Manejo de la hipoxia durante ventilación unipulmonar en un paciente con absceso mediastinal y mediastinitis para toracotomía abierta. Reporte de caso / Hypoxia Management during One-Lung Ventilation in a Patient with Mediastinal Abscess and Mediastinitis for Open Thoracotomy. Case Report

Introducción: la mayoría de los pacientes que se someten a cirugía torácica pueden ser clasificados en el grupo de alto riesgo para hipoxia, especialmente cuando se decide por una ventilación unipulmonar, debido al desequilibrio V/Q; por lo tanto, se han desa-rrollado nuevas estrategias ventilatorias y maniobras de rescate para hipoxia. Curso clínico: presentamos una paciente de 85 años de edad sin comorbilidades programada para toracotomía abierta y manejada con ventilación unipulmonar. Durante el mane-jo anestésico, se presenta hipoxia secundaria a desequilibrio V/Q y choque hipovolémi-co hemorrágico, con respuesta positiva a las maniobras de rescate para hipoxia. Con-clusión: es importante prevenir en la medida de lo posible la hipoxia en la ventilación unipulmonar, siguiendo las nuevas estrategias ventilatorias. Sin embargo, cuando se presenta una crisis, no debemos retrasar las maniobras de rescate de forma moderna. (AU)

Introduction: most of the patients undergoing thoracic surgery fit in the high risk group for hypoxia, especially when deciding to use one-lung ventilation due to the V/Q mis-match; therefore, new ventilation strategies and hypoxia rescue manoeuvres have been developed. Clinical course: we present an 85-year old female with no major co-morbidities scheduled for open thoracotomy and managed with one-lung ventilation. During the course of the anaesthetic management, hypoxia presents secondary to V/Q mismatch and haemorrhagic hypovolemic shock, with a positive response to hypoxia rescue manoeuvres. Conclusion: it is important to prevent as much as we can the hy-poxia in a one-lung ventilation following the new ventilation strategies. Although when facing a crisis, proper hypoxia management with a modern approach should not be de-layed. (AU)

The effect of different anesthesia techniques on cerebral oxygenation in thoracic surgery.

OBJECTIVE: One-lung ventilation may cause negative changes in the oxygenation of cerebral tissue which results in post-operative cognitive dysfunction. We compared the potential effects of total intravenous anesthesia and inhalation general anesthesia techniques on cerebral tissue oxygenation. MATERIALS AND METHODS: In this prospective double-blind trial, patients whose standard anesthesia induction was done were randomly divided into two groups as group total intravenous anesthesia using propofol (Group T, n = 30) and group inhalation general anesthesia using sevoflurane (Group I, n = 30) based on anesthesia maintenance. The intraoperative cerebral oxygen saturation and pre-post-operative mini-mental status test scores of the patients were monitored and recorded. RESULTS: Baseline characteristics were similar between the two groups. The decrease of cerebral oxygen saturation more than 20% in total intravenous anesthesia group was significantly higher than inhalation group (p < 0.05). In both groups, the mini-mental status test values at the post-operative 3rd h were significantly lower than the pre-operative and post-operative 24th h values (p < 0.05). CONCLUSIONS: Inhalation general anesthesia provided better cerebral tissue oxygenation in thoracic surgery with one-lung ventilation compared to total intravenous anesthesia. However, there was no significant correlation between the presence of desaturation and post-operative cognitive dysfunction.

OBJETIVO: La ventilación unipulmonar puede provocar cambios negativos en la oxigenación del tejido cerebral que se traduce en una disfunción cognitiva postoperatoria. Comparamos los efectos potenciales de la anestesia total intravenosa y las técnicas de anestesia general por inhalación en relación con la oxigenación del tejido cerebral. MATERIAL Y MÉTODOS: En este ensayo prospectivo doble ciego, los pacientes en los que se realizó una inducción estándar de anestesia se dividieron aleatoriamente en dos grupos: grupo de anestesia intravenosa total con propofol (Grupo T, n = 30) y grupo de anestesia general por inhalación con sevoflurano (Grupo I, n = 30) basados en el mantenimiento de la anestesia. Se controlaron y registraron la saturación de oxígeno cerebral intraoperatoria y las valoraciones de la miniprueba de estado mental preoperatoria de los pacientes. RESULTADOS: Las características de base fueron similares entre los dos grupos. La disminución de la saturación de oxígeno cerebral de más del 20% en el grupo de anestesia intravenosa total fue significativamente mayor que en el grupo de inhalación (p < 0.05). En ambos grupos, los valores de la mini prueba del estado mental al cabo de la 3a. hora del período posoperatorio fueron significativamente más bajos que los valores preoperatorios y posoperatorios registrados al cabo de 24 horas (p < 0.05). CONCLUSIONES: La anestesia general por inhalación facilitó una mejor oxigenación del tejido cerebral en la cirugía torácica con ventilación unipulmonar en comparación con la anestesia intravenosa total. Sin embargo, no hubo una correlación significativa entre la presencia de desaturación y la disfunción cognitiva posoperatoria.

