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      MEDICIÓN DE GASTO CARDÍACO CON ECOCARDIOGAFÍA TRANSTORÁCICA DURANTE ANESTESIA ESPINAL EN PACIENTES SANOS Translated title: MEASUREMENT OF CARDIAC EXPENDITURE WITH TRANSTORACIAL ECHOCARDIOGRAPHY DURING SPINAL ANESTHESIA IN HEALTHY PATIENTS

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          Abstract

          Resumen Introducción : La anestesia espinal produce cambios hemodinámicos como hipotensión (descrita hasta en un 30% de los pacientes) y bradicardia. La fisiología de estos cambios fue estudiada hace años en modelos animales y humanos experimentales. En la actualidad la ecocardiografia transtorácica (ETT) puede ser un monitor no invasivo útil y moderno para estudiar qué ocurre con el gasto cardíaco (GC) luego de un bloqueo subaracnoideo en la práctica clínica diaria. Objetivo : Evaluar el comportamiento del GC con el uso de ETT luego de la instalación de una anestesia espinal. Material y Método : En forma prospectiva se estudiaron pacientes ASA I propuestos para cirugía bajo anestesia espinal. El GC basal se estudió utilizando la ventana paraesternal izquierda donde se midió el diámetro del tracto de salida del ventrículo izquierdo y se le calculó su área. Luego desde la ventana apical en cinco cámaras se midió con Doppler continuo la integral de la velocidad máxima del tracto de salida (IVT). Al multiplicar IVT por su área se obtuvo el volumen de eyección (VE) que se multiplicó por la frecuencia cardíaca (FC), obteniéndose el GC. Luego se instaló la anestesia espinal utilizando una mezcla estandarizada con chirocaína al 0,5% y fentanyl 20 microgramos en un volumen entre 2,5 y 3 ml. El mismo examen ecocardiográfico para medir GC se realizó una vez comprobada la instalación del bloqueo espinal. Resultados : Se estudiaron 52 enfermos; en sólo 2 no hubo ventanas ecocardiográficas satisfactorias. La edad promedio fue de 44,8 ± 11 años. En todos los casos se realizó la cirugía con el bloqueo espinal. El nivel de bloqueo alcanzado fue T6 en un 36,36% de los casos y T4 en un 32,73%. Las variaciones de la presión arterial sistólica, diastólica y frecuencia cardíaca tuvieron una disminución estadísticamente significativa. No se observó una diferencia significativa en el GC previo y posterior a la anestesia espinal. La altura sensitiva máxima del bloqueo subaracnoideo tampoco se correlacionó con la disminución de la presión arterial media (PAM) ni con los parámetros ecocardiograficos. Conclusión : La anestesia espinal produjo disminución de los parámetros hemodinámicos. El uso de ecocardiografía transtorácica intraoperatoria permitió el estudio directo y real de la fisiología cardiovascular y demostrar que pese a la baja de la presión arterial y frecuencia cardíaca el GC tendió a mantenerse, probablemente por otros mecanismos de compensación como aumento de la contractilidad miocárdica y mejoría de la función diastólica. En el futuro la ETT puede ser una herramienta de estudio para evaluar qué ocurre con diferentes fármacos anestésicos y diferentes tipos de pacientes (obstétricas, cardióptas).

          Translated abstract

          Abstract Background : Spinal anesthesia produces hemodynamic changes such as hypotension (described in up to 30% of patients) and bradycardia. The physiology of these changes was studied years ago in animal and experimental human models. At present, transthoracic echocardiography (TTE) can be a useful and modern noninvasive monitor to study what happens with cardiac output (CO) after a subarachnoid block in daily clinical practice. Objective : To evaluate the behavior of the CO with the use of TTE after the installation of a spinal anesthesia. Material and Method : We prospectively studied ASA I patients proposed for surgery under spinal anesthesia. The baseline CO was studied using the left parasternal window where the diameter of the left ventricular outflow tract was measured and its area was calculated. Then from the apical window in five chamber view the integral of the maximum velocity of the outflow tract (IVT) was measured with continuous Doppler. When IVT was multiplied by its area, the ejection volume (VE) was multiplied by heart rate (HR), obtaining the CO. Spinal anesthesia was then installed using a mixture standardized with 0.5% chirocaine and 20 micrograms fentanyl in a volume between 2.5 and 3 ml. The same echocardiographic examination was done once the installation of the spinal block was verified. Results : We studied 52 patients, in only 2 there were no satisfactory echocardiographic windows. The average age was 44.8 ± 11 years. In all cases, surgery was performed with the spinal block. The level of blockade reached was T6 in 36.36% of the cases and T4 in 32.73%. The variations of the systolic, diastolic and heart rate had a statistically significant decrease. No significant difference was observed in the CO before and after spinal anesthesia. The maximum sensory height of the subarachnoid block did not correlate with the decrease in MAP or echocardiographic parameters. Conclusion : Spinal anesthesia produced decreased hemodynamic parameters. The use of intraoperative transthoracic echocardiography allowed the direct and real study of cardiovascular physiology and showed that despite the drop in blood pressure and heart rate, the CO tended to remain, probably due to other compensation mechanisms such as increased myocardial contractility and improvement of diastolic function. In the future, TTE can be a study tool to evaluate what happens with different anesthetic drugs and different types of patients (obstetric, cardiopathic).

