Introduction: The methods most frequently used at the present time in Colombia for the administration of general anesthesia are based on halogenated and intravenous drugs. However, in view of the ...lack of differential clinical outcomes, the existence of cost variations between the two is not clear.
Objective: To determine the expected cost of the use of both techniques in patients taken to surgery, within the framework of the Colombian national health system.
Methods: A cost minimization study was carried out using the decision tree as the analytical model. A time frame of 6 postoperative hours was used as the assumption. Only direct healthcare-related costs were included using a case study approach. An econometric model was used based on the frequency with which each technology is applied and the type of drug used, and a deterministic and probabilistic sensitivity analysis was performed.
Results: For the case study, total intravenous anesthesia (TIVA) is more costly than the inhalational technique, with an incremental cost of $102,718 per patient. The deterministic analysis shows that both the incidence of postoperative nausea and vomiting (PONV) as well as the use of target controlled infusion (TCI) techniques are the main cost determinants. The probabilistic analysis shows that the cost difference can even be nil in more than 50% of the simulated settings, when the difference in the risk of PONV is higher.
Conclusions: Although the total intravenous technique can be more costly than the inhalational technique, this difference is offset by a lower cost of the postanesthesia care unit, given the lower risk of postoperative nausea and vomiting.
Introduction: Low-dose ketamine infusions have shown analgesic effectiveness for the management of postoperative pain. The impact of low-dose ketamine infusions on cardiovascular response is ...dose-dependent and requires a better knowledge about its effects on this population. Objective: To conduct a systematic review to describe changes in systolic, diastolic and mean arterial pressure, and heart rate 24, 48 and 72 hours after surgery. Methods: Randomized, controlled trials were reviewed in the Cochrane Library, PubMed, EMBASE, SciELO, Lilacs and grey literature on low-dose ketamine infusions for the study variables. The quality of the studies was assessed using the Cochrane’s risk of bias tool. Results: Six randomized, controlled trials with 641 patients were included. Low-quality evidence was found suggestive of a lack of certainty of any significant differences in the systolic blood pressure variables at 24 hours (mean standard deviation -1.00, 95 % CI: -7.27 to 5.27). A statistically significant higher mean heart rate at 24 hours was identified in the low-dose ketamine infusion group, (mean standard deviation 1.64 95 % CI: 0.38 to 2.90) which did not reach clinical significance. A lower pain level and less use of opioids was identified in the low-dose ketamine infusion group. Conclusion: Low quality evidence was found, suggesting that low-dose ketamine infusions are not associated with significant changes in blood pressure or heart rate 24 – 48 hours after surgery. It is important to individualize cardiovascular risk for each case, before initiating treatment.
Introducción: Las infusiones en dosis bajas de ketamina han mostrado eficacia analgésica en el manejo del dolor posoperatorio. El impacto de las infusiones en dosis bajas de ketamina en la respuesta cardiovascular es dosisdependiente y requiere un mejor conocimiento de sus efectos en esta población. Objetivo: Realizar una revisión sistemática para describir los cambios en la presión arterial sistólica, presión arterial diastólica, presión arterial media, frecuencia cardiaca a las 24, 48 y 72 horas del posoperatorio. Métodos: Se revisaron ensayos controlados aleatorizados en Cochrane Library, PubMed, EMBASE, SciELO, Lilacs y literatura gris de infusiones en dosis bajas de ketamina para las variables del estudio. La calidad de los estudios se evaluó usando la herramienta de riesgo de sesgos de Cochrane. Resultados: Se incluyeron seis ensayos controlados aleatorizados con 641 pacientes. Se encontró evidencia de baja calidad sugestiva de ausencia de certeza de diferencias significativas en las variables presión arterial sistólica a las 24 horas (diferencia de medias estandarizada -1,00, IC95 %: -7,27 a 5,27). Para las 24 horas se halló una media de frecuencia cardiaca mayor en el grupo de infusiones en dosis bajas de ketamina, estadísticamente significativa (diferencia de medias estandarizada 1,64 IC95 %: 0,38 a 2,90) sin alcanzar significancia clínica. Se encontró menor nivel de dolor y consumo de opioides en el grupo de infusiones en dosis bajas de ketamina. Conclusión: Se encontró evidencia de baja calidad, sugestiva de que las infusiones en dosis bajas de ketamina no se asocian a cambios significativos en la presión arterial o frecuencia cardiaca a las 24-48 horas en el posoperatorio. Es importante individualizar el riesgo cardiovascular para cada caso previo al inicio del tratamiento.
