Anestesia Analgesia Reanimación

Manejo hemodinámico intraoperatorio del quemado con falla multiorgánica

In order to evaluate the hemodynamic management during escharectomy and grafting in severely burned patients, 1.978 (1.635-2.201) intraoperative records of 56 patients were reviewed. Mean age was 39 years (21-59). Mean burned surface area was 32% (11-75). All patients had a multiorganic failure syndrome (MOF). During the procedure, all vaso and cardioactive drugs infusions were maintained (epinephrine, norepinephrine, dopamine either alone or in combination). The aim of therapy was to maintain a normal mean arterial pressure (MAP), modifying the dosages of vasoactive drugs and/or volume replacement according to the results. Hemodynamic monitoring was performed with an intraoesophagic Eco Doppler device, measuring aortic output (AO) and integrating the values of MAP and ECG for the calculation of the systemic vascular resistances (TSVR) and the systolic time intervals (STI) as estimation of myocardial performance. The results, compared with normal values showed: maintained tachycardia, MAP of 94 ± 22 mmHg, increased AO and diminished TSVR. The STI showed values of myocardial depression in spite of the inotropic infusions: PePi 148±26 mseg (p<0,05), PePi/LVETi 0,40±0,1 (p<0,05) The comparison of the cases between those with MAP > 90 mm Hg and those with MAP <90 mmHg, showed higher TSVR and values suggestive of myocardial depression in the former ones. MAP>90 mmHg :TSVR 1232±568 dyn.s-1.cm-5.m-2, PePi/LVETi 0,42±0,1. MAP<90 mmHg TSVR 802±389, PePi/LVETi 0,39±0,1 (p<0,05 for both). The measured hemodynamic pattern matches with an hyperdinamic one, with a sustained beta stimulus and diminished TSVR, although enough to maintain a normal MAP. In spite of the infusion of vaso and cardioactive drugs and the fall of the TSVR, myocardial depression was almost constantly detected. This one increased when the postcharge raised, even though TSVR were in lower values than the normal mean. This intraanesthetic hemodynamic management, trying to modulate the TSVR the minimun necessary to obtain a MAP within normal limits, seems to be acceptable for this special group of sick patients.

Estudio de la utilización de relajantes musculares en servicios de anestesia en Uruguay

The objective of this work is the study of the consumption of neuromuscular blocking drugs in different services of anaesthesia of Uruguay. It is carried out the analysis of the consumption of neuromuscular blocking drugs in retrospective form during a period of two years (1997-1998) in the Department of Anaesthesiology of the Clinicas Hospital , Canelones Hospital, Las Piedras Hospital and Melo Hospital. It is able to define two patterns of consumption of different neuromuscular blocking drugs. The first consumption pattern is defined for the biggest consumption of neuromuscular blocking drugs corresponds to alcuronium, then succinylcholine and then atracurium. Is indicated in most of the anaesthetic acts two neuromuscular blocking drugs. Succinylcholine is the drug more used for the tracheal intubations almost in an exclusive form. Alcuronium is the drug more used for the maintenance of the muscular relaxation almost in an exclusive form. The second consumption is atracurium with the decrease of the consumption of alcuronium. It can be conclude that scarce readiness of neuromuscular blocking drugs exists in the studied centres. The available drugs are atracurium, alcuronium and succinylcholine. It stands out the excessive use of the succinylcholine in the studied hospitals

Conducta a seguir ante una intubación dificultosa no prevista

Una causa común de morbilidad y mortalidad atribuible a la anestesia es la intubación dificultosa o fallida. Si se identifica previamente a los pacientes en condiciones de riesgo, un anestesista con un equipo preparado puede estar presente para enfrentarse a este problema. Los anestesistas deben tener el conocimiento y entrenamiento en seleccionar racionalmente los métodos de manejo de la vía aérea y realizarlos rápidamente y secuencialmente como sea requerido. Se desarrollan las distintas técnicas que se deben considerar en esta situación.

A common cause of morbidity and mortality attributable to anaesthesia is difficult or failed intubation. If those patients in whom intubation proves difficult could be identified in advanced, it could be arranged that an anesthetist properly equipped could be present to deal with the problem. Anesthetists are advised to become knowledgeable and skillful in selected rational methods of airway management and institute them sequentially and rapidly as required. The techniques to consider in this situation are reviewed

Manejo anestesiológico de las pacientes embarazadas portadoras de valvulopatía mitral: Trabajo de parto y cesárea

During pregnancy, mitral valve illness deteriorates the cardiovascular function. This subject becomes thus relevant, despite the low frequency of these cases. Although anaesthesia management will depend on given obstetric plans, there are general principles that have to be kept in mind in these patients with increased cardiovascular risk, in order to preserve vital functions in the mother as well as in the fetus. Among these are: to maintain normovolemic conditions, avoiding acute increase of volemia, to control heart rate at normal rates, to avoid pain during labor and/or caesarian section, to supply oxygen and finally to avoid aortocaval compression. Patients with structural valvular damage should receive prophylactic antibiotic therapy to prevent bacterial subacute endocarditis. Continuous electrocardiogram (ECG), non invasive arterial pressure, pulse oxymetry and diuresis should be routinely monitored in asymptomatic or low valvulopathy patients. In patients with moderate simtomatology, central venous or arterial measurement with central venous pressure (PVC) may be added. In severe cases cardiac output and capillary pulmonary arterial pressure should be measured by insertion of a Swan Ganz catheter. As pain is avoided, cardiovascular estrés is diminished, promoting the rapid recovery of the patient An ideal anesthetic technique cannot be recommended. For its choice, obstetric opportunity, valvular condition, preference of the anesthesiologist and the patient, etc. have to be considered. At present, regional techniques are being preferred in our environment but it should be estrésed and there is no ideal procedure and its choice depends on multiple aspects. In this review, the most commonly found valvular pathologies (stenosis, insufficiency and prolapse of the mitral valve) and the management of anestehesia before, during and in the postoperation period, will be described for labor as well as for cesarean section

Anestesia para cirugía no cardíaca en pacientes con trasplante de corazón: nuestro primer caso

We present a case of the first noncardiac surgery in a cardiac trasplant patient made in our country. It was a boy of 7 years, 19 kg of weight, with a primitive congenital cardiopathy, a ventricular septal defect (VSD), with concommitment insufficient aortic valve. In its evolution installed severe miocardic failure, wich motivated a cardiac trasplant. In the fifth day of the postoperative period presented an extensive subdural hematoma and was operating on as an urgency. The anesthetic risk of these patients is low, as long as we respect the care of the following factors: · maintenance of inmunosupresion; · prevention of infections; · diagnostic and treatment of rejection; · care of the pharmacologic aspects in relation to cardiac denervation

Bloqueos tronculares de la extremidad inferior en pacientes críticos: A propósito de dos casos

We report two cases of anesthesia of sciaticpopliteal interne nerve, sciaticpopliteal external nerve and femoral nerve in critical ill patients under vascular surgery of lower limbs. One case is a patient diagnosed of recent pulmonary embolism and the other one diagnosed of recent myocardial infarction. The procedures were successful in both cases without complications. We recommend this procedure in critical patients undergoing surgery of lower extremities.