Neumotórax espontáneo persistente como manifestación primaria de sarcoma sinovial pleuropulmonar primario: a propósito de un caso / Persistent spontaneous pneumothorax as a primary manifestation of primary synovial sarcoma of the lung: a case report

El sarcoma sinovial pleuropulmonar (SSPP) es un tumor primario de pulmón, maligno, infrecuente en pediatría (prevalencia 0,1-0,5 %) que afecta predominantemente a adolescentes y adultos jóvenes. Se ha descrito una sobrevida global cercana al 30 % a los 5 años. Se reporta el caso de un paciente de 12 años de edad, previamente sano, que presentó tos, dolor torácico y disnea de comienzo súbito, como manifestación inicial de neumotórax izquierdo, el que persistió a los 4 días y requirió resección quirúrgica de lesión bullosa pulmonar. Se realizó diagnóstico histológico de sarcoma sinovial pleuropulmonar confirmado por estudio molecular, que evidenció la translocación cromosómica entre el cromosoma X y el 18: t(X;18) (p11.2;q11.2) de la pieza quirúrgica extirpada. Ante pacientes con neumotórax persistente o recidivante, es importante descartar causas secundarias, entre ellas, sarcoma sinovial pleuropulmonar. Su ominoso pronóstico determina la necesidad de arribar a un diagnóstico temprano e implementar un tratamiento agresivo

Pleuropulmonary synovial sarcoma (PPSS) is a primary malignancy of the lung, uncommon in pediatrics (prevalence: 0.1­0.5%) that predominantly affects adolescents and young adults. Overall survival has been reported to be close to 30% at 5 years. Here we report the case of a previously healthy 12-year-old male patient who presented with cough, chest pain, and dyspnea of sudden onset as initial manifestation of left pneumothorax, which persisted after 4 days and required surgical resection of pulmonary bullous lesion. A histological diagnosis of pleuropulmonary synovial sarcoma was made and confirmed by molecular study, which showed chromosomal translocation between chromosomes X and 18: t(X;18) (p11.2;q11.2) in the surgical specimen removed. In patients with persistent or recurrent pneumothorax, it is important to rule out secondary causes, including pleuropulmonary synovial sarcoma. Such poor prognosis determines the need for early diagnosis and aggressive treatment.

Fecopneumothorax secondary to a late traumatic diaphragmatic injury

Traumatic diaphragmatic hernias were first described by Ambroise Paré in 1579, who reported the case of an artillery captain, that presented an intestinal perforation that had caused a diaphragmatic hernia (Bhatti and Dawani, 2015). The timely diagnosis of a traumatic diaphragmatic hernia can be a challenge, which requires extensive knowledge of the kinematics of trauma, as well as clinical and radiological evidence (Petrone et al., 2017). We present the case of a 60-year-old male who presented blunt abdominal trauma due to a traffic accident, causing an undetected diaphragmatic hernia in his initial evaluation; months after de incident goes to the emergency room (ER) with hemodynamic instability and septic shock. A diagnosis of complicated diaphragmatic hernia and fecopneumothorax is made, for which he undergoes surgery.

Neumotórax espontáneo bilateral en primigestante adolescente, reporte de un caso / Spontaneous bilateral pneumothorax in a primigestant adolescent, a case report

El neumotórax espontáneo es una patología extremadamente rara durante la gestación. Se define como la presencia de aire dentro de la cavidad pleural que puede generar principalmente dolor torácico y disnea. Esta patología tiene unas bajas incidencia y prevalencia en el embarazo, pero es relevante por una alta tasa de recurrencia, con un buen pronóstico para la madre y el feto si es tempranamente diagnosticada y oportunamente manejada. Se relaciona con factores de riesgo como las maniobras de Valsalva efectuadas durante el trabajo de parto, además de con comorbilidad como el tabaquismo, y con el biotipo longilíneo, entre otros, por lo que son muy importantes una adecuada anamnesis y la evaluación de la exploración física. El obstetra debe sospecharlo ante la clínica de dolor torácico asociado a disnea en gestantes en el trabajo de parto y el parto, y tenerlo en cuenta como diagnóstico diferencial. Es de vital importancia tener un manejo multidisciplinario compuesto por ginecoobstetra, internista, neumólogo y neonatólogo, incluido el apoyo por una unidad de cuidado intensivo para evitar complicaciones materno-perinatales que se puedan asociar al neumotórax espontáneo.

Spontaneous pneumothorax is an extremely rare pathology during pregnancy. It is defined as the presence of air inside the pleural cavity that can mainly generate chest pain and dyspnea. This pathology has a low incidence and prevalence in pregnancy, but a high rate of recurrence with a good prognosis for the mother and the fetus if it is diagnosed early and managed early. It is related to risk factors such as Valsalva maneuvers performed during labor, in addition to comorbidities such as smoking, longilinear biotype, among others, so it is very important to have an adequate history and evaluation of the physical examination. The obstetrician must be attentive to chest pain symptoms associated with dyspnea in pregnant women during labor and delivery, suspect this pathology and take it into account as a differential diagnosis. It is vitally important to have a multidisciplinary management composed of the gynecologist-obstetrician, internist, pulmonologist, neonatologist, including the support of an intensive care unit to avoid maternal-perinatal complications that may be associated with spontaneous pneumothorax.

