Combination of thoracic blocks as a main anesthetic tecnique in modified radical mastectomy for patients with severe respiratory disease. / Combinación de bloqueos torácicos como método anestésico principal en mastectomía radical modificada para pacientes con compromiso respiratorio severo.

The addition of ultrasound to locoregional anaesthesia in the last few years has led to the description of various fascial thoracic blocks with analgesic purposes: PECS 1 and 2 block, serratus plane block, serratus intercostal fascial block, blockade in the plane of the thoracic transverse muscle..., which have been added to other well-known nerve blocks, such as thoracic paravertebral block or intercostal block. In this sense, locoregional anaesthesia has been universally recommended in patients with severe respiratory processes in order to avoid ventilatory support and subsequent weaning that considerably increases postoperative morbidity and mortality rates. However, as regards thoracic wall and axillary hollow, there are very few references which detail the use of nerve or fascial blocks as a main anaesthetic method. Two extreme cases are presented of multi-pathological patients with serious respiratory disease who successfully underwent a modified radical mastectomy plus surgery in the axillary space using a combination of ultrasound-guided thoracic blocks that allowed surgery without general anaesthesia, avoiding mechanical ventilation, and maintaining spontaneous breathing throughout the surgical procedure. The main indications of the anaesthetic blocks used are described, focusing on the performance of the technique and underlining, in a novel way, the possibility of facing aggressive surgery at the level of the armpit with only locoregional anaesthesia.

Intubación de obesos mórbidos despiertos con Airtraq® / No disponible

La obesidad en un paciente hace que la técnica anestésica sea más difícil y peligrosa. Una de las dificultades que más complicaciones puede ocasionar es la intubación endotraqueal. El objetivo principal de este trabajo es describir nuestra experiencia en el manejo de vía aérea difícil de pacientes mórbidos despiertos mediante el uso de Airtraq®. Estudio prospectivo y observacional con pacientes obesos mórbidos programados para cirugía bariátrica y con criterios de vía aérea difícil, a los que se les practicó intubación endotraqueal con Airtraq® despiertos. Se recogieron datos de constantes vitales, tiempo de realización de la técnica y grado de satisfacción. Todos los pacientes fueron intubados con éxito salvo uno. En ninguno hubo grandes variaciones de los parámetros hemodinámicos ni complicación alguna, siendo mantenidos en un grado II/III en la escala de sedación Ramsay. Todos los pacientes informaron de manera positiva la técnica de intubación. La intubación con Airtraq® en obesos mórbidos despiertos parece ser una alternativa totalmente válida para asegurar la vía aérea (AU)

Obesity makes anesthetic technique more difficult and dangerous. One of the difficulties that can cause further complications is endotracheal intubation. The main objective of this paper is to describe our experience in handling difficult airway in awake morbidly patients using Airtraq®. Prospective and observational study with morbidly obese patients scheduled for bariatric surgery and difficult airway criteria, who underwent endotracheal intubation with Airtraq ® awake. Data were collected from vital signs, time of performance of the technique and level of satisfaction. All patients were successfully intubated except one. None showed large variations in hemodynamic parameters or any complications, being held in a grade II / III in Ramsay scale of sedation. All patients reported positively intubation technique. Intubation with Airtraq® in morbid obese awake patients seems to be a totally valid to secure the airway (AU)

Manejo perioperatorio de la hernia diafragmática congénita derecha / No disponible

Presentamos el manejo perioperatorio de una RN prematura con HDCD (diagnosticada mediante ecografía en la semana 22) y la posible asociación con el Síndrome de Frías. La Hernia Diafragmática Congénita es una malformación con una incidencia muy baja y generalmente localizada en el lado izquierdo. Pertenece al grupo de las disgenesias diafragmáticas congénitas y se caracteriza por una hipoplasia pulmonar que se define como anatómica y funcional. Una vez conseguida la estabilización del paciente, y nunca antes, el tratamiento definitivo es la corrección quirúrgica, que hoy en día ya no es considerado como una emergencia, teniendo que ser diferido el tiempo necesario para lograr la estabilización hemodinámica y gasométrica del paciente. El grado de hipoplasia pulmonar, la persistencia de hipertensión pulmonar y el grado de prematuridad son los principales factores pronósticos de estos casos, empeorando la supervivencia aquellos pacientes en los que se asocian otras alteraciones cromosómicas (AU)

