Anestesia regional y periférica guiada por ultrasonido en el paciente critico

El presente trabajo es un capítulo de libro titulado “Anestesia Regional y Periférica Guiada por Ultrasonido en el Paciente Crítico” que será incluido en la última edición del libro “Manual de Ultrasonido en Terapia Intensiva y Emergencias” cuyo editor es el Doctor José de Jesús Rincón Salas y que será publicado por la Editorial Prado de México para distribución latinoamericana desde dicho país. Por solicitud del editor y teniendo en cuenta el enfoque del libro, el presente trabajo está dirigido a estudiantes de formación, médicos graduados y especialistas en las áreas de cuidado intensivo, anestesiología, dolor, medicina interna y medicina de urgencias. Tiene como propósito empapar de conocimientos necesarios y prácticos en anestesia regional a personas que usualmente no han tenido contacto con la anestesia regional, pues desafortunadamente sólo en los últimos años ha sido posible que la anestesia regional haya comenzado a salir de las salas de cirugía, ámbito donde ha estado confinada tradicionalmente. El lenguaje utilizado es sencillo y el capítulo ha sido escrito para que sea fácil de leer y consultar, dejando así mensajes muy claros sobre la utilidad, viabilidad e implicaciones que tiene el uso de anestesia regional guiada por ultrasonido en cuidado intensivo. Los autores esperamos que de esta manera, el presente capítulo permita continuar superando los obstáculos que se interponen entre los invaluables beneficios de la anestesia regional y los pacientes de cuidado intensivo que necesitan de ella.

Metabifurcation analysis of a mean field model of the cortex

Mean field models (MFMs) of cortical tissue incorporate salient, average features of neural masses in order to model activity at the population level, thereby linking microscopic physiology to macroscopic observations, e.g., with the electroencephalogram (EEG). One of the common aspects of MFM descriptions is the presence of a high-dimensional parameter space capturing neurobiological attributes deemed relevant to the brain dynamics of interest. We study the physiological parameter space of a MFM of electrocortical activity and discover robust correlations between physiological attributes of the model cortex and its dynamical features. These correlations are revealed by the study of bifurcation plots, which show that the model responses to changes in inhibition belong to two archetypal categories or “families”. After investigating and characterizing them in depth, we discuss their essential differences in terms of four important aspects: power responses with respect to the modeled action of anesthetics, reaction to exogenous stimuli such as thalamic input, and distributions of model parameters and oscillatory repertoires when inhibition is enhanced. Furthermore, while the complexity of sustained periodic orbits differs significantly between families, we are able to show how metamorphoses between the families can be brought about by exogenous stimuli. We here unveil links between measurable physiological attributes of the brain and dynamical patterns that are not accessible by linear methods. They instead emerge when the nonlinear structure of parameter space is partitioned according to bifurcation responses. We call this general method “metabifurcation analysis”. The partitioning cannot be achieved by the investigation of only a small number of parameter sets and is instead the result of an automated bifurcation analysis of a representative sample of 73,454 physiologically admissible parameter sets. Our approach generalizes straightforwardly and is well suited to probing the dynamics of other models with large and complex parameter spaces.

Preferential location of lidocaine and etidocaine in lecithin bilayers as determined by EPR, fluorescence and H-2 NMR

We have examined the effect of the uncharged species of lidocaine (LDC) and etidocaine (EDC) on the acyl chain moiety of egg phosphatidylcholine liposomes. Changes in membrane organization caused by both anesthetics were detected through the use of EPR spin labels (5, 7 and 12 doxyl stearic acid methyl ester) or fluorescence probes (4, 6, 10, 16 pyrene-fatty acids). The disturbance caused by the LA was greater when the probes were inserted in more external positions of the acyl chain and decreased towards the hydrophobic core of the membrane. The results indicate a preferential insertion of LDC at the polar interface of the bilayer and in the first half of the acyl chain, for EDC. Additionally, 2 H NMR spectra of multilamellar liposomes composed by acyl chain-perdeutero DMPC and EPC (1:4 mol%) allowed the determination of the segmental order (S-mol) and dynamics (T-1) of the acyl chain region. In accordance to the fluorescence and EPR results, changes in molecular orientation and dynamics are more prominent if the LA preferential location is more superficial, as for LDC while EDC seems to organize the acyl chain region between carbons 2-8, which is indicative of its positioning. We propose that the preferential location of LDC and EDC inside the bilayers creates a ""transient site"", which is related to the anesthetic potency since it could modulate the access of these molecules to their binding site(s) in the voltage-gated sodium channel. (C) 2007 Elsevier B.V. All rights reserved.

