Catorce años después de abierto el debate sobre formación de un cirujano torácico general certificado / Fourteen Years following the Discussion about Training a Certified General Thoracic Surgeon

Introducción: En Cuba existen numerosos cirujanos que han dedicado una gran parte de su vida profesional a la cirugía del tórax no cardiovascular, pero solo ostentan el título de especialista de primer o segundo grado en cirugía general. Objetivo: Exponer los argumentos que demuestren la necesidad de crear e implementar la especialización de primer grado en cirugía torácica general o la maestría en cirugía del tórax. Métodos: Se realizó una búsqueda documental a partir de los motores de búsqueda de información científica Google Académico y Highwire Press. De la Web of Science, PubMed, Lilacs y Scopus se seleccionaron 23 artículos relacionados directamente con el objetivo propuesto. Desarrollo: En 2008 el profesor Benito Saínz Menéndez publicó un artículo en el cual expuso la necesidad de crear un programa de posgrado sobre cirugía torácica general; sin embargo, después de 14 años, aún se mantiene el debate sobre este tema. En tal sentido, los reclamos de la comunidad quirúrgica cubana en la propuesta de un programa de maestría y en una tesis doctoral se han hecho sentir en varias reuniones académicas y en diversas publicaciones. La nueva solicitud se justifica desde distintas aristas. Conclusión: El desarrollo de la educación de posgrado y la necesidad de formar recursos humanos capacitados en cirugía general ha acumulado los suficientes preceptos para solicitar la cirugía torácica como una subespecialidad o la inserción de una maestría sobre este tema. Se recomienda que se evalúe la posibilidad de la creación e implementación de la especialización o maestría en cirugía de tórax no cardiovascular(AU)

Introduction: In Cuba, there are numerous surgeons who have dedicated a large part of their professional life to noncardiovascular thoracic surgery, but they only hold the title of first- or second-degree specialist in General Surgery. Objective: To present the fundamentals demonstrating the need to create and implement the first-degree residence for general thoracic surgery or a master's degree in thoracic surgery. Methods: A document search was carried out using the scientific information search engines Google Scholar and Highwire Press. From the Web of Science, PubMed, Lilacs and Scopus, 23 articles directly related to the proposed objective were selected. Development: In 2008, Professor Benito Saínz Menéndez published an article in which he presented the need to create a postgraduate curriculum for general thoracic surgery; however, after 14 years, the debate on this subject is still ongoing. In this respect, the claims of the Cuban surgical community concerning the proposal of a master's program and a doctoral dissertation have been felt in several academic meetings, as well as in several publications. The new request is justified from different points of view. Conclusion: Through the development of postgraduate education and the need to train skilled human resources in general surgery, enough principles have been accumulated for requesting that thoracic surgery be taught as a subspecialty, or the insertion of a master's degree on this subject. The assessment is recommended for the possibility of creating and implementing a specialization or a master's degree in noncardiovascular thoracic surgery(AU)

Intervención de enfermería para disminuir la ansiedad en el perioperatorio en cirugía cardiovascular / Nursing intervention to reduce anxiety in the perioperative period in cardiovascular surgery

Introducción: La adecuada intervención de enfermería puede mejorar los resultados posoperatorios, al disminuir la ansiedad. Objetivo: Desarrollar una intervención personalizada de enfermería para disminuir la ansiedad durante el preoperatorio de personas que requieren cirugía cardiovascular en el Centro de Investigaciones Médico Quirúrgicas. Métodos: Se hizo un estudio longitudinal y preexperimental, que incluyó a 88 personas que acudieron al Servicio de Cirugía Cardiovascular en el Centro de Investigaciones Médico Quirúrgicas desde marzo de 2019 hasta junio de 2020. Se aplicó el test Inventario de Ansiedad Rasgo-Estado para medir la ansiedad. Se realizó una intervención de enfermería personalizada. Los resultados iniciales y finales se compararon y se expresaron en números absolutos, porcentajes y media. Se aplicó la prueba de Chi cuadrado a las variables cualitativas y el test de Student para medias independientes a las variables cuantitativas. Resultados: Predominaron los hombres (57,9 por ciento) con edad media de 57,73 ± 11,9 años. Luego de la intervención de enfermería, se redujo la ansiedad en un 36,6 por ciento (p = 0,000). No se encontró asociación entre la ansiedad posintervención y la estadía, aunque sí se redujeron de forma significativa las complicaciones posoperatorias (p = 0,008). Conclusiones: La intervención de enfermería disminuyó la ansiedad y se asoció de forma significativa a menos complicaciones(AU)