We present the perioperative management of a premature newborn with HDCD (diagnosed by ultrasound at week 22) and the possible association with Frias Syndrome. Congenital diaphragmatic hernia is a malformation with a very low incidence and generally located on the left side. It belongs to the group of congenital diaphragmatic dysgenesis and it is characterized by pulmonary hypoplasia defined as anatomical and funcional. Once achieved patient stabilization, and never before it, definitive treatment is surgical correction, which today is not considered an emergency and had to be delayed long enough to achieve hemodynamic stabilization of the patient and blood gases. The degree of pulmonary hypoplasia, persistent pulmonary hypertension and the degree of prematurity are major predictors of these cases, worse survival in those patients who associate other chromosomal abnormalities (AU)

Miedos a la anestesia / Fears of anesthesia

Objetivo: Un paso lógico para proveer al paciente de una mejor asistencia sanitaria supone determinar qué aspectos de los cuidados médicos son a los que el paciente confiere una mayor importancia y en base a ello programar nuestra técnica anestésica y cuidados postoperatorios. El objetivo de nuestro estudio fue evaluar los principales efectos indeseables relacionados con la anestesia. Material y método: El estudio se efectúo en el Hospital Universitario Central de Asturias entre los meses de octubre y diciembre de 2010. El cuestionario fue entregado a una muestra poblacional mayor de 18 años de edad, de ambos sexos, que había sido programada para una intervención quirúrgica electiva bajo anestesia general o locorregional. Resultados: El cuestionario fue distribuido a 101 pacientes programados para cirugía, sin existencia de diferencia estadísticamente significativa entre hombres y mujeres. Entre los pacientes sometidos al cuestionario, el 37,2% consideraron "despertar respirando por un tubo" después de la intervención quirúrgica, como el efecto anestésico más indeseable, seguido de "dolor en el lugar de la intervención quirúrgica" y "despertar intraoperatorio". Conclusiones: La principal preocupación de los pacientes en relación al periodo postanestésico resultó ser despertarse con un tubo en la garganta. El intercambio de información establecido entre el anestesiólogo y el paciente en la visita preanestésica juega un papel fundamental. La edad, una experiencia quirúrgica previa, o la situación laboral del paciente no definieron diferencias en la preocupación de los pacientes(AU)

No disponible

[Management of peri-operative hypothermia]. / Manejo de la hipotermia perioperatoria.

Hypothermia (body temperature under 36°C) is the thermal disorder most frequently found in surgical patients, but should be avoided as a means of reducing morbidity and costs. Temperature should be considered as a vital sign and all staff involved in the care of surgical patients must be aware that it has to be maintained within normal limits. Maintaining body temperature is the result, as in any other system, of the balance between heat production and heat loss. Temperature regulation takes place through a system of positive and negative feedback in the central nervous system, being developed in three phases: thermal afferent, central regulation and efferent response. Prevention is the best way to ensure a normal temperature. The active warming of the patient during surgery is mandatory. Using warm air is the most effective, simple and cheap way to prevent and treat hypothermia.

[Thoracic paravertebral block compared to thoracic paravertebral block plus pectoral nerve block in reconstructive breast surgery]. / Bloqueo paravertebral torácico frente al bloqueopararavertebral torácico más bloqueo de nervios pectoralesen cirugía reconstructiva de mama.

