[Specialized training in anesthesiology: the opinions of supervising tutors]. / La formación especializada en Anestesiología desde la perspectiva de los tutores.

OBJECTIVE: To evaluate the common curriculum for teaching theoretical knowledge in anesthesiology in Catalonia, Spain; to assess differences between hospital teaching programs, evaluation systems, and the situation for tutors. MATERIAL AND METHODS: A 35-item questionnaire was sent to 49 accredited tutors during the 2005-2006 academic year. The questionnaire covered 1) the curriculum and training rotations, 2) teaching and research, and 3) assessment and tutorial interventions. An additional question asked the respondent's view on how to improve instruction. RESULTS: Eighty-five percent of the tutors responded. Seventy-eight percent of the residents (168/216) follow some form of external rotation, most often in pediatric anesthesia (79%). The common courses are considered useful by 96% of the tutors. Ninety-two percent are satisfied with the current annual examination and 79% would extend the residency training period to 5 years. Eighty-two percent of the teaching centers have weekly instructional sessions. Eighty-one percent of the tutors consider the resident's logbook, filled in by 77% of residents, to be useful for assessment. Eighty-five percent take teacher training courses, 65% feel that their work is being recognized, and 92% do not allot a specific period of time for teaching. CONCLUSIONS: The survey has helped shed light on the current training situation in Catalonia. The common courses are of great help. The number of external rotations is high, overloading certain areas. Improvements could be made by unifying external rotations, updating the curriculum and extending the training period to 5 years, recognizing the role of the tutor, and establishing a specific time for teaching activity.

Anestesia a una paciente con abdomen agudo y porfiria aguda intermitente / Anesthesia in a woman with acute abdomen and intermittent acute porphyria

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Anaesthetic and postoperative analgesic effects of spinal clonidine as an additive to prilocaine in the transurethral resection of urinary bladder tumours.

BACKGROUND AND OBJECTIVE: The alpha 2-adrenoceptor agonist clonidine has potent central antinociceptive properties. The study was designed to investigate the effects of the combined subarachnoid administration of clonidine and prilocaine on spinal block and postoperative analgesia for the transurethral resection of tumours in the urinary bladder. METHODS: The controlled, prospective, double-blind study enrolled 40 patients scheduled for elective transurethral resection of bladder tumours under spinal anaesthesia with prilocaine. Patients were randomly assigned to receive an intrathecal injection of prilocaine 75 mg alone (control group) or in combination with clonidine 75 micrograms. We assessed haemodynamic changes (non-invasive arterial pressure, heart rate), pulse oximetry, the upper level of block, the onset and duration of sensory and motor block, postoperative analgesia and any adverse effects. RESULTS: There were no statistically significant differences in demographic data, heart rate, onset time or the levels of sensory or motor block. Analgesia lasted significantly longer in the clonidine group (498.4 +/- 226.9 versus 187.2 +/- 103.1 min; P < 0.05). The duration of motor block was longer in the clonidine group (165.5 +/- 30.6 min) than in the control group (139.7 +/- 40.4 min; P < 0.05) and the duration of sensory block was also longer in the clonidine group (157.3 +/- 24.5 min) than in the control group (137.2 +/- 31.2 min; P < 0.05). Fewer patients in the recovery room needed metamizol (dipyrone) in the clonidine group (5%) than in the control group (50%). Arterial pressure decreased significantly in the clonidine group 75-135 min after the block. CONCLUSIONS: The addition of clonidine 75 micrograms to prilocaine 75 mg for subarachnoid anaesthesia increased the duration of sensory and motor block and reduced the need for additional postoperative analgesics by providing excellent analgesia for about 8 h during recovery from transurethral resection of bladder tumours.

Colocación de un tubo de doble luz mediante fibrobroncoscopio de 6 mm de diámetro e intercambiador de tubos Cook a un paciente con intubación traqueal difícil no prevista / Insertion of a double-lumen endobronchial tube with a 6 mm fiberoptic bronchoscope and a Cook airway exchange catheter in a patient with an unanticipated difficult airway

Varón de 74 años programado para neumonectomía izquierda, en el que no se preveía dificultad de intubación traqueal. Tras la inducción anestésica con midazolam, fentanilo, propofol y rocuronio, la laringoscopia objetivó Cormack-Lehane grado IV y tras dos intentos no se pudo intubar la traquea. Al no disponer de fibrobroncoscopio fino para intubación con tubo de doble luz, se utilizó un fibrobroncoscopio de 6 mm y se intubó al paciente con un tubo orotraqueal del nº 9 que se insertó en el bronquio principal izquierdo. La intubación se realizó con la ayuda de un adaptador universal para intubación fibroóptica con mascarilla facial y de una cánula de Williams, que permitieron ventilar manualmente al paciente con O2 al 100 por ciento mientras se realizó la fibroscopia. Dado que se precisaba ventilación selectiva durante la intervención, se insertó el intercambiador de tubos traqueales tipo Cook nº 11 en el bronquio principal izquierdo, se retiró el tubo traqueal, y se utilizó como guía el intercambiador, a través de la luz bronquial de un tubo de doble luz nº 39F izquierdo, que se introdujo sin dificultad, consiguiendo una intubación y ventilación selectivas satisfactorias. Ésta es una nueva indicación del intercambiador de tubos Cook que permite la intubación selectiva bronquial en caso de intubación traqueal difícil cuando no se dispone de fibrobroncoscopio fino (AU)

[Placement of a double-lumen tube using a 6 mm diameter fibro-bronchoscope and a Cook exchange catheter in a patient with unforeseen tracheal intubation difficulty]. / Colocación de un tubo de doble luz mediante fibrobroncoscopio de 6 mm de diámetro e intercambiador de tubos Cook a un paciente con intubación traqueal difícil no prevista.

