Anestesia pediatrica. Mitos, dogmas y evidencia.

  • 993 views
Uploaded on

 

More in: Business , Technology
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
    Be the first to like this
No Downloads

Views

Total Views
993
On Slideshare
0
From Embeds
0
Number of Embeds
0

Actions

Shares
Downloads
51
Comments
0
Likes
0

Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n

Transcript

  • 1. ANESTESIAPEDIATRICA
  • 2. ANESTESIA PEDIATRICAMITOS, DOGMAS Y EVIDENCIAS. DR. LUIS VERA LINARES LIMA 2011 email: drluisveralinares@gmail.com
  • 3. SOBRE EVALUAR UN MITO...
  • 4. SOBRE EVALUAR UN MITO...• PROBAR LA VALIDEZ SOBRE EL MITO DANES DE QUE EL ALCOHOL PUEDE SER ABSORBIDO A TRAVES DE LOS PIES: ESTUDIO EXPERIMENTAL DE TIPO ABIERTO.
  • 5. RESEARCH CHRISTMAS 2010: RESEARCH Testing the validity of the Danish urban myth that alcohol can be absorbed through feet: open labelled self experimental study Christian Stevns Hansen, doctor Louise Holmsgaard Færch, doctor Peter Lommer Kristensen, doctor and research fellowEndocrinology Section, Department ABSTRACT in vodka; the Peace On Earth (Percutaneous Ethanolof Cardiology and Endocrinology, Objective To determine the validity of the Danish urban Absorption Could Evoke Ongoing NationwideHillerød Hospital, Dyrehavevej 29,DK-3400 Hillerød, Denmark myth that it is possible to get drunk by submerging feet in Euphoria And Random Tender Hugs) study. TheCorrespondence to: P L Kristensen alcohol. results could have great implications, by freeingpelk@hih.regionh.dk Design Open labelled, self experimental study, with no human resources for other, relevant, activities.Cite this as: BMJ 2010;341:c6812 control group.doi:10.1136/bmj.c6812 Setting Office of a Danish hospital. METHODS Participants Three adults, median age 32 (range 31-35), The Peace on Earth study was open labelled and self free of chronic skin and liver disease and non-dependent experimental, with no control group. It evaluated the on alcohol and psychoactive drugs. effect of submerging feet in 2100 mL of vodka (three bot- Main outcome measures The primary end point was the tles’ worth) on the concentration of plasma ethanol. Sec- concentration of plasma ethanol (detection limit ondary end points were intoxication related symptoms. 2.2 mmol/L (10 mg/100 mL)), measured every 30 minutes Three healthy adults (all authors, CSH, LHF, and for three hours while feet were submerged in a washing- PLK) agreed to participate. None had any chronic skin up bowl containing the contents of three 700 mL bottles of or liver disease or was dependent on alcohol or psy- vodka. The secondary outcome was self assessment of choactive drugs. None was members of local Alcoholics intoxication related symptoms (self confidence, urge to Anonymous communities or had been implicated in speak, and number of spontaneous hugs), scored on a serious incidents or socially embarrassing events related scale of 0 to 10. to alcohol during the week before the experiment. Results Plasma ethanol concentrations were below the detection limit of 2.2 mmol/L (10 mg/100 mL) throughout Study protocol the experiment. No significant changes were observed in The participants abstained from consuming alcohol the intoxication related symptoms, although self 24 hours before the experiment. The evening before confidence and urge to speak increased slightly at the the experiment they rubbed their feet with a loofah to start of the study, probably due to the setup. remove skin debris. On the day of the experiment, a Conclusion Our results suggest that feet are impenetrable baseline blood sample was taken through a venous to the alcohol component of vodka. We therefore conclude line. The participants then submerged their feet in a that the Danish urban myth of being able to get drunk by washing-up bowl containing the contents of three submerging feet in alcoholic beverages is just that; a myth. 700 mL bottles of vodka (Karloff vodka; M R tefánika, The implications of the study are many though. Cífer, Slovakia, 37.5% by volume). Before each blood sample was taken the venous catheter and cannula INTRODUCTION were flushed with saline by a trained study nurse. According to Danish urban folklore, it is possible to Plasma ethanol concentrations were determined become drunk by submerging feet in alcoholic bev- every 30 minutes for three hours. Blood samples erages. Furthermore, claims exist of urine becoming were taken to the laboratory for immediate analysis red when feet are submerged in beetroot juice. Because by the study nurse. Plasma ethanol concentrations, the transcutaneous transport of alcohol to the circula- measured as soon as possible in case of rapid and tion may have widespread implications, such urban potentially fatal increases, were determined using a myths need to be investigated in a scientific setting. photometric method, with a detection limit of
  • 6. • HANSEN ET AL. BMJ 2010; 341:C6812.• POBLACION DE ESTUDIO: 3 MDS.• METODO: PIES INMERSOS EN VODKA DURANTE 3 HORAS.• RESULTADOS: NIVELES DE ETANOL, SINTOMAS SUBJETIVOS.
  • 7. SINTOMAS DE INTOXICACION• HANSEN. BMJ 2010
  • 8. CONCLUSIONES• NUESTROS RESULTADOS SUGIEREN QUE LOS PIES SON IMPENETRABLES AL COMPONENTE ALCOHOLICO DEL VODKA Y EN TANTO CONCLUIMOS QUE ESTE MITO DANES ES TAN SOLO ESO... UN MITO
  • 9. OBJETIVOS DE ESTA CONFERENCIA• EVALUAR ALGUNOS MITOS Y CREENCIAS ACTUALES DE LA PRACTICA ANESTESICA PEDIATRICA.
  • 10. OBJETIVOS DE ESTA CONFERENCIA• USAR LA EVIDENCIA ACTUAL PARA DAR SOPORTE O RECHAZAR ALGUNAS PRACTICAS EN ANESTESIA PEDIATRICA: • VIA AEREA • AGENTES INHALADOS • OTRAS DROGAS • MISCELANEAS• “CREER A CIEGAS ES PELIGROSO” - LUYIA
  • 11. DOGMAS SOBRE VIA AEREA EN PEDIATRIA
  • 12. DOGMAS SOBRE VIA AEREA EN PEDIATRIA• LA PARTE MAS ESTRECHA DE LA VIA AEREA EN NIÑOS ESTA A NIVEL DEL CARTILAGO CRICOIDES.
  • 13. DOGMAS SOBRE VIA AEREA EN PEDIATRIA• LA PARTE MAS ESTRECHA DE LA VIA AEREA EN NIÑOS ESTA A NIVEL DEL CARTILAGO CRICOIDES.• EL DIAMETRO DEL DEDO MEÑIQUE PREDICE DE FORMA MUY PRECISA EL TAMAÑO DEL TUBO ENDOTRAQUEAL.
  • 14. DOGMAS SOBRE VIA AEREA EN PEDIATRIA• LA PARTE MAS ESTRECHA DE • LA PRESION DEL CARTILAGO LA VIA AEREA EN NIÑOS ESTA CRICOIDES ES UN A NIVEL DEL CARTILAGO COMPONENTE IMPORTANTE CRICOIDES. EN LA INDUCCION DE SECUENCIA RAPIDA.• EL DIAMETRO DEL DEDO MEÑIQUE PREDICE DE FORMA MUY PRECISA EL TAMAÑO DEL TUBO ENDOTRAQUEAL.
  • 15. DOGMAS SOBRE VIA AEREA EN PEDIATRIA• LA PARTE MAS ESTRECHA DE • LA PRESION DEL CARTILAGO LA VIA AEREA EN NIÑOS ESTA CRICOIDES ES UN A NIVEL DEL CARTILAGO COMPONENTE IMPORTANTE CRICOIDES. EN LA INDUCCION DE SECUENCIA RAPIDA.• EL DIAMETRO DEL DEDO MEÑIQUE PREDICE DE • LOS TUBOS FORMA MUY PRECISA EL ENDOTRAQUEALES CON TAMAÑO DEL TUBO CUFF SON SEGUROS/ ENDOTRAQUEAL. PELIGROSOS EN NIÑOS.
  • 16. ANATOMIA DE LA VIA AEREA EN PEDIATRIA: TRABAJO INICIAL• “EN EL INFANTE... EL ANILLO CRICOIDEO PUEDE SER MAS PEQUEÑO QUE LA GLOTIS O QUE EL DIAMETRO INTERNO DE LA TRAQUEA”• “EN INFANTES Y NIÑOS, BAYEUX, USANDO CADAVERES Y SECCIONES ANATOMICAS, ENCONTRO QUE LA CIRCUNFERENCIA DEL ANILLO CRICOIDEO ERA MAS ESTRECHA QUE EL DE LA TRAQUEA O QUE EL DE LA GLOTIS”.• (BAYEUX PRESS MED. 1897: ECKENHOFF, ANESTHESIOLOGY 1951)
  • 17. Anesthesiology 2003; 98:41–5 © 2003 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.DevelopmentalAnesthesiology 2003; 98:41–5 Laryngeal Dimensions in Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc. Changes of © 2003 AmericanUnparalyzed, Sedated Children Developmental Changes of Laryngeal Dimensions inRonald S. Litman, D.O.,* Eric E. Weissend, M.D.,† Dean Shibata, M.D.,‡ Per-Lennart Westesson, M.D., Ph.D., D.D.S.§ Unparalyzed, Sedated Children Background: Knowledge of the influence Litman, D.O.,* Eric E. Weissend, M.D.,† Dean Shibata, M.D.,‡ Per-Lennart Westesson, M.D., Ph.D., D.D.S.§ Ronald S. of age on laryngeal bony framework of the larynx throughout childhood.1–3dimensions is essential for all practitioners whose interest is These studies determined that the larynx is conicallythe pediatric airway. Early cadaver studies documented that thelarynx is conically shaped, with the apex of the cone caudally shaped, with the apex of the “cone” caudally positionedpositioned at the nondistensible cricoid cartilage. These dimen- at the nondistensible cricoid cartilage. These dimensions the larynx throughout childhood.1–3 Background: Knowledge of the influence of age on laryngeal bony framework of dimensions isassumes a more all practitioners whose interest is larynx assumes a cylin-sions change during childhood, as the larynx essential for change during childhood as the These studies determined that the larynx is conicallycylindrical shape. The authors the pediatric airway. Early cadaver studies documented that the analyzed laryngeal dimensions drical, rather than a conical shape.4shaped, with the apex of the “cone” caudally positioned It is unknown if thisduring development to determine if thisis conically shaped, with relationship continuescaudally in unparalyzed children in larynx relationship continues the apex of the cone to existin unparalyzed children in whom laryngeal muscles are toni- positioned at the nondistensible cricoid cartilage. These dimen- at the nondistensible cricoid cartilage. These dimensions whom laryngeal muscles demonstrate tonic activity.5cally active. The authors determined the relationships between sions change during childhood, as the larynx assumes a more change during childhood as the larynx assumes a cylin-the vocal cord, sub–vocal cord, and cricoid ring dimensions and Therefore, we undertook this study to determine the influ- 4 ence of age on laryngeal dimensions.drical, rather than a conical shape. It is unknown if this cylindrical shape. The authors analyzed laryngeal dimensionsthe influence of age on these relationships. during development to determine if this relationship continues Most specifically, we Methods: Infants and children undergoing magnetic reso- were interested in the relationshipsrelationship continues to exist in unparalyzed children in in unparalyzed children in whom laryngeal muscles are toni- between vocal cord,nance imaging with propofol sedation had determinations of whom laryngeal muscles demonstrate tonic activity.5 sub–vocal cord, and cricoid ring dimensions, and howthe transverse and anterior–posterior (AP) dimensions of determined the relationships between cally active. The authors the these relationships change as children grow. Wewe undertook this study to determine the influ-larynx at the most cephalad level of the cord, sub–vocal cord, and cricoid ring dimensions and the vocal larynx (vocal cords) Therefore, hypothe- sized that these relationships change during developmentand the most caudad level (cricoid).influence of age on addi- relationships. the Most patients had an these ence of age on laryngeal dimensions. Most specifically, wetional measurement (sub–vocal cord) at a level between children undergoing magnetic reso- management. Methods: Infants and the and may influence clinical airway were interested in the relationships between vocal cord,vocal cords and the cricoid ring. Relationships were obtained sedation had determinations of nance imaging with propofolby plotting age against laryngeal dimensions and the ratio of sub–vocal cord, and cricoid ring dimensions, and how the transverse and anterior–posterior (AP) dimensions of thelaryngeal dimensions at different levelsat the most cephalad level of the larynx (vocal cords) larynx within the larynx. these relationships change as children grow. We hypothe- Materials and Methods Results: The authors measured transverse and AP laryngeal and the most caudad level (cricoid). Most patients had an addi- sized that these relationships change during developmentdimensions in 99 children, aged 2 months–13 yr. The relation- tional measurement (sub–vocal cord) Research Subjects’ Review Board of the Universityclinical airway management.ship between the transverse and AP dimensions at all levels of The at a level between the and may influencethe larynx did not change during development. Transverse and ring. Relationships(Rochester, New York) approved this vocal cords and the cricoid of Rochester were obtained by plotting at allagainstof theAP dimensions increased linearly with age age levels laryngeal dimensions and the ratio of study, and written informed consent was obtained fromlarynx. In all children studied, the narrowest portion at different levels within the larynx. laryngeal dimensions of the all parents of children in the study. Children who were Results: The authors measured transverse and AP laryngeallarynx was the transverse dimension at the level of the vocal Materials and Methodscords. Transverse dimensions dimensions in 99 in a caudad old enough to understand that they were participating in increased linearly children, aged 2 months–13 yr. The relation-direction through the larynx (Pship between the dimensions andaAP dimensions at all their assent. Children aged 0 –14 yr < 0.001), while AP transverse research study gave levels of The Research Subjects’ Review Board of the Universitydid not change relative to laryngeal level. The shape of the who presentedTransverse and magnetic resonance(Rochester, New York) approved this the larynx did not change during development. for an elective of Rochester im- AP dimensions increased linearly with age with deep sedation were eligible to partici- informed consent was obtained from aging scan at all levels of thecricoid ring did not change throughout childhood. Conclusions: In sedated, unparalyzed children, the narrowest study, and written studied, pate.narrowest portion of the larynx. In all children level)portions of the larynx are the glottic opening (vocal cord the Consecutive children were all parents of children in the study. Children who were enrolled within theand the immediate sub–vocal cord level,was there is no change limits of investigator-related and clinical situations. Ex- larynx and the transverse dimension at the level of the vocal old enough to understand that they were participating in clusion criteria included obvious anatomical deformitiesin the relationships of these cords. Transverse dimensions increased linearly in a caudad dimensions relative to cricoiddimensions throughout childhood.direction through the larynx (P < 0.001), while neck, or any other condition the investi- their assent. Children aged 0 –14 yr of the head or AP dimensions a research study gave did not change relative to laryngeal level. would cause abnormal laryngeal anatomy. an elective magnetic resonance im- gators felt The shape of the who presented for Children who received airway management withwith deep sedation were eligible to partici- cricoid ring did during child-throughout childhood.THE development and growth of the larynx not change aging scan either a Conclusions: Ina century.1hood has been a subject of interest for over sedated, unparalyzed children, airway or endotracheal tube were also children were enrolled within the laryngeal mask the narrowest pate. Consecutive portions of the larynx are the glottic opening (vocal cord level) excluded.Knowledge of the influence of the age of the child on limits of investigator-related and clinical situations. Ex- and the immediate sub–vocal cord The study there is no changechildren who were deeply level, and was performed inlaryngeal dimensions is essential for all practitioners clusion criteria included obvious anatomical deformities in the relationships of these dimensions relative ␮g cricoid · minϪ1 propofol. Most sedated with 200 to · kgϪ1whose interest is the pediatric airway. throughout childhood. dimensions Early studies in of the head or neck, or any other condition the investi-cadaver specimens documented the cartilaginous and children did not previously have an indwelling intrave- nous catheter and therefore initially received would cause abnormal laryngeal anatomy. gators felt a mask anesthetic with sevoflurane and Children who received airway management with either a THE development and growth of the larynx during child- nitrous oxide, both of