INTRODUCTION: Major breast surgery was usually performed under general anaesthesia until the first patient series with thoracic paravertebral block was published. This block was introduced into our Hospital, and with the purpose of obtaining a more comfortable perioperative period, it was combined with blocking the pectoral nerves. In this study, both anaesthetic techniques are compared, as regards control of postoperative pain, incidence of postoperative nausea and vomiting, and sedation requirements. MATERIAL AND METHODS: An observational study was conducted with 60 patients scheduled for breast surgery with subpectoral implants (augmentation and /or prosthesis). Two groups were studied. The first (Group I) was randomly selected from a patient records data base to have thoracic paravertebral block and sedation. In the second (Group II), a pectoral nerve block was performed combined with a thoracic paravertebral block. RESULTS: In Group I, 33.3% of the patients had a score of ≤ 3 on the visual analogue scale (VAS) at 8 hours, and 66.7% had a VAS score of ≥ 4 at 24h, compared to 80% of the Group II patients who had a VAS score of ≤ 3 at 8 hours and 20% with a VAS score ≥ 4 at 24h. The mean difference in the VAS scores at 8 hours between the two groups was statistically significant: mean VAS score at 8 hours in Group I, 4.23 ± 2.4 compared to 1.77 ± 2.2 in Group II. There was no difference in the VAS scores at 24 hours. No statistically significant differences were found between the two groups in the incidence of postoperative nausea and vomiting. The need for intra-operative sedation supplements with propofol boluses was less in Group II, 40% compared to 90% in Group II. CONCLUSIONS: Pectoral nerve block is a technique that improves the results obtained with thoracic paravertebral block in reconstructive breast surgery, with better post-operative analgesic control in the immediate post-operative period and a lower requirement for sedation.

Bloqueo paravertebral torácico frente al bloqueo pararavertebral torácico más bloqueo de nervios pectorales en cirugía reconstructiva de mama / Thoracic paravertebral block compared to thoracic paravertebral block plus pectoral nerve block in reconstructive breast surgery

Introducción: La cirugía mayor de la mama se realizaba habitualmente con anestesia general hasta que aparecieron las primeras series publicadas con bloqueos paravertebrales torácicos. En nuestro centro hospitalario se introdujo este bloqueo con el objetivo de obtener un mayor confort perioperatorio, posteriormente se asoció el bloqueo de los nervios pectorales. En este trabajo comparamos ambas técnicas anestésicas, en cuanto a control del dolor postoperatorio, incidencia de náuseas y vómitos postoperatorios y requerimientos de sedación. Material y métodos: Se realizó un estudio observacional con 60 pacientes programadas para cirugía de mama con sustitución de dispositivos subpectorales (expansores y/o prótesis). Se estudiaron dos grupos. El primero (grupo I) fue seleccionado aleatoriamente de una base de datos histórica de pacientes a las que se practicó bloqueo paravertebral torácico y sedación. En el segundo (grupo II) se realizó prospectivamente un bloqueo de nervios pectorales asociado al bloqueo paravertebral torácico. Resultados: En el grupo I, el 33,3% tuvo un valor <= 3 en la escala visual analógica (EVA) a las 8 h y el 66,7%, un valor en la EVA >= 4 a las 24 h, frente al 80% de pacientes del grupo II que tuvieron un valor <= 3 en la EVA a las 8 h y el 20%, un valor en la EVA >= 4 a las 24 h. La diferencia de medias en la puntuación EVA a las 8 h entre los dos grupos alcanza la significación estadística: media en el valor de la EVA a las 8 h en el grupo I de 4,23 +/- 2,4 frente a 1,77 +/- 2,2 en el grupo II. No hubo diferencia en el valor de la EVA a las 24 h. No encontramos diferencias estadísticamente significativas entre ambos grupos en la incidencis de náuseas y vómitos postoperatoiros. La necesidad de suplementación de sedación intraoperatoria con bolos de propofol fue menor en el grupo II, el 40 frente al 90% del grupo II. Conclusiones: El bloqueo de los nervios pectorales es una técnica que mejora los resultados obtenidos con el bloqueo paravertebral torácico en la cirugía reconstructiva de la mama, con mejor control de la analgesia postoperatoria inmediata y menor necesidad de sedación(AU)