Effect of meteorological factors on first episode and recurrence of primary spontaneous pneumothorax

SUMMARY OBJECTIVE: In this study, we evaluated the clinical characteristics and seasonal distribution of patients with primary spontaneous pneumothorax and examined the relationships between meteorological factors and pneumothorax development overall and in terms of first episode and recurrence. METHODS: The hospital records of 168 pneumothorax patients treated in our clinic between January 2016 and December 2020 were reviewed retrospectively. A cluster was defined as two or more patients with pneumothorax presenting within three consecutive days. Meteorological factors were compared between days with and without pneumothorax patients. This comparison was based on meteorological data from the day of symptom onset (D), the day before symptom onset (D1), and the difference between those days (D-D1). Meteorological data from the index day (D) were also compared between patients with first episode and recurrence of pneumothorax. RESULTS: The study included 149 (88.7%) men and 19 (11.3%) women. The mean age was 25.02±6.97 (range, 17-35; median, 26) years. Of note, 73 (43.4%) patients underwent surgery. The highest number of patients presented in November (n=19, 11.3%). In terms of season, most presentations occurred in autumn. Humidity was significantly lower on recurrence days compared with first episode (p=0.041). CONCLUSION: Our results indicated that meteorological factors (i.e., atmospheric pressure, humidity, wind speed, temperature, and precipitation) were not associated with pneumothorax development. By comparing the patients with first episode and recurrence, the humidity was significantly lower in the recurrence group.

Association between ventilatory settings and pneumothorax in extremely preterm neonates

OBJECTIVES: Pneumothorax is a catastrophic event associated with high morbidity and mortality, and it is relatively common in neonates. This study aimed to investigate the association between ventilatory parameters and the risk of developing pneumothorax in extremely low birth weight neonates. METHODS: This single-center retrospective cohort study analyzed 257 extremely low birth weight neonates admitted to a neonatal intensive care unit between January 2012 and December 2017. A comparison was carried out to evaluate the highest value of positive end-expiratory pressure (PEEP), peak inspiratory pressure (PIP), and driving pressure (DP) in the first 7 days of life between neonates who developed pneumothorax and those who did not. The primary outcome was pneumothorax with chest drainage necessity in the first 7 days of life. A matched control group was created in order to adjust for cofounders associated with pneumothorax (CRIB II score, birth weight, and gestational age). RESULTS: There was no statistically significant difference in PEEP, PIP, and DP values in the first 7 days of life between extremely low birth weight neonates who had pneumothorax with chest drainage necessity and those who did not have pneumothorax, even after adjusting for potential cofounders. CONCLUSIONS: Pressure-related ventilatory settings in mechanically ventilated extremely low birth weight neonates are not associated with a higher risk of pneumothorax in the first 7 days of life.

Utilidad del ultrasonido a la cabecera del paciente con neumotórax en infección por SARS-CoV-2. Reporte de caso / Usefulness of bedside ultrasound in patients with pneumothorax in SARS-CoV-2 infection. Case report

It has been described that patients with coronavirus disease 2019 (COVID-19) may present pneumothorax, either spontaneously, primarily due to constant cough, secondary to pneumonia caused by said disease, or iatrogenic due to mechanical ventilation that require high pressures, or traumatic due to urgent approaches, in a difficult airway such as that of these patients. The use of bedside ultrasonography has been gaining great relevance to complement clinical diagnosis, which has become a useful and reliable tool for personnel treating critically ill patients.

Se ha descrito que los pacientes con la enfermedad por coronavirus 2019 (COVID-19), pueden presentar neumotórax, ya sea de forma espontánea, primaria por la tos constante, secundaria a la neumonía causada por dicha enfermedad, o ya sea iatrogénica por la ventilación mecánica que requieren con altas presiones, o traumática por los abordajes urgentes, en una vía aérea difícil como la de estos pacientes. El uso de la ultrasonografía a la cabecera del paciente ha venido cobrando gran relevancia para complementar el diagnóstico clínico, la cual se ha convertido en una herramienta útil y fiable para el personal que atiende pacientes críticamente enfermos.

Neumotórax espontaneo en paciente gestante / Spontaneous Pneumothorax in a Pregnant Woman