  • 18. dotracheal tube based on the size of the cricoid ring may not prevent mucosal damage to the larynx cephalad tobetween tra- EVALUACION POR RMN DE LA VIA AEREA the cricoid ring in unparalyzed children. On the other hand, these more cephalad portions of the larynx consist bottom) di- ic area, and PEDIATRICA of yielding structures that distend with placement of a relatively larger endotracheal tube. The cricoid ring isnearly in a unyielding and prone to development of edema andhe box is the th and 75th scarring in response to excessive mucosal pressures.nd 95th per- 1st and 99th nes are the • A: CUERDAS ildren, the VOCALES • portion ofnot attempt B: NIVEL of respira- ge in spon- SUBGLOTICO •dimensions an average cords dur- C: NIVELossible that tured” in a SUBGLOTICO • ion. If this bjects, then would be ANILLO xplanation CRICOIDEO ropofol onesses vocal Fig. 4. Representative sample of axial magnetic resonance im- aging slices through the vocal cords (A), subglottic levels (B andcle) and vo- C), and cricoid ring (D). Transverse diameters increase in ay8 and may caudad direction. Litman, Anesthesiology 2003
  • 19. EVALUACION POR RMN DE LA VIA AREA44 PEDIATRICA LITMAN ET AL. have influenced vocal cord positions in the children we studied. In 1951, Eckenhoff4 published a seminal article on characteristics of the infant larynx and their influence on endotracheal anesthesia. This article was one of the first to emphasize that the cricoid cartilage is functionally the narrowest point of the upper respiratory tract of the child. Eckenhoff described the cricoid plate as “inclined posteriorly at its superior aspect, so that the larynx is funnel shaped with the narrowest point of the funnel at the laryngeal exit.” This narrowest point is described as Respirando espontaneamente possibly smaller than more cephalad portions of the trachea. Eckenhoff Sedado as the child grows, the stated that cricoid plate becomes vertical, and the larynx becomes Niños sin paralisis more cylindrical shaped. He derived this information from Bayeux,1 who used moulages and anatomic sec- tions of 15 children, aged 4 months to 14 yr. Bayeux documented that the circumference of the cricoid ring was narrower than that of the trachea or the glottis. Our results do not allow us to make direct comparisons with the findings of Eckenhoff and Bayeux since we measured dimensions in the tonically active larynx. The clinical importance of our findings is speculative. On one hand, our results indicate that choosing an en- dotracheal tube based on the size of the cricoid ring may not prevent mucosal damage to the larynx cephalad to the cricoid ring in unparalyzed children. On the other hand, these more cephalad portions of the larynx consistFig. 3. Box plots demonstrating the relationship between tra-cheal transverse (top) and anterior–posterior (A-P; bottom) di- of yielding structures that distendAnesthesiology 2003 Litman, with placement of aameters at the levels of the vocal cords, subglottic area, and relatively larger endotracheal tube. The cricoid ring iscricoid ring. Transverse diameters increased linearly in a unyielding and prone to development of edema andcaudad direction (P < 0.001). The middle line of the box is the
  • 20. Pediatric AnesthesiologySection Editor; Peter J. DavisPediatric Laryngeal Dimensions: An Age-Based Analysis Priti G. Dalal, MD, FRCA* BACKGROUND: In children, the cricoid is considered the narrowest portion of the “funnel-shaped” airway. Growth and development lead to a transition to the more David Murray, MD† cylindrical adult airway. A number of airway decisions in pediatric airway practice are based on this transition from the pediatric to the adult airway. Our primary aim in this study was to measure airway dimensions in children of various ages. The Anna H. Messner, MD‡ measures of the glottis and cricoid regions were used to determine whether a transition from the funnel-shaped pediatric airway to the cylindrical adult airway Angela Feng, MDʈ could be identified based on images obtained from video bronchoscopy. METHODS: One hundred thirty-five children (ASA physical status 1 or 2) aged 6 mo to John McAllister, MD¶ 13 yr were enrolled for measurement of laryngeal dimensions, including cross- sectional area (G-CSA), anteroposterior and transverse diameters at the level of the David Molter, MD# glottis and the cricoid (C-CSA), using the video bronchoscopic technique under general anesthesia. RESULTS: Of the 135 children enrolled in the study, seven patients were excluded from the analysis mainly because of poor image quality. Of the 128 children studied (79 boys and 49 girls), mean values (Ϯstandard deviation) for the demographic data were age 5.9 (Ϯ3.3) yr, height 113.5 (Ϯ22.2) cm and weight 23.5 (Ϯ13) kg. Overall, the mean C-CSA was larger than the G-CSA (48.9 Ϯ 15.5 mm2 vs 30 Ϯ 16.5 mm2, respectively). This relationship was maintained throughout the study popu- lation starting from 6 mo of age (P Ͻ 0.001, r ϭ 0.45, power ϭ 1). The mean ratio for C-CSA: G-CSA was 2.1 Ϯ 1.2. There was a positive correlation between G- and the C-CSA versus age (r ϭ 0.36, P Ͻ 0.001; r ϭ 0.27, P ϭ 0.001, respectively), height (r ϭ 0.34, P Ͻ 0.001; r ϭ 0.29, P Ͻ 0.001, respectively), and weight (r ϭ 0.35, P Ͻ 0.001; r ϭ 0.25, P ϭ 0.003, respectively). No significant gender differences in the mean values of the studied variables were observed. CONCLUSION: In this study of infants and children, the glottis rather than cricoid was the narrowest portion of the pediatric airway. Similar to adults, the pediatric airway is more cylindrical than funnel shaped based on these video bronchoscopic images. Further studies are needed to determine whether these static airway measurements in anesthetized and paralyzed children reflect the dynamic charac- teristics of the glottis and cricoid in children. (Anesth Analg 2009;108:1475–9)T he pediatric laryngeal and cricoid relationship hasbeen described as “funnel-shaped” with the apex of of postmortem airway measurements, forms the ana- tomical basis for a number of pediatric airway man-the funnel at the level of the cricoid.1 This funnel- agement decisions.1–3 Recent clinical studies conductedshaped airway description, based on a limited number using different measurement techniques measured airway dimensions using two different techniques
  • 21. MIDIENDO LAS DIMENSIONES LARINGEAS POR VIDEO BRONCOSCOPIA...Figure 1. Measuring laryngeal dimen-sions. The catheter tip touching thegraph paper (a), the glottis (b), andcricoid (c) regions.Table 1. Results of the Linear Regression Analysis for LaryngealDimensions Versus Age, Height, and Weight, Respectively,in 128 Patients Age Height WeightG-CSA r ϭ 0.36 P Ͻ 0.001 r ϭ 0.34 P Ͻ 0.001 r ϭ 0.35 P Ͻ 0.001 Dalal, Anesth Anag 2009G-AP r ϭ 0.38 r ϭ 0.36 r ϭ 0.39 P Ͻ 0.001 P Ͻ 0.001 P Ͻ 0.001G-trans r ϭ 0.24 r ϭ 0.22 r ϭ 0.17 P ϭ 0.005 P ϭ 0.009 P ϭ 0.047C-CSA r ϭ 0.27 r ϭ 0.29 r ϭ 0.25
  • 22. C-AP r ϭ 0.13 r ϭ 0.12 r ϭ 0.12 P ϭ 0.129 P ϭ 0.167 P ϭ 0.14 C-trans r ϭ 0.13 r ϭ 0.19 r ϭ 0.12 P ϭ 0.117 P ϭ 0.03 P ϭ 0.18DIAGRAMA DE DISPERSION DE LAS SECCIONES study population Cricoid:glottic CSA ments in the r ϭ 0.18 P ϭ 0.04 r ϭ 0.11 P ϭ 0.18 r ϭ 0.14 P ϭ 0.11 Figure 3. Box and whiskers plo CRUZADAS DE AREA GLOTICA Y CRICOIDEA ϭ cricoid anteropo anteroposterior diameter; G-tra G-CSA ϭ glottic cross-sectional area; G-AP ϭ glottic anteroposterior diameter; G-trans ϭ glottic eter; C-AP transverse diameter; C-CSA ϭ cricoid crosssectional area; C-AP ϭ cricoid anteroposterior diam- eter; C-Trans ϭ cricoid transverse diameter. cricoid transverse diameter. gender differences analyses, metric data) and the Mann (nonparametric data) were differences in values of each male and female children. considered as significant. RESULTS Overall, 135 patients were these, seven patients were e mainly because of poor im children studied (79 boys a (Ϯsd) for the demographic d height 113.5 (Ϯ22.2) cm, and Figure 2. Scatterplot with regression line and confidence interval lines for the cross-sectional areas (CSA) versus age. relationship between C-CS C-CSA ϭ cricoid cross-sectional area; G-CSA ϭ glottic given by the equation C-C cross-sectional area. G-CSA), r ϭ 0.45, P Ͻ 0.001 Vol. 108, No. 5, May 2009 © 2009 International Dalal, Anesth Analg 2009
  • 23. MITO O REALIDAD LA TRAQUEA PEDIATRICA Y EL DEDO MEÑIQUE• ¿PREDICE EL DIAMETRO DEL DEDO MEÑIQUE LA TALLA DEL TUBO ENDOTRAQUEAL?
  • 24. QUE NOS DICEN LOS LIBROS?• “OTRO METODO NO COMPROBADO CIENTIFICAMENTE , CLINICAMENTE UTIL USADO POR ALGUNOS ANESTESIOLOGOS ES COMPARAR EL DIAMETRO EXTERNO DEL TUBO ET CON EL DEL DEDO MEÑIQUE”
  • 25. THE ‘BEST FIT’ ENDOTRACHEAL TUBE IN CHILDREN - Comparison of Four Formulae - TURKISTANI A*, ABDULLAH KM***, DELVI B** AND A L -M AZROUA KA ****Abstract Background: Uncuffed endotracheal tubes are still being recommended by most pediatricanesthetists at our Institutes. Different algorithms and formulae have been proposed to choose thebest-fitting size of the tracheal tube. The most widely accepted is related to the age of the child[inner diameter [ID] in mm = (age in yr/4) +4; the second is a body, length-related formula (ID inmm = 2 + height in cm/30); the third, a multivariate formula (ID in mm = 2.44 + age in yr 0.1 +height in cm 0.02 + weight in kg 0.016]5; the fourth, the width of the 5th fingernail is used forID prediction of the ETT (ID in mm = maximum width of the 5th fingernail). The primary endpoint of this prospective study was to compare the size of the ‘best fit’tracheal tube with the size predicted using each of the above mentioned formulae. Patients and Methods: With Institutional Ethics Committee approval and parental consent,27 boys, 23 girls, ASA I-III, 2-10 years, scheduled for different surgical procedures requiringgeneral anesthesia and endotracheal intubation, were enrolled in the study. The size of ‘bestfit’ endotracheal tubes in those children were compared. The internal diameter considered the‘best fit’ by the attending pediatric anesthesiologist was compared to age-based, length-based,multivariate-based and 5th fingernail width-based formulae. For all tests, P < 0.05 was consideredto be statistically significant. Results: The mean (SD) IDs for the ‘best fit’, age-based, length-based, multivariate and 5thfingernail techniques were 5.31 (0.691), 5.54 (0.622), 5.82 (0.572), 5.71 (0.67) and 5.43 (0.821)mm, respectively. Conclusions: The age-based and 5th fingernail width-based predictions of ETT size are moreaccurate than length-based and multivariate-based formulae in terms of mean value and casematching. Key Words: pediatric, endotracheal tube, age, length, multivariate, 5th fingernail, formulaFrom College of Medicine, King Saud University, Riyadh 11461, P.O. Box: 2925, Riyadh, S.A.* MD, Assoc. Prof. of Anaesthesia. ** MD, Assist. Prof. of Anaesth. **** MD, FAAP, Assoc. Prof. Ped. Otolaryngology.From King Abdul-Aziz Medical City, Riyadh 11426, P.O. Box: 22490, Riyadh, S.A.*** MD, Arab Board, Consultant Cardiac Anaesthetist.Address for correspondence: Dr. Khaled M Abdullah, Consultant Cardiac Anaesthetist, King Abdul-Aziz Medical City.E-mail kmabdalla67@hotmail.com 383 M.E.J. ANESTH 20 (3), 2009
  • 26. height in cm 0.02 + weight in kg 0.016]5; the fourth, the width of the 5th fingernail is used forID prediction of the ETT (ID in mm = maximum width of the 5th fingernail). The primary endpoint of this prospective study was to compare the size of the ‘best fit’tracheal tube with the size predicted using each of the above mentioned formulae. Patients and Methods: With Institutional Ethics Committee approval and parental consent,27 boys, 23 girls, ASA I-III, 2-10 years, scheduled for different surgical procedures requiringgeneral anesthesia and endotracheal intubation, were enrolled in the study. The size of ‘bestfit’ endotracheal tubes in those children were compared. The internal diameter considered the‘best fit’ by the attending pediatric anesthesiologist was compared to age-based, length-based,multivariate-based and 5th fingernail width-based formulae. For all tests, P < 0.05 was consideredto be statistically significant. Results: The mean (SD) IDs for the ‘best fit’, age-based, length-based, multivariate and 5thfingernail techniques were 5.31 (0.691), 5.54 (0.622), 5.82 (0.572), 5.71 (0.67) and 5.43 (0.821)mm, respectively. Conclusions: The age-based and 5th fingernail width-based predictions of ETT size are moreaccurate than length-based and multivariate-based formulae in terms of mean value and casematching. Key Words: pediatric, endotracheal tube, age, length, multivariate, 5th fingernail, formulaFrom College of Medicine, King Saud University, Riyadh 11461, P.O. Box: 2925, Riyadh, S.A.* MD, Assoc. Prof. of Anaesthesia. ** MD, Assist. Prof. of Anaesth. **** MD, FAAP, Assoc. Prof. Ped. Otolaryngology.From King Abdul-Aziz Medical City, Riyadh 11426, P.O. Box: 22490, Riyadh, S.A.*** MD, Arab Board, Consultant Cardiac Anaesthetist.Address for correspondence: Dr. Khaled M Abdullah, Consultant Cardiac Anaesthetist, King Abdul-Aziz Medical City.E-mail kmabdalla67@hotmail.com
