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.

Anaesthetic management of breast surgery in a patient with Eisenmenger syndrome. / Anestesia para cirugía de mama en una paciente con síndrome de Eisenmenger.

Eisenmenger syndrome (ES) is a complex combination of cardiovascular abnormalities defined as pulmonary hypertension with investment or bidirectional flow through an intracardiac or aortopulmonary communication, usually secondary to a congenital heart disease not resolved promptly. It carries a significant risk of perioperative mortality, with an incidence close to 30% for non-cardiac surgery. We report the anaesthetic management in a ES patient undergoing breast surgery, which was successfully performed under general anaesthesia combined with thoracic analgesic blocks. The main pathophysiological implications of this syndrome are discussed, emphasizing the importance of appropriate preoperative evaluation with thorough assessment of associated risks, careful intraoperative management, and postoperative care, which should be initially performed in a critical care unit. The need to individualize and tailor the choice of drugs and anesthetic technique to the hemodynamic condition of the patient and the surgical procedure is highlighted.

Hipertiroidismo no controlado inducido por amiodarona: implicaciones anestésicas / Uncontrolled hypertyroidism amiodarone-induced: anesthetic implications

La amiodarona es un fármaco antiarrítmico de clase III utilizado en el manejo urgente de la fibrilación auricular (FA) y taquicardia ventricular sostenida y en el tratamiento crónico de la FA y taquicardias paroxísticas supraventriculares. Por su alto contenido en iodo, puede ocasionar trastornos en la función tiroidea hasta en el 20 % de los pacientes que la toman, siendo la incidencia de hipertiroidismo inducido por amiodarona (HIA) del 2 al 10 %.El hipertiroidismo no controlado puede conllevar en los casos de crisis tirotóxica o tormenta tiroidea (TT) una mortalidad del 20 al 60 % según las series. La incidencia de TT intraoperatoria ha disminuido en los últimos tiempos gracias a la adopción de medidas de optimización preoperatoria encaminadas a disminuir los niveles de hormonas tiroideas circulantes. Presentamos el caso de una paciente con un hipertiroidismo no controlado secundario a amiodarona, propuesta para osteosíntesis tras fractura subtrocantérea femoral derecha. Repasamos las principales consideraciones anestésicas que requiere el manejo de un paciente con HIA, incidiendo en la importancia de una exhaustiva valoración preoperatoria y en los beneficios que aporta la elección de una adecuada técnica anestésica en el control intraoperatorio y postoperatorio inmediato de los episodios de crisis tirotóxica. Describimos el empleo de una técnica intradural complementada con un bloqueo nervioso periférico, como una alternativa válida a la anestesia general (AU)

Amiodarone is a class III antiarrhythmic agent used in the emergency management of atrial fibrillation (AF), sustained ventricular tachycardia and chronic treatment of AF and paroxysmal supraventricular tachycardia. Because of its high iodine content, it may cause disturbances in thyroid function in up to 20 % of patients who take it, with an incidence of amiodarone-induced hyperthyroidism (AIH) from 2 to 10 %.Uncontrolled hyperthyroidism can generate in cases of thyrotoxic crisis or thyroid storm a mortality of 20 to 60 % depending on the series. The incidence of intraoperative thyroid storm has decreased in recent years thanks to the adoption of measures which reduce the levels of circulating thyroid hormones. We report the case of a patient with uncontrolled hyperthyroidism secondary to amiodarone, given right femoral osteosynthesis surgery after subtrochanteric fracture. We review the main anesthetic considerations requiring the management of a patient with AIH, highlighting the importance of a thorough preoperative assessment and the benefits of choosing a suitable anesthetic technique on intraoperative and immediate postoperative episodes of thyroid storm. We describe the use of a spinal technique supplemented by a peripheral nerve block, as a valid alternative to general anesthesia (AU)

Consentimiento informado en anestesiología: la antelación suficiente como requisito de validez / Informed consent in anaesthesiology: Period of notice as a requisite of validity

Se analiza uno de los requisitos de validez del consentimiento informado, en concreto, el tiempo o antelación con que ha de facilitarse la información al paciente para que pueda reflexionar y ejercer con plenitud su derecho kantiano de autodeterminación. Se aprecia cierta insuficiencia de la legislación estatal al tratar este requisito, que es subsanada por algunas legislaciones autonómicas. Concluimos señalando la necesidad de facilitar la información al paciente con la antelación suficiente para que pueda meditar adecuadamente su decisión (AU)

The analysis of one of the requisites of thevalidity of the informed consent, the notice period, during which the patient should be provided with information, so that he/she can reflect and fully exercise his/her Kantian right of self-determination. National legislation appears to be insufficient when dealing with this issue, which is compensated for in some regional legislations. We conclude by pointing the need to provide the patient with information with sufficient notice prior to operations, so that he/she can ponder over his/her decision (AU)

[Informed consent in anaesthesiology: period of notice as a requisite of validity]. / Consentimiento informado en anestesiología: la antelación suficiente como requisito de validez.

