[Chronic postoperative pain after general anesthesia with or without a single-dose preincisional paravertebral nerve block in radical breast cancer surgery]. / Comparación entre anestesia general con o sin bloqueo paravertebral preincisional con dosis única y dolor crónico postquirúrgico, en cirugía radical de cáncer de mama.

BACKGROUND AND OBJECTIVE: Over 50% of patients still experience pain a year after mastectomy with or without lymphadenectomy. We aimed to determine the association between anesthetic technique, acute postoperative pain intensity, and the development of chronic postoperative pain. PATIENTS AND METHODS: Forty patients were randomly assigned to receive general anesthesia with or without a paravertebral nerve block for modified radical mastectomy. Postoperative pain was assessed on a visual analog scale at 60 minutes and 24 hours; the patients were also asked to respond to a telephone questionnaire on chronic pain 4 to 5 months later. RESULTS: No significant differences in acute pain were observed. Twenty-nine responded to the telephone questionnaire. Only 1 patient in the paravertebral block group reported chronic neuropathic pain and none had phantom breast pain. Only 1 patient (6.7%) in the paravertebral block group reported chronic neuropathic pain and none had phantom breast pain. In the group that received general anesthesia alone, 1 patient reported phantom breast pain and 6 patients had neuropathic pain, associated with phantom breast pain in 2 cases (incidence of chronic pain 50%; P = .01, Fischer exact test; relative risk, 7.5, 95% confidence interval, 1.0-53.5). The incidences of myofascial pain (neck muscle tightness) were similar in the 2 groups. CONCLUSIONS: Four to 5 months after mastectomy, fewer cases of chronic pain developed in the group operated under general anesthesia with a preincisional paravertebral block than in the group that received only general anesthesia, with postoperative morphine chloride for analgesia.

Comparación entre anestesia general con o sin bloqueo paravertebral preincisional con dosis única y dolor crónico postquirúrgico, en cirugía radical de cáncer de mama / Chronic postoperative pain after general anesthesia with or without a singledose preincisional paravertebral nerve block in radical breast cancer surgery

Objetivo: En la cirugía del cáncer de mama, en más del 50% de las pacientes con mastectomía y/o linfadenectomía persiste el dolor en el primer año. Nuestro objetivo fue determinar la asociación entre la técnica anestésica, la intensidad del dolor agudo postquirúrgico y el desarrollo del dolor crónico postquirúrgico. Pacientes y métodos: Cuarenta pacientes fueron asignadas aleatoriamente a recibir anestesia general o anestesia general con bloqueo paravertebral para mastectomía radical modificada. Se midió el dolor mediante escala visual analógica a los 60 minutos, a las 24 horas y a los 4-5 meses se realizó encuesta de dolor crónico postquirúrgico. Resultados: No hubo diferencias significativas respecto al dolor agudo. Veintinueve pacientes contestaron a la encuesta telefónica. En el grupo del bloqueo paravertebral sólo hubo un caso de dolor neuropático y ninguno de miembro fantasma mientras que en el grupo de anestesia general hubo 7 casos de dolor neuropático asociados a 3 casos de miembro fantasma [6,7% frente a 50%; test exacto de Fischer, p = 0,01, con un RR de 7,5 (IC95% 1,0-53,5)]. Hubo dolor miofascial (contracturas en cuello) en ambos grupos sin diferencias significativas. Conclusiones: A los 4-5 meses de la cirugía la anestesia general con bloqueo paravertebral preincisional presenta menos casos de dolor crónico que sí se utiliza anestesia general y analgesia con cloruro mórfico(AU)

Background and objective: Over 50% of patients still experience pain a year after mastectomy with or without lymphadenectomy. We aimed to determine the association between anesthetic technique, acute postoperative pain intensity, and the development of chronic postoperative pain. Patients and methods: Forty patients were randomly assigned to receive general anesthesia with or without a paravertebral nerve block for modified radical mastectomy. Postoperative pain was assessed on a visual analog scale at 60 minutes and 24 hours; the patients were also asked to respond to a telephone questionnaire on chronic pain 4 to 5 months later. Results: No significant differences in acute pain were observed. Twenty-nine responded to the telephone questionnaire. Only 1 patient in the paravertebral block group reported chronic neuropathic pain and none had phantom breast pain. Only 1 patient (6.7%) in the paravertebral block group reported chronic neuropathic pain and none had phantom breast pain. In the group that received general anesthesia alone, 1 patient reported phantom breast pain and 6 patients had neuropathic pain, associated with phantom breast pain in 2 cases (incidence of chronic pain 50%; P = .01, Fischer exact test; relative risk, 7.5, 95% confidence interval, 1.0-53.5). The incidences of myofascial pain (neck muscle tightness) were similar in the 2 groups. Conclusions: Four to 5 months after mastectomy, fewer cases of chronic pain developed in the group operated under general anesthesia with a preincisional paravertebral block than in the group that received only general anesthesia, with postoperative morphine chloride for analgesia(AU)