Clinical guide to perioperative management for videothoracoscopy lung resection (Section of Cardiac, Vascular and Thoracic Anesthesia, SEDAR; Spanish Society of Thoracic Surgery, SECT; Spanish Society of Physiotherapy).

The introduction of video-assisted thoracoscopic (VATS) techniques has led to a new approach in thoracic surgery. VATS is performed by inserting a thoracoscope through a small incisions in the chest wall, thus maximizing the preservation of muscle and tissue. Because of its low rate of morbidity and mortality, VATS is currently the technique of choice in most thoracic procedures. Lung resection by VATS reduces prolonged air leaks, arrhythmia, pneumonia, postoperative pain and inflammatory markers. This reduction in postoperative complications shortens hospital length of stay, and is particularly beneficial in high-risk patients with low tolerance to thoracotomy. Compared with conventional thoracotomy, the oncological results of VATS surgery are similar or even superior to those of open surgery. This aim of this multidisciplinary position statement produced by the thoracic surgery working group of the Spanish Society of Anesthesiology and Reanimation (SEDAR), the Spanish Society of Thoracic Surgery (SECT), and the Spanish Association of Physiotherapy (AEF) is to standardize and disseminate a series of perioperative anaesthesia management guidelines for patients undergoing VATS lung resection surgery. Each recommendation is based on an in-depth review of the available literature by the authors. In this document, the care of patients undergoing VATS surgery is organized in sections, starting with the surgical approach, and followed by the three pillars of anaesthesia management: preoperative, intraoperative, and postoperative anaesthesia.

Guía clínica en el manejo perioperatorio para la cirugía de resección pulmonar por videotoracoscopia (Sección de Anestesia Cardiaca, Vascular y Torácica, SEDAR; Sociedad Española de Cirugía Torácica, SECT; Asociación Española de Fisioterapia, AEF) / Clinical guide to perioperative management for videothoracoscopy lung resection (Section of Cardiac, Vascular and Thoracic Anesthesia, SEDAR; Spanish Society of Thoracic Surgery, SECT; Spanish Society of Physiotherapy)

La introducción de técnicas toracoscópicas asistidas por video en cirugía torácica (VATS) ha permitido realizar un nuevo enfoque en la cirugía torácica. El acceso videotoracoscópico se realiza con pequeñas incisiones, preservando al máximo los músculos y los tejidos. En la actualidad, la VATS se considera de elección en la mayoría de los procedimientos torácicos, principalmente debido a la menor morbimortalidad asociada. La resección pulmonar por VATS presenta reducción de las fugas de aire prolongadas, arritmias, neumonía, dolor postoperatorio y una disminución de los marcadores inflamatorios. Esta reducción de las complicaciones postoperatorias está vinculada a una reducción de la estancia hospitalaria, siendo los pacientes de alto riesgo y con poca tolerancia a la toracotomía los principales beneficiarios de esta técnica.En comparación con la toracotomía convencional, los?resultados?oncológicos de la cirugía VATS son similares o incluso superiores a los de la cirugía abierta.Este documento, de redacción multidisciplinar, consensuado por el grupo de trabajo de cirugía torácica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), de la Sociedad Española de Cirugía Torácica (SECT) y la Asociación Española de Fisioterapia (AEF), pretende estandarizar y difundir, con base en la bibliografía más actual, las mejores pautas de manejo clínico perioperatorio de los pacientes que se someten a una cirugía de resección pulmonar por VATS. Cada recomendación parte de una revisión de la literatura disponible y analizada en profundidad por los autores.Con el objetivo de dirigir el curso asistencial que seguirá el paciente que se somete a una cirugía pulmonar por VATS, esta guía se organiza inicialmente en el enfoque quirúrgico, seguido de los tres puntos clásicos del proceso anestésico. Estos puntos son preoperatorio, intraoperatorio y postoperatorio.(AU)

The introduction of video-assisted thoracoscopic (VATS) techniques has led to a new approach in thoracic surgery. VATS is performed by inserting a thoracoscope through a small incisions in the chest wall, thus maximizing the preservation of muscle and tissue. Because of its low rate of morbidity and mortality, VATS is currently the technique of choice in most thoracic procedures. Lung resection by VATS reduces prolonged air leaks, arrhythmia, pneumonia, postoperative pain and inflammatory markers. This reduction in postoperative complications shortens hospital length of stay, and is particularly beneficial in high-risk patients with low tolerance to thoracotomy.Compared with conventional thoracotomy, the oncological results of VATS surgery are similar or even superior to those of open surgery.This aim of this multidisciplinary position statement produced by the thoracic surgery working group of the Spanish Society of Anesthesiology and Reanimation (SEDAR), the Spanish Society of Thoracic Surgery (SECT), and the Spanish Association of Physiotherapy (AEF) is to standardize and disseminate a series of perioperative anaesthesia management guidelines for patients undergoing VATS lung resection surgery. Each recommendation is based on an in-depth review of the available literature by the authors.In this document, the care of patients undergoing VATS surgery is organized in sections, starting with the surgical approach, and followed by the three pillars of anaesthesia management: preoperative, intraoperative, and postoperative anaesthesia.(AU)

Unilateral pulmonary edema associated factors after minimally invasive mitral valve surgery.

