Domínguez-Sansores, Luis; González-Díaz, Sandra; Arias-Cruz, Alfredo; Palacios-Rìos, Dionisio; López-Cabrera, Norma Guadalupe
The incidence of severe intraoperative anesthetic reactions varies among countries from 1:10,000 to 1:13 000 patients submitted to surgery. A 13 year old male, with family history of atopy, who underwent 5 surgeries for hydrocephalus, using general anesthesia. He was on lamotrigine for seizures. He also suffers from chronic rhinitis, and oral allergy syndrome related to bananas since the age of 6 months. He had a posterior fossa tumor resection. During anesthesia induction with atracurium he developed a local rash in one arm, being the intubation without difficulty. Twenty minutes later he presented bipalpebral edema, accompanied by generalized rash, severe bronchoconstriction and hypotension, not reversing with the use of bronchodilators and corticosteroids. With the use of antihistamines, epinephrine and controlled ventilation the reaction subsides. One month later a skin prick test with atracurium besylate (50 mg/mL) diluted 1:10,000, negative and positive controls was performed. The result with atracurium was negative. After the application of intradermal tests with 0.02 mL of atracurium at dilutions of 1:10,000 and 1:1000, we found a positive skin response to atracurium (wheal diameter >8 mm and >9 mm with dilutions 1:10,000 and 1:1000, respectively and erythema). The response to atracurium intradermal test could be related to the ability of histamine release by a nonimmunological mechanism. But the magnitude of the skin response in this case, do not rule out the possibility of an IgE-mediated reaction. Atracurium is a known potent histamine releaser from mast cells, but rarely can it cause IgE-mediated reactions.
Full Text Available Anaphylaxis is an acute, potentially fatal allergic reaction involving multi organ system that is triggered by a wide range of antigens with a subsequent release of chemical mediators from mast cells and basophils. Diagnosis is primarily clinical though laboratory studies are helpful in further confirmation. Anaphylactic reactions during anesthesia are rare, but can be fatal if not promptly recognized and treated. Among all drugs commonly used in anesthesia, muscle relaxants are the most notorious to trigger anaphylactic reactions and benzylisoquinolinium group of drugs are known to be less common an offender than the steroidal compounds. We report severe anaphylactic reaction after administration of atracurium that was promptly diagnosed and managed without any further morbidity.
Conclusion: According to results, use of Atra + Alfen method can replace the standard method (succinylcholine for contraindicated condition. Mild vocal cord movement and mild bucking in the Atracurium + Alfentanyl can be control by that a increase in Atracurium dose.
ERIKSSON, LI; VANDENBROM, RHG; LENNMARKEN, C; AGOSTON, S
A modification of the isolated arm technique was applied in 10 females under opioid-based i.v. anaesthesia for comparison of the offset of an atracurium-induced neuromuscular block in an isolated arm to an arm with maintained circulation. The neuromuscular blocking effect of a bolus dose of
Kirov, K; Motamed, C; Combes, X; Duvaldestin, P; Dhonneur, G
To study the effect of atracurium on the electromyographic activity of the lateral abdominal muscles and adductor pollicis in anaesthetized subjects. Prospective, comparative, open study. Sixteen patients, ASA physical status 1 or 2, undergoing elective orthopaedic surgery under general anaesthesia were studied. Anaesthesia was induced with propofol/fentanyl and orotracheal intubation performed after glottic local anaesthesia without using muscle relaxant. Anaesthesia was maintained with isoflurane/nitrous oxide/oxygen and fentanyl reinjections. Supramaximal percutaneous stimulations in a simple twitch mode (0.1 Hz) were applied at the 9th-10th intercostal nerve on the posterior axillary line and at the ulnar nerve at the wrist. The electromyographic responses were registered using skin surface electrodes, placed on the D9-D10 dermatome in regard of the lateral abdominal muscles and of the thenar muscles. After a single bolus dose of atracurium 0.5 mg.kg-1, the following parameters were studied: the maximum effect (Emax), the time for obtaining Emax (Delay) and the recovery time of 5, 10, 25, 50, 75 and 100% of the control neuromuscular response (T5, T10, T25, T50, T75, T100). The dose of 0.5 mg.kg-1 of atracurium induced 100% block in both lateral abdominal muscles and adductor pollicis. Lateral abdominal muscles blockade had faster onset (136 +/- 4 s versus 205 +/- 29 s) and shorter recovery, T5, T10, T25, T50, T75 and T100 were significantly (p < 0.05) shorter than at the adductor pollicis. Lateral abdominal muscles blockade have faster onset and recovery than adductor pollicis.
Olkkola, K T; Tammisto, T
We have studied the effect of prior administration of suxamethonium on the infusion requirements of atracurium at 50% neuromuscular block in patients undergoing elective general surgery. Anaesthesia was maintained with nitrous oxide in oxygen, propofol and fentanyl. Of 20 patients given atracurium, only 10 were given prior administration of suxamethonium 1 mg kg-1. At the beginning of the infusion, atracurium 0.3 mg kg-1 was given by bolus administration. Interaction between the two drugs was assessed by determining the steady state rate of infusion necessary to produce a constant 50% neuromuscular block. This was accomplished by applying non-linear curve fitting to data on the cumulative dose requirements during anaesthesia. The neuromuscular blocking effect was found to be similar with or without prior administration of suxamethonium. The mean steady-state rate of infusion for atracurium was 0.19 (SD 0.03) mg kg-1 h-1 for patients given suxamethonium and 0.18 (0.09) mg kg-1 h-1 for those who were not given suxamethonium. Thus prior administration of suxamethonium did not affect the infusion requirements of atracurium at 50% neuromuscular block, unlike the situation at constant 90% neuromuscular block.
Full Text Available Background: Cataract surgery when performed under general anesthesia, especially without neuromuscular blocking agents, eccentric position of the eye has been reported. However, no evidence exists for the need and optimal dose of neuromuscular blocking agents for surgical reasons when the anesthetic management may be done without its need. We hypothesize that the minimal dose atracurium may accomplish the surgical requirement of cataract surgery in children. Materials and Methods: After ethical committee approval, this double-blind, prospective, randomized study was conducted in children scheduled for cataract surgery under general anesthesia. Anesthesia was induced in a standardized manner and using laryngeal mask airway. The patients were randomized into four groups of 55 patients each and atracurium was administered as per group allocation: Group 0: No atracurium was administered; Group 50: Received atracurium at 50% dose of ED 95 ; Group 75: Received atracurium at 75% dose of ED 95 ; Group 100: Received atracurium of 100% dose of ED 95 . Surgeon was asked to grade surgical condition just after the stab incision in the cornea. The primary outcome variable included the need of atracurium supplementation based on grading of surgical conditions by the operating surgeon who was blinded to the randomized group. Results: The need of atracurium due to unacceptable surgical conditions based on surgeon satisfaction score was statistically significant when compared among the groups being maximum in Group 0 (P < 0.001. Also, the surgeon satisfaction score was statistically significant among the groups (P < 0.0001 with the least satisfaction in Group 0. The laryngeal mask airway (LMA insertion score was statistically significant in the four groups (P - 0.001. However, number of attempts for LMA placement was comparable among the four groups (P - 0.766. Conclusion: We conclude that a balanced anesthetic technique including atracurium provided better
Conclusions: Compared with atracurium, administration of cisatracurium can better prevent the increase of IOP following tracheal intubation in general anesthesia. The observed difference might be related to different effects on hemodynamic variables. Application of these results in patients under ophthalmic surgery is warranted.
Locks, Giovani de Figueiredo; Almeida, Maria Cristina Simões de
The priming principle consists of administering a low neuromuscular blocker dose, minutes before the total dose for tracheal intubation, to shorten non-depolarizing blockers onset. There is, however, the risk for muscle fade and bronchoaspiration. Laryngeal muscles are of especial interest for tracheal intubation maneuvers and airway protection. Since their direct monitoring imposes technical difficulties, it has been reported that orbicularis oculi correlates with laryngeal muscles in terms of sensitivity to neuromuscular blocks. This study aimed at evaluating the presence of orbicularis oculi muscle fade after priming atracurium dose and at comparing clinical tracheal intubation conditions after two priming dose intervals. Participated in this study 35 adult patients, physical status ASA I or II, without risk factors for bronchoaspiration and submitted to elective surgeries. General anesthesia was induced with alfentanil and propofol and patients were manually ventilated under mask. Surface electrodes were then positioned on the temporal branch of the facial nerve, and the acceleration transducer was placed on the orbicularis oculi. Priming atracurium dose (0.02 mg.kg-1) was administered and T4/T1 ratio was evaluated every minute during 5 minutes in 20 cases (G1) and during 7 minutes in 13 cases (G2). After this interval, complementary atracurium dose (0.5 mg.kg-1) was administered and tracheal intubation was performed one minute later. Fade was defined as T4/T1 ratio below 0.9. There has been no fade in any patient during the monitoring interval. In 80% and 69% of G1 or G2 patients, respectively, tracheal intubation was classified as clinically acceptable (p > 0.05). Priming atracurium dose (0.02 mg.kg-1) does not determine orbicularis oculi fade and there is no difference between 5 or 7 minutes priming intervals.
Full Text Available Fasciculation is a minor adverse effect of succinylcholine and may be an unpleasant experience for patient. The aim of this study was to compare the use of atracurium and methocarbamol to decrease the occurrence and severity of succinylcholine-induced muscle fasciculation. Fifty-nine adults with American Society of Anesthesiologists I or II hospitalized for elective surgery were randomly assigned to two groups: Group A (n = 29 who received succinylcholine 1 mg/kg body weight (BW intravenously followed by 0.2–0.5 mg/kg BW atracurium and patients in Group B (n= 29 who received succinylcholine 1 mg/kg BW intravenously followed by methocarbamol 0.2–0.5 mg/kg BW. Anesthesia was induced in all patients with thiopental sodium 3–5 mg/kg. Fasciculation was scored on a four-point (0–4 Likert scale. There were no statistically significant differences in demographic variables between two groups, whereas in Group A, 27 patients (93.1% suffered from mild fasciculation and two (6.9% from moderate fasciculation. In Group B, twenty patients (68.9% suffered from mild fasciculation, five (17.2% from moderate fasciculation, and four (13.9% from severe fasciculation. The difference between the groups was statistically significant (P < 0.05. Atracurium is more effective than methocarbamol in decreasing the occurrence and severity of succinylcholine-induced fasciculations. In addition, the use of methocarbamol before succinylcholine administration can decrease the incidence of severe fasciculation.
Jaramillo Mendoza, Karol Rodrigo
Es de suma importancia conocer el momento exacto de la descurarización y las dosis más convenientes de la neostigmine y de la atropina, con la finalidad de tener resultados positivos que favorezcan al estado hemodinámico sin que haya mayores alteraciones para el paciente. Se realizó un estudio en 82 pacientes en el Hospital Enrique Sotomayor, los cuales fueron monitoreados con TOF WATCH, con la finalidad de revertir el atracurium con dosis residuales de neostigmine. El 32...
Full Text Available Background: The amount of sedation and muscle relaxation of the jaw may have an impact on complications caused by laryngeal mask airway (LMA. The aim of this study is to evaluate the effect of low-dose Atracurium on conditions of insertion, complications, and hemodynamic responses to LMA insertion following induction of anesthesia with propofol, in patients undergoing cataract surgery. Patients and Methods: In this double-blind randomized clinical trial study, 60 patients were randomly divided into two groups. Initially, the patients in the study group received 0.15 mg/kg intravenous injection of atracurium, and the patients in the control group received 2 ml of intravenous injection of normal saline, after which anesthesia in both groups were induced with midazolam, fentanyl, lidocaine, and propofol. The amount of jaw relaxation, ease of insertion, and the time needed for insertion, hemodynamic responses and complications of LMA insertion were evaluated. Results: Jaw relaxation and ease of LMA insertion in the study group was significantly better than that of the control group (P = 0.02. Average time needed for LMA placement in the study group (5/06 ± 0.52 second was significantly lower than the control group (5/76 ± 0.67 second (P = 0.001. Hemodynamic response to LMA insertion was similar in both groups. Sore throat at recovery and 24 h after surgery in the control group was significantly higher than that of the study group (3/30 vs. 10/30 (P = 0.01. Conclusions: Using low doses of atracurium decreases the time needed for LMA insertion and sore throat after the operation. Atracurium also increases jaw relaxation and facilitates the placement of LMA.