RESUMEN Introducción: El neumotórax es una de las enfermedades pleurales más frecuentes en la práctica médica, siendo excepcional su asociación con el embarazo, existiendo pocos casos reportados en la literatura mundial. La linfangioleiomiomatosis es una enfermedad multisistémica poco frecuente, que afecta predominante al sexo femenino en edad fértil y puede verse exacerbada por el embarazo. Objetivo: Realizar el reporte de un caso y la revisión del tema que permitan un diagnóstico precoz y una conducta de forma temprana. Caso clínico: Paciente gestante de 15 semanas, de 36 años de edad, con antecedentes de salud anterior, que debuta súbitamente con disnea a los medianos esfuerzos, tos, dolor torácico y neumotórax derecho espontáneo, recurrente en su evolución y posteriormente bilateral. Su curso fue tórpido requiriendo tratamiento en Unidad de Cuidados Intensivos por fallo respiratorio agudo, falleciendo luego de 3 meses del inicio del cuadro. Se le realizó, Radiografía de tórax: patrón reticular de tipo panal de abejas, tomografía de tórax: imágenes quísticas múltiples en todo parénquima pulmonar de predominio basal. Biopsia pulmonar compatible con linfangioleiomiomatosis. Conclusiones: La aparición de disnea súbita, dolor pleurítico y neumotórax en una gestante, deben ser siempre suficientes para tener en cuenta la presencia de una linfangioleiomiomatosis. Su inespecificidad sintomática inicial se traduce en un diagnóstico tardío, lo que empobrece su pronóstico(AU)

ABSTRACT Introduction: Pneumothorax is one of the pleural diseases most frequent in medical practice. Its association with pregnancy is essential. Few cases are reported in worldwide medical literature. Lymphangioleiomyomatosis is a rare multisystem disease that predominantly affects individuals of the female sex and at fertile age; it can be aggravated by pregnancy. Objective: To present a case report and a topic review that allow early diagnosis and early management. Clinical case: A 15-week-pregnant patient aged 36 years and with a previous health history suddenly presented dyspnea for average efforts, cough, chest pain, and spontaneous right pneumothorax, recurrent in its evolution and, later, bilateral. Its evolution was slow, a reason why it required intensive care for acute respiratory failure. The patient died three months after the onset of symptoms. The patient was performed chest x-ray, which showed honeycomb-type reticular pattern; and chest tomography, which showed multiple cystic images throughout pulmonary parenchyma, predominantly at baseline. Lung biopsy consistent with lymphangioleiomyomatosis was performed. Conclusions: Onset of sudden dyspnea, pleuritic pain and pneumothorax in a pregnant woman should always be sufficiently indicative of lymphangioleiomyomatosis. Its initial symptomatic non-specificity is determined by late diagnosis, which impoverishes prognosis(AU)

Prevalencias de complicaciones asociadas a la instalación de catéter venoso central para hemodiálisis / Prevalence of complications associated with central venous catheter instalation for hemodyalisis

Background: Placing central venous lines under ultrasonographic guidance reduces the complications of the procedure. Aim: To compare prevalences of complications of central venous line placements with or without ultrasonographic guidance. Material and Methods: Descriptive study that contemplated the comparison of two groups of patients subjected to a central venous line placement at a nephrology service for renal replacement therapy. In one group of 100 patients, the line was placed without ultrasonographic guidance between 2008 and 2012. Between 2015 and 2017 the line was placed in 138 patients using ultrasonographic guidance. The prevalences of complications with both types of procedures were recorded. Results: The frequency of complications of procedures with and without ultrasonographic guidance was 0.7 and 18% respectively (prevalence ratio 0.04, 95% confidence interval 0-0.3). Ninety five percent of recorded complications were arterial puncture, followed by hematomas in 10% and pneumothorax in 5%. The higher prevalence of complications was observed in emergency line placement without ultrasonographic guidance. There was a direct association between the number of line placement attempts in a single procedure and the prevalence of complications. Conclusions: Ultrasonographic guidance is associated with a reduction in the prevalence of central venous line complications.

Resultados del tratamiento con pleurostomía en pacientes con neumotórax espontáneo / Outcomes of Pleurostomy Treatment in Patients with Spontaneous Pneumothorax

RESUMEN Introducción: La presencia de aire dentro de la cavidad pleural es definida como neumotórax. El tratamiento quirúrgico inicial es la pleurostomía, que puede acarrear complicaciones, relacionadas con varios factores, entre los cuales se encuentra el diámetro de la sonda intratorácica utilizada. Objetivo: Evaluar los resultados del tratamiento con pleurostomía en pacientes con neumotórax espontáneo en el Hospital Universitario Manuel Ascunce Domenech. Método: Se realizó un estudio descriptivo longitudinal retrospectivo desde septiembre de 2012 hasta septiembre de 2017. Se estudiaron 63 pacientes afectos de neumotórax espontáneos que recibieron pleurostomía como tratamiento inicial. Resultados: Los neumotórax espontáneos primarios representaron 56 por ciento de los casos. Del total de pacientes, 82 por ciento eran fumadores. En todos los pacientes el síntoma predominante fue el dolor. Las complicaciones fueron más frecuentes con el uso de sondas pleurales de menor diámetro (86 por ciento). Conclusiones: El neumotórax espontáneo primario fue el de mayor frecuencia. Las causas predominantes en el neumotórax secundario fueron las bulas de enfisema y la enfermedad pulmonar obstructiva crónica. En la totalidad de los casos, estuvo presente algunos de los síntomas del síndrome pleural con predominancia absoluta del dolor. El mayor número de complicaciones se presentó en pacientes fumadores(AU)

