[Fastrach laryngeal mask, sevoflurane and remifentanil: an anesthetic alternative for the myasthenic patient]. / Mascarilla laríngea Fastrach, sevoflurano y remifentanilo: una alternativa anestésica del paciente miasténico.

A 46-year-old myasthenic man diagnosed two months earlier and experiencing nocturnal dyspnea was scheduled for transsternal thymectomy. The patient was premedicated with midazolam in the operating room. Anesthetic induction and maintenance were with inhaled sevoflurane and an intravenous infusion of remifentanil, with no need for neuromuscular relaxants. Airway management was achieved by inserting a Fastrach laryngeal mask (LM-Fastrach), through which an endotracheal tube could be inserted easily. The tube was withdrawn through the mask at the end of surgery and the mask was removed in the operating room 6 minutes later. Anesthesia in patients with myasthenia gravis is one of the greatest challenges in clinical anesthesiology. The interest of this case lies mainly in that the anesthetic technique chosen allows neuromuscular relaxants to be avoided. Moreover, airway access through the Fastrach laryngeal mask is highly useful for transsternal thymectomy of the patient with myasthenia gravis, providing immobility and adequate hemodynamic stability during sternotomy as well as facilitating safe and rapid postanesthetic recovery.

Mascarilla laríngea fastrach®, sevoflurano y remifentanilo: una alternativa anestésica del paciente miasténico / The Fastrach® laryngeal mask, sevoflurane and remifentanil: an anesthetic alternative for the myasthenic patient

Un paciente miasténico de 46 años de edad, diagnosticado hacía 2 meses y con disnea nocturna, fue programado para una timectomía transesternal.El paciente fue premedicado con midazolam en quirófano; la inducción y mantenimiento anestésico se realizó con inhalación de sevoflurano y una infusión intravenosa de remifentanilo, sin necesidad del uso de ningún relajante neuromuscular; el manejo de la vía aérea se efectuó mediante la inserción de una mascarilla laríngea Fastrach® (ML-Fastrach®), a través de la cual se introdujo fácilmente un tubo endotraqueal, el cual se retiró al finalizar la cirugía, mientras que la ML-Fastrach® se extrajo en el quirófano 6 minutos después.La anestesia de los pacientes que presentan una miastenia gravis representa uno de los mayores retos en la práctica clínica del anestesiólogo. El interés de este caso reside principalmente en que la técnica anestésica seleccionada permite evitar la administración de los relajantes neuromusculares y el abordaje de la vía aérea con la ML-Fastrach® resulta muy útil en la timectomía transesternal del paciente con miastenia gravis, por lo que consigue una inmovilidad y estabilidad hemodinámica adecuada durante la esternotomía, lo que ha posibilitado además una recuperación postanestésica muy rápida y segura (AU)

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[Lung function and quality of analgesia after lung resection with epidural alfentanyl]. / Función pulmonar y calidad de la analgesia tras cirugía resectiva pulmonar con alfentanilo epidural.

OBJECTIVES: To evaluate the effects on postoperative pulmonary function and quality of analgesia of two protocols for epidural infusion of alfentanil after lung resection. PATIENTS AND METHODS: After informed consent, 30 ASA I-IV patients undergoing chest surgery (lobectomy or pneumonectomy) were randomly assigned to two groups of 15. A catheter was inserted into the epidural space at T5-7 (group T) or L2-3 (group L). After a test dose, an initial bolus of alfentanil (10 micrograms/kg) was administered. After anesthetic induction, epidural analgesia was performed with an infusion of 400 micrograms/h of alfentanil (group L) during and after surgery. Endovenous patent-controlled anesthesia (PCA) was provided with morphine. During the first 24 h after surgery, the following variables were recorded: arterial blood gas concentrations, spirometric parameters, pain on a visual analog scale (VAS) and side effects. ANOVA and Scheffé and chi-square tests were used to analyze the results (p < or = 0.05). RESULTS: In group T, PaO2 was significantly higher at 6 and 18 h (p < or = 0.05), while FEV1 and FVC were significantly higher at 12 and 18 h. Pain assessed by VAS and PCA need for morphine was significantly less in group T. CONCLUSIONS: Thoracic epidural analgesia with alfentanil and lidocaine improves postoperative lung function and reduces the need for top-up analgesia in comparison with lumbar epidural infusion of alfentanil.

