Transcaval approach for aortic endoprosthesis insertion. A new anesthetic challenge.

The treatment of acute aortic syndrome has been benefited in recent years from the huge progress in endovascular techniques, compared to classical surgical treatment, by open surgery. Nevertheless, for endovascular treatment to be successful, it is essential for the patient to present adequate vascular access. Those cases with unfavourable vascular anatomy make it necessary to consider open surgery with significant morbidity, or even to reject surgery. A new approach to the abdominal aorta has recently been described as an indication for these patients with impossibility of other vascular access and absolute or relative contraindication to the transthoracic approach. The anesthetic management of the aortic syndrome is well known and, even though there are a variety of options, all of them have proven safety and efficacy. The implementation of new surgical approaches and new possible complications imply a challenge for the anesthesiologist which, for now, has little or none scientific evidence. We present the first case of transcaval aortic endoprosthesis implantation in Spain, its anesthetic implications, and a review of the literature.

Rotura de bronquio principal izquierdo por tubo de doble luz en paciente con antecedentes de radioterapia / Rupture of left main bronchus due to a left double-lumen tube in patient with a history of radiotherapy

La lesión de vía aérea causada por tubos de doble luz es una complicación infrecuente pero potencialmente muy grave. Describimos el caso de una paciente que presentó una rotura bronquial durante la ventilación unipulmonar con un tubo de doble luz izquierdo, complicándose con una parada cardíaca secundaria de la que se recuperó sin secuelas. Causas intrínsecas de la paciente, como el antecedente de radioterapia externa, y un posible sobreinflado del neumotaponamiento pudieron contribuir al desarrollo de esta complicación. La posible lesión de vía aérea debe ser considerada por todos los profesionales que empleen tubos de doble luz durante el cuidado de sus pacientes (AU)

Airway injury caused by double-lumen tubes is a rare but potentially serious complication. We describe the case of a patient who had a bronchial rupture during one-lung ventilation with left double-lumen tube, complicated with a secondary cardiac arrest. She had a full recovery without sequelae. Underlying causes of the patient were a history of radiotherapy, and a possible overinflation of bronchial cuff, that it could contribute to the development of this complication. The possible airway injury should be considered by all practitioners who employ double-lumen tubes for the care of their patients (AU)

Respuesta de los autores: Comentarios al artículo: «Tratamiento de la rotura traumática del bronquio izquierdo por asta de toro con stent endobronquial. Implicaciones anestésicas» / Reply to authors: Comments to the article: «Endobronchial stent for the treatment of atraumatic rupture of the left bronchial dueto a bull horn. Anesthetic implications»

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Réplica a «Algoritmos de seguridad para bloqueos guiados por ecografía: el próximo reto» / Reply to 'Safety algorithm for ultrasound-guided blocks: the next challenge'

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[Rupture of left main bronchus due to a left double-lumen tube in patient with a history of radiotherapy]. / Rotura de bronquio principal izquierdo por tubo de doble luz en paciente con antecedentes de radioterapia.

Airway injury caused by double-lumen tubes is a rare but potentially serious complication. We describe the case of a patient who had a bronchial rupture during one-lung ventilation with left double-lumen tube, complicated with a secondary cardiac arrest. She had a full recovery without sequelae. Underlying causes of the patient were a history of radiotherapy, and a possible overinflation of bronchial cuff, that it could contribute to the development of this complication. The possible airway injury should be considered by all practitioners who employ double-lumen tubes for the care of their patients.

Anestesia inhalatoria en cirugía ambulatoria / Inhaled anesthesia for ambulatory surgery

La técnica anestésica elegida durante la cirugía mayor ambulatoria tendrá su influencia en el periodo postoperatorio. Las diferencias fundamentales entre la técnica endovenosa y la inhalatoria se basan en una menor incidencia de náuseas y vómitos en el postoperatorio (NVPO) y un mínimo ahorro del tiempo de estancia hospitalaria a favor de la anestesia total endovenosa. El análisis de los costes asociados a cada técnica es difícil de determinar. En relación a las diferencias entre los dos anestésicos inhalatorios de empleo común, el sevoflurano y desflurano, destaca un menor tiempo de despertar con el uso de desflurano (entre 1,2 y 4,2 minutos), sin aumentarse esas diferencias en los casos de cirugías de duración mayor a 2 horas o pacientes obesos. Se describen mínimas diferencias entre ambos fármacos en relación al tiempo de recuperación de las actividades diarias de los pacientes. Existe una mayor irritabilidad de la vía aérea asociada al uso de desflurano que se minimiza añadiendo opioides endovenosos. La incidencia de NVPO es similar entre ambos agentes, así como la intensidad del dolor postoperatorio. De especial relevancia son las consideraciones económicas, ya que con los actuales precios en nuestro país, ante un mismo flujo de gas fresco el gasto en desflurano sería sustancialmente mayor al de sevoflurano. Tanto el sevoflurano como el desflurano son fármacos útiles para su empleo en cirugía mayor ambulatoria. Ambos presentan características comunes pero también diferencias específicas que podrían condicionar su uso en determinados pacientes (AU)

