RESUMEN
Intracerebroventricular (ICV) infusion of morphine is a well-known technique to relieve intractable neoplasic pain when conventional analgesic strategies reach their limits. Through this case report, we present indications, assets, and drawbacks of this procedure in such conditions. We also describe the adaptation of the systemic analgesic treatment to allow discharge from the hospital to home settings. Thanks to the ICV infusion of a mixture of morphine, bupivacaine and clonidine, the patient was weaned from oral opioid medications and reached an acceptable level of comfort. This allowed him to be discharged from the hospital to go back home with a specific setting of mobile palliative care structure. The patient's family followed training about the device to prevent any technical trouble and to react in case of unwanted events.
L'administration de morphine intracérébroventriculaire (ICV) est une technique bien connue pour traiter les douleurs néoplasiques insoutenables lorsqu'un traitement antalgique conventionnel atteint ses limites. A travers un cas clinique, nous présentons les indications, les atouts et les inconvénients de cette procédure dans de telles conditions. Nous décrivons aussi l'adaptation du traitement antalgique per os après implantation du cathéter. Grâce à l'infusion ICV d'un mélange de morphine, de bupivacaïne et de clonidine, le patient a été sevré totalement des dérivés opioïdes oraux et a atteint un niveau de confort acceptable pour rentrer à domicile avec une structure mobile de soins palliatifs mise en place. L'entourage du patient a bénéficié de séances d'information pour prévenir les problèmes techniques liés au dispositif et pour réagir en cas d'incident.
Asunto(s)
Clonidina , Dolor Intratable , Analgésicos Opioides/uso terapéutico , Bupivacaína/uso terapéutico , Clonidina/uso terapéutico , Humanos , Infusiones Intraventriculares , Masculino , Morfina/uso terapéutico , Dolor Intratable/tratamiento farmacológico , Dolor Postoperatorio , Cuidados PaliativosRESUMEN
BACKGROUND: The isolated forearm test (IFT) is the gold standard test of connected consciousness (awareness of the environment) during anaesthesia. The frontal alpha-delta EEG pattern (seen in slow wave sleep) is widely held to indicate anaesthetic-induced unconsciousness. A priori we proposed that one responder with the frontal alpha-delta EEG pattern would falsify this concept. METHODS: Frontal EEG was recorded in a subset of patients from three centres participating in an international multicentre study of IFT responsiveness following tracheal intubation. Raw EEG waveforms were analysed for power-frequency spectra, depth-of-anaesthesia indices, permutation entropy, slow wave activity saturation and alpha-delta amplitude-phase coupling. RESULTS: Volitional responses to verbal command occurred in six out of 90 patients. Three responses occurred immediately following intubation in patients (from Sites 1 and 2) exhibiting an alpha-delta dominant (delta power >20 dB, alpha power >10 dB) EEG pattern. The power-frequency spectra obtained during these responses were similar to those of non-responders (P>0.05) at those sites. A further three responses occurred in (Site 3) patients not exhibiting the classic alpha-delta EEG pattern; these responses occurred later relative to intubation, and in patients had been co-administered ketamine and less volatile anaesthetic compared with Site 1 and 2 patients. None of the derived depth-of-anaesthesia indices could robustly discrimate IFT responders and non-responders. CONCLUSIONS: Connected consciousness can occur in the presence of the frontal alpha-delta EEG pattern during anaesthesia. Frontal EEG parameters do not readily discriminate volitional responsiveness (a marker of connected consciousness) and unresponsiveness during anaesthesia. CLINICAL TRIAL REGISTRATION: NCT02248623.
Asunto(s)
Anestesia General/métodos , Estado de Conciencia/efectos de los fármacos , Electroencefalografía/efectos de los fármacos , Monitoreo Intraoperatorio/métodos , Adulto , Estudios de Cohortes , Electroencefalografía/métodos , Femenino , Antebrazo , Humanos , Masculino , Estudios Prospectivos , Adulto JovenRESUMEN
BACKGROUND: Intraoperative recruitment manoeuvres (RMs) combined with PEEP reverse the decrease in functional residual capacity (FRC) associated with anaesthesia and improve intraoperative oxygenation. Whether these benefits persist after operation remains unknown. We tested the hypothesis that intraoperative RMs associated with PEEP improve postoperative spirometry including FRC and reduce the incidence of postoperative hypoxaemia in morbidly obese (MO) patients undergoing laparoscopic gastric bypass. METHODS: After IRB approval and informed consent, 50 MO patients undergoing laparoscopic gastric bypass under volume-controlled ventilation (tidal volume 6 ml kg(-1) of IBW) were randomly ventilated with either 10 cm H2O PEEP or with 10 cm H2O PEEP and one RM carried out after induction of pneumoperitoneum, and another after exsufflation. Anaesthesia and analgesia were standardized. Spirometry was assessed before operation and 24 h after surgery. Postoperative oxygenation and the apnoea-hypopnoea index (AHI) were recorded during the first postoperative night. RESULTS: Age, BMI, and STOP BANG score were similar in both groups. FRC decrease after surgery was minimal [0.15 (0.14) litre in control and 0.38 (0.19) litre in the RM group] and similar between the groups (P=0.35). FVC, FEV1, mean [Formula: see text], percentage of time spent with [Formula: see text] below 90%, and AHI did not differ significantly between the groups. CONCLUSIONS: This study demonstrates that when added to a protective mechanical ventilation combining low tidal volume and high PEEP, two RMs do not improve postoperative lung function including FRC, arterial oxygenation, and the incidence of obstructive apnoea in MO patients after laparoscopic upper abdominal surgery. CLINICAL TRIAL REGISTRATION: EudraCT 2011-000999-33.
