Diagnóstico ecográfico de un caso de parálisis bilateral transitoria de las cuerdas vocales secundario a infiltración de anestésico local / Ultrasound diagnosis of a case of transient bilateral vocal cord paralysis secondary to local anesthetic infiltration

Una de las complicaciones más importantes asociada la cirugía de tiroides y paratiroides es la parálisis de las cuerdas vocales secundaria a la lesión del nervio laríngeo recurrente. La parálisis del nervio laríngeo recurrente inducida por anestésicos locales es una rara complicación con muy pocos casos publicados.Las técnicas patrón para el examen de las cuerdas vocales son la fibrolaringoscopia flexible y la videoestrobolaringoscopia. Sin embargo, estas técnicas son caras, y frecuentemente se asocian con dolor y malestar para los pacientes. Considerando estas desventajas, la ecografía laríngea transcutánea es una alternativa en pacientes que se someten a cirugía de tiroides y paratiroides.Presentamos un caso en el que se diagnosticó ecográficamente una parálisis bilateral transitoria de las cuerdas vocales tras la infiltración local de 10mL de mepivacaína al 2% administrada para la revisión de la herida quirúrgica por un hematoma subcutáneo ocurrido después de una paratiroidectomía subtotal.(AU)

One of the most important complications associated with thyroid and parathyroid surgery is vocal cord paralysis due to a recurrent laryngeal nerve injury. Recurrent laryngeal nerve injury paralysis induced by local anesthetics is a rare complication with very few published casesVarious techniques are available for diagnosing vocal cord paralysis, including, flexible fiberoptic laryngoscopy, videostrobolaryngoscopy and indirect laryngoscopy. However, these techniques are expensive and are often associated with pain and discomfort among patients. Considering these disadvantages, transcutaneous laryngeal ultrasound is an alternative imaging tool for vocal cord examination in patients undergoing thyroid and parathyroid surgery.We describe a case which was sonographically diagnosed a transient bilateral vocal cord paralysis after the local infiltration of 10mL of 2% mepivacaine administered for the revision of the surgical wound due to a subcutaneous hematoma that occurred after a subtotal parathyroidectomy.(AU)

Ultrasound diagnosis of a case of transient bilateral vocal cord paralysis secondary to local anesthetic infiltration. / Diagnóstico ecográfico de un caso de parálisis bilateral transitoria de las cuerdas vocales secundario a infiltración de anestésico local.

One of the most important complications associated with thyroid and parathyroid surgery is vocal cord paralysis due to a recurrent laryngeal nerve injury. Recurrent laryngeal nerve injury paralysis induced by local anesthetics is a rare complication with very few published cases Various techniques are available for diagnosing vocal cord paralysis, including, flexible fiberoptic laryngoscopy, videostrobolaryngoscopy and indirect laryngoscopy. However, these techniques are expensive and are often associated with pain and discomfort among patients. Considering these disadvantages, transcutaneous laryngeal ultrasound is an alternative imaging tool for vocal cord examination in patients undergoing thyroid and parathyroid surgery. We describe a case which was sonographically diagnosed a transient bilateral vocal cord paralysis after the local infiltration of 10mL of 2% mepivacaine administered for the revision of the surgical wound due to a subcutaneous hematoma that occurred after a subtotal parathyroidectomy.

Immediate postoperative and mid-term survival in nonagenarians undergoing non-traumatic emergency surgery.

BACKGROUND: Nonagenarian people are increasingly using the emergency services, however, few studies have addressed this population. The goal of this prospective observational study is to determine relevant factors that independently reduce their immediate postoperative and mid-term survival. METHODS: We included all the nonagenarians who underwent non-traumatic emergency surgery between 2006-2011. The dependent variable, days of postoperative survival, was studied at 2 intervals: 0-30 days and 31 days to 1 year after surgery (immediate and mid-term respectively). Firstly, we calculated the Kaplan-Meier survival curve (KMsc) of the whole population. To analyse the bivariate relationship between each of the pre-, intra-, and postoperative variables and mortality we used c2 and Fischer's test. Finally, we performed a stepwise Cox regression analysis and developed two models -one for each interval. RESULTS: The study included 142 patients. The overall one-year mortality rate was 47.2%, and the 30-day mortality rate was 35.9%. The KMsc showed a steep drop during the first month, and then a more gradual one for the rest of year. The inflection point was at day 26. The variables associated with a reduced immediate postoperative survival were neoplasms and 4 complications: heart failure, pulmonary aspiration, renal impairment and stroke. The factors associated with a reduced mid-term survival were: postoperative arrhythmia, surgical reintervention, and perioperative red blood cell transfusion. CONCLUSION: Postoperative complications are an important predictor of reduced survival both immediately, and in the mid-term. Furthermore, most postoperative mortality occurs within the first 26 days postsurgery; hence the need for an aggressive treatment of such complications during this period.

Anaemia and transfusion in nonagenarians undergoing emergency, non-traumatic surgery: a prospective observational study.