ABSTRACT Introduction: The presence of air within the pleural cavity is defined as pneumothorax. The initial surgical treatment is pleurostomy, which can lead to complications associated with several factors, among which is the diameter of the intrathoracic probe that is used. Objective: To evaluate the outcomes of the treatment with pleurostomy in patients with spontaneous pneumothorax at Manuel Ascunce Domenech University Hospital. Method: A retrospective, longitudinal, descriptive study was conducted from September 2012 to September 2017. We studied 63 patients affected by spontaneous pneumothorax who received pleurostomy as initial treatment. Results: Primary spontaneous pneumothorax accounted for 56 percent of the cases. From the total amount of patients, 82 percent were smokers. In all patients, the predominant symptom was pain. Complications were more frequent with the use of pleural probes of smaller diameter (86 percent). The primary spontaneous pneumothorax was the most frequent. The predominant causes of secondary pneumothorax were bullous emphysema and chronic obstructive pulmonary disease. In all the cases, some of the symptoms of pleural syndrome with absolute predominance of pain were present. The greatest number of complications occurred in smoking patients. Conclusions: Pleurostomy, with the use of the drainage catheter, is the initial treatment for all patients with spontaneous pneumothorax in our hospital, regardless of the diameter of the probe to be used according to the type of pneumothorax (primary or secondary)(AU)

Linfangioleiomiomatosis pulmonar, una rara enfermedad pulmonar: presentación de un caso clínico / Pulmonary lymphangioleiomyomatosis, a rare lung disease: presentation of a clinical case

Introducción: La linfangioleiomiomatosis Pulmonar (LAM) es una rara y progresiva enfermedad; caracterizada por proliferación excesiva de células musculares lisas a partir de vasos linfáticos, sanguíneos y vías aéreas. En conjunto al anormal crecimiento celular descrito, se aprecia degeneración quística difusa del parénquima pulmonar, lo que puede reflejarse desde cuadros completamente asintomáticos hasta el deterioro severo del intercambio gaseoso con insuficiencia respiratoria fulminante. Descripción del caso: Paciente femenino de 41 años de edad, con cuadro clínico consistente en tos seca ocasional, asociada a dolor leve de características pleuríticas en 'puntada de costado ' derecha. Ante la no mejoría clínica, se indica estudio imagenológico donde se demuestra neumotorax espontáneo derecho. En estudio tomográfico se aprecian además lesiones pulmonares quísticas. El estudio anátomo-patológico demuestra cambios estructurales que se reportan compatibles con LAM. Conclusión: Dada la simplicidad de los síntomas con que la LAM puede debutar, su confirmación diagnóstica se genera en fases avanzadas de la enfermedad, cuando el daño pulmonar importante conlleva a la aparición de factores clínicos con mayor repercusión sobre el estado general de los pacientes por lo que la realización de estudios imagenológicos tempranos gana vital importancia.

Introduction: Pulmonary lymphangioleiomyomatosis (LAM) is a rare and progressive disease; characterized by airway, lymphatic and blood vessels-smooth muscle cells excessive proliferation. Added to the abnormal cell growth, parenchymal cystic degeneration is present, which can be reflected initially as a asymptomatic course and can progress to severe gaseous exchange deterioration and fulminating respiratory insufficiency. Case description: A 41-year-old female patient with a clinical course consisting of occasional dry cough, associated with mild pleuritic pain on the right side of thorax. As no improvement was achieved, thoracic imaging study was performed, where a right pneumothorax was found. Tomography images showed multiple lung cystic lesions. Anatomopathological study reports structural changes compatible with LAM. Conclusion: Given the simplicity of the symptoms that LAM can debut with, its diagnostic confirmation is generated in advanced stages of the disease, when the important pulmonary damage leads to the appearance of clinical factors with greater impact on the general state of patients so early thoracic imaging studies gain vital importance.

CT-guided percutaneous core needle biopsy of pulmonary nodules smaller than 2 cm: technical aspects and factors influencing accuracy / Biópsia percutânea com agulha grossa, guiada por TC, de nódulos pulmonares menores que 2 cm: aspectos técnicos e fatores que influenciam a precisão

ABSTRACT Objective: To evaluate the diagnostic accuracy of CT-guided percutaneous core needle biopsy (CT-CNB) of pulmonary nodules ≤ 2 cm, as well as to identify factors influencing the accuracy of the procedure and its morbidity. Methods: This was a retrospective, single-center study of 170 consecutive patients undergoing CT-CNB of small pulmonary nodules (of ≤ 2 cm) between January of 2010 and August of 2015. Results: A total of 156 CT-CNBs yielded a definitive diagnosis, the overall diagnostic accuracy being 92.3%. Larger lesions were associated with a higher overall accuracy (OR = 1.30; p = 0.007). Parenchymal hemorrhage occurring during the procedure led to lower accuracy rates (OR = 0.13; p = 0.022). Pneumothorax was the most common complication. A pleura-to-lesion distance > 3 cm was identified as a risk factor for pneumothorax (OR = 16.94), whereas performing a blood patch after biopsy was a protective factor for pneumothorax (OR = 0.18). Conclusions: Small nodules (of < 2 cm) represent a technical challenge for diagnosis. CT-CNB is an excellent diagnostic tool, its accuracy being high.

