Estudio prospectivo, aleatorizado comparativo entre el bloqueo guiado por ultrasonidos de las ramas cutáneas laterales de los nervios intercostales frente a analgesia convencional en cirugía no reconstructiva de mama / Prospective, randomized comparative study of ultrasound-guided blocking of the lateral cutaneous branches of the intercostal nerves versus conventional analgesia in non-reconstructive breast surgery

Objetivo: Nuestro objetivo es evaluar si la realización de un bloqueo interfascial, el bloqueo de las ramas cutáneas de los nervios intercostales en la línea axilar media (BRILMA) asociado a una pauta analgésica multimodal mejora la analgesia postoperatoria y permite ahorrar opioides tras cirugía no reconstructiva de mama. Material y métodos: Realizamos un estudio aleatorizado y prospectivo simple, donde los pacientes fueron sometidos a cirugía no reconstructiva de mama. Los pacientes fueron asignados aleatoriamente al grupo de realización del bloqueo, o al grupo de analgesia postoperatoria estándar (paracetamol y dexketoprofeno). Las variables principales analizadas fueron la intensidad del dolor evaluada mediante la escala numérica verbal y las necesidades de rescate analgésico con tramadol. Resultados: Se observaron diferencias estadísticamente significativas en el consumo de tramadol durante el periodo de estudio (10,5mg en el grupo BRILMA, frente a los 34, 3 en el grupo control, p=0,0001). Asimismo también hubo diferencias en la evaluación del dolor con valores más bajos en el grupo BRILMA. Conclusiones: En cirugía no reconstructiva de mama la realización de un bloqueo BRILMA permite obtener unas puntuaciones de dolor más bajas, lo que implica menor necesidad de rescate y un importante ahorro de tramadol en el periodo

Objective: The objective of this study is to determine whether the accomplishment of an interfascial blockade, the blocking of the cutaneous branches of the intercostal nerves in the axillary line (BRILMA) associated with a multimodal analgesic regimen improves post-operative analgesia and allows saving opioids after non-reconstructive surgery of breast. Material and methods: A prospective, randomised and simple blind study was conducted on patients that underwent non-reconstructive breast surgery. The patients were randomly assigned to the blocking group, or to the standard post-operative analgesia group (paracetamol and dexketoprofen). The main variables analysed were the pain intensity assessed by the verbal numerical scale and the analgesic rescue needs with tramadol. Results: Statistically significant differences were observed in the consumption of tramadol during the study period (10.5mg in the BRILMA group, compared to 34.3 in the control group, P=.0001). There were also differences in the pain assessment, with lower values found in the BRILMA group. Conclusions: In non-reconstructive breast surgery, performing a BRILMA block allows obtaining lower pain scores, which implies less need for rescue analgesics and a significant saving of tramadol in the study period

Prospective, randomized comparative study of ultrasound-guided blocking of the lateral cutaneous branches of the intercostal nerves versus conventional analgesia in non-reconstructive breast surgery. / Estudio prospectivo, aleatorizado comparativo entre el bloqueo guiado por ultrasonidos de las ramas cutáneas laterales de los nervios intercostales frente a analgesia convencional en cirugía no reconstructiva de mama.

OBJECTIVE: The objective of this study is to determine whether the accomplishment of an interfascial blockade, the blocking of the cutaneous branches of the intercostal nerves in the axillary line (BRILMA) associated with a multimodal analgesic regimen improves post-operative analgesia and allows saving opioids after non-reconstructive surgery of breast. MATERIAL AND METHODS: A prospective, randomised and simple blind study was conducted on patients that underwent non-reconstructive breast surgery. The patients were randomly assigned to the blocking group, or to the standard post-operative analgesia group (paracetamol and dexketoprofen). The main variables analysed were the pain intensity assessed by the verbal numerical scale and the analgesic rescue needs with tramadol. RESULTS: Statistically significant differences were observed in the consumption of tramadol during the study period (10.5mg in the BRILMA group, compared to 34.3 in the control group, P=.0001). There were also differences in the pain assessment, with lower values found in the BRILMA group. CONCLUSIONS: In non-reconstructive breast surgery, performing a BRILMA block allows obtaining lower pain scores, which implies less need for rescue analgesics and a significant saving of tramadol in the study period.

