RESUMEN
A 4-year-old boy with coarctation of the aorta underwent surgical aortic arch repair with general anaesthesia and thoracic epidural analgesia. In the immediate postoperative period, the child developed a unilateral Horner syndrome which appeared to be related to the epidural infusion rate. Management of this patient as well as alternate aetiologies of Horner syndrome are described. Horner syndrome is a rare complication of epidural catheters and is often unrecognized, especially in children.
Asunto(s)
Analgesia Epidural/efectos adversos , Síndrome de Horner/etiología , Enfermedad Aguda , Aorta Torácica/cirugía , Coartación Aórtica/cirugía , Bupivacaína , Preescolar , Humanos , Masculino , Complicaciones PosoperatoriasRESUMEN
OBJECTIVE: To determine whether selective aortic arch perfusion (SAAP) using serial infusions of oxygenated perflubron emulsion combined with aortic epinephrine (AoE) administration is more effective than conventional therapy in treating cardiac arrest. METHODS: An experimental cardiac arrest model (10 min ventricular fibrillation and 2 min CPR) was used with 12 mixed-breed canines, randomized into 2 groups: control (n = 6), CPR and IV epinephrine, 0.01 mg/kg, at 12 min and then every 3 min; or AoE-SAAP (n = 6), CPR and aortic epinephrine, 0.01 mg/kg, at 12 min and then every 3 min, and serial SAAP with oxygenated 60% weight/volume (w/v) perflubron emulsion as follows: 300 mL over 30 sec at 12 min as continuous SAAP without CPR; 150 mL over 20-30 sec at 15 min and 18 min as pulsed diastolic SAAP during CPR. RESULTS: AoE-SAAP resulted in increased coronary perfusion pressure (CPP) and return of spontaneous circulation (ROSC) compared with control. CPR-diastolic (release phase) CPP during pulsed diastolic SAAP was similar to or greater in magnitude than the CPP generated during the initial SAAP infusion without CPR. ROSC for control was 0/6 and for AoE-SAAP was 4/6 (p < 0.05, Fisher's exact test). Time from initiation of CPR to ROSC with a sustained systolic aortic pressure > 60 mm Hg was 8.0 +/- 1.2 min in the 4 resuscitated AoE-SAAP animals. CONCLUSION: The combination of AoE with SAAP infusions of oxygenated perflubron emulsion was more effective than conventional resuscitation therapy. Pulsed diastolic SAAP is a promising method for performing SAAP.
Asunto(s)
Reanimación Cardiopulmonar , Circulación Coronaria/efectos de los fármacos , Emulsiones/uso terapéutico , Epinefrina/uso terapéutico , Fluorocarburos/uso terapéutico , Paro Cardíaco/terapia , Vasoconstrictores/uso terapéutico , Análisis de Varianza , Animales , Aorta Torácica , Modelos Animales de Enfermedad , Perros , Emulsiones/farmacología , Epinefrina/farmacología , Femenino , Fluorocarburos/farmacología , Paro Cardíaco/mortalidad , Hemodinámica/efectos de los fármacos , Hemodinámica/fisiología , Hidrocarburos Bromados , Inyecciones Intraarteriales , Masculino , Perfusión , Presión , Distribución Aleatoria , Valores de Referencia , Tasa de Supervivencia , Vasoconstrictores/farmacologíaRESUMEN
STUDY OBJECTIVE: To evaluate selective aortic arch perfusion (SAAP) with an oxygenated fluorocarbon emulsion, with and without aortic arch epinephrine during cardiac arrest. METHODS: This randomized, controlled study, undertaken at a university research laboratory, involved 15 mixed-breed dogs. After 10 minutes of ventricular fibrillation and 30 seconds of CPR, the dogs were randomized to three groups, each comprising five dogs. Group 1 (controls) dogs were given CPR and intravenous epinephrine, .01 mg/kg, at 10.5 minutes and then every 3 minutes. Group 2 dogs (IVE-SAAP) were treated with CPR and intravenous epinephrine (IVE) in the same fashion as the control group but were also subjected to SAAP with 275 mL of oxygenated 60% wt/vol perflubron emulsion over 30 seconds. Group 3 dogs (AoE-SAAP) received the same treatment as the IVE-SAAP group, except that the first epinephrine dose was given intraaortically. RESULTS: Coronary perfusion pressure (CPP) increased during SAAP in both the IVE-SAAP and AoE-SAAP groups but was greater in the AoE-SAAP group. CPR diastolic CPP after SAAP was significantly greater in the AoE-SAAP group than in the control group. Return of spontaneous circulation (ROSC) occurred in two control dogs, all five IVE-SAAP dogs, and all five AoE-SAAP dogs. The time elapsed from the initiation of CPR to ROSC was 6.1 +/- 1.9 minutes in the AoE-SAAP group, compared with 11.0 +/- 5.8 minutes in the IVE-SAAP group. CONCLUSION: SAAP with oxygenated perflubron emulsion improved ROSC, both with and without aortic arch epinephrine. The combination of SAAP with perflubron emulsion and aortic arch epinephrine resulted in higher CPP and more rapid ROSC.