RESUMO Objetivo: Avaliar a precisão diagnóstica da biópsia percutânea com agulha grossa, guiada por TC - doravante denominada BAG-TC - de nódulos pulmonares ≤ 2 cm, bem como identificar fatores que influenciam a precisão do procedimento e sua morbidade. Métodos: Estudo retrospectivo, realizado em um único centro, com 170 pacientes consecutivos submetidos a BAG-TC de nódulos pulmonares pequenos (≤ 2 cm) entre janeiro de 2010 e agosto de 2015. Resultados: Do total de biópsias, 156 resultaram em diagnóstico definitivo, com precisão diagnóstica global de 92,3%. Lesões maiores estiveram relacionadas com maior precisão global (OR = 1,30; p = 0,007). A presença de hemorragia parenquimatosa durante o procedimento resultou em menor precisão (OR = 0,13; p = 0,022). Pneumotórax foi a complicação mais comum. Uma distância > 3 cm entre a lesão e a pleura foi identificada como fator de risco de pneumotórax (OR = 16,94), ao passo que a realização de tampão sanguíneo após a biópsia foi um fator de proteção contra o pneumotórax (OR = 0,18). Conclusões: O diagnóstico de nódulos pequenos (< 2 cm) é um desafio do ponto de vista técnico. A BAG-TC é uma excelente ferramenta diagnóstica, cuja precisão é alta.

Enfisema subcutáneo masivo, nemotórax a tensión y neumomediastino tras traqueotomía percutánea / Massive subcutaneous emphysema, nemotórax voltage and pneumomediastinum after percutaneous tracheostomy

Mujer de 68 años que ingresa en la Unidad de Cuidados Intensivos por shock séptico. En el posoperatorio la paciente se mantiene inestable y se decide realizar traqueotomía percutánea (TP) por intubación prolongada. Al inicio la paciente presenta un enfisema subcutáneo que progresa hasta convertirse en masivo. Se realiza TC torácico donde se observa pérdida de la morfología habitual de la pared posterior traqueal con solución de continuidad. Tras revisión mediante traqueobroncoscopía se decide colocar cánula de traqueotomía larga para dejar la lesión proximal al neumotaponamiento y así evitar la fuga de aire. Desde la colocación de la nueva cánula, la paciente presenta una disminución progresiva del enfisema hasta su total resolución. La TP es un procedimiento seguro que se realiza con mucha frecuencia en los servicios de medicina intensiva, sin embargo, no está exenta de complicaciones. En la revisión de Powell y cols describen las complicaciones de la TP destacando la inserción peritraqueal, la hemorragia, las infecciones de la herida, el neumotórax y la muerte. El rango de complicaciones en la literatura oscila entre 3% y 18%. Además, no se encuentran diferencias significativas respecto a las complicaciones entre la TP y la técnica abierta.

A 68-year-old woman who enter in intensive care unit due to septic shock. In the postoperative period, the patient remained unstable and decided to perform a percutaneous tracheotomy (PT) because prolonged intubation. In the first, the patient presents subcutaneous emphysema that progresses until becoming massive. Thoracic CT is performed where loss of the usual morphology of the posterior tracheal wall with continuity solution is observed. After revision by means of tracheobroncoscopia, it is decided to place a long tracheotomy cannula to leave the lesion proximal to pneumotaponamiento and thus avoid air leakage. From the placement of the new cannula, the patient presents a progressive decrease of the emphysema until its total resolution. PD is a safe procedure that is performed very frequently in the Intensive Care Services3, however, it is not without its complications. The review of Powell et al4 describes the complications of PT emphasizing peritracheal insertion, hemorrhage, wound infections, pneumothorax, and death. The range of complications in the literature ranges from 3 to 18% 5. In addition, no significant differences were found regarding the complications between the TP and the open technique.

Tension pneumothorax during peroral endoscopic myotomy for treatment of esophageal achalasia under general anesthesia / Pneumotórax de tensão durante miotomia endoscópica por via oral para tratamento de megaesôfago sob anestesia geral

Abstract More and more endoscopically gastrointestinal procedures require anesthesiologists to perform general anesthesia, such as "peroral endoscopic myotomy". Peroral endoscopic myotomy is a novel invasive treatment for the primary motility disorder of esophagus, called esophageal achalasia. Despite of its minimally invasive feature, there are still complications during the procedure which develop to critical conditions and threat patients' lives. Herein we describe a case about tension pneumothorax subsequent to esophageal rupture during peroral endoscopic myotomy. The emergent management of the complication is stated in detail. The pivotal points of general anesthesia for patients undergoing peroral endoscopic myotomy are emphasized and discussed. Also, intraoperative and post-operative complications mentioned by literature are integrated.