Introduction: Adequate nursing intervention can improve postoperative outcomes by reducing anxiety. Objective: To develop a personalized nursing intervention to reduce anxiety during the preoperative period of people requiring cardiovascular surgery at the Medical and Surgical Research Center. Methods: A longitudinal and pre-experimental study was conducted, which included 88 people who attended the Cardiovascular Surgery Service at the Center for Medical and Surgical Research from March 2019 to June 2020. The Trait-State Anxiety Inventory test was applied to measure anxiety. A personalized nursing intervention was performed. Initial and final results were compared and expressed in absolute numbers, percentages and average. The Chi square test was applied to the qualitative variables and the Student test for independent means to the quantitative variables. Results: Men (57.9 percent) with a mean age of 57.73 ± 11.9 years predominated. After the nursing intervention, anxiety was reduced by 36.6 percent (p = 0.000). No association was found between post-intervention anxiety and stay, although postoperative complications were significantly reduced (p = 0.008). Conclusions: The nursing intervention decreased anxiety and was significantly associated with fewer complications(AU)

Traumatismo torácico con lesión de grandes vasos del tórax: características, tratamiento y variables asociadas a mortalidad / Thoracic trauma with injury to the great vessels of the chest: characteristics, treatments and variables associated with mortality

Resumen Introducción: Las lesiones de grandes vasos del tórax por traumatismo torácico (TTLGV) son un grupo heterogéneo de lesiones con alta morbimortalidad que constituyen un 0,3-10% de los hallazgos en el traumatismo torácico (TT). Objetivos: Describir características, tratamientos y variables asociadas a mortalidad en pacientes hospitalizados con TTLGV. Material y Métodos: Estudio analítico-observacional. Período enero-1981 y diciembre-2020. Revisión de protocolos de TT prospectivos y fichas clínicas. Se clasificaron los TTLGV según American Association for the Surgery of Trauma (AAST), se calcularon índices de gravedad del traumatismo: Injury Severity Score (ISS), Revised Trauma Score Triage (RTS-T) y Trauma Injury Severity Score (TRISS). Se realizó análisis univariado y multivariado con cálculo de Odds Ratio (OR) para variables asociadas a mortalidad. Se usó SPSS25®, con pruebas UMann Whitney y chi-cuadrado, según corresponda. Resultados: de un total 4.577 TT, 97 (2,1%) cumplieron criterios de inclusión. Hombres: 81 (91,8%), edad promedio: 32,3 ± 14,8 años. TT penetrante: 65 (67,0%). Lesión de arterias axilo-subclavias en 39 (40,2%) y aorta torácica en 31 (32,0%) fueron las más frecuentes. Fueron AAST 5-6: 39 (40,2%). Tratamiento invasivo: 87 (89,7%), de éstos, en 20 (20,6%) reparación endovascular, 14 (14,4%) de aorta torácica. Cirugía abierta en 67 (69,1%). Mortalidad en 13 (13,4%), fueron variables independientes asociadas a mortalidad el shock al ingreso (OR 6,34) e ISS > 25 (OR 6,03). Conclusión: En nuestra serie, los TTLGV fueron más frecuentemente de vasos axilo-subclavios y aorta torácica. El tratamiento fue principalmente invasivo, siendo la cirugía abierta el más frecuente. Se identificaron variables asociadas a mortalidad.

Background: Thoracic great vessel injuries in thoracic trauma (TTGVI) are a heterogeneous group of injuries with high morbimortality that constituting 0.3-10% of the findings in thoracic trauma (TT). Aim: To describe characteristics, treatments and variables associated with mortality in hospitalized patients with TTGVI. Methods: Observational-analytical study. Period January-1981 and December-2020. Review of prospective TT protocols and clinical records. TTGVI were classified according to American Association for the Surgery of Trauma (AAST), trauma severity index were calculated: Injury Severity Score (ISS), Revised Trauma Score Triage (RTS-T) and Trauma Injury Severity Score (TRISS). Univariate and multi- variate analysis was performed with calculation of Odds Ratio (OR) for variables associated with mortality. SPSS25® was used, with U Mann Whitney and chi-squared tests, as appropriate. Results: From a total of 4.577 TT in the period, 97 (2.1%) met the inclusion criteria. Males: 81 (91.8%), mean age: 32.3 ± 14.8 years. Penetrating TT: 65 (67.0%). Axillary-subclavian artery lesions in 39 (40.2%) and thoracic aorta in 31 (32.0%) were more frequent. AAST 5-6: 39 (40.2%). Invasive treatment: 87 (89.7%), of these, in 20 (20.6%) endovascular repair, 14 (14.4%) of thoracic aorta. Open surgery in 67 (69.1%). Mortality in 13 (13.4%), shock on admission was independently associated with mortality (OR 6.34) and ISS > 25 (OR 6.03). Conclusión: In our series, TTGVI were more frequent in axillary-subclavian vessels and thoracic aorta. Treatment was mainly invasive, with open surgery being the most frequent. Variables associated with mortality were identified.

