[Mandibular distraction osteogenesis in patients with craniofacial malformation]. / Distracción mandibular osteogénica en pacientes con malformaciones craneofaciales.

Craniofacial malformations (Pierre-Robin sequence, Treacher-Collins syndrome, Nager syndrome, etc.) are frequently associated to severe mandibular hypoplasia, which can cause upper airway obstruction by retroposition of the base of the tongue in the posterior pharyngeal space. Most of the patients respond to postural treatment. In prone decubitus position, it may be necessary to monitor oxygen saturation, insert a nasopharyngeal tube and even an endotracheal one. In more severe cases with prolonged and frequent pauses of apnea, tracheostomy may be necessary, but it is associated with high morbidity and sometimes mortality. In the last two years, in the Multidisciplinary Cleft Lip and Palate Unit of the Hospital Virgen de las Nieves, 4 children with severe obstructive apnea secondary to severe mandibular hypoplasia have been treated with mandibular distraction osteogenesis, this procedure being effective in the resolution of the condition. It has avoided tracheostomy, it has lengthened the jaw in a period of 2-3 weeks. During this time, the obstructive respiratory problems and also swallowing problems have disappeared. The esthetic results were excellent and the complications, for the moment, minimum.

Distracción mandibular osteogénica en pacientes con malformaciones craneofaciales / Mandibular distraction osteogenesis in patients with craniofacial malformation

Las malformaciones craneofaciales (secuencia de Pierre Robin, síndrome de Threacher Collins, síndrome de Nager, etc.) con frecuencia van asociadas a hipoplasia mandibular severa, que puede causar obstrucción de la vía aérea superior por retroposición de la base de la lengua dentro del espacio faríngeo posterior. La mayoría de los pacientes responden al tratamiento postural; ende cúbito prono puede ser necesario monitorizar la saturación de oxígeno ,insertar un tubo nasofaríngeo e incluso endotraqueal. En casos más severos con pausas prolongadas y frecuentes de apnea la traqueostomía puede ser necesaria, pero se asocia a una alta morbilidad y ocasional mente mortalidad. En los últimos dos años, en la Unidad Multidisciplinar de Labio y Fisura Palatina del Hospital Virgen de las Nieves, se ha tratado a 4 niños con apnea obstructiva grave secundaria a hipoplasia mandibular severa mediante distracción mandibular osteogénica, mostrándose este procedimiento eficaz en la resolución del problema. Ha evitado la traqueostomía, se ha elongado la mandíbula en el plazo de 2-3 semanas, en este tiempo han desaparecido los problemas respiratorios obstructivos y también de la deglución, siendo los resultados estéticos obtenidos excelentes y las complicaciones, por el momento, mínimas (AU)

Craniofacial malformations (Pierre-Robin sequence, Treacher-Collins syndrome, Nager syndrome, etc.) are frequently associated to severe mandibular hypoplasia, which can cause upper airway obstruction by retroposition of the base of the tongue in the posterior pharyngeal space. Most of the patients respond to postural treatment. In prone decubitus position, it may be necessary to monitor oxygen saturation, insert a nasopharyngeal tube and even an endotracheal one. In more severe cases with prolonged and frequent pauses of apnea, tracheostomy maybe necessary, but it is associated with high morbidity and sometimes mortality. In the last two years, in the Multidisciplinary Cleft Lip and Palate Unit of the Hospital Virgen de las Nieves, 4 children with severe obstructive apnea secondary to severe mandibular hypoplasia have been treated with mandibular distraction osteogenesis, this procedure being effective in the resolution of the condition. It has avoided tracheostomy, it has lengthened the jaw in a period of 2-3 weeks. During this time, the obstructive respiratory problems and also swallowing problems have disappeared. The esthetic results were excellent and the complications, for the moment, mínimum (AU)

Hematoma epidural dorsal tras implante de neuroestimulador dorsal / Dorsal epidural hematoma after implantation of a dorsal nerve simulation

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Analgesia postoperatoria en la queiloplastia del lactante. Estudio comparativo: bloqueo infraorbitario intraoral bilateral con bupivacaína 0, 25% con adrenalina vs. analgesia intravenosa con tramadol / Postoperative analgesia for the management of chieloplasty in the breast-fed baby. Comparative study: bilateral intraoral blockade of the infraorbitary nerve with bupivacaine 0.25% plus adrenaline versus intravenous analgesia with tramadol