BACKGROUND AND OBJECTIVES: In recent years, minimally invasive cardiac surgery (MICS) has been developed and applied to a greater number of pathologies, especially in mitral valve surgeries, as it obtains results comparable to those of conventional techniques while entailing lower surgical trauma and shorter recovery time. MICS requiring one-lung ventilation has been associated to the appearance of unilateral pulmonary edema (UPE), which is a potentially serious complication. The objective is determining the incidence of UPE after mitral MICS and its development associated factors. MATERIAL AND METHODS: Observational descriptive and single-center study analyzing data from patients undergoing mitral valve MICS (right mini-thoracotomy) consecutively collected between the years 2015 and 2017. RESULTS: A total of 93 patients were included and 26 presented UPE. The most common complications after mitral valve MICS were atrial fibrillation (38.7%), UPE (28%) and transient and/or definitive second- or third-degree auriculoventricular block (19.4%). The UPE group had longer ICU stay (3.3 ± 8.0 vs. 1.84 ± 2.23 days) and longer total hospitalization length-of-stay (15.5 ± 34.7 vs. 10.6 ± 7.5 days). The mortality in the UPE group was 3.9%. A significant association was found between the following collected variables and the development of postoperative UPE: preoperative baseline pulse oximetry, preoperative use of ACE inhibitors, postoperative atrial fibrillation and 24 first-hours cumulative chest tube drainage volume on the first 24 h. CONCLUSIONS: The incidence of UPE is high and its appearance is associated with a longer ICU and total length of stay. More studies are required to understand its pathophysiology and apply measures to help decreasing its appearance.

Factores asociados al edema pulmonar unilateral después de la cirugía mínimamente invasiva de la válvula mitral / Unilateral pulmonary edema associated factors after minimally invasive mitral valve surgery

Antecedentes y objetivo: En los últimos años la cirugía cardíaca mínimamente invasiva (CCMI) se ha desarrollado y aplicado a mayor número de dolencias, especialmente en cirugías sobre la válvula mitral, por presentar resultados comparables a las técnicas convencionales con menor agresividad y tiempo de recuperación. La CCMI que necesita ventilación unipulmonar se ha asociado a la aparición de edema pulmonar unilateral (EPU), que constituye una complicación potencialmente grave. El objetivo es determinar la incidencia de EPU tras CCMI mitral y los factores asociados a su desarrollo. Material y métodos: Estudio observacional descriptivo y unicéntrico. Se analizaron los pacientes tratados con CCMI sobre válvula mitral (minitoracotomía derecha), recogidos de manera consecutiva entre los años 2015 y 2017. Resultados: Se incluyó a un total de 93 pacientes, de los cuales 26 presentaron EPU. Las complicaciones más habituales tras la CCMI mitral fueron: fibrilación auricular (38,7%), EPU (28%) y bloqueo auriculoventricular de segundo o tercer grado transitorio o definitivo (19,4%). El grupo EPU presentó mayor tiempo de estancia en UCI (3,3±8,0 vs. 1,84±2,23 días) y mayor tiempo total de hospitalización (15,5±34,7 vs. 10,6±7,5 días). La mortalidad en el grupo EPU fue del 3,9%. Se encontró asociación significativa entre las siguientes variables recogidas y el desarrollo de EPU postoperatorio: pulsioximetría basal preoperatoria, uso preoperatorio de IECA, fibrilación auricular postoperatoria y volumen de drenajes en las primeras 24h. Conclusiones: La incidencia de EPU es elevada y su aparición se asocia a mayor estancia en UCI y mayor tiempo total de hospitalización. Se requieren más estudios para comprender su fisiopatología y aplicar medidas que ayuden a disminuir su aparición.(AU)

Background and objectives: In recent years, minimally invasive cardiac surgery (MICS) has been developed and applied to a greater number of pathologies, especially in mitral valve surgeries, as it obtains results comparable to those of conventional techniques while entailing lower surgical trauma and shorter recovery time. MICS requiring one-lung ventilation has been associated to the appearance of unilateral pulmonary edema (UPE), which is a potentially serious complication. The objective is determining the incidence of UPE after mitral MICS and its development associated factors. Material and methods: Observational descriptive and single-center study analyzing data from patients undergoing mitral valve MICS (right mini-thoracotomy) consecutively collected between the years 2015 and 2017. Results: A total of 93 patients were included and 26 presented UPE. The most common complications after mitral valve MICS were atrial fibrillation (38.7%), UPE (28%) and transient and/or definitive second- or third-degree auriculoventricular block (19.4%). The UPE group had longer ICU stay (3.3±8.0 vs. 1.84±2.23 days) and longer total hospitalization length-of-stay (15.5±34.7 vs. 10.6±7.5 days). The mortality in the UPE group was 3.9%. A significant association was found between the following collected variables and the development of postoperative UPE: preoperative baseline pulse oximetry, preoperative use of ACE inhibitors, postoperative atrial fibrillation and 24 first-hours cumulative chest tube drainage volume on the first 24h. Conclusions: The incidence of UPE is high and its appearance is associated with a longer ICU and total length of stay. More studies are required to understand its pathophysiology and apply measures to help decreasing its appearance.(AU)

