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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Relajantes neurumusculares en pediatría/Neuromuscular block in infants

No. 2037                                                                                  Julio 28, 2015

Parálisis residual postoperatoria en un hospital infantil Australiano de tercer nivel Postoperative Residual Neuromuscular Paralysis at an Australian Tertiary Children's Hospital. Ledowski T1, O'Dea B2, Meyerkort L2, Hegarty M3, von Ungern-Sternberg BS4. Anesthesiol Res Pract. 2015;2015:410248. doi: 10.1155/2015/410248. Epub 2015 May 10. PDF Existe poca orientación profesional en la literatura para guiar el uso seguro del bloqueo neuromuscular en los infantes. Limited professional guidance and literature are available to guide the safe use of neuromuscular block in infants. Honsel M, Giugni C, Brierley J. Acta Paediatr. 2014 Sep;103(9):e370-3. doi: 10.1111/apa.12682. Epub 2014 Jun 20. Abstract AIM: Neuromuscular blocking agents (NMBAs) are used in a range of critical illnesses in neonates and infants, despite a lack of guidelines and professional standards. This study reviewed the current evidence base and ascertained UK practice regarding the continuous use of these agents in this age range. METHODS: We reviewed the literature and carried out a telephone questionnaire of all tertiary units in England and specialist children's hospital neonatal units in the UK. RESULTS: No best practice guidelines or general consensus statements were found, and the only randomised trial to feature an NMBA protocol expressed concerns about its use in such young babies. Of the 56 units contacted, 54 (96.4%) shared information. Only three of the 56 (5.4%) used intermittent boluses of NMBAs, 91.1% used NMBA infusions, 11 (19.6%) routinely used regular neuromuscular blocker pause to assess depth, and only one (1.8%) used peripheral nerve stimulation monitoring. All the units carried out clinical assessments, but only one (1.8%) had a written protocol. CONCLUSION: There is a paucity of literature and professional standards to guide the safe use of NMBAs in infants. Of the 54 units who participated in the survey, only one had a protocol for using NMBAs in babies. KEYWORDS: Critical care; Neonatology; Neuromuscular blockade; Neuromuscular monitoring; Pharmacology PDF

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Analgesia postoperatoria con TAP/TAP for postoperative analgesia

Bloqueo del plano transverso para analgesia postoperatoria después de cirugía laparoscópica. Revisión sistemática y meta-análisis Transversus abdominis plane block for postoperative analgesia after laparoscopic surgery: a systematic review and meta-analysis. Zhao X, Tong Y, Ren H, Ding XB, Wang X, Zong JY, Jin SQ, Li Q. Int J Clin Exp Med. 2014 Sep 15;7(9):2966-75. eCollection 2014. Abstract BACKGROUND: The increasing use of the transversus abdominis plane (TAP) block, as a form of pain relief after laparoscopic surgery, warrants evaluation of its effectiveness, when compared with other analgesic techniques. METHODS: We searched online databases of MEDLINE, EMBASE, Google scholar and The Cochrane Database of Systematic Review. Mean differences (MD) were formulated for continuous data; odds ratios (OR) were calculated for dichotomous data. Results were produced with a random effects model with 95% confidence intervals (CI). RESULTS: 14 trials with a total of 905 patients were included for the analysis, TAP block resulted in significantly less postoperative analgesic consumption at 24 h (MD = -25.46, 95% CI [-32.22, -18.69], P < 0.00001), and less number of patients requiring analgesic postoperatively (OR = 0.16, 95% CI 0.03-0.87, P = 0.03). Meanwhile, pain sores were significantly different at 2 h (MD = -1.55, 95% CI [-2.50, -0.59], P < 0.00001), a borderline difference between the groups seen at 6 hours ( MD = -1.13, 95% CI [-1.69, -0.56], P = 0.05), and there was not affect pain at 24 h (MD = -0.33, 95% CI [-0.08, 0.15], P = 0.14) with TAP block groups compared with the groups without TAP block. There was a significant difference in postoperative nausea and vomiting (random effects model: OR = 2.04, 95% CI [1.19-3.48], P = 0.34). CONCLUSION: TAP block would result in less analgesic consumption, less requirement of analgesic, and less pain at 2 h and slightly at 6 h but at 24 h after laparoscopic surgery in comparison with usual care alone or placebo block. In addition TAP block can increase the incidence of postoperative nausea and vomiting. KEYWORDS: TAP block; laparoscopic surgery; meta-analysis; transversus abdominis plane block PDF Bloqueo del plano transverso del abdomen para analgesia después de cesárea. Revisión sistemática y meta-análisis Transversus abdominis plane block for analgesia after Cesarean delivery: a systematic review and meta-analysis. Mishriky BM, George RB, Habib AS. Can J Anaesth. 2012 Aug;59(8):766-78. doi: 10.1007/s12630-012-9729-1. Epub 2012 May 24. Abstract PURPOSE: To assess the efficacy of transversus abdominis plane (TAP) block in improving analgesia following Cesarean delivery (CD). SOURCE: We searched MEDLINE, CENTRAL, EMBASE, and CINAHL for randomized controlled trials that assessed the efficacy of TAP block following CD and reported on postoperative pain scores and/or opioid consumption. Studies were combined according to the use or non-use of intrathecal morphine (ITM). Another analysis was performed for studies comparing TAP block with ITM. PRINCIPAL FINDINGS: Nine studies were included. Transversus abdominis plane block significantly reduced opioid consumption (mg morphine equivalents) after Cesarean delivery at six hours (mean difference [MD] -10.18; 95% confidence interval [CI] -13.03 to -7.34), at 12 hr (MD -13.83; 95% CI -22.77 to -4.89), and at 24 hr (MD -20.23; 95% CI -33.69 to -6.77). The TAP block also reduced pain scores for up to 12 hr and nausea in patients who did not receive ITM. When added to ITM, TAP block produced a small reduction in pain scores on movement in the first six hours (MD -0.82, 95% CI -1.52 to -0.11). When compared with ITM, pain scores on movement and opioid consumption at 24 hr were lower (MD 0.98; 95% CI 0.06 to 1.91 and MD 8.42 mg; 95% CI 1.74 to 15.10, respectively), and time to first rescue analgesic was longer with ITM (8 hr vs 4 hr), although opioid-related side effects were more common. CONCLUSION: Transversus abdominis plane block significantly improved postoperative analgesia in women undergoing CD who did not receive ITM but showed no improvement in those who received ITM. Intrathecal morphine was associated with improved analgesia compared with TAP block alone at the expense of an increased incidence of side effects.  PDF

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