Background: Prolonged intensive care unit (ICU) stays are associated with increased morbidity, resource utilization, and cost. Early identification of patients at risk for extended ICU length of stay (LOS) can support clinical decision-making and improve resource management. Objective: To develop and evaluate a machine learning model to predict ICU LOS using routine laboratory tests available early during admission. Methods: We conducted a retrospective study using electronic health record data from adult ICU patients. Evaluated the predictive performance of four machine learning (ML) models to choose the best model, which was trained on a set of demographic and laboratory tests’ results to predict LOS category. Model performance was assessed using accuracy, area under the receiver operating characteristic curve (AUC), sensitivity, and specificity on a validation set. Results: The XGBoost model demonstrated the highest accuracy (90%) and Kappa (79%) among the four evaluated models. On the testing data, XGBoost had an accuracy of 87.5%, sensitivity 88%, specificity 87.1%, and AUC of 95.3%. The top five important predictor variables were blood glucose, arterial partial pressure of oxygen (PaO2), arterial partial pressure of carbon dioxide (PaCO2), body mass index (BMI), and age. Diagnostic accuracy measures on the validation data were: Accuracy = 83.9%, sensitivity = 79.4%, specificity = 88%, and AUC = 92.5% Conclusion: Machine learning can effectively predict ICU length of stay early in the course of admission. Such models could aid clinicians in identifying patients at risk for prolonged ICU stays, facilitating proactive discharge planning and ICU resource optimization. Future studies should focus on external validation and real-world implementation.
Timely thrombolytic therapy is vital for acute ischemic stroke and STEMI, as delays increase tissue damage, worsen recovery, and raise mortality. A 24×7 thrombolysis service within the Emergency Department can reduce door-to-needle times, improve access in resource-limited settings, and enhance outcomes. This review highlights the rationale, epidemiology, clinical evidence, infrastructure, training, implementation, cost-effectiveness, barriers, and future directions. A model for Uttar Pradesh is proposed, focusing on ED integration, task-sharing, point-of-care diagnostics, a “one-room unit,” and robust monitoring, governance, and research linkages, tailored to the Indian context.
Diastolic dysfunction is a common manifestation of sepsis-associated cardiomyopathy and has been associated with poorer outcomes in critically ill patients; however, the factors that contribute to its development during septic shock are not fully defined. This study aimed to determine the association between cumulative fluid balance and diastolic dysfunction in patients with septic shock admitted to the ICU. An observational, prospective, longitudinal, and analytical study was conducted that included 55 adult patients with a diagnosis of septic shock. Cumulative fluid balance and diastolic function were assessed by critical echocardiography using the E/A ratio at admission, 24, and 72 hours. The statistical analysis included descriptive and analytical methods; ROC curves and relative risk calculation were used. It was identified that 40% of the patients had diastolic dysfunction. The most frequent infectious process was abdominal (60%), followed by pulmonary (32.7%). A positive and significant correlation was observed between the accumulated water balance and the mitral E/A ratio at all times evaluated (admission: r=0.531; 24 h: r=0.560; 72 h: r=0.466; p<0.001). The relative risk of diastolic dysfunction increased with water balance: 5.4 times the risk at admission, 8.8 at 24 h, and 13.9 at 72 h. In conclusion, the risk of developing diastolic dysfunction consistently increases with the increase in accumulated water balance.
Background: Lower limb orthopedic surgeries following motorcycle accidents can be performed with spinal anesthesia, and postoperative analgesia often involves morphine along with a local anesthetic. To achieve analgesia with peripheral nerve blocks, it is necessary to block the lumbosacral plexus from L2 to S3. This study aimed to compare the use of morphine with the combined lateral femoral-sciatic block with only one puncture site. Methods: Patients aged 18 to 60 years, after a motorcycle accident with fractures of the distal femur, knee, and proximal tibia, were included in two groups for evaluation of postoperative analgesia after surgery under spinal anesthesia. Group MO received 100 µg of morphine combined with 0.5% hyperbaric bupivacaine. Group CFS received a lateral femoral-sciatic block, with 15 ml of 0.25% levobupivacaine injected into the femoral nerve and 25 ml of the same substance injected into the sciatic nerve, accessed by neurostimulation with a 150 mm needle. The quality of analgesia, side effects, and patient satisfaction were evaluated. Results: There was no difference between the two groups. The time to access both nerves with the neurostimulator was 3:33±0:52 minutes, ranging from 2:04 to 5:51 minutes. The average analgesia time was 18±2 hours with morphine and 21±3 hours, being highly significant. The MO group presented pruritus, nausea, vomiting, and urinary retention, which decreased the degree of patient satisfaction. All patients in the CFS group did not present any complications. Patients were followed up by telephone until the 20th postoperative day without any reported anesthetic or analgesic complications. Conclusion: In this study, morphine presented a high incidence of side effects, resulting in decreased satisfaction. In contrast, the combined lateral femoral-sciatic nerve block with a neurostimulator puncture site was easy to perform, provided longer-lasting analgesia, and had no side effects, resulting in a higher rate of satisfaction.