Efeitos hemodinâmicos do atracúrio e do cisatracúrio e o uso de difenidramina e cimetidina Efectos hemodinámicos del atracurio y del cisatracurio y el uso de la difenidramina y la cimetidina Hemodynamic effects of atracurium and cisatracurium and the use of diphenhydramine and cimetidine
Claudia Maria Nogueira Correa
hipotensión arterial en el hombre, se investigaron los efectos hemodinámicos promovidos por el atracurio y por el cisatracurio, y la protección hemodinámica dada por la difenidramina y la cimetidina en ratones. MÉTODO: 1 Ratones Wistar anestesiados con pentobarbital sódico y preparados de acuerdo con Brown y col. para evaluar las dosis de atracurio y cisatracurio para la reducción de T4/T1 de la secuencia de cuatro estímulos mayor o igual al 95%. 2 Evaluación de las alteraciones hemodinámicas del atracurio y el cisatracurio por inyección venosa, midiendo la presión arterial sistémica de la arteria carótida y electrocardiograma de ratones. 3 Observación de la protección hemodinámica por el tratamiento previo con difenidramina (2 mg.kg-1 y/o cimetidina (4 mg.kg-1 por inyección venosa. Análisis estadístico: test t de Student, ANOVA. RESULTADOS: El atracurio y el cisatracurio no modificaron la presión arterial promedio (PAP en las dosis de 1 mg.kg-1 y 0,25 mg.kg-1, respectivamente. Las dosis de 4 mg.kg-1 disminuyeron la PAP de 62,8 ± 4,5% del control para el atracurio, y de 82,5 ± 2,3% del control para el cisatracurio. Con la difenidramina y la cimetidina, la presión sistólica se redujo a 95,4 ± 2,5% del control. Con la cimetidina, la presión diastólica disminuyó 82,7 ± 8,4% del control. El efecto con-junto sobre las presiones sistólica y diastólica se reflejó en los valores observados de la PAP. CONCLUSIONES: La difenidramina y la cimetidina, aisladamente, no impidieron la disminución de la presión arterial promedio inducida por el atracurio. Sin embargo, la asociación de esos de los fármacos fue eficaz en la prevención de los efectos hemodinámicos inducidos por el atracurio. El cisatracurio, en las dosis del experimento, no promovió una disminución de la presión arterial que justificase las medidas preventivas aplicadas en los grupos donde se utilizó el atracurio.BACKGROUND AND OBJECTIVES: Since atracurium can cause hypotension in
Cardiopulmonary effects and eyeball centralization with low-dose atracurium in spontaneously breathing, anesthetized dogs Avaliação cardiopulmonar e da centralização do globo ocular em cães com baixas doses de atracúrio mantidos em anestesia inalatória sob ventilação espontânea
Adriano Bonfim Carregaro
Full Text Available The objective was to determine the cardiopulmonary effects and eyeball centralization time obtained with 15 or 30µg kg-1 of atracurium in anesthetized dogs under spontaneous breathing. Eighteen healthy adult mixed-breed dogs were used, which received 0.1mg kg-1 acepromazine and 0.5mg kg-1 morphine IM, followed by 4mg kg-1 propofol IV and maintained on isoflurane anesthesia with spontaneous breathing. Animals received 1mL 0.9% NaCl IV (CG, 15µg kg-1 (G15 or 30µg kg-1 (G30 of atracurium IV. Eyeball centralization time was measured; heart rate (HR, systolic (SAP, mean (MAP and diastolic (DAP arterial pressures, respiratory rate (RR, tidal volume (Vt and minute volume (Vm were determined every 5min, and pH, arterial CO2 pressure (PaCO2 , arterial O2 pressure (PaO2 , hemoglobin oxygen saturation (SaO2 , bicarbonate (HCO3- and base excess (BE every 15min until 60min. Both doses of atracurium produced a similar period of eyeball centralization. Vt in groups treated with atracurium was lower than in CG up to 15min. Vm in G15 differed from CG up to 10min and in G30 up to 25min. No differences were observed for cardiovascular parameters, RR, SaO2, PaO2, HCO3- and BE. pH decreased in CG between 30 and 60min and in G15 and G30 at 15min. G30 differed from CG between 15 and 30min. PaCO2 in GC differed from baseline between 30 and 60min and in G15 differed at 15min. Atracurium at the dose of 15µg kg-1 is adequate for short corneal procedures in inhalant-anesthetized dogs under spontaneous breathing.Objetivou-se determinar os efeitos cardiopulmonares e o tempo de centralização do globo ocular obtidos com 15 ou 30µg kg-1 de atracúrio em cães anestesiados sob ventilação espontânea. Dezoito cães adultos foram pré-medicados com 0,1mg kg-1 de acepromazina e 0,5mg kg-1 de morfina IM, anestesiados com 4mg kg-1 de propofol IV e mantidos sob anestesia inalatória com isofluorano em ventilação espontânea. Os animais receberam 1mL de NaCl 0,9% IV (GC, 15
Efeito da administração do atracúrio sobre a recuperação do bloqueio neuromuscular induzido pelo pancurônio Efecto de la administración del atracúrio sobre la recuperación del bloqueo neuromuscular inducido por el pancuronio Effect of atracurium on pancuronium-induced neuromuscular block recovery
Luís Fernando Rodrigues Maria
complementación con atracúrio no promovió alteración en la recuperación espontanea inicial del bloqueo neuromuscular inducido por el pancuronio y promovió diminución de 20% en el tiempo de recuperación total.BACKGROUND AND OBJECTIVES: Additional neuromuscular blocker doses are in general needed during wall closing after abdominal surgeries. This study aimed at determining during partial pancuronium-induced neuromuscular block recovery, the effect of additional atracurium dose on spontaneous neuromuscular block recovery. METHODS: Participated in this study 30 patients divided in two groups: pancuronium group (n = 14 and atracurium group (n = 16. Neuromuscular function was continuously monitored by accelerometry of abductor pollicis muscle using TOF to supramaximally stimulate ulnar nerve. Anesthesia was induced with propofol, fentanyl and 0.08 mg.kg-1 pancuronium, and was maintained with 60% N2O in oxygen and 0.5% isoflurane expired concentration. When T1 returned to 25% of control, 0.025 mg.kg-1 pancuronium or 0.20 mg.kg-1 atracurium were administered to pancuronium or atracurium group, respectively. Time for spontaneous T1 recovery = 10%, 25%, 75% of recovery index (RI 25-75% and time to T4/T1 equal 0.8 after complementary dose, were recorded. RESULTS: There were no differences between groups on T1 spontaneous recovery to 10% (45.00 ± 15.50 vs. 49.69 ± 9.41, 25% (61.64 ± 18.58 vs. 64.25 ± 12.51 and 75% (94.00 ± 28.52 vs. 84.69 ± 16.50. Recovery index (RI 25-75% and time to T4/T1= 0.8 were shorter in the atracurium group. CONCLUSIONS: In this study, atracurium complementation has made no difference in initial spontaneous recovery of pancuronium-induced neuromuscular block, but has decreased total recovery time in 20%.
Efeitos neuromusculares in vitro e in vivo do atracúrio e do rocurônio em ratos submetidos a tratamento de sete dias com carbamazepina Efectos neuromusculares in vitro e in vivo del atracurio y del rocuronio en ratones sometidos a tratamiento de siete días con carbamazepina In vitro and in vivo neuromuscular effects of atracurium and rocuronium in rats treated with carbamazepine for seven days
Caroline Coutinho de Barcelos
neuromuscular producido por el rocuronio y atracurio en ratones tratados con carbamazepina y determinó las concentraciones de citocromo P450 y b5 reductasis en microsomas hepáticos. MÉTODO: Ratones fueron tratados por siete días con carbamazepina (CBZ - 40 mg.kg-1 a través de una sonda y sacrificados al octavo día bajo anestesia con uretana. Las preparaciones in vitro e in vivo fueron montadas de acuerdo con las técnicas de Bulbring y de Leeuwin y Wolters, respectivamente. Las concentraciones y dosis utilizadas de los bloqueadores en las preparaciones in vitro e in vivo fueron, respectivamente, 20 µg.mL-1 y 0,5 mg.kg-1 para atracurio (ATC; 4 µg.mL-1 y 0,6 mg.kg-1 para rocuronio (ROC. Cada protocolo tuvo un n = 5 y las respuestas fueron observadas por 60 minutos. Los efectos del ATC y ROC fueron evaluados en las preparaciones de ratones tratados (Cbz t y comparados a los observados en los de ratones no tratados (CBZst. Las concentraciones de citocromo P450 y b5 reductasis fueron determinadas en microsomas aislados de hígados de ratones tratados (CBZt y comparadas con las obtenidas en ratones no tratados (CBZst RESULTADOS: La carbamazepina no alteró la amplitud de las respuestas musculares; in vitro y in vivo, no hubo diferencia entre el bloqueo neuromuscular producido por el atracurio en las preparaciones CBZt versus CBZst; el bloqueo neuromuscular producido por el Rocuronio en las preparaciones CBZt fue potenciado in vitro. La carbamazepina no alteró las concentraciones de citocromo P450 y b5. CONCLUSIONES: El tratamiento por siete días con carbamazepina, no influenció en el bloqueo producido por el atracurio, y alteró in vitro los efectos del rocuronio. El tiempo de tratamiento no fue suficiente para causar la inducción enzimática y disminuir la sensibilidad al rocuronio.BACKGROUND AND OBJECTIVES: This experimental study investigated the in vitro and in vivo neuromuscular blockade of rocuronium and atracurium in rats treated with carbamazepine and determined
Influência do lítio no bloqueio neuromuscular produzido pelo atracúrio e pelo cisatracúrio: estudo em preparações nervo frênico-diafragma de rato Influencia del litio en el bloqueo neuromuscular producido por el atracurio y por el cisatracurio: estudio en preparo nervio frénico-diafragma del ratón Influence of lithium on the neuromuscular blockade produced by atracurium and cisatracurium: study on rat phrenic nerve-diaphragm preparations
Samanta Cristina Antoniassi Fernandes
alteraciones en los potenciales de placa terminal en miniatura mostraron una acción presináptica.BACKGROUND AND OBJECTIVES: Lithium is widely used for the treatment of bipolar disorders and can interact with neuromuscular blockers. There is a controversy about the mechanisms by which it affects neuromuscular transmission and its interaction with neuromuscular blockers. The objective of this study was to evaluate, on the rat diaphragm, the effects of lithium on the muscular response and indirect stimulation, and the possible interaction with neuromuscular blockers. METHODS: Rats weighing between 250 and 300 g were sacrificed under urethane anesthesia. The phrenic nerve-diaphragm preparation was assembled according to the Bulbring technique. The diaphragm was kept under tension, connected to an isometric transducer, and submitted to indirect stimulation with a frequency of 0.1 Hz. The contractions of the diaphragm were registered on a physiograph. The analysis of the amplitude of the muscular responses evaluated: the effects of the isolated drugs: lithium (1.5 mg.mL-1; atracurium (20 µg.mL-1, and cisatracurium (3 µg.mL-1; the lithium-neuromuscular blockers association; and the effects of lithium on the neuromuscular blockade produced by atracurium (35 µg.mL-1 and cisatracurium (5 µg.mL-1. The effects were evaluated before and 45 minutes after the addition of the drugs. The effects of lithium on membrane potentials (MP and miniature end-plate potentials (MEPP were also evaluated. RESULTS: Lithium by itself did not change the amplitude of the muscular responses, but it decreased significantly the neuromuscular blockade produced by atracurium and cisatracurium. It did not change MP and caused an initial increase in MEPP. CONCLUSIONS: Lithium by itself did not compromise neuromuscular transmission and increased the resistance to the effects of atracurium and cisatracurium. It did not show any action on the muscle fiber, and the changes in miniature end-plate potentials
Influência da nifedipina no bloqueio neuromuscular produzido pelo atracúrio e pelo cisatracúrio: estudo em preparações nervo frênico-diafragma de rato Influencia de la nifedipina en el bloqueo neuromuscular producido por atracurio y cisatracurio: estudio en preparación nervio frénico diafragma de ratón Influence of nifedipine on the neuromuscular block produced by atracurium and cistracurium: study in rat phrenic-diaphragmatic nerve preparation
Silmara Rodrigues de Sousa
neuromuscular del atracurio y del cisatracurio, no cambió el potencial de membrana y produjo el aumento inicial en la frecuencia de los PPTM, seguida de bloqueo. CONCLUSIONES: La nifedipina, en la concentración empleada, potenció el bloqueo neuromuscular que el atracurio e cisatracurio produjeron. Estudios electrofisiológicos demostraron una acción presináptica y la ausencia de acción despolarizante sobre la fibra muscular.BACKGROUND AND OBJECTIVES: Calcium channel blockers may interact with neuromuscular blockers, increasing its effects. Research studies about this interaction display controversial results. In some studies these drugs produced neuromuscular blockage, or contracture, or no effect at all was proved over skeletal neuromuscular response. This study assessed the nifedipine effects over muscular responses and its possible interaction with neuromuscular blockers in rat diaphragm. METHODS: A number of 25 rats were used, weighing between 250 and 300 g and sacrificed under anesthesia with intraperitoneal pentobarbital (40 mg.kg-1. Preparation was mounted according to the technique described by Bulbring. Diaphragm was kept under tension, connected to an isometric transducer and subjected to an indirect stimulation of 0.1 Hz frequency. Diaphragm contractions were registered on a physiograph. In order to evaluate the effect of these drugs on neuromuscular transmission, they were added separately or associated to the preparation, on the following concentrations: nifedipine (4 µg.mL-1; atracurium (20 µg.mL-1; cistracurium (3 µg.mL-1. On phrenic-nerve preparation, the assessed items were: 1 the extent of diaphragm muscle response to indirect stimulation, before and 45 minutes after adding nifedipine and neuromuscular blockers separately and after the association of both drugs; 2 nifedipine effects on membrane potentials (MP and miniature end-plate potentials (MEPP. RESULTS: Employed separately, nifedipine did not alter the extent of muscular responses, but it did
Dose preparatória de atracúrio: aferição da fadiga no músculo orbicular do olho e condições de intubação orotraqueal Dosis preparatoria de atracurio: comparación de la fatiga en el músculo orbicular del ojo y condiciones de intubación orotraqueal Priming dose of atracurium: measuring orbicularis oculi muscle fade and tracheal intubation conditions
Giovani de Figueiredo Locks
és de un minuto. Fue considerada fatiga clínicamente importante la relación T4/T1 inferior a 0,9. RESULTADOS: Ningún paciente presentó fatiga durante el intervalo de monitorización. En 80% y 69% de los pacientes de G1 ó G2, respectivamente, las condiciones de intubación traqueal fueron consideradas clínicamente aceptables (p > 0,05. CONCLUSIONES: La dosis preparatoria de atracúrio (0,02 mg.kg-1 no causa fatiga en el músculo orbicular del ojo y no hay diferencia entre esperar 5 ó 7 minutos como intervalo entre las dosis del bloqueador neuromuscular.BACKGROUND AND OBJECTIVES: The priming principle consists of administering a low neuromuscular blocker dose, minutes before the total dose for tracheal intubation, to shorten non-depolarizing blockers onset. There is, however, the risk for muscle fade and bronchoaspiration. Laryngeal muscles are of especial interest for tracheal intubation maneuvers and airway protection. Since their direct monitoring imposes technical difficulties, it has been reported that orbicularis oculi correlates with laryngeal muscles in terms of sensitivity to neuromuscular blocks. This study aimed at evaluating the presence of orbicularis oculi muscle fade after priming atracurium dose and at comparing clinical tracheal intubation conditions after two priming dose intervals. METHODS: Participated in this study 35 adult patients, physical status ASA I or II, without risk factors for bronchoaspiration and submitted to elective surgeries. General anesthesia was induced with alfentanil and propofol and patients were manually ventilated under mask. Surface electrodes were then positioned on the temporal branch of the facial nerve, and the acceleration transducer was placed on the orbicularis oculi. Priming atracurium dose (0.02 mg.kg-1 was administered and T4/T1 ratio was evaluated every minute during 5 minutes in 20 cases (G1 and during 7 minutes in 13 cases (G2. After this interval, complementary atracurium dose (0.5 mg.kg-1 was administered
Levy, J H; Adelson, D; Walker, B
Chemically and pharmacologically unrelated molecules release histamine in humans to produce both cutaneous and systemic responses. It has been suggested that molecular changes in the new benzylisoquinoline-derived muscle relaxant, atracurium, make it less likely to cause histamine release. We therefore injected volunteers intradermally with equimolar concentrations of various muscle relaxants, morphine, papaverine (a benzylisoquinoline), and histamine, to evaluate the relative ability of these drugs to cause wheal and flare responses, and mast-cell degranulation. There were no significant differences in wheal and flare responses among the three benzylisoquinoline-derived muscle relaxants, D-tubocurarine, metocurine, and atracurium. The cutaneous effects of morphine were significantly greater than those of the benzylisoquinoline muscle relaxants, suggesting both direct vascular changes and histamine release. Papaverine injection was followed by a significant wheal but no flare. Skin biopsies from vecuronium- and papaverine-induced wheals revealed normal intact mast-cell granules, suggesting a direct cutaneous vascular response rather than histamine release. Skin biopsies after morphine and atracurium injections revealed mast-cell degranulation. All evaluated benzylisoquinoline muscle relaxants are equipotent histamine releasers at equimolar concentrations. A hydrogenated, benzylisoquinoline-nitrogen-containing ring, present in atracurium but not in papaverine, appears to be the molecular conformation responsible for mast-cell degranulation by atracurium.
Patients were given 1 μg/kg of fentanyl citrate intravenously. Following inductionwith intravenous propofol, endotracheal intubation was facilitated by atracurium. Anaesthesia was maintained by nitrous oxideIN and oxygen and along with propofol infusion. Muscle relaxation was achieved by intermittent bolus doses of ...
received Ketamina. All ﬁre:- patients received sumethmitnn _. t0 faciiitate endwachml intubation. Al} the patimts receivad nitreus cxide in oxygen and 6.5% halothane. Pancm'anium was used to achieve mascle reiaxatim in 332 (59.8%) patients. Atracuri-um was aiso used to achieve muscle reimtien in 223 (49.2%) mtients.
Induction was with halothane, nitrous oxide and oxygen using a Mapleson F breathing circuit. Endotracheal intubation was performed after a second dose of suxamethonium was administered. Muscle relaxant was maintained using atracurium. Spontaneous ventilation was resumed at the end of operation, after a repeat ...
Anaesthesia was reversed with neostigmine 2.5 mg and glycopyrrolate 0.4 mg. BIS values returned to pre-anaesthetic level of 80-90 after 5-10 min, suggesting that use of propofol, ProSeal Laryngeal Mask Airway and atracurium besylate with peripheral nerve monitoring can be a safe means of inducing and maintaining anaesthesia in patients with polymyositis.
