[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.

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

Los pacientes operados de cirugía cardiaca tienen un riesgo elevado de hemorragia y transfusión. Este riesgo ha ido aumentando en las últimas décadas y, pese a ser una de las complicaciones más frecuentes y con mayor morbimortalidad asociadas a esta cirugía, sigue existiendo una gran variabilidad en cuanto a su manejo entre las instituciones. El uso de algoritmos de manejo de la hemorragia ha demostrado que disminuye los requerimientos de transfusión y por tanto parece imprescindible establecer protocolos que incluyan medidas preventivas, mecanismos eficaces de diagnóstico y algoritmos de tratamiento. Por otra parte, la aparición de nuevos fármacos procoagulantes y de nuevos sistemas de monitorización de la hemostasia están cambiando nuestras posibilidades diagnósticas y terapéuticas. En este trabajo se revisan varios aspectos relacionados con las causas, la prevención, el diagnóstico y el tratamiento de la hemorragia asociada a la cirugía cardiaca y se presenta una propuesta de algoritmo para su manejo(AU)

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(AU)

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 / Insertion of a double-lumen endobronchial tube with a 6 mm fiberoptic bronchoscope and a Cook airway exchange catheter in a patient with an unanticipated difficult airway

Varón de 74 años programado para neumonectomía izquierda, en el que no se preveía dificultad de intubación traqueal. Tras la inducción anestésica con midazolam, fentanilo, propofol y rocuronio, la laringoscopia objetivó Cormack-Lehane grado IV y tras dos intentos no se pudo intubar la traquea. Al no disponer de fibrobroncoscopio fino para intubación con tubo de doble luz, se utilizó un fibrobroncoscopio de 6 mm y se intubó al paciente con un tubo orotraqueal del nº 9 que se insertó en el bronquio principal izquierdo. La intubación se realizó con la ayuda de un adaptador universal para intubación fibroóptica con mascarilla facial y de una cánula de Williams, que permitieron ventilar manualmente al paciente con O2 al 100 por ciento mientras se realizó la fibroscopia. Dado que se precisaba ventilación selectiva durante la intervención, se insertó el intercambiador de tubos traqueales tipo Cook nº 11 en el bronquio principal izquierdo, se retiró el tubo traqueal, y se utilizó como guía el intercambiador, a través de la luz bronquial de un tubo de doble luz nº 39F izquierdo, que se introdujo sin dificultad, consiguiendo una intubación y ventilación selectivas satisfactorias. Ésta es una nueva indicación del intercambiador de tubos Cook que permite la intubación selectiva bronquial en caso de intubación traqueal difícil cuando no se dispone de fibrobroncoscopio fino (AU)