[Anesthesia and fibrobronchoscopy for the study of chronic stridor in a boy with Robinow syndrome]. / Anestesia y fibrobroncoscopia para el estudio de estridor crónico en un niño con síndrome de Robinow.

Robinow's syndrome involves fetal facial features, short stature, brachymelia, hypoplastic genitals and a normal karyotype. A 10-year-old boy with Robinow's syndrome was scheduled for study of chronic stridor by fiberoptic bronchoscopy. Airway exploration with the patient awake revealed hipertelorism, retromicrognathia, poor dental alignment, macroglossia and class IV Mallampati. After anesthetic induction in spontaneous ventilation with 5% sevoflurane, grade IV Cormack-Lehane conditions were observed. A laryngeal mask was placed without muscle relaxation after which the boy was ventilated manually for several minutes without stridor. Anesthetic maintenance was with 3% sevoflurane in 50% oxygen and air. After recovery of spontaneous ventilation, marked stridor presented along with a decrease in oxygen saturation and expired fractions of sevoflurane and CO2. Pulse oxymetry did not increase with increased FiO2. However, when continuous positive airway pressure (CPAP) was set al 10 cm H2O, pulse oxymetry did increase; likewise, expired and inspired sevoflurane concentrations became equal, and expired CO2 increased. Fiberoptic bronchoscopy revealed an area of intrathoracic tracheomalacia, which collapsed partially during spontaneous expiration and collapsed less when CPAP was started. We discuss the relation between the facial dysmorphia characteristic of this syndrome and the possibility of finding a difficult airway, as well as the diagnosis and treatment of intrathoracic tracheomalacia during anesthesia.

Anestesia y fibrobroncoscopia para el estudio de estridor crónicoen un niño con síndrome de Robinow / Anesthesia for the fiberoptic bronchoscopic study of chronic stridor in a child with Robinow's syndrome

El síndrome de Robinow reúne rasgos faciales fetales, talla baja, braquimelia, genitales hipoplásicos y un cariotipo normal1. Un niño de 10 años, con síndrome de Robinow, fue programado para fibrobroncoscopia diagnóstica por presentar un estridor crónico. La exploración de la vía aérea con el paciente despierto mostró: hipertelorismo, retromicrognatia, mala alineación dental, macroglosia y un Mallampatti clase IV. Tras realizar la inducción en ventilación espontánea con sevoflurano al 5 por ciento, presentó en la laringoscopia un test de Cormack-Lehane grado IV. Se introdujo una mascarilla laríngea sin relajación muscular, tras lo cual se le ventiló unos minutos manualmente sin que presentara estridor. El mantenimiento anestésico se realizó con sevoflurano al 3 por ciento y O2/aire al 50 por ciento. Tras dejarle recuperar la ventilación espontánea, presentó un estridor importante junto a disminución de la saturación de oxígeno y de las fracciones espiradas de sevoflurano y de CO2. El incremento de la FiO2 no mejoró la pulsioximetría. Con la instauración de una presión espiratoria continua de 10 cm de H2O, se elevó la pulsioximetría, las concentraciones de sevoflurano espirado e inspirado se igualaron, y el CO2 espirado se incrementó. La fibrobroncoscopia mostró una zona de traqueomalacia intratorácica que se colapsaba parcialmente durante la espiración en ventilación espontánea, y como disminuía el colapso cuando se instauraba la presión espiratoria positiva continua. Se discuten la relación entre la dismorfia facial característica de este síndrome y la posibilidad de presentar una vía aérea difícil y además el diagnóstico y tratamiento de la traqueomalacia intratorácica durante la anestesia. (AU)

Uso de la mascarilla laríngea en un neonato con síndrome de Smith-Lemliopitzy vía aérea difícil / Use of a laryngeal mask in a neonate with Smith-Lemli-Opitz syndrome and a difficult airway

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[A superior vena cava syndrome due to a surgical retractor]. / Síndrome de vena cava superior por retractor quirúrgico.

A 56-year-old male diagnosed of epidermoid carcinoma of the right lung (T4 N0 M0, stage IIIb) is described. He had earlier received chemotherapy and radiotherapy and was scheduled for removal of the right lung. During surgery the need to resect tumor infiltration of the right atrium became evident. During weaning from by-pass sudden deterioration of hemodynamics occurred with poor response to volume and inotropic drugs. Superior vena cava syndrome due to traction of the innominate trunk from a surgical retractor was diagnosed; the crisis resolved when the retractor was withdrawn. We discuss the pathophysiology of this clinical picture and relevant intraoperative aspects.

