Intubación submentoniana en osteosíntesis de fractura de macizo facial / Submental intubation in osteosynthesis of facial mass fracture

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Dexmedetomidina en el manejo de la vía aérea difícil con fibrobroncoscopio en paciente despierto afecto de síndrome de Klippel-Feil / Dexmedetomidine in difficult airway management with a fibre-optic bronchoscope in the awake patient with Klippel-Feil Syndrome

El síndrome de Klippel-Feil es una enfermedad que se caracteriza por la fusión congénita de vértebras cervicales, que condiciona una limitación e inestabilidad cervical. En estos casos la mejor opción es la intubación orotraqueal con fibrobroncoscopio con el paciente despierto. La ventaja es que se minimizan los movimientos cervicales que podrían conllevar un daño neurológico. En estos pacientes una sedación adecuada, junto con la instilación de anestésico local en la faringe y la hipofaringe es clave para reducir las molestias del paciente y conseguir la intubación orotraqueal con éxito. La dexmedetomidina es un agonista selectivo de los receptores α-2 adrenérgicos que produce sedación y ansiolisis al nivel del locus coeruleus, sin provocar depresión respiratoria, y preservando la colaboración del paciente. Presentamos el caso de un paciente con síndrome de Klipple-Feil y vía aérea difícil en el que utilizamos una perfusión de dexmedetomidina a dosis de 0,6μg/kg/h como sedación para la intubación orotraqueal con fibrobroncoscopio con el paciente despierto

Klippel-Feil Syndrome is a disease characterised by congenital fusion of cervical vertebra, which leads to cervical limitation and instability. In these cases, the best option is the orotracheal intubation with the fibre-optic bronchoscope with the patient awake. The advantage is that cervical movements that could lead to neurological damage are minimised. In these patients, adequate sedation, together with instillation of local anaesthetic in the pharynx and hypopharynx, is the key to reducing patient discomfort and achieving successful orotracheal intubation. Dexmedetomidine is a selective α2- adrenergic receptor agonist that produces sedation and analgesia at the locus coeruleus without producing respiratory depression, as well as maintaining patient collaboration. The case is presented of a patient with Klippel-Feil Syndrome and difficult airway management, who was given a dexmedetomidine infusion at 0.6μg/kg/h as sedation for an awake fibre-optic endotracheal intubation

Monitorización con espectrograma del sistema de monitorización BIS VISTA(TM) en una hemisferectomía funcional / Density spectral array of BIS VISTA(TM) monitoring system in a functional hemispherectom

Presentamos el caso de una paciente adulta con epilepsia farmacorresistente secundaria a una inflamación extensa del hemisferio cerebral derecho, que fue programada para realizársele una hemisferectomía funcional. Se trata de una cirugía habitual en pediatría, pero con pocas publicaciones en pacientes adultos. Durante el intraoperatorio se utilizó el espectrograma perteneciente al sistema de monitorización VISTATM del índice biespectral bilateral (BIS). Se objetivó un aumento de potencia en las bandas de baja frecuencia (0,1-4Hz) y en las bandas alfa (8-12Hz) del hemisferio cerebral derecho, donde se encontraba el foco epileptógeno. Durante la desconexión del lóbulo frontal se observó una marcada disminución de potencia en dichas bandas, sin objetivarse cambios durante la desconexión de las otras áreas cerebrales. Pensamos que se necesitan más estudios para saber si el espectrograma puede ser una herramienta útil para monitorizar la efectividad de la hemisferectomía funcional

We present the case of an adult patient with drug-resistant epilepsy caused by extensive inflammation in the right cerebral hemisphere. She was scheduled to undergo right functional hemispherectomy, which is common in pediatric surgery, but about which few studies have been published with respect to adult patients. During the intraoperative period, the density spectral array of the bilateral bispectral index (BIS) VISTATM monitoring system was used. We observed a power increase in low frequency (0.1-4Hz) and alpha bands (8-12Hz) in the right hemisphere, where the epileptogenic focus was. During disconnection from the frontal lobe, there was a marked decrease of power in low frequency and alpha bands on the right side, with no changes during disconnection from other areas of the brain. We think that further studies are needed to determine whether the density spectral array can be a useful tool for monitoring the effectiveness of functional hemispherectomy

