[Convulsions in the operating room in a man with AIDS]. / Convulsión en el quirófano de un paciente con sida.

More than 50 million individuals are infected by the human immunodeficiency virus (HIV), and it is estimated that as many as 25% of them will require surgery. The anesthesiologist must be familiar with the implications of this disease for multiorgan failure and opportunistic infections. Above all, the effects of antiretroviral agents on anesthetics must be understood. We describe the case of an HIV-infected man at risk for difficult intubation who experienced convulsions in the operating room.

Convulsión en el quirófano de un paciente con sida / Convulsions in the operating room in a man with AIDS

Existen más de 50 millones de personas en todo elmundo infectadas por el virus de la inmunodeficienciahumana. Se ha estimado que hasta el 25% de los pacientesinfectados requerirán cirugía. Para el anestesiólogoes fundamental conocer las connotaciones de la enfermedadpor su afectación multiorgánica, las infeccionesoportunistas asociadas y sobre todo, por las implicacionesen el metabolismo que los fármacos antirretroviralespueden tener en nuestros fármacos anestésicos. Presentamosel caso de un paciente infectado con el virus de lainmunodeficiencia humana, con predictores de vía aéreadifícil que presentó convulsiones en el quirófano(AU)

More than 50 million individuals are infected by thehuman immunodeficiency virus (HIV), and it isestimated that as many as 25% of them will requiresurgery. The anesthesiologist must be familiar with theimplications of this disease for multiorgan failure andopportunistic infections. Above all, the effects ofantiretroviral agents on anesthetics must be understood.We describe the case of an HIV-infected man at risk fordifficult intubation who experienced convulsions in theoperating room(AU)

Thoracic epidural anesthesia decreases C-reactive protein levels in patients undergoing elective coronary artery bypass graft surgery with cardiopulmonary bypass.

BACKGROUND: Coronary artery bypass graft surgery with cardiopulmonary bypass induces a systemic inflammatory response. However, when thoracic epidural anaesthesia is administered as part of a combined anesthetic technique, the stress response associated with the cardiopulmonary bypass (CPB) may be attenuated. METHODS: Twenty-two patients undergoing elective coronary artery bypass graft surgery were randomized to receive either balanced general anesthesia with 7-20 microg/kg fentanyl (GA group) or combined anesthesia with 3-6 microg/kg fentanyl and an epidural bolus of 0.33% bupivacaine followed by a continuous perfusion of 0.175% bupivacaine, which was continued up to 48 hours after surgery (TEA group). The hemodynamic levels, troponin I, C-reactive protein (CRP), fibrinogen, leukocyte and platelet counts were recorded preoperatively, and 5 h, 16 h, 24 h, and 36 h after termination of the cardiopulmonary bypass. The time to tracheal extubation and cardiopulmonary complication rate were measured postoperatively. Data were analyzed with the Student's t and Mann Whitney tests, as appropriate. Differences were considered significant at P<0.05. RESULTS: All parameters significantly increased following CPB. The increase in CRP levels were lower in the TEA group at 16 hours (P=0.048). The increase of fibrinogen levels were lower in the TEA group at 24 hours (P=0.047). No differences were found in troponin levels between groups during the study. No significant differences were observed in extubation times (GA group 750+/-144 min; TEA group 702+/-451 min). CONCLUSION: Thoracic epidural anaesthesia, as a part of a combined anesthetic technique, attenuated the inflammatory response (CRP and fibrinogen levels) to cardiac surgery with cardiopulmonary bypass. However, this effect was not reflected in a decrease of troponin I levels, reduced incidence of complications, or in an earlier extubation time.

[Ischemic rhabdomyolysis and acute renal failure]. / Rabdomiolisis isquémica y fracaso renal agudo.