Función pulmonar y calidad de la analgesia tras cirugía resectiva pulmonar con alfentanilo epidural / Lung function and quality of analgesia after lung resection with epidural alfentanil

OBJETIVOS. Evaluar la función pulmonar y la calidad analgésica de dos pautas de infusión epidural de alfentanilo tras la cirugía pulmonar resectiva.MATERIAL Y MÉTODOS. Tras el consentimiento informado, 30 pacientes ASA I-IV fueron incluidos aleatoriamente en dos grupos (n = 15) siendo sometidos a cirugía torácica (lobectomías o neumonectomías), a los cuales se les insertó un catéter epidural torácico en T5-7 (grupo T) o lumbar en L2-3 (grupo L). Tras una dosis test epidural, se administró previamente a la inducción anestésica un bolo de alfentanilo (10 µg/kg), prosiguiéndose con una infusión epidural de 400 µg/h de alfentanilo más 50 mg/h de lidocaína (grupo T) o 400 µg/h de alfentanilo (grupo L) durante la cirugía y postoperatorio. Además, se utilizó una analgesia controlada por el paciente intravenosa con morfina. Durante las primeras 24 h postoperatorias se registraron las siguientes variables: gasometrías arteriales, espirometría, escala analógica visual del dolor y efectos secundarios. El análisis estadístico consistió en los tests de ANOVA, Scheffé y 2 (p 0,05). RESULTADOS. La PaO2 fue significativamente mayor en el grupo T (6 y 18 h) (p 0,05). El volumen espirado forzado en el primer segundo1 y la capacidad vital forzada fueron superiores significativamente en el grupo T (12 y 18 h). El dolor y los requerimientos de morfina fueron significativamente menores en el grupo T. CONCLUSIONES. La analgesia epidural torácica con alfentanilo más lidocaína mejora la función pulmonar postoperatoria y reduce la necesidad de analgesia de rescate con respecto al alfentanilo epidural lumbar (AU)

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[Systematic recording of perioperative events associated with anesthesia as quality indicator in ambulatory anesthesia]. / Registro sistemático de las incidencias anestésicas perioperatorias como indicador de calidad en anestesia ambulatoria.

OBJECTIVES: To analyze the quality of several anesthetic techniques used for major outpatient surgery in our hospital, by quantifying for each the relative risk (RR) of adverse events during anesthesia and in the postoperative period. PATIENTS AND METHODS: One thousand seventeen patients who underwent surgery between 18 May 1998 and 23 October 1998 were studied retrospectively. RESULTS: The mean age of the patients was 52.27 +/- 24.65 yr; 44.18% were ASA I, 40.56% were ASA II, 14.56% ASA III and 0.67% ASA IV. Mean time of surgery was 33 +/- 16.49 min and mean recovery time until discharge was 77.3 +/- 93.4 min. Admission was necessary for 0.6% of the patients and re-admission for 0.3%. General anesthesia was used with 19%, anesthetic monitoring with 17%, regional anesthesia (including peribulbar) with 46% and local anesthesia plus sedation with 16.6%. In 95% of the cases, no adverse events occurred during anesthesia; in 94.8% no such events occurred during the early recovery period. During surgery and postoperative recovery, intradural anesthesia was associated with significantly greater RR of adverse events in comparison with general anesthesia (6.6 and 2.2 respectively) and in comparison with monitored anesthesia (7.2 and 3.3). No differences in RR were found between general anesthesia and monitored anesthesia. Problems were slight to moderate in severity and mainly related to nausea and vomiting (2%). CONCLUSIONS: Recording perioperative events permits evaluation of the quality of anesthesic procedures. Intradural anesthesia is associated with more complications.

Registro sistemático de las incidencias anestésicas perioperatorias como indicador de calidad en anestesia ambulatoria / Systematic recording of perioperative events related to anesthesia as a quality indicator in outpatient anesthesia

Objetivos. Analizar la calidad de las diferentes técnicas anestésicas empleadas en la unidad de cirugía mayor ambulatoria (UCMA) de nuestro hospital, cuantificando los riesgos relativos (RR) de sufrir incidencias adversas durante la anestesia y el período postoperatorio en cada una de ellas. Pacientes y métodos. Se estudiaron retrospectivamente 1.017 pacientes intervenidos entre el 18/5/98 y el 23/10/98.Resultados. La edad media fue de 52,27 ñ 24,65 años, con un 44,18 por ciento de ASA 1, un 40,56 por ciento de ASA 2, un 14,57 por ciento de ASA 3 y un 0,67 por ciento de ASA 4. El tiempo quirúrgico medio fue de 33 ñ 16,49 min y el tiempo medio de recuperación hasta el alta fue de 77,30 ñ 93,4 min. Se registró un 0,6 por ciento de ingresos y un 0,3 de reingresos. El 19 por ciento de los pacientes recibieron anestesia general, el 17 por ciento cuidados anestésicos monitorizados, el 46 por ciento anestesia regional, incluyendo la anestesia peribulbar, y el 16,6 por ciento anestesia local más sedación. El 95 por ciento de los pacientes no presentaron incidencias durante la anestesia y en el 94,8 por ciento tampoco en el período de recuperación inmediata. La anestesia intradural presentó un significativo aumento del RR de padecer incidencias adversas frente a la anestesia general (6,6 y 2,2) y respecto a los cuidados anestésicos monitorizados (7,2 y 3,3) en los períodos intraoperatorio y postoperatorio, respectivamente. No se objetivó un incremento de los RR entre la anestesia general y los cuidados anestésicos monitorizados. Los problemas fueron de gravedad leve a moderada, destacando un 2 por ciento de náuseas y vómitos. Conclusiones. El registro de las incidencias perioperatorias permite valorar la calidad de los procedimientos anestésicos. La anestesia intradural es la técnica que se asocia a una mayor morbilidad (AU)

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Remifentanilo en cirugia mayor ambulatoria / Remifentanil in major outpatient surgery

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[Comparative study of two methods for salvaging red blood cells: centrifugation techniques (cell-saver) versus filtration through a 100,000-dalton filter]. / Estudio comparativo de dos métodos de recuperación de hematíes: técnicas de centrifugación (cell-saver) frente a filtración con filtro de 100,000 daltons.