Anesthetic management of pregnant patients with traumatic brain injury (TBI) requiring non-obstetric surgery represents a clinical challenge due to the need to simultaneously maintain maternal hemodynamic stability, cerebral perfusion pressure, and adequate uteroplacental perfusion. Furthermore, factors that can precipitate secondary brain injury, such as hypotension, hypoxemia, or hypercapnia, must be avoided. The case of a 29-week pregnant patient with TBI mild injury and right radius and ulna fracture, who underwent osteosynthesis under ultrasound-guided brachial plexus costoclavicular block with intravenous sedation. The anesthetic procedure allowed avoiding airway manipulation and hemodynamic variations associated with general anesthesia. Hemodynamic parameters remained stable during the intraoperative period, with mean arterial pressure variation less than ±10% of the baseline value. Fetal heart rate remained within normal ranges throughout the procedure. Postoperative analgesia was adequate, with a visual analog scale (VAS) score of 1/10 during the first 24 hours. This case suggests that ultrasound-guided costoclavicular block may represent a safe and physiologically favorable anesthetic alternative in selected pregnant patients with mild traumatic brain injury undergoing upper extremity surgery. The technique allows maintaining hemodynamic stability, preserving cerebral perfusion, uteroplacental perfusion, and avoids airway manipulation. Additional studies are required to evaluate its potential impact on maternal-fetal neuroprotection. The available literature on regional anesthesia in pregnant patients with traumatic brain injury is limited and mainly restricted to isolated reports of interscalene or supraclavicular blocks. However, these approaches may be associated with respiratory complications or a higher risk of pneumothorax. The brachial plexus costoclavicular block, recently described with the development of ultrasound-guided regional anesthesia, offers anatomical and physiological advantages that could make it particularly useful in this clinical scenario. To our knowledge, there are few reports documenting its use in pregnant patients with traumatic brain injury undergoing upper extremity surgery. The present case illustrates the feasibility and potential hemodynamic benefits of this technique, highlighting its possible role as a neuroprotective anesthetic strategy in complex clinical situations.
Posterior circulation stroke (PCS) involving the vertebrobasilar system constitutes about 20% of ischemic strokes. Unlike anterior strokes, PCS often presents with non-specific symptoms such as dizziness, vomiting, and visual disturbances, leading to frequent misdiagnosis and treatment delay. Owing to its distinct vascular anatomy and varied presentation, integrated clinical and radiological evaluation is vital for early diagnosis and management. Objectives: To assess the clinical patterns and risk factors associated with posterior circulation stroke in patients presenting to a tertiary care hospital. Methods: A prospective cross-sectional study was conducted over 18 months at Al-Ameen Medical College Hospital, Vijayapur, including 100 confirmed cases of PCS. Data were obtained through structured clinical evaluation, laboratory testing, and neuroimaging. MRI and MRA confirmed the diagnosis and vascular localization. Clinical features, risk factors, and arterial territories were analyzed using SPSS version 26. Results: The mean age was 55.2 ± 12.3 years, with males comprising 63%. Hypertension (61%) was the most common risk factor, followed by smoking (27%), dyslipidemia (24%), alcohol use (23%), and diabetes (18%). The leading symptoms were giddiness/vomiting (58%), motor weakness (47%), cranial nerve deficits (38%), cerebellar signs (28%), and visual field defects (24%). Radiologically, the posterior cerebral artery (47%) and posterior inferior cerebellar artery (45%) were most frequently involved, followed by the superior cerebellar (20%) and basilar (17%) arteries. Conclusion: PCS predominantly affects males over 50 years and is strongly linked to hypertension and smoking. Presentations are often non-specific, requiring high clinical suspicion. MRI plays a key role in diagnosis. Early detection and targeted management based on vascular involvement and risk factors can enhance patient outcomes.