Preferential location of prilocaine and etidocaine in phospholipid bilayers: A molecular dynamics study

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Preferential location of lidocaine and etidocaine in lecithin bilayers as determined by EPR, fluorescence and H-2 NMR

We have examined the effect of the uncharged species of lidocaine (LDC) and etidocaine (EDC) on the acyl chain moiety of egg phosphatidylcholine liposomes. Changes in membrane organization caused by both anesthetics were detected through the use of EPR spin labels (5, 7 and 12 doxyl stearic acid methyl ester) or fluorescence probes (4, 6, 10, 16 pyrene-fatty acids). The disturbance caused by the LA was greater when the probes were inserted in more external positions of the acyl chain and decreased towards the hydrophobic core of the membrane. The results indicate a preferential insertion of LDC at the polar interface of the bilayer and in the first half of the acyl chain, for EDC. Additionally, 2 H NMR spectra of multilamellar liposomes composed by acyl chain-perdeutero DMPC and EPC (1:4 mol%) allowed the determination of the segmental order (S-mol) and dynamics (T-1) of the acyl chain region. In accordance to the fluorescence and EPR results, changes in molecular orientation and dynamics are more prominent if the LA preferential location is more superficial, as for LDC while EDC seems to organize the acyl chain region between carbons 2-8, which is indicative of its positioning. We propose that the preferential location of LDC and EDC inside the bilayers creates a "transient site", which is related to the anesthetic potency since it could modulate the access of these molecules to their binding site(s) in the voltage-gated sodium channel. (C) 2007 Elsevier B.V. All rights reserved.

Eugenol em juvenis de tilápia do nilo: concentrações e administrações sucessivas

Several anesthetics are used in aquaculture to reduce the stress caused by management. In the field, the most common anesthetic is benzocaine, but several authors are researching about eugenol. The objective of this study were to compare the action of these drugs on the anesthetics stages and measure the effects of successive administration of eugenol on the anesthetics stages in Oreochromis niloticus. In the first test, fish (47.73 +/- 8.73 g and 14.23 +/- 0.81 cm) were subjected to five concentrations of eugenol (40, 60, 80, 100 and 120 mg L-1) and one of benzocaine (100 mg L-1). All the anesthetic concentrations tested were able to induce fish to all stages of anesthesia, and revealed an inverse relationship between the induction times and increased concentrations. The minimum concentration of eugenol to induce anesthesia was 100 mg L-1. In the second test, the juveniles (38.07 +/- 5.00 g and 12.70 +/- 0.54 cm) were exposed to concentrations of 60, 80, 100 mg L-1 of eugenol, as determined in the first test. Evaluating the differences between successive days, there was no significant difference (P > 0.05) between anesthetics stages in the concentrations of eugenol tested, suggesting that the residue of eugenol was removed from the fish in less than 24 hours.

Cardiopulmonary and acid-base effects of desflurane and sevoflurane in spontaneously breathing cats

The cardiopulmonary effects of desflurane and sevoflurane anesthesia were compared in cats breathing spontaneously. Heart (HR) and respiratory (RR) rates; systolic (SAP), diastolic (DAP) and mean arterial (MAP) pressures; partial pressure of end tidal carbon dioxide (PETCO(2)), arterial blood pH (pH), arterial partial pressure of oxygen (PaO(2)) and carbon dioxide (PaCO(2)); base deficit (BD), arterial oxygen saturation (SaO(2)) and bicarbonate ion concentration (HCO(3)) were measured. Anesthesia was induced with propofol (8 +/- 2.3 mg/kg IV) and maintained with desflurane (GD) or sevoflurane (GS), both at 1.3 MAC. Data were analyzed by analysis of variance (ANOVA), followed by the Tukey test (P < 0.05). Both anesthetics showed similar effects. HR and RR decreased when compared to the basal values, but remained constant during inhalant anesthesia and PETCO(2) increased with time. Both anesthetics caused acidemia and hypercapnia, but BD stayed within normal limits. Therefore, despite reducing HR and SAP (GD) when compared to the basal values, desflurane and sevoflurane provide good stability of the cardiovascular parameters during a short period of inhalant anesthesia (T20-T60). However, both volatile anesthetics cause acute respiratory acidosis in cats breathing spontaneously. (c) 2004 ESFM and AAFP. Published by Elsevier Ltd. All rights reserved.

