[Use of precordial Doppler in the patient undergoing cranial surgery in the sitting position].
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Craniotomy↗
Biomedical subjects
N Fábregas
Publications and source records attributed to N Fábregas.
[Outcome after spontaneous subarachnoid hemorrhage. Relationship between admission glycemia and clinical status on admission and on hospital discharge].
BACKGROUND: To determine the relationship between the glycemia on hospital admission after subarachnoid haemorrhage (SAH) and neurological score. PATIENTS AND METHODS: On 44 patients we recorded the glycemia value on admission, coma Glasgow scale (CGS) and Hunt and Hess scale grade (HH), on admission, on discharge and six months later. RESULTS: The patients with HH IV-V and GCS between 3 and 8 had glycemia values higher than patients with HH I-III and GCS between 9 and 15. The patients with HH IV-V on discharge had glycemia values higher than patients with HH I-III. CONCLUSIONS: Glycemia value on admission is related with the acute injury severity and represents a prognosis factor in spontaneous subarachnoid haemorrhage outcome.
Acute Disease↗
[Determinants associated wtih the presence of risk behaviors in HIV infected patients].
BACKGROUND: Determinants associated with risk behaviours are evaluated in a known HIV-infected population not belonging to the great metropolitan nuclei. PATIENTS AND METHODS: 110 unselected HIV+ patients were interviewed, including 77 variables. Their association with sharing needles, and unprotected sex is analysed. RESULTS: Sharing needles was associated to: low academic achievement (p = 0.045), no children (p = 0.045), any physical limitation (p = 0.004), previous admission to detoxification unit (p = 0.014), and depression. With unprotected sex were associated: low academic achievement (p = 0.005), lesser time of HIV infection (p = 0.009), no family support (p = 0.005), and scanty information about HIV transmission (p = 0.018). CONCLUSIONS: A cohort of HIV-infected subjects who persist with risk practices is remaining. Some easily recognizable variables may be useful for their early recognition.
Adult↗
Venous air embolism during Parkinson surgery in patients with spontaneous ventilation.
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Embolism, Air↗
Bacterial colonization patterns in mechanically ventilated patients with traumatic and medical head injury. Incidence, risk factors, and association with ventilator-associated pneumonia.
We prospectively evaluated the relation of upper airway, lower airway, and gastric colonization patterns with the development of pneumonia and its etiology in 48 patients with surgical (n = 25) and medical (n = 23) head injury. Initial colonization was assessed by cultures of nasal and pharyngeal swabs, tracheobronchial aspirates, gastric juice, and bronchoscopically retrieved protected specimen brush. Follow-up colonization was determined until the end points extubation, suspected ventilator-associated pneumonia (VAP), or death. The initial colonization rate at any site at ICU admission was 39/47 (83%). It mainly accounted for Group I pathogens (Streptococcus pneumoniae, Staphylococcus aureus, Hemophilus influenzae) of the upper and lower airways. At follow-up, colonization rates with Group II pathogens (Gram-negative enteric bacilli and Pseudomonas spp.) increased significantly. The high initial bacterial load with Group I pathogens of the upper airways and trachea decreased during Days 2 to 4, whereas that of Group II pathogens increased. Upper airway colonization was an independent predictor of follow-up tracheobronchial colonization (odds ratio [OR], 9.9; 95% confidence interval [CI], 1.8 to 56.3 for initial colonization with Group I pathogens; OR, 23.9; 95% CI, 3.8 to 153.3 for follow-up colonization with Group II pathogens). Previous (short-term) antibiotics had a protective effect against colonization with Group I pathogens of the lower respiratory tract (OR, 0.2; 95% CI, 0.05 to 0.86), but they were a risk factor for colonization with Group II pathogens (OR, 6.1; 95% CI, 1.3 to 29). Initial tracheobronchial colonization with Group I pathogens was associated with a higher probability of early onset pneumonia (OR, 4. 1; 95% CI, 0.7 to 23.3), whereas prolonged antibiotic treatment (> 24 h) independently predicted late-onset pneumonia (OR, 9.2; 95% CI, 1.7 to 51.3). We conclude that patients with head injury are colonized in the airways mainly by Group I pathogens early in the evolution of illness. The upper airways represent the main reservoir for subsequent lower airway colonization with Group I pathogens. Previous (short-term) antibiotic treatment is protective against initial tracheobronchial colonization with Group I pathogens, but it represents a risk factor for subsequent lower airway colonization by Group II pathogens.