[Pulmonary torsion complicating lobectomy: report of 2 cases]. / Torsión pulmonar como complicación de una lobectomía pulmonar, descripción de dos casos.

We report 2 cases of pulmonary torsion discovered during the early postoperative recovery of patients who had undergone lobectomy. Early diagnosis, based on chest radiography and confirmed by computed tomography, meant we were able to avoid major surgical resection and the development of further complications. Pulmonary torsion is a rare but potentially serious abnormality. Prompt diagnosis is the key to preventing tissue injury and complications such as necrotizing pneumonitis, thromboembolic disease, or septic shock. Among the diagnostic tests that can be carried out if there is good reason to suspect torsion, we emphasize simple chest radiography and fiberoptic bronchoscopy, supported by computed tomography or arteriography, even though a firm diagnosis requires surgical exploration of the affected lung. Definitive treatments range from reversing the torsion and securing the lung to resecting the lung if the parenchymal tissue has been fully compromised.

Torsión pulmonar como complicación de una lobectomía pulmonar, descripción de dos casos / Pulmonary torsion complicating lobectomy: report of 2 cases

Descripción de dos casos de torsión pulmonar enpacientes intervenidos de lobectomía por neoplasia pulmonar.Se muestran dos pacientes que sufrieron complicaciónde torsión de lóbulo pulmonar tras realizarselobectomía pulmonar aparecida en el postoperatorioinmediato. Se realizó el diagnóstico precoz mediante unaradiografía del tórax y la confirmación mediante unTAC, que indicó la toracotomía la cual evitó mayorresección quirúrgica y aparición de otras complicaciones.La torsión pulmonar es una alteración infrecuentepero de potencial gravedad. El diagnóstico precoz es devital importancia para evitar el compromiso tisular yprevenir complicaciones como neumonitis necrotizante,enfermedad tromboembólica o shock séptico. Entre laspruebas diagnósticas que pueden llevar a la alta sospechadiagnóstica destacamos la radiología simple de tóraxy fibrobroncoscopia, apoyadas por la tomografía axial ola arteriografía, aunque el diagnóstico definitivo es laexploración quirúrgica del parénquima afecto. El tratamientodefinitivo abarca desde la simple detorsión y fijacióndel pulmón, hasta resección pulmonar o neumonectomíasi el compromiso tisular es completo(AU)

We report 2 cases of pulmonary torsion discoveredduring the early postoperative recovery of patients whohad undergone lobectomy. Early diagnosis, based onchest radiography and confirmed by computedtomography, meant we were able to avoid major surgicalresection and the development of further complications.Pulmonary torsion is a rare but potentially seriousabnormality. Prompt diagnosis is the key to preventingtissue injury and complications such as necrotizingpneumonitis, thromboembolic disease, or septic shock.Among the diagnostic tests that can be carried out ifthere is good reason to suspect torsion, we emphasizesimple chest radiography and fiberoptic bronchoscopy,supported by computed tomography or arteriography,even though a firm diagnosis requires surgicalexploration of the affected lung. Definitive treatmentsrange from reversing the torsion and securing the lungto resecting the lung if the parenchymal tissue has beenfully compromised(AU)

[Intracranial hypotension syndrome treated with an epidural blood patch]. / Síndrome de hipotensión intracraneal espontánea tratada con parche hemático epidural.

A 41-year-old woman was admitted to the internal medicine department to assess incapacitating postural headache. Clinical findings suggested the need for computed tomography and nuclear magnetic resonance scanning of the head, which led to a diagnosis of spontaneous intracranial hypotension syndrome. Later, isotopic cysternography and nuclear magnetic resonance imaging of the spine were used unsuccessfully to try to locate the cerebrospinal fluid leak that caused the syndrome. When conservative treatment proved ineffective, the pain clinic was called in to perform an epidural blood patch procedure. The patch led to an improvement in symptoms and the syndrome resolved completely after a second lumbar blood patch was used.