Resumo Cada vez mais os procedimentos gastrointestinais feitos por endoscopia, tais como a miotomia endoscópica por via oral (MEVO), exigem anestesiologistas para administrar anestesia geral. A MEVO é um novo tratamento invasivo para o distúrbio de motilidade primária do esôfago, denominado acalasia esofágica (AE). Apesar de sua característica minimamente invasiva, existem complicações durante o procedimento que evoluem para condições críticas e de risco à vida. Descrevemos aqui um caso de pneumotórax hipertensivo após a ruptura do esôfago durante uma MEVO. O tratamento de emergência da complicação é relatado em detalhes. Os pontos cruciais da anestesia geral para pacientes submetidos à MEVO são enfatizados e discutidos. Além disso, as complicações mencionadas pela literatura nos períodos intraoperatório e pós-operatório são integradas ao texto.

Complications of central venous catheter insertion in a teaching hospital / Complicações de punções venosas centrais em um hospital de ensino

Summary Introduction: Central venous catheters are fundamental to daily clinical practice. This procedure is mainly performed by residents, often without supervision or structured training. Objective: To describe the characteristics of central venous catheterization and the complication rate related to it. Method: Retrospective cohort study. Adult patients undergoing central venous catheter insertion out of the intensive care unit (ICU) of a teaching hospital were selected from March 2014 to February 2015. Data were collected from medical charts using an electronic form. Clinical and laboratory characteristics from patients, procedure characteristics, and mechanical and infectious complications rates were assessed. Patients with and without complications were compared. Results: Three hundred and eleven (311) central venous catheterizations were evaluated. The main reasons to perform the procedure were lack of peripheral access, chemotherapy and sepsis. There were 20 mechanical complications (6% of procedures). Arterial puncture was the most common. Procedures performed in the second semester were associated with lower risk of complications (odds ratio 0.35 [95CI 0.12-0.98; p=0.037]). Thirty-five (35) catheter-related infection cases (11.1%) were reported. They were related to younger patients and procedures performed by residents with more than one year of training. Procedures performed after the first trimester had a lower chance of infection. Conclusion: These results show that the rate of mechanical complications of central venous puncture in our hospital is similar to the literature, but more attention should be given to infection prevention measures.

Resumo Introdução: Cateteres venosos centrais são fundamentais na prática clínica diária. Em hospitais de ensino, esse procedimento é realizado por médicos residentes, frequentemente sem supervisão ou treinamento estruturado. Objetivo: Descrever as características das punções venosas centrais e a taxa de complicações relacionadas. Método: Estudo de coorte retrospectiva. Foram selecionados pacientes adultos submetidos a punção venosa central fora de unidade de terapia intensiva (UTI) de um hospital de ensino no ano letivo de 2014 (março de 2014 a fevereiro de 2015). Os dados foram coletados por meio de revisão de prontuários com o uso de formulário eletrônico. Foram avaliadas características clínicas e laboratoriais dos pacientes, características do procedimento, taxa de complicações mecânicas e infecciosas relacionadas. Foram comparados os pacientes com complicações em relação àqueles sem complicações. Resultados: Foram avaliadas 311 punções venosas centrais. Os principais motivos para realização do procedimento foram falta de rede periférica, quimioterapia e sepse. Ocorreram 20 complicações mecânicas (6% dos procedimentos); punção arterial foi a mais comum. Procedimentos realizados no segundo semestre do ano letivo foram associados a menor risco de complicações (razão de chances de 0,35 [IC95 0,12-0,98; p=0,037]). Foram descritos 35 casos de infecção relacionada ao cateter (11,1%). Casos de infecção foram associados a pacientes mais jovens e procedimentos realizados por residentes com mais de um ano de treinamento. Procedimentos realizados após o primeiro trimestre tiveram menor chance de infecção. Conclusão: Esses resultados mostram que a taxa de complicações mecânicas de punção venosa central em nosso hospital é semelhante à da literatura; porém, maior atenção deve ser dada para medidas de prevenção de infecção.

Neumotórax espontáneo debido a bulas subpleurales: presentacion de un caso / Spontaneous pneumothorax and subpleural bulla: case report

Pneumothorax is defined as the presence of air within the pleural cavity. It may be traumatic, iatrogenic, spontaneous secondary or primary. In the latter cause, the most frequent are subpleural and apical bulla in longiline patients, with connective tissue diseases and smokers. Treatment should be conservative in patients who present a small pneumothorax. Instead, a probe should be installed if it is greater. In the presence of frequent recurrences or persistent air leakage, pleurodesis should be considered, or resection of the bullous should be practiced. In this article we review a patient with Elhers Danlos syndrome, who presents a primary spontaneous pneumothorax due to subpleural bulla

El neumotórax se define como la presencia de aire dentro de la cavidad pleural. Puede ser traumático, iatrogénico, espontáneo secundario o primario, dentro de esta última causa la más frecuente son las bulas subpleurales y apicales, en pacientes longilíneos, portadores de enfermedades del tejido conectivo y fumadores. En neumotórax pequeños el tratamiento debe ser conservador, en cambio en los de mayor cuantía se debe proceder a la instalación de una sonda pleural. Frente a recidivas frecuentes o persistencia del escape aéreo, se debe considerar la pleurodesis o bien practicar la resección de las bulas.En el presente artículo se reporta a un paciente con síndrome de Elhers Danlos que presenta un neumotórax espontáneo primario debido a bulas subpleurales.