Rhabdomyolysis is a clinical syndrome characterized by the breakdown and later necrosis of skeletal muscle, leading to the release of various intracellular components into the blood stream. The clinical expression of rhabdomyolysis ranges from asymptomatic to severe forms involving multiorgan failure with electrolyte imbalance, respiratory distress syndrome, acute renal failure and disseminated intravascular coagulation. Diagnosis is based on a finding of elevated serum levels of components that are normally found within the muscle cell, chiefly muscle enzymes and myoglobin. Acute kidney failure, one of the main consequences of rhabdomyolysis, occurs in 4% to 33% of cases. Treatment requires prompt volume replacement with crystalloids. In spite of successful resuscitation and prophylaxis against myoglobulin-induced renal failure, 1 out of every 3 patients develops kidney damage and requires continuous replacement therapy.

Rabdomiolisis isquémica y fracaso renal agudo / Ischemic rhabdomyolysis and acute renal failure

La rabdomiolisis es un síndrome clínico caracterizadopor la destrucción y posterior necrosis del músculoesquelético que produce un aumento de sus componentesintracelulares en la circulación sanguínea. Su expresiónclínica puede variar desde un cuadro asintomático, hastaun cuadro grave asociado a fracaso multiorgánico conalteraciones electrolíticas, síndrome de distrés respiratorioagudo, fallo renal agudo y coagulación intravasculardiseminada. El diagnóstico se basa en la detección en lacirculación general de los componentes normalmentecontenidos en la célula muscular, principalmente losenzimas musculares y la mioglobina. El fracaso renalagudo es una de las consecuencias más importantes de larabdomiolisis, presentándose en un 4%-33% de loscasos. El tratamiento se basa en una reposición enérgicade volumen con cristaloides. A pesar de una adecuadareanimación y profilaxis contra el fallo renal mioglobinúrico,uno de cada tres pacientes lo desarrollan, precisandoalguna terapia continua de reemplazo renal (AU)

Rhabdomyolysis is a clinical syndrome characterized by the breakdown and later necrosis of skeletal muscle, leading to the release of various intracellular components into the blood stream. The clinical expression of rhabdomyolysis ranges from asymptomatic to severe forms involving multiorgan failure with electrolyte imbalance, respiratory distress syndrome, acute renal failure and disseminated intravascular coagulation. Diagnosis is based on a finding of elevated serum levels of components that are normally found within the muscle cell, chiefly muscle enzymes and myoglobin. Acute kidney failure, one of the main consequences of rhabdomyolysis, occurs in 4% to 33% of cases. Treatment requires prompt volume replacement with crystalloids. In spite of successful resuscitation and prophylaxis against myoglobulin-induced renal failure, 1 out of every 3 patients develops kidney damage and requires continuous replacement therapy (AU)

Revisión de calidad en dolor agudo postoperatorio / Quality revision in acute postoperative pain

La mejora continua de la calidad en el tratamiento del dolor nos indica los pasos a seguir para instaurar una Unidad de Dolor Agudo (UDA) Postoperatorio. El primer paso es saber el punto de partida mediante la realización de una auditoría para poder plantear unos objetivos y unos valores estándares a alcanzar. El siguiente paso después de realizar la auditoría es la organización y el desarrollo de los procesos asistenciales siguiendo el esquema de las vías clínicas para introducir innovaciones o modificaciones de la actividad asistencial y evitar la variabilidad en los tratamientos, instaurando con ello la Unidad de Dolor Agudo Postoperatorio. El tercer paso consiste en valorar el impacto de su instauración mediante: por una parte la evaluación de los resultados asistenciales obtenidos del cumplimiento de la vía clínica, aplicando los indicadores de calidad, y por otra parte a través del conocimiento del punto de vista del paciente (la calidad percibida) mediante la realización de encuestas de satisfacción donde además puedan expresar sus sugerencias. Se emplea un modelo de encuesta donde se recogen aspectos demográficos y se aplican indicadores de calidad percibida: el conocimiento del nombre del médico y de la enfermera de la UDA, la calidad de la información recibida sobre el tratamiento del dolor y sobre sus posibles efectos secundarios, la máxima y la mínima intensidad percibida de dolor, la importancia dada al alivio del dolor, el trato recibido por parte de médicos y enfermeras, la satisfacción global con la UDA y un apartado para sugerencias