Asunto(s)
Aorta Torácica , Epinefrina/uso terapéutico , Fluorocarburos/uso terapéutico , Paro Cardíaco/terapia , Infusiones Intraarteriales/métodos , Resucitación/métodos , Vasoconstrictores/uso terapéutico , Animales , Modelos Animales de Enfermedad , Perros , Evaluación Preclínica de Medicamentos , Quimioterapia Combinada , Hemodinámica/efectos de los fármacos , Hidrocarburos Bromados , Infusiones Intravenosas , Distribución AleatoriaAsunto(s)
Análisis de los Gases de la Sangre/métodos , Monitoreo Fisiológico/métodos , Análisis de los Gases de la Sangre/instrumentación , Análisis de los Gases de la Sangre/estadística & datos numéricos , Costos y Análisis de Costo , Humanos , Concentración de Iones de Hidrógeno , Monitoreo Fisiológico/instrumentación , Monitoreo Fisiológico/estadística & datos numéricosRESUMEN
STUDY OBJECTIVE: To determine if delivery of epinephrine to the peripheral arterial system by an aortic arch catheter is more effective than central venous epinephrine administration during cardiac resuscitation. DESIGN: Randomized, nonblinded, controlled trial. TYPE OF PARTICIPANTS: Sixteen mongrel canines (25 to 31 kg). INTERVENTIONS: Animals had aortic arch pressure, and right atrial pressure, superior vena cava infusion, and descending aortic arch infusion catheters placed using fluoroscopy. After ten minutes of ventricular fibrillation, three DC countershocks were delivered over one minute. If unsuccessful, CPR at 120 compressions per minute was begun, and at 60 seconds of CPR, epinephrine (1 mg/50 mL normal saline) was administered either through the superior vena cava or the aortic arch catheter followed by one more minute of CPR. Defibrillation then was attempted and, if unsuccessful, further resuscitative efforts followed advanced cardiac life support guidelines, except route and dose of epinephrine remained the same. MEASUREMENTS AND MAIN RESULTS: Aortic arch pressure, right atrial pressure, and coronary perfusion pressure (diastolic aortic arch pressure minus diastolic right atrial pressure) were recorded continuously. Aortic arch pressure and coronary perfusion pressure increased more rapidly and to a greater magnitude with aortic arch-epinephrine than superior vena cava-epinephrine. Coronary perfusion pressure doubled by ten seconds in seven of eight in the aortic arch-epinephrine group versus none in the superior vena cava-epinephrine group. Aortic arch pressure and coronary perfusion pressure increases consistently plateaued within 60 seconds after aortic arch-epinephrine but not after superior vena cava-epinephrine. Return of spontaneous circulation was faster (P < .05) in the aortic arch-epinephrine group. Maximal coronary perfusion pressure after epinephrine correlated with the coronary perfusion pressure immediately before epinephrine administration in both groups, but more strongly in the aortic arch-epinephrine group (P = .0001). CONCLUSION: For an equivalent dose of epinephrine, aortic arch administration produces a more rapid response and more rapid peak effect than central venous administration. The combination of aortic arch-epinephrine administration and aortic pressure monitoring may be useful when initial standard resuscitative measures have not been successful.