Protocolo ERATS en cirugía pulmonar / ERATS Protocol in Pulmonary Surgery

Introducción: Los cuidados perioperatorios estandarizados ayudan a asegurar que todos los pacientes reciban un tratamiento óptimo. Objetivo: Aplicar un método de cuidados perioperatorios multimodales sistemáticos, en pacientes sometidos a cirugía pulmonar mayor. Métodos: Se realizó una revisión narrativa de la literatura relevante, publicada sobre el tema en las bases de datos MEDLINE, Cochrane, además de Medigraph, en idiomas inglés, español y francés. Se hizo énfasis en los artículos de los últimos 5 años, sobre todo estudios aleatorizados, bases de datos institucionales y nacionales, revisiones sistemáticas, metanálisis y programas y protocolos ERAS/ERATS, además de artículos de revisión. Desarrollo: Los estudios obtenidos fueron evaluados por los autores por separado y, más tarde, en conjunto para definir cuáles se ajustaban a los objetivos. El protocolo se dividió en 5 fases: preoperatoria, ingreso hospitalario, preoperatoria inmediata, intraoperatoria, posoperatoria. Para cada una de ellas se definieron las acciones a realizar, según la evidencia disponible. Conclusiones: La implantación del protocolo permitirá pasar de una fase empírica a una investigativa, de manera que se podrán obtener resultados superiores en el tratamiento quirúrgico de los pacientes enrolados en las investigaciones que se realicen(AU)

Introduction: Standardized perioperative care helps ensure that all patients receive optimal treatment. Objective: To apply a method of systematic multimodal perioperative care in patients undergoing major pulmonary surgery. Methods: A narrative review was performed of the relevant literature published on the subject in MEDLINE, Cochrane, and Medigraph databases in English, Spanish, and French. Emphasis was made on articles from the last 5 years, especially randomized studies, institutional and national databases, systematic reviews, meta-analyses, and ERAS/ERATS programs and protocols, as well as review articles. Discussion: The studies retrieved were evaluated by the authors separately and, later, together to define which ones met the objectives. The protocol was divided into 5 phases: preoperative, hospital admission, immediate preoperative, intraoperative, and postoperative. For each of them, the actions to be carried out were defined, according to the available evidence. Conclusions: The implementation of the protocol will allow to go from an empirical phase to an investigative one, so that better results can be obtained in the surgical treatment of patients enrolled in the investigations(AU)

Pectus excavatum ­ Correção cirúrgica utilizando tala externa de poliuretano fabricada com tecnologia de impressão 3D / Pectus excavatum ­ Surgical correction, using polyurethane external splint made with 3D printing technology

Objetivou-se relatar o emprego de uma tala externa confeccionada com material de poliuretano e cobertura interna de neopreme na reparação cirúrgica do pectus excavatum em um felino jovem. O felino apresentava deformidade anatômica congênita na região do externo e sinais clínicos respiratórios. Imagens avançadas de tomografia foram utilizadas para moldar a tala impressa com tecnologia tridimensional. Esta alternativa possibilitou melhor planejamento cirúrgico e, com isso, conforto para o paciente, além da qualidade própria do material de poliuretano que é levemente maleável, o que permitiu melhor moldagem e expansão torácica durante a respiração. A tala se provou resistente o suficiente para suportar a tração ocasionada pelos fios de sutura e possibilitou o reposicionamento adequado do osso esterno ao mesmo tempo que se mostrou confortável e acarretou mínimas lesões ao paciente.

The aim of this paper was to report the use of an external splint made of polyurethane material and internal neopreme covering in the surgical repair of a pectus excavatum in a young feline. The feline exhibited a congenital anatomical deformity in the external region and clinical respiratory signs. Advanced CT images were used to shape the 3D-printed splint. This alternative allowed better surgical planning and, therefore, comfort for the patient, this because to the quality of the polyurethane material, which is slightly malleable, and allowed for better molding and chest expansion during breathing. The splint proved to be strong enough to withstand the traction caused by the suture threads and allowed the proper repositioning of the sternum, at the same time it was comfortable and caused minimal injuries to the patient.