Dexmedetomidine in difficult airway management with a fibre-optic bronchoscope in the awake patient with Klippel-Feil Syndrome. / Dexmedetomidina en el manejo de la vía aérea difícil con fibrobroncoscopio en paciente despierto afecto de síndrome de Klippel-Feil.

Klippel-Feil Syndrome is a disease characterised by congenital fusion of cervical vertebra, which leads to cervical limitation and instability. In these cases, the best option is the orotracheal intubation with the fibre-optic bronchoscope with the patient awake. The advantage is that cervical movements that could lead to neurological damage are minimised. In these patients, adequate sedation, together with instillation of local anaesthetic in the pharynx and hypopharynx, is the key to reducing patient discomfort and achieving successful orotracheal intubation. Dexmedetomidine is a selective α2- adrenergic receptor agonist that produces sedation and analgesia at the locus coeruleus without producing respiratory depression, as well as maintaining patient collaboration. The case is presented of a patient with Klippel-Feil Syndrome and difficult airway management, who was given a dexmedetomidine infusion at 0.6µg/kg/h as sedation for an awake fibre-optic endotracheal intubation.

Density spectral array of BIS VISTA™ monitoring system in a functional hemispherectomy. / Monitorización con espectrograma del sistema de monitorización BIS VISTA™ en una hemisferectomía funcional.

We present the case of an adult patient with drug-resistant epilepsy caused by extensive inflammation in the right cerebral hemisphere. She was scheduled to undergo right functional hemispherectomy, which is common in pediatric surgery, but about which few studies have been published with respect to adult patients. During the intraoperative period, the density spectral array of the bilateral bispectral index (BIS) VISTATM monitoring system was used. We observed a power increase in low frequency (0.1-4Hz) and alpha bands (8-12Hz) in the right hemisphere, where the epileptogenic focus was. During disconnection from the frontal lobe, there was a marked decrease of power in low frequency and alpha bands on the right side, with no changes during disconnection from other areas of the brain. We think that further studies are needed to determine whether the density spectral array can be a useful tool for monitoring the effectiveness of functional hemispherectomy.

Manejo anestésico en la cirugía de epilepsia con electrocorticografía intraoperatoria / Anaesthesia management in epilepsy surgery with intraoperative electrocorticography

La cirugía de la epilepsia es un tratamiento bien establecido para pacientes con epilepsia farmacorresistente. El éxito de la cirugía depende de una localización prequirúrgica precisa de la zona epileptógena. Existen diferentes técnicas para determinar su localización y extensión. A pesar de las mejoras en los tests diagnósticos no invasivos, en aquellos pacientes en los que no son concluyentes, se necesitarán técnicas más invasivas como la electrocorticografía intraoperatoria. La electrocorticografía intraoperatoria se utiliza para guiar la resección quirúrgica de la lesión epileptógena y para comprobar que la resección ha sido completa. Sin embargo, se puede ver afectada por algunos de los fármacos anestésicos que utilizamos. Nuestro objetivo con este caso clínico es revisar qué fármacos se pueden utilizar en la cirugía de epilepsia con electrocorticografía intraoperatoria (AU)

Epilepsy surgery is a well-established treatment for patients with drug-resistant epilepsy. The success of surgery depends on precise presurgical localisation of the epileptogenic zone. There are different techniques to determine its location and extension. Despite the improvements in non-invasive diagnostic tests, in patients for whom these tests are inconclusive, invasive techniques such intraoperative electrocorticography will be needed. Intraoperative electrocorticography is used to guide surgical resection of the epileptogenic lesion and to verify that the resection has been completed. However, it can be affected by some of the anaesthetic drugs used by the anaesthesiologist. Our objective with this case is to review which drugs can be used in epilepsy surgery with intraoperative electrocorticography (AU)

Anaesthesia management in epilepsy surgery with intraoperative electrocorticography. / Manejo anestésico en la cirugía de epilepsia con electrocorticografía intraoperatoria.