The analysis of one of the requisites of the validity of the informed consent, the notice period, during which the patient should be provided with information, so that he/she can reflect and fully exercise his/her Kantian right of self-determination. National legislation appears to be insufficient when dealing with this issue, which is compensated for in some regional legislations. We conclude by pointing the need to provide the patient with information with sufficient notice prior to operations, so that he/she can ponder over his/her decision.

Responsabilidad en Anestesiología: teoría del daño desproporcionado / Liability in Anaesthesiology: theory of disproportionate damage

Se analiza la controvertida aplicabilidad de la doctrina del daño desproporcionado en el acto anestésico, dado el elevado riesgo inherente al mismo, abstracción hecha de la gravedad y trascendencia del acto quirúrgico que lo motiva. La existencia de un resultado desproporcionado, esto es, no previsto ni explicable dentro de la esfera de la actuación profesional del anestesista, no determina por sí sola la existencia de responsabilidad del médico, sino la exigencia al mismo de una explicación coherente acerca del porqué de la importante disonancia existente entre el riesgo inicial que implicaba su actividad y la consecuencia finalmente producida (AU)

[Liability in Anaesthesiology: theory of disproportionate damage]. / Responsabilidad en Anestesiología: teoría del daño desproporcionado.

An analysis is made of the controversial application of the theory of disproportionate damage in the anaesthetic act, due to the high inherent risk, and regardless of the seriousness and importance of the surgery being performed. The existence of a disproportionate damage, that is, damage not foreseen nor accountable within the framework of the professional performance of the anaesthetist, does not by itself determine the existence of liability on the part of the anaesthetist, but the demand from the professionals themselves for a coherent explanation of the serious disagreement between the initial risk implied by their actions and the final consequence produced.

Acidosis láctica y distrés respiratorio tras intoxicvación por metformina: La importancia de un tratamiento precoz / No disponible

La metformina, es una biguanida ampliamente utilizada en el tratamiento de la diabetes mellitus (DM). Entre los efectos secundarios derivados de su empleo, destaca por su baja frecuencia de presentación, pero potencial gravedad, la acidosis láctica. El diagnóstico de intoxicación por metformina se basa, generalmente, en la coexistencia de acidosis láctica, en un paciente en tratamiento con este fármaco, con uno o más factores de riesgo para la presentación de la misma. El desarrollo de acidosis láctica en relación con el tratamiento con metformina, conlleva una mortalidad, que oscila entre el 30 y el 80% según las series. Presentamos, a este respecto, el caso de una paciente en tratamiento con metformina, que presentó un cuadro de acidosis láctica grave que motivó su ingreso en la Unidad de Reanimación. El interés del mismo radica en el desarrollo de un episodio de fallo multiorgánico (fallo hemodinámico y fracaso renal agudo) con un síndrome de distrés respiratorio agudo del adulto (SDRA), que precisó terapia de depuración extrarrenal mediante hemodiafiltración venovenosa continua (HDFVVC), además de instauración de tratamiento con drogas vasoactivas y óxido nítrico inhalado (AU)

Metformin, is a biguanide widely used in the treatment of diabetes mellitus. One of the most important side effects from its employment is lactic acidosis, known for its low frequency of occurrence, but potential lethality. The diagnosis of poisoning by metformin is generally based on the coexistence of lactic acidosis in a patient treated with this drug, with one or more risk factors for its occurrence. The development of lactic acidosis in connection with the treatment with metformin, carries a mortality ranging between 30 and 80%depending on the studies. We present, the case of a patient treated with metformin, who suffered from a severe lactic acidosis that led to her entry into the recovery unit. The interest of this case in based on the development of an episode of multiple organ failure (hemodynamic failure and acute renal failure) with acute respiratory distress syndrome (ARDS) which required renal replacement therapy by continuous veno-venous hemodiafiltration (CVVHDF) and employment of vasoactive drugs and inhaled nitric oxide (AU)