Estrategias de ventilación protectora en cirugía cardiovascular / Protective ventilation strategies in cardiovascular surgery

Introducción: La alteración en el intercambio gaseoso es una complicación de la cirugía cardíaca con circulación extracorpórea. La causa de este deterioro es multifactorial. Durante la derivación, ambos pulmones colapsan y al término de la circulación extracorpórea los pulmones se vuelven a expandir, sin existir una técnica estándar para ello. La aplicación de reclutamiento alveolar durante la anestesia general en este tipo de cirugía mejora la oxigenación arterial. Objetivo: Describir aspectos esenciales de fisiopatología de la injuria pulmonar asociada a la ventilación mecánica en procedimientos quirúrgicos cardíacos y el efecto de la ventilación mecánica protectora perioperatoria como estrategia para prevenirla. Método: Se realizó una búsqueda de la literatura publicada durante el período comprendido entre enero de 1990 y diciembre de 2020 que hiciera referencia a las estrategias de ventilación mecánica protectora en cirugía cardiovascular. Resultados: La evidencia experimental y clínica sugiere que los bajos volúmenes corrientes de ventilación pulmonar y la aplicación por un corto período del aumento de las presiones inspiratorias, conocidas como "maniobras de reclutamiento" seguidas de la aplicación de presión positiva al final de la espiración para mantener los alveolos reclutados abiertos, incrementan la capacidad residual funcional y reducen la injuria pulmonar asociada a la ventilación mecánica. Estas recomendaciones han sido extrapoladas de estudios retrospectivos realizados en otro tipo de poblaciones. Conclusiones: No existe evidencia contundente de que esta estrategia disminuya la respuesta proinflamatoria, mejore la función pulmonar posoperatoria y disminuya la mortalidad perioperatoria, cuando se compara con la ventilación convencional(AU)

Introduction: The alteration in gas exchange is a complication of cardiac surgery with extracorporeal circulation. The cause of this deterioration is multifactorial. During the shunt, both lungs collapse and at the end of the extracorporeal circulation the lungs expand again, without a standard technique for it. The application of alveolar recruitment during general anesthesia in this type of surgery improves arterial oxygenation. Multiple strategies are used and have as a reference the extracorporeal circulation and its contribution to the pulmonary and systemic inflammatory response. This forces the anesthesiologist to understand the pathophysiology of lung injury associated with mechanical ventilation. Objective: Describe essential aspects of pathophysiology of pulmonary injury associated with mechanical ventilation in cardiac surgical procedures and the effect of perioperative protective mechanical ventilation as a strategy to prevent it. Method: A search of the literature published during the period between January 1990 and December 2020 was carried out that referred to protective mechanical ventilation strategies in cardiovascular surgery. Results: Experimental and clinical evidence suggest that low current volumes of pulmonary ventilation and the application for a short period of increased inspiratory pressures, known as "recruitment maneuvers" followed by the application of positive pressure at the end of expiration to keep the recruited alveoli open, increase functional residual capacity and reduce lung injury associated with mechanical ventilation. These recommendations have been extrapolated from retrospective studies conducted in other types of populations. Conclusions: There is no strong evidence that this strategy decreases the pro-inflammatory response, improves postoperative lung function and decreases perioperative mortality, when compared to conventional ventilation(AU)

Cirugías por traumatismo torácico: caracterización y variables asociadas a mortalidad / Thoracic trauma surgery: indications, findings and mortality associated variables

Resumen Introducción: El traumatismo torácico (TT) es la causa de aproximadamente un cuarto de las muertes por traumatismos. Los pacientes tratados con cirugía por traumatismo torácico (CTT) presentan un amplio espectro de características y pronósticos. Objetivos: Describir características clínicas, indicaciones, temporalidad, morbilidad, mortalidad y las variables asociadas a mortalidad en pacientes con CTT. Materiales y Método: Estudio observacional de pacientes tratados con CTT, período enero-1981 a diciembre-2019. Revisión de protocolos prospectivos de TT y base de datos. Se realizó regresión logística para variables asociadas a mortalidad. Se utilizó SPSS25® con prueba chi-cuadrado para comparar clasificación, tipo de TT y su distribución temporal, considerando significativo p < 0,05. Resultados: En total 808 casos (18,2%) de 4.448 TT requirieron CTT. Fueron hombres 767 (94,9%) y la edad promedio fue 31,5 ± 13,8 años. El traumatismo fue penetrante y por arma blanca en la mayoría de los casos. Fueron politraumatizados 164 (20,3%). La cirugía fue urgente en 474 (58,7%), precoz en 41 (5,0%) y diferida en 293 (36,3%) casos. La mortalidad global fue de 6,7% y fue significativamente mayor en TT contusos, politraumatizados y en cirugía urgente. La mortalidad fue 9,7% en CTT urgente, 4,9% en precoz y 2,0% en diferida (p < 0,001). Se observaron variables independientes asociadas a mortalidad. Conclusión: En nuestra serie, las CTT se realizaron principalmente en hombres jóvenes con TT penetrantes. Correspondieron a un grupo heterogéneo en cuanto a las indicaciones, hallazgos y lesiones intratorácicas y/o asociadas. Múltiples variables demostraron influir significativamente en la mortalidad de los pacientes tratados con CTT.