Objetivo: Comparar la eficacia y duración del bloqueo del nervio infraorbitario intraoral bilateral frente a la analgesia intravenosa convencional con tramadol en el control del dolor postoperatorio en lactantes sometidos a queiloplastia por labio leporino. Material y métodos: Tras la realización de una adecuada valoración preanestésica y la obtención del consentimiento informado de los padres, realizamos un estudio prospectivo, controlado aleatorizado y doble ciego en 25 niños, ASA I, con edades comprendidas entre los 3-10 meses, tras obtener el consentimiento informado de los padres, propuestos para cirugía correctora de labio leporino (queiloplastia). Todos ellos fueron premeditados, media hora antes de la intervención quirúrgica, con midazolan oral (0,5 mg.kg-1) y, en todos los casos, se practicó la técnica anestésica y el bloqueo nervioso por el mismo anestesiólogo, que consistió en una inducción inhalatoria con sevoflurano previa a la venoclisis. La anestesia general se completó con atropina, fentanilo y rocuronio a las dosis establecidas que se administraron, por vía intravenosa, previamente a la intubación endotraqueal y la ventilación mecánica. Los pacientes fueron divididos aleatoriamente en dos grupos: Grupo A (n = 12): se administró 1-2 ml de bupivacaína al 0,25% con adrenalina para el bloqueo infraorbitario bilateral y solución salina intravenosa como sustitutivo de la analgesia intravenosa con tramadol. Grupo B (n = 13): se administró solución salina para el bloqueo nervioso, en lugar de la bupivacaína, y tramadol intravenoso (1,5 mg.kg-1) como analgesia postoperatoria. En todos ellos se realizó anestesia general con sevoflurano y fentanilo "a demanda" según parámetros convencionales (tensión arterial, frecuencia cardiaca, tamaño pupilar, etc.). Durante sus primeras seis horas de estancia en Reanimación se valoró la duración de la analgesia, grado de disconfort e intensidad dolorosa. Además se anotó la aparición de cualquier complicación o efecto adverso. Los datos se analizaron mediante t Student y test χ2. Resultados: No existieron diferencias en cuanto a las características demográficas. La duración de la analgesia fue mayor en el grupo A (7,3 ± 5,1 h) que en el grupo B (2,8 ± 2,2 h) (p < 0,01). La valoración subjetiva de la intensidad dolorosa fue mayor en el grupo B (2,23 ± 0,83) que en el grupo A (0,66 ± 0,6) (p < 0,01). El grado de confort, según escala objetiva, fue significativamente mayor en el grupo que recibió el bloqueo con anestésico local. Discusión: La anestesia para neonatos sometidos a reparación de labio leporino, empleando bloqueo bilateral intraoral del nervio infraorbitario es una técnica segura, simple y rápida, que permite una analgesia duradera en el postoperatorio a la vez que minimiza los riesgos de depresión respiratoria, ya que posibilita una reducción en la utilización de analgésicos opioides, permitiendo un inmediato y confortable despertar (AU)