Adult↗
[Learning cardiopulmonary resuscitation using conventional external cardiac massage or active compression-decompression in simulated cardiopulmonary resuscitation].
OBJECTIVE: To compare medical students' simulated learning of two different techniques of cardiopulmonary resuscitation (CPR). One was conventional external cardiac massage (ECM) and the other was active compression-decompression (ACD-CPR). MATERIAL AND METHODS: The study group (group S) comprised 111 students enrolled in their fourth year of medical studies who had no prior experience of CPR. Group R, the control group, was made up of 32 medical residents in anesthesiology and post-anesthetic intensive care. Before the study, group S received 5 hours of theoretical classes on CPR and both groups saw a video explaining each technique just before performing the test. All subjects applied each method to an adult dummy for one minute. The variables evaluated were frequency of complete and effective thoracic compressions and the body weight of the resuscitator. RESULTS: Each group performed similarly using the two techniques in terms of frequency of total compressions achieved. For each technique, the number of effective compressions achieved by group S (49.4 +/- 22.9 with ECM and 42.5 +/- 20.7 with ACD-CPR) was significantly lower (p < 0.05) than the number attained by group R (71.2 +/- 18.6 with ECM and 58.8 +/- 12 with ACD-CPR). Group R's frequency of effective compressions was significantly higher (p < 0.05) with CPR than with ACD-CPR. Body weight had no influence on the number of total compressions or efficacy in group R, whereas lower body weight in group S was significantly related to lower frequency of effective compressions with ECM p < 0.05). Neither group achieved a frequency of 80 total compressions in one minute. CONCLUSIONS: With the present teaching method, the medical students' performance was poor for both types of CPR and was affected by body weight. The residents' performance was less effective with ACD-CPR, a technique that was new to them, than with conventional ECM, with which they were expert and on which body weight had no impact.
Adult↗
[Outcome of patients who underwent surgical repair of aneurysm after subarachnoid hemorrhage].
BACKGROUND: Follow-up study of patients with surgical repair of aneurysmal subarachnoidal hemorrhage (SAH), looking for clinical outcome predictors. PATIENTS AND METHODS: Sixty two patients consecutively admitted to a teaching hospital, from January 1992 to December 1995 were included in the study. We studied preoperative, intraoperative and postoperative features looking for their relationship with the outcome. The ultimate outcome was evaluated by means of Glasgow Outcome Scale on discharge and 6 months later. RESULTS: Smoking (p = 0.0001) and arterial hypertension (AHT) (p = 0.0186) were more frequent in these patients than in general population, but without relationship to the outcome as with the age of the clinical status on admission. The greatest statistical relationship was found between the level of consciousness on postoperative awakening (measured by the Hunt and Hess scale), and the outcome (p = 2.53 x 10(-8). From our results we made an algorithm that correctly assigned 92% of studied patients to their outcome. CONCLUSIONS: All patients admitted on with aneurysm SAH deserve intensive care treatment besides their clinical grade. The level of consciousness on postoperative awakening was a good outcome predictor.
Adult↗
Unilateral trigeminal and facial nerve palsies associated with epidural analgesia in labour.
PURPOSE: To report a rare complication related to epidural analgesia for obstetrics: the association of unilateral trigeminal and facial nerve palsies in a patient with the clinical syndrome of intracranial hypotension. CLINICAL FEATURES: A 38-yr-old woman was admitted in pre-term labour (at 35 wk gestation). She was receiving 40 mg methadone po daily for opioid addiction. Epidural analgesia for labour was established with 9 ml bupivacaine 0.25%. The patient underwent normal vaginal delivery of a 2500 g female infant. She developed post-dural puncture headache (PDPH) on the third postpartum day which was managed by palliative measures: bed rest (patient's position of choice), increased hydration (water: 3 litres po per day), lysine acetyl salicylate (5.4 g po per day) and caffeine (600 mg po per day). She developed paraesthesiae and numbness of the right side of the face one day after the onset of PDPH and unilateral facial nerve palsy two days later. There was no evidence of dural puncture and no cause was found. Treatment of the nerve palsies with epidural blood patch or epidural dextran 40 was not considered to be indicated. Headache disappeared on the 10th postpartum day and trigeminal palsy regressed. At the time of discharge, on the 17th postpartum day, neurological examination showed minimal facial assimetry. The patient refused further exploration and follow-up. CONCLUSION: Post delivery trigeminal and facial nerve palsy in a 38 yr old woman recovered spontaneously with conservative therapy.
Adult↗
[Effect of mivacurium in patients chronically treated with anticonvulsant agents].
