Individualised, perioperative open-lung ventilation strategy during one-lung ventilation (iPROVE-OLV): a multicentre, randomised, controlled clinical trial.

BACKGROUND: It is uncertain whether individualisation of the perioperative open-lung approach (OLA) to ventilation reduces postoperative pulmonary complications in patients undergoing lung resection. We compared a perioperative individualised OLA (iOLA) ventilation strategy with standard lung-protective ventilation in patients undergoing thoracic surgery with one-lung ventilation. METHODS: This multicentre, randomised controlled trial enrolled patients scheduled for open or video-assisted thoracic surgery using one-lung ventilation in 25 participating hospitals in Spain, Italy, Turkey, Egypt, and Ecuador. Eligible adult patients (age ≥18 years) were randomly assigned to receive iOLA or standard lung-protective ventilation. Eligible patients (stratified by centre) were randomly assigned online by local principal investigators, with an allocation ratio of 1:1. Treatment with iOLA included an alveolar recruitment manoeuvre to 40 cm H2O of end-inspiratory pressure followed by individualised positive end-expiratory pressure (PEEP) titrated to best respiratory system compliance, and individualised postoperative respiratory support with high-flow oxygen therapy. Participants allocated to standard lung-protective ventilation received combined intraoperative 4 cm H2O of PEEP and postoperative conventional oxygen therapy. The primary outcome was a composite of severe postoperative pulmonary complications within the first 7 postoperative days, including atelectasis requiring bronchoscopy, severe respiratory failure, contralateral pneumothorax, early extubation failure (rescue with continuous positive airway pressure, non-invasive ventilation, invasive mechanical ventilation, or reintubation), acute respiratory distress syndrome, pulmonary infection, bronchopleural fistula, and pleural empyema. Due to trial setting, data obtained in the operating and postoperative rooms for routine monitoring were not blinded. At 24 h, data were acquired by an investigator blinded to group allocation. All analyses were performed on an intention-to-treat basis. This trial is registered with ClinicalTrials.gov, NCT03182062, and is complete. FINDINGS: Between Sept 11, 2018, and June 14, 2022, we enrolled 1380 patients, of whom 1308 eligible patients (670 [434 male, 233 female, and three with missing data] assigned to iOLA and 638 [395 male, 237 female, and six with missing data] to standard lung-protective ventilation) were included in the final analysis. The proportion of patients with the composite outcome of severe postoperative pulmonary complications within the first 7 postoperative days was lower in the iOLA group compared with the standard lung-protective ventilation group (40 [6%] vs 97 [15%], relative risk 0·39 [95% CI 0·28 to 0·56]), with an absolute risk difference of -9·23 (95% CI -12·55 to -5·92). Recruitment manoeuvre-related adverse events were reported in five patients. INTERPRETATION: Among patients subjected to lung resection under one-lung ventilation, iOLA was associated with a reduced risk of severe postoperative pulmonary complications when compared with conventional lung-protective ventilation. FUNDING: Instituto de Salud Carlos III and the European Regional Development Funds.

Anestesia tópica de contacto versus anestesia general en cirugía de estrabismo / Contact topical anesthesia versus general anaesthesia in strabismus surgery

OBJETIVO: Evaluar el bloqueo anestésico proporcionado por la anestesia tópica de contacto (ATC) en cirugía de estrabismo en pacientes adultos. Analizar el dolor postoperatorio y el resultado quirúrgico obtenido mediante ATC y compararlo con la anestesia general (AG). METODOLOGÍA: Estudio de cohortes longitudinal prospectivo en pacientes adultos intervenidos de estrabismo mediante ATC o AG. Se midió la intensidad del dolor percibido por los pacientes durante el desarrollo de la intervención y en el periodo postoperatorio mediante la Escala Numérica del Dolor (END). Se evaluó el éxito del resultado quirúrgico, considerado como una desviación ocular residual < 10 dioptrías prismáticas. RESULTADOS: Se intervino a un total de 23 pacientes con ATC y a 26 con AG. Durante el desarrollo de la intervención quirúrgica, la intensidad del dolor padecido por los pacientes del grupo ATC fue de 3,17 ± 2,44. No hubo diferencias entre el grupo ATC y el grupo AG en la intensidad de dolor en el postoperatorio inmediato (2,13 ± 2,39 vs. 2,77 ± 2,18 respectivamente; p = 0,510) ni durante el primer día postoperatorio (3,22 ± 2,84 vs. 3,17 ± 2,73; p = 0,923). El éxito quirúrgico fue significativamente mayor en el grupo ATC que en el grupo AG (78,3 vs. 73,1%; p = 0,019). CONCLUSIONES: La ATC proporciona un adecuado bloqueo sensitivo para poder llevar a cabo la cirugía de estrabismo, logrando un control del dolor postoperatorio similar al obtenido con la AG. La conservación de la motilidad ocular que proporciona la ATC permite obtener un mejor resultado quirúrgico

