Impacto de un programa de recuperación intensificada en cistectomía radical. Estudio comparativo de cohortes / Impact of an enhanced recovery after surgery programme in radical cystectomy. A cohort-comparative study

Objetivo. Evaluar los resultados de la instauración de un programa de recuperación intensificada (ERAS) para cistectomía radical en abordaje abierto con respecto a la cohorte histórica de un mismo hospital. Material y métodos. Estudio de análisis retrospectivo de 138 pacientes sometidos a cistectomía radical con derivación ileal tipo Bricker o Studer de forma consecutiva (97 históricos vs. 41 ERAS). Se compararon tasa de complicaciones a 30 días, complicaciones estadio Clavien-Dindo>2, mortalidad, estancia y tasa de readmisión en el hospital y en cuidados críticos, reintervención y necesidad de sondaje nasogástrico, trasfusión o nutrición parenteral. Resultados. No se hallaron diferencias estadísticamente significativas en cuanto a la tasa de complicaciones globales tras 30 días de alta (73,171 vs. 77.32%; OR 1,25, IC 95% 0,54-2,981; p=0,601) ni en Clavien-Dindo>2 (41,463 vs. 42.268%; OR 1.033, IC 95% 0,492-2,167; p=0,93), así como en mortalidad, estancias o tasas de readmisión y reintervención. La necesidad de sondaje nasogástrico fue menor en el grupo ERAS (43,902 vs. 78,351%; OR 4,624, IC 95% 2,112-10,123; p<0,0001), así como la necesidad de nutrición parenteral total (26,829 vs. 34,021%; OR 12,234, IC 95% 5,165-28,92; p<0,0001) y el tiempo bajo intubación orotraqueal desde la inducción anestésica (mediana [RIC]=325 (285-355) vs. 540 (360-600) min; p<0,0001). Conclusión. Los programas de recuperación intensificada en cistectomía radical disminuyen el intervencionismo sobre el paciente sin aumentar la morbimortalidad (AU)

Objective. To evaluate the results of the implementation of an enhanced recovery program (ERAS) for open approach radical cystectomy compared to the historical cohort of the same hospital. Material and methods. A retrospective analysis of 138 consecutive patients who underwent radical cystectomy with Bricker or Studer ileal derivation (97 historical vs. 41 ERAS). Overall complication rate, Clavien-Dindo stage>2 complications, mortality, hospital and critical care length of stay and readmission rates, as well as need for reoperation, nasogastric intubation, transfusion or parenteral nutrition were compared. Results. No statistically significant differences in overall complication rate were found (73.171 vs. 77.32%; OR 1.25, 95% CI 0.54-2.981; P=.601) nor in Clavien-Dindo>2 complications (41.463 vs. 42.268%; OR 1.033, 95% CI 0.492-2.167; P=.93), mortality, lengths of stays readmission and reoperation rates. The need for nasogastric tube insertion was lower in the ERAS group (43.902 vs. 78.351%; OR 4.624, 95% CI 2.112-10.123; P<.0001), as well as the need for total parenteral nutrition (26.829 vs. 34.021%; OR 12.234, 95% CI 5.165-28.92; P<.0001), and time under endotracheal intubation since anaesthesia induction (median [IRQ]=325 (285-355) vs. 540 (360-600) min; P<.0001). Conclusion. Enhanced recovery programs in radical cystectomy decrease interventionism on the patient without increasing morbidity and mortality (AU)

Impact of an enhanced recovery after surgery programme in radical cystectomy. A cohort-comparative study. / Impacto de un programa de recuperación intensificada en cistectomía radical. Estudio comparativo de cohortes.

OBJECTIVE: To evaluate the results of the implementation of an enhanced recovery program (ERAS) for open approach radical cystectomy compared to the historical cohort of the same hospital. MATERIAL AND METHODS: A retrospective analysis of 138 consecutive patients who underwent radical cystectomy with Bricker or Studer ileal derivation (97 historical vs. 41 ERAS). Overall complication rate, Clavien-Dindo stage>2 complications, mortality, hospital and critical care length of stay and readmission rates, as well as need for reoperation, nasogastric intubation, transfusion or parenteral nutrition were compared. RESULTS: No statistically significant differences in overall complication rate were found (73.171 vs. 77.32%; OR 1.25, 95% CI 0.54-2.981; P=.601) nor in Clavien-Dindo>2 complications (41.463 vs. 42.268%; OR 1.033, 95% CI 0.492-2.167; P=.93), mortality, lengths of stays readmission and reoperation rates. The need for nasogastric tube insertion was lower in the ERAS group (43.902 vs. 78.351%; OR 4.624, 95% CI 2.112-10.123; P<.0001), as well as the need for total parenteral nutrition (26.829 vs. 34.021%; OR 12.234, 95% CI 5.165-28.92; P<.0001), and time under endotracheal intubation since anaesthesia induction (median [IRQ]=325 (285-355) vs. 540 (360-600) min; P<.0001). CONCLUSION: Enhanced recovery programs in radical cystectomy decrease interventionism on the patient without increasing morbidity and mortality.

