Paradoxical intraoperative embolism in a patient with Eisenmenger syndrome undergoing hip arthroplasty. / Embolismo paradójico intraoperatorio en paciente con síndrome de Eisenmenger sometida a hemiartroplastia de cadera.

Hip arthroplasty is associated with a high incidence of embolic events that, although usually not relevant at a clinical level, may be an important cause of morbidity and mortality in certain situations. Extreme caution should be taken in patients with cardiac defects that favor communication between the pulmonary and systemic circulation, due to their greater risk of complications. We present the case of a 72-year-old patient who suffered a paradoxical embolism during the intervention, with devastating consequences.

[General management in intensive care of patient with spontaneous subarachnoid hemorrhage]. / Manejo general en Cuidados Intensivos del paciente con hemorragia subaracnoidea espontánea.

Aneurysmal subarachnoid hemorrhage (SAH) is a neurologic emergency and often a neurologic catastrophe. Nontraumatic subarachnoid hemorrhage is characterized by the extravasation of blood into the spaces covering the central nervous system. The leading cause of SAH is rupture of an intracranial aneurysm, which accounts for about 80-85% of cases. Mortality and morbidity can be reduced if SAH is treated urgently. Sudden, explosive headache is a cardinal but nonspecific feature in the diagnosis of SAH; computered tomography (CT) scanning is mandatory in all the patients with symp toms that are suggestive of SAH. Catheter angiography for detecting aneurysms is gradually being replaced by CT angiography. Diagnosing SAH can be challenging and treatment is complex, sophisticated and multidisciplinary. Reble eding is the most imminent danger, which must be prevented by endovascular occlusion with detachable coils (coiling) or by surgical clipping of the aneurysm; the risk of delayed cerebral ischemia is reduced with nimodipine and avoiding hypovolemia; hydrocephalus can be treated by ventricular drainage. Intensive care plays a more important role in the management of SAH than in any other neurological disorder. Excellence in neurologic diagnosis, in operative neurosurgery or neuroradiologic procedures must be accompanied by excellence in Intensive Care. This review emphasizes treatment in the Intensive Care Unit, surgical and endovascular therapeutic options and the current state of treatment of major complications such as rebleeding, cerebral vasospasm and acute hydrocephalus.

[Extubation of the difficult airway]. / La extubación de la vía aérea difícil.

Extubation, like intubation, is a critical moment in general anesthesia. There are no algorithms or ordered sequences of steps for extubation. Rather, the approach to take is strict observation of the patient in a setting equipped with monitors, material for managing the difficult airway, and experienced staff who should be able to establish access immediately, provide oxygen, and facilitate gas exchange, keeping the airway open and safeguarding it in case of a failed extubation attempt. This review will analyze the clinical conditions and pathophysiology associated with extubations at high risk of complications. We will describe strategies for extubating in situations in which a difficult airway is known or suspected.

[A case of "ventilation difficulty-intubation difficulty" solved with transtracheal jet ventilation]. / Un caso de "dificultad de ventilación-dificultad de intubación" resuelto con ventilación jet transtraqueal.

A 56-year-old man recovering from a glossectomy and radical neck dissection presented severe oral bleeding, tracheal deviation with an asphyxiating hematoma and cyanosis. When 2 attempts at orotracheal intubation with the patient awake failed, transtracheal jet ventilation was used temporarily until a definitive airway could be established. Transtracheal jet ventilation is highly useful for managing an airway and maintaining gas exchange in life-threatening situations in which intubation and ventilation has become impossible, yet it is rarely used for that purpose. An easy, fast procedure that has not been widely used in Spain, this technique provides effective ventilation and oxygen while a definitive resolution of the emergency is sought.