Background: Thoracic Trauma (TT) is the cause of approximately a quarter of trauma deaths. The patients who undergo Thoracic Trauma Surgery (TTS) present a wide spectrum of characteristics and prognosis. Aim: To describe clinical characteristics, indications, temporality, morbidity, mortality and mortality associated variables in TTS patients. Materials and Method: Observational study of TT hospitalized patients, period January-1981 to December-2019. A review of operation notes and database was done. A logistic regression for mortality associated variables was made. To compare classification, type of TT and its temporal distribution, SPSS25® with chi-square test was used, considering significant p < 0.05. Results: A total of 808 (18.2%) of 4.448 TT patients required TTS, 767 (94.9%) were men with average age: 31.5 ± 13.8. The trauma was penetrating trauma due to a stab in most cases, 164 (20.3%) were polytraumatized. The surgery was urgent in 474 (58.7%), early in 41 (5.0%) and delayed in 293 (36.3%) cases. The global mortality was 6.7% and was significantly higher in the blunt TT, polytrauma, urgent and early surgery patients. Mortality in urgent TTS was 9.7%, early 4.9% and 2.0% in delayed (p < 0.001). Independent variables associated with mortality were observed. Conclusions: In our series, TTS were performed mainly in young men with penetrating TT. The group was heterogeneous regarding surgical indications, findings and intrathoracic or associated injuries. Multiple variables showed to influence significantly on mortality in patients who underwent TTS.

Development and validation of a machine learning method to predict intraoperative red blood cell transfusions in cardiothoracic surgery.

Accurately predicting red blood cell (RBC) transfusion requirements in cardiothoracic (CT) surgery could improve blood inventory management and be used as a surrogate marker for assessing hemorrhage risk preoperatively. We developed a machine learning (ML) method to predict intraoperative RBC transfusions in CT surgery. A detailed database containing time-stamped clinical variables for all CT surgeries from 5/2014-6/2019 at a single center (n = 2410) was used for model development. After random forest feature selection, surviving features were inputs for ML algorithms using five-fold cross-validation. The dataset was updated with 437 additional cases from 8/2019-8/2020 for validation. We developed and validated a hybrid ML method given the skewed nature of the dataset. Our Gaussian Process (GP) regression ML algorithm accurately predicted RBC transfusion amounts of 0 and 1-3 units (root mean square error, RMSE 0.117 and 1.705, respectively) and our GP classification ML algorithm accurately predicted 4 + RBC units transfused (area under the curve, AUC = 0.826). The final prediction is the regression result if classification predicted < 4 units transfused, or the classification result if 4 + units were predicted. We developed and validated an ML method to accurately predict intraoperative RBC transfusions in CT surgery using local data.

Italian survey on non-intubated thoracic surgery: results from INFINITY group.

BACKGROUND: Non-Intubated Thoracic Surgery (NITS) is becoming increasingly adopted all over the world. Although it is mainly used for pleural operations,, non-intubated parenchymal lung surgery has been less frequently reported. Recently, NITS utilization seems to be increased also in Italy, albeit there are no multi-center studies confirming this finding. The objective of this survey is to assess quantitatively and qualitatively the performance of NITS in Italy. METHODS: In 2018 a web-based national survey on Non-Intubated management including both thoracic surgeons and anesthesiologists was carried out. Reference centers have been asked to answer 32 questions. Replies were collected from June 26 to November 31, 2019. RESULTS: We raised feedbacks from 95% (55/58) of Italian centers. Seventy-eight percent of the respondents perform NITS but only 38% of them used this strategy for parenchymal surgery. These procedures are more frequently carried out in patients with severe comorbidities and/or with poor lung function. Several issues as obesity, previous non-invasive ventilation and/or oxygen therapy are considered contraindications to NITS. The regional anesthesia technique most used to provide intra- and postoperative analgesia was the paravertebral block (37%). Conversion to general anesthesia is not anecdotal (31% of answerers). More than half of the centers believed that NITS may reduce postoperative intensive care unit admissions. Approximately a quarter of the centers are conducting trials on NITS and, three quarters of the respondent suppose that the number of these procedures will increase in the future. CONCLUSIONS: There is a growing interest in Italy for NITS and this survey provides a clear view of the national management framework of these procedures.