Disminución idiopática del índice biespectral durante la educción anestésica: posibles causas del fenómeno delta paradójico / Idiopathic decreased bispectral index during anaesthesia emergence: possible causes for the phenomenon of paradoxical arousal

En un pequeño porcentaje de pacientes, la estimulación sonora, táctil e incluso nociceptiva en presencia de una ligera profundidad anestésica no provoca la aparición de ondas cerebrales propias de la activación cerebral (ondas α, β), sino que desencadena un enlentecimiento del trazado de las ondas del electroencefalograma. Presentamos el caso de una paciente en la que se registra una actividad cerebral muy enlentecida en el electroencefalograma procesado del monitor del índice biespectral, así como una disminución del valor algorítmico, que dura aproximadamente 5min en el momento de la educción anestésica, coincidiendo con la estimulación sonora y táctil, que tras mantenerla en observación durante 24h en el postoperatorio, no coincide con ningún trastorno a nivel cerebral que lo pueda justificar (AU)

In a small percentage of patients, sound, touch and even nociceptive stimulation in the presence of a light anaesthetic depth does not cause an electroencephalogram wave pattern of cortical activation (α, β waves) as would be expected, but leads to a slowed electroencephalogram pattern instead. We report the case of a patient who on emerging from anaesthesia showed very slowed brain activity on the electroencephalogram and reduced algorithmic value, that lasted approximately 5min coinciding with sound and tactile stimulation. After keeping her under observation for 24h during the postoperative period she did not present any brain disorder that could justify that event (AU)

Cuidados Intensivos de Anestesia: recomendaciones de la Sección de Cuidados Intensivos de la Sociedad Española de Anestesiología / Intensive Care of Anaesthesia: recommendations of the Intensive Care Section of the Spanish Society of Anaesthesiology

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Idiopathic decreased bispectral index during anaesthesia emergence: Possible causes for the phenomenon of paradoxical arousal. / Disminución idiopática del índice biespectral durante la educción anestésica: posibles causas del fenómeno delta paradójico.

In a small percentage of patients, sound, touch and even nociceptive stimulation in the presence of a light anaesthetic depth does not cause an electroencephalogram wave pattern of cortical activation (α, ß waves) as would be expected, but leads to a slowed electroencephalogram pattern instead. We report the case of a patient who on emerging from anaesthesia showed very slowed brain activity on the electroencephalogram and reduced algorithmic value, that lasted approximately 5min coinciding with sound and tactile stimulation. After keeping her under observation for 24h during the postoperative period she did not present any brain disorder that could justify that event.

Pancreatitis aguda en la unidad de cuidados intensivos secundaria a tratamiento con tigeciclina / Acute pancreatitis in ICU secondary to treatment with tigecycline

La tigeciclina es un antibiótico de amplio espectro estructuralmente similar a la minociclina y que comparte algunos de los efectos adversos de las tetraciclinas. Presentamos el caso de una mujer de 68 años que se trató con tigeciclina por una sepsis de origen desconocido y desarrolló al 5° día de tratamiento un cuadro sugerente de pancreatitis aguda con dolor abdominal junto con elevación de enzimas pancreáticas. Tras descartar diferentes etiologías y basándonos en la escala de Naranjo para la probabilidad de reacciones adversas a fármacos, la tigeciclina fue la causa probable de la pancreatitis aguda, complicación de la cual ha habido 5 comunicaciones en la base de datos del sistema español de farmacovigilancia desde 2009. Se recomienda una vigilancia estrecha de signos y síntomas abdominales durante el uso de tigeciclina, ya que los efectos adversos en el aparato digestivo son los más prevalentes con este fármaco (AU)

Tigecycline is a broad spectrum antimicrobial agent, structurally similar to minocycline and that shares some tetracycline-related side effects. A case report is presented on a 68-year-old female who received tigecycline for a sepsis of unknown origin and who, in the following 5 days, developed abdominal pain and elevated pancreatic enzymes, which suggested acute pancreatitis. After ruling out other origins, and according to the Naranjo adverse drug reaction probability scale, tigecycline was the probable cause of the acute pancreatitis, a complication that has been reported 5 times in the database of the Spanish pharmacosurveillance system since 2009. Close monitoring of abdominal signs and symptoms is recommended during treatment with tigecycline, since adverse effects affecting the digestive system are the most prevalent ones when using this drug (AU)

Acute pancreatitis in ICU secondary to treatment with tigecycline. / Pancreatitis aguda en la unidad de cuidados intensivos secundaria a tratamiento con tigeciclina.

