Submental intubation in pediatric maxillofacial surgery: report of 2 cases / Intubación submentoniana en cirugía maxilofacial pediátrica: reporte de 2 casos

Abstract Submental intubation (SMI) is useful in surgical procedures where nasotracheal intubation is contraindicated and orotracheal intubation is not ideal, making it an alternative to tracheostomy since it is performed in less time, with less morbidity and mortality, minimal postoperatory care, as well as an aesthetically acceptable scar. We present 2 cases of pediatric patients with a successful SMI. In addition, we briefly review current literature regarding pediatric population.

Resumen La intubación submentoniana (ISM) es útil en procedimientos quirúrgicos en donde la intubación nasotraqueal está contra indicada y la intubación orotraqueal no es ideal, siendo así una alternativa a la traqueostomía, ya que se realiza en menor tiempo, con menor morbimortalidad y mínimos cuidados posoperatorios, y con una cicatriz estéticamente aceptable. Se presentan dos casos de pacientes pediátricos en los cuales la ISM fue exitosa y se revisa de forma breve la literatura relacionada en población infantil.

Opioid overdoses: Emerging clinical challenges.

OBJECTIVE: Analysis of a large consecutive case series of cases brought to an Emergency Department (ED). DESIGN: Retrospective chart review. SETTING: Emergency Department in Broward County, Florida. PATIENTS: Medical records of patients with registered diagnoses of opioid overdose in 2016 and 2017. OUTCOMES: Demographics, toxicology results, mental-health comorbidities, use/response to naloxone, and hospital disposition. RESULTS: Seven hundred and seventy nine opioid-overdose cases were identified (35 percent female, 65 percent male; age 36.2). Her-oin intoxication was registered in 77 percent of discharge diagnoses, and 17.7 percent were prescription pain medications. Urine sam-ples were collected in 39 percent and 81.5 percent of patients received naloxone (mean dose 4.0 mg ± 2.2). Sixty-five percent of cases were discharged home, 17.5 percent left the ED against medical advice, and 17.5 percent were admitted to the hospital/intensive care unit/behavioral unit. CONCLUSION: There is an alarming number of visits to the ED due to opioid overdoses with differences in age and gender. Clinicians are facing diagnostic, treatment and follow-up challenges for the management of these cases.

Videolaryngoscopy versus Fiber-optic Intubation through a Supraglottic Airway in Children with a Difficult Airway: An Analysis from the Multicenter Pediatric Difficult Intubation Registry.

BACKGROUND: The success rates and related complications of various techniques for intubation in children with difficult airways remain unknown. The primary aim of this study is to compare the success rates of fiber-optic intubation via supraglottic airway to videolaryngoscopy in children with difficult airways. Our secondary aim is to compare the complication rates of these techniques. METHODS: Observational data were collected from 14 sites after management of difficult pediatric airways. Patient age, intubation technique, success per attempt, use of continuous ventilation, and complications were recorded for each case. First-attempt success and complications were compared in subjects managed with fiber-optic intubation via supraglottic airway and videolaryngoscopy. RESULTS: Fiber-optic intubation via supraglottic airway and videolaryngoscopy had similar first-attempt success rates (67 of 114, 59% vs. 404 of 786, 51%; odds ratio 1.35; 95% CI, 0.91 to 2.00; P = 0.16). In subjects less than 1 yr old, fiber-optic intubation via supraglottic airway was more successful on the first attempt than videolaryngoscopy (19 of 35, 54% vs. 79 of 220, 36%; odds ratio, 2.12; 95% CI, 1.04 to 4.31; P = 0.042). Complication rates were similar in the two groups (20 vs. 13%; P = 0.096). The incidence of hypoxemia was lower when continuous ventilation through the supraglottic airway was used throughout the fiber-optic intubation attempt. CONCLUSIONS: In this nonrandomized study, first-attempt success rates were similar for fiber-optic intubation via supraglottic airway and videolaryngoscopy. Fiber-optic intubation via supraglottic airway is associated with higher first-attempt success than videolaryngoscopy in infants with difficult airways. Continuous ventilation through the supraglottic airway during fiber-optic intubation attempts may lower the incidence of hypoxemia.