Effects of the Ottonia martiana Miq. (Piperaceae) extract on dog's ocular surface

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Effects of isoflurane on echocardiographic parameters in healthy dogs

Obejective To study the echocardiographic effects of isoflurane at an end-tidal concentration approximating 1.0 times the minimum alveolar concentration (MAC) in healthy unpremedicated dogs.Study design Prospective experimental trial.Animals Sixteen mature mongrel dogs of either sex weighing 11.06 +/- 2.72 kg.Methods After performing a baseline echocardiogram in the awake animal, anesthesia was induced with increasing inspired concentrations of isoflurane via a face mask until tracheal intubation was possible. Following intubation, the end-tidal concentration was decreased to 1.4% for the rest of the anesthetic period. Serial echocardiograms were recorded at 25, 40, and 55 minutes after the end-tidal concentration was reached.Results No changes were observed in heart rate. However, significant decreases were seen in left ventricular end-diastolic diameter (Mean maximal change: 13.8%), interventricular septal thickness during systole (15.2%), interventricular septal thickening fraction (72.2%), left ventricular free wall thickening fraction (63.5%), ejection fraction (39.9%), and fractional shortening (46.7%). In addition, peak flow velocities across mitral, pulmonic, and aortic valves were significantly lower than baseline values. Decreases were also observed in end-diastolic left ventricular volume index (approximately 32.1% from the awake value), stroke index (58.2%), and cardiac index (55.3%) when compared with awake measurements.Conclusions Our results indicate that 1 x MAC isoflurane caused significant myocardial depression in healthy dogs. These changes in myocardial function need to be considered carefully when isoflurane is to be used in dogs with poor cardiovascular reserve.

Comportamento da pressão intra-ocular segundo os efeitos cardiorrespiratórios e hemodinâmicos induzidos pela anestesia com desflurano, em cães submetidos à hipovolemia experimental

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Efeitos do desfluorano, sevofluorano e isofluorano sobre variáveis respiratórias e hemogasométricas em cães

Com este estudo objetivou-se avaliar, comparativamente, os efeitos de três anestésicos inalatórios sobre variáveis respiratórias e hemogasométricas em cães. Para tal, utilizaram-se 30 cães sadios, adultos, machos e fêmeas evitando-se aquelas em estro ou em gestação. Os animais foram separados e protocolados em três grupos de 10 cães cada (G1, G2 e G3). Induziu-se a anestesia geral com administração intravenosa de propofol, na dose de 10±1,3 mg/kg. em seguida procedeu-se à intubação orotraqueal e anestesia geral inalatória pelo desfluorano (G1), sevofluorano (G2) e isofluorano (G3), diluídos em oxigênio a 100,00%, por meio de circuito anestésico tipo semi-fechado, dotado de vaporizadores calibrados para cada agente anestésico. As variáveis estudadas foram Freqüência Respiratória, CO2 ao Final da Expiração, Saturação de Oxihemoglobina, Volume Corrente, Volume Minuto, Pressão Parcial Arterial de O2, Pressão Parcial Arterial de CO2, Excesso de Bases e pH. A avaliação estatística destas variáveis foi realizada pela Análise de Perfil, sendo considerado o nível de significância de 5,00%. Os resultados obtidos permitiram concluir que o desfluorano deprime o sistema respiratório aumentando a pressão parcial arterial de CO2 e o CO2 ao final da expiração; e diminuindo a pressão parcial arterial de O2 e o volume minuto, quando comparado com os outros anestésicos em teste.

Encoding mechanisms based on fast oscillations in the retina of the cat and their dependencies on anesthesia

Processing in the visual system starts in the retina. Its complex network of cells with different properties enables for parallel encoding and transmission of visual information to the lateral geniculate nucleus (LGN) and to the cortex. In the retina, it has been shown that responses are often accompanied by fast synchronous oscillations (30 - 90 Hz) in a stimulus-dependent manner. Studies in the frog, rabbit, cat and monkey, have shown strong oscillatory responses to large stimuli which probably encode global stimulus properties, such as size and continuity (Neuenschwander and Singer, 1996; Ishikane et al., 2005). Moreover, simultaneous recordings from different levels in the visual system have demonstrated that the oscillatory patterning of retinal ganglion cell responses are transmitted to the cortex via the LGN (Castelo-Branco et al., 1998). Overall these results suggest that feedforward synchronous oscillations contribute to visual encoding. In the present study on the LGN of the anesthetized cat, we further investigate the role of retinal oscillations in visual processing by applying complex stimuli, such as natural visual scenes, light spots of varying size and contrast, and flickering checkerboards. This is a necessary step for understanding encoding mechanisms in more naturalistic conditions, as currently most data on retinal oscillations have been limited to simple, flashed and stationary stimuli. Correlation analysis of spiking responses confirmed previous results showing that oscillatory responses in the retina (observed here from the LGN responses) largely depend on the size and stationarity of the stimulus. For natural scenes (gray-level and binary movies) oscillations appeared only for brief moments probably when receptive fields were dominated by large continuous, flat-contrast surfaces. Moreover, oscillatory responses to a circle stimulus could be broken with an annular mask indicating that synchronization arises from relatively local interactions among populations of activated cells in the retina. A surprising finding in this study was that retinal oscillations are highly dependent on halothane anesthesia levels. In the absence of halothane, oscillatory activity vanished independent of the characteristics of the stimuli. The same results were obtained for isoflurane, which has similar pharmacological properties. These new and unexpected findings question whether feedfoward oscillations in the early visual system are simply due to an imbalance between excitation and inhibition in the retinal networks generated by the halogenated anesthetics. Further studies in awake behaving animals are necessary to extend these conclusions