Introduction: Major breast surgery was usually performed under general anaesthesia until the first patient series with thoracic paravertebral block was published. This block was introduced into our Hospital, and with the purpose of obtaining a more comfortable perioperative period, it was combined with blocking the pectoral nerves. In this study, both anaesthetic techniques are compared, as regards control of postoperative pain, incidence of postoperative nausea and vomiting, and sedation requirements. Material and methods: An observational study was conducted with 60 patients scheduled for breast surgery with subpectoral implants (augmentation and /or prosthesis). Two groups were studied. The first (Group I) was randomly selected from a patient records data base to have thoracic paravertebral block and sedation. In the second (Group II), a pectoral nerve block was performed combined with a thoracic paravertebral block. Results: In Group I, 33.3% of the patients had a score of <= 3 on the visual analogue scale (VAS) at 8 hours, and 66.7% had a VAS score of >= 4 at 24h, compared to 80% of the Group II patients who had a VAS score of <= 3 at 8 hours and 20% with a VAS score >= 4 at 24 h. The mean difference in the VAS scores at 8 hours between the two groups was statistically significant: mean VAS score at 8 hours in Group I, 4.23+/-2.4 compared to 1.77+/-2.2 in Group II. There was no difference in the VAS scores at 24 hours. No statistically significant differences were found between the two groups in the incidence of postoperative nausea and vomiting. The need for intra-operative sedation supplements with propofol boluses was less in Group II, 40% compared to 90% in Group II. Conclusions: Pectoral nerve block is a technique that improves the results obtained with thoracic paravertebral block in reconstructive breast surgery, with better post-operative analgesic control in the immediate post-operative period and a lower requirement for sedation(AU)

[Anesthesia in a patient with Ellis-van Creveld syndrome]. / Tratamiento anestésico de una paciente con síndrome de Ellis-Van Creveld.

Ellis-van Creveld syndrome is a rare type of developmental chondroectodermal dysplasia. We report the case of a 32-year-old woman with this syndrome who was scheduled for cesarean section. She had no related heart defect. A spinal block was attempted but after confirming that no sensory blockade had been achieved, general anesthesia was administered. Both the operation and the anesthetic procedure were without complications. The clinical manifestations of Ellis-van Creveld syndrome are short-limbed dwarfism, postaxial polydactyly, fingernail dysplasia, cleft palate and lips, and heart defects. Diagnosis is based on clinical manifestations and radiography. Treatment involves correction of heart defects and orthopedic problems. Perioperative airway management problems may develop. A preoperative echocardiogram should be done to assess heart function and ascertain anatomical abnormalities. Thoracic deformities may make mechanical ventilation difficult and there is risk of barotrauma. Intraoperative management requires rapid control of the airway and prevention of bronchial aspiration. Vigilance in preventing hemodynamic instability and myocardial depression is essential. Postoperative analgesia must be managed carefully and adverse cardiorespiratory events avoided.

Tratamiento anestésico de una paciente con síndrome de Ellis-Van Creveld / Anesthesia in a patient with Ellis-van Creveld syndrome