Contrast-induced nephropathy is one of the main causes of acute kidney injury and increased hospital-acquired morbidity and mortality. The use of sodium bicarbonate for nephroprotection has emerged ...as a preventative strategy; however, its efficacy is controversial compared to other strategies, such as hydration using 0.9% saline solution.
To compare the effectiveness of sodium bicarbonate vs. hydration using 0.9% saline solution to prevent contrast-induced acute kidney injury.
A systematic review of studies registered in the COCHRANE, PUBMED, MEDLINE, LILACS, SCIELO and EMBASE databases was conducted. Randomized controlled studies that evaluated the use of 0.9% saline solution vs. sodium bicarbonate to prevent contrast-induced nephropathy were included.
A total of 22 studies (5,686 patients) were included. Sodium bicarbonate did not decrease the risk of contrast-induced nephropathy (RD= 0.00; 95% CI= -0.02 to 0.03; p= 0.83; I(2)= 0%). No significant differences were found in the demand for renal replacement therapy (RD= 0.00; 95% CI= -0.01 to 0-01; I(2)= 0%; p= 0.99) or in mortality (RD= -0.00; 95% CI= -0.001 to 0.001; I(2)= 0%; p= 0.51).
Sodium bicarbonate administration is not superior to the use of 0.9% saline solution for preventing contrast-induced nephropathy in patients with risk factors, nor is it better at reducing mortality or the need for renal replacement therapy.
Resumen La anestesia en lazo cerrado busca incrementar la exactitud con que se administran los fármacos, dando la cantidad necesaria de acuerdo con las condiciones del paciente y las necesidades del ...cirujano, al integrar el monitoreo a los sistemas de perfusión. Objetivo: Evaluar el desempeño de un sistema de administración de anestesia intravenosa en lazo cerrado con propofol y remifentanilo, utilizando el monitor de profundidad anestésica PatientStateIndex). Métodos: Estudio observacional prospectivo multicéntrico en pacientes ASA I-II sometidos a cirugía electivacon un sistema de anestesia en lazo cerradocapaz de retroalimentarse en tiempo real de las variables hemodinámicas y la profundidad anestésica del paciente.La medición del desempeño clínico se realizó a partir del porcentaje de tiempo de permanencia del ÍNDICE en el rango 20-50. El análisis de precisión se evaluó midiendo error medio de desempeño, error medio absoluto de desempeño y Wobble. Resultados: Se obtuvieron datos de 76 pacientes, recogidos en dos instituciones. El porcentaje de tiempo de permanencia del PSI en el rango 20-50 fue de 96% (89-99) en una institución y del 84,8% (70,8-94) en otra. El ERROR MEDIO de DESEMPEÑO fue de 11 y 10,7, el ERROR MEDIO ABSOLUTO de 21 y 21,4 y el Wobble de 7 y 14,2 respectivamente para cada institución. No se reportó ningún evento quirúrgico o anestésico adverso. Conclusiones: El sistema de administración de anestesia total intravenosa en lazo cerrado guiado por un nuevo monitor de profundidad anestésica mostró en esta serie de casos un buen desempeño clínico y técnico.
Efficacy of paravertebral block techniques in thoracic surgery Cadavid-Puentes, Adriana Margarita; Casas-Arroyave, Fabián David; Palacio-Montoya, Laura María ...
Colombian journal of anesthesiology (Inglâes),
01/2020, Letnik:
48, Številka:
1
Journal Article
Introduction: In-hospital cardiac arrest (CA) is a rare but lifethreatening event. However, the epidemiology of this event in intensive care units (ICU) is not clear.