Objective: To compare the effectiveness and length of bilateral intraoral blockade of the infraorbitary nerve versus standard intravenous analgesia with tramadol for the management of postoperative pain in breast-fed infants undergoing chieloplasty due to harelip. Material and methods: After conducting an adequate pre-anesthetic assessment and obtaining the informed consent from their parents, we performed a double-blind, randomized, controlled and randomized study in 25 ASA I infants with ages ranging from 3 to 10 months that were candidates to corrective harelip surgery (chieloplasty). All of them were pretreated half an hour before the surgical procedure with oral midazolan (0.5 mg.kg-1) and the same anesthesiologist performed the anesthetic technique and the nerve blockade in all the cases, this being inhaled induction with sevoflurane prior to venoclysis. General anesthesia was achieved with intravenous administration of atropine, fentanyl and rocuronium at the standard doses prior to endotracheal intubation and mechanical ventilation. Patients were randomized to one of the following groups: Group A (n = 12): 1-2 ml of bupivacaine 0.25% plus adrenaline was administered for bilateral blockade of the intraorbitary nerve and intravenous saline solution instead of intravenous analgesia with tramadol. Group B (n = 13): saline solution was administered for nerve blockade, instead of bupivacaine, and intravenous tramadol (1.5 mg.kg-1) was provided as postoperative analgesia. All of the patients underwent general anesthesia with sevoflurane and fentanyl "on-demand" according to standard parameters (blood pressure, heart rate, pupil size, etc.). During the first six hours at Reanimation, length of analgesia, degree of discomfort and pain severity were assessed. The presence of complications or side effects was also recorded. Data were analyzed using the t Student and the χ2 test. Results: No differences were found regarding demographic features. Analgesia lasted more in group A (7.3 ± 5.1 h) compared to group B (2.8 ± 2.2 h) (p < 0.01). Subjective assessment of pain severity was higher in group B (2.23 ± 0.83) compared to group A (0.66 ± 0.6) (p < 0.01). Degree of comfort, as assessed through an objective scale, was significantly greater in the group undergoing blockade with local anesthetic. Discussion: Anesthesia for neonates undergoing surgical reparation of harelip with intraoral bilateral blockade of the infraorbitary nerve is a safe, simple and quick technique that provides a lasting postoperative analgesia and also reduces the risks of respiratory depression, since it allows a lower use of opiate analgesics and, hence, an immediate and comfortable awakening (AU)

[Criss-cross heart: anesthetic considerations for total cavopulmonary shunt (Fontan procedure)]. / Corazón en criss-cross. Consideraciones anestésicas para derivación cavopulmonar total (Fontan).

We report the anesthetic technique used for interatrial septal defect a 2-year-old girl weighing 11 Kg who presented with crossed atrioventricular connection (criss-cross heart), transposition of the great vessels, interatrial and interventricular septal defects, and subpulmonary and pulmonary valve stenoses. The patient was proposed for total cavopulmonary anastomosis with basal arterial oxygen saturation (SapO2) at 65%. Anesthesia was induced with inhaled agents and after intubation, hyperventilation was induced to achieve an end-tidal carbon dioxide pressure around 27 mm Hg. General anesthesia was provided in combination with spinal infusion of morphine chloride (100 microg Kg(-1)) for pain control. A Fontan procedure was carried out uneventfully with cardiopulmonary bypass. Milrinone was used at the extracorporeal circuit pump outlet. The patient was transferred to the pediatric intensive care unit where she was extubated without complications 90 minutes after admission. Anesthetic management is based on maintaining adequate preloading doses by administering volume, inhaled and/or intravenous agents, or use of vasoconstrictors and adjustment of ventilator parameters to modify pulmonary or systemic vascular resistance. We were able to maintain normal arterial pressure in our patient and provide adequate preloading through hyperventilation to reduce pulmonary vascular resistance.

Corazón en criss-cross. Consideraciones anestésicas para derivación cavopulmonar total (Fontan) / Criss-cross heart: anesthetic considerations for total cavopulmonary shunt (Fontan procedure)

Presentamos la técnica anestésica realizada en una paciente de 2 años de edad y 11 Kg de peso que presenta corazón con conexión atrioventricular cruzada o corazon en criss-cross, transposición de los grandes vasos, comunicación interauricular, comunicación interventricular, y estenosis subpulmonar y valvular pulmonar. Propuesta para anastomosis cavopulmonar total, presentaba SapO2 basal de 65%. Se realizó inducción inhalatoria y tras la intubación se inició hiperventilación para conseguir ETCO2 en torno a 27 mmHg. Se realizó una anestesia combinada general y caudal con cloruro mórfico (100 μg Kg-1) para control del dolor. Se practicó una intervención tipo Fontan, bajo circulación extracorpórea sin incidentes, empleándose milrinona a la salida de bomba. Se trasladó a la Unidad de Cuidados Intensivos pediátricos donde se extubó 90 minutos después de su ingreso, sin complicaciones. El manejo anestésico se basa en mantener precargas adecuadas mediante administración de volumen, uso de agentes inhalados y/o intravenosos, o uso de vasoconstrictores y variación parámetros ventilatorios para modificar resistencias vasculares pulmonares y/o sistémicas. En nuestro caso se procuró mantener una presión arte-rial normal y precarga adecuada, con hiperventilación para disminuir las resistencias vasculares pulmonares