The continuous quality improvement in pain treatment shows us the steps to follow in order to create a Postoperative Acute Pain Unit. It is necessary to carry out an Auditorship so as to know the situation and establish a number of aims and standards values to attain. When the Auditorship is done, the next step is to create Guidelines to quantify the pain intensity and to avoid thetreatment variability. Then we can establish the Postoperative Acute Pain Unit. The third step is to measure the impact of creating the Unit. It is necessary to know the evaluation of the clinical results from the Guidelines application through Quality Indicators, and to know the quality perceptions of the patients and the suggestions given in the satisfaction questionnaires. We use a satisfaction questionnaire model with demografic factors and Quality Indicators: the nurses and doctors’ names of the APU, the quality of the information about the pain treatment and its possible secondary effects, the maximum and minimum pain intensity, the importance given to the pain relief, the quality of the doctors and nurses’ behaviour towards the patients, the global satisfaction with the Acute Pain Unit, and a patients suggestion section

[Postoperative pain management in a tertiary care hospital: initial situation prior to starting a quality assurance program]. / Atención del dolor postoperatorio en un hospital de tercer nivel: situación inicial previa a la implantación de un programa de calidad.

OBJECTIVE: To characterize the initial situation in postoperative pain management among the services General and Vascular surgery as the first step in developing a program to improve postoperative analgesia. METHODS: An anonymous questionnaire with 14 items covered the characteristics of postoperative pain, information received about analgesic treatments and requesting medication, and degree of satisfaction. The questionnaire was filled in during an early postoperative interview with all patients undergoing surgery in the aforementioned departments. RESULTS: A total of 158 patients were interviewed; 89% were from the general surgery department and 11% from vascular surgery. At 24 hours after surgery, 18% were free of pain, 35% had mild pain, and 47% had moderate or intense pain. Nonsteroidal anti-inflammatory drugs were the most frequently used postoperative analgesics, in 94% of patients, and the dosage and timing had been prescribed for 74%. Thirty-six percent of the patients asked for an analgesic to be administered. The correlation between degree of greatest pain and request for an analgesic was statistically significant (P < 0.001). CONCLUSIONS: Postoperative pain is an area in which improvements can be implemented to provide better care and treatment of surgical patients, particularly since there are efficacious analgesic treatments for pain control that are presently not being used. The custom of prescribing pain medication on demand should be avoided in all surgical procedures that are known to produce postoperative pain.

Atención del dolor postoperatorio en un hospital de tercer nivel: situación inicial previa a la implantación de un programa de calidad / Postoperative pain management in a tertiary care hospital: initial situation prior to starting a quality assurance program

OBJETIVOS: Conocer la situación inicial de la atención ytratamiento del dolor postoperatorio en los pacientes intervenidosen los servicios de Cirugía General y Cirugía Vascularcomo fase inicial para el desarrollo de un programade mejora de la calidad de la analgesia postoperatoria.METODOLOGÍA: Se elaboró una encuesta anónima queconsta de 14 preguntas que recogen las características dedolor postoperatorio, la información recibida sobre el tratamientodel dolor, la solicitud de medicación, y el gradode satisfacción. La encuesta se llevó a cabo medianteentrevista en el postoperatorio inmediato a todos lospacientes intervenidos en los servicios citados.RESULTADOS: Fueron entrevistados 158 pacientes, un89% de Cirugía General y un 11% de Vascular. El dolorpostoperatorio a las 24 horas muestra un 18% de lospacientes sin dolor, un 35% de los pacientes con dolor levey un 47% de los mismos con dolor moderado-intenso. Laanalgesia postoperatoria más empleada fueron los AINEen un 94%, un 74% con prescripción pautada. Un 36%de los pacientes solicitaron la administración de un analgésico.Existe una relación estadísticamente significativaentre la solicitud de analgesia y el grado de dolor máximo(p<0,001).CONCLUSIONES: El dolor postoperatorio constituye unaoportunidad para el establecimiento de mejoras en la atencióny tratamiento de los pacientes intervenidos, máximecuando existen tratamientos analgésicos eficaces para elcontrol del dolor que no se están utilizando, debiendo acabarcon la modalidad de prescripción a demanda en todasaquellas intervenciones que de antemano se sabe que vana experimentar dolor postoperatorio

