Manejo anestésico de las pacientes embarazadas tetrapléjicas durante el parto: una revisión sistemática

IntroductionPregnancy in spinal cord injured patients has specific issues that must be carefully addressed. However, guidelines for their management are scarce.MethodsA systematic review of the literature regarding the anaesthetic management during delivery of pregnant patients with cervical spinal cord injury was performed on the electronic databases of PubMed (Medline) and Cochrane.ResultsA higher incidence of preterm birth and caesarean delivery were seen. Anaesthetic management was diverse, although most pregnant patients received epidural analgesia. Autonomic dysreflexia symptoms were present in 51% of pregnancies.ConclusionTimely management of these patients could possibly reduce caesarean and preterm delivery rates, avoid or minimize common complications, as well as reduce costs. An early reference to anaesthesiology consultation and a multidisciplinary approach is recommended.     

The challenges in scoring hypopneas in children: is pulse wave amplitude drop the answer?

BackgroundIdentifying electroencephalogram (EEG) cortical arousals are crucial in scoring hypopneas and respiratory efforts related arousals (RERAs) during a polysomnogram. As children have high arousal threshold, many of the flow limited breaths or hypopneas may not be associated with visual EEG arousals, hence this may lead to potential underestimation of the degree of sleep disordered breathing. Pulse wave amplitude (PWA) is a signal obtained from finger photoplethysmography which correlates directly to finger blood flow. The drop in PWA has been shown to be a sensitive marker for subcortical/autonomic and cortical arousals. Our aim was to use the drop in PWA as a surrogate for arousals to guide scoring of respiratory events in pediatric patients.MethodsTen polysomnograms for patients between the ages of 5–15 years who had obstructive apnea-hypopnea indices between 1 and 5 events/hour were identified. Patients with syndromes were excluded. A drop in PWA signal of at least 30% that lasted for 3 s was needed to identify subcortical/autonomic arousals. Arousals were rescored based on this criteria and subsequently respiratory events were rescored. Paired t-tests were employed to compare PSG indices scored with or without PWA incorporation.ResultsThe sample of 10 children included 2 females, and the average age was 9.8 ± 3.1 years. Overall, polysomnography revealed an average total sleep time of 464.1 ± 25 min, sleep efficiency of 92% +/−4.2, sleep latency of 19.6 ± 17.0 min, rapid eye movement (REM) latency 143 ± 66 min, N1 3.9% +/−2.0, N2 50.3% +/−12.0, N3 28.2% +/−9.1, REM 16.7% +/−4.0, and wakefulness after sleep onset (WASO) 18.1 ± 7.5 min. Including arousals from PWA changes, respiratory indices significantly increased including total AHI (2.3 ± 0.7 vs 5.7 ± 2.1, p < 0.001), obstructive AHI (1.45 ± 0.7 vs 4.8 ± 1.8, p < 0.001), and RDI (2.36 ± 0.7 vs 7.6 ± 2.0, p < 0.001). Likewise, total arousal index was significantly higher (8.7 ± 2.3 vs 29.4 ± 6.5, p < 0.001).ConclusionsThe drop in pulse wave amplitude signal is a useful marker to guide scoring arousals that are not otherwise easily identified in pediatric polysomnography and subsequently helped in scoring respiratory events that otherwise would not be scored. Further studies are needed to delineate if such methodology would affect clinical outcome.     

Investigating the association between eye colour and the Neurological Pupil index

IntroductionBrown or dark brown eyes make it difficult to distinguish the contrast between a black pupil and the surrounding iris, which may result in clinical assessment errors. The pupillometer can be used to derive an indexed value, the Neurological Pupil index™ (NPi) for pupillary light reflex. However, there are limited data associating the NPi and iris colour. We examine the NPi and eye colour association.MethodsData were pooled from the Establishing Normative Data for Pupillometer Assessments in Neuroscience Intensive Care (END-PANIC) Registry. The analysis includes 14,168 observations collected from 865 patients with neurological conditions who were admitted to the intensive care unit. Summary statistics and statistical models were developed to examine the association using Statistical Analysis Software (SAS) summary procedure.ResultsThe mean age of the cohort was 56 years (standard deviation = 17). Eye colour included dark brown (n = 339), blue (n = 234), brown (n = 173), green (n = 82), and other (n = 37). There was significant differences (p < 0.0001) between mean NPi values by eye colour [blue = 4.08 (0.92), brown = 3.34 (1.45), dark = 3.71 (1.33), green = 4.08 (0.67), other = 3.76 (1.25)]. However, a further random-effects mixed model after controlling for confounding variables revealed no significant difference in NPi values among different eye colour groups.ConclusionsThe pupillary light reflex, when assessed using the pupillometer, is not dependent on the eye colour. Practitioners are not required to consider eye colour as a confounder when they perform pupillary assessment for examining patients with neurological conditions.     