Introduction: Healthcare personnel face high levels of work-related stress, which impacts their well-being and performance. Mindfulness practice has been shown to reduce stress and improve emotional self-regulation, possibly through an increase in vagal tone and parasympathetic activity. Objective: To evaluate the relationship between mindfulness practice and parasympathetic activity—measured through the Analgesia–Nociception Index (ANI)—in healthcare personnel. Methods: Clinical, prospective, and longitudinal study in 52 healthcare professionals. ANI was compared between meditators and non-meditators under controlled conditions. Parametric and non-parametric analyses were performed, in addition to adjusted ANCOVA and bootstrap analyses. Results: Meditators showed significantly higher ANI than non-meditators (t=2.760, p=0.008), with a moderate-to-high effect size (g=0.775). The effect remained significant after adjustments for age, sex, and time of measurement. Conclusion: Mindfulness practice is associated with an increase in vagal tone and parasympathetic activity, objectively measured through ANI. This index could be used as a physiological biomarker of autonomic well-being in mind-body interventions.
Background: Fournier's gangrene is a serious condition caused by a multibacterial infection, developing a necrotizing fascitis of the soft tissue of genital and perineal area, with a high mortality rate. An appropriate therapeutic approach includes antibiotics, surgical debridement and reconstructive surgery. With the aim to describe the results of plastic surgical procedures in patients suffering from Fournier’s disease, the present study was performed. Methods: An observational, descriptive, cross-sectional and prospective study was carried out at the Plastic Department of Calixto García Hospital, La Habana, from January 2018 to January 2022. All patients referred from the Urology Department with the diagnosis of Fournier Gangrene in recovery phase, with a proper granulation tissue, normal Complete Blood Counts values and negative bacteriological culture were included. A characterization of the sample was performed according to demographics parameters, reconstructive surgical techniques and the incidence of complications. Results: Of a total of 21 referred patients, 15 were included. Male were predominant (93,3%), skin grafting and local flaps the main surgeries performed, and the incidence of complications was unremarkable (13,3%). Diabetes Mellitus the main associated condition found (80 %). Conclusion: Skin Grafting and local flaps were the main reconstructive techniques performed with a low incidence of complications. In spite of several reconstructive techniques described, the combination of them was the roule.
Pulmonary embolism (PE) is a life-threatening cardiovascular emergency requiring rapid, coordinated, and multidisciplinary care. A Pulmonary Embolism Response Team (PERT) model provides a framework for evidence-based, timely diagnosis and treatment of PE. This article describes the development of a standardized clinical pathway supported by risk stratification tools, advanced imaging, and a collaborative team activation protocol. The PERT pathway enables streamlined, consistent, and safe management of acute PE, improving patient outcomes while ensuring optimal resource use.
Post-dural puncture headache (PDPH) is a side effect of the first spinal anesthesia and can also occur after an accidental dural puncture during epidural anesthesia. The risk of PDPH can be influenced by the size, shape, and orientation of the spinal needles, as well as the patient's posture. Leakage of cerebrospinal fluid (CSF) through the dura mater opening leads to traction on pain-sensitive structures, causing PDPH. There are various proposed mechanisms explaining how headaches are brought on by CSF hypotension. Spinal CSF dynamics are sensitive to varying respiratory performances. Since the beginning of the last century, subarachnoid blocks can be performed at any of the thoracic and lumbar spinal levels. Thoracic spinal anesthesia has been extensively studied in the 21st century, as have several new indications for spinal anesthesia. Thoracic spinal anesthesia (TSA) has been extensively studied in the 21st century, as have several new indications for spinal anesthesia. Several published articles on TSA demonstrate its safety, with a lack of neurological complications, particularly PDPH. Several mechanisms have been implicated in the lower incidence of thoracic puncture compared to lumbar puncture. This article shows several mechanisms for this lower incidence, and the low incidence after TSA compared with lumbar spinal anesthesia (LSA).
Background: This is a case report of a patient who presented in adrenal crisis after the abrupt cessation of a supplement, Artri King®, which is marketed for the treatement of joint pain. Artri King® was the subject of a 2020 Food and Drug Administration (FDA) advisory due to the product containing undisclosed dexamethasone, diclofenac, and methocarbamol. Case report: This patient used Artri King® daily for 2 years to manage her chronic joint pain and abruptly stopped, yielding a presentation of hypotension that was unresponsive to aggressive fluid resuscitation and initiation of peripheral vasopressors. The patient’s blood pressure stabilized after stress-dose steroids were given and peripheral vasopressors were up-titrated. Why should an emergency physician be aware of this? To our knowledge, this is the first case of a patient developing adrenal shock after discontinuing a health supplement that contains undisclosed corticosteroids. This case shows the broad presentation of adrenal crisis and emphasizes the importance of asking about the use of over-the-counter supplements when evaluating patients.
