Asunto(s)

Asunto(s)

RESUMEN

BACKGROUND: : The combination of dexamethasone (DEX), ondansetron (OND) and droperidol (DRO) is efficacious in preventing postoperative nausea and vomiting in adults, but has not been well assessed in children. METHODS: : Children undergoing elective surgery under general anaesthesia and considered at high risk for postoperative vomiting (POV) were randomly assigned to receive a combination of DEX, OND and placebo (Group A) or a combination of DEX, OND and DRO (Group B). The primary outcome was the incidence of POV during the first 24 hours after surgery. We hypothesized that the addition of DRO to the standard antiemetic prophylaxis would provide a further 15% reduction in the residual risk for POV. The secondary outcome considered was any adverse event occurring during the study. RESULTS: : One hundred and fifty-three children, aged three to 16 years, were randomized to Group A and 162 to Group B. The overall incidence of POV did not differ significantly between the two groups, with 16 patients in Group A (10.5%) and 18 in Group B (11.1%) presenting with one or more episodes of POV, P =0.86. Fewer patients presented with adverse events in Group A (2%) compared with Group B (8%), P =0.01. Drowsiness and headache were the principal adverse events reported. CONCLUSIONS: : The addition of DRO to a combination of OND and DEX did not decrease POV frequency below that obtained with the two-drug combination in children at high risk of POV, but increased the risk of drowsiness. The combination of DEX and OND should be recommended in children with a high risk of POV. CLINICAL TRIAL REGISTRATION.: NCT01739985.

Asunto(s)

RESUMEN

The early use of continuous positive airway pressure ventilation has been shown to be effective and is recommended for patients with obstructive sleep apnea. The complications of continuous positive airway pressure ventilation are not well described. We report two cases of pneumocephalus following the use of continuous positive airway pressure ventilation after transsphenoidal surgery. One patient had an obstructive sleep apnea and the other suffered acute respiratory failure. In both cases, pneumocephalus caused major morbidity and required specific treatment and prolonged considerably hospital stay. Based on these observations we believe new precautions in the use of noninvasive continuous positive airway pressure ventilation should be recommended.

Asunto(s)

RESUMEN

Interpreting a Bispectral Index (BIS) of "0", corresponding to an isolelectric electroencephalography, can be difficult. After ruling out technical issues, such as leads disconnection, several possible causes for a decrease in the BIS persists, including deep anesthesia, hypothermia, decrease in the cerebral perfusion pressure and cerebral ischemia. We report a sudden transient decrease of the BIS to "0" in a patient that underwent a coil embolization of a ruptured intracranial aneurysm and suggest that the change in BIS values could provide useful information about the cerebral hemodynamic during aneurysm treatment and might provide indications of a serious cerebral event.

Asunto(s)

Asunto(s)

Asunto(s)

RESUMEN

BACKGROUND: The aim of this study was to compare intubating conditions and adverse events after sevoflurane induction in infants, with or without the use of rocuronium or alfentanil. METHODS: Seventy-five infants, aged 1-24 months, undergoing elective surgery under general anaesthesia were randomly assigned to receive 8% sevoflurane with either placebo (i.v. saline 0.5 ml kg⁻¹), rocuronium (0.3 mg kg⁻¹), or alfentanil (20 µg kg⁻¹). The primary outcome measure was intubating conditions evaluated 90 s after test drug injection by an anaesthetist unaware of the patient's group. The secondary outcome criteria were respiratory (Sp(O2) <90%, laryngospasm, closed vocal cords preventing intubation, bronchospasm) and haemodynamic adverse events (heart rate and mean arterial pressure variations ≥30% control value). RESULTS: Intubating conditions were significantly better in the rocuronium group, with clinically acceptable intubating conditions in 92%, vs 70% in the alfentanil group and 63% in the placebo group (P=0.044). Adverse respiratory events were significantly less frequent in the rocuronium group: 0% vs 33% in the placebo group and 30% in the alfentanil group (P=0.006). Haemodynamic adverse events were more frequent in the alfentanil group: 48% vs 7% in the placebo group and 16% in the rocuronium group (P=0.0019). CONCLUSIONS: In 1- to 24-month-old infants, the addition of 0.3 mg kg⁻¹ rocuronium to 8% sevoflurane improved intubating conditions and decreased the frequency of respiratory adverse events. Alfentanil provided no additional benefit in this study.