Etiology of primary spontaneous pneumothorax / A etiologia do pneumotórax espontâneo primário

ABSTRACT With the advent of HRCT, primary spontaneous pneumothorax has come to be better understood and managed, because its etiology can now be identified in most cases. Primary spontaneous pneumothorax is mainly caused by the rupture of a small subpleural emphysematous vesicle (designated a bleb) or of a subpleural paraseptal emphysematous lesion (designated a bulla). The aim of this pictorial essay was to improve the understanding of primary spontaneous pneumothorax and to propose a description of the major anatomical lesions found during surgery.

RESUMO Com o advento da TCAR, o pneumotórax espontâneo primário passou a ser mais bem entendido e conduzido, pois sua etiologia pode ser atualmente identificada na maioria dos casos. O pneumotórax espontâneo primário tem como principal causa a rotura de uma pequena vesícula enfisematosa subpleural, denominada bleb ou de uma lesão enfisematosa parasseptal subpleural, denominada bulla. O objetivo deste ensaio pictórico foi melhorar o entendimento do pneumotórax espontâneo primário e propor uma descrição das principais lesões anatômicas encontradas durante a cirurgia.

Pleurodesis con sangre autóloga en neumotórax espontaneo secundario con fuga aérea persistente / Autologous blood pleurodesis in secondary spontaneous pneumothorax with persistent air leak

Introducción: El neumotórax espontáneo secundario (NES) es la presencia de aire en la cavidad pleural con ausencia de traumatismo, asociado a alguna enfermedad pulmonar subyacente. La pleurodesis es considerada una alternativa al tratamiento de esta patología. La fuga aérea persistente o masiva es una complicación importante del NES, donde la utilización de pleurodesis con sangre autóloga constituye una opción conveniente en pacientes con alto riesgo quirúrgico. Objetivos: Se propuso describir las características de pacientes con NES tratados con pleurodesis con sangre autóloga en Hospital Regional de Concepción. Pacientes y método: Estudio descriptivo transversal, período enero 2012 - enero 2015. Se realizó una revisión de base de datos, protocolos quirúrgicos y fichas clínicas, seguimiento clínico a 36 meses, donde se describieron características clínicas, morbimortalidad, resultados inmediatos y tardíos. Resultados: Del total de pacientes (n=7), 5 (71,4 %) fueron hombres, con edad promedio de 60,7±8,2 años. La causa del NES fue mayoritariamente enfermedad pulmonar difusa en seis pacientes (85,7 %). Se realizaron siete pleurodesis con sangre autóloga sin necesidad de repetir el procedimiento. Se observó cierre de fístula en el 100 % de los pacientes. Al seguimiento no se observó necesidad de nuevos procedimientos. Discusión: La pleurodesis con sangre autóloga es un tratamiento efectivo y seguro en el manejo de la fuga aérea persistente o masiva, con adecuados resultados inmediatos y tardíos en casos seleccionados.

Introduction: Secondary spontaneous pneumothorax (NES) is pleural air occupation without trauma associated with the presence of some underlying lung disease. Pleurodesis is considered an alternative to the treatment of this disease. Persistent or massive air leak is a major complication of NES, where the use of pleurodesis with autologous blood is an accepted option in patients with high surgical risk and air leak. Objetive: Describe characteristics of patients with NES treated with pleurodesis with autologous blood in Hospital Regional of Concepción. Patients and methods: Cross-sectional descriptive study period January 2012- January 2015. It`s made a review of Database, surgical protocols and review medical records, 36 months' clinical follow-up. Description of clinical features, morbidity and mortality, immediate and remote results. Results: Of all patients (n=7), 5 (71.4 %) were males, mean age 60.7 ± 8.2 years. The cause of NES was predominantly diffuse lung disease in 6 (85.7%) patients. Seven pleurodesis with autologous blood were performed without repeating the procedure. Fistula closure was observed in 100% of patients. In follow the need for new procedures wasn't observed. Discussion: Pleurodesis with autologous blood is an effective and safe treatment in the management of persistent or massive air leak, with immediate and remote adequate results.

CT-Guided Core Needle Biopsy of Pleural Lesions: Evaluating Diagnostic Yield and Associated Complications

OBJECTIVE: The purpose of this study was to retrospectively evaluate the diagnostic accuracy and complications of CT-guided core needle biopsy (CT-guided CNB) of pleural lesion and the possible effects of influencing factors. MATERIALS AND METHODS: From September 2007 to June 2013, 88 consecutive patients (60 men and 28 women; mean [+/- standard deviation] age, 51.1 +/- 14.4 years; range, 19-78 years) underwent CT-guided CNB, which was performed by two experienced chest radiologists in our medical center. Out of 88 cases, 56 (63%) were diagnosed as malignant, 28 (31%) as benign and 4 (5%) as indeterminate for CNB of pleural lesions. The final diagnosis was confirmed by either histopathological diagnosis or clinical follow-up. The diagnostic accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and complication rates were statistically evaluated. Influencing factors (patient age, sex, lesion size, pleural-puncture angle, patient position, pleural effusion, and number of pleural punctures) were assessed for their effect on accuracy of CT-guided CNB using univariate and subsequent multivariate analysis. RESULTS: Diagnostic accuracy, sensitivity, specificity, PPV, and NPV were 89.2%, 86.1%, 100%, 100%, and 67.8%, respectively. The influencing factors had no significant effect in altering diagnostic accuracy. As far as complications were concerned, occurrence of pneumothorax was observed in 14 (16%) out of 88 patients. Multivariate analysis revealed lesion size/pleural thickening as a significant risk factor (odds ratio [OR]: 8.744, p = 0.005) for occurrence of pneumothorax. Moreover, presence of pleural effusion was noted as a significant protective factor (OR: 0.171, p = 0.037) for pneumothorax. CONCLUSION: CT-guided CNB of pleural lesion is a safe procedure with high diagnostic yield and low risk of significant complications.