The anesthetic technique chosen for the ambulatory surgery will influence on the postoperative period. The following article discusses the results of several recently published works in this field. The main differences between intravenous and inhalation techniques are based on a lower incidence of postoperative nausea and vomiting and a minimum saving of hospital stay for total intravenous anesthesia. The analysis of the costs associated with each technique is difficult to determine. Regarding to the differences between the two most common inhalation anesthetic, sevoflurane and desflurane, there is less time for awakening with desflurane (between 1.2 and 4.2 minutes), and these differences don't increase in cases of surgeries longer than 2 hours or in obese patients. Minimal differences between the two drugs in relation to the recovery time for the daily activities of the patients are described. There is an increased airway irritability associated with the use of desflurane but it is minimized by adding intravenous opioids. The incidence of PONV and the intensity of postoperative pain are similar between the two agents. The economical matters are extremely relevant, since with the same fresh gas flow the amount of desflurane spent is considerably bigger than sevoflurane. Sevoflurane and desflurane are useful drugs for ambulatory surgery. Both have common features but also specific differences that could influence their use in certain patients (AU)

Tratamiento de la rotura traumática del bronquio izquierdo por asta de toro con stent endobronquial. Implicaciones anestésicas / Endobronchial stent for the treatment of a traumatic rupture of the left bronchial due to a bull horn. Anesthetic implications

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Complicaciones neurológicas asociadas a bloqueos interescalénico y supraclavicular guiados con ecografía en cirugía electiva de hombro y extremidad superior. Estudio observacional prospectivo en un hospital universitario / Neurological complications associated with ultrasound-guided interscalene and supraclavicular block in elective surgery of the shoulder and arm. Prospective observational study in a university hospital

Objetivos. La incidencia de síntomas neurológicos postoperatorios tras la realización de bloqueo interescalénico varía entre un 4 y un 16%. La mayoría de los casos se resuelven de forma espontánea antes de un año, pero algunos pacientes mantienen sus síntomas de forma permanente. Nuestro objetivo fue valorar la incidencia de síntomas neurológicos postoperatorios tras la realización de los bloqueos anestésicos ecoguiados interescalénico y supraclavicular. Material y métodos. Estudio prospectivo, observacional. Se incluyeron, de forma consecutiva, pacientes sometidos a cirugía de extremidad superior en un hospital universitario, en los que se realizó un bloqueo interescalénico o supraclavicular como técnica aislada o con anestesia general. Siete días después de la intervención se realizó una entrevista telefónica enfocada a la detección de síntomas neurológicos en la extremidad intervenida. En los pacientes con síntomas se realizaron nuevas entrevistas seriadas (al cabo de uno, 3 y 6 meses, y al año de la intervención) hasta la resolución de la sintomatología. A aquellos pacientes con persistencia de sintomatología al cabo de un año se les ofreció la posibilidad de evaluación neurológica. Resultados. Fueron incluidos 121 pacientes, en los que se realizaron 96 bloqueos interescalénicos y 22 bloqueos supraclaviculares. Un 9,9% (IC 95% 5-15%) de los pacientes presentaron algún síntoma neurológico postoperatorio durante la primera semana. No hubo diferencias significativas entre el bloqueo interescalénico (9%) y el supraclavicular (14%). A los 3 meses los síntomas se mantuvieron en 9 pacientes (7,4%), permaneciendo en 4 de ellos (3,3%) la sintomatología al cabo de 1,5 años. Se realizó electromiograma en 3 de ellos, con resultado positivo para lesión nerviosa en todos ellos. Conclusiones. Observamos una elevada incidencia de síntomas neurológicos postoperatorios, así como un preocupante porcentaje de permanencia de la sintomatología. No se evidenciaron diferencias relevantes en la incidencia según el tipo de bloqueo, y tampoco se identificó ninguna característica del paciente o del procedimiento anestésico que estuvieran asociadas con la incidencia de dichos síntomas, salvo una relación marginal con la edad. Basados en estos resultados, es imprescindible la explicación detallada de esta complicación a los pacientes antes de realizar estos bloqueos(AU)

Objectives. The incidence of postoperative neurological symptoms after performing interscalene block varies between 4 and 16%. The majority of cases are resolved spontaneously within a year, but some patients have their symptoms permanently. Our objective was to assess the incidence of postoperative neurological symptoms after performing the ultrasound-assisted interscalene and supraclavicular anaesthetic blocks. Material and methods. A prospective and observational study was conducted on consecutive patients who had undergone upper extremity surgery with an interscalene or supraclavicular block as an isolated technique, or as a complement to general anaesthesia. Seven days after the intervention, a telephone interview was conducted that focused on the detection of neurological symptoms in the operated limb. Further serial interviews were conducted on patients with symptoms (after the first, the third and the sixth month, and one year after surgery) until resolution of symptoms. Neurological evaluation was offered to those patients with persistent symptoms after one year. Results. A total of 121 patients were included, on whom 96 interscalene blocks and 22 supraclavicular blocks were performed. Postoperative neurological symptoms were detected in 9.9% (95% CI , 5-15%) of patients during the first week. No significant differences were observed between interscalene (9%) and supraclavicular block (14%). After 3 months the symptoms persisted in 9 patients (7.4%), with symptoms remaining in 4 patients (3.3%) after 1.5 years. Electromyogram was performed on 3 patients who tested positive for nerve damage. Conclusions. A high incidence of postoperative neurological symptoms was observed, and a worrying percentage of permanence of them. There were no significant differences in incidence according to the type of block, or any features of the patient or the anaesthesia technique that were associated with the incidence of these symptoms, except a marginal relationship with age. These complications must be clearly explained to the patients before performing these blocks(AU)