Asunto(s)
Reanimación Cardiopulmonar/métodos , Epinefrina/administración & dosificación , Paro Cardíaco/terapia , Animales , Aorta Torácica , Presión Sanguínea/efectos de los fármacos , Cateterismo Venoso Central , Cateterismo Periférico , Perros , Vena Cava SuperiorRESUMEN
STUDY OBJECTIVES: To demonstrate the technique of selective aortic arch perfusion during cardiac arrest and to observe the hemodynamic effects of volume infusion and aortic epinephrine administration. DESIGN: Sequential series, nonrandomized, noncontrolled. TYPE OF PARTICIPANTS: Fourteen mongrel dogs weighing 21 to 36 kg. INTERVENTIONS: Animals had midaortic arch pressure, right atrial pressure, and descending aortic arch balloon occlusion catheters placed. After ten minutes of ventricular fibrillation, balloon inflation and aortic arch infusions were initiated as follows: group 1 (six), 30 mL/kg/min of 0.9% NaCl for two minutes; group 2 (four), 30 mL/kg/min of oxygenated lactated Ringer's with 2 mg/L epinephrine for two minutes, followed by CPR; and group 3 (four), 20 mL/kg/min of oxygenated perfluorochemicals with 4 mg/L epinephrine for one minute, then CPR. MEASUREMENTS AND MAIN RESULTS: Midaortic arch pressure, right atrial pressure, and coronary perfusion pressure each rose significantly in all groups. Midaortic arch pressure and coronary perfusion pressure increases were greater in groups 2 and 3 than in group 1. In groups 1 and 2, right atrial pressure increases at end-selective aortic arch perfusion were excessive as midaortic arch pressure and right atrial pressure increased linearly and similarly after 20 to 30 seconds. In groups 2 and 3, CPR-diastolic midaortic arch pressure and coronary perfusion pressure after selective aortic arch perfusion were good and similar to midaortic arch pressure and coronary perfusion pressure at end-selective aortic arch perfusion. CONCLUSION: Selective aortic arch perfusion is technically feasible, but excessive right atrial pressure increases limit maximal infusion rates and volumes. Selective aortic arch perfusion infusates with epinephrine produce greater midaortic arch pressure and coronary perfusion pressure during infusion than infusate without epinephrine. Controlled studies are needed to determine if selective aortic arch perfusion improves resuscitation outcome.
Asunto(s)
Reanimación Cardiopulmonar/métodos , Paro Cardíaco/terapia , Hemodinámica/fisiología , Reperfusión Miocárdica/métodos , Animales , Aorta Torácica , Terapia Combinada , Perros , Electrocardiografía , Epinefrina/uso terapéutico , Paro Cardíaco/fisiopatología , Hemodinámica/efectos de los fármacos , Contrapulsador IntraaórticoRESUMEN
Changes in plasma adenosine and inosine were measured during high-dose narcotic anesthesia and surgery for coronary artery bypass grafting (CABG), and mitral or aortic valve replacement (V). Arterial and mixed venous blood samples were obtained for measurement of adenosine and inosine at eight sampling intervals ranging from preanesthesia induction to discontinuation of cardiopulmonary bypass (CPB). Arterial but not mixed venous adenosine was markedly elevated in blood samples 10 minutes after intubation, but the fourfold elevation was significant only in the CABG patient group. Mixed venous inosine and adenosine were most consistently elevated in post-CPB samples. In a separate study of arterial adenosine changes during induction, a uniform drug administration protocol was used, and again adenosine was significantly increased immediately after intubation. It is possible that adenosine and perhaps inosine may contribute to cardiovascular responses following induction-intubation and also after discontinuing CPB.