Full Text Available Three patients of myasthenia gravis, who under went video-assisted thoracoscopic surgery (VATS were given general anaesthesia by propofol infusion and muscle relaxation by atracurium infusion. Isoflurane was added to control depth of anaesthesia on the basis of haemodynamic changes during surgery. One lung ventilation (OLV was achieved by placement of Carlens left sided double lumen bronchocatheter. Right-sided surgical approach was used to perform thymectomy. Contrary to claimed short duration of surgery, in first patient, OLV lasted for 10 hours 30 minutes and patient developed re-expansion pulmonary oedema. OLV in second and third patient was for six hours thirty minutes and three hours 45 minutes respectively. Morning dose of pyridostigmine was omitted and atracurium (0.1 mg/kg was found to be satisfactory for intubation and relaxation was maintained with atracurium infusion to get desired monitored effect. We could not extubate our patients due to longer duration of surgery and the sequelae there off. Post-operative elective ventilation and spontaneous weaning off the atracurium effect was thus preferred.
Moneret-Vautrin, D A; Kanny, G
IgE-dependent allergy to muscle relaxants (MR) has an estimated prevalence of 1 out of 6500 General Anesthesias (GA). 62% of anaphylaxis during surgery are due to MR anaphylaxis. All the molecules are divalent, carrying two NH4+ epitopes (quaternary ammonium ions), either structurally or after rapid in vivo protonization (vecuronium). The excellent overall performance of skin test makes them the golden standard for the diagnosis of anaphylactoid reactions. Techniques include intradermal tests and prick-tests. The current localizations are the forearm and the back. Positivity criteria are 3 mm for prick-tests. For IDTs, the criterium is the doubling of the size of the injection papula, when 0.02 to 0.04 ml is injected: 8 mm. The recommended concentrations are not falsely negative. Commercial concentrations can be tested by prick tests, except for mivacurium and atracurium tested of 1:10 dilution. A scale of concentrations is advised for IDT starting with 1:10,000, up to a normally non reactive concentration that is: 100 micrograms/ml (succinylcholine), 200 micrograms/ml (gallamine), 10 micrograms/ml (atracurium), 2 micrograms/ml (mivacurium), 200 micrograms/ml (pancuronium), 400 micrograms/ml (vecuronium), 1,000 micrograms/ml (rocuronium), 200 micrograms/ml (cis atracurium). The specificity and sensitivity of the skin tests to MRs are greater than 95%. The reproducibility over years is 88%. The overall concordance of PT and IDR is 97%. Both types of tests can be used for the diagnosis. IDT have to be carried out for the search of the cross sensitization. 84% of patients do have cross sensitization to MRs but only 16% react to all MRs. The further use of MRs selected by negative IDTs has been proved to be safe.
Full Text Available Objective: Through comparing the clinical observation of mivacurium and cisatracurium in vocal polyp extraction, to study the advantage of mivacurium in vocal polyp extraction. Methods: Forty American Society of Anesthesiologists(ASA physical status I~II patients for vocal polyp extraction, aged 18~60 years old, were randomly divided into two groups as Mivacurium injection group(Group M and Cis-atracurium injection group(Group C, each group includes 20 subjects. None of the patients are allergic, has serious diseases of cardiovascular system, liver or kidney.None of them has asthma, airway high response, difficult airway or neuromuscular diseases.Those patients who use beta-blockers or calcium channel blockers for a long time were excluded .All the subjects had the same premedication, fasting and fluid fobidden time. All the subjects who get into the operating room get the routine monitoring of electrocardiogram(EEG, blood pressure(BP, heart rate(HR, pulse oxygen saturation(SpO2 and the TOF WATCH SX. Each group gives the same medicine other than the muscle relaxant during induction of general anesthesia to do the vocal polyp extraction by the same experienced operator. Two groups were recorded in each index of anesthesia induction and tracheal intubation conditions, operation conditions, anesthesia, muscle relaxation monitoring. Results: There are no statistically significant in Cormack-Lehane grading system,Cooper’s grading system and operation satifaction(p>0.05. 2. Group A have shorter intubation time than Group B(p0.05. Conclusion: 1. A single intubating dose of mivacurium can provide similar intubation and surgeon satisfaction for the vocal polyp extraction. 2. Compared with cis-atracurium, mivacurium can shorten the intubation time and the recovery time of anesthesia. The adverse reactions of mivacurium is mild, and it has less Residual muscle relaxation. Therefore mivacurium is more suitable for the vocal polyp extraction than cis-atracurium.
Full Text Available Yajiao Sun,1 Ranran Zhang,2 Zhe Jiang,1 Rongyao Xia,1 Jingwen Zhang,1 Jing Liu,1 Fuhui Chen1 1Department of Respiratory, The Second Affiliated Hospital of Harbin Medical University, 2Department of Respiratory, Harbin First Hospital, Harbin, People’s Republic of China Abstract: Despite recent advances in therapeutic strategies for lung cancer, mortality is still increasing. Therefore, there is an urgent need to identify effective novel drugs. In the present study, we implement drug repositioning for lung adenocarcinoma (LUAD by a bioinformatics method followed by experimental validation. We first identified differentially expressed genes between LUAD tissues and nontumor tissues from RNA sequencing data obtained from The Cancer Genome Atlas database. Then, candidate small molecular drugs were ranked according to the effect of their targets on differentially expressed genes of LUAD by a random walk with restart algorithm in protein–protein interaction networks. Our method identified some potentially novel agents for LUAD besides those that had been previously reported (eg, hesperidin. Finally, we experimentally verified that atracurium, one of the potential agents, could induce A549 cells death in non-small-cell lung cancer-derived A549 cells by an MTT assay, acridine orange and ethidium bromide staining, and electron microscopy. Furthermore, Western blot assays demonstrated that atracurium upregulated the proapoptotic Bad and Bax proteins, downregulated the antiapoptotic p-Bad and Bcl-2 proteins, and enhanced caspase-3 activity. It could also reduce the expression of p53 and p21Cip1/Waf1 in A549 cells. In brief, the candidate agents identified by our approach may provide greater insights into improving the therapeutic status of LUAD. Keywords: lung adenocarcinoma, drug repositioning, bioinformatics, protein–protein interaction network, atracurium
Sosis, M B
Cystoscopy was postponed on an 80-year-old male found to have a hematocrit of 57%. After the diagnosis of polycythemia vera was made, he was phlebotomized and treated with hydroxyurea. He was readmitted 2 months later for transurethral resection of the prostate. After the induction of general endotracheal anesthesia with thiopental and succinylcholine, anesthesia was maintained with nitrous oxide, oxygen, thiopental, and atracurium. Recovery was uneventful. Polycythemia vera is a disease process in which control prior to surgery decreases the frequency of perioperative complications. A discussion and short literature review on polycythemia vera and anesthesia are included.
Full Text Available Background: Gabapentin attenuates the haemodynamics, decreases the catecholamine release and has a neuroprotective effect. The aim of the present study was to assess the effect of gabapentin in patients with supratentorial brain tumours undergoing craniotomy under general anaesthesia. Methods: A radial arterial line, central venous line and ventriculostomy catheters were inserted before surgery. Anaesthesia was induced with thiopental, fentanyl and atracurium and maintained with sevoflurane, fentanyl and atracurium infusion. The study included 160 patients classified randomly into two groups: Group G: The patients received gabapentin capsules 1200 mg orally 2 h before surgery. Group C: The patients received placebo capsules. Results: The heart rate, mean arterial blood pressure and intracranial pressure decreased significantly with gabapentin as compared to the control group (P < 0.05. The dose of fentanyl and end-tidal sevoflurane was lower with gabapentin than the control group (P < 0.05. The urine output was higher in the gabapentin group than the control group (P < 0.05. The Glasgow coma scale score was better in the gabapentin group as compared to the control group (P < 0.05. The incidence of nausea and vomiting was lower in the gabapentin group as compared to the control group (P < 0.05. Conclusions: Pre-operative administration of gabapentin in patients undergoing craniotomy under general anaesthesia minimised the fluctuations in haemodynamics, reduced the requirements for sevoflurane and fentanyl, decreased intracranial pressure and improved the outcomes. There were some side effects associated with gabapentin such as hypotension and bradycardia.
Mohammad Reza Safavi
Full Text Available BACKGROUND: The oculocardiac reflex (OCR, which is most often encountered during strabismus surgery in children,
may cause bradycardia, arrhythmias and cardiac arrest following a variety of stimuli arising in or near the eyeball. The
main purpose of this study was to evaluate the effects of various anesthetic regimens on modulation of the cardiovascular
effects of the OCR during strabismus surgery.
METHODS: Three hundred ASA physical status I-II patients, scheduled for elective strabismus surgery under general
anesthesia, randomly allocated in a double blind fashion to one of the three anesthetic regimens: group P: propofol (2
mg/kg, alfentanil 0.02 mg/kg and atracurium 0.5 mg/kg at induction; group K: ketamine racemate (2 mg/kg, alfentanil
0.02 mg/kg and atracurium 0.5 mg/kg at induction; group T: thiopental (5 mg/kg, alfentanil 0.02 mg/kg, and atracurium
0.5 mg/kg at induction. Mean arterial pressure (MAP and heart rate (HR were recorded just before induction, at
1, 15, 30, 45 and 60 minutes after induction. OCR was defined as a 20 beats/minute change in HR induced by traction
compared with basal value.
RESULTS: Mean HR (± SD during total period of surgery in group P was significantly slower than that in group K
(111.90 ± 1.10 vs. 116.7 ± 0.70, respectively; P<0.05. Mean HR changes (± SD in group K was significantly higher
than that in group P (11.2 ± 1.44 vs. 8.7 ± 1.50 respectively, P<0.05. MAP changes (± SD was significantly lower in
patients in group P compared with patients in group K or T (12.5 ± 1.13 vs. 19.3 ± 0.80 or 18.9 ± 0.91, respectively;
P<0.05. Incidence of OCR was significantly lower in patients in group K compared with patients in group T or P (9%
vs. 16% and 13%. Respectively; P<0.05.
CONCLUSIONS: Induction of anesthesia with ketamine is associated with the least
Hagau, Natalia; Gherman, Nadia; Cocis, Mihaela; Petrisor, Cristina
Skin tests for neuromuscular blocking agents (NMBAs) are not currently recommended for the general population undergoing general anaesthesia. In a previous study we have reported a high incidence of positive allergy tests for NMBAs in patients with a positive history of non-anaesthetic drug allergy, a larger prospective study being needed to confirm those preliminary results. The objective of this study was to compare the skin tests results for patients with a positive history of antibiotic-induced immediate type hypersensitivity reactions to those of controls without drug allergies. Ninety eight patients with previous antibiotic hypersensitivity and 72 controls were prospectively included. Skin tests were performed for atracurium, pancuronium, rocuronium, and suxamethonium. We found 65 positive skin tests from the 392 tests performed in patients with a positive history of antibiotic hypersensitivity (1 6.58%) and 23 positive skin tests from the 288 performed in controls (7.98%), the two incidences showing significant statistical difference (p = 0.0011). The relative risk for having a positive skin test for NMBAs for patients versus controls was 1.77 (1.15-2.76). For atracurium, skin tests were more often positive in patients with a positive history of antibiotic hypersensitivity versus controls (p = 0.02). For pancuronium, rocuronium and suxamethonium the statistical difference was not attained (p-values 0.08 for pancuronium, 0.23 for rocuronium, and 0.26 for suxamethonium). Patients with a positive history of antibiotic hypersensitivity seem to have a higher incidence of positive skin tests for NMBAs. They might represent a group at higher risk for developing intraoperative anaphylaxis compared to the general population. Copyright © 2015 The Authors. Production and hosting by Elsevier B.V. All rights reserved.
Full Text Available Background: Laparoscopy though minimally invasive produces significant hemodynamic surge and neuroendocrine stress response. Though general anesthesia (GA is the conventional technique, now-a-days, regional anesthesia has been accepted for laparoscopic diagnostic procedures, and its use is also being extended to laparoscopic surgeries. Objective: The aim was to compare the hemodynamic surge and neuroendocrine stress response during laparoscopic cholecystectomy (LC under GA and spinal anesthesia (SA in American Society of Anesthesiologists (ASA PS 1 patients. Materials and Methods: Thirty ASA physical status I patients, aged 18-65 years were randomly allocated into two equal groups of 15 each. Group A received GA with controlled ventilation. Patients were preoxygenated for 5 min with 100/5 oxygen, premedicated with midazolam 0.03 mg/kg intravenous (i.v, fentanyl 2 mcg/kg i.v; induction was done with thiopentone 3-5 mg/kg i.v; intubation was achieved after muscle relaxation with 0.5 mg/kg atracurium besylate i.v. Anesthesia was maintained with 1-2% sevoflurane and N2O:O2 (60:40 and intermittent i.v injection of atracurium besylate. Group B SA with 0.5% hyperbaric bupivacaine and 25 μg fentanyl along with local anesthetic instillation in the subdiaphragmatic space. Mean arterial pressure, heart rate (HR, oxygen saturation, end tidal carbon-dioxide were recorded. Venous blood was collected for cortisol assay before induction and 30 min after pneumoperitoneum. All data were collected in Microsoft excel sheet and statistically analyzed using SPSS software version 16 (SPSS Inc., Chicago, IL, USA. All numerical data were analyzed using Student′s t-test and paired t-test. Any value <0.05 was taken as significant. Results: Mean arterial pressure and mean HR and postpneumoperitoneum cortisol level were lower in group B than group A though the difference was not statistically significant in hemodynamic parameters but significant in case of cortisol
Ciçek, S; Attar, A; Tuna, H; Keçik, Y; Egemen, N
The aim of this study is to find out the effects of different doses of midazolam, when used epidurally, on somatosensory evoked potentials (SEP) by delaying neuronal conduction. Thirty two New Zeland albino male rabbits were divided into four groups. All rabbits were anesthetised with ketamine and xylasine combination and atracurium was used as muscle relaxant. 10 mg/kg/hr ketamine infusion was used for maintenance of anesthesia. After insertion of the epidural catheter surgically; Group 1 received 1.5 ml isotonic saline (Control), Group 2 received 150 microg/kg, Group 3 received 250 microg/kg, and Group 4 received 500 microg/kg midazolam epidurally. With the stimulation of sciatic nerve. SEP records were recorded from the epidural space. Records were received before the injection of the drug, and 20, 40, 60 minutes after injection of the drug. "Latency" results were increased according to control in all groups (including isotonic saline-control-group). Increase in latency in the control group was interpreted as due to the effect of temperature mismatch of the saline and the rabbits. While in the first and second group amplitudes showed no differences, group 3 and 4 showed decreases of up to 50%. Epidurally administered midazolam up to 150 microg/kg caused no change in SEP records, but 250 and 500 microg/kg doses caused decreases in SEP records which can lead to misinterpretation as neurological damage.
Full Text Available Endotracheal tube (ETT cuff herniation is a rare, and often difficult to diagnose, cause of bronchial obstruction. We present a case of outside cuff herniation of an endotracheal tube that caused pulmonary right lung atelectasis. A 29-year-old man ,a case of car accident with multiple fractures, was admitted to the emergency ward and transferred to the operating room(OR for open reduction and internal fixation (ORIF of all fractures .The procedures were done under general anesthesia (G/A. The past medical history of the patient did not indicate any problem. Anesthesia was induced with thiopental, atracurium and then maintained by propofol and remifentanyl infusions and 100% O2 via orally inserted ETT. The patient was positioned in left lateral decubitus position for operation. Two hours after induction of anesthesia, the oxygen saturation level dropped to 85 % and the breath sounds in the right side of the chest were weakened. The chest x-ray images showed right lung atelectasis especially in the upper lobe. The problem was disappeared after removal of the ETT. In this case, we observed that an ETT cuff herniation can be a cause of airway obstruction. If there is a decreased unilateral breath sounds, we recommend replacement or repositioning of ETT.