Cardiovascular responses to various autonomic tests in males and females

The results of cardiovascular autonomic reflex tests on 224 healthy, randomly selected subjects were analysed to study possible sex differences in the autonomic responses. The heart rate response to the Valsalva manoeuvre (Valsalva ratio) was greater in females over 50 years than in males of the same age (1.58 ± 0.34 vs. 1.44 ± 0.30,p < 0.05). The heart rate response to deep breathing (E/I ratio) was higher in females under 50 years than in males under 50 years (1.37 ± 0.17 vs. 1.34 ± 0.18,p < 0.001). The diastolic blood pressure response to isometric handgrip was higher in males under 50 years than in females of the same age (p < 0.05). Although there were sex differences in the magnitude of the responses, the effect of age was similar in males and females and accelerated attenuation of the autonomic responses could not be demonstrated with increasing age. It can be concluded that significant sex differences exist in cardiovascular autonomic responses. The implication of such differences need consideration.     

Cutaneous nerves in patients with diabetic neuropathy--an electron microscopic study

Since the role of cutaneous nerves in the pathogenesis of cutaneous diseases associated with diabetes mellitus is not well defined, cutaneous nerves in ten patients with severe diabetic neuropathy were electron microscopically investigated as a preliminary study. The specimens were taken from normal-appearing skin of their lower extremities. Cutaneous nerves were seen as axon-Schwann cell complexes in which variously degenerated axons and Schwann cells coexisted with normal ones. The degenerative changes were not, however, specific for diabetes mellitus.     

Trigone sensitivity testing is a measure of exteroceptive function

The trigone sensitivity test, a complementary test to cystometry, has been proposed as a method for distinguishing certain clinical disorders. Pressure is applied to the trigone region of the bladder by pulling upon a Foley catheter with the balloon inflated and the amount of force needed to induce an urge to void is recorded. Although the trigone sensitivity test has been proposed as a test of exteroceptive function, it is possible that deeper receptors, perhaps proprioceptors, are actually responsible for the awareness of the urge to void during the study. The present investigation compared the trigone sensitivity test with provoked detrusor contraction in 107 patients. The findings indicate that variations in the two responses occur independently of each other. It is concluded that different neural pathways are responsible for the two functions. The hypothesis that exteroceptive and not proprioceptive nerves are being measured during trigone sensitivity testing is supported by these findings.     

100例高血压病患者短程心率变异性分析

目的:评价自主神经活动在高血压病中的调节作用。方法:观测100例高血压病(Ⅰ组)和54例正常人(Ⅱ组)及高血压病伴心电图改变(ⅠA组)和不伴心电图改变(ⅠB组)心率变异性(以下称HRV)时域参数SDNN、rMSSD、PNN50、Bottom4项指标。结果:Ⅰ组与Ⅱ组差异有显著性(P<0.05);ⅠA组与ⅠB组组差异无显著性(P>0.05)。结论:在高血压病中,交感神经张力增高,副交感神经活动减弱及损伤可能是HRV降低的重要因素。     

神经移植重建面神经在腮腺癌根治术中的应用

目的：探讨腮腺深叶癌切除面神经后，即刻功能性修复的临床效果。方法：对1984年1月至2005年10月间收治的11例腮腺癌患者，术中采用将肿瘤连同腮腺及面神经切除，同时行颈丛神经移植重建面神经的治疗方法。结果：术后面神经功能均完全恢复，所有患者术后6个月复诊，见患者静态时面部对称，动态时口角轻度偏斜，术后一年两侧面部完全对称，睁、闭眼及提口角功能基本恢复正常。结论：腮腺癌根治术中采用颈丛神经移植能有效地恢复面神经的功能，既达到肿瘤切除的彻底性，又符合功能外科的发展要求，是一种比较理想的手术方法。