Asunto(s)
Adenosina/sangre , Puente de Arteria Coronaria , Prótesis Valvulares Cardíacas , Anestesia Intravenosa , Válvula Aórtica , Arterias , Fentanilo/análogos & derivados , Humanos , Inosina/sangre , Válvula Mitral , Sufentanilo , VenasRESUMEN
Subcutaneous emphysema can occur as the result of trauma, surgery, and anesthesia. A case is presented of extensive subcutaneous emphysema after anesthesia for oral surgical reduction of a mandibular fracture. A discussion of the diagnosis, pathophysiology, and treatment of subcutaneous emphysema follows.
Asunto(s)
Obstrucción de las Vías Aéreas/etiología , Anestesia Endotraqueal/efectos adversos , Fracturas Mandibulares/cirugía , Enfisema Subcutáneo/complicaciones , Adulto , Obstrucción de las Vías Aéreas/diagnóstico por imagen , Humanos , Intubación Intratraqueal/efectos adversos , Masculino , Cóndilo Mandibular/cirugía , Enfisema Subcutáneo/diagnóstico por imagen , Enfisema Subcutáneo/etiología , Tomografía Computarizada por Rayos XRESUMEN
Intra-aortic balloon pump therapy is often life-saving in patients with refractory cardiac failure following cardiopulmonary bypass, in the peri-infarct period, or in treating complications of coronary artery angioplasty. Anesthesiologists are intimately involved in the care of the majority of IABP patients and require a thorough understanding of the equipment, its physiologic effects, and potential complications.
Asunto(s)
Insuficiencia Cardíaca/terapia , Contrapulsador Intraaórtico , Animales , Perros , Femenino , Humanos , Contrapulsador Intraaórtico/efectos adversos , Contrapulsador Intraaórtico/métodos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/terapiaRESUMEN
Isolated perfused paced hearts from rats rendered hypothyroid by chronic administration of propylthiouracil have a delayed onset of ischemia-induced myocardial contracture in contrast to hearts from control rats. In addition, the time to reach maximum contracture is delayed, and the magnitude of the contracture pressure is reduced. Preischemia myocardial adenosine triphosphate (ATP) values in the hypothyroid rat hearts are similar to those of control, but the rate of decrease in ATP is slower in the hearts of hypothyroid rats. Thus, it appears that in the hypothyroid state the development of ischemic contracture is associated with a slower fall of ATP.
Asunto(s)
Nucleótidos de Adenina/metabolismo , Circulación Coronaria , Hipotiroidismo/fisiopatología , Contracción Miocárdica , Adenosina Difosfato/metabolismo , Adenosina Monofosfato/metabolismo , Adenosina Trifosfato/metabolismo , Animales , Isquemia/metabolismo , Isquemia/fisiopatología , Miocardio/metabolismo , Perfusión , Ratas , Ratas Endogámicas , Factores de TiempoRESUMEN
Plasma atrial natriuretic peptide immunoreactivity (IrANP) was measured before, during, and after cardiopulmonary bypass for coronary artery bypass graft placement. Eight subjects scheduled for elective operation had in the premedicated preoperative state slightly elevated IrANP compared to controls. Neither induction of anesthesia with a high dose narcotic/non-depolarising relaxant/diazepam technique nor cardiopulmonary bypass changed IrANP significantly. Mixed venous and arterial IrANP increased immediately after discontinuing bypass, and remained elevated 1 h later. Because ANPs affect peripheral resistance as well as urinary sodium loss, the post-bypass elevations in these peptides may contribute to cardiovascular and diuretic effects after cardiopulmonary bypass.
Asunto(s)
Factor Natriurético Atrial/sangre , Anestesia , Puente Cardiopulmonar , Puente de Arteria Coronaria , Diazepam , Humanos , Narcóticos , Resistencia VascularRESUMEN
This article presents basic anesthetic management problems and procedures together with newer anesthetic drugs and monitoring techniques that are likely to be encountered by intensive care physicians. The author's goal is to familiarize all critical care unit based members of the resuscitation team with current aspects of anesthetic management of the trauma patient.
