Epidural administration of ropivacaine and midazolam is superior to intra-articular administration as postoperative analgesia after isolated arthroscopic anterior cruciate ligament reconstruction with hamstrings autograft: a randomized controlled clinical trial.

OBJECTIVE: Reconstructive surgery of the anterior cruciate ligament (ACL) is quite common, previous studies have documented that adequate pain control in the early phases of the postoperative period translates into early mobility and a rapid start of rehabilitation. Therefore, the search for new strategies for postoperative pain control is justified. The aim of this study was to compare intra-articular to the epidural administration of ropivacaine and midazolam as postoperative analgesia after arthroscopic ACL reconstruction with hamstring autograft (HA). MATERIAL AND METHODS: Double-blinded, prospective randomized clinical trial included 108 consecutive patients aged from 18 to 50 years that had undergone arthroscopic ACL reconstruction with HA. The patients were randomly assigned to 2 groups. The first group received intraarticular ropivacaine and midazolam. The second group received epidural ropivacaine and midazolam. The need for rescue analgesia, the postoperative pain experienced, side effects and complications of the analgesic drugs were evaluated. RESULTS: The intra-articular group received statistically significantly higher mean doses of rescue analgesia on the first two days (2.8 â€‹± â€‹1.0 vs. 1.3 â€‹± â€‹0.6 in the epidural group; p â€‹= â€‹0.001). Visual Analogue Scale scores at flexion were statistically significantly higher in the intra-articular group over the entire study period. The intra-articular group also reported a statistically significantly lower range-of-motion 87 â€‹± â€‹15 vs. 102 â€‹± â€‹11 in the epidural group (p â€‹= â€‹0.001). CONCLUSIONS: Epidural administration of ropivacaine combined with midazolam in patients undergoing primary ACL reconstruction with HA was clinically and significantly better relative to rescue analgesia and the intensity of pain in the first 48 postoperative hours when compared to intraarticular administration. There was no difference in terms of adverse effects and complications.

Anestesia en un caso de estenosis traqueal secuela de COVID-19, para un procedimiento de traqueoplastía / Anesthesia in a case of tracheal stenosis sequelae of COVID-19, to a tracheoplasty procedure

Resumen: Introducción: La pandemia por COVID-19 es una enfermedad de predominio respiratorio que ha afectado a nivel mundial y ha dejado más de 151 millones de casos, los cuales suelen requerir un manejo de ventilación mecánica con la intensión de controlar las vías aéreas superiores para la adecuada oxigenación de las personas con COVID-19, y que se reduzca así el riesgo de contagio para el personal médico. Objetivo: Describir el abordaje anestésico para la inducción y mantenimiento de una traqueoplastía derivado a estenosis traqueal secundaria por COVID-19. Material y métodos: Se aborda la descripción de un caso y los lineamientos que se han dado para el manejo de la estenosis traqueal. Conclusiones: El control oportuno anestésico y la instalación de férula laríngea son apropiados para el manejo de la estenosis traqueal secundaria al proceso de intubación mecánica prolongada por COVID-19.

Abstract: Introduction: The COVID-19 pandemic is a predominantly respiratory disease that has affected worldwide and has left more than 151 million cases, which usually require mechanical ventilation management with the intention of managing the upper airways for ventilation adequate oxygenation of people with COVID-19 and that reduces the risk of contagion for medical personnel. Objective: To describe the anesthetic approach for the induction and maintenance of a tracheoplasty derived from tracheal stenosis secondary to COVID-19. Material and methods: The description of a case and the guidelines that have been given for the management of tracheal stenosis are addressed. Conclusions: Timely anesthetic management and installation of a laryngeal splint is appropriate for the management of tracheal stenosis secondary to the process of prolonged mechanical intubation due to COVID-19.

Fast-track extubation in patients after intracranial hematoma surgery.