Asunto(s)

RESUMEN

OBJECTIVE: To evaluate the early use of magnetic resonance imaging (MRI) for the diagnosis of diplopia following cataract surgery under peribulbar anaesthesia. STUDY DESIGN: Single centre prospective study. PATIENTS AND METHOD: From January 2003 to January 2005 every patient undergoing cataract surgery under peribulbar anaesthesia was included. Any patient spontaneously complaining of double vision on day 1 received a full ophthalmologic examination. When binocular diplopia was confirmed by a positive Hess-Lancaster test, the patient immediately underwent an MRI. RESULTS: During the two year period, 4805 patients underwent cataract surgery under peribulbar anaesthesia. Eight patients reported double vision on day 1 (0.16% prevalence). Clinical examination confirmed binocular diplopia and a positive Hess-Lancaster test identified the paralysed muscle. In 7 out of 8 patients, the MRI performed on the same day showed a T2 hyper intensity signal within the paralysed muscle, it was interpreted as inflammatory oedema following an accidental intra muscular injection of a myotoxic local anaesthetic. In one patient the MRI was normal, suggesting a preoperative undiagnosed diplopia having no relation to the peribulbar anaesthesia. CONCLUSION: A slit-lamp exam and a Hess-Lancaster test are necessary to confirm postoperative strabismic diplopia after cataract surgery. An early MRI can accurately distinguish postanaesthetic myotoxic diplopia from a preoperative diplopia revealed by the corrective cataract surgery.

Asunto(s)

RESUMEN

Compulsory professional practice evaluation will require holding frequent morbidity mortality staffs. Those staffs must follow strict methodology. We report successive steps of systemic analysis according to ALARM process of two successive non lethal anaesthetic incidents. Such analysis helped identifying care management problems and their systemic causes. Thus it leaded to corrective measures in order to prevent such events recurrence. Moreover, it allowed systemic defaults correction that prevent future other accidents.

Asunto(s)

RESUMEN

Sedation has been used widely for reducing patient anxiety during peribulbar block for ocular surgery. We report the case of a patient in whom a spontaneous move after injection of propofol for peribulbar block resulted in a globe perforation.

Asunto(s)

Asunto(s)

RESUMEN

BACKGROUND: Measure of blood flow velocity in retrobulbar vessels is performed to determine the severity of ophthalmic pathologies as glaucoma. In children, this measure is usually performed under general anaesthesia. Sevoflurane is known to not modify cerebral blow flow velocities. However, its effect on retrobulbar circulation is not known. This study was designed to evaluate the effect of sevoflurane on retrobulbar circulation flow velocity in children undergoing examination for ocular disorders under general anaesthesia. METHODS: Thirteen mechanically ventilated children (Fi(O2))=1) were included. Blood flow velocities of central retinal artery, ophthalmic artery, and middle cerebral artery were measured by Doppler ultrasound during 1 and 2 age-adjusted minimal alveolar concentration (MAC) sevoflurane anaesthesia. Intra-ocular pressure and non-invasive haemodynamic parameters were also measured. End-tidal carbon dioxide tension was controlled during all the study period. RESULTS: Mean arterial pressure decreased from 1 to 2 age-adjusted MAC sevoflurane (58 [12] vs 54 [12] mm Hg, P=0.01). In the ophthalmic artery, end diastolic velocity (EDV) decreased significantly at 2 MAC (1 MAC: 4.4 [4] cm s(-1) vs 2 MAC: 1.4 [2.4] cm s(-1); P=0.04) and resistivity index (RI) increased significantly (1 MAC: 0.83 [0.11] vs 2 MAC: 0.93 [0.09]; P=0.007). Systolic velocity, EDV, and RI remained constant in the central retinal artery and in the middle cerebral artery. CONCLUSION: High alveolar concentration of sevoflurane decreased blood flow velocity in the ophthalmic artery, but not in the central retinal and the middle cerebral arteries in children ventilated in hyperoxic condition. This effect was related to a decrease in mean arterial pressure. This vessel-dependent effect may be explained by the different autoregulatory mechanisms of these arteries. In the present hyperoxic conditions, the vascular effect of sevoflurane may have been limited in the central retinal artery and not in the ophthalmic artery.

Asunto(s)

RESUMEN

BACKGROUND: Tracheal mucosal damage related to tracheal intubation has been widely described in pediatric and adult patients. High volume-low pressure cuffs (HVLPC) are being advertised as safe to avoid this particularly unpleasant complication. Compliances of these supposed pediatric and adult HVLPC are not mentioned by manufacturers and still remain unknown. METHODS: The compliance of HVLPC was measured in vitro and defined as the straight portion of the pressure-volume curve. Cuff pressure was measured after incremental 0.1 ml filling volumes of air for sizes 3.0-8.0 of internal diameter of Rüsch and Mallinckrodt tracheal tubes. Compliances were assessed in air and in a rigid tube. The filling volume to achieve a 25-mmHg intracuff pressure was also measured. RESULTS: In air, each 0.1 ml step almost linearly increased cuff pressure by 1 mmHg (size 8.0) to 9 mmHg (size 3). In air, the volume needed to maintain a cuff pressure < 25 mmHg was small for sizes 3-5.5 (0.35-2 ml). The 25 mmHg inflated cuff volume and compliance were decreased within a rigid tube, especially for adult sizes. In a rigid tube simulating a trachea, the compliances of almost every Rüsch tracheal tube were statistically higher than those of the Mallinckrodt. CONCLUSION: We conclude that the tested tracheal tube cuffs have low compliance and cannot be defined as high volume-low pressure.