Leutzow, Bianca; Lange, Jörn; Gibb, Andreas; Schroeder, Henry; Nowak, Andreas; Wendt, Michael; Usichenko, Taras I
Transcutaneous vagal nerve stimulation is a promising treatment modality in patients suffering mood disorders and chronic pain, however, the mechanisms are still to be elucidated. A recently developed technique of EEG responses to electrical stimulation of the inner side of the tragus suggests that these responses are far field potentials, generated in the vagal system - Vagal Sensory Evoked Potentials (VSEP). To reproduce the VSEP technique free from myogenic artifacts. Fourteen ASA I-II patients scheduled for elective surgery in standardized Total Intravenous Anesthesia (TIVA) were enrolled. Transcutaneous electrical stimulation was applied to the inner side of the right tragus. Averaged EEG responses were recorded from the electrode positions C4-F4 and T4-O2 before and after induction of TIVA, during the maximal effect of the non-depolarizing muscle relaxing agent, cis-atracurium (C-AR) and after recovery from C-AR under TIVA. Typical response curves with P1, N1 and P2 peaks could be reproduced in all patients before and after anesthesia induction. The response curves disappeared during the C-AR action and re-appeared after recovery from C-AR under TIVA. The disappearance of the scalp responses to electrical tragus stimulation under the neuromuscular block suggests a muscular origin of these potentials. Copyright © 2013 Elsevier Inc. All rights reserved.
Seyed mojtaba Karimi
Full Text Available Introduction: Endoscopic surgery is a new standard method of treatment for chronic sinusitis. During this operation even small amount of bleeding may reduce the visual field of surgeon significantly and make the procedure troublesome. In this study we have compared the operative condition between patients who receive either remifentanil or halothane for general anesthesia. Materials and Methods: Endoscopic sinus surgery was performed in 60 patents. Pre- medication was done by fentanil and midazolam and induction was done by propofol and atracurium. Halothane or remifentanil was used in two groups of patients respectively for anesthesia maintenance. Monitoring was performed during anesthesia. Bleeding volume was measured and operation field condition was assessed by the surgeon. Results: Personal characteristics such as age and sex were the same in both groups. Intra- operative systolic blood pressures was significantly lower in remifentanil group but diastolic and mean blood pressure and heart rate didn’t change after induction and during maintenance in both groups. Recovery time in remifentanil group was also significantly shorter than halothane group. Finally bleeding volume was lower and operation field condition was better significantly in remifentanil group. Conclusion: Remifentanil is a good choice to maintain an ideal anesthesia for endoscopic sinus surgery.
Rosenberger, A D; Treudler, R; Blume-Peytavi, U; Zouboulis, C C; Schaffartzik, W; Orfanos, C E
Nearly all drugs currently used during the course of general anaesthesia may lead to hypersensitivity reactions of various types. There may be an acute type I allergic reactions or to a more or less severe pseudo-allergic reactions, in rare cases with lethal outcome. Routine preoperative testing appears of little predictive value, in spite of the high frequency of so-called risk factors (atopy, other kind of allergy) among the evaluated group of patients. Careful allergological testing should be performed 4 to 6 weeks after any incidents of suspected drug intolerance, in order to discover the underlying causative agent. Skin testing is of diagnostic value for neuromuscular blockers and intravenous narcotics. RAST- and RIA-tests and/or mediator releasing tests may also used additionally. Together with all other administered drugs, all the routinely used neuromuscular blockers (suxamethonium, vecuronium, pancuronium, alcuronium, atracurium, mivacurium) should be tested, since they often represent the cause for such reactions. For other classes of drugs (for example, volatile anesthetics and opioids) the clinical relevance of skin testing still remains uncertain. For less severe incidents seen during general anaesthesia such as pruritus, or exanthema, skin testing seems to be less relevant.
Gul, Rauf; Goksu, Sitki; Ugur, Berna K; Sahin, Levent; Koruk, Senem; Okumus, Seydi; Erbagci, Ibrahim
To compare proseal laryngeal mask airway (PLMA) with an endotracheal tube (ET) for airway safety, maintained ease of insertion, and hemodynamic stability in pediatric strabismus surgery (PSS). This prospective-randomized clinical study was carried out in the Department of Anesthesiology, Faculty of Medicine, Gaziantep University, Turkey between April 2008 and July 2009. Eighty American Society of Anesthesiology (ASA) I-II children, weight 10-30 kg, aged between 1-12 years undergoing PSS were selected. The anesthesia was induced with 8% sevoflurane, 50% nitrous oxide/oxygen mixture, and a neuromuscular blockade with 0.5 mg/kg atracurium in both groups. After a sufficient dosage of anesthesia, the patients were randomized into 2 groups (Group P: PLMA, n= 40, Group T: ET, n=40) and an airway management device; either a PLMA or ET was inserted. The number of placement attempts, placement success or failure, success or failure of a gastric suction tube placement during the procedures and perioperative complications were assessed. Thirty-eight patients (95%) in the PLMA group, 39 (97.5%) patients in the ET group were successfully placed with a PLMA and ET on the first attempt (p>0.05). There were no statistically significant differences in the hemodynamic parameters, end-tidal carbon dioxide, and complications. This study revealed that PLMA may offer an alternative airway to ET wherein positive pressure ventilation was the preferred choice for children undergoing PSS.
Santeularia, M T; Unzueta, M C; Casas, J I; Vilanova, F; Roldán, J; Villar Landeira, J
To report our experience in managing anesthesia during obstetric delivery of women with myasthenia gravis (MG) and to review the anesthetic technique of choice for vaginal or cesarean delivery in such cases. Fifteen pregnancies in 12 patients were recorded between 1980 and 1996; 14 cases were documented. Disease course during pregnancy, delivery and postpartum, the course of pregnancy, the presence of severe neonatal myasthenia and anesthetic treatment during vaginal or cesarean delivery were analyzed. Improvement in MG was observed in 6 cases. No change was seen in 4 patients and 3 worsened. In one woman generalized MG debuted 15 days after delivery. Two neonates were premature and a third suffered severe neonatal myasthenia. Six vaginal deliveries were aided by forceps; 8 deliveries were by cesarean and 1 fetus was aborted. Lumbar epidural anesthesia was employed in 73.33% (5 vaginal deliveries and 6 cesareans) and general anesthesia in 26.66% (1 abortion, 1 vaginal delivery and 2 cesareans). Continuous lumbar epidural anesthesia is the technique of choice for vaginal as well as cesarean deliveries. The combination of opioids and local anesthetics is considered particularly beneficial for patients, as it allows the motor blockade to be decreased. General anesthesia is only indicated when there is bulbar involvement. Short-acting non depolarizing agents, among them atracurium Besilate, are the muscle relaxants of choice. Succinylcholine is contraindicated. Thanks to current optimization of anesthetic and recovery techniques and administration of non depolarizing muscle relaxants with neuromuscular monitoring, the prognosis for pregnant MG patients has improved considerably.
Teixeira, Miguel; Mendonça, Teresa; Rocha, Paula; Rabiço, Rui
This paper presents a model based switching control strategy to drive the neuromuscular blockade (NMB) level of patients undergoing general anesthesia to a predefined reference. A single-input single-output Wiener system with only two parameters is used to model the effect of two different muscle relaxants, atracurium and rocuronium, and a switching controller is designed based on a bank of total system mass control laws. Each of such laws is tuned for an individual model from a bank chosen to represent the behavior of the whole population. The control law to be applied at each instant corresponds to the model whose NMB response is closer to the patient's response. Moreover a scheme to improve the reference tracking quality based on the analysis of the patient's response, as well as, a comparison between the switching strategy and the Extended Kalman Kilter (EKF) technique are presented. The results are illustrated by means of several simulations, where switching shows to provide good results, both in theory and in practice, with a desirable reference tracking. The reference tracking improvement technique is able to produce a better reference tracking. Also, this technique showed a better performance than the (EKF). Based on these results, the switching control strategy with a bank of total system mass control laws proved to be robust enough to be used as an automatic control system for the NMB level.
Villani, A; Primieri, P; Adducci, G; Mennella, M; Lattanzi, A; De Cosmo, G
The authors have conducted a retrospective study on 115 patients with myasthenia gravis undergoing transsternal or transcervical thymectomy at the Policlinico A. Gemelli of Rome in the period June 1984- to June 1991. A prolonged postoperative mechanical ventilation immediately and a few days following surgery was required respectively in 7 and 3 patients, while atelectasia and broncopneumonia have developed in 10 patients. No relationship could be established between the incidence of respiratory complications and factors such as preoperative symptomatology and treatment anesthetic agents, the surgical approach to the thymus and thymic pathology. However a significantly greater postoperative morbidity has been observed in the group of patients receiving suxametonium as compared to the patients receiving non-depolarizing muscle relaxants. Vecuronium and atracurium very frequently allowed ad adequate resumption of spontaneous respiration after anesthesia and made possible a safe early extubation of patients before leaving the operating room. The authors also stressed that all patients, irrespective of their clinical conditions, must be transferred after thymectomy. Oto the surgical ICU where anticholinesterase therapy can be safely restarted and cardiorespiratory status carefully monitored.
Gentili, Francesco G; Fick, Jerker
The purpose of this study was to investigate whether pharmaceutical pollutants in urban wastewater can be reduced during algal cultivation. A mixed population of wild freshwater green algal species was grown on urban wastewater influent in a 650 L photobioreactor under natural light and with the addition of flue gases. Removal efficiencies were very high (>90 %), moderate (50-90 %), low (10-50 %), and very low or non-quantifiable (pharmaceuticals, respectively, over a 7-day period. High reduction was found in the following pharmaceuticals: the beta-blockers atenolol, bispropol, and metoprolol; the antibiotic clarithromycine; the antidepressant bupropion; the muscle relaxant atracurium; hypertension drugs diltiazem and terbutaline used to relive the symptoms of asthma. Regression analysis did not detect any relationship between the reduction in pharmaceutical contents and light intensity reaching the water surface of the algal culture. However, the reduction was positively correlated with light intensity inside the culture and stronger when data collected during the night were excluded. Algae cultivation can remove partially or totally pharmaceutical pollutants from urban wastewater, and this opens up new possibilities for treating urban wastewater.
Grobosch, T; Lemm-Ahlers, U
In all, 3872 urine specimens were screened for lysergic acid diethylamide (LSD) using the CEDIA DAU LSD assay. Forty-eight samples, mainly from psychiatric patients or drug abusers, were found to be LSD positive, but only 13 (27%) of these could be confirmed by high-performance liquid chromatography with fluorescence detection (HPLC-FLD) following immunoaffinity extraction (IAE). Additional analysis for LSD using the DPC Coat-a-Count RIA was performed to compare the two immunoassay screening methods. Complete agreement between the DPC RIA assay and HPLC-FLD results was observed at concentrations below a cutoff concentration of 500 pg/mL. Samples that were LSD positive in the CEDIA DAU assay but not confirmed by HPLC-FLD were also investigated for interfering compounds using REMEDI HS drug-profiling system. REMEDI HS analysis identified 15 compounds (parent drugs and metabolites) that are believed to cross-react in the CEDIA DAU LSD assay: ambroxol, prilocaine, pipamperone, diphenhydramine, metoclopramide, amitriptyline, doxepine, atracurium, bupivacaine, doxylamine, lidocaine, mepivacaine, promethazine, ranitidine, and tramadole. The IAE/HPLC-FLD combination is rapid, easy to perform and reliable. It can reduce costs when standard, rather than more advanced, HPLC equipment is used, especially for labs that perform analyses for LSD infrequently. The chromatographic analysis of LSD, nor-LSD, and iso-LSD is not influenced by any of the tested cross-reacting compounds even at a concentration of 100 ng/mL.
Chung, Peter Chi-Ho; Ng, Yuet-Tong; Hsieh, Jing-Ru; Yang, Min-Wen; Li, Allen Hon-Lun
To evaluate the effect of pretreatment with the mixed alpha- and beta-adrenergic blocker, labetalol, on blood pressure instability during surgical resection of pheochromocytoma. Blood pressure stability and surgical results were compared between patients in the saline (n = 11) and labetalol (n = 15) groups. Anesthesia was induced with fentanyl, sodium thiopental and atracurium, and maintained with isoflurane in a 50% oxygen/nitrous oxide mixture. Intravenous labetalol was administered in the labetalol group before surgical incision, with the maximal dose being 1.2 mg/kg, while normal saline was administered to patients in the control, saline, group. Supplemental intravenous sodium nitroprusside (SNP) infusion was administered whenever systolic blood pressure exceeded 180 mmHg. The number of patients with intraoperative hypertension or hypotension, dosage of SNP administered, number of intraoperative hypertension episodes, use of fluid and blood transfusion, and heart rate (defined as the mean of heart rate every 5 minutes throughout the operation) were compared between these two groups. The number of patients with intraoperative hypertension, number of patients receiving SNP, dose of SNP administered, and number of hypertension episodes were significantly lower in patients who received labetalol pretreatment than in control patients. This study has demonstrated that labetalol pretreatment (1.2 mg/kg) with supplemental SNP provides more favorable blood pressure control during surgical resection of pheochromocytoma than with SNP alone.
Full Text Available Objective: To observe the effects of dexmedetomidine on stress responses and circulation of ICU patients with trachea cannula treatment and to discuss its clinical values. Methods: A total of 60 cases who were admitted in our hospital from June 2014 to February 2016 were selected and were randomly divided into study group and control group (n=30. Intravenous line of 60 cases was opened before trachea cannula treatment and radial artery puncture was performed for monitoring the invasive artery blood pressure. Patients in study group were given dexmedetomidine treatment for 10 min, with pump injection of 0.5 μg•kg-1 ; then patients in study group were given the right dosage of propofol and cis-atracurium treatment, with intravenous injection; while patients in control group were given the equivalent normal saline (NS treatment with pump injection and then were given the right dosage of propofol and cisatracurium treatment. After mask oxygen inhalation, trachea cannula treatment was performed. Haemodynamics relevant index changes of both groups at different time were recorded and arterial blood was collected for determining the cortisol levels for statistical analysis. Results: The used dosage of propofol and cis-atracurium in both groups had no obvious statistical significance. MAP and HR levels of patients in study group were (85.5±10.6 mmHg and (68.5±6.9 times/min respectively immediately after trachea cannula treatment and were (83.7±9.4 mmHg and (68.4±6.5 times/min respectively 5 min after trachea cannula treatment, which were lower than that in control group, with (95.2±9.5 mmHg and (75.5±6.6 times/min respectively immediately after trachea cannula treatment and (92.2±9.6 mmHg and (76.5±7.2 times/min respectively 5min after trachea cannula treatment, haemodynamics was more stable. Cortisol levels of patients in study group were (33.4±1.5, (34.1±1.8, (34.5±1.6 respectively after pump injection of dexmedetomidine, immediately
Full Text Available Objective To explore the feasibility of dexmedetomidine as an adjuvant of sevoflurane for controlled hypotension in endoscopic sinus surgery. Methods Forty-eight patients (ASA Ⅰor Ⅱ scheduled for endoscopic sinus surgery were randomly assigned into two groups (n=24: control group (group I and dexmedetomidine group (group Ⅱ. In both groups, intravenous injection of midazolam, propofol, fentanyl, and atracurium besilate was given to induce anesthesia, and propofol, fentanyl, atracurium besilate, together with sevoflurane inhalation were used to maintain anesthesia. The radial artery was cannulated to monitor the invasive mean arterial pressure (MAP. Controlled hypotension was induced by adjusting the sevoflurane concentration in group Ⅰ. In group Ⅱ, within 15min to 30min before the induction of anesthesia, dexmedetomidine was administered in a dose of 0.8μg/kg via intravenous infusion pump, then maintained at 0.4μg/(kg·h. Sevoflurane concentration was adjusted to maintain the target blood pressure at the beginning of surgery. The MAP was maintained at 65-75mmHg up to the end of operation. Meanwhile, the heart rate (HR, MAP, epinephrine (E, and norepinephrine (NE concentrations were recorded at the time of induction of anesthesia (T0, beginning of controlled hypotension (T1, 30min after controlled hypotension (T2, and at the time when extubation was performed (T3. Blood gas analysis and determination of lactic acid concentration were conducted using the blood drawn from the radial artery during the operation. The surgical field quality was assessed based on Fromme scores of surgical field quality (SSFQ. Meanwhile, the dose of sevoflurane, propofol, and fentanyl, MAP, the recovery time of anesthesia, and the incidence rate of untoward eﬀects were recorded. Results The doses of propofol, fentanyl and sevoflurane, and MAC value in group Ⅱwas significantly diminished compared with group Ⅰ(P＜0.01. In addition, the surgical
L D Mishra
Full Text Available Background : Often conventional Inhalational agents are used for maintenance of anaesthesia in spine surgery. This study was undertaken to compare propofol with isoflurane anaesthesia with regard to haemodynamic stability, early emergence, postoperative nausea and vomiting (PONV and early assessment of neurological functions. Patients & Methods: Eighty ASA grade I &II adult patients were randomly allocated into two groups. Patients in study group received inj propofol for induction as well as for maintenance along with N 2O+O2 and the control group patients received inj thiopentone for induction and N 2 O+O 2 +isoflurane for maintenance. BIS monitoring was used for titrating the anaesthetic dose adjustments in all patients. All patients received fentanyl boluses for intraoperative analgesia and atracurium as muscle relaxant. Statistical data containing haemodynamic parameters, PONV, emergence time, dose of drug consumed & quality of surgical field were recorded and compared using student t′ test and Chi square test. Results: The haemodynamic stability was coparable in both the groups. The quality of surgical field were better in study group. Though there was no significant difference in the recovery profile (8.3% Vs 9.02% between both the groups, the postoperative nausea and vomiting was less in propofol group than isoflurane group (25%Vs60%. The anaesthesia cost was nearly double for propofol than isoflurane anaesthesia. Conclusion: Haemodynamic stability was comparable in both the groups. There was no significant difference in the recovery time between intravenous and inhalational group. Patients in propofol group were clear headed at awakening and were better oriented to place than inhalational group.