Some trauma and orthopedic pathology procedures must be performed immediately; delaying them can lead to a poor prognosis and sequelae that compromise patients' quality of life. However, patients sometimes present with comorbidities such as respiratory infections, which can increase the risk of adverse events during the perioperative period, such as laryngospasm, bronchospasm, and desaturation, and can be life-threatening. Furthermore, if general anesthesia is required, the spread of these pathogens to the lower airway can increase the risk of ventilator-associated pneumonia. With the advent of ultrasound and its use in regional anesthesia, risks have been reduced, techniques have been refined, and postoperative pain has been better controlled. Brachial plexus block can be performed using various approaches. The recently described ultrasound-guided costoclavicular block in the costoclavicular space has gained popularity, showing promising results for upper limb anesthesia and postoperative analgesia. This block is presented as an alternative to the traditional infraclavicular approach, with results showing better block quality and a lower risk of complications.
Severe traumatic brain injury (TBI) is a serious brain injury that involves secondary damage at the neuronal level and complications such as cerebral edema and intracranial hypertension, which increase morbidity and mortality. Management in the Intensive Care Unit (ICU) focuses on preventing secondary brain injury by optimizing cerebral perfusion pressure and reducing intracranial pressure (ICP) with osmotic therapy and non-invasive techniques such as optic nerve sheath ultrasonography. The objective of the present observational, cohort, and retrospective study carried out in the ICU of a second-level hospital in Mexico City was to determine the effect of hypertonic solutions on the optic nerve sheath diameter (ONSD) and its relationship with mortality in patients with severe TBI. Objective: To determine the impact on mortality in patients with severe traumatic brain injury (TBI) who are treated with hypertonic solutions and monitored via the optic nerve sheath diameter. Methods: It is a retrospective and observational study conducted on forty patients with TBI admitted to the ICU from November 2024 to June 2025. The patients admitted to the ICU underwent hyperosmotic or hypertonic therapy to reduce intracranial pressure. Patient monitoring was performed using ultrasonography placed at the bedside. Sociodemographic data, ultrasound results, treatment received, and the outcome of each patient were analyzed. Results: The study comprised 40 patients, of whom 26 were men (65%), and 14 were women (35%), with an average age of 34.2 ± 10.9 and 34.1 ± 12.5 years, respectively. It was identified that an Optic Nerve Sheath Diameter (ONSD) greater than 5mm [OR: 14.76; 2.58, 84.48; p-value<0.05] significantly increased mortality in TBI patients, while treatment with 20% mannitol significantly reduced the mortality rate [OR: 8.08; 1.08, 60.74; p-value<0.05, aR2=27.06%]. Conclusion: Treatment with hypertonic saline solution is an effective therapy that reduces mortality in patients with TBI. Furthermore, the optic nerve sheath diameter is a reliable indicator for non-invasive monitoring of these patients.
Introduction: The combination of Extracorporeal Carbon Dioxide Removal (ECCO₂R) with Continuous Renal Replacement Therapy (CRRT) represents an essential therapeutic approach for treating hypercapnic respiratory failure and multi-organ dysfunction in critically ill patients. This protocol-based study outlines the implementation of a standardized combined ECCO₂R-CRRT strategy in a critical care setting using the PrismaLung platform. Methods: We established a comprehensive protocol addressing patient selection criteria, cannulation methods, device settings, and anticoagulation protocols and strategies for managing complications during ECCO₂R-CRRT therapy. The protocol was developed through evidence-based and expert consensus methods to treat patients who have concurrent respiratory and renal failure. Results: The protocol defines specific inclusion criteria for ARDS patients (driving pressure >14 cmH₂O, plateau pressure >25 cmH₂O), COPD exacerbations (pH <7.25, PaCO₂ >70 mmHg), and concurrent renal failure requiring CRRT. The technical specifications include dual-lumen catheters (≥13F), blood flow rates of 350-450 mL/min, and sweep gas flow of 2-10 L/min. The anticoagulation strategy with systematic monitoring protocols. Conclusion: The implementation of a structured ECCO₂R-CRRT protocol using PrismaLung in ICU settings proves safe for specific patient populations. This combined approach provides simultaneous lung and kidney protective support and may reduce ventilator dependence in hypercapnic respiratory failure with concurrent renal dysfunction. The safety concerns associated with standalone ECCO₂R machines must be re-evaluated in integrated ECCO₂R-CRRT utilizing this novel protocol.