Objective: To determine the ...clinical characteristics of CA in adult patients hospitalized in several ICU of the Metropolitan Area of the Aburrá Valley, Colombia, over a period of 1 year.
Methods: Observational study for a limited period of 1 year for adult patients with CA in the ICU of the hospitals of the Metropolitan Area of the Aburrá Valley, Colombia: San Vicente Foundation University Hospital, IPS University, and Manuel Uribe Ángel Hospital.
Results: Of 3710 eligible patientswhowere treated in 91 beds, 646 CA events occurred during this period, of which 151 were candidates for resuscitation maneuvers. The overall incidence of CA in the ICU was 17.1%, without differences between the 3 hospitals included and the incidence of resuscitable CA was 39.9 cases per 1000 admissions to the ICU. The most common CA rhythm was asystole (54.3%) and the overall survival at hospital discharge was 3.3%.
Conclusion: In the analyzed ICU, CA was an infrequent event, but it presents a high mortality at discharge from the ICU and hospital. However, the few patients who survive have a good neurological prognosis.
La anestesia total intravenosa es una técnica ampliamente utilizada que tiene como base el uso de anestésicos intravenosos para su realización, siendo el propofol el más usado y estudiado para tal ...fin. Actualmente se dispone de herramientas farmacéuticas y farmacocinéticas que generan modelos matemáticos para el uso de esta técnica de manera segura y moderadamente eficaz. Sin embargo, la profundidad del estado anestésico es una medida netamente clínica que requiere el uso de monitorización neurológica tipo índice biespectral, el cual permite correlacionar los datos generados por los modelos farmacocinéticos empleados para la administración del anestésico y su efecto clínico deseado.
Para tal efecto diseñamos un sistema operativo que retroalimenta y controla de manera automática la infusión de propofol tomando como base los datos generados por un monitor de índice biespectral, sistema que se programa para aumentar y disminuir la infusión de propofol de acuerdo a un rango específico de valor del índice biespectral, y por ende las necesidades especificas de cada paciente.
Describimos el manejo anestésico con esta técnica en una paciente sometida a implante de prótesis mamaria bajo anestesia general en la IPS Universitaria en la cual se logro generar un récord intraoperatorio de la profundidad anestésica y su consecuente acción sobre la concentración de propofol en sitio efectivo usando este sistema de administración y control automático.
Concluimos que el uso de la anestésica total intravenosa de lazo cerrado con monitorización neurológica es el siguiente paso en la evolución de esta técnica, la cual ofrece menor dependencia a los modelos farmacocinéticas usados en la actualidad y mayor capacidad de adaptación a las necesidades particulares de cada paciente y tipo de intervención quirúrgica.
Total intravenous anesthesia is a widely used technique that relies on the use of intravenousanesthetics, propofol being the most frequently used and studied. At present, there are pharmaceutical and pharmacokinetic tools that are used to generate mathematical models to ensure the safe and moderately effective use of this technique. However, the depth of anesthesia is determined purely on the clinical findings and this requires neurological monitoring such as the bi-spectral index (BIS) in order to correlate the data derived from the pharmacokinetic models used for the administration of the anesthetic with the determination of its desired clinical effect.
We designed an operating system for automated control of the propofol infusion that provides feedback on the basis of the data generated by the BIS monitor. The system is programmed to increase or decrease the propofol infusion within a specific BIS range and, consequently, in accordance with the needs of the individual patient.
We describe anesthetic management using this technique in a female patient taken to surgery for prosthetic mammary implantation under general anesthesia at the University Hospital. An intraoperative record was generated including the depth of anesthesia and its action on propofol concentration at the effective site using the automated administration and control system.
We concluded that the use of closed-loop total intravenous anesthesia under neurologic monitoring is the next step in the evolution of this technique. It is less reliant on the pharmacokinetic models available at present, and is better suited to adapt to the specific needs of individual patients and to the type of surgical intervention.
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