INTRODUCCIÓN: El síndrome de Ellis-Van Creveld es una enfermedad rara del desarrollo, perteneciente al grupo de las displasias condroectodérmicas. CASO CLÍNICO: Mujer de 32 años diagnosticada de síndrome de Ellis van Creveld, programada para cesárea. Carecía de patología cardiaca. Se realizó un bloqueo subaracnoideo pero tras la comprobación de que no había bloqueo sensitivo, se decidió anestesia general. Tanto la cesárea como el procedimiento anestésico trascurrieron sin incidencias. DISCUSIÓN: Las manifestaciones clínicas del síndrome de Ellis van Creveld son enanismo con extremidades muy cortas, polidactilia postaxial, tórax pequeño, displasia ungueal, alteraciones de la boca y labios y anomalías cardiacas. El diagnóstico es clínico-radiológico. El tratamiento viene dado por la corrección de las alteraciones cardiacas y el tratamiento ortopédico. La morbilidad perioperatoria puede venir dada por las dificultades en el manejo de la vía aérea. Es necesaria la realización de una ecocardiografía preoperatoria para valorar la función cardiaca y concretar las anormalidades anatómicas. Las anormalidades torácicas también pueden dificultar la ventilación mecánica, incluido el riesgo de barotrauma. El manejo intraoperatorio debe basarse en un rápido control de la vía aérea, con prevención de la broncoaspiración. Debe evitarse la inestabilidad hemodinámica y la depresión miocárdica. En el postoperatorio, es primordial el correcto manejo de la analgesia y la prevención de episodios cardiorrespiratorios desfavorables(AU)

Ellis-van Creveld syndrome is a rare type of developmental chondroectodermal dysplasia. We report the case of a 32-year-old woman with this syndrome who was scheduled for cesarean section. She had no related heart defect. A spinal block was attempted but after confirming that no sensory blockade had been achieved, general anesthesia was administered. Both the operation and the anesthetic procedure were without complications. The clinical manifestations of Ellis-van Creveld syndrome are short-limbed dwarfism, postaxial polydactyly, fingernail dysplasia, cleft palate and lips, and heart defects. Diagnosis is based on clinical manifestations and radiography. Treatment involves correction of heart defects and orthopedic problems. Perioperative airway management problems may develop. A preoperative echocardiogram should be done to assess heart function and ascertain anatomical abnormalities. Thoracic deformities may make mechanical ventilation difficult and there is risk of barotrauma. Intraoperative management requires rapid control of the airway and prevention of bronchial aspiration. Vigilance in preventing hemodynamic instability and myocardial depression is essential. Postoperative analgesia must be managed carefully and adverse cardiorespiratory events avoided(AU)

Luxación cervical C6-C7 / No disponible

No disponible

[Multiple-injection thoracic paravertebral block for reconstructive breast surgery]. / Bloqueo paravertebral torácico con punción múltiple en cirugía reconstructiva de la mama.

OBJECTIVE: To describe the use of multiple-injection thoracic paravertebral blockade, with intravenous sedation, for anesthesia during reconstructive breast surgery. MATERIAL AND METHODS: Descriptive, prospective study in 100 scheduled operations for major reconstructive breast surgery. The paravertebral block was performed by means of 3 injections at the lower edges of the vertebral apophyses at T3-5. We recorded time performing the procedure, latency (time until block onset), dermatomes blocked, degree of effectiveness, conversion to general anesthesia, postoperative complications and pain, and patient satisfaction. RESULTS: Dermatomes T3, T4, and T5 were blocked in 99% of the patients. The block took 7.39 minutes to perform and latency was 7.37 minutes. Postoperative analgesia with anti-inflammatory drugs was adequate for most patients. There were 3 cases of epidural diffusion, 10 patients with hypotension, 12 with postoperative nausea or vomiting, and 3 with symptoms of epidural blockade. Intravascular puncture occurred, without complications, in 3 cases. There were no cases of pneumothorax or intrathecal injection. Ninety-one percent of the patients declared they were satisfied or very satisfied with the technique. CONCLUSIONS: Triple-injection paravertebral blocks, in which 3 fractions of the total anesthetic dose are delivered to block dermatomes T3-5 is an effective technique that is easy to perform and leads to few complications. Most patients express a high degree of satisfaction with this anesthetic technique.