Early extubation, also known as fast track, is desirable after intracranial hematoma surgery to avoid ventilator-associated complications associated with admission to an intensive care unit (ICU). The objective of the present study was to determine whether ICU stay and ventilator-associated complications are reduced in patients who received surgery for intracranial hematoma if they are extubated early. A total of 17 patients were randomly assigned to two groups: In Group 1, patients were extubated early or using the fast track method, while those in Group 2 were conventionally extubated at a later stage and were managed at the ICU. Patients from both groups were assessed on admission to the operating room per the established standards and after the selection criteria had been confirmed, general anesthesia was applied. Extubation time and hemodynamic stability (number of anesthetic adjustments required to maintain hemodynamic parameters within 20% of the predicted values) were assessed post-operatively. Patients in the conventional group (n=10) were transferred to the ICU and extubated at 8 h post-operatively; hemodynamic stability and the presence of complications were evaluated. The fast track group had no complications associated with ventilation or any other parameter. All patients extubated in a conventional manner and who were transferred to the ICU presented with complications, including seizures, aspiration, atelectasis or failed extubation. In the future, fast track should be regarded as a routine technique in patients who meet the required criteria, so that they may be discharged quickly and with fewer complications. The present study was authorized by the ethics committee of the hospital and the research sub-directorate with the number AN14-003; it was submitted to and approved by the ISRCTN registry for clinical trials (ID, ISRCTN16924441).

[Anaphylaxis by atracurium. One case report]. / Anafilaxia por atracurio. Reporte de un caso.

BACKGROUND: The incidence of severe intraoperative anesthetic reactions varies among countries from 1:10,000 to 1:13 000 patients submitted to surgery. CASE REPORT: A 13 year old male, with family history of atopy, who underwent 5 surgeries for hydrocephalus, using general anesthesia. He was on lamotrigine for seizures. He also suffers from chronic rhinitis, and oral allergy syndrome related to bananas since the age of 6 months. He had a posterior fossa tumor resection. During anesthesia induction with atracurium he developed a local rash in one arm, being the intubation without difficulty. Twenty minutes later he presented bipalpebral edema, accompanied by generalized rash, severe bronchoconstriction and hypotension, not reversing with the use of bronchodilators and corticosteroids. With the use of antihistamines, epinephrine and controlled ventilation the reaction subsides. One month later a skin prick test with atracurium besylate (50 mg/mL) diluted 1:10,000, negative and positive controls was performed. The result with atracurium was negative. After the application of intradermal tests with 0.02 mL of atracurium at dilutions of 1:10,000 and 1:1000, we found a positive skin response to atracurium (wheal diameter >8 mm and >9 mm with dilutions 1:10,000 and 1:1000, respectively and erythema). The response to atracurium intradermal test could be related to the ability of histamine release by a nonimmunological mechanism. But the magnitude of the skin response in this case, do not rule out the possibility of an IgE-mediated reaction. Atracurium is a known potent histamine releaser from mast cells, but rarely can it cause IgE-mediated reactions.

Modification of the technique for subclavian-vein catheterization.

INTRODUCTION: In invasive monitoring, subclavian-vein puncture is a routine procedure indicated for central vein cathe-terization. It is indicated in patients according to hospital stay, including the administration of drugs and the treatment of chronic and cardiac disease. The techniques described to date include infraclavicular percutaneous puncture; others place catheters using angiographic methods, and the use of magnetic resonance imaging and ultrasound has also been reported. Studies have been done in cadavers to get a better understanding of the procedure since the relationship between vascular elements and surrounding tissues are obtained. The usual technique is with the patient in Trendelenburg position, with the arm in adduction, the placement of an interscapular roll, and the head turned away from the puncture site. OBJECTIVE: The aim of this study was to demonstrate less frequent technical failures and complications using a modification of the usual technique. We propose catheterization of the right subclavian vein with the patient in decubitus, without an interescapular roll, with the arm in abduction and using the distal third of the clavicle and the suprasternal notch as anatomical references. RESULTS: Two technical puncture failures and three complications occurred in a total of 42 patients with a statistically significant difference (p = 0.0410) in frequency (11.9%) from that reported with the traditional technique (21.8%). CONCLUSIONS: Greater efficacy with the technique modified by the authors was confirmed. Anatomical cadaver dissections showed a greater space between the right subclavian vein and the clavicle.

Inyector jet modificado para ventilación con presión positiva durante laringoscopía / Modified jet injector for ventilation with positive pressure during laringoscopy

Se reporta una serie de 15 pacientes programados para laringoscopía y toma de biopsia, los cuales fueron ventilados en el transoperatorio con un inyector jet de oxígenio modificado y construído en nuestro departamento. Este sistema está basado en el principio de Venturi y consideramos que es una técnica segura y adeucada para el paciente, con una buena aceptación por el cirujano y el anestesiólogo