Tigecycline is a broad spectrum antimicrobial agent, structurally similar to minocycline and that shares some tetracycline-related side effects. A case report is presented on a 68-year-old female who received tigecycline for a sepsis of unknown origin and who, in the following 5days, developed abdominal pain and elevated pancreatic enzymes, which suggested acute pancreatitis. After ruling out other origins, and according to the Naranjo adverse drug reaction probability scale, tigecycline was the probable cause of the acute pancreatitis, a complication that has been reported 5 times in the database of the Spanish pharmacosurveillance system since 2009. Close monitoring of abdominal signs and symptoms is recommended during treatment with tigecycline, since adverse effects affecting the digestive system are the most prevalent ones when using this drug.

Assessment of acid-base balance. Stewart's approach.

The study of acid-base equilibrium, its regulation and its interpretation have been a source of debate since the beginning of 20th century. Most accepted and commonly used analyses are based on pH, a notion first introduced by Sorensen in 1909, and on the Henderson-Hasselbalch equation (1916). Since then new concepts have been development in order to complete and make easier the understanding of acid-base disorders. In the early 1980's Peter Stewart brought the traditional interpretation of acid-base disturbances into question and proposed a new method. This innovative approach seems more suitable for studying acid-base abnormalities in critically ill patients. The aim of this paper is to update acid-base concepts, methods, limitations and applications.

Los anestesiólogos somos los garantes de la seguridad y calidad en las salas de endoscopia / Anesthesiologists are the guarantors of security and quality in endoscopy rooms

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Síndrome de distrés respiratorio agudo: revisión a propósito de la definición de Berlín / Acute respiratory distress syndrome: A review of the Berlin definition

El síndrome de distrés respiratorio agudo (SDRA) constituye una entidad de etiología muy diversa. La ausencia de definición universal se ha traducido en una serie de problemas a la hora de realizar un diagnóstico exhaustivo. Por ello, en los estudios publicados hasta el momento, la incidencia del SDRA y lesión pulmonar aguda (LPA) presentan cifras muy variables. La definición de la Conferencia Americana-Europea de Consenso se ha aplicado desde su publicación en 1994 después de 18 años, la Sociedad Europea de Medicina Intensiva convocó en 2011 a un equipo internacional de expertos en Berlín, para revisar la definición de SDRA. El objetivo de la definición de Berlín no es emplearla como pronóstico, sino mejorar la coherencia entre la investigación y la práctica clínica (AU)

Acute Respiratory Distress Syndrome (ARDS) is due to many causes. The absence of a universal definition up until now has led to a series of practical problems for a definitive diagnosis. The incidences of ARDS and Acute Lung Injury (ALI) vary widely in the current literature. The American-European Consensus Conference definition has been applied since its publication in 1994 and has helped to improve knowledge about ARDS. However, 18 years later, in 2011, the European Intensive Medicine Society, requested a team of international experts to meet in Berlin to review the ARDS definition. The purpose of the Berlin definition is not to use it as a prognostic tool, but to improve coherence between research and clinical practice

[Acute respiratory distress syndrome: a review of the Berlin definition]. / Síndrome de distrés respiratorio agudo: revisión a propósito de la definición de Berlín.

Acute Respiratory Distress Syndrome (ARDS) is due to many causes. The absence of a universal definition up until now has led to a series of practical problems for a definitive diagnosis. The incidences of ARDS and Acute Lung Injury (ALI) vary widely in the current literature. The American-European Consensus Conference definition has been applied since its publication in 1994 and has helped to improve knowledge about ARDS. However, 18 years later, in 2011, the European Intensive Medicine Society, requested a team of international experts to meet in Berlin to review the ARDS definition. The purpose of the Berlin definition is not to use it as a prognostic tool, but to improve coherence between research and clinical practice.