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Anticonvulsants↗
[Analysis of the current status of neuroanesthesia in Spain using a national survey].
OBJECTIVES: Advances in complementary diagnostic explorations, surgical support technology and the complexity of neurophysiological monitoring require anesthesiologists to acquire specific knowledge for dealing with neurosurgery. We aimed to study the implantation of new anesthetic-surgical techniques in the field of neurosurgery, and the state of neuroanesthesia as a subspecialty in Spain. MATERIAL AND METHODS: A 20-item postal questionnaire sent to anesthesiology department heads of Spanish hospitals with neurosurgery teams. RESULTS: We received responses from 62% of the hospitals surveyed. Of these, 69% performed stereotaxic surgery, 30% functional cerebral surgery (for Parkinson's disease and epilepsy) and 21% offered neuroendoscopy. In 38% of the hospitals cerebral metabolism was monitored (hemoglobin oxygen saturation in the jugular or regional cerebral oxygen saturation) and/or cerebral electrophysiology (electroencephalogram, evoked potentials) and in 23.8% flows and pressures were measured (transcranial precordial and/or tracheoesophageal Doppler). Anesthesiologists specializing in neurosurgery are present in 62% of the hospitals. Interventionist neuroradiology is performed in 57%. It was noteworthy that 14.3% do not regularly have an anesthesiologist present during such high risk procedures. CONCLUSIONS: Although most centers continue performing "classical" neurosurgery with standard monitoring, a substantial proportion of hospitals (38%) show evidence of advancing in anesthetic techniques for neurosurgery in Spain. Anesthesia for neurosurgery as a subspecialty is available in 62% of the responding hospitals.
Anesthesia↗
[A new case of acute pulmonary edema secondary to phenylephrine administered on the conjunctiva in cataract surgery].
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Acute Disease↗
Value of intracellular bacteria detection in the diagnosis of ventilator associated pneumonia.
BACKGROUND: Markers of ventilator associated pneumonia are of interest for confirming the diagnosis and for guiding the initial management of this frequent complication of mechanical ventilation. The detection of intracellular organisms in the polymorphonuclear leucocytes (PMNLs) and/or macrophages of bronchoalveolar lavage (BAL) fluid has been suggested as a specific test for the early indication of an infectious pulmonary process. METHODS: The diagnostic value of detecting intracellular organisms in two types of BAL fluid--protected (P-BAL) and conventional (C-BAL)--in 25 patients who died in one unit was prospectively studied. Immediately after death both P-BAL and C-BAL were performed bilaterally. Through a minithoracotomy on both sides of the chest bilateral bronchoscopically guided open lung biopsy samples were obtained from the same area, and an average of eight open lung blind biopsy samples (not bronchoscopically guided) were taken from each lung for histological examination. BAL fluid was examined for quantitative cultures (threshold 10(4) cfu/ml) and for the presence of intracellular organisms and extracellular organisms, and differential cell counts were also performed. RESULTS: Using the histopathology of the bronchoscopically guided open lung biopsies as the gold standard, detection of intracellular organisms in P-BAL (> or = 5%) and C-BAL (> or = 5%) fluids yielded 75% and 57% positive predictive values, and 83% negative predictive values, respectively. Prior treatment with antibiotics decreased the positive and negative predictive values of intracellular organism detection for both types of BAL fluid. The presence of intracellular organisms was correlated with the quantitative cultures of P-BAL and C-BAL samples. Quantitative cultures from P-BAL fluid were less sensitive (22% versus 45%) and more specific (100% versus 55%) than those from C-BAL samples. The percentage of extracellular organisms and the differential cell count in P-BAL and C-BAL samples could not discriminate between the presence or absence of pneumonia. CONCLUSIONS: The presence of > or = 5% intracellular organisms infecting PMNLs or macrophages in P-BAL or C-BAL fluids is a specific marker of ventilator associated pneumonia.
Bronchoalveolar Lavage Fluid↗
[Subcutaneous and mediastinal emphysema after easy orotracheal intubation].
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Female↗
[Intravenous anesthesia using propofol during lengthy neurosurgical interventions].