Clinical guide to perioperative management for videothoracoscopy lung resection (Section of Cardiac, Vascular and Thoracic Anesthesia, SEDAR; Spanish Society of Thoracic Surgery, SECT; Spanish Society of Physiotherapy). / Guía clínica en el manejo perioperatorio para la cirugía de resección pulmonar por videotoracoscopia (Sección de Anestesia Cardiaca, Vascular y Torácica, SEDAR; Sociedad Española de Cirugía Torácica, SECT; Asociación Española de Fisioterapia, AEF).

The introduction of video-assisted thoracoscopic (VATS) techniques has led to a new approach in thoracic surgery. VATS is performed by inserting a thoracoscope through a small incisions in the chest wall, thus maximizing the preservation of muscle and tissue. Because of its low rate of morbidity and mortality, VATS is currently the technique of choice in most thoracic procedures. Lung resection by VATS reduces prolonged air leaks, arrhythmia, pneumonia, postoperative pain and inflammatory markers. This reduction in postoperative complications shortens hospital length of stay, and is particularly beneficial in high-risk patients with low tolerance to thoracotomy. Compared with conventional thoracotomy, the oncological results of VATS surgery are similar or even superior to those of open surgery. This aim of this multidisciplinary position statement produced by the thoracic surgery working group of the Spanish Society of Anesthesiology and Reanimation (SEDAR), the Spanish Society of Thoracic Surgery (SECT), and the Spanish Association of Physiotherapy (AEF) is to standardize and disseminate a series of perioperative anaesthesia management guidelines for patients undergoing VATS lung resection surgery. Each recommendation is based on an in-depth review of the available literature by the authors. In this document, the care of patients undergoing VATS surgery is organized in sections, starting with the surgical approach, and followed by the three pillars of anaesthesia management: preoperative, intraoperative, and postoperative anaesthesia.

Esofagectomía minimamente invasiva / Minimally invasive esophagectomy

INTRODUCTION: Minimally invasive esophagectomy aims to reduce complications compared to open esophagectomy. In this report of the first patient undergoing this procedure at Hospital Pasteur, we highlight the importance of multidisciplinary management, and the main anesthesiological objectives. OBJECTIVE: To present the case report highlighting the anesthetic management, together with the bibliographic review carried out in order to update the anesthetic action protocols, with the main objective of reducing the appearance of perioperative complications. MATERIAL AND METHOD: Bibliographic search in PubMed bibliographic databases. Initially, 67 articles were obtained, selecting 20 considered relevant by the authors. CLINICAL CASE: It was a 46-year-old patient coordinated for esophagectomy for squamous neoplasm. Rapid sequence induction, selective endobronchial intubation and anesthetic maintenance with Isoflurane and epidural analgesia were performed. The hydroelectric replacement was restricti- ve. The surgical technique was performed in 3 stages: thoracic time by thoracoscopy; a second laparoscopic abdominal stage and a third stage for left cervicotomy. Extubation was carried out in the operating room with transfer to the ICU where she remained for 6 days to manage analgesia and due to the presence of a mild infectious complication, with good subsequent evolution. CONCLUSION: The use of perioperative multidisciplinary management protocols has fundamental importance as a strategy aimed at reducing morbidity and mortality. Advances in surgical technique added to anesthetic management constitute strategies that aim to reduce perioperative complications.

INTRODUCCIÓN: La esofagectomía minimamente invasiva tiene como objetivo disminuir las complicaciones en comparación con la esofagectomía abierta. En este reporte del primer paciente sometido a este procedimiento en el Hospital Pasteur destacamos la importancia del manejo multidisciplinario, y los principales objetivos anestesiológicos. OBJETIVO: Presentar el reporte de caso destacando el manejo anestésico, junto con la revisión bibliográfica realizada en vistas a la actualización de protocolos de actuación anestésica, con objetivo principal de disminuir la aparición de complicaciones perioperatorias. MATERIAL Y MÉTODO: Búsqueda bibliográfica en las bases bibliográficas PubMed. Inicialmente se obtuvieron 67 artículos, seleccionando 20 considerados relevantes por los autores. CASO CLÍNICO: Se trató de una paciente de 46 años coordinada para esofagectomía por neoplasma epidermoide. Se realizó inducción en secuencia rápida, intubación endobronquial selectiva y mantenimiento anestésico con Isofluorano y analgesia peridural. La reposición hidroelectrolítica fue restrictiva. La técnica quirúrgica se realizó en 3 tiempos: tiempo torácico por toracoscopía; un segundo tiempo abdominal laparoscópico y un tercer tiempo para cervicotomía izquierda. La extubación se realizó en sala de operaciones con traslado a CTI donde permaneció por 6 días para manejo de la analgesia y por presencia de complicación infecciosa leve, con buena evolución posterior. CONCLUSIÓN: Resulta de fundamental importancia el uso de protocolos de manejo multidisciplinario perioperatorio como estrategia destinada a disminuir la morbimortalidad. Los avances en cuanto a la técnica quirúrgica sumado al manejo anestésico constituyen estrategias que apuntan a disminuir las complicaciones perioperatorias.