Alcoholización de nervios intercostales en el postoperatorio de la cirugía torácica / Alcoholization of the Intercostal Nerves on the Postoperative Period of Thoracic Surgery

Introducción: La cirugía torácica figura entre los procedimientos quirúrgicos más dolorosos. Objetivo: Describir los resultados de la alcoholización de nervios intercostales para analgesia postoperatoria. Métodos: Se realizó un estudio prospectivo, observacional y descriptivo de pacientes tratados quirúrgicamente por afecciones torácicas durante 2018-2019. La muestra incluyó 50 pacientes que cumplieron los criterios de inclusión: operados por el autor principal, mayores de 18 años, acceso intercostal y firmaron el consentimiento informado. Se excluyeron los operados por otros cirujanos o presentaron afectación de la pared torácica. La intensidad del dolor se categorizó en cuatro grupos: leve, moderado, intenso e insoportable, según escala análogo visual. Resultados: Durante la primera noche, predominaron el dolor leve (25/50 por ciento) y moderado (9/18 por ciento). El dolor intenso se presentó en dos (4 por ciento) pacientes y 14(28 por ciento) no necesitaron medicación adicional. Al día siguiente no hubo casos con dolor intenso y solo 9 acusaron dolor moderado. La analgesia peridural solo se utilizó la primera noche y al siguiente día. La tendencia a disminuir el dolor se mantuvo al segundo y tercer día. No hubo casos con dolor insoportable. A largo plazo solo un paciente presentó dolor intenso que necesitó tratamiento con bloqueos. Conclusiones: La alcoholización disminuyó el uso adicional de analgésicos. No hubo complicaciones ni dolor insoportable, por lo que consideramos que este método podría ser una alternativa segura, sobre todo cuando no se dispone de fármacos costosos o personal entrenado en las técnicas modernas de analgesia postoperatoria(AU)

Introduction: Thoracic surgery is among the most painful surgical procedures. Objective: To describe the outcomes of the alcoholization of the intercostal nerves for postoperative analgesia. Methods: A prospective, observational and descriptive study was carried out, with patients treated surgically for thoracic conditions during 2018-2019. The sample included fifty patients who met the inclusion criteria: operated by the corresponding author, older than eighteen years, intercostal access and patients who signed the informed consent. Those operated on by other surgeons or who had chest wall involvement were excluded. Pain intensity was categorized into four groups: mild, moderate, intense and unbearable, according to the analog-visual scale. Results: During the first night, mild (25: 50 percent) and moderate (9: 18 percent) pain predominated. Severe pain occurred in two (4 percent) patients, while 14 (28 percent) did not require any additional medication. The next day, there were no cases of severe pain and only nine reported moderate pain. Epidural analgesia was only used the first night and the next day. The tendency to decrease in pain was maintained on the second and third days. There were no cases with unbearable pain. In the long term, only one patient had severe pain and required, therefore, treatment with blocks. Conclusions: Alcoholization decreased the additional use of analgesics. There were no complications or unbearable pain, a reason why we consider that this method could be a safe alternative, especially when expensive drugs or personnel trained in modern postoperative analgesia techniques are not available(AU)

Hiperglucemia en ayuno como factor pronóstico en cirugía cardíaca / Fasting hyperglycemia as a prognostic factor in cardiac surgery

Introducción: La hiperglucemia de ayuno es un factor pronóstico en cirugía. Encontrar el umbral de riesgo mayor en cirugía cardiovascular es una necesidad en la práctica médica actual. Objetivo: Estimar el umbral glucémico ideal de ayuno para un mejor pronóstico en la evolución clínica de los pacientes sometidos a cirugía cardiaca. Métodos: Se realizó un estudio descriptivo prospectivo en pacientes sometidos a cirugía cardíaca, en el Hospital Hermanos Ameijeiras durante el periodo de enero a junio del año 2017. La muestra quedó constituida por 191 pacientes, a todos los pacientes se les determinó glucemia de ayuno. Se empleó la prueba de independencia Ji-cuadrado (X2) para evaluar la asociación entre variables. Se realizó un análisis de regresión logística para identificar el efecto independiente de las variables estudiadas. Además, se construyó una curva Receiver Operating Characteristic Curve (por sus siglas en inglés) en la que se graficaron especificidad 1 y sensibilidad para cada punto de corte definido para los valores glucémicos. Resultados: La edad de los pacientes predominó entre 40-69 años, el sexo masculino representó 60,7 por ciento de la muestra, el 55,5 por ciento presentó glucemias normales y solo el 1,6 por ciento presentó glucemias mayores a 15 mmol/L. El 33,5 por ciento presentó algún tipo de complicación, los pacientes que presentaron complicaciones tenían la glucemia por encima de 9,9 mmol/L en el 84,4 por ciento. En el análisis multivariado solo hubo significación estadística para la aparición de complicaciones para la glucemia mayor a 10 mmol/L. Conclusiones: La hiperglucemia de ayuno se asoció a mayor riesgo de complicaciones(AU)