Manejo anestésico de un escolar con tronco arterioso tipo I no corregido e hipertensión pulmonar severa sometido a reparación de luxación congénita de rodilla. Reporte de caso / Anesthetic management of a schoolboy with uncorrected truncus arteriosus type I, and severe pulmonary hypertension undergoing repair of congenital dislocation of the knee. Case report

Introduction: The presence of truncus arteriosus represents just 1.2-3% of all complex congenital heart pathologies and if not corrected, less than 20% survive beyond one year of life. When the disease progresses patients usually develop severe pulmonary hypertension and may even develop into Eisenmenger's syndrome. The paper discusses a case of a schoolboy with a diagnosis of uncorrected truncus arteriosus type I, and severe pulmonary arterial hypertension undergoing non-cardiac surgery. Case discussion: This is a 9-year old schoolboy with complex heart disease and similar pulmonary and systemic blood pressures, undergoing elective orthopedic surgery under regional anesthesia, with lumbar plexus block and posterior sciatic block. This anesthetic approach provided adequate anesthesia with hemodynamic stability and no impact on vascular resistance. Conclusion: The choice of the anesthetic technique should be a planned decision based on the cardiovascular pathophysiology of the truncus arteriosus, the level of pulmonary hypertension, and the surgical procedure to be performed. Patients with severe pulmonary hypertension are at increased risk of developing suprasystemic pulmonary pressures with considerable hemodynamic involvement. Consequently, the anesthetic technique chosen shall provide adequate anesthesia and ensure the least hemodynamic impact. Whenever possible, it is important to consider the peripheral nerve block as the first line approach for orthopedic surgery.

Introducción: La presencia de tronco arterioso representa únicamente del 1.2 al 3% de las cardiopatías congénitas complejas y de no ser corregida, menos del 20% sobreviven después del año de vida. Si la patología progresa usualmente desarrollan hipertensión arterial pulmonar severa y pueden manifestarse incluso como un Síndrome de Eisenmenger. Se presenta un caso de un escolar con diagnóstico de tronco arterioso tipo I no corregido e hipertensión arterial pulmonar severa llevado a cirugía no cardiaca. Presentación del caso: Escolar de 9 años de edad con cardiopatía compleja y presión arterial pulmonar similar a la presión arterial sistémica sometido a cirugía ortopédica electiva bajo anestesia regional con bloqueo de plexo lumbar y bloqueo ciático posterior. Esta técnica anestésica nos proporcionó una adecuada anestesia con estabilidad hemodinámica sin repercusión en las resistencias vasculares. Conclusión: La elección de la técnica anestésica debe ser planeada en base a la fisiopatología cardiovascular del tronco arterioso, del grado de hipertensión pulmonar y del procedimiento quirúrgico a realizarse. Los pacientes con hipertensión pulmonar severa tienen mayor riesgo de manifestar presiones pulmonares suprasistémicas con compromiso hemodinámico importante, por lo que la técnica anestésica elegida será aquella que produzca una adecuada anestesia y menor repercusión hemodinámica. Es importante considerar de ser posible, el bloqueo de nervios periféricos como primera elección en cirugía ortopédica.

