[Obstetric analgesia using continuous epidural perfusion of bupivacaine, adrenaline, and fentanyl]. / Analgesia obstétrica mediante perfusión epidural continua de bupivacaína, adrenalina y fentanilo.

OBJECTIVES: To determine the efficacy and complications of continuous epidural perfusion of bupivacaine, adrenaline and fentanyl in the relief of pain during first and second stage labour during vaginal birth. PATIENTS AND METHODS: Between January 1990 and March 1993 we used continuous epidural perfusion for control of pain during labor in 1307 women. The solution administered through an epidural catheter and maintained until expulsion was one 10 ml bolus of bupivacaine 0.25% with adrenaline 1:200,000 and fentanyl 25 micrograms followed by continuous perfusion of bupivacaine 0.0625% with adrenaline 1:200,000 and fentanyl 2 micrograms/ml at an infusion rate of 12 ml/h. When analgesia was insufficient, a bolus of local anesthetic was administered or a pudendal block was carried out. RESULTS: Ninety-two percent of the birthing women reported good analgesic effect during the first stage; for 7% the effect was fair and for 0.55% it was poor. During the second stage 88% reported satisfactory analgesia, and 8% fair or poor. Assessment was not possible for the remaining women, who underwent cesarean sections. Complications were few and easily controllable. CONCLUSIONS: Maintenance of epidural perfusion with 0.0625% bupivacaine with adrenaline 1:200,000 and fentanyl 2 micrograms/ml provides sufficient analgesia during all stages of childbirth.

[EMLA. A new topical anesthetic]. / EMLA. Un nuevo anestésico por vía tópica.

The method most widely used at present for cutaneous analgesia is local anesthetic infiltration. Pain occurs when the needle penetrates and when the anesthetic is deposited and diffuses. The procedure is not risk-free. It is therefore not surprising that many attempts have been made to develop an anesthetic formula that is effective when applied topically to intact skin. Early efforts were unsuccessful due to either low analgesic efficacy or side effects. The problem was solved several years ago in the European market by the EMLA (Eutetic Mixture of Local Anesthetics) cream. The EMLA cream has been shown to be useful as a topical anesthetic on either intact or damaged skin. Its clinical profile is safe, with a low incidence of side effects. We feel it is a useful tool for preventing pain in a variety of procedures that call for cutaneous analgesia. It may also be used as premedication for perineural injection of anesthetics, providing greater comfort for the patient. This article describes the main pharmacological principles that make EMLA an effective topical analgesic, as well as indications for its use in the clinical practice of anesthesiology.

[Massive endobronchial hemorrhage due to pulmonary artery rupture caused by a Swan-Ganz catheter]. / Hemorragia endobronquial masiva por rotura de la arteria pulmonar producida por un catéter de Swanz-Ganz.

We present the case of a 69-year-old male bearing a Swan-Ganz catheter while undergoing aortic and mitral valve replacement. Massive hemorrhage through the endotracheal tube began after closure of the sternotomy. Selective endobronchial intubation was performed and the thorax immediately reopened to reveal a tear in the right pulmonary artery at the level of the middle lobar branch. The tear was sutured, and throughout the early postoperative hours the patient presented signs of active bleeding through thoracic drains, with persistent slight hemoptysis in the right branch of the endotracheal tube. Ventilation was controlled artificially with two synchronized respirators and positive end-expiratory pressure (PEEP) up to 10 cm H2O in the right lung. The double-lumen tube was removed after 15 days with no complications and the patient was released two months after surgery. Massive endobronchial hemorrhage resulting from perforation of the pulmonary artery or its tributaries caused by Swan-Ganz catheters requires early diagnosis and treatment based on airway protection and immediate location and control of the point of hemorrhage. Selective endobronchial intubation with double-lumen tubes, direct arterial surgery and use of PEEP may constitute a valid alternative for management of these patients, making resection unnecessary.

[Anesthetic considerations in patients with human immunodeficiency virus infection]. / Consideraciones anestésicas en pacientes con infección por virus de la inmunodeficiencia humana.

In the last few years many articles have been published on AIDS, the mechanism of transmission, prophylaxis and therapeutic possibilities; however, very few publications are available related with anesthesia of patients infected with HIV or AIDS. The authors have therefore undertaken this review in which following a brief description of the etiology, pathogenesis, physiopathology and treatment of the disease, the problems of anesthesia are specifically dealt with. The need for knowing the different active or latent clinical alterations, such as neurologic (encephalitis, meningitis, peripheral neuropathies, myelopathies, etc.), respiratory (pneumonias by Pneumocystis carinii), cardiovascular (myocardiopathies), digestives (oropharingeal candidiasis, hepatopathies), psychologic (drug addiction), hematic (anemias, leucopenias) coagulopathies, nephropathies, etc. must be emphasized. Before the possibility of such a broad pathology good evaluation and preoperatory preparation is essential. With regard to anaesthetic technique, regional anesthesia is of choice except in certain cases of neuropathies. Although patients with a high degree of immunosuppression present a high risk of infections of the nervous system, the global risk is lower than if general anesthesia with prolonged artificial respiration were received.

[Cardiac tamponade: a fatal complication of parenteral nutrition]. / Taponamiento cardíaco: una complicación fatal de la nutrición parenteral.

Several complications are associated with the use of central venous catheters for total parenteral nutrition; cardiac tamponade is one of the most severe. The recent use of flexible materials made of silastic polymeric silicone has great decreased the incidence of this complication, but has not eliminated wholly. We report the case of a patient with fatal cardiac tamponade, while receiving parenteral hyperalimentation trough a silicone central venous catheter placed in the right jugular internal vein, secondary to superior vena cava perforation. The physiopathological mechanisms, precautionary measures and treatment are discussed.

[Anesthesia in a case of hyperkalemic familial periodic paralysis]. / Anestesia en un caso de parálisis periódica familiar hiperpotasémica.

Periodic familial hyperpotassemic paralysis is a dominant autosomic disease of brief periods of acute flaccid paralysis with complete posterior recovery. During surgical-anesthesia a number of factors concur which may trigger a paralytic episode. To this effect anesthetic drugs such as barbiturates and muscle relaxants have been involved. The case of a 12 year old patient with familial hyperpotassemic paralysis who received general anesthesia with propofol and atracurium besylate for emergency appendectomy is presented. During surgery the plasma levels of potassium were monitored and prophylaxis of the factors which potentially trigger a paralytic picture was performed. Both, the perioperative and the postoperative period, were without complications.