Perioperative neuromuscular blockade. 2020 update of the SEDAR (Sociedad Española de Anestesiología y Reanimación) recommendations.

We present an update of the 2020 Recommendations on neuromuscular blockade of the SEDAR. The previous ones dated 2009. A modified Delphi consensus analysis (experts, working group, and previous extensive bibliographic revision) 10 recommendations were produced1: neuromuscular blocking agents were recommended for endotracheal intubation and to avoid faringo-laryngeal and tracheal lesions, including critical care patients.2 We recommend not to use neuromuscular blocking agents for routine insertion of supraglotic airway devices, and to use it only in cases of airway obstruction or endotracheal intubation through the device.3 We recommend to use a rapid action neuromuscular blocking agent with an hypnotic in rapid sequence induction of anesthesia.4 We recommend profound neuromuscular block in laparoscopic surgery.5 We recommend quantitative monitoring of neuromuscular blockade during the whole surgical procedure, provided neuromuscular blocking agents have been used.6 We recommend quantitative monitoring through ulnar nerve stimulation and response evaluation of the adductor pollicis brevis, acceleromyography being the clinical standard.7 We recommend a recovery of neuromuscular block of at least TOFr ≥ 0.9 to avoid postoperative residual neuromuscular blockade.8 We recommend drug reversal of neuromuscular block at the end of general anesthetic, before extubation, provided a TOFr ≥ 0.9 has not been reached.9 We recommend to choose anticholinesterases for neuromuscular block reversal only if TOF≥2 and a TOFr ≥ 0.9 has not been attained.10 We recommend to choose sugammadex instead of anticholinesterases for reversal of neuromuscular blockade induced with rocuronium.

[Acute myocardial infarction complicating radiofrequency catheter ablation in a girl]. / Infarto agudo de miocardio tras ablación por radiofrecuencia de vía cardiaca anómala en un niño.

Paroxysmal supraventricular tachycardia is the most common tachyarrhythmia in childhood and adolescence. The current treatment of choice for managing and preventing frequent recurrences is radiofrequency catheter ablation, which provides a definitive solution in most cases. This technique is very effective but not devoid of potential complications, particularly in children and adolescents. We report the case of a 3-year-old girl who suffered acute myocardial infarction after occlusion of the right coronary artery during this procedure. We describe intraoperative and postoperative management. Progress was good and the patient was discharged 14 days after ablation.

[Hafnia alvei in a rare case of severe pneumonia in a postanesthesia recovery unit]. / Hafnia alvei: una causa infrecuente de neumonía grave en la unidad de reanimación.

An 85-year-old man with a history of moderate chronic obstructive pulmonary disease in treatment with anticholinergic drugs was admitted to the recovery unit for postoperative monitoring after right inguinal herniorrhaphy surgery and removal of a strangulated intestinal section. On the third day after surgery the patient developed radiographic signs consistent with pneumonia and required mechanical ventilation. Two blood cultures and a respiratory secretion sample grew a microorganism identified as Hafnia alvei. H. alvei is a gram-negative bacillus that colonizes the digestive tract of humans and animals and in immunodepressed patients it can colonize the mouth and pharynx. Isolation of H. alvei is described in the literature on pediatric patients and those with a history of immune deficiency or chronic disease. Infection has a severe impact on general health. We report a rare and interesting case of pneumonia and bacteremia from H. alvei infection acquired by an immunocompetent patient soon after arrival in the postoperative recovery unit. The patient died of the infection.

