A total of 90 patients were distributed in three groups of 30 each: Dexmedetomidine 0.5 μg/kg (DL), dexmedetomidine 1.0 μg/kg (DH) and normal saline (C). The initial loading dose was followed by maintenance infusion of 0.2-0.7 μg/kg/h of dexmedetomidine or equivalent volume of saline. Study drug was started at least 15 min before placement of local anaesthesia. Drugs were titrated to a target level of sedation (=3 on Ramsay sedation scale [RSS]). Midazolam 0.02 mg/kg for RSS < 3 and fentanyl 0.5 μg/kg were supplemented as required. The statistical analysis was performed using Chi-square test and mean and anova analysis. RESULTS: In groups DL and DH fewer patients required supplemental midazolam, 56.7% (17/30) and 40% (12/30), compared with control, where 86.7% (26/30)needed midazolam supplements. P = 0.000. Both groups DL and DH required significantly less fentanyl (84.8 and 83.9 μg) versus control (144.2 μg). There was significantly increased ease of achieving and maintaining targeted sedation and analgesia in both dexmedetomidine groups when compared with placebo (P = 0.001). Adverse events observed with dexmedetomidine were bradycardia and hypotension. CONCLUSIONS: Dexmedetomidine in the doses studied was considered safe and effective sedative and analgesic for patients undergoing procedures under MAC. KEYWORDS: Conscious sedation; dexmedetomidine; monitored anaesthesia care; respiratory depression PDF   Estudio prospectivo, aleatorizado, doble ciego comparando dexmedetomidina vs. midazolam-fentanilo para timpanoplastía en cuidado anestésico monitorizado A prospective randomized double-blind study comparing dexmedetomidine vs. combination of midazolam-fentanyl for tympanoplasty surgery under monitored anesthesia care. Parikh DA, Kolli SN, Karnik HS, Lele SS, Tendolkar BA. J Anaesthesiol Clin Pharmacol. 2013 Apr;29(2):173-8. doi: 10.4103/0970-9185.111671. Abstract BACKGROUND: Analgesia and sedation are usually required for the comfort of the patient and surgeon during tympanoplasty surgery done under local anesthesia. In this study, satisfaction scores and effectiveness of sedation and analgesia with dexmedetomidine were compared with a combination of midazolam-fentanyl. MATERIALS AND METHODS: Ninety patients undergoing tympanoplasty under local anesthesia randomly received either IV dexmedetomidine 1 μg kg(-1) over 10 min followed by 0.2 μg kg(-1)h(-1) infusion (Group D) or IV midazolam 0.06 mg kg(-1) plus IV fentanyl 1 μg kg(-1) over 10 min (Group MF) followed by normal saline infusion at 0.2 ml kg(-1)h(-1). Sedation was titrated to Ramsay sedation score (RSS) of three. Vital parameters, rescue analgesics (fentanyl 1 μg kg(-1)) and sedatives (midazolam 0.01 mg kg(-1)), patient and surgeon satisfaction scores were recorded. RESULTS: Patient and surgeon satisfaction score was better in Group D than Group MF (median interquartile range (IQR) 9 (8-10) vs. 8 (6.5-9.5) and 9 (8.5-9.5) vs. 8 (6.75-9.25), P = 0.0001 for both). Intraoperative heart rate and mean arterial pressure in Group D were lower than the baseline values and the corresponding values in Group MF (P < 0.05). Percentage of patients requiring rescue fentanyl was higher in Group MF than Group D (40% vs. 11.1%, P = 0.01). One patient in Group D while four in Group MF (8.8%) required rescue sedation with midazolam (P > 0.17). Seven patients in Group D had dry mouth vs. none in Group MF (P = 0.006). One patient in Group D had bradycardia with hypotension which was effectively treated. CONCLUSION: Dexmedetomidine is comparable to midazolam-fentanyl for sedation and analgesia in tympanoplasty with better surgeon and patient satisfaction. Hemodynamics need to be closely monitored. KEYWORDS: Dexmedetomidine; midazolam fentanyl sedation; monitored anesthesia care; otological; satisfaction scores; sedation; surgery PDF

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Medwave Agosto 2015

Los últimos artículos publicados en Medwave son los siguientes:

RESUMEN EPISTEMONIKOS

¿Debemos agregar vancomicina en polvo a la profilaxis antibiótica en cirugía de columna? - Primera actualización
Mario López, Marcelo Molina (Chile)

Medwave 2015; 15(Suppl 2):e6202
http://dx.doi.org/10.5867/medwave.2015.6202


ESTUDIO PRIMARIO

Variantes anatómicas de las ramas del arco aórtico en una población peruana
Julio Arturo Huapaya, Kristhy Chávez-Trujillo, Miguel Trelles, Roy Dueñas Carbajal, Renato Ferrandiz Espadin (Perú)

Medwave 2015 Jul;15(6):e6194
http://dx.doi.org/10.5867/medwave.2015.06.6194


DE LOS EDITORES

Una cachorra y los reportes de casos en Medwave
Vivienne C. Bachelet (Chile)