Epidural catheters are commonly used after surgery to manage pain effectively, but they carry risks, including complications like epidural hematomas and abscesses. Although these complications are rare, if left untreated, they can cause severe neurological damage. In contrast to epidural hematomas, intramuscular and subcutaneous hematomas are less risky but can be challenging to diagnose. This report discusses two cases of subcutaneous hematomas that occurred 24 hours following the removal of epidural catheters, highlighting the importance of close monitoring and collaboration among medical teams. Case 1 involves a young male with a complex medical history who underwent an exploratory laparotomy, while Case 2 involves a pediatric patient who underwent nephroureterectomy. The placement of the epidural catheters was uneventful. None of these patients had a coagulation disorder or received anticoagulation treatment. Both cases illustrate the diagnosis and management of subcutaneous hematomas, emphasizing the importance of early identification, differentiation from abscesses, and appropriate treatment. This report aims to increase awareness among healthcare providers about this uncommon but significant postoperative complication and to emphasize the importance of proactive management and patient education in ensuring a successful recovery.
Objective: The neutrophil-to-lymphocyte ratio (NLR) is increasingly utilized as a practical and cost-effective parameter for evaluating systemic inflammation and predicting the prognosis of various diseases. This study aimed to compare the effects of low-flow and high-flow anesthesia on hemodynamic parameters and NLR levels. Methods: With ethics committee approval, this retrospective study included 50 patients who underwent tympanoplasty or myringoplasty. Patients receiving high-flow anesthesia (Group Y) at 3 L/min and those receiving low-flow anesthesia (Group D) at 0.75 L/min were included. Data on age, sex, weight and hemodynamics were obtained from anesthesia records. NLR was calculated from preoperative and postoperative complete blood count results. Sevoflurane consumption was also determined. Results: The groups did not differ significantly in terms of age, sex, body mass index, anesthesia duration, and complication rates. A significant postoperative increase in NLR was observed in Group Y, but not in Group D. Intergroup comparison revealed that postoperative NLR was significantly lower in Group D compared to Group Y. Sevoflurane consumption was also significantly lower in the low-flow group. Conclusion: Low-flow anesthesia may offer environmental and economic advantages by reducing volatile anesthetic consumption. Furthermore, it may help attenuate the systemic inflammatory response, suggesting a potential clinical benefit in its use.
Background: Porphyrias are congenital disorders of heme synthesis, a molecule necessary for aerobic life. Its synthesis is catalyzed by eight enzymes that can be affected, resulting in seven different porphyrias. Mutations in these eight genes affect the following enzymes: aminolevulinate dehydratase (ALAD), porphobilinogen deaminase (PBGD), uroporphyrinogen synthase (UROS), uroporphyrinogen decarboxylase (UROD), coproporphyrinogen oxidase (CPOX), protoporphyrinogen oxidase (PPOX), and ferrochelatase (FECH).1,2 There are four acute porphyrias and four non-acute porphyrias. The clinical presentation of the latter is primarily sensitivity to sunlight.2 In porphyria, the different intermediates initially accumulate in the liver or bone marrow. Therefore, porphyrias are classified as hepatic or erythropoietic. Method: We report three cases of patients in the productive stage, including high-performance athletes, whose main symptom was abdominal pain. In one case, surgery was performed multiple times, resulting in various abdominal and systemic complications. We therefore emphasize the importance of early diagnosis and avoiding fatal outcomes, as described in one of the patients. Case presentation: Case 1: A 45-year-old female patient with multiple surgical history, recurrent cholangitis with stent placement on 4 occasions, presents abdominal pain predominantly in the hypochondrium and right flank of 16 hours of evolution, in her admission laboratories she presents anemia, mild hyponatremia. A CT scan and intestinal transit were performed with a report of intestinal occlusion with a site of origin in the sigmoid colon in which tachycardia, arterial hypertension, anemia and hyponatremia were reported. She underwent LAPE in which adhesions of the colon to the cystic fossa were found mainly, for which adherenciolysis was performed. In the postoperative period, the anemia worsened, so 2 red blood cell concentrates were transfused, later she was discharged due to improvement. Two months later, she was readmitted and transferred from another institution where LAPE + intestinal resection was performed, presenting data of respiratory distress, in relation to pulmonary thromboembolism, pleural effusion thoracentesis was performed, she was discharged due to improvement; Two months later, she was readmitted and transferred from