El síndrome de Guillain Barré en la unidad de cuidados críticos en los últimos 10 años / Guillain-Barré syndrome in the critical care unit in the last 10 years

Objetivos. El síndrome de Guillain Barré (SGB) es una polirradiculoneuropatía inflamatoria aguda que constituye una proporción importante de los casos de parálisis flácida aguda. Nuestro objetivo es presentar las características clínicas de los pacientes con diagnóstico de este síndrome que requirieron ingreso en la unidad de cuidados críticos. Métodos. Estudio retrospectivo de los pacientes con SGB que fueron admitidos en la unidad de cuidados críticos de un hospital terciario durante un periodo de 10 años. Se estudia la proporción de pacientes que requirieron ventilación mecánica invasiva (VMI) y las complicaciones asociadas. Se analizan características clínicas que implican mayor severidad de la enfermedad y una recuperación funcional peor. Resultados. La VMI fue necesaria en el 58,8% de los pacientes (duración media de 29,8 días). A 9 se les realizó traqueostomía. Se observaron complicaciones respiratorias en todos los casos que precisaron VMI (50% traqueobronquitis y 50% neumonía asociada a ventilación mecánica). La VMI se asoció a complicaciones respiratorias (p=0,001) y estas a su vez a la aparición de sepsis (p=0,006). Falleció un paciente (5,88%). No se observó asociación entre edad avanzada, necesidad de VMI, presencia de comorbilidad, sepsis o complicaciones hemodinámicas con la mortalidad del SGB. Conclusiones. Las complicaciones respiratorias, la sepsis y en menor medida la disfunción autonómica y el tromboembolismo pulmonar son las principales causas de muerte en estos pacientes, por lo que su prevención, detección y manejo son fundamentales(AU)

Objectives. The Guillain-Barré syndrome (GBS) is an acute inflammatory polyradiculoneuropathy, which constitutes an important proportion of acute flaccid paralysis cases. Our objective was to present the clinical characteristics of patients with the GBS who required admission to a critical care unit. Methods. A retrospective study over a period of ten years was conducted on patients with GBS, who were admitted to the critical care unit in a tertiary hospital. The proportion of patients requiring connection to mechanical ventilation (MV) and associated complications was analysed, along with certain clinical features which implied a more severe illness and worse functional recovery. Results. MV was required in 58.8% of cases (mean duration 29.8 days). Nine patients received tracheostomy. Pulmonary complications were observed in all patients that needed MV (50% tracheobronchitis and 50% ventilator-associated pneumonia). MV is associated with pulmonary complications (P=.001) and those, in turn, to the development of sepsis (P=.006). Only one patient died (5.88%). No relationship was found between advanced age, MV, comorbidity, sepsis, or hemodynamic complications and the mortality of GBS. Conclusions. Death in these patients results from pulmonary complications, sepsis and less frequently due to autonomic dysfunction or pulmonary embolism. Emphasising the importance of their prevention, detection and management(AU)

[Guillain-Barré syndrome in the critical care unit in the last 10 years]. / El síndrome de Guillain Barré en la unidad de cuidados críticos en los últimos 10 años.

OBJECTIVES: The Guillain-Barré syndrome (GBS) is an acute inflammatory polyradiculoneuropathy, which constitutes an important proportion of acute flaccid paralysis cases. Our objective was to present the clinical characteristics of patients with the GBS who required admission to a critical care unit. METHODS: A retrospective study over a period of ten years was conducted on patients with GBS, who were admitted to the critical care unit in a tertiary hospital. The proportion of patients requiring connection to mechanical ventilation (MV) and associated complications was analysed, along with certain clinical features which implied a more severe illness and worse functional recovery. RESULTS: MV was required in 58.8% of cases (mean duration 29.8 days). Nine patients received tracheostomy. Pulmonary complications were observed in all patients that needed MV (50% tracheobronchitis and 50% ventilator-associated pneumonia). MV is associated with pulmonary complications (P=.001) and those, in turn, to the development of sepsis (P=.006). Only one patient died (5.88%). No relationship was found between advanced age, MV, comorbidity, sepsis, or hemodynamic complications and the mortality of GBS. CONCLUSIONS: Death in these patients results from pulmonary complications, sepsis and less frequently due to autonomic dysfunction or pulmonary embolism. Emphasising the importance of their prevention, detection and management.

Hipotermia grave accidental con onda J de Osborn en el electrocardiograma / Severe accidental hypothermia with an Osborn J wave on the electrocardiogram

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Síndrome de Guillain-Barré (variante Miller-Fisher) en la Unidad de Reanimación / No disponible

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