OBJECTIVE: To evaluate the anesthetic block provided by contact topical anesthesia (CTA) in strabismus surgery in adult patients. To analyze postoperative pain and surgical outcome obtained by CTA compared with general anesthesia (GA). METHODOLOGY: Prospective longitudinal cohort study of adult patients undergoing strabismus surgery by CTA or GA. The intensity of pain perceived by patients during the course of surgery and in the postoperative period was measured using Numerical Pain Scale. The success of the surgical outcome, considered as a residual ocular deviation < 10 prism diopters, was evaluated. RESULTS: Twenty-three patients were operated using CTA and 26 using AG. During the course of surgery, pain intensity experienced by patients in ATC group was 3.17 ± 2.44. There were no differences between CTA group and AG group in the intensity of pain in the immediate postoperative period (2.13 ± 2.39 vs. 2.77 ± 2.18, respectively; P=.510) and during the first postoperative day (3.22 ± 2.84 vs. 3.17 ± 2.73;P=.923). Surgical success was significantly higher in the CTA group than in the GA group (78.3 vs. 73.1%; P=.019). CONCLUSIONS: CTA provides adequate sensory block to perform strabismus surgery. The control of postoperative pain is similar to that obtained with AG. Conservation of ocular motility providing CTA enables better surgical outcome

Contact topical anesthesia versus general anaesthesia in strabismus surgery.

OBJECTIVE: To evaluate the anesthetic block provided by contact topical anesthesia (CTA) in strabismus surgery in adult patients. To analyze postoperative pain and surgical outcome obtained by CTA compared with general anesthesia (GA). METHODOLOGY: Prospective longitudinal cohort study of adult patients undergoing strabismus surgery by CTA or GA. The intensity of pain perceived by patients during the course of surgery and in the postoperative period was measured using Numerical Pain Scale. The success of the surgical outcome, considered as a residual ocular deviation<10 prism diopters, was evaluated. RESULTS: Twenty-three patients were operated using CTA and 26 using AG. During the course of surgery, pain intensity experienced by patients in ATC group was 3.17±2.44. There were no differences between CTA group and AG group in the intensity of pain in the immediate postoperative period (2.13±2.39 vs. 2.77±2.18, respectively; P=.510) and during the first postoperative day (3.22±2.84 vs. 3.17±2.73; P=.923). Surgical success was significantly higher in the CTA group than in the GA group (78.3 vs. 73.1%; P=.019). CONCLUSIONS: CTA provides adequate sensory block to perform strabismus surgery. The control of postoperative pain is similar to that obtained with AG. Conservation of ocular motility providing CTA enables better surgical outcome.

Cuerpo extraño en vía aérea tras intubación asistida con guía Frova ® / Foreign body in airway after assisted Frova ® guide intubation

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Anestesia tópica de contacto para cirugía de estrabismo / Contact topical anesthesia for strabismus surgery in adult patients

Objetivo: Analizar la eficacia y utilidad de la anestesia tópica de contacto en cirugía de estrabismo en pacientes adultos. Material y método: Estudio prospectivo de 20 pacientes intervenidos de estrabismo utilizando anestesia tópica de contacto más sedación con remifentanilo. Mediante la escala numérica del dolor se registró la intensidad de este en el momento de la aplicación de la anestesia, durante la intervención quirúrgica, a los 30 min y durante el primer día posoperatorio. Se valoró la aparición de reflejo oculocardiaco durante la intervención, la incidencia de náuseas y vómitos posoperatorios, la presencia de úlceras corneales, la satisfacción de los pacientes de forma numérica del 0 al 10, y el grado de desviación ocular residual. Resultados: La intervención quirúrgica se realizó de forma satisfactoria en todos los pacientes. La intensidad del dolor fue de 1,40 ± 1,73 en el momento de la aplicación de la anestesia; 4,20 ± 2,57 durante el desarrollo de la intervención; 2,50 ± 2,54 a los 30 min, y 3,55 ± 2,89 durante el primer día posoperatorio. Se observó aparición de reflejo oculocardiaco en 7 pacientes (35%), náuseas y vómitos posoperatorios en 4 (20%), y úlcera corneal en 4 (20%). La satisfacción de los pacientes alcanzó un valor promedio de 9,53 ± 2,51. El 70% de los pacientes presentaban una desviación ocular residual menor a 10 dioptrías prismáticas. Conclusiones: La anestesia tópica de contacto es una alternativa segura y eficaz para la cirugía del estrabismo en pacientes adultos. Permite un adecuado control del dolor, ofrece una baja incidencia de reflejo oculocardiaco y náuseas y vómitos posoperatorios, y proporciona un ajuste óptimo de la alineación ocular (AU)