Garvey, Gráinne Patricia; Wasade, Vibhangini S; Murphy, Kellie E; Balki, Mrinalini
Syringomyelia is a rare, slowly progressive neurological condition characterized by the presence of a syrinx within the spinal cord. Consensus regarding the safest mode of delivery and anesthetic management in patients with syringomyelia remains controversial and presents management dilemmas. This study reviews the cases of syringomyelia at our institution and provides a systematic review of the literature to guide decisions regarding labor and delivery management. A retrospective review of cases at our hospital from 2002 to 2014 and a systematic review of the literature from 1946 to 2014 were undertaken. Hospital records and electronic databases were interrogated using International Classification of Diseases, 10th Revision codes and the keywords "syringomyelia," "syringobulbia," and "pregnancy." Data regarding demographics, diagnosis, radiology reports, neurological symptoms, mode of delivery, anesthetic management, and maternal-fetal outcomes were collected. We collected and analyzed data on a total of 43 pregnancies in 39 patients. The most common location for syrinx was in the cervicothoracic region (41.9%). The large majority of patients (n = 34; 87%) demonstrated signs and symptoms associated with syringomyelia before delivery. Syringomyelia associated with Arnold Chiari malformation was documented in 49% (n = 21) cases. General anesthesia was the most commonly used (n = 21/30, 70%) anesthetic technique for cesarean delivery. The majority (n = 9/13, 69%) of patients had an epidural sited for labor analgesia. There were no maternal or neonatal complications associated with neuraxial anesthesia; however, 3 cases (14%) raised concerns regarding general anesthesia including difficult intubation, transient worsening of neurological symptoms postpartum, and prolonged muscle paralysis after atracurium. Despite concerns regarding aggravation of the syrinx with vaginal delivery, this mode of delivery has never caused any documented long-term worsening of neurological
Aceto, P; Perilli, V; Lai, C; Sacco, T; Modesti, C; Luca, E; De Santis, P; Sollazzi, L; Antonelli, M
Many factors affect postoperative dream recall, including patient characteristics, type of anesthesia, timing of postoperative interview and stress hormone secretion. Aims of the study were to determine whether Bispectral Index (BIS)-guided anesthesia might decrease sevoflurane minimum alveolar concentration (MAC) when compared with hemodynamically-guided anesthesia, and to search for a MAC threshold useful for preventing arousal, dream recall and implicit memory. One hundred thirty patients undergoing elective thyroidectomy were enrolled. Anesthesia was induced with propofol 2 mg kg(-1), fentanyl 3 mcg kg(-1) and cis-atracurium 0.15 mg kg(-1). For anesthesia maintenance, patients were randomly assigned to one of two groups: a BIS-guided group in which sevoflurane MAC was adjusted on the basis of BIS values, and a hemodynamic parameters (HP)-guided group in which MAC was adjusted based on HP. An auditory recording was presented to patients during anesthesia maintenance. Dream recall and explicit/implicit memory were investigated upon awakening and approximately after 24 h. Mean sevoflurane MAC during auditory presentation was similar in the two groups (0.85 ± 0.16 and 0.87 ± 0.17 [P = 0.53] in BIS-guided and HP-guided groups, respectively). Frequency of dream recall was similar in the two groups: 27% (N. = 17) in BIS-guided group, 18% (N. = 12) in HP-guided group, P = 0.37. In both groups, dream recall was less probable in patients anesthetized with MAC values ≥ 0.9 (area under ROC curve = 0.83, sensitivity = 90%, and specificity = 49%). BIS-guided anesthesia was not able to generate different MAC values compared to HP-guided anesthesia. Independent of the guide used for anesthesia, a sevoflurane MAC over 0.9 was required to prevent postoperative dream recall.
Movasseghi, Gholamreza; Hassani, Valiollah; Mohaghegh, Mahmood Reza; Safaeian, Reza; Safari, Saeid; Zamani, Mohammad Mahdi; Nabizadeh, Roya
Background Hemodynamic stability and blood loss reduction are subjects to further consideration in patients undergoing percutaneous nephrolithotomy (PNCL). Objectives This study compared the preference of spinal anaesthesia (SA) or general anaesthesia (GA) in respect to mentioned concerns. Patients and Methods In this randomized clinical trial, 59 patients who underwent PCNL divided into SA and GA groups. 15-20 mg from intra-thecal bupivacaine 0.5%, and premedication of 0.01-0.02 mg from midazolam, were given to patients in SA group (n = 29). Patients in GA group (n = 30) received premedication of 1-2 µg/kg from fentanyl and 0.01-0.02 mg/kg from midazolam, and intravenously anaesthetized with 100 µg/kg/min of propofol and 0.5 mg/kg of atracurium, given by continuous infusion and N2O/O2 50%. Mean arterial pressure (MAP) and heart rate were recorded intra-operatively and during recovery. Results MAP and heart rate show no significant differences at designated time points between two groups (P > 0.05). Surgery time, anesthesia time, bleeding volume, and analgesic intake were significantly reduced in SA group (P < 0.05). Conclusions It seems that, in patients undergoing PNCL, SA is as effective and safe as GA. Patients who undergo PNCL under SA require smaller amounts of analgesic dose and show hemodynamic stability during surgery and recovery time. Also, SA technique provides decreased blood loss and shortened surgery as well as anesthesia times compared to GA. PMID:24660147
Arif H.M. Marsaban
Full Text Available Background: Increased blood pressure and heart rate are the most frequent response to laryngoscopy which sometimes causes serious complications. Laryngoscopy technique and tools modification lessen the nociceptive stimulation, thus preventing hemodynamic response. BURP maneuver is used to lower Cormack-Lehane level, but it can cause additional pain stimulation during laryngoscopy. The aim of this study was to compare the cardiovascular response and the need of BURP maneuver during laryngoscopy between CMAC® and conventional Macintosh.Methods: A randomized, single blinded, control trial was performed to 139 subjects who underwent general anesthesia with endotracheal tube. Subjects were randomised into a control group (conventional Macintosh and an intervention group (CMAC®. The cardiovascular parameters (systolic, dyastolic, mean arterial pressure, and heart rate were measured prior to induction (T1. Midazolam 0.05 mg/kg and Fentanyl 2 micrograms/kg were given 2 minutes before the induction. Moreover, they were given propofol 1 mg/kg followed by propofol infusion of 10 mg/kg/hour and Atracurium 0.8–1 mg/kg. After TOF-0 cardiovascular parameters (T2 were remeasured, it was proceeded to laryngoscopy. When Cormack-Lehane 1–2 was reached (with or without BURP maneuver, cardiovascular parameters were measured again (T3.Results: Unpaired T-test showed that cardiovascular response during laryngoscopy were significantly lower in the intervention group compared to the control group (p<0.05. The need of BURP maneuver was significantly lower in the CMAC® group compared to the Convensional Macintosh group (13.9% vs 40.3%; p<0.05.Conclusion: Cardiovascular response and BURP maneuver during laryngoscopy with CMAC® were significantly lower compared to conventional Macintosh.
Igboko, J O; Desalu, I; Akinsola, F B; Kushimo, O T
Laryngoscopy and tracheal intubation lead to acute elevation in intraocular pressure (IOP); the ocular hypertensive response. The Laryngeal mask airway prevents sudden surges in IOP. We compared IOP changes to the insertion and removal of the Laryngeal mask airway (LMA) and the endotracheal tube (ETT). Seventy ASA I and II patients aged 18 to 60 years at the Lagos University Teaching Hospital between January and December 2003 were randomly allocated to receive either an LMA or ETT for airway management. Anaesthesia was induced with propofol and atracurium. Intraocular pressure was measured by applanation tonometry post induction (baseline) and prior to removal (pre-extubation), after insertion or removal (0 minute), at 1,2,3,5 and 10 minutes after insertion or removal. Insertion of the airway device caused an immediate rise in IOP of 4.6% in the LMA group (from 13.1 +/- 2.4 to 13.7 +/- 2.4 mmHg) and 49.2 in the ETT group (from 12.0 +/- 2.5 to 17.9 +/- 4.0 mmHg) (p<0.001). Removal of the airway device caused an immediate rise in IOP of 14.6 in the LMA group (from 11.26 +/- 2.4 to 12.9 +/-2.4 mmHg) and 50.3 in the ETT group (from 11.37 +/- 2.0 to 17.1 +/- 3.3 mmHg) (p<0.001). IOP thereafter declined towards baseline in both groups. Cardiovascular responses accompanied IOP changes. The mean insertion time was 39.8 +/- 9.1 seconds (ETT) vs 31.5 +/- 4.4 seconds (LMA). (p<0.001) Cough (17.1) and mild laryngeal spasm (2.9) occurred in the ETT group only following removal. The LMA produced better IOP stability following its insertion and removal compared to the tracheal tube.
Sener, Elif Bengi; Ustun, Emre; Ustun, Burcu; Sarihasan, Binnur
We compared hemodynamic responses and upper airway morbidity following tracheal intubation via conventional laryngoscopy or intubating laryngeal mask airway in hypertensive patients. Forty-two hypertensive patients received a conventional laryngoscopy or were intubated with a intubating laryngeal mask airway. Anesthesia was induced with propofol, fentanyl, and cis-atracurium. Measurements of systolic and diastolic blood pressures, heart rate, rate pressure product, and ST segment changes were made at baseline, preintubation, and every minute for the first 5 min following intubation. The number of intubation attempts, the duration of intubation, and airway complications were recorded. The intubation time was shorter in the conventional laryngoscopy group than in the intubating laryngeal mask airway group (16.33 ± 10.8 vs. 43.04 ± 19.8 s, respectively) (pmask airway group were higher than those in the conventional laryngoscopy group at 1 and 2 min following intubation (pmask airway group (15970.90 ± 3750 and 13936.76 ± 2729, respectively) were higher than those in the conventional laryngoscopy group (13237.61 ± 3413 and 11937.52 ± 3160, respectively) (pelevation between the groups. The maximum ST changes compared with baseline values were not significant between the groups (conventional laryngoscopy group: 0.328 mm versus intubating laryngeal mask airway group: 0.357 mm; p = 0.754). The number and type of airway complications were similar between the groups. The intense and repeated oropharyngeal and tracheal stimulation resulting from intubating laryngeal mask airway induces greater pressor responses than does stimulation resulting from conventional laryngoscopy in hypertensive patients. As ST changes and upper airway morbidity are similar between the two techniques, conventional laryngoscopy, which is rapid and safe to perform, may be preferred in hypertensive patients with normal airways.
Pietkiewicz, Piotr; Machała, Waldemar; Kuśmierczyk, Krzysztof; Miłoński, Jarosław; Wiśniewski, Tomasz; Urbaniak, Joanna; Olszewski, Jurek
The aim of the work was to assess early complications of Griggs percutaneous tracheotomy in the own material. The study covered 155 patients aged 17-88, including 36 women and 119 men. The patients were treated at the Department of Anaesthesiology and Intensive Therapy between 2006-2010. They underwent Griggs percutaneous tracheostomy by a laryngologist or a trained anaesthesiologist. Each surgical procedure was conducted with the use of Portex Blue Line Ultra Percutaneous Tracheotomy Kit (Smiths Medical Co., USA), the trachea was intubated while the patient was under general anaesthesia with propofol, fentanyl and relaxation with atracurium. The studied material revealed Griggs percutaneous tracheotomy complications in 26 patients (16.8%), in which 11 patients (7.1%) presented complications within the perioperative period while 15 patients (9.7%) reported early complications. Haemorrhage, usually not very profuse, occurred 7 times (4.6%), mainly in tracheopunction, and was the most often perioperative complication. Moreover, in the perioperative period, 3 patients (1.9%) had trachea identifications difficulties, which required tracheopunction many a time, and 1 patient (0.65%) encountered sudden circulatory arrest with asystolia and effective CPR. In the early postoperative period after Griggs percutaneous tracheotomy, the most common complication was haemorrhage in the operative twenty-four hours, which was noted in 10 patients (6.5%). Among other adverse complications were found: infection of the tissues near the tracheostomal region in 3 patients (1.9%), subcutaneous oedema in 1 patient (0.65%), accidental removing the tube from an unformed tracheostoma in 1 patient (0.65%). In the studied material, complications after Griggs percutaneous tracheotomy amounted to 16.8%, of which 7.1% occurred in the perioperative period while 9.7% were early complications, mainly light bleeding. This may prove good preparation of the surgical team for the surgical procedures
Full Text Available Purpose: Airtraq™ is an optical laryngoscope that allows viewing of the vocal cords without a direct line of sight. The main objective of this prospective, randomized, controlled trial was to evaluate Airtraq intubation characteristics, mainly intubation time and cardiovascular changes in the pediatric patients. Methods: Fifty children of American Society of Anesthesiologists class I, 2-10 years of age were divided into 2 groups using sealed envelope technique. Children were premedicated with midazolam. Anesthesia was induced with sevoflurane, fentanyl, and atracurium. Patients were randomly allocated to be intubated with either Airtraq (Airtraq group or Macintosh laryngoscope (Macintosh group. Intubation time, number of intubation attempts, optimization maneuvers, and ease of intubation were recorded. Hemodynamic variables were recorded before and after anesthetic induction, 1, 3, and 5 min after tracheal intubation. Results: The mean age of children was 6.1 years. Compared with Macintosh group, the use of Airtraq was associated with shorter intubation time (51.6±26.7 s vs 22.8±6.1 s, respectively, P=0.001, less median number of intubation attempts 2 (1-2 versus 1 (1-1, P=0.001, more ease of intubation [2 (1-3 versus 1 (1-1, P=0.001] and less increase in the heart rate 5 min after intubation (P=0.007. No optimization maneuvers required for Airtraq laryngoscope (P=0.001. Conclusion: Airtraq decreases intubation time, number of attempts, and optimization maneuvers, less heart rate changes during intubation compared with Macintosh laryngoscope.