Lung recruitment maneuvers: opening the door to a hidden enemy. / Maniobras de reclutamiento pulmonar: abriendo la puerta a un enemigo oculto.

Recruitment manoeuvres (RM) are common practice in anaesthesiology; however, they can have adverse effects. We present an unforeseen complication in a patient undergoing surgical resection of a bronchial tumour who presented cardiac arrest due to pulseless electrical activity immediately after RMs. A transoesophageal echocardiogram performed after return of spontaneous circulation showed a patent foramen ovale (PFO), left ventricular dysfunction with segmental changes, and air in the left ventricle, leading to suspicion of paradoxical air embolism. The contractility changes normalised spontaneously, and postoperative evolution was uneventful. RMs cause changes in intracavitary pressures that can lead to opening of a PFO (present in up to 30% of the population) and reversal of the physiological left-right shunt. Transoesophageal echocardiography facilitated immediate diagnosis and follow-up.

Validation study of the dynamic parameters of pulse wave in pulmonary resection surgery. / Estudio de validación de los parámetros dinámicos de onda de pulso en cirugía de resección pulmonar.

INTRODUCTION: In lung resection surgery, restrictive fluid therapy is recommended due to the risk of acute lung injury. In contrast, this recommendation increases the risk of hypoperfusion. Guided fluid therapy allows individualization of fluid intake. The use of dynamic volume response parameters is not validated during one-lung ventilation. The main objective is the validation of dynamic parameters, stroke volume variation (SVV) and pulse pressure variation (PPV), during lung resection surgery as fluid response predictors, after the administration of 250ml crystalloid volume loads, if IC<2.5ml/min/m2 and if SVV≥8% and/or PPV≥10%. MATERIAL AND METHODS: Pilot, prospective, observational and single centre study. Twenty-five patients monitored with the PiCCO system were included during open lung resection surgery with the patient in a lateral position, one lung ventilation with tidal volume (TV): 6ml/kg and open chest. Hemodynamic variables were collected before and after volume loading. The results were classified into two groups: volume responders (increase IC≥10% and/or VSI≥10% after volume loading) and non-responders (no increase or increase IC<10% and/or VSI<10% after volume loading). We assess the diagnostic efficacy of SVV and PPV by analyzing the AUC (area under curve) in the ROC curves. RESULTS: In the analysis of ROC curves, SVV and PPV did not reach a discriminative value (AUCSVV: 0.47; AUCPPV: 0.50), despite the decrease in the threshold value of SVV and PPV to initiate an overload of volume during one-lung ventilation, in lateral position and open chest. CONCLUSIONS: The results obtained show that the values of the dynamic parameters of volume response (SVV≥8% and PPV≥10%) do not discriminate against responders patients and non-responders during open lung resection surgery.

Single-lung ventilation with bronchofibroscopy during lung resection surgery. / Oxigenación unilobar con fibroscopio durante cirugía de resección pulmonar.

Lung isolation using one-lung ventilation is common during thoracic surgery procedures, as it allows proper visualisation and manipulation of the lung to be operated on. Selective lobar blockade has been described in patients that do not tolerate one-lung ventilation, and is usually achieved using endobronchial blockers. However, it depends on endobronchial blocker availability, its complexity regarding proper positioning, and the need for constant monitoring to ensure the correct placement of the bronchial seal. In the clinical case to be described, a new method was used to increase the available surface for oxygen exchange. This was accomplished by means of direct supply of oxygen through the bronchoscope's working channel to one of the not-to-be operated-on, non-ventilated lung lobes. With this technique, the surgeon had an optimal operating field, oxygenation from one-lung ventilation improved and no perioperative complications were found.

New evidence in one-lung ventilation. / Nueva evidencia en ventilación unipulmonar.

Mechanical ventilation in thoracic surgery has undergone significant changes in recent years due to the implementation of the protective ventilation. This review will analyze recent ventilatory strategies in one-lung ventilation. A MEDLINE research was performed using Mesh term "One-Lung Ventilation" including randomized clinical trials, metanalysis, reviews and systematic reviews published in the last 6 years. Search was performed on 21st March 2017. A total of 75 articles were initially found. After title and abstract review 14 articles were included. Protective ventilation is not simply synonymous of low tidal volume ventilation, but it also includes routine use of PEEP and alveolar recruitment maneuver. New techniques are still in discussion namely PEEP adjustment, ratio inspiration:expiration, ideal type of anesthesia during one-lung ventilation and hypercapnic ventilation.