Objective: To analyze the effectiveness and usefulness of contact topical anesthesia in strabismus surgery in adult patients. Material and methods: A prospective study was conducted on 20 patients undergoing strabismus surgery using contact topical anesthesia and sedation with remifentanil. The intensity of pain was recorded using a numeric pain rating scale at the time of anesthesia implementation, during the surgical procedure, 30 min afterwards, and during the first postoperative day. The incidence of oculocardiac reflex, postoperative nausea and vomiting, corneal ulcers, patient satisfaction (numerically from 0 to 10) and the degree of residual ocular deviation were also assessed. Results: The operation was performed successfully in all patients. Average pain intensity was 1.40 ± 1.73 during anesthesia implementation, 4.20 ± 2.57 during the surgical procedure, 2.50 ± 2.54 30 min after surgery, and 3.55 ± 2.89 during the first postoperative day. Oculocardiac reflex was observed in 7 patients (35%), postoperative nausea and vomiting in 4 (20%), and corneal ulcer in 4 (20%). The patient satisfaction was 9.53 ± 2.51. More than two-thirds (70%) of patients had a residual ocular deviation less than 10 prism diopters. Conclusions: Contact topical anesthesia is a safe and effective alternative for strabismus surgery in adult patients. Contact topical anesthesia provides adequate pain control, lower incidence of postoperative nausea and vomiting and oculocardiac reflex, and optimal setting of ocular alignment (AU)

Contact topical anesthesia for strabismus surgery in adult patients.

OBJECTIVE: To analyze the effectiveness and usefulness of contact topical anesthesia in strabismus surgery in adult patients. MATERIAL AND METHODS: A prospective study was conducted on 20 patients undergoing strabismus surgery using contact topical anesthesia and sedation with remifentanil. The intensity of pain was recorded using a numeric pain rating scale at the time of anesthesia implementation, during the surgical procedure, 30 min afterwards, and during the first postoperative day. The incidence of oculocardiac reflex, postoperative nausea and vomiting, corneal ulcers, patient satisfaction (numerically from 0 to 10) and the degree of residual ocular deviation were also assessed. RESULTS: The operation was performed successfully in all patients. Average pain intensity was 1.40 ± 1.73 during anesthesia implementation, 4.20 ± 2.57 during the surgical procedure, 2.50 ± 2.54 30 min after surgery, and 3.55 ± 2.89 during the first postoperative day. Oculocardiac reflex was observed in 7 patients (35%), postoperative nausea and vomiting in 4 (20%), and corneal ulcer in 4 (20%). The patient satisfaction was 9.53 ± 2.51. More than two-thirds (70%) of patients had a residual ocular deviation less than 10 prism diopters. CONCLUSIONS: Contact topical anesthesia is a safe and effective alternative for strabismus surgery in adult patients. Contact topical anesthesia provides adequate pain control, lower incidence of postoperative nausea and vomiting and oculocardiac reflex, and optimal setting of ocular alignment.

Técnicas anestésicas locorregionales en la cirugía de estrabismo: ventajas e inconvenientes / Local and regional anesthetic techniques in strabismus surgery: Advantages and disadvantages

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Edema pulmonar por reexpansión tras resección de timoma gigante / Pulmonary oedema due to re-expansion after resection of a giant thymoma

Mujer de 36 años que fue sometida a una resección de timoma gigante que ocupaba gran parte del hemitórax izquierdo. Tras la resección del tumor y la insuflación del pulmón izquierdo apareció un edema pulmonar por reexpansión precoz. Se trató con diuréticos, corticoides y se mantuvo la ventilación mecánica. La paciente evolucionó favorablemente. El edema pulmonar por reexpansión es una complicación poco frecuente, pero con una alta mortalidad. Es fundamental conocer los factores implicados en su etiopatogenia. El diagnóstico y tratamiento se deben realizar de forma inmediata(AU)