  • 27. Increasing discrepancy between uncuffed ETT OD and sub- in the use of racemic epinephrine for postext glottic diameter in proportion as a function of subglottic tic edema, the rate of successful extubation diameter indicates that the narrowest part of the pediatric tracheotomy between intubations with cu PERIOPERATIVE MEDICINE larynx must lie above the cricoid ring level even among par- cuffed ETTs.16 –18 alyzed patients (fig. 3). In summary, previous established formu Although ultrasonography is an operator-dependent poorly predicted pediatric ETT size. In con technique, it is relatively simple to learn. A total of approxi- upper airway diameter measured by ultraso mately 15 procedures are required for operators to obtain good predictor of correct cuffed and uncuff reliable and reproducible measurements.11 Another concern pediatric patients. about ultrasonic measurements is that age-dependent physi- ologic calcification of the larynx creates an acoustic shadow. References However, as calcification begins to occur in the laryngeal 1. Browning DH, Graves SA: Incidence o endotracheal tubes in children. J Pediatr cartilage during the third decade of life, ultrasonography can 2. Oshodi A, Dysart K, Cook A, Rodriguez be applied with few problems in pediatrics.20 TH, Miller TL: Airway injury resulting fFig. 1. Photograph and illustration of ultrasonography ofsizeneck to be selected from measurement of Optimal ETT the could measure subglottic diameter. Patient consent was obtained intubation: Possible prevent dotracheal 21 diatr Crit Care Med 2010 Apr 1. [Epub afor use of this photograph. the tracheal diameter on chest radiography. A good corre- lation in tracheal diameter between computed tomography 3. Roy WL: Intraoperative aspiration in a p Can Anaesth Soc J 1985; 32:639 – 41as determined by ultrasonography, better predicts optimal indicatesof the true vocal folds as paired hyperechoic linear struc- and chest radiography ization that the latter could give aETT size than existing methods. representative measurement of that moved with respiration and swallowing4. Sherman JM, Nelson H: Decreased incid tures tracheal diameter.22 A length before pa- stenosis using an “appropriate-sized” end tients were paralyzed. The probe was then moved caudally to Pediatr Pulmonol 1989; 6:183 of approximately 70% (uncuffed) or 60% (cuffed) of the neonates.Materials and Methods visualize the cricoid arch (i.e., round hypoechoic structure with 5. Dillier CM, Trachsel D, Baulig W, Gys hyperechoic as Determined by air-column diameter was Laryngeal damage due to an u edges). The transverseThis study was approved by the Review Board2. Human Exper- Tube Size the lower edge of the cricoid cartilage afterWeiss M: Table for Endotracheal measured at patients and inappropriately designed cuffed piments at Kyoto Prefectural UniversityUltrasonography for Pediatric Patients of Medicine (Kyoto, Japan). were paralyzed, and was considered tracheal diameter. These mea- a 13-month-old child. Can J Anae tube inWritten informed consent was obtained from custodial adults. We surements were Outer Diameter, mm or positive end-ex- Pediatric formulas for the anesth performed without ventilationenrolled a total of 192 patients aged 1Inner 6 yr, split intomm mo to Diameter, devel- 6. Cole F: piratory pressure to minimize fluctuation in tracheal diameter.Child 1957; 94:672–3 Disopment and validation phases. Each patient was scheduled for sur- 3.0 4.3 The ultrasonographer had considerable experience7. Motoyama EK: Endotracheal intubation. performinggery requiring general endotracheal anesthesia. Those with condi- 3.5 4.9 laryngeal ultrasonography before the starting this investigation. Infants and Children. St Louis thesia fortions known or suspected to predispose them4.0 laryngeal or to 5.6 269 –75. Typically, the ultrasound measurements took approximately 30 s.tracheal pathology were excluded. General anesthesia was induced 4.5 6.2 The trachea was then intubated using direct laryngos- Wears RL, Broselow J, Zarits 8. Luten RC,by inhalation of sevoflurane or intravenous administration of thio- 5.0 copy. Size of the initial 6.9 was selected as follows: T, Bailey A, Vally R, Brown R, Ros tube Lee (1)pental. Vecuronium was given to all patients for muscle relaxation. 5.5 7.5 formulas: ID (inner diameter)endotracheal tube and emergen based Our primary endpoint was a regression of outer ETT uncuffed tubes, with the Cole pediatrics. Ann Emerg Med 1992; 21:90diameter against subglottic diameter as determined by ultra- in mm ϭ 0.25 ϫ (age in years) ϩ 4; (2) cuffed ETTs insonography. In a pilot study, the SD of subglottic diameter children aged 2 yr or older, with the Motoyama formulas: ID Shibasaki et al. Anesthesiology, V 113 • No 4 • Octwas 2.9 mm, the correlation coefficient between ETT outer in mm ϭ 0.25 ϫ (age in years) ϩ 3.5; (3) cuffed ETTs indiameter (OD) and subglottic diameter was 0.7. The slope children younger than 2 yr, with the Khine formulas: ID inestimate obtained from regression equation was 0.5. Assum- mm ϭ 0.25 ϫ (age in years) ϩ 3.0.ing a true regression slope of 0.5, a total of 19 subjects were If there was resistance to ETT passage into the trachea, orrequired to reject the null hypothesis that this slope equals there was no audible leak when the lungs were inflated to azero with 90% power at an ␣ level of 0.01.13 Our primary pressure of 20 –30 cm H2O, the tube was exchanged with one
  • 28. PERIOPERATIVE MEDICINE Anesthesiology 2010; 113:819 –24 Copyright © 2010, the American Society of Anesthesiologists, Inc. Lippincott Williams & WilkinsPrediction of Pediatric Endotracheal Tube Sizeby UltrasonographyMasayuki Shibasaki, M.D.,* Yasufumi Nakajima, M.D., Ph.D.,† Sachiyo Ishii, M.D.,*Fumihiro Shimizu, M.D.,* Nobuaki Shime, M.D., Ph.D.,‡ Daniel I. Sessler, M.D.§ABSTRACT Conclusions: Measuring subglottic airway diameter with ul-Background: Formulas based on age and height often fail to trasonography facilitates the selection of appropriately sizedreliably predict the proper endotracheal tube (ETT) size in ETTs in pediatric patients. This selection method better pre-pediatric patients. We, thus, tested the hypothesis that sub- dicted optimal outer ETT diameter than standard age- andglottic diameter, as determined by ultrasonography, better height-based formulas.predicts optimal ETT size than existing methods.Methods: A total of 192 patients, aged 1 month to 6 yr,who were scheduled for surgery and undergoing general What We Already Know about This Topicanesthesia were enrolled and divided into development ❖ The proper endotracheal tube size for children is poorly pre-and validation phases. In the development group, the op- dicted by formulas relying on age and height.timal ETT size was selected according to standard age- What This Article Tells Us That Is Newbased formulas for cuffed and uncuffed tubes. Tubes werereplaced as necessary until a good clinical fit was obtained. ❖ In 192 children aged 1 month to 6 yr, ultrasound measure- ment of subglottic airway diameter better predicted appropri-Via ultrasonography, the subglottic upper airway diame- ately sized endotracheal tube than traditional formulas usingter was determined before tracheal intubation. We con- age and height.structed a regression equation between the subglottic up-per airway diameter and the outer diameter of the ETTfinally selected. In the validation group, ETT size wasselected after ultrasonography using this regression equa- I NTUBATION of pediatric patients with an endotracheal tube (ETT) that is too small may result in insufficient ventilation, poor reliability of end-tidal gas monitoring, leak-tion. The primary outcome was the fraction of initialcuffed and uncuffed tube sizes, as selected through the age of anesthetic gases into the operating room environment,regression formula, that proved clinically optimal. and an enhanced risk of aspiration.1–3 In contrast, an ETTResults: Subglottic upper airway diameter was highly corre- that is too large can cause upper airway damage (e.g., locallated with outer ETT diameter deemed optimal on clinical ischemia, ulceration, scar formation) and the potential forgrounds. The rate of agreement between the predicted ETT subsequent subglottic stenosis.4,5size based on ultrasonic measurement and the final ETT size Age-based formulas, such as those of Cole and Mo-selected clinically was 98% for cuffed ETTs and 96% for toyama, have been used to estimate optimal ETT size foruncuffed ETTs. more than half a century.6,7 Predictive formulas for ap- propriate ETT size have also been based on patient weight and height.8 –10 However, none of these systems work * Instructor, ‡ Assistant Professor, Department of Anesthesiology especially well. The result is that repeated laryngoscopiesand Intensive Care, Kyoto Prefectural University of Medicine, Kyoto, are often necessary to identify the appropriate tube forJapan. † Assistant Professor, Department of Anesthesiology and In- individual patients.tensive Care, Kyoto Prefectural University of Medicine, and Member,OUTCOMES RESEARCH Consortium/Group. § Professor and Chair, Depart- Recent reports suggest that the diameter of the subglottic
  • 29. MITO O REALIDAD PRESION CRICOIDEA• ¿ES LA PRESION CRICOIDEA UN COMPONENTE IMPORTANTE EN LA INDUCCION DE SECUENCIA RAPIDA EN NIÑOS?
  • 30. DOCUMENTO DE SELLICK• EN EL ENFERMO CRITICO, SE PUEDE PREFERIR LA INDUCCION INHALADA.• TAN PRONTO COMO SE PIERDA LA CONCIENCIA, UNA PRESION FIRME DEBE SER APLICADA.• DURANTE LA PRESION CRICOIDEA, LOS PULMONES PUEDEN SER VENTILADOS.• LA ANTIGUA INDUCCION INHALADA... CON LA CABEZA DIRIGIDA HACIA ABAJO, TIENE ALGO QUE RECOMENDAR...
  • 31. Editorial Sellick’s Maneuver: To Do or Not Do Andranik Ovassapian, MD* T he introduction of cricoid pressure (CP) by Sellick1 in 1961 “to control regurgitation until intubation with a cuffed endotracheal tube was com- M. Ramez Salem, MD† pleted” was met with an enthusiastic reception worldwide and rapidly became an integral component of the rapid sequence induction/intubation technique (RSII). The maneuver consisted of “occlusion of the upper esophagus by backward pressure on the cricoid ring against the bodies of cervical vertebrae to prevent gastric contents from reaching the pharynx.”1 Sellick1 provided evidence that extension of the neck and application of CP obliterated the esophageal lumen at the level of the 5th cervical vertebra, as seen in a previously placed soft latex tube distended with contrast media to a pressure of 100 cm H2O. He also confirmed the value of CP in preventing saline (run into the esophagus from a height of 100 cm H2O) from reaching the pharynx in a patient undergoing gastroesophagectomy.2 Sellick1,2 emphasized that the lungs can be ventilated by intermittent positive pressure and that CP can prevent inflation of the stomach during positive pressure ventilation. References to CP were found in the literature more than 230 yr ago.3 In a letter from Dr. W. Cullen to Lord Cathcart dated August 8, 1774, concerning the recovery of persons “drowned and seemingly dead,” the use of CP by Dr. Monro was referred to as a means of preventing gastric distension during inflation of the lungs.3 Before Sellick described CP, several techniques were used in patients at risk of aspiration of gastric contents: awake intubation, induced hyperven- tilation with carbon dioxide during inhaled induction,4 and RSII per- formed with the patient in a 40° head-up tilt.5 The rationale behind the head-up tilt was that gastric contents could not reach the laryngeal level even if contents were moved up into the esophagus.5 The RSII with CP was extended not only to emergency surgical and obstetrical procedures and the critical care setting, but also to elective procedures in patients at risk of aspiration of gastric contents. The plethora of manuscripts, correspon- dence, and reviews on CP is a testimony to its relevance to anesthetic practice and continuing interest to clinicians.6 In the last 2 decades, clinicians have questioned the efficacy of CP and therefore the necessity of the maneuver.7,8 Some suggested abandoning it on the following grounds: (a) Its effectiveness has been demonstrated only in cadavers,9 –11 and therefore its efficacy lacks scientific validation. (b) It induces relaxation of the lower esophageal sphincter.8,12 (c) There have From the *Department of Anesthesia and been reports of regurgitation of gastric contents and aspiration despite CP.13Critical Care, Airway Study and Training (d) The esophagus is not exactly posterior to the cricoid, and thus theCenter, University of Chicago; and †Depart-ment of Anesthesiology, Advocate Illinois maneuver is unreliable in producing midline esophageal compression.14 (e) ItMasonic Medical Center, Department of An- is associated with nausea/vomiting and also with esophageal rupture.15 (f) Itesthesiology, University of Illinois College of makes tracheal intubation and mask ventilation difficult or impossible.15–18Medicine, Chicago, Illinois. Because of ethical considerations, a controlled study of the efficacy of CP is Accepted for publication June 18, 2009. not feasible. Even if such a study were conducted, it would probably yield Address correspondence and reprint re-quests to Andranik Ovassapian, MD, Depart- little information, given the low incidence of pulmonary aspiration. Thement of Anesthesia and Critical Care, Airway compelling evidence supporting the effectiveness of CP comes from studiesStudy and Training Center, University of Chi- that unequivocally demonstrate its efficacy in preventing gastric inflation incago, 5841 South Maryland Ave., Chicago, IL60637. Address e-mail to aovassap@dacc. anesthetized children and adults.19 –21 It is inconceivable that a maneuveruchicago.edu. effective in preventing gastric inflation during manual ventilation would not Copyright © 2009 International Anesthe- be effective in preventing esophageal contents from reaching the pharynx.sia Research Society The study by Rice et al.22 in the current issue sheds new light on theDOI: 10.1213/ANE.0b013e3181b763c0 efficacy of CP. In 24 awake volunteers, magnetic resonance imaging was1360 Vol. 109, No. 5, November 2009
  • 32. Editorial Sellick’s Maneuver: To Do or Not Do Andranik Ovassapian, MD* T he introduction of cricoid pressure (CP) by Sellick1 in 1961 “to control regurgitation until intubation with a cuffed endotracheal tube was com- M. Ramez Salem, MD† pleted” was met with an enthusiastic reception worldwide and rapidly became an integral component of the rapid sequence induction/intubation technique (RSII). The maneuver consisted of “occlusion of the upper esophagus by backward pressure on the cricoid ring against the bodies of cervical vertebrae to prevent gastric contents from reaching the pharynx.”1 Sellick1 provided evidence that extension of the neck and application of CP obliterated the esophageal lumen at the level of the 5th cervical vertebra, as seen in a previously placed soft latex tube distended with contrast media to a pressure of 100 cm H2O. He also confirmed the value of CP in preventing saline (run into the esophagus from a height of 100 cm H2O) from reaching the pharynx in a patient undergoing gastroesophagectomy.2 Sellick1,2 emphasized that the lungs can be ventilated by intermittent positive pressure and that CP can prevent inflation of the stomach during positive pressure ventilation. References to CP were found in the literature more than 230 yr ago.3 In a letter from Dr. W. Cullen to Lord Cathcart dated August 8, 1774, concerning the recovery of persons “drowned and seemingly dead,” the use of CP by Dr. Monro was referred to as a means of preventing gastric distension during inflation of the lungs.3 Before Sellick described CP, several techniques were used in patients at risk of aspiration of gastric contents: awake intubation, induced hyperven- tilation with carbon dioxide during inhaled induction,4 and RSII per- formed with the patient in a 40° head-up tilt.5 The rationale behind the head-up tilt was that gastric contents could not reach the laryngeal level even if contents were moved up into the esophagus.5 The RSII with CP was extended not only to emergency surgical and obstetrical procedures and the critical care setting, but also to elective procedures in patients at risk of aspiration of gastric contents. The plethora of manuscripts, correspon- dence, and reviews on CP is a testimony to its relevance to anesthetic practice and continuing interest to clinicians.6 In the last 2 decades, clinicians have questioned the efficacy of CP and therefore the necessity of the maneuver.7,8 Some suggested abandoning it on the following grounds: (a) Its effectiveness has been demonstrated only in cadavers,9 –11 and therefore its efficacy lacks scientific validation. (b) It induces relaxation of the lower esophageal sphincter.8,12 (c) There have From the *Department of Anesthesia and been reports of regurgitation of gastric contents and aspiration despite CP.13Critical Care, Airway Study and Training (d) The esophagus is not exactly posterior to the cricoid, and thus theCenter, University of Chicago; and †Depart-ment of Anesthesiology, Advocate Illinois maneuver is unreliable in producing midline esophageal compression.14 (e) ItMasonic Medical Center, Department of An- is associated with nausea/vomiting and also with esophageal rupture.15 (f) Itesthesiology, University of Illinois College of makes tracheal intubation and mask ventilation difficult or impossible.15–18Medicine, Chicago, Illinois.
