Fístula en H: a propósito de un caso / H-type fistula: A case report

Las fístulas traqueoesofágicas son las anomalía congénita más frecuente del tracto respiratorio, con una incidencia 1/3.500 recién nacidos. Existen 5 tipos según su anatomía, siendo la fístula en H la menos frecuente. Esta variedad no se asocia a atresia de esófago, por lo que su diagnóstico es más tardío. Presentamos un niño de 6 años con antecedentes de prematuridad tardía. Desde el mes y medio de vida presenta episodios de regurgitaciones, tos y broncoespasmo. La gammagrafía evidencia episodios de reflujo gastroesofágico, sin paso a vía aérea; se instaura tratamiento con omeprazol, domperidona y monitorización domiciliaria, con mejoría de la clínica digestiva, persistiendo episodios de broncoespasmo. Con sospecha de asma del lactante inicia tratamiento con corticoides inhalados a dosis crecientes con control parcial de los síntomas. Fue diagnosticado de neumonía a los 4 años, con posterior exacerbación de su sintomatología, atragantamiento con líquidos y dificultad respiratoria. La pHmetría constata reflujo gastroesofágico patológico. El tránsito con bario evidencia paso de contraste a tráquea y bronquios principales a través de trayecto fístuloso de 7 mm de longitud y 3 mm de grosor entre cara anterior del esófago y posterior de la tráquea, sugestivo de fístula en H. Intervenido quirúrgicamente, disminuyen los episodios de broncoespasmo, sin síntomatología intercrisis. El 4% de las fístulas traqueoesofágicas son en H. Su diagnóstico suele ser tardío, en relación con problemas respiratorios crónicos, reflujo gastroesofágico y episodios de atragantamiento con líquidos. Generalmente presentan buen pronóstico, dependiendo de la asociación con atresia esofágica u otras anomalías (VACTERL) (AU)

Tracheoesophageal fistulea are the most frequent congenital abnormality of the respiratory tract, with an incidence of 1/3,500 in newborns. There are 5 types according to it anatomy, the H-type fistula being the least frequent. This variety is not associated to esophageal atresia, so that its diagnosis is later. We present the case of a 6-year old boy with background of late preterm. He presented episodes of regurgitations, coughing and bronchospasms beginning at one month and a half of life. The scintigraphy showed episodes of gastroesophageal reflux, that did not pass to the airway. Treatment was initiated with omeprazole, domperidone and home monitoring. There was improvement of the digestive symptoms, the bronchospasm episodes persisting. Due to suspicion of asthma of the infant, treatment was begun with inhaled corticosteroids in growing doses with partial control of the symptoms. He was diagnosed of Pneumonia at 4 years of age, with subsequent exacerbation of his symptoms, chocking with liquids and respiratory distress. The Ph meter showed pathological gastroesophageal reflux. The barium transit showed passage of the contrast to the trachea and main bronchi through the fistulous pathway of 7 mm in length and 3 mm thick between the anterior face of the esophageal and posterior one of the tracheal, suggestive of H fistula. He was operated on, decreasing the episodes of bronchospasm, without inter-episode symptoms. A total of 4% of the tracheal-esophageal fistulae are in H. These are usually diagnosed late, in relation with chronic respiratory problems, gastroesophageal reflux and episodes of choking with liquids. There prognosis is generally good, depending on the association with esophageal atresia or other abnormalities (VACTERL) (AU)

Fístula en H: a propósito de un caso / H type fistula: a case report

Las fístulas traqueoesofágicas son la anomalía congénita más frecuente del tracto respiratorio, con una incidencia 1/3.500 recién nacidos. Existen 5 tipos según su anatomía, siendo la fístula en H la menos frecuente. Esta variedad no se asocia a atresia de esófago, por lo que su diagnóstico es más tardío. Presentamos un niño de 6 años con antecedentes de prematuridad tardía. Desde el mes y medio de vida presenta episodios de regurgitaciones, tos y broncoespasmo. La gammagrafía evidencia episodios de reflujo gastroesofágico, sin paso a vía aérea; se instaura tratamiento con omeprazol, domperidona y monitorización domiciliaria, con mejoría de la clínica digestiva, persistiendo episodios de broncoespasmo. Con sospecha de asma del lactante inicia tratamiento con corticoides inhalados a dosis crecientes con control parcial de los síntomas. Fue diagnosticado de neumonía a los 4 años, con posterior exacerbación de su sintomatología, atragantamiento con líquidos y dificultad respiratoria. La pHmetría constata reflujo gastroesofágico patológico. El tránsito con bario evidencia paso de contraste a tráquea (..) (AU)