OBJETIVE: To characterize the initial situation inpostoperative pain management among the servicesGeneral and Vascular surgery as the first step in developinga program to improve postoperative analgesia.METHODS: An anonymous questionnaire with 14items covered the characteristics of postoperativepain, information received about analgesic treatmentsand requesting medication, and degree of satisfaction.The questionnaire was filled in during an early postoperativeinterview with all patients undergoing surgeryin the aforementioned departments.RESULTS: A total of 158 patients were interviewed;89% were from the general surgery department and11% from vascular surgery. At 24 hours after surgery,18% were free of pain, 35% had mild pain, and 47%had moderate or intense pain. Nonsteroidal anti-inflammatorydrugs were the most frequently used postoperativeanalgesics, in 94% of patients, and the dosage andtiming had been prescribed for 74%. Thirty-six percentof the patients asked for an analgesic to be administered.The correlation between degree of greatest pain andrequest for an analgesic was statistically significant(P<0.001).CONCLUSIONS: Postoperative pain is an area in whichimprovements can be implemented to provide bettercare and treatment of surgical patients, particularlysince there are efficacious analgesic treatments for paincontrol that are presently not being used. The customof prescribing pain medication on demand should beavoided in all surgical procedures that are known toproduce postoperative pain

Neumonía aspirativa y edema de pulmón por laringoespasmo. Diagnóstico diferencial / Aspiration pneumonia and pulmonary edema due to laryngea spasm: differential diagnosis

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[Magnesium in anesthesia and postoperative recovery care]. / Magnesio en anestesia y reanimación.

Magnesium is involved in many physiological processes and in the pathophysiology of many diseases that affect surgical patients. The incidence of hypomagnesemia in the perioperative setting is high and is sometimes underestimated, with important prognostic implications. Magnesium also has a variety of therapeutic indications in postoperative recovery care, obstetrics, cardiology, heart surgery, pain treatment, anesthesia, pneumology, etc. Magnesium's role in the organism and its pharmacological properties continue to be studied and new situations in which the ion plays a relevant part are being suggested. It has become essential for the anesthesiologist to understand the pharmacological, clinical, and physiological properties of magnesium. The present review aims to give a simple but complete overview of the physiological importance of the magnesium ion, the perioperative changes that occur, and its therapeutic applications in numerous clinical contexts.

Magnesio en Anestesia y Reanimación / Magnesium in anesthesia and postoperative recovery care

El magnesio es un ión implicado en numerosas funciones fisiológicas y en la fisiopatología de muchas enfermedades que afectan al paciente quirúrgico. La incidencia de hipomagnesemia en el ambiente perioperatorio es alta y en ocasiones menospreciada con importantes implicaciones pronósticas. El magnesio es además empleado como fármaco con distintas indicaciones: en reanimación, obstetricia, cardiología, cirugía cardíaca, tratamiento del dolor, anestesia, neumología, etc. El papel del magnesio en el organismo y sus propiedades farmacológicas siguen siendo objeto de estudio y cada vez aparecen nuevas situaciones en las que este ión adquiere un papel relevante. El conocimiento de sus características farmacológicas, clínicas y fisiológicas se ha vuelto imprescindible para el médico anestesiólogo. El objetivo de esta revisión es dar una visión sencilla y completa del papel del magnesio en el organismo, sus alteraciones en el medio perioperatorio y su relevancia como fármaco eficaz en numerosas situaciones clínicas