Bloqueo paravertebral torácico con punción múltiple en cirugía reconstructiva de la mama / Multiple-injection thoracic paravertebral block for reconstructive breast surgery

INTRODUCCIÓN: Estudio descriptivo con pacientessometidas a cirugía reconstructiva de la mama con bloqueoparavertebral torácico como única técnica anestésica,asociado a sedación endovenosa.MATERIAL Y MÉTODOS: Estudio descriptivo y prospectivoen 100 pacientes para cirugía mayor reconstructivade la mama. Se realizó el bloqueo paravertebral mediantetriple punción en el extremo inferior de las apófisistransversas T3-4-5. Se midieron: tiempo de realización dela técnica, periodo de latencia hasta la instauración delbloqueo, dermatomas bloqueados, grado de eficacia delbloqueo, reconversión en anestesia general. Tambiéncomplicaciones perioperatorias, el control del dolor postoperatorioy el grado de satisfacción de la paciente.RESULTADOS: En el 99% de las pacientes se bloquearonlos dermatomas T3-4-5. El tiempo de realización de latécnica fue de 7,39 min y el periodo de latencia 7,37 min.El control analgésico postoperatorio con antiinflamatoriosfue adecuado en la mayoría de los pacientes. Hubo3 casos de difusión epidural, 10 casos de hipotensiónarterial, 12 pacientes con náuseas o vómitos en el postoperatorioy 3 casos con clínica de bloqueo epidural.Hubo 3 punciones intravasculares sin repercusión. Noobservamos ningún caso de neumotórax ni de inyecciónintratecal. El 91% de los pacientes declararon sentirsesatisfechos o muy satisfechos con la técnica anestésica.CONCLUSIONES: El bloqueo paravertebral con triplepunción dividiendo en tres fracciones la dosis total deanestésico local, consiguiendo bloquear los dermatomasT3-4-5 es una técnica efectiva, sencilla y con baja incidenciade complicaciones. Además aportó un alto grado desatisfacción de la mayoría de los pacientes(AU)

OBJECTIVE: To describe the use of multiple-injectionthoracic paravertebral blockade, with intravenous sedation,for anesthesia during reconstructive breast surgery.MATERIAL AND METHODS: Descriptive, prospectivestudy in 100 scheduled operations for majorreconstructive breast surgery. The paravertebral blockwas performed by means of 3 injections at the loweredges of the vertebral apophyses at T3-5. We recordedtime performing the procedure, latency (time until blockonset), dermatomes blocked, degree of effectiveness,conversion to general anesthesia, postoperativecomplications and pain, and patient satisfaction.RESULTS: Dermatomes T3, T4, and T5 were blocked in99% of the patients. The block took 7.39 minutes toperform and latency was 7.37 minutes. Postoperativeanalgesia with anti-inflammatory drugs was adequatefor most patients. There were 3 cases of epiduraldiffusion, 10 patients with hypotension, 12 withpostoperative nausea or vomiting, and 3 with symptomsof epidural blockade. Intravascular puncture occurred,without complications, in 3 cases. There were no cases ofpneumothorax or intrathecal injection. Ninety-onepercent of the patients declared they were satisfied orvery satisfied with the technique.CONCLUSIONS: Triple-injection paravertebral blocks,in which 3 fractions of the total anesthetic dose aredelivered to block dermatomes T3-5 is an effectivetechnique that is easy to perform and leads to fewcomplications. Most patients express a high degree ofsatisfaction with this anesthetic technique(AU)

[Sugammadex, a novel drug for neuromuscular blockade reversal]. / Sugammadex. Nuevo fármaco reversor del bloqueo neuromuscular.

Significant progress in the management of aminosteroid nondepolarizing neuromuscular blockers will follow the introduction of sugammadex (Org 25969). Safety and rapid recovery of muscle force will improve and the adverse effects of acetylcholinesterase inhibitors will be avoided. Sugammadex is a modified gamma-cyclodextrin agent developed for the specific reversal of rocuronium and, to a lesser extent, vecuronium. This novel drug functions by means of encapsulation (chelation). Sugammadex was recently approved by the European Medicines Evaluation Agency and became available in Spain in 2009, leading to a series of changes related to patient safety and surgical conditions. We review the literature on sugammadex published to date.