Valoracion del bloqueo pulmonar mediante ecografia en cirugia de tórax. primera experiencia en nuestro medio / Assessment of pulmonary blocking through ecography in torax surgery. first experience in our environment

Objetivo: evaluar validez y eficacia de la ecografía pulmonar frente al método clínico para corroborar intubación selectiva izquierda en cirugía de tórax. Material y Método: estudio transversal, observacional, prospectivo, doble ciego. Se incluyeron en forma consecutiva 59 pacientes en 2 etapas: (etapa 1- n 15 puesta a punto de la técnica; etapa 2- n 44) . Luego de la intubación con un tubo doble luz izquierdo, pinzamiento secuencial de ambas luces, evaluación de posición clínicamente y por ecografía con confirmación posterior por fibrobroncoscopia (gold estándar) . Resultados etapa 2: 56,8% (n=25) de los casos el tubo estaba bien colocado. Validez de la ecografía (correcta colocación): sensibilidad de 84,00% (IC 95%: 63,08-94,75), especificidad de 94,74% (IC 95%: 71,89-99,72), Valor predictivos positivo 95,45% (IC 95%: 75,12-99,76), Valor predictivo negativo de 81,82% ((IC al 95%: 58,99-94,01). Validez de la auscultación pulmonar: sensibilidad de 96,00% (IC al 95%: 77,68-99,79), especificidad de 100.00% (IC al 95%: 79,08-100.00), valor predictivos positivo de 100.00% (IC al 95%: 82,83-100.00) , Valor predictivo negativo de 95.00% ((IC al 95%: 73,06-99,74). Discusión: las diferencias de resultados con otros autores podrían responder a diferencias en la experticia (primera experiencia en nuestro medio), criterios de inclusión más amplios, número de pacientes. Se propone aumentar el tamaño de la muestra ''n '' e incorporar otros signos ecográficos de evaluación. Conclusión: la ecografía se presenta en forma prometedora como una herramienta complementaria a la evaluación clínica.

Goal: assessing the validity and effectiveness of pulmonary ultrasound against clinical method to corroborate left selective intubation on thorax surgery. Material and method: transversal study, observational, prospective, double blind. 59 patients in 2 different stages where included: (1-n 15 technique development; 2-n 44). After intubation with left double-lumen tube, sequential clamping of both lights, both clinically assessment of position and through ultrasound with subsequent confirmation through fibrobronchoscopy (reference standards). Stage 2 results: In 56.8% (n=25) of cases the tube was placed properly. Ultrasound validation (proper collocation): sensitivity of 84,00% (IC 95%:63.08-94.75), specificity of 94.74% (IC 95%: 71.89-99.72), Positive predictive values 95,45% (IC 95%: 75.12-99.76), Negative predictive value 81,82% ((IC at 95%: 58.99-94.01). Validity of pulmonary auscultation: sensitivity of 96.00% (IC at 95%: 77.68-99.79), Specificity of 100.00% (IC at 95%: 79.08-100.00), positive predictive values of 100.00% (IC at 95%: 82.83-100.00), Negative predictive value of 95.00% ((IC at 95%: 73.06-99.74). Discussion: the difference in results with other authors might respond to difference in expertise (first experience on our medium), wider inclusion criteria, and number of patients. We propose increasing the "n" and adding other ultrasonic signs of assessment. Conclusion: ultrasound is presented in a promising way as a complementary tool to clinic evaluation.

Scimitar syndrome: Anaesthetic management for pulmonary resection of the unaffected lung. / Síndrome de la cimitarra: manejo anestésico para resección pulmonar del pulmón no afecto.

Scimitar syndrome is a rare congenital anomaly characterized by anomalous drainage of the right pulmonary veins in the inferior vena cava, frequently associated with right lung and pulmonary artery hypoplasia, dextrocardia and abnormal systemic arterial supply to the lower lobe. Pulmonary resection surgery on healthy lung is exceptional, and there are no published records of it, as far as we know. A man with scimitar syndrome diagnosed with a lung nodule with malignant features in the contralateral lung. This situation implies huge anaesthetic complexity, mainly for intraoperative ventilation. Although spirometry and stress test did not contraindicate the planned lobectomy, scintigraphy showed a hypoplastic right lung with an uptake of 15%. From an anaesthetic point of view we discarded selective ventilation of the right lung, since the shunt made it functionally non-existent. In consequence we proposed four anaesthetic possibilities. After the placement of an epidural catheter and left selective intubation, thoracoscopy with intermittent apnoeas was our first choice, and we could complete the extirpation and avoid excessive complexity.