Introduction: Fasting hyperglycemia is a prognostic factor in surgery. Finding the highest risk threshold in cardiovascular surgery is a necessity in current medical practice. Objective: To estimate the ideal fasting glycemic threshold for a better prognosis in the clinical evolution of patients undergoing cardiac surgery. Methods: A prospective descriptive study was carried out in patients undergoing cardiac surgery, at Hermanos Ameijeiras Hospital from January to June 2017. The sample consisted of 191 patients; fasting blood glucose was determined in all patients. The Chi-square (X2) test of independence was used to evaluate the association between variables. A logistic regression analysis was performed to identify the independent effect of the variables studied. In addition, a Receiver Operating Characteristic Curve was constructed in which 1-specificity and sensitivity were plotted for each cut-off point defined for the glycemic values. Results: The 40-69 years age of the patients predominated, the male sex represented 60.7 percent of the sample, 55.5 percent had normal blood glucose levels and only 1.6 percent showed blood glucose levels higher than 15 mmol/L. Moreover, 33.5 percent had some type of complication; the patients with complications had blood glucose levels above 9.9 mmol/L in 84.4 percent. In the multivariate analysis, there was only statistical significance for the appearance of complications for glycaemia higher than 10 mmol/L. Conclusions: Fasting hyperglycemia was associated with higher risk of complications(AU)

Intraoperative cerebral oximetry in open heart surgeries reduced postoperative complications: A retrospective study.

Cardiothoracic surgeries are life-saving procedures but often it results in various complications. Intraoperative cerebral oximetry monitoring used to detect regional cerebral oxygen saturation (rScO2) is a non-invasive method that provides prognostic importance in cardiac surgery. The main aim of the present study was to evaluate the association of intraoperative cerebral oxygen monitoring during cardiac surgery on postoperative complications. This was a case-controlled retrospective study conducted on adult patients, who underwent open-heart surgery in National Heart Institute, Malaysia. The case group comprised patients on protocolized cerebral oximetry monitoring. They were treated using a standardized algorithm to maintain rScO2 not lower than 20% of baseline rScO2. The control group comprised patients with matched demographic background, preoperative risk factors, and type of surgical procedures. Propensity score stratification was utilized to contend with selection bias. Retrospective analysis was performed on 240 patients (case group) while comparing it to 407 patients (control group). The non-availability of cerebral oximetry monitoring during surgery was the prominent predictor for all outcome of complications; stroke (OR: 7.66), renal failure needing dialysis (OR: 5.12) and mortality (OR: 20.51). Postoperative complications revealed that there were significant differences for risk of mortality (p<0.001, OR = 20.51), renal failure that required dialysis (p<0.001, OR = 5.12) and stroke (p <0.05, OR = 7.66). Protocolized cerebral oximetry monitoring during cardiothoracic surgeries was found to be associated with lower incidence of stroke, renal failure requiring dialysis and mortality rate.

Oxygen reserve index guided oxygen titration in one lung ventilation with low fresh gas flow

Background/aim: Continuous oxygen reserve index (ORI) measurement with multiple wave pulse co-oximetry is a noninvasive measurement. The decrease in the ORI trend provides a prediction for the development of hypoxemia and provides info rmation on hyperoxia. Our aim is to determine the effect of ORI-guided oxygen titration on hyperoxemia-mediated morbidity. Materials and methods: Consecutive 120 ASA I-III patients, 18­70 years of age, without severe obstruction or restriction, undergoing one lung ventilation (OLV), were included in the study. Patients were divided into 4 groups. Oxygen titration without ORI monitoring with low-flow anesthesia (1 L/min, Group 1, n = 25) and high-flow anesthesia (4 L/min, Group 2, n = 28). Oxygen titration by ORI monitoring with low flow anesthesia (1 L/min, Group 3, n = 25) and high flow anesthesia (4 L/min, Group 4, n = 25). FiO2 increased up to 100% if necessary. OLV time, duration of surgery and anesthesia, FiO2 applied during OLV, oxygen application time (T) over 60%, vital signs, hospital and ICU stay time, and complications were recorded. Results: There was a statistically significant difference in terms of FiO2 used during OLV (p < 0.05). There was no difference in ORI values (p < 0.05). In Group 3, both PaO2 and SpO2 were significantly lower than the others both before and during OLV. There was no significant difference in terms of ORI parameters between low flow and high flow anesthesia groups. There was a strong, positive correlation between the duration of hospital stay and FiO2 used above 80% during OLV. Conclusion: We concluded that ORI-guided thoracic anesthesia may reduce hospital stay and increase patient safety.