OBJECTIVE: To compare the hemodynamic stability and time to recovery of consciousness after long-duration (> 3 h) neurosurgery with 2 anesthetic protocols: total intravenous anesthesia with propofol as the single hypnotic agent and inhalational anesthesia with isoflurane. PATIENTS AND METHOD: We studied 58 middle-aged patients (range 40-50 years) scheduled for intracranial surgery. The patients, who all scored over 13 on the Glasgow coma scale before surgery, were randomly divided into two groups: 27 in group I received isoflurane and 31 in group II received propofol. Anesthetic induction was with sodium thiopental 4 mg/kg i.v. in group I and with propofol 2.5 mg/kg i.v. in group II. Both groups then received fentanyl 2 micrograms/kg i.v., lidocaine 1.5 mg/kg i.v. and vecuronium 0.2 mg/kg i.v. Before placement of the Mayfield head grip, with clamps, or before start of surgery in those cases in which the head grip was not used, all patients were given a 3 micrograms/kg i.v. dose of fentanyl. Hypnosis was maintained in group I with concentrations of isoflurane that were adequate for keeping minimum alveolar concentration (MAC) between 0.6 and 1. In group II maintenance was by continuous i.v. perfusion of propofol 10 mg/kg/h for 30 min., followed by 8 mg/kg/h for 30 min. and 6 mg/kg/h until the end of surgery. N2O was never used. RESULTS: After induction systolic and mean arterial pressures (SAP and MAP) decreased significantly in both groups in comparison with baseline values (SAP: 113.1 +/- 30.0 vs. 140.9 +/- 27.08 mmHg in group I and 109.6 +/- 22.1 vs. 135.0 +/- 19.7 mmHg in group II; MAP: 76.8 +/- 18.7 vs. 95.6 +/- 17.0 mmHg in group I and 74.9 +/- 13.2 vs. 93.4 +/- 13.7 mmHg in group II). The patients in group II showed less tendency to develop arterial hypertension in response to orotracheal intubation (SAP and MAP at the moment of intubation: 156.4 +/- 33.7 and 104.6 +/- 18.1 mmHg, respectively, in group I as compared to 135.1 +/- 31.2 and 93.5 +/- 22.4 mmHg in group II; p < 0.05 between the 2 groups and p < 0.05 for the baseline and intubation pressures in group I). Time to recovery of effective, spontaneous breathing was shorter in group I (5.9 +/- 4.9 and 8.9 +/- 5.7 min.) than in group II (10.9 +/- 9.6 and 13.0 +/- 7.4 min.) and tubes could be extracted earlier from patients in the isoflurane group (10.4 +/- 6.1 min. vs. 17.6 +/- 12.8 min.; p < 0.01). We found no differences between the 2 groups for time until eye opening, response to verbal orders or time until start of spontaneous movement. CONCLUSIONS: Propofol can be considered an alternative to the traditional thiopental-isoflurane sequence in neurosurgery lasting more than 3 h. In our study the hypertensive response to the stimulus of orotracheal intubation was lower in the propofol group than in the thiopental-isoflurane group.
Adult↗
[Postoperative analgesia in herniated disk surgery. Comparative study of diclofenac , lysine acetylsalicylate, and ketorolac].
INTRODUCTION: Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in treating musculoskeletal pain and are theoretically ideal for treating postoperative pain of the lumbar column. OBJECTIVES: To compare the analgesic efficacy and side effects of treatment with 3 NSAIDs (lysine acetylsalicylate, ketorolac and diclofenac) in the treatment of pain after surgery for lumbar disc hernia. PATIENTS AND METHODS: We enrolled 75 ASA I-II patients undergoing discectomy because of lumbar disc hernia; balanced general anesthesia was used in all cases. The patients were randomly distributed in 3 groups based on type of analgesia given in the immediate postoperative period. Group A received lysine acetylsalicylate (1800 mg), group B received ketorolac (30 mg) and group C received diclofenac (75 mg). The analgesics were diluted in 100 mg of saline solution and administered through a peripheral vein over 10 min. We evaluated the analgesia attained on a visual analog scale (VAS) and the physiological response to pain was assessed by monitoring changes in arterial pressure, heart rate and breathing frequency. If analgesia was insufficient 30 min after administration of the drug, 200 mg of lysine cloximate was given as a top-up. The side effects of each drug were also recorded. RESULTS: VAS evaluation showed significant reductions in pain 60 min after administration in groups A and B and after 120 min in group C. Nine patients in each group required lysine cloximate. There were no significant differences in physiological response among the 3 groups. No patient suffered major side effects. Mild side effects were reported most often in group B. CONCLUSIONS: The NSAIDs studied were inadequately for treating pain after surgery for lumbar disc hernia. Ketorolac was no better than the other analgesics studied but was associated with a higher number of mild side effects.
Adult↗
[Primary pulmonary hypertension in an HIV-positive pregnant woman].
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Adult↗