Bhardwaj, Neerja; Yaddanapudi, Sandhya; Singh, Swati; Pandav, Surinder S
It is hypothesized that in children with glaucoma, the insertion of laryngeal mask airway (LMA) will cause lesser rise in intraocular pressure (IOP) than tracheal tube (TT). To compare the IOP response to LMA and TT insertion in children with glaucoma. A prospective, randomized, single-blind study was conducted in 30 glaucomatous ASA-1 children, aged 1-10 years scheduled to undergo trabeculectomy. Anesthesia was induced with halothane and maintained for 5 min with 1 MAC of halothane after administering atracurium 0.5 mg·kg(-1) following which LMA or TT was introduced. IOP was measured in both the eyes before and after insertion of airway device for 5 min. The IOP increased significantly from 27.3 ± 5.2 to 31.2 ± 5.4 mmHg (P insertion of LMA. The IOP was significantly higher in group TT compared to group LMA at 2 min (P = 0.004) and 5 min (P = 0.01) after the device insertion. The heart rate (HR) increased significantly after tracheal intubation and returned to baseline 4 min after intubation. The HR increase was significantly more in TT group compared to LMA group at all times of observation. Both systolic blood pressure (SBP; P = 0.01) and diastolic blood pressure (DBP; P = 0.02) showed an increase at 1 min in children in group TT. Insertion of LMA in glaucomatous children is not associated with an increased IOP response or cardiovascular changes. © 2011 Blackwell Publishing Ltd.
Jain, Divya; Ghai, Babita; Bala, Indu; Gandhi, Komal; Banerjee, Gargi
Studies that have compared and quantified the oropharyngeal leak pressure (OPLP) and adequacy of ventilation with supraglottic airway devices in different head and neck positions have been done in adult populations. The effects of head-neck position changes on the functioning of I-gel(™) in pediatric population still remain unevaluated. This study aimed to quantify the influence of different head and neck positions namely neutral, maximum flexion, and maximum extension on OPLP, ventilation scoring, and fiberoptic grading using I-gel(™) in anesthetized, paralyzed children. I-gel(™) was inserted in 30 paralyzed, anesthetized children scheduled for elective urological and orthopedic procedures. Anesthesia was induced with sevoflurane in oxygen. Atracurium was administered intravenously to facilitate neuromuscular relaxation. Recordings of OPLP in neutral, maximum flexion, and maximum extension were taken as primary outcome. Fiberoptic grading, insertion of ryle's tube and ventilation scoring were also measured in different head and neck positions as secondary outcomes. The OPLP was significantly higher in flexion (27.6 ± 3.3 cm H2 O, P = 0.000) and lower in extension (19.6 ± 3.2 cm H2 O, P = 0.006) in comparison to the neutral position (23.2 ± 3.2 cm H2 O). There was a worsening of the fiberoptic view in flexion compared to neutral position (0/5/19/6 vs 5/21/4/0). The ventilation score was poorer (1 [0-3], P flexion (15.2 ± 1.4 cm H2 O, P = 0.000) compared to the neutral position (10.4 ± 1.6 cm H2 O). Caution is warranted in pediatric patients while ventilating with I-gel(™) in extreme flexion of head and neck owing to poor ventilation despite increase in OPLP. © 2015 John Wiley & Sons Ltd.
Yuan, Lan; Tang, Wei; Wang, Jian; Fu, Guo-Qiang
To observe the protective effect of transcutaneous electrical acupoint stimulation (TEAS) on cerebral tissue in elderly hip replacement operation patients during general anesthesia under controlled hypotension. Forty hip replacement operation patients were randomly divided into general anesthesia (GA) control group and TEAS + GA group (n = 20 in each group). Patients of the two groups during operation were treated with controlled hypotension for reducing blood loss. TEAS (2 Hz/100 Hz, 8-12 mA) was applied to bilateral Yuyao (EX-HN 4) and Fengchi (GB 20) and began 30 min before GA. General anesthesia was performed by intravenous injection of Midazolam, Diprivan, Fentanyl and Cis-atracurium, sevoflurane-inhaling, Remifentanil, etc., and the patient's mean arterial pressure was maintained to be about 70% of the normal level (controlled hypotension) by using venous administration of Remifentanil about 10 min after the operation. GEM Premier 3000 blood gas analyzer was used to analyze levels of the arterial oxygen (CaO2), internal jugular venous oxygen (CjvO2), arterio-venous oxygen content difference (Da-jvO2) and cerebral oxygen (CERO2) uptake rates of blood samples before controlled hypotension (T0), 20 min after controlled hypotension (T ). 40 min after controlled hypotension (T2) and 20 min after the end of controlled hypotension (T3). Self-comparison of each group showed that in comparison with pre-controlled hypotension, CjvO2 levels at the time-points of T, T2 and T3 were significantly increased in both GA control and TEAS+GA groups (P control group (Pcontrol group(P 0.05). TEAS can reduce cerebral oxygen uptake rate in elderly patients undergoing hip replacement during controlled hypotension, suggesting a protective effect of TEAS on patient's cerebral tissue.
Videira, Rogerio L R; Vieira, Joaquim E
In anesthesia practice, inadequate antagonism of neuromuscular blocking drugs (NMBD) may lead to frequent prevalence of residual neuromuscular block that is associated with morbidity and death. In this study we analyzed the clinical decision on antagonizing NMBD to generate hypotheses about barriers to the introduction of experts' recommendations into clinical practice. Sequential surveys were conducted among 108 clinical anesthesiologists to elicit the rules of thumb (heuristics) that support their decisions and provide a measurement of the confidence the clinicians have in their own decisions in comparison with their peers' decisions. The 2 most frequently used heuristics for administering reversal were "the interval since the last NMBD dose was short" and "the breathing pattern is inadequate," chosen by 73% and 71% of the clinicians, respectively. Clinicians considered that the prevalence of clinically significant residual block is higher in their colleagues' practices than in their own practice (60% vs 16%, odds ratio=7.8, 95% confidence interval, 3.8 to 16.2, P=0.0001). The clinicians were less likely to use antagonists if >60 minutes had elapsed after a single dose of atracurium (0.5 mg/kg) (31%) in comparison with after rocuronium 0.6 mg/kg (53%) (P=0.0035). In our institution, the clinical decision to antagonize NMBD is mainly based on the pharmacological forecast and a qualitative judgment of the adequacy of the breathing pattern. Clinicians judge themselves as better skilled at avoiding residual block than they do their colleagues, making them overconfident in their capacity to estimate the duration of action of intermediate-acting NMBD. Awareness of these systematic errors related to clinical intuition may facilitate the adoption of experts' recommendations into clinical practice.
Sudré, Eliana C M; de Batista, Priscila R; Castiglia, Yara M M
We compared the effects of two anesthesia protocols in both immediate recovery time (IRT) and postoperative respiratory complications (PRCs) after laparotomy for bariatric surgery, and we determined the association between the longer IRT and the increase of PRC incidence. We conducted the study in two stages: (i) in a randomized controlled trial (RCT), patients received either intervention (sevoflurane-remifentanil-rocuronium-ropivacaine) or control protocol (isoflurane-sufentanil-atracurium-levobupivacaine). All patients received general anesthesia plus continuous epidural anesthesia and analgesia. Treatment was masked for all, except the provider anesthesiologist. We defined IRT as time since anesthetics discontinuation until tracheal extubation. Primary outcomes were IRT and PRCs incidence within 15 days after surgery. We also analyzed post-anesthesia care unit (PACU) and hospital length of stays; (ii) after the end of the RCT, we used the available data in an extension cohort study to investigate IRT > 20 min as exposure factor for PRCs. Control protocol (n = 152) resulted in longer IRT (30.4 ± 7.9 vs 18.2 ± 9.6 min; p protocol (n = 200); PRC relative risk (RR) = 2.6. Patients with IRT > 20 min (n = 190) presented higher incidence of PRCs (7.37 vs 0.62 %; p protocol, with short-acting anesthetics, was more beneficial and safe compared to control protocol, with long-acting drugs, regarding the reduction of IRT, PRCs, and PACU and hospital stays for laparotomy in bariatric patients. We identified a 4.5-fold increase in the relative risk of PRCs when morbid obese patients are exposed to an IRT > 20 min.
Effects of avoiding neuromuscular blocking agents during maintenance of anaesthesia on recovery characteristics in patients undergoing craniotomy for supratentorial lesions: A randomised controlled study
Ruchi A Jain
Full Text Available Background and Aims: Neuromuscular blocking agents have been one of the cornerstones of anaesthesia. With the advent of newer surgical, anaesthetic and neurological monitoring techniques, their utility in neuroanaesthesia practice seems dispensable. The aim of this prospective, comparative, randomised study was to determine whether neuromuscular blocking agents are required in patients undergoing supratentorial surgery when balanced anaesthesia with desflurane, dexmedetomidine and scalp block is used. Methods: Sixty patients with the American Society of Anesthesiologists physical status I or II, aged between 18 and 60 years were included in the study. All patients received anaesthesia including desflurane, dexmedetomidine and scalp block. The patients were randomly allocated to receive no neuromuscular blocking agent (Group A or atracurium infusion to keep train-of-four count 2 (Group B. The two groups were compared with respect to haemodynamic stability, brain relaxation scores and recovery characteristics. Haemodynamic parameters and time taken to achieve Aldrete score >9 and other secondary outcomes were analysed using Student's t-test. Non-parametric data were analysed using the Mann–Whitney test. Results: The mean arterial pressure was comparable between the groups. The intraoperative heart rate was comparable; however, in the post-operative period, it remained higher in Group B for 30 min after extubation (P = 0.02. The brain relaxation scores were comparable among the two groups (P = 0.27. Tracheal extubation time, time taken for orientation and time required to reach Aldrete score ≥9 were comparable among the two groups. Conclusion: The present study suggests that balanced anaesthesia using desflurane, dexmedetomidine and scalp block can preclude the use of neuromuscular blocking agents in patients undergoing supratentorial surgery under intense haemodynamic monitoring.
Full Text Available Background: In cataract surgery, the periorbital area is prepared anddraped after induction of general anesthesia and endotracheal intubation (ETI.For this purpose, the patient’s head and neck is usually flexed 30 to 45degrees. Neck flexion causes displacement of the endotracheal tube tip towardthe carina. Stimulation of the tracheal mucosa may cause bucking, increasedintraocular pressure (IOP, laryngospasm and/or bronchospasm, during lightanesthesia. Laryngeal constriction and all components of the tracheal responsemay affect end-tidal carbon dioxide pressure (PETCO2 and peripheral arterialhemoglobin oxygen saturation (SpaO2. Thus, in the current study, weinvestigated the influence of head and neck flexion on heart rate (HR, systolicand diastolic blood pressure (SAP and DAP, SpaO2, PETCO2, and IOP in patientsundergoing cataract surgery with endotracheal intubation during generalanesthesia.Patients and Methods: The present prospective study comprised patientsaged from 40 to 80 year with 106 American Society of Anesthesia (ASA physicalstatus I and II. Anesthesia was induced with thiopental sodium, lidocaine andfentanyl. Atracurium 0.5 mg/kg was administered to facilitate trachealintubation. HR, SAP, DAP, SpaO2, PETCO2, and IOP were measured at 1, 2, and 5minutes after head flexion.Results: Mean SAP, DAP, IOP, and HR was increased after ETI and headflexion compared with baseline values. PETCO2 and SpaO2 were decreased after ETIand at 1, 2 minutes after head flexion compared with baseline values.Conclusion: In patients undergoing cataract surgery during generalanesthesia, endotracheal tube movement caused changes in head and neck positionresulting in significant effects on heart rate, systolic and diastolic bloodpressures, laryngeal reflexes, SpaO2, PETCO2, and intraocular pressure.
Dawidowicz, A L; Fijałkowska, A; Nestorowicz, A; Kalityński, R; Trojanowski, T
The aim of this paper is to compare the propofol concentration in blood and cerebrospinal fluid (CSF) in patients scheduled for different neurosurgical procedures and anaesthetized using propofol as part of a total intravenous anaesthesia technique. Thirty-nine patients (ASA I-III) scheduled for elective intracranial procedures, were studied. Propofol was infused initially at 12 mg kg(-1) h(-1) and then reduced in steps to 9 and 6 mg kg(-1) h(-1). During anaesthesia, bolus doses of fentanyl and cis-atracurium were administered as necessary. After tracheal intubation the lungs were ventilated to achieve normocapnia with an oxygen-air mixture (FI(O(2))=0.33). Arterial blood and CSF samples for propofol examination were obtained simultaneously directly after intracranial drainage insertion and measured using high-performance liquid chromatography. The patients were divided into two groups depending on the type of neurosurgery. The Aneurysm group consisted of 13 patients who were surgically treated for ruptured intracranial aneurysm. The Tumour group was composed of 26 patients who were undergoing elective posterior fossa extra-axial tumour removal. Blood propofol concentrations in both groups did not differ significantly (P>0.05). The propofol concentration in CSF was 86.62 (SD 37.99) ng ml(-1) in the Aneurysm group and 50.81 (26.10) ng ml(-1) in the Tumour group (P<0.005). Intracranial pathology may influence CSF propofol concentration. However, the observed discrepancies may also result from quantitative differences in CSF composition and from restricted diffusion of the drug in the CSF.