  • 33. PRESION CRICOIDEA• FUE USADA POR PRIMERA VEZ EN 1774 POR MONRO,Y DESCRITA POR CULLEN EN UNA CARTA DIRIGIDA A LORD CATHCART, PRESIDENTE DEL COMITE POLICIAL DE ESCOCIA.• CULLEN ABOGA QUE LA PRESION CRICOIDEA ES UN MEDIO PARA PREVENIR LA INSUFLACION GASTRICA CUANDO SE DA REANIMACION A “PERSONAS AHOGADAS O QUE PARECEN MUERTAS”.
  • 34. LA ISR CONTEMPORANEA EN ADULTOS• PREOXIGENACION• INYECCION RAPIDA DEL ANESTESICO Y RELAJANTE.• PRESION CRICOIDEA.• EVITAR LA VENTILACION MANUAL.• INSERCION DEL TUBO ET, INFLADO DEL CUFF, CONFIRMACION DE LA POSICION.• LIBERACION DE LA PRESION CRICOIDEA.
  • 35. ISR PEDIATRICA• “... LAS CARACTERISTICAS CLAVES DE UNA ISR PEDIATRICA MENCIONA UNA INDUCCION EFECTIVA DE UNA ANESTESIA PROFUNDA, EVITAR LA PRESION CRICOIDEA Y LA CONFIRMACION DE LA PARALISIS MUSCULAR COMPLETA...”.• “... SE DEBE ABANDONAR LA PRESION CRICOIDEA EN TODOS LOS PACIENTES CON EXCEPCION DE LOS PEDIATRICOS...”
  • 36. ISR PEDIATRICA• “... LAS CARACTERISTICAS CLAVES DE UNA ISR PEDIATRICA MENCIONA UNA INDUCCION EFECTIVA DE UNA ANESTESIA PROFUNDA, EVITAR LA PRESION CRICOIDEA Y LA CONFIRMACION DE LA PARALISIS MUSCULAR COMPLETA...”.• “... SE DEBE ABANDONAR LA PRESION CRICOIDEA EN TODOS LOS PACIENTES CON EXCEPCION DE LOS PEDIATRICOS...”
  • 37. ¿POR QUE ESTA CONTROVERSIA?• NO HA SIDO LLEVADO A CABO UN ENSAYO CLINICO RANDOMIZADO SOBRE ISR CLASICA.• EL HECHO DE SER REALIZADO EN ADULTOS NO PUEDE SER APLICADO A NIÑOS, DE TAL MODO QUE:• LA PREOXIGENACION RARAMENTE ES ADECUADA.• DESATURACION OCURRE MAS RAPIDAMENTE.• LA APLICACION DE PRESION CRICOIDEA PUEDE HACER DEL PROCEDIMIENTO DE INTUBACION UN PROCEDIMIENTO MAS DIFICIL.
  • 38. Pediatric Anesthesia 2010 20: 421–424 doi:10.1111/j.1460-9592.2010.03287.xComplications during rapid sequence induction ofgeneral anesthesia in children: a benchmark study F R A N K J. GE N C O R E L LI M D * , R Y A N G. F I E L D S DO, MBA† AND RONALD S. LITMAN DO‡ *Department of Anesthesiology, Hospital of the University of Pennsylvania School of Medicine, Philadelphia, PA, USA, †Jersey Shore University Medical Center, Neptune, NJ, USA and ‡Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia, Professor of Anesthesiology and Pediatrics, University of Pennsylvania School of Medicine, PA, USA Section Editor: Dr Andrew Davidson Summary Objectives: Determine incidence of complications such as difficult or failed intubation, hypoxemia, hypotension, and bradycardia in chil- dren undergoing rapid sequence intubation (RSI) in a pediatric anesthesia department in a tertiary care children’s hospital. Aim: To establish a benchmark to be used by other institutions and nonanesthesiologists performing RSI in children. Background: RSI is being increasingly performed in the nonoperating room setting by nonanesthesiologists. No published studies exist to establish a benchmark of intubation success or failure and complica- tions in this patient population. Methods ⁄ Materials: Retrospective cohort analysis of children aged 3– 12 undergoing RSI from 2001 to 2006. Results: One thousand seventy children underwent RSI from 2001 to 2006. Twenty (1.9%) developed moderate hypoxemia (SpO2 80–89%), 18 (1.7%) demonstrated severe hypoxemia (SpO < 80%), 5 (0.5%)
  • 39. Professor of Anesthesiology and Pediatrics, University of Pennsylvania School of Medicine, PA, USA Section Editor: Dr Andrew Davidson Summary Objectives: Determine incidence of complications such as difficult or failed intubation, hypoxemia, hypotension, and bradycardia in chil- dren undergoing rapid sequence intubation (RSI) in a pediatric anesthesia department in a tertiary care children’s hospital. Aim: To establish a benchmark to be used by other institutions and nonanesthesiologists performing RSI in children. Background: RSI is being increasingly performed in the nonoperating room setting by nonanesthesiologists. No published studies exist to establish a benchmark of intubation success or failure and complica- tions in this patient population. Methods ⁄ Materials: Retrospective cohort analysis of children aged 3– 12 undergoing RSI from 2001 to 2006. Results: One thousand seventy children underwent RSI from 2001 to 2006. Twenty (1.9%) developed moderate hypoxemia (SpO2 80–89%), 18 (1.7%) demonstrated severe hypoxemia (SpO2 < 80%), 5 (0.5%) developed bradycardia (heart rate <60), and 8 (0.8%) developed hypotension (systolic blood pressure <70 mmHg). One patient had emesis of gastric contents but no evidence of pulmonary aspiration or hypoxemia. Eighteen (1.7%) children were noted to be difficult to intubate and required more than one intubation attempt. All were eventually intubated without significant complications. Patients between 10 and 19 kg had a higher incidence of severe hypoxemia when compared with older children (P < 0.001). There was no association between choice of muscle relaxant and any complication. Conclusions: In our cohort of 1070 children who underwent RSI, difficult intubation was encountered in 1.7% and transient oxy- hemoglobin desaturation occurred in 3.6%. Severe hypoxemia was more likely in children <20 kg. There were no children who could not be intubated, and there were no long-term or permanent complica- tions.Correspondence to: Ronald S. Litman, DO, Department of Anesthesiology & Critical Care, The Children’s Hospital of Philadelphia, 34th St. &Civic Center Blvd, Philadelphia, PA 19104, USA (email: Litmanr@email.chop.edu).
  • 40. ISR PEDIATRICA3 Y P E D IA T R I C R A P I D S E Q U E N C E IN D U C T I O N 42 DESATURACION (a) ± (range) • SD2.92 (3–12) 1070 ISR.16.5 (10–180) 677 N (%) (63.3) • 1.7 % casos dificiles. • 61 (5.7) 18 (1.7) 3.6 % de pacientes mostraron 21 (2.0) 262 (24.6) (b) desaturacion. 29 (2.7) N (%) • Pacientes entre 10 y 19 kg no 911 77 (85.1) (7.2) demostraron hipoxemia moderada 64 10 (6.0) (0.9) comparado con los demas grupos. • nted in the Pacientes entre 10 y 19 kg SIuscle relaxant Figure 1 demostraron hipoxemia mas (a) Patients between 10 and 19 kg were not more likely to demonstrate moderate hypoxemia (SpO2 80–89%) than patients severa que los demas grupos weighing 20 kg or greater (P = 0.19). (b) Patients between 10 andation 19 kg were more likely to demonstrate severe hypoxemia than patients weighing 20 kg or greater (SpO2 < 80%) (P < 0.0001). N (%) 20 (1.9) were no further details. Of the 18 children who 18 5 (1.7) (0.5) developed severe hypoxemia, there were accompa- Gencorelli, Ped Anesth 2010 8 (0.8) nying comments on four. One was noted to be 18 (1.7)
  • 41. EL ESTUDIO WARNER
  • 42. EL ESTUDIO WARNER• 63180 ANESTESIAS GENERALES EN NIÑOS MENORES DE 18 AÑOS.• ASPIRACION PULMONAR EN 24 PACIENTES. (0.04%).• NO HUBO MUERTES. SOLO 3 PACIENTES QUE REQUIRIERON IPPV POR MAS DE 48 H.• ASPIRACION OCURRIO MAYORMENTE EN EL MOMENTO DE INDUCCION, A PESAR DEL USO DE LA PRESION CRICOIDEA.• EN RIESGO: PACIENTES MENORES DE 3A CON CUADROS OBSTRUCTIVOS INTESTINALES. Warner X 5, Anesthesiology 1999
  • 43. ISR MODIFICADA EN NIÑOS• PREOXIGENAR DE LA MEJOR MANERA POSIBLE.• ASEGURAR UN PLANO PROFUNDO DE ANESTESIA Y PARALISIS MUSCULAR COMPLETA.• VENTILACION CON PRESION POSITIVA GENEROSA.• NO APLICAR PRESION CRICOIDEA DE RUTINA.• PRESION CRICOIDEA EN CIRCUNSTANCIAS ESPECIALES. EJ: DISTENSION ABDOMINAL SEVERA.
  • 44. MITO O REALIDADTUBOS ENDOTRAQUEALES EN PEDIATRIA: ¿CON CUFF O SIN CUFF? • EL USO DE TUBOS ET SIN CUFF,YA SEA DE BAJA O ALTA PRESION, NO ESTA RECOMENDADO EN INFANTES Y NIÑOS MENORES DE 8 AÑOS DE EDAD. Bissonnette y Dalens, Ped Anesthesia 2002
  • 45. .$B1D664&2$,6??$+%0136+( `1: JXXX *+,"##$%&f&RX&<$02( Z1: JXX` *+,"##$%&f&Z&<$02( V1: JXXS& !"##$%&^U&$$+&3+& 3+#0+1(
  • 46. .$B1D664&2$,6??$+%0136+(.$B1D664&2$,6??$+%0136+( 2% 2% JXXR JXXR *+,"##$%&f&]&<$02( *+,"##$%&f&]&<$02( 1:T1: JXXS T JXXS .20%3136+0A& .20%3136+0A& ]&<$02( ]&<$02(
  • 47. .$B1D664&2$,6??$+%0136+( Z1: RSSZ& *+,"##$%&f&]&<$02( V1: JXXZ *+,"##$%&1"D$(&?0<& D$&^U
  • 48. -B,$AA$+1&F+(3C:1 @(&#02&D0,4&0(&1:$&2% -%3136+&3+&RSST&1:$& "($&6#&,"##$%&1"D$(&3(& ,6+(3%$2$%) !:0=1$2&D<&9$++3(& K3(:$27&89
  • 49. ¿TUBOS ET CON CUFF O SIN CUFF EN NIÑOS?• HISTORICAMENTE, UNA ALTA INCIDENCIA DE COMPLICACIONES EN VIA AEREA, NOTABLE EDEMA SUB GLOTICO Y ESTENOSIS, CON EL USO DE LOS TUBOS ET CON CUFF DE LATEX ROJO.• LOS DATOS PICU (NEWTH,2004) SUGIEREN Q NO HAY DIFERENCIAS EN CUANTO A COMPLICACIONES CON EL USO DE TUBOS ET CON CUFF.• LOS NUEVOS DISEÑOS DE LOS TUBOS ET HAN PERMITIDO EL INCREMENTO EN EL USO DE MANERA SEGURA DE LOS TUBOS ET CON CUFF.
  • 50. Evidence-Based Positive Clinical OutcomesProspective Randomized Multi-Center Study 24 centros hospitalarios en Europa: n = 2,249 patients Promedio de edad de pctes: 1.9 years (3.0mm-4.5mm tubos ET) Recambio de Tubo: 2.1% MICROCUFF, 29.9% Tubos sin cuff Estridor Post extubacion: 4.38% MICROCUFF, 4.69% Tubos sin cuff Pressure del cuff para sellar la traquea: 10.6 cm H2O
  • 51. EL ESTUDIO WEISS METODOS• TAMAÑO MUESTRAL GRANDE.• RAMDOMIZADO DE FORMA ADECUADA.• CIEGO.• INCLUYO ESTRIDOR DE VARIAS CAUSAS.• SOLO USO UN TIPO DE TUBO ET: MICROCUFF.• USO INSUFLACION MINIMA DEL CUFF CON MEDICION DE PRESION DE CUFF.
  • 52. SOBRE TUBOS ET SIN CUFF... Fuga en Via Presion sobre cricoides Aerea 3.0mm 3.5mm 4.0mmTubo muy pequeño Tubo muy grande - Ventilacion dificil - Alto riesgo de estenosis subglotica
  • 53. Diferencias de Sellado con Tubo ET sin Cuff Fuga Texto de Aire GlotisCrIcoides Carina Suominen P et al. Paediatric Anaesthesia, 2006. Holzki J. Paediatric Anaesthesia, 1997. Weiss and Gerber. Pediatric Anesthesia, 2006.