The trachea of a 74-year-old man undergoing left pneumonectomy could not be intubated in two attempts after induction of anesthesia with midazolam, fentanyl, propofol and rocuronium. Difficult intubation had not been foreseen, but inspection through the laryngoscope revealed Cormack and Lehane grade IV conditions. Because a small-caliber fiberoptic bronchoscope was unavailable for intubation with a double-lumen endobronchial tube, we inserted a No. 9 orotracheal tube with a 6 mm bronchoscope as far as the left main bronchus. Intubation was aided by a universal adaptor for fiberoptics with a face mask and a Williams cannula. We were then able to ventilate the patient manually with 100% oxygen during bronchoscopy. As selective ventilation was required during surgery, a No. 11 Cook-type airway exchange catheter was inserted into the left main bronchus, the tracheal tube was removed, and was used to guide a No. 39F left double-lumen endobronchial tube through the bronchus. Insertion was uncomplicated and selective ventilation was satisfactory. The technique described is a new application for the Cook exchange catheter that allows selective bronchial in difficult cases when a small-caliber fiberoptic bronchoscope is unavailable.

[Comparative study between 5% prilocaine and 2% mepivacaine by the subarachnoid route in transurethral resections]. / Estudio comparativo entre prilocaína al 5% y mepivacaína al 2% por vía subaracnoidea en resecciones transuretrales.

OBJECTIVE: To compare the duration of spinal block with 5% prilocaine and 2% mepivacaine in short procedures for transurethral resection and to assess possible complications in the immediate postoperative period. MATERIAL AND METHODS: Fifty-seven patients scheduled for transurethral resection of the prostate or a vesical tumor. Patients were ASA I-III, over 55 years of age and randomly assigned to two groups to receive 5% prilocaine (1 mg/kg, n = 27) or 2% mepivacaine (0.8 mg/kg, n = 30). We collected data on anesthetic technique, levels of extension of motor and sensory blockades, duration of blockades and complications within the first 24 hours after surgery. RESULTS: Demographic data, ASA classification and duration of surgery were similar in both groups. We found statistically significant differences (p < 0.05) in duration of sensory blockade (120.92 +/- 36.21 min with prilocaine and 145.83 +/- 35.81 min with mepivacaine) and in motor blockade (106.29 +/- 38.16 min with prilocaine and 133.16 +/- 42.21 min with mepivacaine). Five cases of hypotension and 4 of bradycardia occurred in each group and one patient in the mepivacaine group suffered slight postoperative cephalea. CONCLUSIONS: Both local anesthetics offer good surgical conditions with hemodynamic stability and few complications. The duration of sensory and motor blockade is shorter with prilocaine than with mepivacaine, making prilocaine more appropriate for short interventions.

Estudio comparativo entre prilocaína al 5 por ciento y mepivacaína al 2 por ciento por vía subaracnoidea en resecciones transuretrales / Comparison of 5 por ciento prilocaine and 2 por ciento mepivacaine in spinal anesthesia for transurethral resection

Objetivo. Comparar la duración del bloqueo subaracnoideo con prilocaína al 5 por ciento y con mepivacaína al 2 por ciento en resecciones transuretrales de corta duración y valorar las posibles complicaciones en el postoperatorio inmediato. Material y métodos. Se estudiaron 57 pacientes programados para resecciones transuretrales de próstata o tumores vesicales, ASA I-III y edad superior a 55 años. Fueron distribuidos aleatoriamente en dos grupos, de manera que 27 sujetos recibieron prilocaína al 5 por ciento (1 mg/kg) y 30 mepivacaína al 2 por ciento (0,8 mg/kg). Se recogieron los datos sobre la técnica anestésica, los grados de extensión del bloqueo motor y sensitivo, el tiempo de duración de los mismos y las complicaciones en las primeras 24 h de la intervención. Resultados. Ambos grupos fueron comparables en cuanto a datos demográficos ASA y duración de la intervención. Encontramos diferencias estadísticamente significativas (p < 0,05) en la duración del bloqueo sensitivo (120,92 ñ 36,21 min con prilocaína y 145,83 ñ 35,81 min con mepivacaína) y la del bloqueo motor (106,29 ñ 38,16 min con prilocaína y 133,16 ñ 42,21 min con mepivacaína). Se presentaron 5 casos de hipotensión y 4 de bradicardia en cada grupo, y un caso de cefalea postoperatoria leve en el grupo mepivacaína. Conclusiones. Ambos anestésicos locales ofrecen unas buenas condiciones para la cirugía con estabilidad hemodinámica y escasas complicaciones. La prilocaína es superior a la mepivacaína por la menor duración de sus efectos sensoriales y motores, y constituye un anestésico local muy adecuado para intervenciones de corta duración (AU)

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[Primary lesions caused by explosions]. / Lesiones primarias por explosión.

The lesions produced by the expansive wave are characteristic of severe injury produced by explosion. This type of injury is being classified as primary lesion. We report a 28 years old male patient who suffered amputation of both lower extremities associated with hypovolemic shock. The patient presented primary tympanic perforation and pneumothorax after initiation of mechanical ventilation at positive pressure. In the discussion section we analyze the physical mechanisms leading to this primary lesion and we indicate the organs most commonly affected. We rise general considerations dealing with the management of these patients and we remark the advantages of a coordinated medical attendance policy.