Ácido valproico y riesgo de sangrado perioperatorio. Reporte de caso y revisión de la literatura / Valproic acid and the risk of perioperative bleeding. Case report and literature review

El ácido valproico es uno de los medicamentos más usados para el tratamiento de la epilepsia en niños y adultos desde inicios de 1967 hasta la actualidad, y es útil también para el tratamiento de epilepsia refractaria y múltiples enfermedades. Sin embargo, el uso de este medicamento se ha asociado con alteraciones hematológicas que incluyen supresión medular, alteración de la cascada de la coagulación, disminución del factorVIII y factor Von Willebrand, y alteración del número y función de las plaquetas, que en el contexto del paciente llevado a cirugía mayor representa un aumento del riesgo de sangrado perioperatorio y mayor requerimiento de transfusión en el postoperatorio. Todavía es tema de discusión si la presencia de estas alteraciones establece una relevancia en la morbimortalidad de los pacientes, y si existe evidencia clínica de que la suspensión del ácido valproico antes del procedimiento representa un beneficio para el paciente. Muchos centros hospitalarios recomiendan la suspensión del ácido valproico de una a dos semanas antes del procedimiento quirúrgico, a pesar de que esta recomendación está basada en una evidencia controvertida. Es de nuestro interés presentar un reporte de caso de hemorragia uterina anormal en el postoperatorio inmediato de un legrado obstétrico por aborto incompleto con antecedente de ingesta crónica de ácido valproico.

Valproic acid is one of the most widely used drugs for the treatment of epilepsy in children and adults since early in 1967 to the present, and it is also useful for the treatment of refractory epilepsy and multiple conditions. However, the use of this drug has been associated with blood disorders, including bone marrow suppression, alteration of the coagulation cascade and reduction of factor VIII and Von Willebrand factor, in addition to changes in the platelet numbers and function. In terms of the major surgery patient, all of these issues result in an increased risk of perioperative bleeding and a higher requirement of perioperative blood transfusion. A topic for discussion should then be whether the presence of these disorders is relevant for the morbidity and mortality of the patients and whether there is any clinical evidence of benefits for the patient when the drug is interrupted prior to surgery. Many hospital centers recommend stopping the use of valproic acid one to two weeks prior to surgery, though this recommendation is based on controversial evidence. It is our intent to submit a report of an abnormal uterine hemorrhage in the immediate postoperative period of curettage due to incomplete abortion with a history of chronic intake of valproic acid.

Manejo de la vía aérea en pacientes llevados a cirugía bariátrica en el Hospital Universitario de San Ignacio, Bogotá, Colombia / Airway Management in Bariatric Surgery Patients at Hospital Universitario de San Ignacio, Bogotá (Colombia)

Introducción: La obesidad ha aumentado en los últimos años y aún más los obesos mórbidos, en quienes se han reconocido comorbilidades que dificultan el manejo perioperatorio anestésico, incluido el manejo de la vía aérea. En la valoración preanestésica existen parámetros del examen físico y de la historia clínica que son predictores de intubaciones difíciles o fallidas, y es en estos casos cuando el fibroscopio retromolar de Bonfils ha sido una herramienta útil. Objetivo: Observar los predictores de vía aérea difícil a partir del examen físico, la incidencia de intubación difícil y las herramientas utilizadas para el manejo de la vía aérea en pacientes obesos. Material y métodos: Estudio observacional descriptivo de 352 pacientes obesos llevados a cirugía bariátrica en el Hospital Universitario de San Ignacio, Bogotá, en quienes se evaluó índice de masa corporal, apertura oral, Mallampati, distancia tiromentoniana, circunferencia del cuello y uso de laringoscopio o fibroscopio retromolar de Bonfils y su dificultad en la utilización. Conclusiones: La intubación con fibroscopio retromolar de Bonfils es exitosa en el 100% de los casos observados en pacientes obesos y la dificultad de la intubación con dicho dispositivo no se correlaciona con los parámetros evaluados.