Asunto(s)
Anestesia/métodos , Cuidados Críticos/métodos , Heridas y Lesiones/cirugía , Humanos , Intubación/métodos , Monitoreo Fisiológico , Traumatismo Múltiple/cirugía , Narcóticos/administración & dosificación , Grupo de Atención al Paciente , Transporte de Pacientes , Heridas y Lesiones/complicacionesAsunto(s)
Dantroleno/efectos adversos , Hipertermia Maligna/prevención & control , Músculos/efectos de los fármacos , Anestesia General , Preescolar , Femenino , Humanos , Intubación Intratraqueal , Enfermedades Periodontales/cirugía , Premedicación , Respiración/efectos de los fármacos , Factores de TiempoRESUMEN
Development of the flow-directed pulmonary artery catheter in combination with reflective fiberoptic oximetry techniques allows the clinician to continuously measure mixed venous oxygen saturation (SvO2). A brief review of the determinants of oxygen balance, the Fick principle, and the technology of continuous SvO2 monitoring is preliminary to a debate between two clinicians on the usefulness of SvO2 monitoring. One clinician highly recommends use of the flow-directed pulmonary artery catheter in patients who require pulmonary artery catheterization. Monitoring of SvO2 is described as a safe, convenient, and reliable option that is cost-effective. Continuous availability of this dynamic physiologic monitor is of great value in improving understanding of serious disturbances in oxygen balance, providing information for rapid diagnosis, and guiding therapeutic interventions. Another clinician suggests a less enthusiastic approach to SvO2 monitoring and argues that SvO2 is a nonspecific index of the matching of oxygen delivery with supply. Although it is a useful adjunct in specific clinical situations, it provides uncertain information in the presence of a number of diseases. Major mistakes in patient management could follow from overreliance upon either absolute SvO2 measurements or analysis of trends over time. Use of the SvO2 monitor has not been proven cost-effective and may actually increase monitoring costs. Both clinicians agree that continuous SvO2 monitoring is valuable in many clinical circumstances, provided the limitations of the measurement are understood.
Asunto(s)
Oximetría/métodos , Oxígeno/sangre , Gasto Cardíaco , Cateterismo/métodos , Análisis Costo-Beneficio , Tecnología de Fibra Óptica , Humanos , Monitoreo Fisiológico/métodos , Consumo de Oxígeno , Arteria Pulmonar , SeguridadRESUMEN
The cardiovascular effects of the calcium channel blockers verapamil (V), nifedipine (N) and diltiazem (D) were compared in halothane-anesthetized swine. Equipotent hypotensive doses of the three calcium channel blocking drugs were administered randomly by continuous infusion to three groups of six animals each to produce a uniform 25-30% reduction in mean systemic arterial blood pressure (BP). An additional group of six animals received sodium nitroprusside (S) to demonstrate the effects of lowering blood pressure with a pure vasodilator on this experimental preparation. Hemodynamic indices monitored before and after drug administration included ECG, mean systemic and pulmonary artery blood pressure, mean central venous and pulmonary capillary wedge pressure, thermodilution cardiac output, left ventricular pressure, and left ventricular dP/dt. All four study drug infusions reduced BP an average of 28%. V and D reduced BP by decreasing cardiac output (41% and 42%, respectively) without affecting systemic vascular resistance. N and S produced hypotension by decreasing systemic vascular resistance (36% and 21%, respectively) without affecting cardiac output. D reduced heart rate (18%) and both D and V increased the PR interval (60% and 40%, respectively). Calcium chloride (20 mg X kg-1 intravenous bolus) improved indices of myocardial contractility but did not affect drug-induced changes in cardiac electrophysiology. These data demonstrate that in this halothane-anesthetized swine model the administration of equihypotensive doses of verapamil or diltiazem has a more pronounced affect on cardiac conduction and myocardial contractility than does nifedipine, which predominantly reduces systemic vascular resistance with minimal effects on cardiac function.