OBJECTIVES: To characterise transfusion and determine its main predictors in nonagenarians undergoing non-elective, non-traumatic surgery. Simultaneously, we compared nonagenarians to a similar, but younger sample, as far as the transfusional policy is concerned. BACKGROUND: Perioperative anaemia and transfusion are currently topical, but little is known about them in this population. METHODS: In this prospective observational study, we recruited 135 patients older than 90 who underwent a non-elective, non-traumatic procedure, between 2006 and 2011. A descriptive statistical analysis was performed and a logistic regression model developed. As a control sample, we used a similar number of patients in their third age (between 65 and 85 years old), who underwent the same procedure, during the same period. RESULTS: Thirty-five per cent of the nonagenarians were transfused. The main independent factors associated with transfusion were anaemia (OR 6·77, P < 0·01), a coexisting neoplasm (OR 10·99, P < 0·01) and the need for an exploratory laparotomy (OR 3·05, P = 0·01). When comparing the nonagenarians to the younger group, we found a significant difference in their basal health status and the mortality rate (P < 0·01), but the transfusion policy did not differ substantially, except for the haemoglobin threshold (P = 0·01). CONCLUSIONS: The independent transfusion predictors in nonagenarians should be taken into account for cross-matching. Transfusional policy being similar between nonagenarians and third-aged patients; the differences in thresholds were due to the differences in the populations.

Observational study of nonogenarians undergoing emergency, non-trauma surgery.

BACKGROUND: Nonagenarian population is growing, and so is the number of them needing emergency surgery. Yet, their treatment is often based on the outcomes of younger patients: although old age is known to be a risk factor for surgery, its level is not clear. This is a prospective, observational study to describe the population. It is aimed at providing quantified scientific evidence of the current procedures and their outcomes. METHODS: All non-traumatic nonagenarians who underwent surgery between July 2006 and September 2010 in our University Hospital were recruited and followed up over a month after discharge. A descriptive statistical analysis was performed. RESULTS: Of the approximately 12 660 surgical emergencies, 102 were nonagenarians: 69.6% were women, who mostly had an ASA score III (62.7%). Perioperative morbidity and mortality rates of 61.6% [95% confidence interval (CI): 52.33-71.19%] and 35.3% (95% CI: 26.01-44.57%), respectively, were found statistically associated with preoperative neoplasms. The most frequent causes of surgery were acute limb arterial thrombosis (20), incarcerated hernia (17), and bowel occlusion (14). Confusion, renal failure, and abdominal problems accounted for the most frequent causes of morbidity. Among them, abdominal complications, cardiogenic pulmonary oedema, aspiration, stroke, and renal failure were associated with mortality. CONCLUSIONS: The study gave scientific support and actual figures to many intuitive beliefs: morbidity and mortality are high and are associated with many preoperative comorbidities. All this, combined with an already reduced life expectancy, and a presumably low physiological reserve makes these patients particularly vulnerable to emergency surgery.

[Is morphine still the analgesic of choice in acute myocardial infarction?]. / Sigue siendo la morfina el analgésico de elección en el infarto agudo de miocardio?

Chest pain is the most common symptom of patients who present with ischemic heart disease. Morphine has traditionally been the drug of choice for managing chest pain in acute coronary syndrome (ACS) due to its high analgesic potency, though its physiological effects are poorly understood. Routinely used for managing chest pain, morphine is recommended in the 2002 guidelines of the American College of Cardiology/American Heart Association. This recommendation, however, is not based on a high level of scientific evidence but on expert opinion. Studies have found both for and against the use of morphine in ACS, suggesting that its benefits are perhaps not altogether clear. This review examines the pathophysiological effects of morphine and their cardiac implications, with special attention to a possible negative effect on ACS. We reviewed articles in the MEDLINE database from 1982 to 2006.

¿Sigue siendo la morfina el analgésico de elección en el infarto agudo de miocardio? / Is morphine still the analgesic of choice in acute myocardial infarction?

El dolor torácico es el síntoma más frecuente de presentación en pacientes con cardiopatía isquémica. Tradicionalmente la morfina ha sido el fármaco de elección para el control del dolor torácico en el síndrome coronario agudo (SCA) ya que su potencia analgésica es muy elevada, sin embargo sus efectos fisiológicos no están del todo claros. Su uso como terapéutica para el control del dolor torácico es de rutina, e incluso está incluida como recomendación en las guías de la ACC/AHA (American College of Cardiology/American Heart Association) delaño 2002, aunque esta recomendación no está basada enestudios científicos sólidos, sino en la opinión de expertos de la práctica clínica. La presencia de estudios a favor y en contra del uso de la morfina en el SCA, hacen ver que tal vez su beneficio no esté del todo claro. El objetivo de este trabajo es revisar los efectos fisiopatológicos de la morfina y sus implicaciones a nivel cardiaco, alertando de un posible efecto deletéreo en el SCA. Revisamos artículos desde el año 1982 al 2006 incluidos en la base de datos MEDLINE

Chest pain is the most common symptom of patientswho present with ischemic heart disease. Morphine hastraditionally been the drug of choice for managing chestpain in acute coronary syndrome (ACS) due to its highanalgesic potency, though its physiological effects arepoorly understood. Routinely used for managing chestpain, morphine is recommended in the 2002 guidelinesof the American College of Cardiology/American HeartAssociation. This recommendation, however, is not basedon a high level of scientific evidence but on expertopinion. Studies have found both for and against the useof morphine in ACS, suggesting that its benefits are perhaps not altogether clear. This review examines the pathophysiological effects of morphine and their cardiacimplications, with special attention to a possible negative effect on ACS. We reviewed articles in the MEDLINE database from 1982 to 2006