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          Most cited references13

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          Transthoracic echocardiography for cardiopulmonary monitoring in intensive care.

          To evaluate the feasibility of an abbreviated focus assessed transthoracic echocardiographic protocol, consisting of four standardized acoustic views for cardiopulmonary screening and monitoring. The protocol was applied in 210 patients in a 20-bed multidisciplinary intensive care unit in a university hospital. When inconclusive, an additional transoesophageal echocardiographic examination was performed. Diagnosis, indication, acoustic window, position and value were recorded. Significant pathology, load, dimensions and contractility were assessed. Two-hundred-and-thirty-three transthoracic and four transoesophageal echoes were performed. The protocol provided usable images of the heart in 97% of the patients, 58% subcostal, 80% apical and 69% parasternal. Images through one window were obtainable in 23%, through two windows in 41% and through three windows in 34%. In 227 patients (97.4%) the focus assessed echo protocol contributed positively. In 24.5% of cases the information was decisive, in 37.3% supplemental and in 35.6% supportive. By means of an abbreviated, focus assessed transthoracic echo protocol it is feasible to visualize the haemodynamic determinants for assessment and optimization. One or more useful images are obtainable in 97% of critically ill patients.
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            Three years' experience of focused cardiovascular ultrasound in the peri-operative period.

            B Cowie (2011)
            Ultrasound applications in peri-operative medicine have become common place in modern anaesthesia practice. Anaesthetists have performed transoesophageal echocardiography in cardiac and selected non-cardiac surgery for over two decades. We aimed to assess the indications, impact on clinical management and accuracy of focused cardiovascular ultrasound performed by anaesthetists in the peri-operative period. One hundred and seventy patients over a 3-year period had a focused transthoracic echocardiogram. Adequate images to answer the clinical question were obtained in 167 out of 170 patients (98%). The undifferentiated systolic murmur was the commonest indication (98 out of 170, 58%). Some degree of aortic stenosis was present in 47 out of 170 (26%) of patients; mitral valve disease (30 out of 170 (18%)) and pulmonary hypertension (25 out of 170 (14%)) were also common. Changes in peri-operative management occurred in 140 out of 170 (82%) patients and major findings correlated with a formal cardiology transthoracic echocardiogram in 52 out of 57 (92%) patients. Focused cardiovascular ultrasound performed by anaesthetists in the peri-operative period accurately detects major cardiac pathology and significantly alters peri-operative management. © 2011 The Author. Anaesthesia © 2011 The Association of Anaesthetists of Great Britain and Ireland.
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              Hemodynamic changes associated with spinal anesthesia for cesarean delivery in severe preeclampsia.

              Hemodynamic responses to spinal anesthesia (SA) for cesarean delivery in patients with severe preeclampsia are poorly understood. This study used a beat-by-beat monitor of cardiac output (CO) to characterize the response to SA. The hypothesis was that CO would decrease from baseline values by less than 20%. Fifteen patients with severe preeclampsia consented to an observational study. The monitor employed used pulse wave form analysis to estimate nominal stroke volume. Calibration was by lithium dilution. CO and systemic vascular resistance were derived from the measured stroke volume, heart rate, and mean arterial pressure. In addition, the hemodynamic effects of phenylephrine, the response to delivery and oxytocin, and hemodynamics during recovery from SA were recorded. Hemodynamic values were averaged for defined time intervals before, during, and after SA. Cardiac output remained stable from induction of SA until the time of request for analgesia. Mean arterial pressure and systemic vascular resistance decreased significantly from the time of adoption of the supine position until the end of surgery. After oxytocin administration, systemic vascular resistance decreased and heart rate and CO increased. Phenylephrine, 50 mug, increased mean arterial pressure to above target values and did not significantly change CO. At the time of recovery from SA, there were no clinically relevant changes from baseline hemodynamic values. Spinal anesthesia in severe preeclampsia was associated with clinically insignificant changes in CO. Phenylephrine restored mean arterial pressure but did not increase maternal CO. Oxytocin caused transient marked hypotension, tachycardia, and increases in CO.
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                Author and article information

                Contributors
                Role: ND
                Role: ND
                Journal
                aar
                Anestesia Analgesia Reanimación
                Anest Analg Reanim
                Sociedad de Anestesiología del Uruguay (Montevideo, , Uruguay )
                0255-8122
                1688-1273
                December 2017
                : 30
                : 2
                : 83-98
                Affiliations
                [1] Valparaíso orgnameUniversidad de Valparaíso orgdiv1Hospital Clínico Fach Chile
                [2] orgnameHospital Clínico Fach
                Article
                S1688-12732017000300083
                05f1ff8a-60fe-4061-ae5c-cd105d60e32d

                This work is licensed under a Creative Commons Attribution 4.0 International License.

                History
                : 01 October 2017
                : 22 August 2017
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 14, Pages: 16
                Product

                SciELO Uruguay


                spinal anesthesia,Transthoracic echocardiography,Hemodinamia,Ecocardiografía Transtorácica,hemodynamics,Anestesia Espinal

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