  • 54. Diferencias de Sellado con Tubo ET sin Cuff Fuga Texto de Aire Tubos Pequeños GlotisCrIcoides Monitoreo Inadecuado Carina Suominen P et al. Paediatric Anaesthesia, 2006. Holzki J. Paediatric Anaesthesia, 1997. Weiss and Gerber. Pediatric Anesthesia, 2006.
  • 55. Diferencias de Sellado con Tubo ET sin Cuff Fuga Texto de Aire Tubos Pequeños GlotisCrIcoides Monitoreo Inadecuado Carina Suominen P et al. Paediatric Anaesthesia, 2006. Holzki J. Paediatric Anaesthesia, 1997. Weiss and Gerber. Pediatric Anesthesia, 2006.
  • 56. Diferencias de Sellado con Tubo ET sin Cuff Fuga Texto de Aire Tubos Pequeños GlotisCrIcoides Monitoreo Inadecuado Alto riesgo de aspiracion Carina Suominen P et al. Paediatric Anaesthesia, 2006. Holzki J. Paediatric Anaesthesia, 1997. Weiss and Gerber. Pediatric Anesthesia, 2006.
  • 57. Diferencias de Sellado con Tubo ET sin Cuff Fuga Texto de Aire Tubos Pequeños GlotisCrIcoides Monitoreo Inadecuado Alto riesgo de aspiracion Carina Suominen P et al. Paediatric Anaesthesia, 2006. Holzki J. Paediatric Anaesthesia, 1997. Weiss and Gerber. Pediatric Anesthesia, 2006.
  • 58. Diferencias de Sellado con Tubo ET sin Cuff Fuga Texto de Aire Tubos Pequeños GlotisCrIcoides Monitoreo Inadecuado Alto riesgo de aspiracion Dificultad para ventilacion Carina Suominen P et al. Paediatric Anaesthesia, 2006. Holzki J. Paediatric Anaesthesia, 1997. Weiss and Gerber. Pediatric Anesthesia, 2006.
  • 59. Diferencias de Sellado con Tubo ET sin Cuff Fuga Texto de Aire Tubos Pequeños GlotisCrIcoides Monitoreo Inadecuado Alto riesgo de aspiracion Dificultad para ventilacion Carina Suominen P et al. Paediatric Anaesthesia, 2006. Holzki J. Paediatric Anaesthesia, 1997. Weiss and Gerber. Pediatric Anesthesia, 2006.
  • 60. Diferencias de Sellado con Tubo ET sin Cuff Fuga Texto de Aire Tubos Pequeños GlotisCrIcoides Monitoreo Inadecuado Alto riesgo de aspiracion Dificultad para ventilacion Carina Alto Flujo de gas fresco Suominen P et al. Paediatric Anaesthesia, 2006. Holzki J. Paediatric Anaesthesia, 1997. Weiss and Gerber. Pediatric Anesthesia, 2006.
  • 61. Diferencias de Sellado con Tubo ET sin Cuff Fuga Texto de Aire Tubos Pequeños Tubos Grandes GlotisCrIcoides 2.8 veces mas Monitoreo Inadecuado posibilidades de desarrollar eventos adversos. Alto riesgo de aspiracion Cause primaria (92%) de trauma laringeo en un Dificultad para ventilacion estudio con 65 pacientes. Carina Alto Flujo de gas fresco Suominen P et al. Paediatric Anaesthesia, 2006. Holzki J. Paediatric Anaesthesia, 1997. Weiss and Gerber. Pediatric Anesthesia, 2006.
  • 62. Localización Ideal y Características de los Tubos ET Pediatricos con Cuff  Cortos, cuff cilíndrico localizado cerca de la punta del tubo ET.Glotis  Localización del Cuff en la traquea, y no en la laringe Posicion que es sensible a los cambios de presión del cuff.Cricoides Adecuada del cuff  Marca de profundidad basada anatómicamente lo que Traquea resulta en una correcta posición. Media  La punta debe situarse en la mitad de la traquea para evitar la migración endobronquial. Carina  Debe tener un cuff de baja presión para reducir los riesgos de trauma a la via aerea.
  • 63. Muchos Tubos ET tienen diseños no adecuados para usopediatrico Posición del cuff muy alta, cuffs muy largos. Ausencia de marcas de profundidad. No tienen recomendaciones para la selección de tamaño. Cuff position should avoid pressure- sensitive vocal cords and cricoid ring Weiss M et al, BJA 2004 Texto
  • 64. The Solution: KIMBERLY-CLARK* MICROCUFF* ET Tube Finally, a cuffed ET tube specifically designedDullenkopf A et al. Pediatric Anesthesia, 2004.
  • 65. The Solution: KIMBERLY-CLARK* MICROCUFF* ET Tube Confidence in a Introducing a sealed airway microthin polyurethane cuff Superior seal at ultra-low pressuresShort, distally-placed cuff Ensures correct placement, avoiding repeated intubations Clinically verified, anatomically correct vocal cord depth mark Finally, a cuffed ET tube specifically designed Dullenkopf A et al. Pediatric Anesthesia, 2004.
  • 66. Acta Anaesthesiol Scand 2005; 49: 232—237 Copyright # Acta Anaesthesiol Scand 2005Printed in Denmark. All rights reserved ACTA ANAESTHESIOLOGICA SCANDINAVICA doi: 10.1111/j.1399-6576.2004.00599.xFit and seal characteristics of a new paediatric trachealtube with high volume—low pressure polyurethane cuffA. DULLENKOPF, A. C. GERBER and M. WEISSDepartment of Anaesthesia, University Children’s Hospital Zurich, Zurich, SwitzerlandBackground: To evaluate a new paediatric tracheal tube (4—20). In two patients postextubation croup required singular(Microcuff, Weinheim, Germany) with an ultrathin high short-term therapy.volume—low pressure polyurethane cuff. Conclusions: Microcuff paediatric tracheal tubes provided tra-Methods: With approval of the Hospital Ethics Committee cheal sealing with cuff pressures considerably lower thantracheas of children undergoing general anaesthesia were intub- usually accepted. The rate of tube exchange was very lowated using a Microcuff tube. Tube sizes were selected accord- (1.6%), as was the rate of airway morbidity (croup requiringing to: internal diameter (mm) ¼ age/4 þ 3.5 in children aged therapy; 0.4%).!2 years. In newborns (!3 kg) 1 year, ID 3.0-mm tubes, and inchildren from 1 to 2 years, internal diameter 3.5-mm tubes wereused. Tubes were classified too large if no air leakage was Accepted for publication 1 October 2004obtained at an airway pressure of 20 cm H2O with the cuff notinflated. Sealing pressure was assessed by auscultation. Post- Key words: Children, paediatric; croup, sealing, tracheal;extubation croup requiring therapy was noted. cuff, high volume-low pressure; morbidity; tracheal tube.Results: Five-hundred children were studied. In eight childrenthe tubes were too large. Sealing pressure was 9.7 Æ 2.5 cm H2O # Acta Anaesthesiologica Scandinavica 49 (2005)T HEuse of cuffed tracheal tubes is a controversial topic in paediatric anaesthesia and intensive care(1, 2). Whereas traditionally recommended for chil- sized uncuffed tubes in order to avoid air leakage (4). Oversized tracheal tubes in children are the main cause of subglottic mucosal ischemia and ulcerationdren older than 8—10 years, during the past decade leading to subglottic stenosis (1, 10, 11).several authors have argued for the use of cuffed The selection of cuffed tubes with a smaller internal
  • 67. TUBOS ET CON CUFF EN NIÑOS• NO HAY ALTA INCIDENCIA DE COMPLICACIONES EN TANTO SE ELIJA : • UN TAMAÑO ADECUADO DEL TUBO ET PARA SER USADO. • UN DISEÑO DE TUBO ET ADECUADO. • EVITE LA SOBREDISTENSION DEL CUFF.
  • 68. USO DE TUBOS ET EN NIÑOS• ENCUESTA POSTAL EN 2001:• > 80 % USO 25%• 20% − 80% USO 38%• < 20% USO 18%• EXCEPCIONALMENTE 19%• ENCUESTA POR EMAIL EN REINO UNIDO, 2008:• RARAMENTE 13%• OCASIONALMENTE 60%• DE RUTINA 27% Flynn, Eur Jour Anesth 2008
  • 69. SOBRE AGENTES INHALADOS...
  • 70. AGENTES INHALADOS...• ES SEVOFLUORANO EL CAUSANTE DEL DELIRIO AL DESPERTAR?• EL OXIDO NITROSO. REALMENTE CONTRIBUYE A LAS NAUSEAS Y VOMITOS POSTOPERATORIOS?
  • 71. SOBRE LA AGITACION AL DESPERTAR...• QUIEN CAUSA MAS AGITACION AL DESPERTAR: SEVOFLUORANO? ISOFLUORANO?
  • 72. AD: SEVOFLUORANO VS HALOTANOAnesthesiology 2008; 109:225–32 Copyright © 2008, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.Greater Incidence of Emergence Agitation in Children afterSevoflurane Anesthesia as Compared with HalothaneA Meta-analysis of Randomized Controlled TrialsNorifumi Kuratani, M.D., Ph.D.,* Yumiko Oi, M.D.† Background: Sevoflurane is a popular inhalational anesthetic source of dissatisfaction for parents, nurses, and othersfor general anesthesia in children. The higher incidence of taking care of these children. The irritable, uncoopera-emergence agitation has been suspected after sevoflurane an-esthesia as compared with halothane, whereas some controlled tive, incoherent child who is inconsolably crying, moan-studies showed conflicting results. In this report, the authors ing, kicking, or thrashing is at risk for injury and requiresperformed a meta-analysis of randomized controlled trials to extra nursing care and supplemental sedative and/orcompare the incidence of emergence agitation in children after analgesic medications, which may delay patient dis-sevoflurane or halothane anesthesia. charge from hospital. Methods: A comprehensive literature search was conductedto identify clinical trials that compared the incidence of emer- Pediatric anesthesiologists mostly agree that sevoflu-gence agitation in children anesthetized with sevoflurane ver- rane causes a higher incidence of emergence agita-sus halothane. Two reviewers independently assessed each re- tion,1–3 whereas some controlled studies comparingport to meet the authors inclusion criteria and extracted data. sevoflurane and halothane showed conflicting results.4,5The data from each trial were combined using the Mantel- The conflicting results may arise from the differences ofHaenszel fixed-effect model to calculate the pooled odds ratioand 95% confidence interval. Funnel plots were used to assess study design, the background of study patients, andpublication bias. Subgroup analysis was used to clarify the ef- study quality. Under the existence of many confoundingfects of age, surgical procedure, pain treatment, and premedi- factors regarding emergence agitation, it is hard to drawcation on the incidence of emergence agitation. from a single study a definitive answer about whether Results: The authors identified 23 studies that met their sevoflurane results in a higher probability of emergenceinclusion criteria. Overall, 1,252 patients received sevofluraneand 1,111 had halothane. Heterogeneity of data was statistically agitation in children. Various methods, including treat-refuted. The pooled odds ratio for all studies was 2.21, with a ments against surgical pain and prescriptions of sedative95% confidence interval of 1.77–2.77 (P < 0.0001). Publication premedication, have been tried to prevent emergencebias was not apparent in a funnel plot. All subgroup analyses agitation after sevoflurane anesthesia, but their validitiesshowed a higher incidence of agitation after sevoflurane have not been well clarified.anesthesia. Conclusions: This meta-analysis revealed that emergence ag- Meta-analysis is a statistical tool that can be used toitation occurred more frequently with sevoflurane than with evaluate the literature in both qualitative and quantita-halothane anesthesia in children. tive ways, accounting for variations in characteristics that can influence the overall estimate of outcomes of interest. Statistical aggregation of randomized trials
  • 73. HISTORIA CON ISOFLUORANO• EXPERIENCIA INICIAL CON 100 PACIENTES EN LOS AÑOS 70. (DRIPPS Y PAUCA).• USO GENERAL EN NORTEAMERICA DESDE 1982.• INTRODUCCION EN REINO UNIDO EN EL AÑO 1983.• NUNN PUBLICO UNA SERIE DE CASOS SOBRE LA EXPERIENCIA EN REINO UNIDO EN EL AÑO 1983 Y 1984.• 135 PACIENTES EN EL HOSPITAL GENERAL DEL DISTRITO.• 2 MESES A 95 AÑOS. Dripps, Nunn, BJA 1973 y 1985
  • 74. QUE DIJO NUNN SOBRE ISOFLUORANO?• “EL UNICO GRAN PROBLEMA FUE EL DELIRIO, LO QUE REQUIRIO LA INTERVENCION MAS DE 1 ENFERMERA Y NO RESPONDIA A MORFINA EV”.• “ESTOY DE ACUERDO CON LO VISTO POR DRIPPS Y PAUCA, DE QUE LA CONDICION (DELIRIO) ES CAUSADO POR LA PERCEPCION SUBITA DEL DOLOR POSTOPERATORIO COMO RESULTADO DE LA RAPIDA ELIMINACION DEL ISOFLUORANO”. Nunn, British Journal of Anesthesia 1985
  • 75. ISOFLUORANO VS SEVOFLUORANO Tracheal Extubation of Deeply Anesthetized Pediatric Patients: A Comparison of Isoflurane and Sevoflurane Robert D. Valley, MD, Justin T. Ramza, MD, Pauletta Calhoun, RN, Eugene B. Freid, MD, FCCM, Ann G. Bailey, MD, Vincent J. Kopp, MD, and Linda S. Georges, MD Department of Anesthesiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina We studied the emergence characteristics of unpre- either group. Breath-holding was more common in medicated children tracheally extubated while deeply Group I. We conclude that the overall incidence of air- anesthetized (“deep extubation”) with isoflurane or way problems and desaturation episodes was similar sevoflurane. Forty children were assigned to one of two between groups. Emergency delirium was common in groups, Group I or Group S. At the end of the operation, both groups (32% overall: 40% for Group I, 25% for Group I patients were extubated while breathing 1.5 Group S). Implications: Deep extubation of children times the minimum alveolar anesthetic concentration can be safely performed with either isoflurane or (MAC) of isoflurane. Group S patients were tracheally sevoflurane. After deep tracheal extubation, airway extubated while breathing 1.5 times the MAC of problems occur but are easily managed. Return to an sevoflurane. Recovery characteristics and complica- arousable state occurred more quickly with sevoflu- tions were noted. Group S patients were arousable rane, although time to meeting discharge criteria was sooner than Group I patients (10.1 ϩ 6.5 vs 16.3 ϩ not different between the two groups. Emergence delir- 9.9 min). Later arousal scores and times to discharge ium occurs frequently with either technique. were the same. There were no serious complications in (Anesth Analg 1999;88:742–5)• T ENSAYO CLINICOhas the advantage of induction of anesthesia and has aMESES for inhaled racheal extubation of patients while deeply anes- thetized (deep extubation) RANDOMIZADO, 40 NIÑOS, DE 4 tolerated A 14 Because sevoflurane is easily relatively low blood- AÑOS, CIRUGIA DE ABDOMEN INFERIOR CON BLOQUEO deep extu- removing a potent stimulus to coughing and gas solubility partition coefficient, we hypothesized that sevoflurane may be more effective for breath-holding before the return of upper airway re- REGIONAL. activity (1,2). This technique may provide a smoother bation than isoflurane (4,5).