A 36 year-old woman who was subjected to resection of a giant thymoma that occupied a large area of the left hemithorax. After resection of the tumour and insufflation of the left lung there was pulmonary oedema due to early re-expansion. She was treated with diuretics and corticoids and was kept on mechanical ventilation. The patient progressed favourably. Although pulmonary oedema due to re-expansion is an uncommon complication it has a high mortality. It is essential to be aware of the factors involved in its aetiopathogenesis. It should be diagnosed and treated immediately(AU)

Anestesia tópica de contacto en cirugía de estrabismo / Contact Topical anesthesia in strabismus surgery

Introducción. Se describe el uso de anestesia tópica de contacto (ATC) en cuatro pacientes intervenidos de cirugía de estrabismo. Este tipo de anestesia consiste en la aplicación sobre la superficie ocular de una esponja de gelatina empapada en anestésico local, lo que permite mayor penetración del anestésico local en el área conjuntival. Material y Métodos. Cuatro pacientes adultos fueron intervenidos de estrabismo mediante ATC. Una porción de esponja de gelatina empapada en anestésico local (lidocaína 2% y bupivacaína 0,75% en proporción 1:1) se aplicó durante cinco minutos sobre la superficie ocular a intervenir. Todos los pacientes recibieron sedación con midazolam 0,2 mg/kg iv y perfusión continua de remifentanilo iv (0,02-0,1 mcg/kg/min). Se registraron los eventos adversos ocurridos durante la intervención quirúrgica y durante las primeras 24 horas postoperatorias. Resultados. La intervención quirúrgica se realizó de forma exitosa en los cuatro pacientes. En ninguno de ellos fue necesario aumentar el grado de sedación. Durante la intervención, dos pacientes presentaron reflejo oculocardiaco. Uno de los pacientes refirió molestias en el momento de la disección y manipulación del músculo, que fueron controladas de forma eficaz con la instilación de lidocaína 2%. En cuanto al dolor postoperatorio, tres pacientes refirieron haber padecido dolor de intensidad leve. Todos los pacientes manifestaron estar satisfechos con la técnica anestésica y la recomendarían a otros pacientes. Conclusiones. La ATC permite realizar intervenciones de estrabismo de forma segura y eficaz, proporcionando un adecuado control del dolor y evitando el uso de anestesia general (AU)

Introduction. We describe the use of contact-topical anesthesia in four patients undergoing strabismus surgery. This anesthetic method consists in applying into the fornix a fragment of gelatin sponge soaked in local anesthetic, allowing greater penetration of local anesthetic into the conjunctival area. Material and Methods. Contact-topical anesthesia was applied in four adult patients undergoing strabismus surgery. A piece of gelatin sponge soaked local anesthetic (lidocaine 2% and bupivacaine 0.75% in ratio 1:1) was applied during five minutes on the ocular surface. All patients received sedation with midazolam 0.2 mg/kg iv and continuous infusion of remifentanil (0.02-0.1 mcg / kg / min). We recorded adverse events occurred during surgery and during the first 24 postoperative hours. Results. The operation was performed successfully in all patients. No increase in the level of sedation was necessary. Two patients presented oculocardiac reflex during the intervention. One of the patients reported discomfort during dissection and manipulation of the muscle, which were controlled effectively with instillation of lidocaine 2%. In terms of postoperative pain, three patients reported having had mild pain. All patients were satisfied with the anesthetic technique and would recommend it to other patients. Conclusions. Contact-topical anesthesia in strabismus is safe and effective, providing suitable pain control and avoiding the use of general anesthesia (AU)

[Pulmonary oedema due to re-expansion after resection of a giant thymoma]. / Edema pulmonar por reexpansión tras resección de timoma gigante.

A 36 year-old woman was subjected to resection of a giant thymoma that occupied a large area of the left hemithorax. After resection of the tumour and insufflation of the left lung there was pulmonary oedema due to early re-expansion. She was treated with diuretics and corticoids and was kept on mechanical ventilation. The patient progressed favourably. Although pulmonary oedema due to re-expansion is an uncommon complication it has a high mortality. It is essential to be aware of the factors involved in its aetiopathogenesis. It should be diagnosed and treated immediately.

Manejo anestésico en el síndrome de Berdon / No disponible

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Megaesófago en un paciente con acalasia avanzada / No disponible

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