Bloqueo neuromuscular perioperatorio. Actualización 2020 de las Recomendaciones de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR) / Perioperative neuromuscular blockade. 2020 update of the SEDAR (Sociedad Española de Anestesiología y Reanimación) recommendations

Se presenta la actualización 2020 de las Recomendaciones de bloqueo neuromuscular de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR). Las anteriores databan de 2009. Tras un análisis de consenso Delphi (expertos, grupo de trabajo y revisión bibliográfica previa) se generaron 10 recomendaciones: 1) Se recomienda el uso de fármacos bloqueantes neuromusculares (fbnm) para facilitar la intubación traqueal y evitar lesiones faringo-laringo-traqueales en cualquier paciente, incluidos pacientes críticos. 2) Se recomienda no utilizar fbnm para la inserción rutinaria de dispositivos supraglóticos y utilizar solo en caso de obstrucción de la vía aérea o intubación traqueal a través de este. 3) Se recomienda utilizar un fármaco bloqueante neuromuscular de inicio de acción rápido asociado al agente hipnótico en la inducción de secuencia rápida. 4) Se recomienda utilizar un nivel de bloqueo neuromuscular profundo en cirugía laparoscópica. 5) Se recomienda el uso de monitorización cuantitativa del bloqueo neuromuscular durante todo el procedimiento quirúrgico, siempre que se utilicen fbnm. 6) Se recomienda la monitorización cuantitativa mediante estimulación del nervio cubital y evaluación de la respuesta en el músculo aductor corto del pulgar, siendo el estándar clínico la aceleromiografía (AMG). 7) Se recomienda una recuperación del bloqueo neuromuscular al menos hasta alcanzar un TOFr ≥ 0,9 para evitar el bloqueo neuromuscular residual postoperatorio. 8) Se recomienda la reversión farmacológica del bloqueo neuromuscular al finalizar la anestesia general, previo a la extubación traqueal siempre que no se haya alcanzado un TOFr ≥ 0,9. 9) Se recomienda utilizar fármacos anticolinesterásicos para la reversión del bloqueo neuromuscular solo cuando el tren de cuatro estímulos (TOF) es ≥ 2 y no se haya alcanzado un TOFr ≥ 0,9. 10)...(AU)

We present an update of the 2020 Recommendations on neuromuscular blockade of the SEDAR. The previous ones dated 2009. A modified Delphi consensus analyisis (experts, working group, and previous extensive bibliographic revision) 10 recommendations were produced: (1) neuromuscular blocking agents were recommended for endotracheal intubation and to avoid faringo-laryngeal and tracheal lesions, including critical care patients. (2) We recommend not to use neuromuscular blocking agents for routine insertion of supraglotic airway devices, and to use it only in cases of airway obstruction or endotracheal intubation through the device. (3) SWe recommend to use a rapid action neuromuscular blocking agent with an hypnotic in rapid sequence induction of anesthesia. (4) We recommed profound neuromuscular block in laparoscopic surgery. (5) We recommend quantitative monitoring Sof neuromuscular blockade during the whole surgical procedure, provided neuromuscular blocking agents have been used. (6) We recommend quantitative monitoring through ulnar nerve stimulation and response evaluation of the adductor pollicis brevis, acceleromyography being the clinical standard. (7) We recommned a recovery of neuromuscular block of at least TOFr ≥ 0.9 to avoid postoperative residual neuromuscular blockade. (8) We recommend drug reversal of neuromuscular block at the end of general anesthetic, before extubation, provided a TOFr ≥ 0.9 has not been reached. (9) We recommend to choose anticholinesterases for neuromuscular block reversal only if TOF ≥ 2 and a TOFr ≥ 0.9 has not been atained. (10) We recommend to choose sugammadex instead of anticholinesterases for reversal of neuromuscular blockade induced with rocuronium.(AU)

Do latex allergens potentiate other skin tests?

We report the case of a 33 year old atopic female patient, who worked for the last 4 years as a cleaner in the surgical area of a hospital. One year after starting the work in this area, the patient noticed upper respiratory symptoms and soon later dyspnea immediately after entering the operating room. Other allergic symptoms were perennial rhinoconjunctivitis and urticaria after contact with peaches. Common skin prick tests were positive for Dermatophagoides pteronyssinus. Fifteen min later a skin prick test with latex was done with a strong positive result after 10 min. At the same time, several allergens (cat dander, grass and olive pollens) showed positive results. The patient experienced a fall in the FEV1 that returned to basal levels after two inhalations of a bronchodilator. New skin tests to common allergens performed one week later were only positive to mites.