Epilepsy surgery is a well-established treatment for patients with drug-resistant epilepsy. The success of surgery depends on precise presurgical localisation of the epileptogenic zone. There are different techniques to determine its location and extension. Despite the improvements in non-invasive diagnostic tests, in patients for whom these tests are inconclusive, invasive techniques such intraoperative electrocorticography will be needed. Intraoperative electrocorticography is used to guide surgical resection of the epileptogenic lesion and to verify that the resection has been completed. However, it can be affected by some of the anaesthetic drugs used by the anaesthesiologist. Our objective with this case is to review which drugs can be used in epilepsy surgery with intraoperative electrocorticography.

Respuesta a la carta: Contestación a la carta «Actuación ante un caso de extubación accidental con paciente en posición de decúbito prono» / Reply to letter: Response to the letter «Anaesthesia management of accidental extubation in the prone position»

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Actuación ante un caso de extubación accidental con paciente en posición de decúbito prono / Anesthesia management of accidental extubation in the prone position

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Femoral and sciatic nerve block for knee arthroscopy in a patient with acute intermittent porphyria / Bloqueo nervioso femoral y ciático para una artroscopia de rodilla en paciente con porfiria aguda intermitente

Acute intermittent porphyria is an autosomal dominant disorder that results from a partial deficiency of porphobilinogen deaminase and that causes very severe symptoms. Attacks may be triggered by a series of drugs and by other factors that the anesthesiologist should be aware of in order to reduce morbidity and mortality. Our objective is to review anesthetic considerations in acute intermittent porphyria. We present the case of a patient diagnosed with acute intermittent porphyria who was scheduled for knee arthroscopy. The anesthetic technique used was a femoral and sciatic nerve block under sedation with an infusion of remifentanil. The surgery proceeded without incident and the patient was discharged home after 24h. We consider the use of a peripheral plexus block of the lower limb to have been the safest anesthetic technique for this patient (AU)

La porfiria aguda intermitente es una enfermedad autosómica dominante que resulta de un déficit de porfobilinógeno deaminasa y que causa síntomas muy severos. Los ataques se pueden desencadenar por fármacos y otros factores que el anestesiólogo debe conocer para reducir la morbilidad y la mortalidad. Nuestro objetivo es revisar las consideraciones anestésicas en la porfiria aguda intermitente. Presentamos el caso de una paciente diagnosticada de que porfiria aguda intermitente programada para una artroscopia de rodilla. La técnica anestésica realizada fue bloqueo nervioso femoral y ciático bajo sedación con perfusión de remifentanilo. La cirugía transcurrió sin incidencias y la paciente fue dada de alta a domicilio a las 24 h. Consideramos que el bloqueo nervioso periférico de la extremidad inferior es la técnica anestésica más segura para esta paciente (AU)

Femoral and sciatic nerve block for knee arthroscopy in a patient with acute intermittent porphyria.

Acute intermittent porphyria is an autosomal dominant disorder that results from a partial deficiency of porphobilinogen deaminase and that causes very severe symptoms. Attacks may be triggered by a series of drugs and by other factors that the anesthesiologist should be aware of in order to reduce morbidity and mortality. Our objective is to review anesthetic considerations in acute intermittent porphyria. We present the case of a patient diagnosed with acute intermittent porphyria who was scheduled for knee arthroscopy. The anesthetic technique used was a femoral and sciatic nerve block under sedation with an infusion of remifentanil. The surgery proceeded without incident and the patient was discharged home after 24h. We consider the use of a peripheral plexus block of the lower limb to have been the safest anesthetic technique for this patient.