Caso Clínico: Resolución quirúrgica de coartación de aorta en un paciente pediátrico / Case Report: Surgical resolution of aortic coarctation in pediatric patient

INTRODUCCIÓN: La coartación de aorta es una cardiopatía congénita con una incidencia de 4 por cada 10 000 nacidos vivos y puede asociarse o no a ductus arterioso persistente u otras malformaciones. Suele ser asintomático, normalmente se diagnostica mediante los signos clásicos; con gradiente de presión arterial entre extremidades, pulsos reducidos en extremidades inferiores, hipertensión arterial en miembros superiores o, en casos graves, fallo cardiaco izquierdo. Su resolución puede ser percutánea o quirúrgica, dependiendo de la edad y sus características. CASO CLÍNICO: Paciente masculino de 6 años, asintomático, con sospecha de coartación aórtica, por presentar una diferencia entre presiones arteriales de miembros superiores e inferiores, extremidades inferiores con pulsos reducidos y soplo sistólico en foco aórtico. Se solicitó ecocardiograma que informó válvula aórtica bicúspide con rafe, insuficiencia ligera y coartación de aorta; angiotomografía evidenció coartación de aorta yuxtaductal; cateterismo cardiaco objetivó casi nulo paso de contraste a través del defecto, por lo que se programó tratamiento quirúrgico. EVOLUCIÓN: La corrección quirúrgica se realizó mediante coartectomía con anastomosis termino-terminal más cierre del conducto arterioso. Posterior a la intervención se logró objetivar una mejora relevante en el gradiente de presión entre las extremidades. En el postquirúrgico el paciente presentó hipertensión que logró ser controlada, evolucionó favorablemente y recibió el alta a los 4 días sin tratamiento antihipertensivo ambulatorio. CONCLUSIÓN: La expectativa de vida en pacientes intervenidos para corregir su cardiopatía congénita es superior en relación a aquellos que no son intervenidos, por lo que el diagnóstico oportuno supone una herramienta importante para mejorar la calidad y esperanza de vida.

BACKGROUND: Coarctation of the aorta is a congenital heart disease with an incidence of 4 per 10 000 live births, it may or may not be associated with patent ductus arteriosus as well as other malformations. It is usually asymptomatic and diagnosed by its classic signs such as; arterial pressure gradient between extremities, reduced pulses in the lower extremities, arterial hypertension in the upper extremities or, in severe cases, left heart failure. Its resolution can be percutaneous or surgical, depending on the patient's age and the characteristics of the defect. CASE REPORTS: A 6-year-old male patient, asymptomatic, with suspected aortic coarctation, due to a difference between arterial pressures in the upper and lower limbs, lower limbs with reduced pulses, and a systolic murmur in the aortic focus. An echocardiogram was requested, which reported a bicuspid aortic valve with raphe, mild regurgitation, and coarctation of the aorta; CT angiography showed coarctation of the juxtaductal aorta; cardiac catheterization showed almost no passage of contrast through the defect, so surgical treatment was scheduled. EVOLUTION: Surgical correction was performed by coartectomy with end-to-end anastomosis and closure of the ductus arteriosus. After the intervention, a relevant improvement in the pressure gradient between the extremities was observed. In the postoperative period the patient presented hypertension, that we managed to control, the patient progressed favorably and was discharged after 4 days without antihypertensive treatment. CONCLUSION: Life expectancy in patients who underwent surgery to correct a congenital heart disease is higher than in those who don't, so timely diagnosis is an important tool to improve life quality and life expectancy.

How far will minimally invasive thoracic surgery go? Uniportal video-assisted thoracoscopic lingulectomy with 1 cm incision complicated by a mediastinal lingual artery: A case report.

Here, we present the case of a 36-year-old female patient who was found to have a ground-glass nodule (GGN) in the left lingual segment on chest computed tomography (CT) and who successfully underwent lingulectomy via 1 cm incision uniportal video-assisted thoracoscopic surgery (VATS). This is a technically safe and feasible procedure in selected patients and produces better cosmetic results than traditional thoracoscopic surgery.

Joint Statement of the German Respiratory Society and German Society of Thoracic Surgery in Cooperation with the German Radiological Society: Structural Prerequisites of Centres for Interventional Treatment of Emphysema.

Interventional treatment of emphysema offers a wide range of surgical and endoscopic options for patients with advanced disease. Multidisciplinary collaboration of pulmonology, thoracic surgery, and imaging disciplines in patient selection, therapy, and follow-up ensures treatment quality. The present joint statement describes the required structural and quality prerequisites of treatment centres. This is a translation of the German article "Positionspapier der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin und der Deutschen Gesellschaft für Thoraxchirurgie in Kooperation mit der Deutschen Röntgengesellschaft: Strukturvoraussetzungen von Zentren für die interventionelle Emphysemtherapie" Pneumologie. 2020;74:17-23.