Tracheoesophageal fistulas are the most common congenital anomaly of the respiratory tract, with an incidence of 1/3,500 newborns. There are five types according to their anatomy, H being the fistula in the least frequent. This strain is not associated with esophageal atresia, so that the diagnosis is delayed. We report a 6 year old boy with a history of late prematurity. From month and a half has episodes of regurgitation, cough and bronchospasm. The scan evidence of gastroesophageal reflux episodes without airway passage; establishing treatment with omeprazole, domperidone and home monitoring, with improvement of digestive symptoms, persisting episodes of bronchospasm. With infant suspected asthma, treatment with increasing dose inhaled corticosteroids with partial control of symptoms. Pneumonia at age 4, with subsequent exacerbation of their symptoms, choking and difficulty breathing liquids. The notes pHmetry gastroesophageal reflux disease. The evidence barium (..) (AU)

[Comparison of the effects of midazolam and thiopental on the neuromuscular response of vecuronium, atracurium, and pancuronium]. / Comparación de los efectos del midazolam y del tiopental en la respuesta neuromuscular del vecuronio, atracurio y pancuronio.

To assess the possible interactions of midazolam and thiopental with the muscular relaxants vecuronium (0.08 mg/kg), atracurium (0.5 mg/kg), and pancuronium (0.1 mg/kg), a comparative analysis was undertaken in two groups of 18 and 32 patients treated respectively with midazolam (0.3 mg/kg) and thiopental (5 mg/kg). The beginning of the effect, maximal blockade, duration of the clinical response, and the spontaneous recovery index were measured on electromyographic recordings of action potentials evoked by train of four supramaximal stimuli delivered every 20 sec on the ulnar nerve. Conditions for intubation were assessed 2 minutes after administration of muscular relaxant. There were no significant differences in neuromuscular parameters in either of the two groups of patients treated with midazolam or with thiopental independently of the relaxant drug administered.

[Use of vecuronium and atracurium in continuous infusion. A comparative study using electromyography and accelerometry]. / Utilización del vecuronio y atracurio en infusión continua. Estudio comparativo con electromiografía y acelerometría.

Vecuronium and atracurium, muscle relaxant agents of intermediate action, were administered in continuous infusion to 175 patients undergoing prolonged surgical operations with the purpose of achieving serum concentrations inducing maintained blocking of neuromuscular function. We used a 0.08 mg/kg or 0.5 mg/kg bolus intubation dose followed by a continuous infusion of vecuronium (72 patients) or atracurium (103 patients) 10 minutes after, at the necessary pace to maintain inhibition of neuromuscular transmission over 90%. Monitoring of relaxation was done by means of four supramaximal stimuli trains which were repeated every 20 seconds and applied to the cubital nerve. Composite electromyogram (electromyography) and thumb acceleration (mechanomyography-accelerometry) were simultaneously recorded. Infusion was interrupted 15 minutes before ending the operation; reversion occurred spontaneously in 143 patients and 32 patients had to be reversed with neostigmine. Beginning of action, total duration of infusion, infusion speed, and 25-75 spontaneous and after decurarization recovery index were measured. Initial dose allowed an easy tracheal intubation and the constant relaxation achieved with 0.068 mg/kg/h and 0.46 mg/kg/h infusion of vecuronium and atracurium was adequate for all operations. Spontaneous recovery is often adequate at the end of operations in carefully monitored patients. Both monitoring methods are useful for clinical evaluation of neuromuscular transmission.