Comparison between S-ketamine and clonidine in caudal analgesia

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Perioperative cardiac arrest and its mortality in children. A 9-year survey in a Brazilian tertiary teaching hospital

Background: the incidence of perioperative cardiac arrest and mortality in children is higher than in adults. This survey evaluated the incidence, causes, and outcome of perioperative cardiac arrests in a pediatric surgical population in a tertiary teaching hospital between 1996 and 2004.Methods: the incidence of cardiac arrest during anesthesia was identified from an anesthesia database. During the study period, 15 253 anesthetics were performed in children. Data collected included patient demographics, surgical procedures (elective, urgent, or emergency), ASA physical status classification, anesthesia provider information, type of surgery, surgical areas, and outcome. All cardiac arrests were reviewed and grouped by the cause of arrest and death into one of four groups: totally anesthesia-related, partially anesthesia-related, totally surgery-related, or totally child disease or condition-related.Results: There were 35 cardiac arrests (22.9 : 10 000) and 15 deaths (9.8 : 10 000). Major risk factors for cardiac arrest were neonates and children under 1 year of age (P < 0.05) with ASA III or poorer physical status (P < 0.05), in emergency surgery (P < 0.05), and general anesthesia (P < 0.05). Child disease/condition was the major cause of cardiac arrest or death (P < 0.05). There were seven cardiac arrests because of anesthesia (4.58 : 10 000) - four totally (2.62 : 10 000) and three partially related to anesthesia (1.96 : 10 000). There were no anesthesia attributable deaths reported. The main causes of anesthesia attributable cardiac arrest were respiratory events (71.5%) and medication-related events (28.5%).Conclusions: Perioperative cardiac arrests were relatively higher in neonates and infants than in older children with severe underlying disease and during emergency surgery. The fact that all anesthesia attributable cardiac arrests were related to airway management and medication administration is important in prevention strategies.

Efeitos do halotano, isoflurano e sevoflurano sobre a função renal em cães sob pinçamento aórtico infra-renal

JUSTIFICATIVA E OBJETIVOS: O pinçamento infra-renal da aorta abdominal pode produzir alterações renais. O objetivo do estudo foi avaliar os efeitos do halotano, isoflurano e sevoflurano sobre a função renal, em cães submetidos a pinçamento aórtico infra-renal. MÉTODO: O estudo aleatório foi realizado em 30 cães, distribuídos em três grupos, de acordo com o anestésico halogenado utilizado durante a anestesia, em concentrações equipotentes de 0,75 CAM: GH (n = 10) - halotano a 0,67%; GI (n = 10) - isoflurano a 0,96%; e GS (n = 10) - sevoflurano a 1,8%. em todos os animais foi realizada ligadura infra-renal da aorta, por período de 30 minutos. Os atributos renais foram estudados nos momentos: C (controle), após 15 (Ao15) e 30 (Ao30) minutos de pinçamento aórtico, e após 15 (DAo15) e 30 (DAo30) minutos do despinçamento aórtico. RESULTADOS: A depuração de água livre foi menor nos grupos GI e GS, em relação ao GH, após o despinçamento aórtico (p < 0,05). Durante o pinçamento aórtico, nos três grupos, houve aumento do débito urinário, da excreção urinária de sódio e da depuração de sódio, e diminuição da osmolaridade urinária (p < 0,05). A resistência vascular renal e a fração de filtração aumentaram somente em GS (p < 0,05), enquanto a excreção fracionária de sódio aumentou em GH e GI (p < 0,05). Após o despinçamento aórtico, houve normalização dos atributos que haviam se alterado, com exceção da osmolaridade urinária, que continuou em níveis menores do que os do controle em todos os grupos (p < 0,05). A resistência vascular renal e a fração de filtração continuaram mais elevadas em GS, acompanhadas por diminuição do fluxo sangüíneo renal e da depuração de para-aminohipurato de sódio (p < 0,05). CONCLUSÕES: No cão nas condições experimentais empregadas, a inalação de halotano e isoflurano a 0,75 CAM, mas não de sevoflurano, atenuou a principal alteração após o pinçamento infra-renal da aorta, que é o aumento da resistência vascular renal.