another institution where LAPE + intestinal resection was performed, presenting data of respiratory distress, in relation to pulmonary thromboembolism, pleural effusion thoracentesis was performed, and treatment with anticoagulants was started. Case 2 : Female patient of 33 years old who presents important history: practices endurance sport Triathlon, surgical, Appendectomy, initial clinical picture, abdominal pain predominantly in the hypochondrium and right flank of 24 hours of evolution, being evaluated in the emergency service where an abdominal CT scan was performed without showing alterations, evaluated by the surgery department who considered that the clinical and tomographic findings do not correspond to cholecystopathy, supportive management was started with Intravenous Glucose and a hypercaloric diet, her admission laboratories with slight hyponatremia, the evolution is towards normalization, ALA and CPB tests in urine are requested, resulting positiveCase 3: 29-year-old female with the following important history: Gynecological and obstetrical: Pregnancy 1, Cesarean section 1, begins with a picture of approximately 1 week of evolution characterized by generalized abdominal pain being evaluated by a doctor, whodiagnoses functional colonopathy, being managed with antispasmodic drugs, without resolution of the picture, presenting with greater intensity, reason why it is decided to admit her for hospital management, opioid drugs are administered due to persistence of abdominal pain, abdominal distension and constipation, studies are performed Computed axial tomography of the abdomen without acute pathology, persisting with the picture without response to management, relevant laboratory tests with hyponatremia 125 mEq / l, with further deterioration, primarily in the neurological sphere, with the presence of restlessness and disorientation, without response to management with anxiolytics and subsequently antipsychotics, subsequently presenting symptoms of respiratory difficulty, with supplementary oxygen support, it is decided to admit him to the Intensive Care Unit, due to progression of ventilatory failure, it is decided to manage his airway with orotracheal intubation, with sedation and analgesia and airway hemorrhage occurs, a dark uresis is presented, for which ALA and CPB tests are requested in urine, resulting positive, his management begins with intravenous glucose, cimetidine, without response, due to prolonged intubation it is decided to perform a tracheostomy, evolving with relative stability, but presenting a new episode of airway hemorrhage and coagulation disorders, with manifestations of severe pulmonary hemorrhage, without response to the management of blood derivatives, she dies of multiple organ failure, hematological, renal, hepatic, neurological disorder mainly. Conclusion: Due to the complexity and diagnostic difficulty involved in identifying this disease, it is of vital importance and medical interest to share experience, established approaches, and management of the case identified in our hospital unit, in order to provide comprehensive support to the medical community.
Background: All drugs have their own density. The baricity of the solutions injected into spinal anesthesia is an important factor for their dispersion. Various adjuvants are added to local anesthetic solutions for spinal anesthesia in the same syringe. The objective of this laboratory study using a DMA 4500 densimeter was to determine the density of the mixture obtained from anesthetic and adjuvant of various anesthetists who use it in plastic surgeries at 20°C, 25°C, and 37°C. Second objective to compare with the baricity of the CSF, through the published media. Methods: The density of the mixtures was evaluated at three temperatures, the solution being hyperbaric if its density exceeds 1.00099, hypobaric when the density is below 1.00019 and isobaric when the density is greater than 1.00019 and less than 1.00099. For each mixture, a sufficient volume was obtained to make two measurements of the densities, and the average density value was obtained with two evaluations. The second part of the study was to evaluate the baricity (δ drug÷δ CSF of 37oC), compared with the density of the CSF. The final concentration of LA and glucose in the mixture were evaluated. Results: Nine different mixtures were found. All mixtures exhibited a decrease in density as the temperature was increased. At 37°C, all solutions containing glucose are hyperbaric. In the absence of glucose, all solutions are hypobaric. There was a decrease in the concentration of bupivacaine from 0.5% to between 0.27 and 0.37%, and in the glucose concentration from 8% to between 4.3 and 5.9%. Conclusion: The density of the mixtures obtained decreases with increasing temperature in the same way as the baricity of the final solution. Likewise, the mixture of LA and various adjuvants reduced the concentrations of bupivacaine and glucose produced by the laboratory. The ideal for spinal anesthesia safety in humans would be for each drug to be injected separately into its own syringe, with no change in the characteristics of each drug.