Asunto(s)
Derivación Gástrica/métodos , Hipoxia/prevención & control , Cuidados Intraoperatorios/métodos , Obesidad Mórbida/cirugía , Respiración con Presión Positiva/métodos , Complicaciones Posoperatorias/prevención & control , Adulto , Anciano , Dióxido de Carbono/análisis , Femenino , Capacidad Residual Funcional/fisiología , Humanos , Hipoxia/complicaciones , Hipoxia/fisiopatología , Laparoscopía/métodos , Masculino , Persona de Mediana Edad , Obesidad Mórbida/complicaciones , Espirometría/métodos , Espirometría/estadística & datos numéricos , Volumen de Ventilación Pulmonar/fisiología , Adulto JovenRESUMEN
BACKGROUND: Intravenous lidocaine can be used intraoperatively for its analgesic and antihyperalgesic properties but local anaesthetics may also prolong the duration of action of neuromuscular blocking agents. We hypothesized that intravenous lidocaine would prolong the time to recovery of neuromuscular function after cisatracurium. METHODS: Forty-two patients were enrolled in this randomized, double-blind, placebo-controlled study. Before induction, patients were administered either a 1.5 mg/kg bolus of intravenous lidocaine followed by a 2 mg/kg/h infusion or an equal volume of saline. Anaesthesia was induced and maintained using propofol and remifentanil infusions. After loss of consciousness, a 0.15 mg/kg bolus of cisatracurium was administered. No additional cisatracurium injection was allowed. Neuromuscular function was assessed every 20 s using kinemyography. The primary endpoint was the time to spontaneous recovery of a train-of-four (TOF) ratio ≥ 0.9. RESULTS: The time to spontaneous recovery of a TOF ratio ≥ 0.9 was 94 ± 15 min in the control group and 98 ± 16 min in the lidocaine group (P=0.27). CONCLUSIONS: No significant prolongation of spontaneous recovery of a TOF ratio ≥ 0.9 after cisatracurium was found in patients receiving intravenous lidocaine.
Asunto(s)
Anestésicos Locales/farmacología , Atracurio/análogos & derivados , Lidocaína/farmacología , Bloqueo Neuromuscular , Fármacos Neuromusculares no Despolarizantes , Adulto , Anciano , Periodo de Recuperación de la Anestesia , Anestesia General , Anestésicos Intravenosos , Anestésicos Locales/administración & dosificación , Método Doble Ciego , Estimulación Eléctrica , Determinación de Punto Final , Femenino , Humanos , Infusiones Intravenosas , Lidocaína/administración & dosificación , Masculino , Persona de Mediana Edad , Monitoreo Intraoperatorio , Músculo Esquelético/inervación , Músculo Esquelético/fisiología , Piperidinas , Propofol , Estudios Prospectivos , Remifentanilo , Adulto JovenRESUMEN
We report a case of pneumopericardium occuring after cardiac surgery. Pneumopericardium is a rare condition; trauma is the most frequent etiology. Nontraumatic causes include fistulae in relationship with the bronchial tree or oesophagus and intrapericardial gazeous production due to bacterial pericarditis. Pericardiocentesis is indicated in case of air tamponade and local infection.
Asunto(s)
Neumopericardio/diagnóstico , Esternón/microbiología , Dehiscencia de la Herida Operatoria/complicaciones , Anciano , Puente de Arteria Coronaria/efectos adversos , Humanos , Masculino , Neumopericardio/etiología , Infecciones Estafilocócicas/complicaciones , Dehiscencia de la Herida Operatoria/microbiologíaRESUMEN
We report the case of a 41-year-old man admitted for lower limb and liver trauma following a car accident. Surgical repair of a tibial fracture was performed under general anesthesia 5 days after admission while the liver injury was managed conservatively. At the time of tourniquet inflation, the patient presented a pulmonary embolism. Low-molecular-weight heparin administration had been delayed for 72 hours after admission due to the liver injury. Risk factors for bleeding and thromboembolism in trauma patients with liver injury are discussed.