We report the anesthetic technique used for interatrial septal defect a 2-year-old girl weighing 11 Kg who presented with crossed atrioventricular connection (criss-cross heart), transposition of the great vessels, interatrial and interventricular septal defects, and subpulmonary and pulmonary valve stenoses. The patient was proposed for total cavopulmonary anastomosis with basal arterial oxygen saturation (SapO2 ) at 65%. Anesthesia was induced with inhaled agents and after intubation, hyperventilation was induced to achieve an end-tidal carbon dioxide pressure around 27 mm Hg. General anesthesia was provided in combination with spinal infusion of morphine chloride (100 µg Kg–1) for pain control. A Fontan procedure was carried out uneventfully with cardiopulmonary bypass. Milrinone was used at the extra-corporeal circuit pump outlet. The patient was transferred to the pediatric intensive care unit where she was extubated without complications 90 minutes after admission. Anesthetic management is based on maintaining ad-equate preloading doses by administering volume, inhaled and/or intravenous agents, or use of vasoconstrictors and adjustment of ventilator parameters to modify pulmonary or systemic vascular resistance

Neumomediastino espontáneo (síndrome de hamman). Consideraciones anestésicas / On anesthesia in spontaneous pneumomediastinum (Hamman syndrome)

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Analgesia postoperatoria en el neonato / Postoperative analgesia in the neonate

Sabemos desde hace tiempo que el neonato siente dolor, y que los mecanismos álgicos en el recién nacido están suficientemente desarrollados. Aunque el empleo de métodos analgésicos en el postoperatorio de la cirugía neonatal es actualmente una práctica habitual, no lo es tanto en el dolor asociado a otros procedimientos. En la actualidad disponemos de métodos adecuados y objetivos para la valoración del dolor neonatal y de estrategias adecuadas para tratarlo, amén de un gran número de fármacos y procedimientos analgésicos seguros para la edad. El dolor postoperatorio es minimizado tomando actitudes previas en quirófano, empleando analgésicos o bien bloqueos con continuidad analgésica en el postoperatorio. En el dolor por procedimientos disponemos desde medidas conductuales, métodos no farmacológicos muy efectivos así como métodos analgésicos seguros. (AU)

[Efficacy of EMLA cream, effect of time and place of application]. / Eficacia de la crema EMLA, influencia del lugar y tiempo de aplicación.

OBJECTIVE: To evaluate the anesthetic efficacy of EMLA cream for alleviating pain associated with puncture and pressure in areas where venous catheters are normally inserted. MATERIAL AND METHODS: We performed a prospective, double blind study in 38 volunteers between 25 and 36 years of age, after obtaining informed consent. A 1.5 g dose of EMLA cream was applied to three sites on each patient: the back of the hand, the antecubital fossa and the side of the neck. Placebo cream with similar characteristics was applied to contralateral sites. Pain was evaluated on a visual analog scale (VAS, 0-10). Tactile sensitivity was assessed on a four-point scale (0 = no sensation; 1 = slight sensation; 2 = moderate, and 3 = strong). An analysis of variance study was performed to compare baseline scores to results over time, and placebo results to EMLA scores for each test site. RESULTS: The assessment of response to puncture and pressure gradually decreased over time for the sites where EMLA cream was applied, but not for the areas where placebo was applied. CONCLUSION: The efficacy of EMLA cream varies demonstrably depending on type of stimulus, site of application and time since application.

[Analysis of regional anesthetic efficacy in pediatric postop pain]. / Análisis de la eficacia analgésica de la anestesia locorregional en cirugía infantil.

A randomized, double blind study was carried out in 76 paediatric surgical patients scheduled for herniography or circumcision. Patients were randomly assigned to receive ilioinguinal and iliohipogastric nerve block (group A), penile block (group B), caudal block (group C) or metamizol intravenously (group D). Postoperative pain was evaluated by Objective pain scale at the end of surgical process and at 15, 30, 60 minutes and 6 hours after surgery. Pain free time was also recorded. There was no difference between groups regarding demographic data. We find a significatively less pain scores in the children who received regional anaesthesia. In those groups the administration of any analgesic were not necessary. No side effects were recorded. We conclude that locorregional anaesthesia techniques are safe and effective for minor surgery in children, because they are easy to carry out, comfortable for the patient, and provide a good postoperative analgesia.