Magnesium is involved in many physiological processes and in the pathophysiology of many diseases that affect surgical patients. The incidence of hypomagnesemia in the perioperative setting is high and is sometimes underestimated, with important prognostic implications. Magnesium also has a variety of therapeutic indications in postoperative recovery care, obstetrics, cardiology, heart surgery, pain treatment, anesthesia, pneumology, etc. Magnesium's role in the organism and its pharmacological properties continue to be studied and new situations in which the ion plays a relevant part are being suggested. It has become essential for the anesthesiologist to understand the pharmacological, clinical, and physiological properties of magnesium. The present review aims to give a simple but complete overview of the physiological importance of the magnesium ion, the perioperative changes that occur, and its therapeutic applications in numerous clinical contexts

[Noninvasive ventilation]. / Ventilación mecánica no invasiva.

Endotracheal intubation and mechanical ventilation have traditionally been employed in patients with acute respiratory insufficiency. However, this form of management can have serious adverse effects, mainly infections and barotrauma. Noninvasive ventilation (NIV) has been shown to be an effective alternative, as it reduces both the frequency of complications and cost of care. In fact, NIV is currently the first choice treatment for acute respiratory insufficiency in patients who have chronic obstructive pulmonary disease or who are immunocompromised. It is also commonly applied in patients with asthma, pneumonia, and acute cardiogenic pulmonary edema. Correct indication and training in use of NIV equipment is necessary to ensure success and facilitate patient tolerance.

Ventilación mecánica no invasiva / Noninvasive ventilation

La intubación endotraqueal con ventilación mecánica convencional es el tratamiento habitual de la insuficiencia respiratoria. Sin embargo, a veces se pueden producir efectos secundarios importantes, fundamentalmente de tipo infeccioso y por barotrauma. La ventilación mecánica no invasiva (VMNI),ha demostrado ser una alternativa eficaz, ya que disminuye la incidencia de complicaciones y reduce costes. De hecho, en el momento actual se considera de primera elección en pacientes con insuficiencia respiratoria secundaria a Enfermedad Pulmonar Obstructiva Crónica (EPOC) reagudizada y en inmunocomprometidos, además se utiliza habitualmente en pacientes con asma, neumonía y edema agudo de pulmón. Una correcta motivación y entrenamiento de todo el equipo que utiliza estas técnicas, es imprescindible para asegurar su éxito y favorecer la tolerancia por el paciente

Endotracheal intubation and mechanical ventilation have traditionally been employed in patients with acute respiratory insufficiency. However, this form of management can have serious adverse effects, mainly infections and barotrauma. Noninvasive ventilation (NIV)has been shown to be an effective alternative, as it reduces both the frequency of complications and cost of care. In fact, NIV is currently the first choice treatment for acute respiratory insufficiency in patients who have chronic obstructive pulmonary disease or who are immunocompromised. It is also commonly applied in patients with asthma, pneumonia, and acute cardiogenic pulmonary edema. Correct indication and training in use of NIV equipment is necessary to ensure success and facilitate patient tolerance

[AIDS and anesthesia]. / SIDA y anestesia.

AIDS concerns anaesthetic practice for various reasons. First, this syndrome can affect different organs that have anaesthetic implications. Second, drugs usually taken by the patient can interact with anaesthetic agents. And last, the risk of infection for health workers must be taken into account, as well as the procedure to follow after accidental injures.

SIDA y anestesia / AIDS and anesthesia education

El síndrome de inmunodeficiencia adquirida (sida) preocupa al anestesiólogo por diferentes motivos. En primer lugar, puede alterar la función de distintos órganos condicionando la práctica anestésica. En segundo lugar, la medicación que precisan estos enfermos puede desencadenar interacciones con los anestésicos. Por último, se debe conocer el riesgo que supone para el trabajador sanitario y la conducta a seguir en caso de lesión accidental (AU)

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