Presión positiva continua en la vía aérea comparada con la respiración mecánica asistida en prematuros de 28 a 32 semanas de gestación con administración precoz de surfactante pulmonar / Nasal CPAP versus mechanical ventilation in 28 to 32-week preterm infants with early surfactant administration

Introducción. La presión positiva continua en la vía aérea ( Continuous Positive Airway Pressure , CPAP) es útil en prematuros de 28 a 32 semanas de gestación con síndrome de dificultad respiratoria, pero no se ha precisado si es mejor que la respiración mecánica asistida después de la administración precoz de surfactante pulmonar. Objetivo. Comparar la incidencia de eventos adversos en prematuros de 28 a 32 semanas de gestación con síndrome de dificultad respiratoria atendidos con surfactante y respiración mecánica asistida o CPAP de burbuja. Materiales y métodos. Se atendieron 147 neonatos con respiración mecánica asistida y 176 con CPAP, ninguno de los cuales presentaba asfixia perinatal o apnea. Resultados. La incidencia de fracaso de la CPAP fue de 6,5 % (IC 95% 11,3-22,8 %). Fallecieron 29 pacientes, 7 de los cuales habían recibido CPAP (4,0 %) y, 22, respiración mecánica asistida (15,0 %; p<0,001). El riesgo relativo (RR) de morir de quienes recibieron CPAP, comparado con el de quienes recibieron respiración mecánica asistida, fue de 0,27 (IC 95% 0,12-0,61), pero, al ajustar por los factores de confusión, el uso de CPAP no implicó mayor riesgo de morir (RR=0,60; IC 95% 0,29-1,24). La letalidad con respiración mecánica asistida fue de 5,70 (IC 95% 3,75-8,66) muertes por 1.000 días-paciente, mientras que con CPAP fue de 1,37 (IC 95% 0,65-2,88; p<0,001). La incidencia de neumopatía crónica fue menor con CPAP (RR=0,71, IC 95% 0,54-0,96), al igual que la de hemorragia cerebral (RR=0,28; IC 95% 0,09-0,84) y la de sepsis (RR=0,67; IC 95% 0,52-0,86), pero fue similar en cuanto a escapes de aire (RR=2,51; IC 95% 0,83-7,61) y enterocolitis necrosante (RR=1,68; IC 95% 0,59-4,81). Conclusión. La incidencia de neumopatía crónica, hemorragia ventricular y sepsis es menor con el uso de CPAP.

Introduction: Continuous positive airway pressure (CPAP) is useful in low birth weight infants with respiratory distress, but it is not known if it is a better alternative to mechanical ventilation after early pulmonary surfactant administration. Objective: To compare the incidence of adverse events in 28 to 32-week newborns with respiratory distress managed with mechanical ventilation or CPAP after early surfactant administration. Materials and methods: In total, 176 newborns were treated with CPAP and 147 with mechanical ventilation, all with Apgar scores >3 at five minutes and without apnea. Results: The incidence of CPAP failure was 6.5% (95% CI: 11.3-22.8%); 29 patients died: 7 with CPAP (4.0%) and 22 with mechanical ventilation (15.0%, p<0.001). The relative risk of dying with CPAP versus mechanical ventilation was 0.27 (95% CI: 0.12-0.61), but after adjusting for confounding factors, CPAP use did not imply a higher risk of dying (RR=0.60; 95% CI: 0.29-1.24). Mechanical ventilation fatality rate was 5.70 (95% CI: 3.75-8.66) deaths/1,000 days-patient, while with CPAP it was 1.37 (95% CI: 0.65-2.88, p<0.001). Chronic lung disease incidence was lower with CPAP than with mechanical ventilation (RR=0.71; 95% CI: 0.54-0.96), as were intracranial hemorrhage (RR=0.28, 95% CI: 0.09-0.84) and sepsis (RR=0.67; 95%CI: 0.52-0.86), and it was similar for air leaks (RR=2.51; 95% CI: 0.83-7.61) and necrotizing enterocolitis (RR=1.68, 95% CI: 0.59-4.81). Conclusion: CPAP exposure of premature infants with respiratory distress syndrome is protective against chronic lung disease, intraventricular hemorrhage and sepsis compared to mechanical ventilation. No differences were observed regarding air leak syndrome or death.