Anaesthetic management in thoracoscopic distal tracheal resection. / Manejo anestésico en la resección traqueal distal toracoscópica.

Surgical resection of tracheal tumours, especially distal tracheal tumours, is a challenge for the anaesthesiologists involved, mainly due to difficulties in ensuring adequate control of the airway and ventilation. We report the case of a patient undergoing tracheal resection and anastomosis by VATS, emphasizing the anaesthetic management.

Anesthetic management for thoracic surgery in Rubinstein-Taybi syndrome.

Rubinstein-Taybi syndrome (RTS) is a chromosomopathy associated to molecular mutations or microdeletions of chromosome 16. It has an incidence of 1:125,000-700,000 live births. RTS patients present craniofacial and thoracic anomalies that lead to a probable difficult-to-manage airway and ventilation. They also present mental retardation and comorbidity, such as congenital cardiac defects, pulmonary structural anomalies and recurrent respiratory infections, which increase the risk of aspiration pneumonia. Cardiac arrhythmias have been reported after the use of certain drugs such as succinylcholine and atropine, in a higher incidence than in general population. There is an increased risk of postoperative apnea-hypopnea in these patients. We report the anesthetic management in a RTS patient undergoing emergent thoracic surgery due to oesophageal perforation and mediastinitis. Lung isolation was achieved with a bronchial blocker guided with a fiberoptic bronchoscope and one-lung ventilation was performed successfully.

Evolution of regional oxygen saturation in the peri-operative of thoracic surgery and its relationship with central venous saturation. / Evolución de la saturación regional cerebral de oxígeno en el perioperatorio de cirugía torácica y su relación con la saturación venosa central.

OBJECTIVE: To study the relationship between the values of SvcO2 and SrcO2 in lung resection with one lung ventilation (OLV) and changes in these variables and mean arterial pressure (MAP) and arterial oxygen saturation (SpO2) during the perioperative period. MATERIAL AND METHODS: Prospective, observational study of 25 patients in whom pulmonary resection was performed with OLV. The values of MAP, SpO2, SvO2, and SrcO2 were recorded at 6 different times: 1)baseline; 2)double-lung ventilation before the OLV (VBP1); 3)during OLV; 4)after double-lung ventilation (VBP2); 5)30minutes after surgery, and 6)6hours after surgery. RESULTS: The SrcO2 showed a significant increase from baseline to starting ventilation (65.72±9.05% vs 70.44±7.24%; P<.01). There were no significant changes in their values at the different intraoperative times. Post-operatively, as in the case of the SvcO2, a significant decrease (P<.001) of its value compared with the previous value was observed. CONCLUSIONS: SrcO2 showed a significant increase after induction of anaesthesia and initiation of mechanical ventilation compared to baseline, and a significant decrease at the end of surgery after extubation in the immediate postoperative period. Being a tissue monitoring, non-invasive technique and with continuous values it can alert the clinician of changes in the ratio of oxygen consumption (VO2) to oxygen delivery (DO2) at times of greatest risk, such as OLV, extubation, and the early postoperative period.

Caso de hemoptisis masiva en el transoperatorio, manejo de la hipoxia en ventilación unipulmonar / A case of massive hemoptysis during transoperative; hypoxia handling in one-lung ventilation

Introducción: relatar un caso de hemoptisis masiva en el transoperatorio de cirugía pulmonar para establecer el manejo de la hipoxia en ventilación unipulmonar y con esto evitar devastadoras consecuencias. Caso clínico: paciente masculino de 46 años de edad con antecedente de varios episodios de hemoptisis, se sometió a lobectomía superior izquierda, presentando episodio de hemoptisis masiva en el transoperatorio, se siguió algoritmo de hipoxia en ventilación unipulmonar; a pesar de ello mantiene hipoxia prolongada por lo que se presentan secuelas importante de encefalopatía hipoxia. Conclusión: todo anestesiólogo que realice cirugías de pulmón debe estar en la capacidad de dominar el manejo de cualquier evento de hipoxia en ventilación unipulmonar.

Introduction: to relate a clinical case in OR of a pulmonary surgery for review the management of hypoxia in unipulmonar ventilation and with this realize that we could have catastrophic consequences. Clinic case: male patient, 46 years of age with a history of several episodes of hemoptysis underwent left upper lobectomy, presenting episode of intraoperative massive hemoptysis. Algorithm of hypoxia in one lung ventilation was followed nevertheless maintains prolonged hypoxia with important consequences of hypoxic encephalopathy. Conclusion: every anesthesiologist that have in OR a pulmonary surgery must have the knowledge of hypoxia in unipulmonar ventilation management.