  • 76. ISOFLUORANO VS SEVOFLUORANO• ENSAYO CLINICO RANDOMIZADO, 40 NIÑOS, DE 2 MESES A 6 AÑOS, CIRUGIA DE ABDOMEN INFERIOR CON BLOQUEO CAUDAL. AGITACION AL AGENTE DESPERTAR ISOFLUORANO ? 0 SEVOFLUORANO 6/20 ( 30% ) Le Berre, Pediatric Anesthesia 2001
  • 77. AGITACION AL DESPERTAR POR AGENTE ANESTESICO AGITACION AL AGENTE VALOR P RR DESPERTARSEVOFLUORANO 57/236 (24%) 0.002 1.77ISOFLUORANO 68/300 (23%) 0.004 1.78 HALOTANO 44/282 (16%) 0.07 NA PROPOFOL 6/62 (10%) 0.06 NA Voepel Lewis, Anesth Analg 2003
  • 78. ISOFLUORANO VS SEVOFLUORANO• ENSAYO CLINICO ALEATORIZADO, 59 NIÑOS, DE 1 AÑO A 6 AÑOS,CIRUGIA DE HERNIA INGUINAL O CIRCUNCISION CON BLOQUEO CAUDAL. AGENTE AGITACION AL DESPERTAR ISOFLUORANO 10/29 (34%) SEVOFLUORANO 9/30 (30%) Meyer, Pediatric Anesth 2007
  • 79. AGITACION AL DESPERTAR: SEVOFLUORANO VS ISOFLUORANO• LA MAYORIA DE LA EVIDENCIA CONCERNIENTE A LA AGITACION AL DESPERTAR RELACIONADA CON SEVOFLUORANO USO HALOTANO COMO EL AGENTE A COMPARAR.• EN REALIDAD HAY MAS AGITACION AL DESPERTAR CON SEVOFLUORANO COMPARADO A HALOTANO. ESPECIALMENTE EN NIÑOS EN EDAD PRE ESCOLAR.• LA EVIDENCIA SUGIERE QUE EL ISOFLUORANO ES SIMILAR AL SEVOFLUORANO CON RESPECTO A ESTE PUNTO.
  • 80. MITO O REALIDAD OXIDO NITROSO• ES EL OXIDO NITROSO UNA CAUSA POTENTE DE NAUSEAS Y VOMITOS POST OPERATORIOS EN NIÑOS?
  • 81. OXIDO NITROSO Y NAUSEAS Y VOMITOS POSTOPERATORIOS EN ADULTOS Anaesthesia, 2010, 65, pages 379–387 doi:10.1111/j.1365-2044.2010.06249.x ..................................................................................................................................................................................................................... REVIEW ARTICLE Association between nitrous oxide and the incidence of postoperative nausea and vomiting in adults: a systematic review and meta-analysis J. Fernandez-Guisasola,1 J. I. Gomez-Arnau,2 Y. Cabrera3 and S. Garcıa del Valle4 ´ ´ ´ ´ 1 Staff Anaesthesiologist, Anaesthesia Department, Hospital Ruber, 2 Chief, Anaesthesia and Critical Care Department, ´ ´ 4 Chief, Unit of Anaesthesia, Hospital Universitario Fundacion Alcorcon, 3 Staff Gynaecologist, Obstetrics and ´ ´ Gynaecology Department, Hospital Infanta Sofıa, San Sebastian de los Reyes, Madrid, Spain Summary Some, but not all studies have suggested intra-operative use of nitrous oxide is correlated with postoperative nausea and vomiting. We performed a meta-analysis of randomised controlled trials to compare the incidence of nausea and vomiting in adults following general anaesthesia with or without nitrous oxide. We retrieved 30 studies (incorporating 33 separate trials) that investigated a ‘nitrous oxide group’ (total 2297 patients) vs a ‘no-nitrous oxide group’ (2301 patients). Omitting nitrous oxide significantly reduced postoperative nausea and vomiting (pooled relative risk 0.80, 95% CI 0.71–0.90, p = 0.0003). However, the absolute incidence of nausea and vomiting was high in both the nitrous oxide and no-nitrous oxide groups (33% vs 27%, respectively). In sub- group analysis, the maximal risk reduction was obtained in female patients (pooled relative risk 0.76, 95% CI 0.60–0.96). When nitrous oxide was used in combination with propofol, the ant- iemetic effect of the latter appeared to compensate the emetogenic effect of nitrous oxide (pooled relative risk 0.94, 95% CI 0.77–1.15). We conclude that avoiding nitrous oxide does reduce the risk of postoperative nausea and vomiting, especially in women, but the overall impact is modest. . ...................................................................................................... ´ ´ Correspondence to: Jaime Fernandez-Guisasola Mascıas E-mail: jfguisasola@telefonica.net Accepted 27 December 2009
  • 82. OXIDO NITROSO Y NAUSEAS Y VOMITOS POSTOPERATORIOS EN ADULTOS Anaesthesia, 2010, 65, pages 379–387 doi:10.1111/j.1365-2044.2010.06249.x ..................................................................................................................................................................................................................... REVIEW ARTICLE Association between nitrous oxide and the incidence of postoperative nausea and vomiting in adults: a systematic review and meta-analysis J. Fernandez-Guisasola,1 J. I. Gomez-Arnau,2 Y. Cabrera3 and S. Garcıa del Valle4 ´ ´ ´ ´ 1 Staff Anaesthesiologist, Anaesthesia Department, Hospital Ruber, 2 Chief, Anaesthesia and Critical Care Department, ´ ´ 4 Chief, Unit of Anaesthesia, Hospital Universitario Fundacion Alcorcon, 3 Staff Gynaecologist, Obstetrics and ´ ´ Gynaecology Department, Hospital Infanta Sofıa, San Sebastian de los Reyes, Madrid, Spain Summary Some, but not all studies have suggested intra-operative use of nitrous oxide is correlated with postoperative nausea and vomiting. We performed a meta-analysis of randomised controlled trials to compare the incidence of nausea and vomiting in adults following general anaesthesia with or without nitrous oxide. We retrieved 30 studies (incorporating 33 separate trials) that investigated a ‘nitrous oxide group’ (total 2297 patients) vs a ‘no-nitrous oxide group’ (2301 patients). Omitting nitrous oxide significantly reduced postoperative nausea and vomiting (pooled relative risk 0.80, 95% CI 0.71–0.90, p = 0.0003). However, the absolute incidence of nausea and vomiting was high in both the nitrous oxide and no-nitrous oxide groups (33% vs 27%, respectively). In sub- group analysis, the maximal risk reduction was obtained in female patients (pooled relative risk 0.76, 95% CI 0.60–0.96). When nitrous oxide was used in combination with propofol, the ant- iemetic effect of the latter appeared to compensate the emetogenic effect of nitrous oxide (pooled relative risk 0.94, 95% CI 0.77–1.15). We conclude that avoiding nitrous oxide does reduce the risk of postoperative nausea and vomiting, especially in women, but the overall impact is modest. . ...................................................................................................... ´ ´ Correspondence to: Jaime Fernandez-Guisasola Mascıas E-mail: jfguisasola@telefonica.net Accepted 27 December 2009
  • 83. OXIDO NITROSO Y NAUSEAS Y VOMITOS POSTOPERATORIOS EN ADULTOS Anaesthesia, 2010, 65, pages 379–387 doi:10.1111/j.1365-2044.2010.06249.x ..................................................................................................................................................................................................................... REVIEW ARTICLE Association between nitrous oxide and the incidence of postoperative nausea and vomiting in adults: a systematic review and meta-analysis J. Fernandez-Guisasola,1 J. I. Gomez-Arnau,2 Y. Cabrera3 and S. Garcıa del Valle4 ´ ´ ´ ´ 1 Staff Anaesthesiologist, Anaesthesia Department, Hospital Ruber, 2 Chief, Anaesthesia and Critical Care Department, ´ ´ 4 Chief, Unit of Anaesthesia, Hospital Universitario Fundacion Alcorcon, 3 Staff Gynaecologist, Obstetrics and ´ ´ Gynaecology Department, Hospital Infanta Sofıa, San Sebastian de los Reyes, Madrid, Spain Summary Some, but not all studies have suggested intra-operative use of nitrous oxide is correlated with postoperative nausea and vomiting. We performed a meta-analysis of randomised controlled trials to compare the incidence of nausea and vomiting in adults following general anaesthesia with or without nitrous oxide. We retrieved 30 studies (incorporating 33 separate trials) that investigated a ‘nitrous oxide group’ (total 2297 patients) vs a ‘no-nitrous oxide group’ (2301 patients). Omitting nitrous oxide significantly reduced postoperative nausea and vomiting (pooled relative risk 0.80, 95% CI 0.71–0.90, p = 0.0003). However, the absolute incidence of nausea and vomiting was high in both the nitrous oxide and no-nitrous oxide groups (33% vs 27%, respectively). In sub- group analysis, the maximal risk reduction was obtained in female patients (pooled relative risk 0.76, 95% CI 0.60–0.96). When nitrous oxide was used in combination with propofol, the ant- iemetic effect of the latter appeared to compensate the emetogenic effect of nitrous oxide (pooled relative risk 0.94, 95% CI 0.77–1.15). We conclude that avoiding nitrous oxide does reduce the risk of postoperative nausea and vomiting, especially in women, but the overall impact is modest. . ...................................................................................................... ´ ´ Correspondence to: Jaime Fernandez-Guisasola Mascıas E-mail: jfguisasola@telefonica.net Accepted 27 December 2009
  • 84. OXIDO NITROSO Y NAUSEAS Y VOMITOS POSTOPERATORIOS EN ADULTOS Anaesthesia, 2010, 65, pages 379–387 doi:10.1111/j.1365-2044.2010.06249.x ..................................................................................................................................................................................................................... REVIEW ARTICLE Association between nitrous oxide and the incidence of postoperative nausea and vomiting in adults: a systematic review and meta-analysis J. Fernandez-Guisasola,1 J. I. Gomez-Arnau,2 Y. Cabrera3 and S. Garcıa del Valle4 ´ ´ ´ ´ 1 Staff Anaesthesiologist, Anaesthesia Department, Hospital Ruber, 2 Chief, Anaesthesia and Critical Care Department, ´ ´ 4 Chief, Unit of Anaesthesia, Hospital Universitario Fundacion Alcorcon, 3 Staff Gynaecologist, Obstetrics and ´ ´ Gynaecology Department, Hospital Infanta Sofıa, San Sebastian de los Reyes, Madrid, Spain Summary Some, but not all studies have suggested intra-operative use of nitrous oxide is correlated with postoperative nausea and vomiting. We performed a meta-analysis of randomised controlled trials to compare the incidence of nausea and vomiting in adults following general anaesthesia with or without nitrous oxide. We retrieved 30 studies (incorporating 33 separate trials) that investigated a ‘nitrous oxide group’ (total 2297 patients) vs a ‘no-nitrous oxide group’ (2301 patients). Omitting nitrous oxide significantly reduced postoperative nausea and vomiting (pooled relative risk 0.80, 95% CI 0.71–0.90, p = 0.0003). However, the absolute incidence of nausea and vomiting was high in both the nitrous oxide and no-nitrous oxide groups (33% vs 27%, respectively). In sub- group analysis, the maximal risk reduction was obtained in female patients (pooled relative risk 0.76, 95% CI 0.60–0.96). When nitrous oxide was used in combination with propofol, the ant- iemetic effect of the latter appeared to compensate the emetogenic effect of nitrous oxide (pooled relative risk 0.94, 95% CI 0.77–1.15). We conclude that avoiding nitrous oxide does reduce the risk of postoperative nausea and vomiting, especially in women, but the overall impact is modest. . ...................................................................................................... ´ ´ Correspondence to: Jaime Fernandez-Guisasola Mascıas E-mail: jfguisasola@telefonica.net Accepted 27 December 2009
  • 85. OXIDO NITROSO Y NAUSEAS Y VOMITOS POSTOPERATORIOS EN ADULTOS Anaesthesia, 2010, 65, pages 379–387 doi:10.1111/j.1365-2044.2010.06249.x ..................................................................................................................................................................................................................... REVIEW ARTICLE Association between nitrous oxide and the incidence of postoperative nausea and vomiting in adults: a systematic review and meta-analysis J. Fernandez-Guisasola,1 J. I. Gomez-Arnau,2 Y. Cabrera3 and S. Garcıa del Valle4 ´ ´ ´ ´ 1 Staff Anaesthesiologist, Anaesthesia Department, Hospital Ruber, 2 Chief, Anaesthesia and Critical Care Department, ´ ´ 4 Chief, Unit of Anaesthesia, Hospital Universitario Fundacion Alcorcon, 3 Staff Gynaecologist, Obstetrics and ´ ´ Gynaecology Department, Hospital Infanta Sofıa, San Sebastian de los Reyes, Madrid, Spain Summary Some, but not all studies have suggested intra-operative use of nitrous oxide is correlated with postoperative nausea and vomiting. We performed a meta-analysis of randomised controlled trials to compare the incidence of nausea and vomiting in adults following general anaesthesia with or without nitrous oxide. We retrieved 30 studies (incorporating 33 separate trials) that investigated a ‘nitrous oxide group’ (total 2297 patients) vs a ‘no-nitrous oxide group’ (2301 patients). Omitting nitrous oxide significantly reduced postoperative nausea and vomiting (pooled relative risk 0.80, 95% CI 0.71–0.90, p = 0.0003). However, the absolute incidence of nausea and vomiting was high in both the nitrous oxide and no-nitrous oxide groups (33% vs 27%, respectively). In sub- group analysis, the maximal risk reduction was obtained in female patients (pooled relative risk 0.76, 95% CI 0.60–0.96). When nitrous oxide was used in combination with propofol, the ant- iemetic effect of the latter appeared to compensate the emetogenic effect of nitrous oxide (pooled relative risk 0.94, 95% CI 0.77–1.15). We conclude that avoiding nitrous oxide does reduce the risk of postoperative nausea and vomiting, especially in women, but the overall impact is modest. . ...................................................................................................... ´ ´ Correspondence to: Jaime Fernandez-Guisasola Mascıas E-mail: jfguisasola@telefonica.net Accepted 27 December 2009
