Profundidad de sedación durante raquianestesia y el desarrollo de delirio postoperatorio en ancianos después de cirugía por fractura de la cadera

Profundidad de sedación durante raquianestesia y el desarrollo de delirio postoperatorio en ancianos después de cirugía por fractura de la cadera  Sedation depth during spinal anesthesia and the development of postoperative delirium in elderly patients undergoing hip fracture repair. Sieber FE, Zakriya KJ, Gottschalk A, Blute MR, Lee HB, Rosenberg PB, Mears SC. Department of Anesthesiology & Critical Care Medicine, Johns Hopkins Bayview Medical Center, 4940 Eastern Ave, Baltimore, MD 21224, USA.fsieber1@jhmi.edu Erratum in Mayo Clin Proc. 2010 Apr;85(4):400. Dosage error in article text. Abstract OBJECTIVE: To determine whether limiting intraoperative sedation depth during spinal anesthesia for hip fracture repair in elderly patients can decrease the prevalence of postoperative delirium. PATIENTS AND METHODS: We performed a double-blind, randomized controlled trial at an academic medical center of elderly patients (>or=65 years) without preoperative delirium or severe dementia who underwent hip fracture repair under spinal anesthesia with propofol sedation. Sedation depth was titrated using processed electroencephalography with the bispectral index (BIS), and patients were randomized to receive either deep (BIS, approximately 50) or light (BIS, >or=80) sedation. Postoperative delirium was assessed as defined by Diagnostic and Statistical Manual of Mental Disorders (Third Edition Revised) criteria using the Confusion Assessment Method beginning at any time from the second day after surgery. RESULTS: From April 2, 2005, through October 30, 2008, a total of 114 patients were randomized. The prevalence of postoperative delirium was significantly lower in the light sedation group (11/57 [19%] vs 23/57 [40%] in the deep sedation group; P=.02), indicating that 1 incident of delirium will be prevented for every 4.7 patients treated with light sedation. The mean +/- SD number of days of delirium during hospitalization was lower in the light sedation group than in the deep sedation group (0.5+/-1.5 days vs 1.4+/-4.0 days; P=.01). CONCLUSION: The use of light propofol sedation decreased the prevalence of postoperative delirium by 50% compared with deep sedation. Limiting depth of sedation during spinal anesthesia is a simple, safe, and cost-effective intervention for preventing postoperative delirium in elderly patients that could be widely and readily adopted. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800291/pdf/ mayoclinproc_85_1_004.pdf   Despertar durante anestesia: ¿Que tan seguros podemos estar de que el paciente en efecto esté dormido? Awareness during anesthesia: how sure can we be that the patient is sleeping indeed? Kotsovolis G, Komninos G. Postgraduate Education in Medical Research Methodology, School of Medicine, Aristotle University of Thessaloniki, Department of Anesthesiology and Intensive Care, 424 General Military Training Hospital, Thessaloniki, Greece. gskotsos@yahoo.gr Hippokratia. 2009 Apr;13(2):83-9. Abstract Awareness during surgery is a very serious problem for the anesthetist and the patient as well. Such incidents are the cause for 2% of the legal claims against anesthetists while patients with intraoperative awareness experience describe it as the worst thing they have ever suffered from. Pain, anxiety and inability to react due to muscle paralysis often lead to the situation called posttraumatic stress disorder which demands psychiatric support. The fact that there are patients who report intraoperative experience, even several days after surgery, raises questions about the way the anesthetic drugs interfere with the mechanisms of memory and consciousness while, in bibliography, there are studies proving that even deeply anesthetized patients can be influenced by auditory stimuli without being able to recall them. Intraoperative monitoring of the anesthesia depth is important for the prevention of this problem. From all the available devices only the Bispectral Index Monitoring (BIS) has been proven to be effective for this purpose but the high cost per person and the low specificity in preventing awareness episodes do not allow its everyday use. The surgeon and especially the anesthesiologist must be aware of the risk factors, the prevention measures and the actions that must be taken after an awareness incident in order to minimize the unfortunate complications for both the patient and the doctors. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2683150/pdf/hippokratia-13-83.pdf   Manejo de las crisis durante anestesia: despertar y anestesia Crisis management during anaesthesia: awareness and anaesthesia. Osborne GA, Bacon AK, Runciman WB, Helps SC. Department of Anaesthesia and Intensive Care, Royal Adelaide Hospital and University of Adelaide, Adelaide, South Australia, Australia. Qual Saf Health Care. 2005 Jun;14(3):e16. Abstract BACKGROUND: Patient awareness during general anaesthesia has considerable potential for severe emotional distress in the patient as well as professional, personal, and financial consequences for the anaesthetist. OBJECTIVES: To examine the role of a previously described core algorithm "COVER ABCD-A SWIFT CHECK", supplemented by a specific sub-algorithm for awareness, in the detection and management of potential awareness in association with general anaesthesia.Method: The potential performance of this structured approach for each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved.  RESULTS: Of the first 4000 reports received by AIMS, there were 21 incidents of patient awareness under general anaesthesia, and 20 of patients being paralysed while awake from "syringe swaps" before induction of anaesthesia. In 12 of the 21 reports there was an obvious cause, most commonly a low concentration of volatile agent (8 of 12 reports). The AIMS "core" crisis management algorithm would have detected the cause of awareness in all of these cases. In nine reports the course of anaesthesia appeared unremarkable, and in these the algorithm would not have been expected to detect or prevent awareness. Volatile agent monitoring would have prevented some cases of awareness, as would bispectral index electroencephalographic (BIS) monitoring. The role of BIS monitoring is still contentious, but it should be considered for high risk patients. CONCLUSION: Awareness should be minimised by thorough checking of equipment, particularly vaporisers, and frequent application of a structured scanning routine. Awareness may occur during crisis management and aftermath protocols should include patient follow up to detect and manage awareness when it occurs. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1744013/pdf/v014p00e16.pdf

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