RESUMEN
An adult patient with epidermolysis bullosa dystrophica underwent uneventful spinal anaesthesia. Insertion of a Quincke spinal needle proved easier and produced less skin distortion than insertion of a pencil-point spinal needle. Taping of intravenous lines is an alternative to the more usually recommended approach of suturing.
Asunto(s)
Anestesia Raquidea , Epidermólisis Ampollosa Distrófica/fisiopatología , Adulto , Humanos , Masculino , AgujasRESUMEN
PURPOSE: The purpose of this study was to validate the commonly accepted indicators of risk of ischemic stroke that indicate the necessity for cerebral protection during carotid endarterectomy (CEA), and to examine the efficacy of high-dose thiopentone sodium (thiopental) as a cerebral protection method in patients who are at high risk of intraoperative ischemic stroke. METHOD: In a prospective study of 37 CEAs performed for symptomatic stenosis > 70%, functional and clinical indicators of risk of ischemic stroke during carotid cross-clamping were identified. Functional indicators of risk were the development of ischemic electro-encephalogram (EEG) changes and stump pressure < 25 mm Hg. Clinical indicators of risk were previous ischemic hemispheric stroke and severe bilateral disease. These indicators were correlated in all patients, some of whom had two or three coexisting indicators of risk. The EEG and stump pressure were monitored continuously during carotid occlusion in all operations. Carotid occlusion times were recorded. Intraluminal shunting was eliminated in favor of high-dose thiopental cerebral protection in all patients. Neurologic outcome was deemed to measure the efficacy of thiopental protection in patients who are identified to be at risk and, hence, in need of cerebral protection. The validity of the indicators used to identify risk of ischemic stroke during CEA was assessed. RESULTS: The absolute stroke risk was found to be 29.7% for the whole group (37 patients) and 57.9% in 19 patients who had commonly accepted indications for protective shunting. The correlation of ischemic EEG changes with stump pressure < 25 mm Hg was only 27.3%, whereas the expected correlation based on well-documented reports in the literature was 100%. The lack of correlation may have been related to the prevention of ischemic EEG changes by thiopental. There were no neurologic deficits in the series. CONCLUSIONS: The absence of neurologic deficit in the study indicated that thiopental protection was effective in preventing ischemic stroke in high-risk patients and safely replaced intraluminal shunting.
Asunto(s)
Isquemia Encefálica/etiología , Trastornos Cerebrovasculares/etiología , Endarterectomía Carotidea/efectos adversos , Complicaciones Intraoperatorias/prevención & control , Fármacos Neuroprotectores/uso terapéutico , Medición de Riesgo , Tiopental/uso terapéutico , Anciano , Anciano de 80 o más Años , Presión Sanguínea , Isquemia Encefálica/prevención & control , Arterias Carótidas/patología , Estenosis Carotídea/patología , Estenosis Carotídea/cirugía , Circulación Cerebrovascular/efectos de los fármacos , Trastornos Cerebrovasculares/prevención & control , Constricción , Electroencefalografía , Femenino , Hemodinámica , Humanos , Masculino , Persona de Mediana Edad , Monitoreo Intraoperatorio , Examen Neurológico , Fármacos Neuroprotectores/administración & dosificación , Estudios Prospectivos , Reproducibilidad de los Resultados , Factores de Riesgo , Tiopental/administración & dosificación , Factores de Tiempo , Resultado del TratamientoRESUMEN
The relationship of train-of-four (TOF) ratio to the depression of the first twitch (TD) was investigated in 16 patients given pancuronium in doses insufficient to eliminate the fourth response in the train. In ten patients the block was allowed to spontaneously recover (Group 1) and in six it was reversed with neostigmine (Group 2) once maximum depression of TOF ratio had occurred. Maximum depression of the first response occurred in 6.5 +/- 4.3 min (mean +/- SD). Maximum depression of the TOF ratio was not present until 28.0 +/- 11.0 min. TOF ratio was usually still decreasing when recovery of TD had begun. However, once the TOF ratio began to recover, the recovery rates for TD and TOF ratio were similar in both the spontaneously recovering and the reversed groups. TOF ratio at complete TD recovery was 74.9 +/- 15.7 and 86.2 +/- 15.4% for the two groups. A kinetic analysis yielded significantly different elimination rate constants for the two effects from the "effect compartment." These findings suggest that these two effects of pancuronium are exerted at different sites.