  • 86. OXIDO NITROSO Y NAUSEAS Y VOMITOS POSTOPERATORIOS EN ADULTOS Anaesthesia, 2010, 65, pages 379–387 doi:10.1111/j.1365-2044.2010.06249.x ..................................................................................................................................................................................................................... REVIEW ARTICLE Association between nitrous oxide and the incidence of postoperative nausea and vomiting in adults: a systematic review and meta-analysis J. Fernandez-Guisasola,1 J. I. Gomez-Arnau,2 Y. Cabrera3 and S. Garcıa del Valle4 ´ ´ ´ ´ 1 Staff Anaesthesiologist, Anaesthesia Department, Hospital Ruber, 2 Chief, Anaesthesia and Critical Care Department, ´ ´ 4 Chief, Unit of Anaesthesia, Hospital Universitario Fundacion Alcorcon, 3 Staff Gynaecologist, Obstetrics and ´ ´ Gynaecology Department, Hospital Infanta Sofıa, San Sebastian de los Reyes, Madrid, Spain Summary Some, but not all studies have suggested intra-operative use of nitrous oxide is correlated with postoperative nausea and vomiting. We performed a meta-analysis of randomised controlled trials to compare the incidence of nausea and vomiting in adults following general anaesthesia with or without nitrous oxide. We retrieved 30 studies (incorporating 33 separate trials) that investigated a ‘nitrous oxide group’ (total 2297 patients) vs a ‘no-nitrous oxide group’ (2301 patients). Omitting nitrous oxide significantly reduced postoperative nausea and vomiting (pooled relative risk 0.80, 95% CI 0.71–0.90, p = 0.0003). However, the absolute incidence of nausea and vomiting was high in both the nitrous oxide and no-nitrous oxide groups (33% vs 27%, respectively). In sub- group analysis, the maximal risk reduction was obtained in female patients (pooled relative risk 0.76, 95% CI 0.60–0.96). When nitrous oxide was used in combination with propofol, the ant- iemetic effect of the latter appeared to compensate the emetogenic effect of nitrous oxide (pooled relative risk 0.94, 95% CI 0.77–1.15). We conclude that avoiding nitrous oxide does reduce the risk of postoperative nausea and vomiting, especially in women, but the overall impact is modest. . ...................................................................................................... ´ ´ Correspondence to: Jaime Fernandez-Guisasola Mascıas E-mail: jfguisasola@telefonica.net Accepted 27 December 2009
  • 87. OXIDO NITROSO Y NAUSEAS Y VOMITOS POSTOPERATORIOS EN ADULTOS Anaesthesia, 2010, 65, pages 379–387 doi:10.1111/j.1365-2044.2010.06249.x ..................................................................................................................................................................................................................... REVIEW ARTICLE Association between nitrous oxide and the incidence of postoperative nausea and vomiting in adults: a systematic review and meta-analysis J. Fernandez-Guisasola,1 J. I. Gomez-Arnau,2 Y. Cabrera3 and S. Garcıa del Valle4 ´ ´ ´ ´ 1 Staff Anaesthesiologist, Anaesthesia Department, Hospital Ruber, 2 Chief, Anaesthesia and Critical Care Department, ´ ´ 4 Chief, Unit of Anaesthesia, Hospital Universitario Fundacion Alcorcon, 3 Staff Gynaecologist, Obstetrics and ´ ´ Gynaecology Department, Hospital Infanta Sofıa, San Sebastian de los Reyes, Madrid, Spain Summary Some, but not all studies have suggested intra-operative use of nitrous oxide is correlated with postoperative nausea and vomiting. We performed a meta-analysis of randomised controlled trials to compare the incidence of nausea and vomiting in adults following general anaesthesia with or without nitrous oxide. We retrieved 30 studies (incorporating 33 separate trials) that investigated a ‘nitrous oxide group’ (total 2297 patients) vs a ‘no-nitrous oxide group’ (2301 patients). Omitting nitrous oxide significantly reduced postoperative nausea and vomiting (pooled relative risk 0.80, 95% CI 0.71–0.90, p = 0.0003). However, the absolute incidence of nausea and vomiting was high in both the nitrous oxide and no-nitrous oxide groups (33% vs 27%, respectively). In sub- group analysis, the maximal risk reduction was obtained in female patients (pooled relative risk 0.76, 95% CI 0.60–0.96). When nitrous oxide was used in combination with propofol, the ant- iemetic effect of the latter appeared to compensate the emetogenic effect of nitrous oxide (pooled relative risk 0.94, 95% CI 0.77–1.15). We conclude that avoiding nitrous oxide does reduce the risk of postoperative nausea and vomiting, especially in women, but the overall impact is modest. . ...................................................................................................... ´ ´ Correspondence to: Jaime Fernandez-Guisasola Mascıas E-mail: jfguisasola@telefonica.net Accepted 27 December 2009
  • 88. OXIDO NITROSO Y NAUSEAS Y VOMITOS POSTOPERATORIOS EN ADULTOS Anaesthesia, 2010, 65, pages 379–387 doi:10.1111/j.1365-2044.2010.06249.x ..................................................................................................................................................................................................................... REVIEW ARTICLE Association between nitrous oxide and the incidence of postoperative nausea and vomiting in adults: a systematic review and meta-analysis J. Fernandez-Guisasola,1 J. I. Gomez-Arnau,2 Y. Cabrera3 and S. Garcıa del Valle4 ´ ´ ´ ´ 1 Staff Anaesthesiologist, Anaesthesia Department, Hospital Ruber, 2 Chief, Anaesthesia and Critical Care Department, ´ ´ 4 Chief, Unit of Anaesthesia, Hospital Universitario Fundacion Alcorcon, 3 Staff Gynaecologist, Obstetrics and ´ ´ Gynaecology Department, Hospital Infanta Sofıa, San Sebastian de los Reyes, Madrid, Spain Summary• Some, but not all studies have suggested intra-operative use of nitrous oxide is correlated with 4598 PCTES, 30 ESTUDIOS. postoperative nausea and vomiting. We performed a meta-analysis of randomised controlled trials to compare the incidence of nausea and vomiting in adults following general anaesthesia with or without nitrous oxide. We retrieved 30 studies (incorporating 33 separate trials) that investigated a ‘nitrous oxide group’ (total 2297 patients) vs a ‘no-nitrous oxide group’ (2301 patients). Omitting nitrous oxide significantly reduced postoperative nausea and vomiting (pooled relative risk 0.80, 95% CI 0.71–0.90, p = 0.0003). However, the absolute incidence of nausea and vomiting was high in both the nitrous oxide and no-nitrous oxide groups (33% vs 27%, respectively). In sub- group analysis, the maximal risk reduction was obtained in female patients (pooled relative risk 0.76, 95% CI 0.60–0.96). When nitrous oxide was used in combination with propofol, the ant- iemetic effect of the latter appeared to compensate the emetogenic effect of nitrous oxide (pooled relative risk 0.94, 95% CI 0.77–1.15). We conclude that avoiding nitrous oxide does reduce the risk of postoperative nausea and vomiting, especially in women, but the overall impact is modest. . ...................................................................................................... ´ ´ Correspondence to: Jaime Fernandez-Guisasola Mascıas E-mail: jfguisasola@telefonica.net Accepted 27 December 2009
  • 89. OXIDO NITROSO Y NAUSEAS Y VOMITOS POSTOPERATORIOS EN ADULTOS Anaesthesia, 2010, 65, pages 379–387 doi:10.1111/j.1365-2044.2010.06249.x ..................................................................................................................................................................................................................... REVIEW ARTICLE Association between nitrous oxide and the incidence of postoperative nausea and vomiting in adults: a systematic review and meta-analysis J. Fernandez-Guisasola,1 J. I. Gomez-Arnau,2 Y. Cabrera3 and S. Garcıa del Valle4 ´ ´ ´ ´ 1 Staff Anaesthesiologist, Anaesthesia Department, Hospital Ruber, 2 Chief, Anaesthesia and Critical Care Department, ´ ´ 4 Chief, Unit of Anaesthesia, Hospital Universitario Fundacion Alcorcon, 3 Staff Gynaecologist, Obstetrics and ´ ´ Gynaecology Department, Hospital Infanta Sofıa, San Sebastian de los Reyes, Madrid, Spain Summary• Some, but not all studies have suggested intra-operative use of nitrous oxide is correlated with 4598 PCTES, 30 ESTUDIOS. postoperative nausea and vomiting. We performed a meta-analysis of randomised controlled trials to compare the incidence of nausea and vomiting in adults following general anaesthesia with or without nitrous oxide. We retrieved 30 studies (incorporating 33 separate trials) that investigated• a ‘nitrous oxide group’ (total 2297 patients) vs a ‘no-nitrous oxide group’ (2301 patients). Omitting REVISION SISTEMATICA Y META ANALISIS. nitrous oxide significantly reduced postoperative nausea and vomiting (pooled relative risk 0.80, 95% CI 0.71–0.90, p = 0.0003). However, the absolute incidence of nausea and vomiting was high in both the nitrous oxide and no-nitrous oxide groups (33% vs 27%, respectively). In sub- group analysis, the maximal risk reduction was obtained in female patients (pooled relative risk 0.76, 95% CI 0.60–0.96). When nitrous oxide was used in combination with propofol, the ant- iemetic effect of the latter appeared to compensate the emetogenic effect of nitrous oxide (pooled relative risk 0.94, 95% CI 0.77–1.15). We conclude that avoiding nitrous oxide does reduce the risk of postoperative nausea and vomiting, especially in women, but the overall impact is modest. . ...................................................................................................... ´ ´ Correspondence to: Jaime Fernandez-Guisasola Mascıas E-mail: jfguisasola@telefonica.net Accepted 27 December 2009
  • 90. OXIDO NITROSO Y NAUSEAS Y VOMITOS POSTOPERATORIOS EN ADULTOS Anaesthesia, 2010, 65, pages 379–387 doi:10.1111/j.1365-2044.2010.06249.x ..................................................................................................................................................................................................................... REVIEW ARTICLE Association between nitrous oxide and the incidence of postoperative nausea and vomiting in adults: a systematic review and meta-analysis J. Fernandez-Guisasola,1 J. I. Gomez-Arnau,2 Y. Cabrera3 and S. Garcıa del Valle4 ´ ´ ´ ´ 1 Staff Anaesthesiologist, Anaesthesia Department, Hospital Ruber, 2 Chief, Anaesthesia and Critical Care Department, ´ ´ 4 Chief, Unit of Anaesthesia, Hospital Universitario Fundacion Alcorcon, 3 Staff Gynaecologist, Obstetrics and ´ ´ Gynaecology Department, Hospital Infanta Sofıa, San Sebastian de los Reyes, Madrid, Spain Summary• Some, but not all studies have suggested intra-operative use of nitrous oxide is correlated with 4598 PCTES, 30 ESTUDIOS. postoperative nausea and vomiting. We performed a meta-analysis of randomised controlled trials to compare the incidence of nausea and vomiting in adults following general anaesthesia with or without nitrous oxide. We retrieved 30 studies (incorporating 33 separate trials) that investigated• a ‘nitrous oxide group’ (total 2297 patients) vs a ‘no-nitrous oxide group’ (2301 patients). Omitting REVISION SISTEMATICA Y META ANALISIS. nitrous oxide significantly reduced postoperative nausea and vomiting (pooled relative risk 0.80, 95% CI 0.71–0.90, p = 0.0003). However, the absolute incidence of nausea and vomiting was high in both the nitrous oxide and no-nitrous oxide groups (33% vs 27%, respectively). In sub- group analysis, the maximal risk reduction was obtained in female patients (pooled relative risk• 0.76, 95% CI 0.60–0.96). When nitrous oxide was used in combination with propofol, the ant- NVPO: CON OXIDO NITROSO: 33% iemetic effect of the latter appeared to compensate the emetogenic effect of nitrous oxide (pooled relative risk 0.94, 95% CI 0.77–1.15). We conclude that avoiding nitrous oxide does reduce the risk of postoperative nausea and vomiting, especially in women, but the overall impact is modest. SIN OXIDO NITROSO: 27% . ...................................................................................................... ´ ´ Correspondence to: Jaime Fernandez-Guisasola Mascıas E-mail: jfguisasola@telefonica.net Accepted 27 December 2009
  • 91. OXIDO NITROSO Y MIRINGOTOMIA• N20/O2/HALOTANO (n=158) 13% NVPO• 02/HALOTANO (n=162) 13% NVPO• EFECTO DE LA EDAD Edad (Años) % Vomito 0.5 a 2.9 4% 3.0 a 5.9 11% 6.0 a 8.9 17% 9.0 a 12.9 31% Splinter, Can J Anesth 1995
  • 92. OXIDO NITROSO Y CIRUGIA DENTAL Resultado Oxido Nitroso Control NV en Hospital 24% 15% Vomito luego del alta 23% 20% (mismo dia) Vomito luego del alta 4% 3% (dia siguiente) Total 35% 30%• n= 330, no antiemeticos Splinter, Anesth Analg 1997
  • 93. NVPO Y CIRUGIA DENTAL• DEXAMETASONA/ONDANSETRON (n=87)• SOLO ONDANSETRON (n=91)• TODOS LOS SUJETOS DE ESTUDIO RECIBIERON N2O, ISOFLUORANO, FENTANILO Y 20 ML/KG DE LACTACTO RINGER.• NINGUNO DE LOS SUJETOS ESTUDIADOS VOMITO EN EL HOSPITAL.• LUEGO DE 24 H: • 1/87 VOMITO EN GRUPO DEXA/ONDA • 8/91 VOMITO EN GRUPO SOLO ONDA McIntyre, SPA 2010
  • 94. NVPO Y TONSILECTOMIA Resultado Oxido Nitroso Control NV en URPA 50% 40% NV luego del Alta 60% 53% Total 67% 60%• n = 60 , no recibieron antiemeticos Pandit, Anesth Analg 1995
  • 95. OXIDO NITROSO Y NVPO EN NIÑOS• NO HAY EVIDENCIA PERSUASIVA QUE EVITE QUE EL OXIDO NITROSO EN NIÑOS DE RIESGO BAJO O MODERADO EVITE NVPO.• OTROS FACTORES SON IMPORTANTES (EJ. CARGA HIDRICA).• LOS ANTIEMETICOS SI FUNCIONAN...!!!
  • 96. PUNTOS SOBRE OTROS MEDICAMENTOS• PROBLEMAS DE SEGURIDAD: • DEXAMETASONA • KETOROLACO
  • 97. DEXAMETASONA Y TONSILECTOMIA• EXISTEN RIESGOS? • SANGRADO? • NECROSIS AVASCULAR? • OTROS?