Intubación bronquial selectiva en paciente con alteraciones del árbol traqueobronquial / Selective bronchial intubation in patient with tracheobronchial alterations

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[Systemic lupus erythematosus in the pregnant patient. Implications for anesthesia]. / Lupus eritematoso sistémico en la paciente gestante. Implicaciones anestésicas.

A 28-year-old woman with systemic lupus erythematosus and a history of aseptic meningitis, digestive bleeding due to thrombopenia and deep venous thrombosis underwent elective cesarean for transverse presentation at 35 weeks. Preoperative blood work-up showed an antinuclear antibody titre that was slightly positive and steroid treatment was started. Surgery operation was performed with general anesthesia. The outcome was satisfactory even though serious complications can develop during the management of anesthesia in such patients. Systemic lupus erythematosus is a chronic, multisystemic disease that mainly affects women of childbearing age. Antibodies and immunocomplexes play a fundamental role. Given the multiorgan involvement in this disease, preoperative study of the lupus patient should assess all such involvement, including maternal-fetal risk, as well as consider the drug and anesthetic management to be applied. Among the clinical signs that can affect management of anesthesia are the following: aseptic meningitis, high blood pressure, pericarditis, pneumonitis and recurrent venous thrombosis. Anemia, thrombopenia and significantly altered coagulation events are common.

Lupus eritematoso sistémico en la paciente gestante. Implicaciones anestésicas / Systemic lupus erythematosus in the pregnant patient. Implications for anesthesia

A una mujer de 28 años afectada de lupus eritematoso sistémico, con antecedentes de meningitis aséptica, hemorragia digestiva por trombopenia y trombosis venosa profunda, se le practicó una cesárea electiva por presentación transversa a las 35 semanas de gestación. En la analítica preoperatoria se observó un título de anticuerpo antinuclear (ANA) débilmente positivo, iniciándose tratamiento esteroide. La intervención se realizó bajo anestesia general. El caso evolucionó satisfactoriamente a pesar de las graves complicaciones que se pueden presentar en el manejo anestésico de estas pacientes.El lupus eritematoso sistémico es una enfermedad crónica, multisistémica, que afecta sobre todo a mujeres en edad fértil, en las que los anticuerpos y los inmunocomplejos desempeñan un papel postogenético fundamental.Dada la afectación multiorgánica de esta enfermedad, el estudio preoperatorio de la paciente lúpica debe evaluar cada una de estas afectaciones, los riesgos maternofetales y el manejo farmacológico y anestésico a desarrollar.Las manifestaciones clínicas que pueden determinar el manejo anestésico son, entre otras, meningitis aséptica, hipertensión arterial, pericarditis, neumonitis, trombosis venosas recidivantes, etc. Son frecuentes la anemia, la trombopenia e importantes alteraciones de la coagulación (AU)

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[Tetraplegia in the immediate postoperative period of stapedectomy]. / Tetraplejía en el postoperatorio inmediato de una estapedectomía.

Management of the cervical spine in orotracheal intubation for general anesthesia is an important aspect of daily practice in anesthesiology. Also important are the requirements, techniques and consequences of patient position during surgery. We report a case of tetraplegia during the early postoperative period after stapedectomy for otosclerosis. After surgery, the spontaneously breathing patient was transferred to the recovery room, where a clinical picture of anesthesia and paralysis of all four limbs was evident. We ordered an emergency magnetic resonance image of the cervical spine, which revealed a massive acutely herniated disk at C6-C7 with signs of ischemia or necrosis of the medulla at the same level. After eight months, the patient was still paraplegic and lacked sensation in the lower limbs. Sensation and motor function in the upper limbs was nearly normal. We review the etiopathogenetic mechanisms that might be responsible for this clinical profile.