Full Text Available The aim of this study was to evaluate the efficiency of lightwand-guided endotracheal intubation (LWEI performed using either the right (dominant or left (nondominant hand. Two hundred and forty patients aged 21–64 years, with a Mallampati airway classification grade of I—II and undergoing endotracheal intubation under general anesthesia, were enrolled in this randomized and controlled study. Induction of anesthesia was initiated by intravenous administration of fentanyl (2 mg/kg and thiopentone (5mg/kg, and tracheal intubation was facilitated by intravenous atracurium (0.5 mg/kg. In the direct-vision laryngoscope group (group D; n = 80, the intubator held the laryngoscope in the left hand and inserted the endotracheal tube (ETT into the glottic opening with the right hand. In the group in which LWEI was performed with the right hand (group R; n = 80, the intubator lifted the patients' jaws with the left hand and inserted the ETT-LW unit into the glottic openings with the right hand. On the contrary, in the group in which LWEI was performed with the left hand (group L; n = 80, the intubator lifted the jaws with the right hand and inserted the ETT-LW unit with the left hand. Data including total intubation time, the number of intubation attempts, hemodynamic changes during intubation, and side effects following intubation, were collected. Regardless of whether lightwand manipulation was performed with the left hand (group L; 11.4 ± 9.3 s or the right-hand (group R; 12.4 ± 9.2 s, less time was consumed in the LWEI groups than in the laryngoscope group (group D; 17.9 ± 9.9s (p 95% on their first intubation attempts. The changes in mean arterial blood pressure and heart rate were similar among the three groups. A higher incidence of intubation-related oral injury and ventricular premature contractions (VPC was found in group D compared with groups L and R (oral injury: group D 8.5%, group L 1.3%, group R 0%, p = 0.005; VPC: group D 16
Elif Bengi Sener
Full Text Available OBJECTIVES: We compared hemodynamic responses and upper airway morbidity following tracheal intubation via conventional laryngoscopy or intubating laryngeal mask airway in hypertensive patients. METHODS: Forty-two hypertensive patients received a conventional laryngoscopy or were intubated with a intubating laryngeal mask airway. Anesthesia was induced with propofol, fentanyl, and cis-atracurium. Measurements of systolic and diastolic blood pressures, heart rate, rate pressure product, and ST segment changes were made at baseline, preintubation, and every minute for the first 5 min following intubation. The number of intubation attempts, the duration of intubation, and airway complications were recorded. RESULTS: The intubation time was shorter in the conventional laryngoscopy group than in the intubating laryngeal mask airway group (16.33 ± 10.8 vs. 43.04±19.8 s, respectively (p<0.001. The systolic and diastolic blood pressures in the intubating laryngeal mask airway group were higher than those in the conventional laryngoscopy group at 1 and 2 min following intubation (p<0.05. The rate pressure product values (heart rate x systolic blood pressure at 1 and 2 min following intubation in the intubating laryngeal mask airway group (15970.90 ± 3750 and 13936.76 ± 2729, respectively were higher than those in the conventional laryngoscopy group (13237.61 ± 3413 and 11937.52 ± 3160, respectively (p<0.05. There were no differences in ST depression or elevation between the groups. The maximum ST changes compared with baseline values were not significant between the groups (conventional laryngoscopy group: 0.328 mm versus intubating laryngeal mask airway group: 0.357 mm; p = 0.754. The number and type of airway complications were similar between the groups. CONCLUSION: The intense and repeated oropharyngeal and tracheal stimulation resulting from intubating laryngeal mask airway induces greater pressor responses than does stimulation resulting from
Joel Massari Rezende
inducida con propofol (140 mg, fentanil (350 µg, atracúrio (30 mg y mantenida con isoflurano, dos dosis subsecuentes en bolus de atracúrio (10 mg cada y ventilación controlada mecánica. En el final de la cirugía, después de antagonización del bloqueo neuromuscular, la paciente fue extubada, obedeció a los comandos para respirar y colaboró en el pasaje a la maca, siendo transportada para la SRPA, donde llegó consciente. Minutos después presentó apnea, cianosis e inconsciencia. Fue realizada ventilación manual con oxígeno a 100% seguida de inyección de naloxona (0,2 mg por vía venosa, habiendo retorno de la ventilación espontanea y de la consciencia. CONCLUSIONES: Los cuidados ventilatorios en el pós-operatorio, durante el transporte, admisión a la SRPA, y permanencia en esa unidad, deben ser continuos en pacientes que recibieron opioides, mismo demostrando estar conscientes al dejar la sala quirúrgica.BACKGROUND AND OBJECTIVES: Respiratory depression is a postoperative complication which may occur when opioids are employed in anesthesia. This report aimed at discussing a case of apnea in a conscious patient admitted to the post anesthetic recovery room, after thyroidectomy under general anesthesia with propofol, fentanyl and isoflurane. CASE REPORT: Female patient, 50 years old, 60 kg, physical status ASA I, submitted to thyroidectomy under general anesthesia induced with propofol (140 mg, fentanyl (350 µg and atracurium (30 mg, and maintained with isoflurane, two subsequent atracurium boluses (10 mg each and mechanically controlled ventilation. At surgery completion and after neuromuscular block recovery, patient was extubated, responded to breathing commands and cooperated during transfer to the stretcher, being taken to the PACU, where she arrived fully conscious. Minutes after, she was apneic, cyanotic and unresponsive. Manual ventilation was installed with 100% oxygen, followed by intravenous naloxone (0,2 mg and patient recovered spontaneous
Anestesia em paciente portadora de doença de moyamoya: relato de caso Anestesia en paciente portadora de enfermedad de moyamoya: relato de caso Anesthesia in patient with moyamoya disease: case report
Adriano Bechara de Souza Hobaika
, la paciente fue mantenida en normocapnia y normotermia. La extubación fue realizada y la paciente transferida a la sala de recuperación pos-anestésica sin complicaciones. CONCLUSIONES: Este artículo presenta los cuidados anestésicos dados a una paciente portadora de la enfermedad de moyamoya.BACKGROUND AND OBJECTIVES: Moyamoya disease is an uncommon progressive cerebral vasculopathy, more frequently diagnosed among Asian individuals, but which has also been described in Brazil. Moyamoya patients may be submitted to different surgical procedures throughout their lives. Anesthesiologists must understand the pathophysiology of the disease and institute adequate perioperative measures to improve patients' prognosis. CASE REPORT: Female patient, 22 yr-old, chronic renal failure, with moyamoya disease, scheduled for surgical arterial-venous fistula installation. Anesthesia was induced with fentanyl, propofol and atracurium and maintained with sevoflurane. Patient was maintained in normocapnia and normothermia throughout the procedure. Patient was extubated and transferred to the post-anesthetic care unit without complications. CONCLUSIONS: This article describes the anaesthetic care of a moyamoya disease patient.
anhydrase) for a two-faced inhibitor, which allowed stimuli responsive regulation of enzymatic activity. These results prompted us to examine the use of CB[n]-type receptors in both in vitro and in vivo biological systems. We demonstrated that adamantaneammonium ion can be used to intracellularly sequester CB from gold nanoparticles passivated with hexanediammonium ion·CB complexes and thereby trigger cytotoxicity. CB derivatives bearing a biotin targeting group enhance the cytotoxicity of encapsulated oxaliplatin toward L1210FR cells. Finally, acyclic CB[n]-type receptors function as solubilizing excipients for insoluble drugs for drug delivery purposes and as a broad spectrum reversal agent for the neuromuscular blocking agents rocuronium, vecuronium, and cis-atracurium in rats. The work highlights the great potential for integration of CB[n]-type receptors with biological systems. PMID:24785941
Fabiano Timbó Barbosa
forma segura sin el aparecimiento de toxicidad desde que sean evitados los factores que puedan llevar a la diminución de la actividad de la glicuroniltransferasis.BACKGROUND AND OBJECTIVES: Gilbert's syndrome is a chronic benign disease leading to recurrent jaundice and major unconjugated bilirubin increase that may be toxic after the use of routine medication. This report aimed at describing the anesthetic approach in Gilbert's syndrome patient submitted to videolaparoscopic surgery. CASE REPORT: Female patient, 22 years old with Gilbert's syndrome, submitted to videolaparoscopic surgery under general anesthesia with propofol, alfentanil, succinylcholine, atracurium and isoflurane. There were no evidences of toxicity during anesthesia. Postoperative recovery was satisfactory and patient was discharged three days later. CONCLUSIONS: Gilbert's syndrome patients may be safely submitted to general anesthesia without toxicity, provided factors leading to glucuronosyltransferase activity decrease are avoided.
Maria Cristina Simões de Almeida
BNM. Las complicaciones más apuntadas fueron el bloqueo prolongado, el broncoespasmo grave y la curarización residual. CONCLUSIONES: El atracúrio es el bloqueador neuromuscular más empleado en Brasil, hay alto percentual del uso de la succinilcolina en situaciones no emergenciales, el uso de monitores de la transmisión neuromuscular es raro, y, como un corolario, un percentual significativo de uso de criterios eminentemente clínicos para considerar el paciente descurarizado. Se registró que, cerca del 30% de los anestesiologistas tuvo algún tipo de complicación consecuente del uso de eses fármacos.BACKGROUND AND OBJECTIVES: There are no statistical data on the use of neuromuscular blockers in Brazil. This study aimed at statistically analyzing this topic. METHODS: Our study has compiled 831 answers to a questionnaire filled by anesthesiologists attending the 48th Brazilian Congress of Anesthesiology in Recife, 2001, and via Internet by anesthesiologists whose e-mail addresses are in the Brazilian Society of Anesthesiology web page (www.sba.com.br. The following data were evaluated: years of experience with the specialty, region where anesthesiologists practice, neuromuscular blockers (NMB usage in order of preference, indications for succinylcholine, neuromuscular transmission monitor usage, blockade recovery criteria, neostigmine usage, NMB administration routes and description of observed complications. RESULTS: Most anesthesiologists practice for more than 11 years and the highest number of answers have come from the Southeastern region of Brazil. Most common NMB is atracurium, followed by pancuronium and succinylcholine. Succinylcholine is more frequently used for rapid sequence induction and in children (80% and 25%, respectively. Neuromuscular transmission monitors are never used by 53% of anesthesiologists, and 92% of them use clinical signs as blockade recovery criteria. Neostigmine is routinely used by 45% of professionals and 94% of them administer
Remifentanil associado ao propofol ou sevoflurano para colecistectomia videolaparoscópica: estudo comparativo Remifentanil asociado al propofol o sevoflurano para colecistectomia videolaparoscópica Remifentanil associated to propofol or sevoflurane for videolaparoscopic cholecystectomy: a comparative study
Fernanda Fischer Estivalet
medidas en los siguientes momentos: M1, antes de la inducción anestésica; M2, 1 minuto antes de la IOT; M3, 1 minuto después IOT; M4, 5 minutos después IOT; M5, 5 minutos después de la incisión quirúrgica; M6 y M7,10 y 30 minutos, respectivamente, después el pneumoperitonio. Después del término del procedimiento fueron analizados los tiempos, en minutos, para abertura ocular, ventilación espontanea, extubación, hablar el nombre completo y el aprieto de la mano del anestesiologista, sobre comando. También fueron estudiada la frecuencia del uso de atropina y efedrina y la ocurrencia de náuseas, vómitos y dolor. RESULTADOS: Las alteraciones hemodinámicas (PAS, PAD, PAM y FC y el despertar de los pacientes no tuvieron diferencias significativas entre los grupos. El uso de efedrina y atropina fueron semejantes. Entre las complicaciones solamente los vómitos tuvieron mayor incidencia en el Grupo 2. CONCLUSIONES: Ambas técnicas promovieron diminución de la presión arterial y de la frecuencia cardíaca. La recuperación anestésica es semejante para las dos técnicas. La incidencia de vómitos es mayor cuando el remifentanil fue asociado al sevoflurano.BACKGROUND AND OBJECTIVES: Different intravenous, inhalational or combined anesthetic techniques have been used for videolaparoscopic cholecystectomy. This study aimed at comparing hemodynamic parameters, anesthetic recovery and side-effects of remifentanil associated to propofol or sevoflurane. METHODS: Participated in this study 40 patients, who were divided in two groups: Group 1 (G1 - induced with 3 µg.ml-1 propofol and a 0.3 µg.kg-1.min-1 remifentanil infusion. Atracurium (0.5 mg.kg-1 was administered for tracheal intubation. Anesthesia was maintained with 2.5 to 3 µg.ml-1 propofol in target controlled infusion and 100% oxygen, and remifentanil by continuous infusion (0.3 µg.kg-1.min-1; Group 2 (G2 - induced with 6% sevoflurane and 100% oxygen at a 4 L.min-1 flow and a 0.3 µg.kg-1.min-1 remifentanil
Avaliação do efeito antinociceptivo do fentanil transdérmico no controle da dor lombar pós-operatória Evaluación del efecto antinociceptivo del fentanil transdérmico en el control del dolor lumbar postoperatorio Efficacy of fentanyl transdermal delivery system for acute postoperative pain after posterior laminectomy
Gabriela Rocha Lauretti
ía posterior sobre anestesia general estandarizada. Los adhesivos transdérmicos fueron colocados en los pacientes diez horas antes del inicio de la cirugía y removidos 24 horas después de haber terminado la misma. Cetoprofeno por vía venosa fue administrado por vía venosa en el inicio de la cirugía. Dipirona estaba disponible para analgesia de rescate, si era necesario, a intervalos mínimos de seis horas. RESULTADOS: los pacientes que recibieron F transdérmico presentaron reducción de 60% en el consumo de dipirona en el periodo postoperatorio (pObjectives: patients who are submitted to posterior laminectomy often complain of severe pain that is difficult to treat. The transdermal application of the potent opioid fentanyl results in its continuous liberation and consequently could be useful in controlling the pain. This study evaluated the efficacy of transdermal fentanyl (F delivery system for acute postoperative pain after posterior laminectomy. METHODS: the study was approved by the local Ethic Committee and conducted in the Teaching Hospital. After the patient's consent, 24 patients were randomized to either transdermic F 25 mg/h (n=12 or transdermic placebo (n=12. All patients were submitted to posterior laminectomy under a standard general anesthesia. Transdermic systems were placed during 10 hours preoperatively and removed 24 hours later; 20 minute IV ketoprofen, 2.5 mg/kg was administered following traqueal intubation with propofol, alfentanil and atracurium. IV 20 mg/kg dipyrone act as rescue at a minimum six hours interval. Data was recorded for 36 hours. RESULTS: the transdermic F Group showed 60% of reduction in the rescue dipyrone consumption (p<0.05; and displayed lesser VAS scores after the 12th hour, which was maintained until the 36th hour (p<0.02. All physiological parameters fluctuated within normal range and no differences were observed between the treatments. The incidence of adverse events was similar between the groups, there was local erythema
Anestesia em paciente portadora de síndrome de Mckusick-Kaufman: relato de caso Anestesia en paciente portadora de síndrome de Mckusick-Kaufman: relato de caso Anesthesia in Mckusick-Kaufman syndrome patient: case report
Adriano Bechara de Souza Hobaika
índrome. RELATO DEL CASO: Paciente del sexo femenino de 11 años, 37 kg, portadora del síndrome de Mckusick-Kaufman, insuficiencia renal crónica, encefalopatia hipertensiva y asma grave sometida a la retirada de catéter peritoneal infectado y a una confección de fístula arteriovenosa. Historia anterior de intubación prolongada. La anestesia fue inducida con alfentanil (1 mg, propofol (50 mg y atracúrio (25 mg y mantenida con sevoflurano (2% a 4% y dosis fraccionadas de alfentanil. La tráquea fue intubada sin complicaciones y la extubación fue realizada en la sala de cirugía después del retorno satisfactorio de la función neuromuscular. CONCLUSIONES: A pesar que el síndrome de Mckusick-Kaufman se trate de una asociación variable de defectos congénitos, algunas atenciones anestésicas comunes pueden ser definidas. Este caso presentó factores complicadores de la anestesia y la inducción con propofol y alfentanil y el mantenimiento con sevoflurano proporcionaron a la paciente una anestesia con mínimas repercusiones ventilatorias y hemodinámicas.BACKGROUND AND OBJECTIVES: Mckusick-Kaufman syndrome is an uncommon disease, typically characterized by hydrometrocolpos, polydactyly and congenital heart defects. These patients are often submitted to different surgical procedures throughout their lives and the anesthesiologist must be prepared to deal with possible complications. This article aimed at reporting the anesthetic management adopted for a patient with this syndrome. CASE REPORT: A 11-year-old, 37 kg, female with Mckusick-Kaufman syndrome, chronic renal failure, hypertensive encephalopathy and severe asthma was scheduled for surgical arterial-venous fistula preparation and removal of infected peritoneal dialysis catheter. Previous prolonged tracheal intubation was reported. Anesthesia was induced with alfentanil (1 mg, propofol (50 mg and atracurium (25 mg and was maintained with inhalational sevoflurane (2% to 4% and intermittent IV alfentanil doses. Trachea
Efeito da anestesia geral na cognição e na memória do idoso Efecto de la anestesia general en la cognición y memoria del paciente de edad avanzada Effects of general anesthesia in elderly patients’ memory and cognition
Régis Borges Aquino
en el post operatorio de paciente com edad 60 a 80 años de ambos los sexos, sometidos a la anestesia general con duración de 3 a 7 horas.BACKGROUND AND OBJECTIVES: General anesthesia and mental function have been subject to studies and considerations, especially for the feeling that, especially in the elderly, it could induce changes in cognition and memory. This study aimed at evaluating the effects of general anesthesia in cognition and memory of elderly patients, correlating them to gender, age and anesthesia duration. METHODS: This is a cohort, controlled study with patients divided in two observation groups: a - anesthetic; b - clinical (control. Outcome variables studied were Mini-mental test, Verbal Fluency test and Numeric Remembrance test scores; general anesthesia with halothane, isoflurane, sevoflurane, thiopental, propofol, etomidate, fentanyl, alfentanil, succinylcholine, atracurium and pancuronium; intraoperative period with PaCO2 30 to 45 mmHg, hemoglobin saturation above 90% and blood pressure tolerance with up to 20% decrease as compared to baseline. Patients presenting any intra and postoperative adverse event were excluded from the study. Chi-square test was used for categorical data. Student’s t test for independent samples was used for initial comparison between groups at baseline moment (preanesthetic. Analysis of variance (ANOVA for repeated measures was used to evaluate anesthetic process effects along time. RESULTS: Groups were similar in the Mini-Mental test with increased scores along time. Both groups had virtually unchanged Verbal Fluency test scores. Both groups were very similar in Numeric Remembrance test with increased scores in both groups. CONCLUSIONS: No postoperative cognition or memory decline has been observed in patients of both genders, aged 60 to 80 years, submitted to general anesthesia lasting 3 to 7 hours.