  • 98. SANGRADO EN AMIGDALAS Y DEXAMETASONA PRELIMINARYCOMMUNICATIONDexamethasone and Risk of Nauseaand Vomiting and Postoperative BleedingAfter Tonsillectomy in ChildrenA Randomized TrialChristoph Czarnetzki, MD, MBA Context Dexamethasone is widely used to prevent postoperative nausea and vom-Nadia Elia, MD, MSc iting (PONV) in pediatric tonsillectomy.Christopher Lysakowski, MD Objective To assess whether dexamethasone dose-dependently reduces the risk ofLionel Dumont, MD PONV at 24 hours after tonsillectomy.Basile N. Landis, MD Design, Setting, and Patients Randomized placebo-controlled trial conducted among 215 children undergoing elective tonsillectomy at a major public teaching hospital inRoland Giger, MD Switzerland from February 2005 to December 2007.Pavel Dulguerov, MD Interventions Children were randomly assigned to receive dexamethasone (0.05,Jules Desmeules, MD 0.15, or 0.5 mg/kg) or placebo intravenously after induction of anesthesia. Acetami- nophen-codeine and ibuprofen were given as postoperative analgesia. Follow-up con-Martin R. Tramèr, MD, DPhil tinued until the 10th postoperative day.T ONSILLECTOMY IS ONE OF THE Main Outcome Measures The primary end point was prevention of PONV at 24 most frequently performed sur- hours; secondary end points were decrease in the need for ibuprofen at 24 hours and evaluation of adverse effects. gical procedures in children. In 1998, the rate varied from 19 Results At 24 hours, 24 of 54 participants who received placebo (44%; 95% con-per 10 000 children in Canada to 118 fidence interval [CI], 31%-59%) had experienced PONV compared with 20 of 53 (38%;per 10 000 in Northern Ireland.1 In the 95% CI, 25%-52%), 13 of 54 (24%; 95% CI, 13%-38%), and 6 of 52 (12%; 95% CI, 4%-23%) who received dexamethasone at 0.05, 0.15, and 0.5 mg/kg, respec-United States, about 186 000 proce- tively (PϽ.001 for linear trend). Children who received dexamethasone received sig-dures are performed on an outpatient nificantly less ibuprofen. There were 26 postoperative bleeding episodes in 22 chil-basis every year.2 Common complica- dren. Two of 53 (4%; 95% CI, 0.5%-13%) children who received placebo had bleedingtions of tonsillectomy are postopera- compared with 6 of 53 (11%; 95% CI, 4%-23%), 2 of 51 (4%; 95% CI, 0.5%-tive nausea and vomiting (PONV), pain, 13%), and 12 of 50 (24%; 95% CI, 13%-38%) who received dexamethasone at 0.05,and bleeding. 3 Nonsteroidal anti- 0.15, and 0.5 mg/kg, respectively (P=.003). Dexamethasone, 0.5 mg/kg, was asso-inflammatory drugs (NSAIDs) have ciated with the highest bleeding risk (adjusted relative risk, 6.80; 95% CI, 1.77-16.5).been widely used in this setting for their Eight children had to undergo emergency reoperation because of bleeding, all of whom had received dexamethasone. The trial was stopped early for safety reasons.pronounced analgesic efficacy and alack of the emetogenic effect inherent Conclusion In this study of children undergoing tonsillectomy, dexamethasone de-to opioids. However, classic NSAIDs, creased the risk of PONV dose dependently but was associated with an increased riskthrough reversible platelet inhibition, of postoperative bleeding.further increase the risk of bleeding af- Trial Registration clinicaltrials.gov Identifier: NCT00403806ter tonsillectomy.4,5 JAMA. 2008;300(22):2621-2630 www.jama.com Dexamethasone has antiemetic Author Affiliations: Divisions of Anesthesiology (Drs Medical Faculty, University of Geneva (Drs Dulguerov,properties in the surgical setting.6 An Czarnetzki, Elia, Lysakowski, Dumont, and Tramèr); Oto- Desmeules, and Tramèr), Geneva, Switzerland.international expert panel recom- laryngology–Head and Neck Surgery (Drs Landis, Giger, Corresponding Author: Martin R. Tramèr, MD, DPhil, and Dulguerov), and Clinical Pharmacology and Toxi- Division of Anesthesiology, University Hospitals ofmended dexamethasone, alone or as cology (Dr Desmeules), University Hospitals of Geneva, Geneva, 24 rue Micheli-du-Crest, CH-1211 Genevapart of a multimodal regimen, for Institute of Social and Preventive Medicine (Dr Elia), and 14, Switzerland (martin.tramer@hcuge.ch).©2008 American Medical Association. All rights reserved. (Reprinted) JAMA, December 10, 2008—Vol 300, No. 22 2621 Downloaded from jama.ama-assn.org by guest on November 5, 2011
  • 99. RESULTADOS: INCIDENCIA TOTAL DE EPISODIOS DE SANGRADO 20 18 16 14% Sangrado 12 10 8 6 4 2 0 Placebo 0.05 0.15 0.5 Dexametasona (mg/kg) Czarnetszki, JAMA 2008
  • 100. RESULTADOS: INCIDENCIA DE REOPERACION POR SANGRADO 20 16 12 % Reop 8 4 0 Placebo 0.05 0.15 0.5 Dexametasona (mg/kg) Czarnetzki, JAMA 2008
  • 101. PUNTOS SOBRE EL ESTUDIO DE CZARNETZKI• ¿POR QUE TAN ALTA TASA DE SANGRADO?• ¿POR QUE EL SANGRADO NO PARECE ESTAR LIGADO A LA DOSIS?• ¿EL TERMINO TEMPRANO DEL ESTUDIO LE RESTO PODER A LOS RESULTADOS?• COMO EL SANGRADO NO ERA SU PRIMER OBJETIVO, ¿ESTABA EL ESTUDIO DISEÑADO PARA HACER CONCLUSIONES FINALES SOBRE ESTA COMPLICACION? Czarnetzki, JAMA 2008
  • 102. EL ESTUDIO BRIGGER 2778 Tonsilectomias 2 a 18 a1237 Dex 0.5 mg/kg 1551 Dex 1 mg/kg 4.53% ED Rx 2.45% ED Rx 3.6% Admitted 2.06% Admitted 2.75% Reop 1.55% Reop
  • 103. DEXAMETASONA Y OTRAS COMPLICACIONES• NO EXISTE EVIDENCIA DE QUE EL USO DE DEXAMETASONA CAUSE NECROSIS AVASCULAR DE CADERA CUANDO SEA USADO COMO DOSIS UNICA EN INTRAOPERATORIO.• REPORTE RARO DE CASOS DE LISIS TUMORAL EN NIÑOS:• NIÑO DE 8 AÑOS CON DX DE LLA, SE RECUPERO.• NIÑO DE 3 AÑOS SIN DX DE LLA, FALLECIO. McDonell, Anesthesia 2008
  • 104. KETOROLACO Y CONSOLIDACION OSEA• LA EVIDENCIA ACTUAL SE LIMITA A ESTUDIOS ANIMALES Y A ESTUDIOS EN ADULTOS SANOS.• NO EXISTE EVIDENCIA EN NIÑOS A EXCEPCION DE LOS ESTUDIOS EN CIRUGIA DE ESCOLIOSIS.• EN CIRUGIA DE ESCOLIOSIS IDIOPATICA, NO CONSOLIDACION OSEA : • KETOROLACO 1.9% • NO KETOROLACO 3.1% Sucato, Spine 2008
  • 105. MISCELANEAS• ¿ES NECESARIO EL USO DE ULTRASONIDO EN LA INSERCION DEL CATETER VENOSO CENTRAL?• LOS PADRES... ¿CUANDO DEBEN SER REUNIDOS CON SUS NIÑOS?
  • 106. INSERCION DE VIA CENTRAL• ¿EL ULTRASONIDO MEJORA LA TASA DE EXITO EN NIÑOS?
  • 107. VIAS CENTRALES Y ULTRASONIDO• NICE MENCIONA:• EL ULTRASONIDO QUE MUESTRE IMAGENES EN 2D DEBE SER EL METODO DE ELECCION CUANDO SE INSERTE CATETERES VENOSOS CENTRALES EN VENA YUGULAR INTERNA EN ADULTOS Y NIÑOS EN “SITUACIONES ELECTIVAS”.• EL ULTRASONIDO QUE MUESTRE IMAGENES EN 2D DEBE SER CONSIDERADO EN LA MAYORIA DE SITUACIONES CLINICAS EN LAS CUALES LA INSERCION DEL CVC SEA NECESARIA SEA ESTA UNA SITUACION ELECTIVA O DE EMERGENCIA.
  • 108. META ANALISIS SOBRE USO DE US PARA CVC VIA YUGULAR INTERNA EN NIÑOS Pediatric Anesthesia 2009 19: 1199–1206 doi:10.1111/j.1460-9592.2009.03171.x Ultrasound guided internal jugular vein access in children and infant: A meta-analysis of published studies S T E P H A N I E S I G A U T M D * , A L I A S K H IR I M D *, ID A S TA NY M D * , J O N A T H A N G O L M A R M D * , Y V E S N I V O C H E M D P h D †, I S A BE L L E C O N S T A N T M D P h D ‡, I S A B EL L E M U R A T M D P h D § A N D SO U H A Y L D A H M A N I M D P h D * *Assistant Professor of Anesthesia, Robert Debre University Hospital, †Professor of Anesthesia, Head of Department, Robert Debre University Hospital, ‡Professor of Anesthesia, Trousseau University Hospital and §Professor of Anesthesia, Head of Department, Trousseau University Hospital, Paris, France• Summary 5 RCT IDENTIFICADOS, 359 PACIENTES. catheter placement is technically difficult Introduction: Central venous in pediatric population especially in the younger patients. Ultrasound• prelocation and ⁄ guidance (UPG) of internal jugular vein (IJV) NO SE DEMOSTRO DIFERENCIASorEN CUANTO A TASA DE EXITO, AL TIEMPO DE access has been shown to decrease failure rate and complications CANULACION, A PUNCIONthis invasive procedure. The goal of the present study was to O NEUMOTORAX. related to CAROTIDEA, HEMATOMA, HEMOTORAX perform a systematic review of the advantages of UPG over• anatomical landmarks (AL) during IJV access in children and infants. LA TASA DE FALLA Y PUNCION CAROTIDEA FUEliterature search was con- Material and methods: A comprehensive MENOR EN NOVATOS QUE USARON ULTRASONIDO. ducted to identify clinical trials that focused on the comparison of UPG to AL techniques during IJV access in children and infants. Two reviewers independently assessed each study to meet inclusion criteria and extracted data. Data from each trial were combined to calculate the pooled odds ratio (OR) or the mean differences (MD), and their 95% confidence intervals [CI 95%]. I2 statistics were used to assess statistics heterogeneity and to guide the use of fixed or random effect for computation of overall effects. Subgroup analysis was used to clarify the effects of the techniques used (prelocation or guidance) or the
  • 109. CVC EN PEDIATRIA Y ULTRASONIDO• DEBE ESTAR DISPONIBLE EL EQUIPO DE ULTRASONIDO.• LA EVIDENCIA SUGIERE QUE ES MAS UTIL EN PACIENTES PEQUEÑOS (MENORES DE 10 KG), EN AQUELLOS CON ENFERMEDAD CARDIACA CONGENITA Y EN AQUELLOS QUE SON RECIEN INICIAN SU ENTRENAMIENTO EN CVC.• EN PERSONAL ENTRENADO Y CON EXPERIENCIA SE HA VISTO RESULTADOS Y TASAS DE COMPLICACIONES SIMILARES USANDO O NO EL EQUIPO DE ULTRASONIDO.• LA EVIDENCIA ESTA BASADA EN LA CANULACION VENOSA CENTRAL POR ACCESO YUGULAR, MAS NO POR VIA SUBCLAVIA.
  • 110. PADRES EN LA URPA• ¿EXISTE ALGUNA EVIDENCIA DE QUE LA PRESENCIA DE LOS PADRES EN LA URPA (RECUPERACION FASE 1) MEJORE LOS RESULTADOS OPREATORIOS?
  • 111. RCT DE PADRES EN URPAThe Effects of Parental Presence in the PostanestheticCare Unit on Children’s Postoperative Behavior: AProspective, Randomized, Controlled StudyDavid R. Lardner, MBChB, FANZCA,* Bruce D. Dick, PhD, R. Psych,† and Susan Crawford, MSc‡ BACKGROUND: The effects on children of parental presence in the postanesthesia care unit (PACU) have not been extensively studied. The few published studies are retrospective, nonrandomized, or lack adequate controls. They suggest that parental presence in the PACU decreases crying and negative behavior change postoperatively. We performed this prospective, randomized, controlled study to determine whether the presence of a parent affected crying behaviors in the PACU and behavior change 2 weeks postoperatively. METHODS: Randomly selected patients, aged 2.0 to 8 years 11 months, ASA physical status I or II, and scheduled for elective outpatient surgery with an anticipated PACU stay of Ͼ10 minutes were randomly assigned to the parent present group (n ϭ 150) or parent absent group (n ϭ 150) in the PACU. All parents underwent the same preparation program. Reunification occurred once children’s eyes had opened for the parent present group. In the PACU, crying was scored each minute after eye opening using a 5-point scale. Negative behavior change 2 weeks after discharge was determined using the Post Hospitalization Behavior Questionnaire. Because the anesthesia technique to be used was not determined a priori, data on the technique used were collected to ensure that groups were similar. Multiple and logistic regression techniques were used to determine predictors of crying in the PACU and behavior change 2 weeks postoperatively. RESULTS: Parental presence in the PACU made no difference in crying in the PACU. Negative behavior change 2 weeks postoperatively occurred more frequently in the parent absent group than the parent present group (45.8% vs 29.3%; P ϭ 0.007). Multiple regression identified the following significant factors as predictive of larger proportion of time spent crying in the PACU (R2 ϭ 0.256, F[5, 273] ϭ 15.66, P Ͻ 0.001): age Ͻ5 years (P Ͻ 0.001) and higher Children’s Hospital of Eastern Ontario Pain Scale score at 15 minutes after arrival in day surgery (P Ͻ 0.001). Parental presence or absence from the PACU was not predictive of crying in the PACU, and neither were socioeconomic status nor intraoperative opioid analgesia. Logistic regression identified the following factors (␹2[4] ϭ 26.62, P Ͻ 0.001) as predictive of negative behavior change at 2 weeks postoperatively: being younger than 5 years (P Ͻ 0.001) and being in the parent absent group (P ϭ 0.003). CONCLUSION: For fit healthy children undergoing outpatient surgery, parental presence in the PACU decreases negative behavior change at 2 weeks postoperatively but makes no difference in crying in the PACU. Future studies of behavior change postoperatively should consider parental presence in the PACU a factor and determine whether the effect persists with other interventions. (Anesth Analg 2010;110:1102–8)S uccess of anesthesia is no longer determined solely by the avoidance of mortality and major morbidity. Quality of recovery, speed of return to perioperativefunction, and patient/family satisfaction are increasingly It is clear that perioperative anxiety has been found to be related to higher levels of postoperative pain, sleep distur- bance, and other behavioral problems.1 It is also evident that younger children, those with more severe illness, and
  • 112. EN CONCLUSION...• EL MENSAJE ES QUE HAY CONOCIMIENTOS CONOCIDOS. HAY COSAS QUE SABEMOS QUE CONOCEMOS. TAMBIEN HAY COSAS QUE CONOCEMOS QUE DESCONOCEMOS. ES DECIR QUE HAY COSAS QUE AHORA SABEMOS QUE NO CONOCEMOS. PERO TAMBIEN HAY COSAS NO CONOCIDAS QUE NO CONOCEMOS. FINALMENTE HAY COSAS QUE NO CONOCEMOS Y QUE NO LAS SABEMOS.