Radiothelemetric monitoring of hydrogen ion levels of the small intestine.

A radiotelemetric technique was used to document the pH level within the intact small intestine of the dog. It was found that the pH in the area of the upper part of the jejunum ranged in a neutral zone between 6 to 7 in the fasting dog. Stimulation of the Thiry-Vella loop in these dogs, with either acid or alkaline solution, always resulted in the pH rising toward a higher level, the highest pH level being recorded as 8.2. All dogs demonstrated a lowering of this pH level toward a neutral range of 6 to 7 within three hours after Thiry-Vella loop challenge.

Occupational asthma caused by Papaver somniferum.

Twenty eight workers of a pharmaceutical factory were studied. The company produced morphine and other alkaloids extracting the active principles from shells of Papaver somniferum. Six of the exposed subjects had clinical symptoms of sensitization to this allergen and positive skin tests. A bronchial provocation test was found to be positive on 4 workers and specific IgE could be found on the 6 sensitized patients by an ELISA and a RAST test using an aqueous extract of P. somniferum. A histamine release using the same antigen was also positive in the 4 samples from sensitized patients available. An SDS-PAGE of the extract revealed a major protein band with an estimated mol wt of 52,000 d. This band had the highest IgE-binding capacity as shown by immunoblotting. All these facts suggest that P. somniferum allergy is mediated by an IgE mediated mechanism and not by a pharmacological or toxic effect of the alkaloids or polyphenols.

alpha-Amylase hypersensitivity in non-exposed millers.

Occupational hypersensitivity to alpha-amylase among bakers and workers in the pharmaceutical industry has been described. We present the results of skin tests and in vitro methods used to assess alpha-amylase sensitivity in 259 millers. There was no occupational contact with the enzyme in this population. Positive skin tests to this allergen were obtained in 16 subjects (6.18 per cent), specific IgE values were found in seven subjects (2.7 per cent), specific IgG was detected on 45 workers (17.37 per cent) and high values for IgG (> 2.5 absorbance units) were found in 12 subjects (4.63 per cent). Furthermore, specific IgE and IgG could be determined in several sera by immunoblotting. All these facts suggested that millers were sensitized to Aspergillus oryzae alpha-amylase, although the allergen was not used by these workers. A cross-reaction cannot be excluded; however, it is the authors' opinion that wheat or wheat flour is a natural substrate for fungi and that the moulds that grow on cereals or cereal-derived by-products need to secrete amylases to support their own development. Hence the workers may be indirectly sensitized to amylases.

Isolation and characterization of Tha p 1, a major allergen from the pine processionary caterpillar Thaumetopoea pityocampa.

BACKGROUND: Pine processionary caterpillars induce dermatitis by a toxic-irritative mechanism. The existence of true allergic reactions to allergens from these caterpillars has been recently demonstrated by positive immediate skin prick tests and specific IgE determination by immunoblotting using crude larval extracts. The aim of this work was to purify allergens from the crude larval extract in order to characterize IgE-binding proteins from these caterpillars. METHODS: Allergens were separated by ethanol gradient fractionation and reversed phase HPLC. The N-terminal amino acid sequence of a selected allergen was obtained after SDS-PAGE and transfer. The clinical relevance of this allergen was measured using sera from patients allergic to caterpillar. RESULTS: An allergen with a molecular weight close to 15 kDa was purified. It was recognized by 9 out of 11 allergic patients (82%). Its N-terminal amino acid sequence had no homologies to any other protein already described in data bases. For this reason, no information about its biological function could be obtained. CONCLUSIONS: This 15-kDa IgE-binding protein is a major caterpillar allergen and shows no homologies to other insect allergens already described.