Síndrome de hipotensión intracraneal espontánea tratada con parche hemático epidural / Intracranial hypotension syndrome treated with an epidural blood patch

Paciente mujer de 41 años que ingresó en el servicio de Medicina Interna para estudio de cefalea postural invalidante. Ante los hallazgos clínicos se le realizó una tomografía axial computerizada y resonancia magnética nuclear craneales llegando al diagnóstico de síndrome de hipotensión intracraneal espontáneo. Posteriormente se intentó localizar el punto de fuga de líquido cefalorraquídeo causante del síndrome mediante cisternografía isotópica y resonancia magnética nuclear de columna sin éxito. El tratamiento conservador resultó ineficaz y se solicitó la colaboración de la unidad de dolor para la realización de un parche hemático epidural. La aplicación de un parche epidural a nivel dorsal mejoró los síntomas, que se resolvieron definitivamente tras un segundo parche a nivel lumbar

A 41-year-old woman was admitted to the internal medicine department to assess incapacitating postural headache. Clinical findings suggested the need for computed tomography and nuclear magnetic resonance scanning of the head, which led to a diagnosis of spontaneous intracranial hypotension syndrome. Later, isotopic cysternography and nuclear magnetic resonance imaging of the spine were used unsuccessfully to try to locate the cerebrospinal fluid leak that caused the syndrome. When conservative treatment proved ineffective, the pain clinic was called in to perform an epidural blood patch procedure. The patch led to an improvement symptoms and the syndrome resolved completely after a second lumbar blood patch was used

[PiCCO monitoring of 4 critically ill patients]. / Utilización del monitor PiCCO en cuatro pacientes en estado crítico.

The PiCCO physiological monitor (Pulsion Medical Systems, Munich, Germany) was used for hemodynamic diagnosis and monitoring of 4 patients: a polytraumatized female patient with septic shock and ventilator-associated pneumonia; a man with congestive heart failure and cor pulmonale who developed acute heart failure while recovering from anterior resection of the rectum; a man with severe head injury and acute respiratory distress syndrome; and a polytraumatized male patient with a myocardial contusion. All were in a life-threatening situation, either immediately as in the case of the patient with myocardial contusion or eventually as in the patient with septic shock. The PiCCO monitor recorded hemodynamic parameters satisfactorily, facilitating adjustments to optimize treatment. The risks and complications of the usual method of monitoring by Swan-Ganz catheter are well-known. New less invasive monitoring systems designed to record parameters similar to those detected by the Swan-Ganz catheter but with fewer complications and risks have become available. One example, the PiCCO monitor, combines arterial thermodilution with analysis of the pulse waveform, providing a series of hemodynamic parameters useful for managing the critically ill patient.

Utilización del monitor PiCCO® en cuatro pacientes en estado crítico / PiCCO monitoring of 4 critically ill patients

En cuatro pacientes se empleó el monitor de PiCCO como método de diagnóstico y de monitorización hemodinámica: una paciente politraumatizada con shock séptico y neumonía asociada a ventilación mecánica; un paciente con insuficiencia cardiaca congestiva y cor pulmonale que en el postoperatorio de una resección anterior de recto presentó un cuadro de insuficiencia cardiaca aguda; un paciente con síndrome de distrés respiratorio agudo en el contexto de un traumatismo craneoencefálico grave y un paciente politraumatizado con una contusión miocárdica. En todos los pacientes había un denominador común, una situación clínica que amenazaba su vida, bien de forma inmediata como en la contusión miocárdica o más tardíamente como el shock séptico. En estos pacientes el monitor de PiCCO proporcionó una monitorización hemodinámica adecuada que facilitó ajustar el tratamiento idóneo. El método de monitorización hemodinámica más conocido y utilizado es el catéter de Swan-Ganz siendo bien conocidos sus riesgos y complicaciones. Han aparecido nuevos sistemas de monitorización que buscan obtener parámetros similares a los obtenidos por el catéter de Swan-Ganz, pero con menos invasividad, menos riesgos y complicaciones para los pacientes. Uno de estos es el monitor de PiCCO® (Pulsion Medical Systems, Munich, Alemania) que combinando la termodilución arterial con el análisis del contorno de la onda de pulso permite la obtención de una serie de parámetros hemodinámicos útiles en el tratamiento del enfermo crítico (AU)