[Prevention, diagnosis and treatment of bleeding in cardiac surgery]. / Prevención, diagnóstico y tratamiento de la hemorragia en cirugía cardiaca.

Patients undergoing cardiac surgery are at high risk of bleeding and transfusion. This risk has increased in recent years and is associated with increased morbidity and mortality. Moreover, despite being one of the most common complications associated with this surgery, there remains a large variability in its management between institutions. Implementation of algorithms for coagulation management has been shown to reduce transfusion requirements and therefore it seems essential to establish protocols that include preventive measures, effective mechanisms for diagnosis and treatment algorithms. On the other hand, the emergence of new drugs and the use of point of care coagulation monitoring systems, is changing our diagnostic and therapeutic options. This paper reviews several aspects related to the causes, diagnosis and treatment of bleeding associated with cardiac surgery and presents an algorithm for its management.

[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.

[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.