Introduction: Obesity has increased in the past few years, more so for the morbidly obese; in whom comorbilities that complicate the perioperative anaesthetic and airway management have been identified. The pre-anaesthetic assessment of the patient includes parameters of physical examination and medical history that predict difficulties when intubating or failure to do so. In such cases, the Bonfils retromolar fibroscope has proven to be a useful tool. Goal: To observe and identify predicting evidence of a difficult airway through physical examination; to revise the incidence of difficult intubation and the use of tools for airway management of obese patients. Methods: This is a descriptive observational study carried out on 352 obese patients who underwent bariatric surgery at Hospital Universitario San Ignacio, Bogotá. On these patients we assessed the following parameters: body mass index (BMI), oral opening, mallampati score, distance between thyroid and chin, neck circumference, use of laryngoscope or Bonfils retromolar fibroscope and the difficulties encountered for both. Conclusions: Intubation with the Bonfils retromolar fibroscope proves successfull in 100% of observed cases of obese patients, and intubation difficulty does not correlate with the parameters considered in our assessment.

Un método participativo para mapeo de fincas y recolección de información agrícola aplicable a diferentes escalas espaciales / A participatory method for farm mapping and recollection of agricultural information applicable at different spatial scales / Um método participativo para mapeamento de sitios e coleta de informação agricola aplicável a diferentes escalas espaciais

Se diseñó y probó un método para el mapeo participativo de fincas y la recolección de información agrícola, en el cual los pobladores delimitan los linderos de sus fincas y realizan su sectorización interna directamente sobre imágenes remotas impresas en gran tamaño. La actividad se realiza durante talleres colectivos, con ayuda de facilitadores, lo cual permite atender simultáneamente a un alto número de participantes. Los mapas sectorizados obtenidos se utilizan como material de apoyo para la aplicación de una encuesta agrícola, quedando la información referida a superficies conocidas, lo cual permite estimar los rendimientos, el área cultivada por rubro, la carga animal y la superficie bajo riego, entre otras variables. La aplicación del método en dos comunidades de los Andes venezolanos generó mapas de calidad equivalente a los obtenidos por levantamiento de campo e información agrícola detallada y espacializada. Se recomienda su utilización por ser una alternativa eficiente, confiable y económica para generar cartografía digital de fincas, que podría ser utilizada para implementar un sistema de recolección de información agrícola a nivel tanto local como nacional.

A method for participatory mapping of farms and the gathering of agricultural information is proposed and tested, based on the knowledge of the local residents, who outline their farm boundaries and the internal management units and plots on orthorectified aerial images printed in a large format. The activity is carried out in collective workshops, where the participation of previously trained facilitators allows that a large number of participants be attended simultaneously. The resulting sectorized farm maps are used in the collection of agricultural information, linking it to known areas and allowing the estimation of productivity, area dedicated to different crops, animal stocking rates and irrigated areas, among other variables. The application of this method in two communities of the Venezuelan Andes generated maps of equivalent quality to those obtained with field methods and detailed, spatially referenced agricultural information. The use of this method is recommended as an efficient, reliable and economic alternative to generate digital farm maps, which could be used for implementing an agricultural information collection system, not only at local level, but also at the national one.

Desenhou-se e provou-se um método para o mapeamento participativo de sitios e a coleta de informação agrícola, no qual os povoadores definem os limites de seus sitios e realizam sua setorização interna diretamente sobre imágens remotas impressas em grande tamanho. A atividade se realiza durante ateliers coletivos, com ajuda de facilitadores, o qual permite atender simultaneamente um alto número de participantes. Os mapas setorizados obtidos são utilizados como material de apoio para a aplicação de uma pesquisa agrícola, ficando a informação referida a superfícies conhecidas, o qual permite estimar os rendimentos, a área cultivada por item, a carga animal e a superfície sob irrigação, entre outras variáveis. A aplicação do método em duas comunidades dos Andes Venezuelanos gerou mapas de qualidade equivalente aos obtidos por levantamento de campo e informação agrícola detalhada e espacializada. Recomenda-se sua utilização por ser uma alternativa eficiente, confiável e econômica para gerar cartografia digital de sitios, que poderia ser utilizada para implementar um sistema de coleta de informação agrícola tanto a nível local como nacional.