OBJECTIVES: Some loss of blood occurs during blood salvage. We hypothesized that plasmapheresis filtering would damage blood much less than centrifugation techniques do, thereby allowing more red blood cells to be transfused. MATERIAL AND METHODS: Laboratory study in which 16 units of whole donor blood were distributed randomly in two groups and processed either by a conventional "cell-saver" method or by hemofiltration using recirculation through a 100,000 dalton filter. We analysed hemoglobin, hematocrit, free hemoglobin, extracellular potassium, platelets, leukocytes, protein and albumin in whole blood before and after processing, and in the waste bag in each group. RESULTS: The recovery of hemoglobin and red blood cell volume was about 80% with both methods. More free plasma hemoglobin was found in the waste bag with the filtration technique. Hemolysis in processed blood was low, less than 0.1% in both groups. Platelet recovery with conventional centrifugation and filtration was 11 and 49%, respectively. Albumin, total protein and extra-cellular potassium were recovered at a rate of about 20% with the filtration technique, whereas recovery of these elements was minimal with the cell saver method. CONCLUSIONS: Both methods of autotransfusion caused moderate loss of red blood cells and low plasma levels of free hemoglobin in processed blood. Recovery of platelets, albumin, total protein and potassium was better with filtration than with the "cell-saver" method.

[Comparative study of preemptive and postincisional lumbar epidural morphine in pulmonary resection. Preliminary report]. / Estudio comparativo entre morfina epidural lumbar preventiva o postincisional en cirugía resectiva pulmonar. Informe preliminar.

OBJECTIVES: To evaluate the efficacy and incidence of side effects of two types of lumbar epidural analgesia with morphine, preemptive or postincisional, combined with total intravenous anesthesia in chest surgery. PATIENTS AND METHODS: This double-blind prospective study enrolled 20 patients (ASA I-IV) undergoing lobectomy or pneumonectomy. Anesthetic induction and maintenance was provided with propofol, atracurium and alfentanil. Lumbar epidural analgesia (L2-L3) with morphine was provided for group A patients with 2 to 4 mg upon excision of tissue and for group B with 2 to 4 mg during anesthetic induction. The following variables were recorded: arterial blood gas concentrations, heart rate, SpO2, EtCO2, postanesthetic recovery, arterial gases, side effects and pain on a visual analogue scale. Top-up analgesia was provided by intravenous metamizole and/or epidural morphine. For statistical analysis we used ANOVA, chi-square tests and Student-Newman-Keuls tests. RESULTS: The need for propofol and alfentanil during anesthesia, and for morphine and metamizole after surgery were statistically greater in group A. Pain 18 hours after surgery was also greater in group A. No significant differences between groups for other variables was observed. CONCLUSIONS: Preemptive analgesia with lumbar epidural morphine in addition to the general anesthesia described here seems to provide higher-quality analgesia with few side effects, reducing the need for propofol and alfentanil during surgery and for postoperative morphine and metamizole.

[Intramucosal intraoperative gastric pH (pHi) during cardiac surgery] surgery]. / pH intramucoso gástrico (pHi) durante el intraoperatorio de cirugía cardíaca.

OBJECTIVE: To evaluate the monitoring of intramucosal pH (pHi) and standard pH (pHs) during heart surgery with extracorporeal circulation (ECC) and moderate hypothermia. The correlations of pHi and pHs and the postoperative APACHE III score after surgery were analyzed. PATIENTS AND METHODS: Sixteen patients with cardiac output > 0.4 scheduled for coronary bypass surgery, or aortic or mitral valve replacement were studied. Arterial pH (pHa), pHi and pHs were measured and the difference between pHa and pHi was calculated before starting ECC (T0), during ECC and hypothermia (T1) and after termination of ECC (T2). The APACHE III score was recorded 18 h after surgery. RESULTS: No significant differences between the pHi and pHs were observed in these patients. pHi was significantly higher during ECC with hypothermia (T1) than at baseline (T0). pHi and pHs were significantly correlated during the study period. There was no correlation between the APACHE III score in the immediate postoperative period and either pHi or pHs during surgery. CONCLUSION: Periods of splanchnic hypoxia (pHi < 7.32) during heart surgery with moderate hypothermia were not seen in patients with cardiac output > 0.4. pHs is a reliable measurement of pHi. There is no relation between APACHE III scores in the early postoperative period and pHi or pHs levels during surgery.