Riesgos y complicaciones durante la sedación para endoscopía diagnóstica del tubo digestivo sin enfermedad concomitante / Risks and complications during sedation for diagnostic endoscopy of the gastrointestinal tract without concomitant disease

Resumen: Durante la sedación en procedimientos endoscópicos del tubo digestivo alto y bajo, es frecuente que se susciten complicaciones ventilatorias y hemodinámicas. Se presenta una revisión de las estrategias para prevenir y tratar las complicaciones ventilatorias más frecuentes: espasmo laríngeo, apnea por fármacos anestésicos endovenosos y broncoespasmo. También se revisan las complicaciones hemodinámicas: reflejo vagal e hipotensión aguda. Se propone un algoritmo de manejo que sintetiza y esquematiza las medidas profilácticas y terapéuticas descritas en la literatura, ordenándolas de acuerdo a su prioridad y eficacia, permitiendo identificar con claridad el nivel de tratamiento necesario y la viabilidad del procedimiento endoscópico.

Abstract: During sedation in endoscopic procedures of the lower and upper digestive tract, it is common for ventilatory and hemodynamic complications to arise. This article presents a review of the strategies to treat and prevent the most common ventilatory complications: laryngeal spasm, apnea due to intravenous anesthetic drugs and bronchospasm. Hemodynamic complications are also reviewed: vagal reflex and acute hypotension. A management algorithm is proposed which synthesizes and schematizes the prophylactic and therapeutic measures described in the bibliography, ordering them by their priority and effectiveness, allowing to clearly identify the degree of treatment necessary and the viability of the endoscopic procedure.

Edema pulmonar por presión negativa con máscara laríngea clásica. Presentación de un caso pediátrico / Pulmonary edema due to negative pressure with classical laryngeal mask. Presentation of a pediatric case

RESUMEN El edema pulmonar por presión negativa es una complicación rara y dramática en la anestesia general. Habitualmente ocurre como consecuencia de un laringoespasmo u otra causa de obstrucción de la vía aérea. Se presentó un caso con el objetivo de mostrar los elementos usados para el diagnóstico y tratamiento del edema pulmonar por presión negativa. Paciente de 7 años de edad, femenina, ASA I, operada de metatarso varo funcional con anestesia general balanceada y máscara laríngea clásica # 3. Desarrolló dicho evento adverso durante la recuperación anestésica. El diagnóstico se basó en la disociación toraco abdominal al restablecer la ventilación espontanea, crepitantes en ambos hemitórax, cianosis central, hipoxemia y la presencia de infiltrado difuso bilateral alveolar. Se intubó la tráquea, se controló la ventilación con presión positiva al final de la espiración y se administró furosemida. La paciente fue trasladada a la Unidad de Cuidados Intensivos donde evolucionó satisfactoriamente. Este es un síndrome cuya verdadera incidencia se desconoce debido a la escasa familiarización con el mismo. La evolución de los pacientes es favorable siempre que se establezca el diagnóstico y el tratamiento oportuno (AU).

ABSTRACT Pulmonary edema due to negative pressure is a rare and dramatic complication in general anesthetic. It usually occurs as a consequence of a laryngeal spasm or another cause of respiratory tract obstruction.A case was presented with the aim of showing the elements used for the diagnosis and treatment of the pulmonary edema due to negative pressure. An ASA I, 7-year-old female patient, was operated on a functional metatarsus varus with balanced general anesthetic and classical laryngeal mask number 3. She developed this adverse event during the anesthetic recovery. The diagnosis was based on the thoracoabdominal dissociation when recovering spontaneous ventilation, crepitation in hemithoraxes, central cyanosis, hypoxemia, and alveolar bilateral diffused infiltrate. The trachea was intubated, ventilation was controlled with positive pressure at the end of the expiration and furosemide was administered. The patient was transferred to the Intensive Care Unit where she evolved satisfactorily. This is a syndrome whose true incidence is unknown as a result of the lack of familiarization with it. Patients' evolution is favorable whenever the right diagnosis and treatment are timely established (AU).

Laryngeal Spasm in Scorpion Envenoming Syndrome

Death due to scorpion envenoming syndrome is a common event all over the world in tropical and sub-tropical countries. Scorpion envenoming syndrome results in a severe autonomic storm with a massive release of catecholamines, increased levels of angiotensin II, glucagon, cortisol, thyroid hormones, either hypoinsulinemia or hyperinsulinemia, hyperglycemia and increased free fatty acid levels. Under these conditions, scorpion envenoming syndrome with laryngeal spasm, fasciculations, clonus and tetany like skeletal muscle contractions, myocardial damage, disseminated intravascular coagulation, cardiovascular disturbances, peripheral circulatory failure, cardiac pulmonary oedema, adult respiratory distress syndrome, and many other clinical manifestations cause multi-systemorgan-failure and death. Under these altered conditions, scorpion envenoming essentially results in a syndrome of fuel – energy deficits and an inability to use the existing metabolic substrates by vital organs causing MSOF and death. Based on our animal experiments in which insulin administration reversed the metabolic and ECG changes induced by scorpion envenoming and treating the poisonous scorpion sting victims with insulin, we consider that insulin has a primary metabolic role in preventing and reversing laryngeal spasm, fasciculations, clonus and tetany like contractions, the cardiovascular, neurological manifestations and pulmonary oedema. Administration of insulinglucose infusion to scorpion sting victims is the physiological basis for the control of the metabolic response when that has become a determinant to survival. Continuous infusion of regular crystalline insulin at the rate of 0.3 U/g glucose and glucose at the rate of 0.1 g/kg body weight/hour, for 48–72 hours, potassium supplementation and maintenance of fluid, electrolytes and acid–base balance.

Laryngeal Spasm Mimicking Asthma and Vitamin D Deficiency

We present a woman with heterozygous carnitine palmitoyl transferase 2 (CPT-2) deficiency who in the last 6 months suffered from episodic dyspnea and choking. Symptoms could not be attributed to her muscular energy defect, since heterozygous CPT-2 deficiency is usually asymptomatic or causes only mild muscle fatigability. Myopathy is usually triggered by concurrent factors, either genetic (additional muscle enzymes defects) or acquired (metabolic stress). The patient was referred to our respiratory clinic for suspect bronchial asthma. Spirometry showed mild decrease in inspiratory flows. Methacholine challenge was negative. Dyspnea was triggered by hyperventilation-induced hypocapnia, which produced marked decrease in airflow rates, particularly in inspiratory flows, consistent with laryngospasm. Nutritional assessment of the patient showed low serum level of calcium and vitamin D, attributable to avoidance of milk and dairy products for lactose intolerance and to insufficient sunlight exposure. After calcium and vitamin D supplementation episodic laryngospasm disappeared and hypocapnic hyperventilation test induced very mild change in airflow rates. Calcium and vitamin D deficiency may favour laryngeal spasm mimicking asthma, particularly in subjects with underlying myopathy.

Acute Pulmonary Edema Following Esophagoscopy - A case report / 대한마취과학회지

There are many predisposing factors for acute pulmonary edema, Pulmonary edema in well recognized complication of acute airway obstruction, especially in small children, but rarely seen in adults. We present a case of noncardiogenic pulmonary edema that developed in adult following removal of endotracheal intubation after esophagoscopy, The sequence of events suggest that laryngospasm precipitated the development of the pulmonary edema in this patient.