[Efficacy of 0.1 mg of subarachnoid morphine combined with bupivacaine on postoperative analgesia in total hip arthroplasty]. / Eficacia de 0,1 mg de morfina subaracnoidea asociada a la bupivacaína sobre la analgesia postoperatoria en la artroplastia total de cadera.

OBJECTIVES: To analyze the analgesic efficacy, safety and side effects of subarachnoid morphine (0.1 mg) with bupivacaine in patients undergoing total hip arthroplasty. PATIENTS AND METHODS: Thirty patients scheduled for total hip replacement under spinal anesthesia with bupivacaine were randomly assigned to two groups according to whether local anesthetic with 0.1 mg subarachnoid morphine was also provided or not (group M [n = 15] and group S n = 15[, respectively). Top-up analgesia with morphine was available through a patient-controlled device. Postoperative pain was assessed on a visual analogue scale (VAS) and consumption of intravenous morphine in the first 48 hours after surgery was recorded. RESULTS: VAS scores (mean +/- SD) were significantly lower in the first six hours in group M, but no differences between the two groups were observed thereafter. Total consumption of morphine at 48 hours was much lower in group M (6.80 +/- 7.74 mg) than in group S (31.38 +/- 13.17 mg). The incidence of nausea was high in both groups (46%). Slight pruritus affected 26.6% of patients in group M. Urinary retention necessitating temporary placement of a catheter was observed only in group M, where the incidence was 35.7%. No cases of respiratory depression occurred. Drowsiness was observed in 26.6% of patients in group S in comparison with 6.6% in group M. CONCLUSIONS: Combining 0.1 mg morphine and bupivacaine for total spinal anesthesia during hip arthroplasty significantly decreased the consumption of intravenous morphine during the first 48 hours after surgery. No respiratory depression occurred and the only side effects were urinary retention and mild pruritus and drowsiness.

Repeated transient neurological symptoms after spinal anaesthesia with hyperbaric 5% lidocaine.

We report a case of repeated delayed pain after cystoscopy under spinal lidocaine anaesthesia, which may be caused by transient radicular irritation. The possible aetiology of the symptoms is discussed.

[Common variable immunodeficiency associated with autoimmune thrombocytopenia: anesthetic management]. / Inmunodeficiencia variable común asociada a trombopenia autoinmune: manejo anestésico.

A 44-year-old man diagnosed of common variable immunodeficiency associated with thrombopenia due to autoimmunity required anesthesia for anal fissure repair and hemorrhoidectomy. Hemostatic complications developed after surgery, with extreme thrombopenia (1,000 platelets/pl) and analytical changes that necessitated administration of six units of platelets from apheresis, as well as immunoglobulins, antifibrinolytic agents (e-aminocaproic acid) and granulocytic colony stimulating factors. Anesthesia for such patients is reviewed, with emphasis on careful management of the airways, preparation of sufficient material for surgery (rapid transfusion equipment, large caliber intravenous catheters, sterile material) and orientation of anesthetic technique toward general anesthesia through a laryngeal mask.

Is management of anesthesia in achondroplastic dwarfs really a challenge?

STUDY OBJECTIVE: To review our eight-year anesthetic experience with achondroplastic patients. DESIGN: Retrospective study. SETTING: University hospital. PATIENTS: 15 achondroplastic patients who underwent 53 surgical procedures of orthopedic surgery between 1987 and 1994. INTERVENTIONS: Anesthetic technique, drugs, number of incidents, and complications in the intraoperative and postoperative period were recorded. MEASUREMENTS AND MAIN RESULTS: Adequate premedication before the transfer to the operating room was very useful to reduce anxiety and increase cooperation. Inhalation induction was well tolerated and allowed easy peripheral venous cannulation. Only one patient presented difficulties during intubation (on two occasions). In the other patients, we found small difficulties only during ventilation with a face mask, which was easily corrected by modifying the position of the patient and/or inserting an oropharyngeal airway. No adverse effect was identified for any particular anesthetic drug or technique used. CONCLUSIONS: Although the characteristic deformities of achondroplastic patients can impede the management of anesthesia, in our study we found no special difficulties. Airway complications did not occur. Thus, no specific optimal anesthetic regimen can be recommended.