Skin-prick tests for hypersensitivity to alpha-amylase preparations.

Twenty-five asthmatic subjects with suspected alpha-amylase hypersensitivity were studied by skin-prick tests, a capture ELISA, immunoblotting and bronchial provocation tests. At the same time, different amylases were analysed by SDS-PAGE and immunoblotting using a polyclonal rabbit antiserum. Eight patients showed a positive bronchial response to amylase. Seven of them had positive skin-prick tests, with this method being the most sensitive approach for diagnosis. However, in four cases, skin tests were also positive although the patients had a negative provocation test, thus demonstrating that skin tests are not specific. ELISA and blotting showed similar results in terms of sensitivity and specificity. The enzymes used by the workers included several antigens besides alpha-amylase. The rabbit antiserum to alpha-amylase detected a protein in a wheat flour extract. In one case, the IgE antibodies were specific only for a contaminant of lower molecular weight than amylase. These facts suggest that proteins from the culture medium could be responsible for some cases of amylase hypersensitivity, making the diagnosis difficult. The presence of amylase in another enzymatic extract, a protease produced by Aspergillus oryzae, was proved by means of skin tests and immunoblotting, thus demonstrating the allergenic properties of this enzymatic preparation.

Periodate treatment of Anisakis simplex allergens.

Anaphylactic reactions after parasitized fish consumption are mediated by an IgE response. However, positive skin tests and specific IgE can also be found in many asymptomatic subjects who recognize a single medium-mol.-wt. antigen by IgE immunoblot. The study aimed to find out whether this unspecificity was due to the carbohydrate moieties of parasite antigens. Sixty-two patients with suspected parasite allergy, 51 blood donors, 18 bakers, and 38 atopic patients were studied by blotting. Parasite proteins were treated with periodate. Several selected sera were inhibited with a crude wheat extract and fungal amylase. Twelve patients (19%), eight donors (16%), six bakers (33%), and one atopic patient (3%) recognized a single medium-mol.-wt. band in blotting and should be considered false-positive. This band was periodate-sensitive, but specific IgE to this allergen could not be inhibited by a wheat extract nor by fungal amylase and was clinically irrelevant. Diagnosis of Anisakis simplex hypersensitivity by skin tests and/ or specific IgE values should always be confirmed by specific IgE immunoblotting in order to detect the presence of clinically unrelated antibodies directed to periodate-sensitive allergens. These allergens are probably not a carbohydrate moiety of a parasite glycoprotein.

Lack of crossreaction with Bet v 1 in patients sensitized to Dau c 1, a carrot allergen.

BACKGROUND: Pollen-related food allergies to fresh fruit and vegetables are a well-known clinical phenomenon. Allergens related to Bet v 1 are responsible for these cross-reactions. OBJECTIVE: To characterize the allergen recognized by four carrot-allergic patients. METHODS: Sera from four patients showing strong immediate systemic reactions after contact or ingestion of raw carrot were studied by immunoblotting. The 18-kD allergen, named Dau c 1, was isolated by ethanol precipitation and specific extraction after SDS-PAGE and its N-terminal amino acid sequence was determined. RESULTS: All the patients had significant levels of specific IgE to carrot, but no specific IgE to birch pollen was detected in any of them. IgE immunodetection with the sera only recognized a single band of around 18 kD in raw carrot and in celery (with weaker reaction). No reactive band was found with birch pollen. These results were confirmed using a polyclonal anti-carrot antiserum. The carrot IgE-binding protein had a pl of 4.2 and its N-terminal sequence was homologous to that of Bet v 1 and to allergens previously described in celery and other foods. The four patients studied were not sensitized to birch pollen and three of them tolerated fruit ingestion. CONCLUSION: The whole study indicated that a sensitization to Dau c 1 induces IgE antibodies that do not cross-react with birch pollen allergens.