Asunto(s)

RESUMEN

Repeated sodium depletion enhances spontaneous sodium intake in animals and humans, and may be a significant determinant of lifelong sodium intake. In rats, even a single sodium depletion is reported to enhance both need-induced and spontaneous sodium intakes enduringly. Both types of increases are reported to plateau after two to three depletions, and to be greater in females. Here, in two strains of rats, Wistar (W) and Sprague-Dawley (SD), and in two laboratories using different W substrains, in Israel and France, we studied the influence of repeated sodium depletions on need-induced and spontaneous sodium intake. Need-induced intake in W increased incrementally, but in SD, need-induced intake occurred fully at the first depletion. In both cases, the response was not related to changes in the diuretic efficacy of furosemide. In all strains, depletions enhanced spontaneous sodium intake, but the enhancement dissipated within days following each depletion, and only attained significance over the whole 7-week experiment in male SD. Enhancement was not greater in females, despite their greater spontaneous sodium intakes. Finally, in rats given a choice of NaCl and CaCl2, depletions enhanced only NaCl intake, both need-induced and spontaneous, attesting to the specificity of the appetite in both its forms. Our findings show that enhancement of need-induced and spontaneous sodium intake resulting from repeated sodium depletions depends upon the gender and strain of rats, and it does not result from an altered diuretic response. Persistent enhancement of spontaneous sodium intake is not a ubiquitous phenomenon.

Asunto(s)

RESUMEN

We report the cases of five patients who have experienced postoperative diplopia after cataract surgery under peribulbar anaesthesia and in whom orbital Magnetic Resonance Imaging was performed immediately after the diagnosis. In four patients, the imaging study showed a T2 hyper-intensity signal and swelling of one extraocular muscle that was interpreted as oedema. Therefore, these cases were most probably a result of an accidental i.m. injection of local anaesthetics. In the other patient, the imaging study revealed no abnormality.

Asunto(s)

RESUMEN

OBJECTIVE: Define the pressure-volume relationship of the cuff of paediatric cuffed tracheal tubes. STUDY DESIGN: Experimental study. MATERIALS AND METHODS: The cuff pressure was measured after incremental 0.1 ml filling volumes for 6 sizes (3.0 to 5.5 mm of internal diameter) of paediatric high volume-low pressure cuffed-tracheal tubes. The pressure-volume relationship of the cuff was assessed with and without resistance to the filling. Results were expressed with medium +/- SD. RESULT: Each increment increased the cuff pressure, without resistance, of 7.3 +/- 1.7 mmHg for sizes 3.0, 3.5 and 4.0, 4.8 +/- 1.6 mmHg for size 4.5, and 2.3 +/- 0.9 mmHg for sizes 5 and 5.5. The resistance decreased the filling volume of the cuff for each size of tracheal tubes. CONCLUSION: The margin of safety provided by cuff of smallest cuffed tracheal tubes is too small. Then, the smallest sizes (3.0 to 4.5) should not be called low pressure-high volume cuff.

Asunto(s)

RESUMEN

A 67-year-old patient suffering from an ocular myasthenia gravis was scheduled for an elective ENT surgery. General anaesthesia was induced intravenously. Neuromuscular responses after train-of-four stimulation were normal at both the adductor pollicis (T(4)/T(1) = 1) and the corrugator supercilii (4 visual responses). Then cisatracurium (0,15 mg kg(-1)) was administered to allow tracheal intubation. The laryngoscopy attempted 45 s after cisatracurium injection (no response at the supercilii, T(1)/T(0) = 1 at the adductor pollicis) was unsuccessful because of closing and moving vocal cords. The second attempt was successful 4 min after cisatracurium injection (no response at the corrugator supercilii, T(1)/T(0) = 0.05 at the adductor pollicis). Residual neuromuscular blockade was antagonized at the end of surgery (1 h long) allowing an uneventful extubation. We concluded that monitoring neuromuscular blockade at the corrugator supercilii to assess the intubating conditions is not recommended in a case of ocular myasthenia gravis.

Asunto(s)

RESUMEN

Orbitary exenteration for tumor may concern ethmoidal wall, and may create a large communication between the orbital cavity and the cavum. We present the case of a patient scheduled for ocular prosthetic surgery after an unilateral orbitary exenteration. After intravenous induction of the general anaesthesia, anaesthesiologist failed to achieve adequate facial mask ventilation because of a great gas leakage from cavum to orbital cavity. Inserting packing in the orbitary cavity allowed to decrease gas leakage and to get adequate facemask ventilation. We recommend orbitary radiographic and clinical evaluations for patient with orbitary exenteration before general anaesthesia to evaluate the communication between the orbital cavity and the cavum. Such an anatomic communication may result in inefficient facial mask ventilation.

Asunto(s)

RESUMEN

We report a case of acute pulmonary oedema following upper airway obstruction in a 1-year-old patient. We discuss the pathophysiology of this infrequent complication of upper airway obstruction and the interest of alveolar protein/blood protein ratio measurement to determine the mechanism of pulmonary oedema.

Asunto(s)