Medwave 2015 Jul;15(6):e6197
http://dx.doi.org/10.5867/medwave.2015.06.6197


CARTAS A LA EDITORA

Redes sociales, salud, humanismo y eutanasia
Juan Carlos Medrano Rodríguez (México)

Medwave 2015 Jul;15(6):e6193
http://dx.doi.org/10.5867/medwave.2015.06.6193


REPORTE DE CASO

Adenoma pleomorfo sobre heterotopía salival: reporte de caso y revisión de la literatura
Cristian Papuzinski Aguayo, Rodrigo Selamé Glena, Jaime Bermeo Sanchez, Carlo Lozano Burgos (Chile)

Medwave 2015 Jul;15(6):e6192
http://dx.doi.org/10.5867/medwave.2015.06.6192


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Cuidado anestésico monitoreado/Monitored anesthesia care

Estudio comparativo de cuidado anestésico monitoreado A comparative study on monitored anesthesia care. Sen J1, Sen B2. Anesth Essays Res. 2014 Sep-Dec;8(3):313-8. doi: 10.4103/0259-1162.143121. Abstract AIM: The aim of this study is to compare the effectiveness, hemodynamic changes and duration of sedation and analgesia between combinations of fortwin-phenergan-midazolam (FPM) and ketamine - midazolam (KM) along with local anesthesia for the surgeries done under the umbrella of monitored anesthesia care.MATERIALS AND METHODS: A total of 50 patients undergoing surgeries as tympanoplasty, septoplasty, lip repair, dacrocystectomy and cataract under local anesthesia, randomly received either intravenous (IV) fortwin 0.3 mg/kg over 1 min followed by IV midazolam 0.04 mg/kg plus IV phenergan 12.5 mg (Group FPM) or IV ketamine 0.3 mg/kg over 1 min plus IV midazolam 0.04 mg/kg (Group KM). Sedation was titrated to Ramsay sedation score (RSS) of 3. Patients' mean arterial pressure (MAP), heart rate (HR), saturation peripheral pulse, duration of sedation and need for intraoperative rescue sedation/analgesic were recorded and compared. Satisfaction of patients (using a 1-7 point Likert verbal rating scale) and readiness for discharge towards (time to Aldrete score of 10) were also determined. RESULT: Group KM had significant rise in HR (20-25%) and MAP (25-30%) from 30 min after the bolus dose given until the end of the surgery in contrast to Group FPM. The target sedation level (RSS ≥ 3) was higher in Group FPM (n = 23 [92%]) as compared with Group KM (n = 12 [48%]). Time until need for rescue sedation was 66.96 ± 17.19 min in FPM and 32.80 ± 8.90 min in KM group. The patient satisfaction (Likert scale) is more with the FPM group (6.12 ± 0.83 vs. 4.40 ± 1.20). CONCLUSION: We found that the combination of FPM is superior to the KM combination as per the hemodynamic changes, duration of analgesia, patients' satisfaction and efficacy of the drugs are concerned. KEYWORDS: Fortwin; ketamine; local anesthesia; midazolam; monitored anesthesia; phenergan; sedation PDF

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Vía aérea prehospitalaria/Prehospital airway

Intubación endotraqueal prehospitalaria: ¿Elemental o perjudicial? Prehospital endotracheal intubation: elemental or detrimental? Pepe PE, Roppolo LP, Fowler RL. Abstract This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2015 and co-published as a series in Critical Care. Other articles in the series can be found online at http://ccforum.com/series/annualupdate2015. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901. PDF Avances en el manejo prehospitalario de la vía aérea Advances in prehospital airway management. Jacobs P, Grabinsky A. Int J Crit Illn Inj Sci. 2014 Jan;4(1):57-64. doi: 10.4103/2229-5151.128014. Abstract Prehospital airway management is a key component of emergency responders and remains an important task of Emergency Medical Service (EMS) systems worldwide. The most advanced airway management techniques involving placement of oropharyngeal airways such as the Laryngeal Mask Airway or endotracheal tube. Endotracheal tube placement success is a common measure of out-of-hospital airway management quality. Regional variation in regard to training, education, and procedural exposure may be the major contributor to the findings in success and patient outcome. In studies demonstrating poor outcomes related to prehospital-attempted endotracheal intubation (ETI), both training and skill level of the provider are usually often low. Research supports a relationship between the number of intubation experiences and ETI success. National standards for certification of emergency medicine provider are in general too low to guarantee good success rate in emergency airway management by paramedics and physicians. Some paramedic training programs require more intense airway training above the national standard and some EMS systems in Europe staff their system with anesthesia providers instead. ETI remains the cornerstone of definitive prehospital airway management, However, ETI is not without risk and outcomes data remains controversial. Many systems may benefit from more input and guidance by the anesthesia department, which have higher volumes of airway management procedures and extensive training and experience not just with training of airway management but also with different airway management techniques and adjuncts. KEYWORDS: Airway; anesthesiology; emergency; management; prehospital PDF

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