Efectos de la ventilación mecánica intraoperatoria y de la ventilación de protección pulmonar en el paciente quirúrgico adulto / Effects of intraoperative mechanical ventilation and of pulmonary protective ventilation in the adult surgical patient

La ventilación mecánica es esencial para un adecuado intercambio gaseoso durante la anestesia general, siendo empleada con volúmenes corrientes altos para prevenir la hipoxemia y la formación de atelectasias; pero volúmenes corrientes altos y altas presiones de meseta pueden agravar o incluso iniciar una lesión pulmonar. La ventilación de protección pulmonar consiste en el uso de un volumen corriente bajo, limitar la presión meseta para minimizar la sobredistensión y utilizar presión positiva al final de la espiración. Más recientemente se está investigando su aplicación al paciente quirúrgico con anestesia general y ventilación controlada. Objetivo: analizar la evidencia en cuanto al beneficio de la ventilación de protección pulmonar durante la cirugía con ventilación controlada bipulmonar o unipulmonar en paciente adulto. Metodología de búsqueda: búsqueda en la base de datos Pubmed-Medline 2010-2014 de artículos de revisión clínica y fisiopatológica y revisiones sistemáticas, metaanálisis, estudios observacionales y controlados aleatorizados, incluyéndose en total 2031 artículos. Resultados: la mayoría de estudios que emplean ventilación de protección pulmonar: volumen corriente 6-8 ml/kg, presión positiva al final de la expiración 4-8 cmH2O y maniobras de reclutamiento, obtuvieron una mejoría en los parámetros fisiológicos y ventilatorios. Algunas investigaciones ofrecen resultados no homogéneos; sin embargo, clínicamente la evidencia no es tan notoria. Estudios con tamaño de muestra grande registran un aumento de la morbimortalidad respiratoria postoperatoria en pacientes en los que no se emplea esta estrategia. Conclusiones: la aplicación de estrategias de ventilación de protección pulmonar intraoperatoria podrían mejorar el pronóstico y los resultados inmediatos y diferidos -especialmente respiratorios- de los pacientes quirúrgicos normales y poblaciones especiales...

Artificial ventilation is essential for an adequate gas interchange during general anesthesia, it has been used with high tidal volume to prevent hypoxemia and atelectasis, but high tidal volumes and high plateau pressures might aggravate or start a lung injury. Pulmonary protective ventilation consists of use of low tidal volumes, limit plateau pressure to minimize overdistension and use positive pressure at the end of expiration and controlled ventilation. Objective: to analize the evidence on the possible benefit of protective pulmonary ventilation during surgery with bipulmonar or unipulmonar controlled ventilation. Materials and Methods: the Pubmed-Medline database was searched for years 2010-2014 for articles on clinical and pathophysiological reviews, systematic reviews, metaanalysis, observational studies, and randomized controlled trials. A total of 2031 articles were included. Results: most studies using pulmonary protective ventilation: tidal volume 6-8 ml/kg, positive end expiratory pressure 4-8 cmH2O and recruitment maneuvers, showed improved physiologic and ventilatory parameters. Some investigations offered not homogeneous results; however, the clinical evidence of improvement is not as clear. Studies with wide sample sizes showed increased respiratory morbimortality in patients in whom this strategy was not applied. Conclusions: application of protective pulmonary ventilation strategies might improve the immediate and delayed prognostic and outcomes, specially respiratory of normal sugical patients. Special populations could benefit of these stratiegies...

Comparison between transthoracic lung ultrasound and a clinical method in confirming the position of double-lumen tube in thoracic anaesthesia. A pilot study.

OBJECTIVE: To compare the ability of lung ultrasound and a clinical method in the confirmation of a selective bronchial intubation by left double-lumen tube in elective thoracic surgery. MATERIAL AND METHODS: A prospective and blind, observational study was conducted in the setting of a university hospital operating room assigned for thoracic surgery. A single group of 105 consecutive patients from a total of 130, were included. After blind intubation, the position of the tube was confirmed by clinical and ultrasound assessment. Finally, the fiberoptic bronchoscopy confirmation as a reference standard was used to confirm the position of the tube. Under manual ventilation, by sequentially clamping the tracheal and bronchial limbs of the tube, clinical confirmation was made by auscultation, capnography, visualizing the chest wall expansion, and perceiving the lung compliance in the reservoir bag. Ultrasound confirmation was obtained by visualizing lung sliding, diaphragmatic movements, and the appearance of lung pulse sign. RESULTS: The sensitivity of the clinical method was 84.5%, with a specificity of 41.1%. The positive and negative likelihood ratio was 1.44 and 0.38, respectively. The sensitivity of the ultrasound method was 98.6%, specificity was 52.9%, with a positive likelihood ratio of 2.10 and a negative likelihood ratio of 0.03. Comparisons between the diagnostic performance of the 2 methods were calculated with McNemar's test. There was a significant difference in sensitivity between the ultrasound method and the clinical method (P=.002). Nevertheless, there was no statistically significant difference in specificity between both methods (P=.34). A p value<.01 was considered statistically significant. CONCLUSION: Lung ultrasound was superior to the clinical method in confirming the adequate position of the left double-lumen tube. On the other hand, in confirming the misplacement of the tube, differences between both methods could not be ensured.