[Paradoxical reaction to midazolam after its use as a sedative in regional anesthesia]. / Reacción paradójica al midazolam tras su uso como sedante en anestesia regional.

We report 3 cases of paradoxical reaction to midazolam after being used for sedation during regional anesthesia. The picture was characterized by a marked aggressiveness. In one case the reaction was treated with general anesthesia, whereas in the other two patients the clinical picture was rapidly reversed by administration of flumazenil. We describe the possible causative mechanisms of this reaction as well as their treatment.

Ultrastructural, immunocytochemical and morphometric studies of pituitary prolactin cells after chronic administration of met-enkephalin.

The effects of chronic administration of met-enkephalin (40 micrograms/day, for 20 days) on the pituitary prolactin cells of Wistar male rats were studied at the light (PAP-immunohistochemical for PRL demonstration technique) and electron microscopy levels. The D. CIRCLE (mean diameter), D. MAX (maximum diameter) and FORM PE (circular factor of form; irregularity degree) form secretory granules, as well as their percent distribution, were also evaluated. The cellular alterations were variable. Most prolactin cells showed an increase in immunohistochemical reaction. At the electron microscope level the prolactin cells showed an enlargement and swelling of the RER and Golgi apparatus. The secretory granules were bigger and more spherical in experimental than in untreated and control animals. A number of cells showed a variable number of cytoplasmic vacuoles or a large central vacuole formed from dilated RER-cisternae. The authors discuss the possible mechanism whereby met-enkephalin exerts a control on prolactin cells.

[Innervation of the ventral prostate of the rat: ultrastructural study]. / Inervación de la próstata ventral de la rata: estudio ultraestructural.

The innervation of the rat ventral prostate was studied at the ultrastructural level. The nerve fascicles, amyelinics, are found in the interstitial tissue of the gland. We have observed varicosities with synaptic vesicles in close contact with the smooth muscle and epithelial cells. Inside the nerve endings, 5 types of vesicles could be distinguished. The role of the different nerve endings is discussed.

[Cholinergic innervation of the prostate in the white rat (Rattus norvegicus)]. / Inervación colinérgica de la próstata en la rata blanca (Rattus norvegicus).

We studied the cholinergic innervation of the prostate in male albino rats using a technic for demonstrating acetylcholinesterase (AChE) activity. We observed AChE-positive nerve fibers surrounding the acini and blood vessels. In the prostatic ventral lobe, a large number of AChE-reactive neurons (isolated or forming microganglia) were observed. However, no neurons were observed in the dorsal-lateral prostatic lobe. The foregoing findings suggest a different cholinergic innervation for these prostatic lobes.

Histochemical detection of monoamine oxidase and alcohol dehydrogenase activities in the Syrian hamster Harderian glands: existence of a sexual dimorphism.

Monoamine oxidase (MAO) and alcohol dehydrogenase (AD) activities were studied histochemically in the Syrian hamster Harderian gland using tryptamine as substrate and Nitroblue Tetrazolium as the final electron acceptor. No dark: light-related changes were observed. Male type I secretory cells showed an intense MAO reaction. Female type I cells exhibited a moderate MAO activity. Both male and female glands showed a moderate/intense AD-positive reaction. Male type II cells were lacking MAO and AD activities. MAO activity found in the hamster Harderian glands corresponded mainly to MAO type A since treatment with chlorgyline (0.01, 0.1 and 0.5 mM) totally inhibited it. The possible role of these two enzymes in Harderian gland indolalkylamine metabolism is discussed.

Acetyl-cholinesterase and fluoride-resistant acid phosphatase activities in dorsal root ganglia in the rat.

Acetylcholinesterase and fluoride-resistant acid phosphatase activities were contrasted in alternative serial sections of rat dorsal root ganglia. The morphometric analysis demonstrated no correlation between cellular size and enzymatic activity. Differences with previous works in this area are discussed.

Sexual dimorphism in the cholinergic innervation of the hamster (Mesocricetus auratus) harderian glands.

We study the cholinergic innervation of the Harderian gland in male and female golden hamsters. There is a clear sexual dimorphism in the cholinergic innervation between both sexes. The Harderian gland from male animals contain much more nervous fibers with acetylcholinesterase (AChE) positive reaction than in female. The nervous fibers containing AChE activity are surrounding the acini and blood vessels.