[Perioperative treatment of a man receiving a left-lung transplant combined with coronary revascularization without use of extracorporeal circulation: with a brief review of pathophysiology and the literature]. / Tratamiento perioperatorio de un paciente para trasplante unipulmonar izquierdo combinado con revascularización coronaria sin empleo de circulación extracorpórea. Breve revisión fisiopatológica y de la bibliografía.

Patients with significant coronary artery disease were once traditionally rejected as candidates for lung transplants because of higher risk of morbidity and mortality. We report the case of a man who received a left lung transplant and coronary revascularization without extracorporeal circulation in a combined surgical procedure after being diagnosed with significant coronary disease during the preoperative study for acceptance as a candidate for lung transplantation. We review the history of such combination procedures, which are changing clinicians' attitudes as to appropriate therapeutic approaches to take for complex patients. We also discuss the possible advantages of performing surgery without extracorporeal circulation. To our knowledge, this is the first report of a combined procedure that took place in a Spanish hospital.

Tratamiento perioperatorio de un paciente para trasplante unipulmonar izquierdo combinado con revascularización coronaria sin empleo de circulación extracorpórea. Breve revisión fisiopatológica y de la bibliografía / Perioperative treatment of a man receiving a left-lung transplant combined with coronary revascularization without use of extracorporeal circulation: with a brief review of pathophysiology and the literature

Los pacientes con enfermedad coronaria relevanteeran tradicionalmente rechazados como candidatos altrasplante pulmonar por el riesgo de incremento de lamorbimortalidad. Presentamos el caso de un paciente alque se le realizó un trasplante pulmonar izquierdo ycirugía de revascularización coronaria sin circulaciónextracorpórea en un procedimiento combinado, tras serdiagnosticado de enfermedad coronaria significativadurante su estudio para inclusión como candidato atrasplante pulmonar. Se revisan los antecedentes descritosde este tipo de procedimientos, que están permitiendoun cambio en el enfoque terapéutico de estos pacientescomplejos, así como las posibles ventajas de larealización del procedimiento sin circulación extracorpórea.En nuestro conocimiento es el primer caso deeste tipo de intervenciones combinadas descrito ennuestro país(AU)

Patients with significant coronary artery disease wereonce traditionally rejected as candidates for lungtransplants because of higher risk of morbidity andmortality. We report the case of a man who received aleft lung transplant and coronary revascularizationwithout extracorporeal circulation in a combinedsurgical procedure after being diagnosed with significantcoronary disease during the preoperative study foracceptance as a candidate for lung transplantation. Wereview the history of such combination procedures,which are changing clinicians’ attitudes as toappropriate therapeutic approaches to take for complexpatients. We also discuss the possible advantages ofperforming surgery without extracorporeal circulation.To our knowledge, this is the first report of a combinedprocedure that took place in a Spanish hospital(AU)

[Fentanyl or remifentanil to potentiate a single dose of rocuronium in patients anesthetized with propofol with evaluation by accelerometry]. / Potenciación de una dosis única de rocuronio por fentanilo o remifentanilo en pacientes anestesiados con propofol. Evaluación por acelerometría.

OBJECTIVE: To compare the increase in potency of a single dose of rocuronium during anesthesia with propofol combined with either fentanyl or remifentanil. PATIENTS AND METHODS: Forty patients scheduled for plastic surgery were distributed in 2 groups of 20 according to the opioid drug assigned: fentanyl or remifentanil. Induction with propofol was accomplished by computer-controlled infusion, with response measured in the adductor pollicis muscle. After calibration, a dose of 0.6 mg/Kg of rocuronium was infused. Anesthesia was maintained with propofol, oxygen in air, and an equipotent dose of either fentanyl or remifentanil, which was modified to maintain heart rate and systolic arterial pressure within 30% above or below baseline levels. Patient characteristics recorded were age, sex, height, weight, ASA class, type of surgery, and the propofol and opioid doses consumed. Intubation conditions and time to onset of action of rocuronium (T1), of recovery of the first response in a train of four (RT1), and of recovery of 25% of the first response or clinical duration. RESULTS: The groups were statistically similar in terms of demographic variables, type of surgery, propofol and opioid consumption, intubation conditions, and rocuronium T1 and RT1. Clinical duration of anesthesia was longer (p<0.05) in the remifentanil group (33.1 +/- 10 minutes) than in the fentanyl group (27.1 +/- 7.4 minutes). CONCLUSIONS: Remifentanil administered in combination with propofol for anesthesia does not affect time of onset of a single dose of 0.6 mg/Kg dose of rocuronium, but clinical duration of anesthesia is longer with remifentanil and propofol than with the fentanyl and propofol combination. The surgical and intubation conditions achieved with both combinations are adequate and similar.

[Fat embolism syndrome after surgery to replace the femoral stem of a hip prosthesis]. / Síndrome de embolia grasa tras recambio de vástago femoral de prótesis de cadera.

A 66-year-old woman developed hemodynamic instability, oliguria, prostration, fever, and coagulopathy 4 hours after surgery to replace the femoral stem component of a hip prosthesis under a combined subarachnoid-epidural block. Dyspnea and tachypnea developed, and a petechial rash appeared 24 hours later. The diagnosis was fat embolism after other possible causes were ruled out. Supplementary oxygen, fluid replacement therapy, and inotropic support were started. The patient's condition improved and she was discharged from the postoperative recovery unit 5 days after admission. Although fat embolism usually appears in young men after large bone fractures, it should be considered when symptoms consistent with this diagnosis arise in patients who have undergone orthopedic surgery so that appropriate treatment can be started early.

[Ventilation in prone decubitus in a patient with respiratory distress during heart surgery]. / Ventilación en decúbito prono en un paciente con distrés respiratorio tras cirugía cardíaca.

Acute respiratory failure and adult respiratory distress syndrome are serious complications after heart surgery and are associated with a high mortality rate. We report the case of a 50-year-old man who developed severe respiratory distress after heart surgery with extracorporeal circulation and for whom oxygenation was possible with ventilation in prone decubitus position only after other therapeutic measured had failed. The physiological bases of ventilation in prone decubitus position, as well as the indications and contraindications of the technique are discussed. Early treatment, which is fundamental for managing these patients, facilitates a favorable outcome as is illustrated by the case we report.