Anestesia em paciente obstétrica portadora de anemia falciforme e traço talassêmico após plasmaféresis: relato de caso Anesthesia in obstetric patient with sickle cell anemia and thalassemic trait after plasmapheresis: case report
Eduardo Barbosa Leão
encaminada a la UTI, bajo intubación orotraqueal, y en uso de drogas vasoactivas, habiendo sido extubada después de 3 horas. CONCLUSIONES: Este caso se mostró un desafío para el equipo, ya que la paciente presentaba inestabilidad hemodinámica y alteración del coagulograma, condiciones que contraindican la anestesia regional, además de esto, la plasmaféresis potencialmente depleta las existencias de colinesterasas plasmáticas, lo que interfiere en la anestesia. Mientras, el arsenal medicamentoso disponible, permitió el manoseo seguro de esta situación.BACKGROUND AND OBJECTIVES: Plasmapheresis is the technique of choice for severe hemolytic anemia patients. A consequence is plasma cholinesterase depletion, which interferes with metabolism of some neuromuscular blockers currently used in anesthesiology. CASE REPORT: Pregnant patient, 26 years old, physical status ASA IV, 30 weeks and 3 days gestational age, with sickle cell anemia, thalassemic trait and allo-immunization for high frequency antigens. Patient presented sickling crisis being transfused with incompatible blood. Patient evolved with massive hemolysis being admitted with 3 g/dL hemoglobin and 10% hematocrit, severe jaundice, tachycardia, apathic and pale. Hematological evaluation has concluded for the inexistence of compatible blood for transfusion. Patient was treated with steroids, immunoglobulins and plasmapheresis. In the second admission day patient evolved with acute renal failure and pulmonary edema, general state worsening and hemodynamic instability. Gestation resolution was indicated due to patient's clinical conditions and consequent acute fetal suffering. Patient was admitted to the operating room conscious, pale, with dyspnea, jaundice, 91% SpO2 in room air, heart rate of 110 bpm and blood pressure of 110 x 70 mmHg, under dopamine (1 µg.kg-1.min-1 and dobutamine (10 µg.kg-1.min-1. We decided for balanced general anesthesia with alfentanil (2.5 mg, etomidate (14 mg, atracurium (35 mg and
Anestesia para septoplastia e turbinectomia em paciente portador de doença de von Willebrand: relato de caso Anestesia para septoplastia y turbinectomia en paciente portador de enfermedad de von Willebrand: relato de caso Anesthesia for septoplasty and turbinectomy in von Willebrand disease patient: case report
Múcio Paranhos de Abreu
OBJECTIVES: Although von Willebrand’s disease is the most common hereditary hemorrhagic disorder, there are few reports in Brazilian literature relating this disease to anesthesia. This report aimed at describing a case of general anesthesia for septoplasty and turbinectomy in a von Willebrand’s disease type I patient, prophylactically treated with desmopressin (1-deamine-8-D- arginine vasopressin, DDAVP in the pre and postoperative period. CASE REPORT: A female patient, 19 years old, 58 kg, with hypothyroidism controlled with L-tiroxine (75 mg had her von Willebrand’s disease manifested three years before after a wisdom tooth extraction with persistent bleeding in the postoperative period. To prevent new per and postoperative hemorrhagic episodes, patient was prophylactically treated with desmopressin (0.3 µg.kg-1. Anesthesia was induced with midazolam (2.5 mg, fentanyl (150 µg, droperidol (2.5 mg, lidocaine (60 mg, atracurium (30 mg and metoprolol (4 mg, followed by tracheal intubation and ventilation under intermittent positive pressure. Anesthesia was maintained with 2% sevoflurane in a mixture of 50% oxygen and nitrous oxide. This technique provided a good heart rate and blood pressure control during surgery. Patient remained with a nasal tampon for 24 hours and no bleeding was observed at its removal. Patient was discharged the day after surgery uneventfully. There were no immediate or late postoperative bleeding. CONCLUSIONS: The prophylactic treatment with DDAVP associated to the anesthetic technique used in this case was effective in controlling peri and postoperative bleeding.
Instabilidade hemodinâmica grave durante o uso de isoflurano em paciente portador de escoliose idiopática: relato de caso Severe hemodynamic instability during the use of isoflurane in a patient with idiopathic scoliosis: case report
Adriano Bechara de Souza Hobaika
ámica grave causada por isoflurano en pacientes previamente saludables. Anafilaxia, taquicardia supraventricular con repercusión hemodinámica y sensibilidad cardiaca aumentada al isoflurano son discutidas como posibles causas de la inestabilidad hemodinámica. Actualmente, existen evidencias de que el isoflurano pude interferir en el sistema de acoplamiento y desacoplamiento de la contratilidad miocárdica a través de la reducción del Ca2+ citosólico y/o deprimiendo la función de las proteínas contráctiles. Los mecanismos moleculares fundamentales de este proceso deben ser elucidados todavía. El relato sugiere que la administración del isoflurano fue la causa de las alteraciones hemodinámicas presentadas por el paciente y que este, probablemente, presentó una sensibilidad cardiovascular no común al fármaco.BACKGROUND AND OBJECTIVES: Isoflurane is considered a safe inhalational anesthetic. It has a low level of biotransformation, and low hepatic and renal toxicity. In clinical concentrations, it has minimal negative inotropic effect, causes a small reduction in systemic vascular resistance, and, rarely, can cause cardiac arrhythmias. The objective of this report was to present a case of severe hemodynamic instability in a patient with idiopathic scoliosis. CASE REPORT: Male patient, 13 years old, ASA physical status I, with no prior history of allergy to medications, scheduled for surgical repair of idiopathic scoliosis. After anesthetic induction with fentanyl, midazolam, propofol, and atracurium, 1% isoflurane with 100% oxygen was initiated for anesthesia maintenance. After five minutes, the patient presented severe hypotension (MAP = 26 mmHg associated with sinus tachycardia (HR = 166 bpm that did not respond to the administration of vasopressors and fluids. Lung and heart auscultation, pulse oxymetry, capnography, nasopharyngeal temperature, and arterial blood gases did not change. The patient was treated for anaphylaxis and the surgery was cancelled. The
Eficácia do propofol e da associação de propofol e dexametasona no controle de náusea e vômito no pós-operatório de laparoscopia ginecológica Eficacia del propofol y de la asociación de propofol y dexametasona en el control de náusea y vómito en el pós-operatorio de laparoscopia ginecológica Efficacy of propofol and propofol plus dexamethasone in controlling postoperative nausea and vomiting of gynecologic laparoscopy
Eliana Marisa Ganem
patients submitted to gynecological laparoscopy. METHODS: Forty female patients, physical status ASA I and II, aged 18 to 46 years, with no previous gastric complaint, undergoing diagnostic or surgical laparoscopy were randomly distri- buted in 2 groups: Group 1 - patients were given 2 ml IV saline solution, while Group 2 was given intravenous dexamethasone (8 mg, before anesthetic induction. All patients were premedicated with oral midazolam (7.5 mg and induced with sufentanil (0.5 µg.kg-1 and propofol targed controlled infusion (BIS 60, with N2O/O2 (F I O2=0.4 for maintenance. Neuromuscular block was obtained with atracurium (0.5 mg.kg-1. Postoperative analgesia consisted of ketoprofen (100 mg and butyl-eschopolamine plus dipirone. Patients were evaluated in the PACU and in the ward after 1, 2, 3 and 12 hours after PACU discharge. RESULTS: Both groups were identical regarding demographics data as well as surgery and anesthesia duration. One Group 1 patient referred nausea in postanesthetic care unit and in the ward, and 3 patients referred vomiting in the ward. In Group 2, no patient referred nausea and vomiting, but the difference was not statistically significant. CONCLUSIONS: Propofol or propofol plus dexamethasone were efficient in preventing PONV in patients submitted to gynecological laparoscopy.
Manuseio de grave diminuição de hemoglobina em paciente jovem, testemunha de Jeová, submetido à proctocolectomia total: relato de caso Manoseo de grave disminución de hemoglobina en paciente joven, testigo de Jehová, sometido a la proctocolectomia total: relato de caso Extreme intraoperative hemodilution in Jehovah’s witness patient submitted total proctocolectomy: case report
Luiz Eduardo Imbelloni
family history of adenomatous polyposis. The disease was manifested at eight years of age, characterized by bleeding. At 13 years of age he was submitted to total colectomy. At 17 years of age he was submitted to total proctocolectomy. Patient was prepared with erythropoietin, folic acid, infusion of iron and vitamin B12. Red blood cell count revealed He = 4,200,000/mm³, hemoglobin = 10.5 g/dL, hematocrit = 37% platelets = 273,000/mm³ and normal prothrombin time. Patient was continuously monitored with NIBP, pulse oximetry, capnography and ECG. Anesthesia was induced with propofol, sufentanil, pancuronium and enflurane in closed system. Patient received 7,000 mL lactated Ringer’s and 150 mL of 20% human albumin. Total diuresis was 2,900 mL. Surgery lasted 10 hours and 30 minutes. Patient was referred to the ICU with 20% hematocrit, 2,300,000/mm³ red cells, 4,2 g/dL hemoglobin and was maintained with propofol and atracurium. Next day evaluation revealed 18% hematocrit, 2,050,000/mm³ red cells and 4 g/dL hemoglobin. Patient was extubated 18 hours after surgery and was referred to the ward. Patient started eating four days after surgery and was discharged the 10th postoperative day. Thirty days later patient presented 35% hematocrit, 4,000,000/mm³ red cells and 9.5 g/dL hemoglobin. Six months later he returned for ileostomy closing. Patient was submitted to 12 surgeries without a single blood transfusion. CONCLUSIONS: A good planning of the whole team (clinician, surgeon, anesthesiologist, intensive care staff allows us to perform surgical procedures associated to major blood losses without administering blood.
Estudo comparativo entre anestesia peridural torácica e anestesia geral em mastectomia oncológica Estudio comparativo entre la anestesia epidural torácica y la anestesia general en mastectomia oncológica Comparative study between thoracic epidural block and general anesthesia for oncologic mastectomy
Sérgio D. Belzarena
esthetic breast surgeries but reports of its use in mastectomies with axillary exploration are very rare. The present study compared this technique with general anesthesia in oncologic surgeries of the breasts. METHODS: Forty patients were divided in two groups. The epidural group (n = 20 underwent epidural thoracic block with bupivacaine and fentanyl associated with sedation with midazolam. The other group (n = 20 underwent conventional general anesthesia with propofol, atracurium, and fentanyl, and maintenance with O2 and isoflurane. Duration of the surgery, the need for intraoperative complementation of anesthesia or sedation, and intraoperative hemodynamic parameters were recorded. In the postoperative period, length of time until discharge from the recovery room and from the hospital, severity of pain, analgesic consumption, adverse effects, and satisfaction with the anesthetic techniques were recorded. RESULTS: Both groups were similar and differences in the duration of the surgery were not observed. Complementary sedation was necessary in 100% of the patients who underwent epidural block and complementary sedation with infiltration of local anesthetic in the axilla in 15% of the patients in this group. The rate of hypertension was more frequent in the group of patients who underwent general anesthesia, while hypotension was more frequent in the epidural group. Pruritus was observed in 55% of the patients in the epidural group. Nausea (30% and vomiting (45% were more frequent in the general anesthesia group. The quality of postoperative analgesia was better in the epidural group, which also presented lower consumption of analgesics; the length hospitalization in this group was also lower. CONCLUSIONS: Epidural block has some advantages when compared with general anesthesia and can be considered an anesthesia option in oncologic mastectomies with axillary lymph node dissection.
Anestesia para implante de marca-passo em paciente adulto com ventrículo único não-operado: relato de caso Anestesia para implante de marcapaso en paciente adulto con ventrículo único no operado: relato de caso Anesthesia for pacemaker implant in an adult patient with unoperated univentricular heart: case report
Adriano Bechara de Souza Hobaika
were reported in the literature. The aim of this report was to describe the anesthetic conduct in a patient with univentricular heart undergoing pacemaker implant. CASE REPORT: A female patient, 47 years old, with double outlet left ventricle, L-transposition of the great vessels, and pulmonary stenosis, without prior surgical correction, was scheduled for definitive implant of a sequential dual-chamber pacemaker. The ABPM demonstrated second degree atrioventricular block and a mean heart rate of 45 bpm. Preoperative exams showed a hematocrit of 57%, normal coagulation studies, and preserved ventricular function. Monitoring consisted of pulse oxymeter, ECG on D II and V5, IBP, capnograph, and gas analyzer. A temporary transcutaneous pacemaker was available in case of severe bradycardia. Anesthesia was induced with fentanyl (0.25 mg, etomidate (20 mg, and atracurium (35 mg. Four minutes after anesthetic induction, the heart rate decreased to 30 bmp and 1 mg of atropine was administered with reversal of the bradycardia. Anesthesia was maintained with 2.5% sevoflurane, 60% room air, and 40% oxygen. Hemodynamic parameters and oxygen saturation remained stable. The patient was transferred to the intensive care unit in stable condition and extubated at the end of the procedure. CONCLUSIONS: The anesthetic conduct for pacemaker implant in a 47-year old patient with non-operated double outlet left ventricle and pulmonary stenosis was appropriate, since it allowed the procedure to be performed.
Dexmedetomidina como droga adjuvante no despertar transitório no intra-operatório de correção cirúrgica de escoliose: relato de caso Dexmedetomidina como droga adyuvante en el despertar transitorio en el intra-operatorio de corrección quirúrgica de escoliosis: relato de caso Dexmedetomidine as adjuvant drug for wake-up test during scoliosis correction surgery: case report
infusión alvo-controlada. En el momento del test para movimentación de los miembros inferiores, fueron interrumpidas las infusiones de propofol y remifentanil, manteniendo la dexmedetomidina. Con la superficialización del plano anestésico, la paciente se encargó de la ventilación espontanea y después de 14 minutos de la interrupción de las drogas, sobre comando verbal, movimentó los miembros inferiores. Durante este procedimiento, la paciente permaneció en la parte 3 de sedación de Ramsay, esto es, bajo analgesia, respirando espontáneamente y tranquila. CONCLUSIONES: La dexmedetomidina asociada a la anestesia venosa total se mostró una opción interesante, como droga coadyuvante en el test de despertar, bien como para el propósito de analgesia y sedación en el período perioperatorio.BACKGROUND AND OBJECTIVES: Scoliosis is a spinal defect very often requiring surgical correction. A uniqueness of this correction is the need for intraoperative emergence and leg movement (wake up test to rule out central nervous system (CNS injury after correction of the orthopedic defect. In our report, dexmedetomidine was associated to total intravenous anesthesia with propofol and remifentanil to induce sedation, analgesia and ventilatory stability during wake up test in patient submitted to surgical scoliosis correction. CASE REPORT: Caucasian, female patient, 16 years old, physical status ASA I, with lumbar and thoracic scoliosis in 12 levels, submitted to surgery under general anesthesia. Patient was premedicated with 2 mg oral lorazepam the day before and 90 minutes before surgery. Venoclysis and left arm radial artery puncture were performed after monitoring; right subclavian vein was punctured with double lumen catheter for drug infusion and hemodynamic evaluation. Anesthesia was induced with 1 µg.kg-1 remifentanil and propofol in target-controlled infusion, for 3 µg.mL-1 plasma concentration. Neuromuscular block was achieved with 0.5 mg.kg-1 atracurium. Anesthesia