Riesgo anestésico actual de las masas mediastínicas anteriores / Current anesthesia risk of anterior mediastinal masses

Objetivo. Analizar el riesgo actual de eventos anestésicos durante intervenciones quirúrgicas en pacientes con masas mediastínicas anteriores (MMA) en un centro terciario, utilizando los factores de riesgo publicados en la literatura para planificar el procedimiento. Materiales y métodos. Estudio retrospectivo (2009-2015) de los pacientes pediátricos con MMA sometidos a procedimientos quirúrgicos al debut. Se registraron: factores de riesgo publicados (clínicos, radiológicos), particularmente los estadísticamente significativos, diagnóstico, procedimiento quirúrgico y anestésico, medidas especiales y eventos anestésicos. Los pacientes se clasificaron como alto o bajo riesgo según presentasen compresión en vía aérea o vascular o síntomas de gravedad. Resultados. Registramos a 38 pacientes (media de edad 11,9 años ± 4,2). El 94,7% presentaban trastornos linfoproliferativos. El 50% tenían síntomas respiratorios y el 76,3% fueron considerados como de alto riesgo, al presentar uno o más factores ES. Solo 4 casos recibieron neoadyuvancia. Se realizaron 29 biopsias (3 toracoscópicas), 11 colocaciones de catéteres centrales, 2 drenajes torácicos y 3 resecciones. La técnica anestésica consistió en sedoanalgesia (60,5%) y diversas técnicas de anestesia general (41,4% de los casos de alto riesgo). Solo registramos 2 eventos (5,3%) consistentes en dificultad para la ventilación, respondiendo ambos a medidas básicas. Todas las intervenciones se finalizaron satisfactoriamente. Conclusiones. La evaluación preoperatoria del riesgo en MMA mediante historia clínica y TAC/RMN junto a la planificación anestésicoquirúrgica conduce a unos resultados excelentes. Deben favorecerse los procedimientos menos invasivos, pero si son precisos, la anestesia general planificada y en manos expertas es segura incluso en pacientes de riesgo

Aim. To analyze the current risk of an anesthetic event during surgical acts in pediatric patients with anterior mediastinal masses (AMM) in a tertiary oncology center, using the previously published risk factors to plan the procedure. Materials and methods. Retrospective study (2009-2015) of pediatric patients with AMM who underwent surgical procedures at debut. Published risk factors (symptoms, radiological findings), with special focus on the statistically significant ones, diagnosis, surgical and anesthetic procedure, special measures, and anesthetic events were recorded. Patients were classified as high or low-risk when airway or vascular compression or severe symptoms were present. Main results. 38 patients (average age 11.9 years, 1.4-17.3) were included. Diagnosis was lymphoproliferative disorder in 94.7%. 50% showed respiratory symptoms and 76.3% were considered as ‘high-risk’ patients, presenting one or more SS risk factors. Only 4 patients received neoadjuvant treatment. The procedures were: 29 biopsies (3 thoracoscopically), 11 placement of central venous catheters, 2 chest drains and 3 mass resections. Anesthetic management consisted on sedoanalgesia (60.5%) and different general anesthesia techniques (41.4% of the high-risk cases). Only 2 events (5.3%) happened, consisting on difficult ventilation, and both responded to basic rescue measures. All procedures could be satisfactorily finished. Conclusions. Preoperative evaluation of risk in AMM through clinical history and CT/MRI and surgical/anesthetic planning leads to excellent outcomes. The least aggressive procedures should be favored, but if needed, planned general anesthesia under experienced hands is safe even in risk patients

[Current anesthesia risk of anterior mediastinal masses]. / Riesgo anestésico actual de las masas mediastínicas anteriores.

AIM: To analyze the current risk of an anesthetic event during surgical acts in pediatric patients with anterior mediastinal masses (AMM) in a tertiary oncology center, using the previously published risk factors to plan the procedure. MATERIALS AND METHODS: Retrospective study (2009-2015) of pediatric patients with AMM who underwent surgical procedures at debut. Published risk factors (symptoms, radiological findings), with special focus on the statistically significant ones, diagnosis, surgical and anesthetic procedure, special measures, and anesthetic events were recorded. Patients were classified as high or low-risk when airway or vascular compression or severe symptoms were present. MAIN RESULTS: Retrospective study (2009-2015) of pediatric patients with AMM who underwent surgical procedures at debut. Published risk factors (symptoms, radiological findings), with special focus on the statistically significant ones, diagnosis, surgical and anesthetic procedure, special measures, and anesthetic events were recorded. Patients were classified as high or low-risk when airway or vascular compression or severe symptoms were present. CONCLUSIONS: Preoperative evaluation of risk in AMM through clinical history and CT/MRI and surgical/anesthetic planning leads to excellent outcomes. The least aggressive procedures should be favored, but if needed, planned general anesthesia under experienced hands is safe even in risk patients.

OBJETIVO: Analizar el riesgo actual de eventos anestésicos durante intervenciones quirúrgicas en pacientes con masas mediastínicas anteriores (MMA) en un centro terciario, utilizando los factores de riesgo publicados en la literatura para planificar el procedimiento. MATERIALES Y METODOS: Estudio retrospectivo (2009-2015) de los pacientes pediátricos con MMA sometidos a procedimientos quirúrgicos al debut. Se registraron: factores de riesgo publicados (clínicos, radiológicos), particularmente los estadísticamente significativos, diagnóstico, procedimiento quirúrgico y anestésico, medidas especiales y eventos anestésicos. Los pacientes se clasificaron como alto o bajo riesgo según presentasen compresión en vía aérea o vascular o síntomas de gravedad. RESULTADOS: Registramos a 38 pacientes (media de edad 11,9 años ± 4,2). El 94,7% presentaban trastornos linfoproliferativos. El 50% tenían síntomas respiratorios y el 76,3% fueron considerados como de alto riesgo, al presentar uno o más factores ES. Solo 4 casos recibieron neoadyuvancia. Se realizaron 29 biopsias (3 toracoscópicas), 11 colocaciones de catéteres centrales, 2 drenajes torácicos y 3 resecciones. La técnica anestésica consistió en sedoanalgesia (60,5%) y diversas técnicas de anestesia general (41,4% de los casos de alto riesgo). Solo registramos 2 eventos (5,3%) consistentes en dificultad para la ventilación, respondiendo ambos a medidas básicas. Todas las intervenciones se finalizaron satisfactoriamente. CONCLUSIONES: La evaluación preoperatoria del riesgo en MMA mediante historia clínica y TAC/RMN junto a la planificación anestésico-quirúrgica conduce a unos resultados excelentes. Deben favorecerse los procedimientos menos invasivos, pero si son precisos, la anestesia general planificada y en manos expertas es segura incluso en pacientes de riesgo.

Algoritmo de la vía aérea difícil en pediatría / No disponible

No disponible

Tratamiento anestésico para cesárea en una paciente con epidermolisis bullosa distrófica recesiva / Anesthesia for cesarean section in a patient with recessive dystrophic epidermolysis bullosa

La epidermolisis bullosa distrófica recesiva es unaenfermedad cutánea genéticamente determinada, debaja incidencia, y que consiste en la formación deampollas en la dermis. Describimos el tratamiento anestésicode una gestante de 39 años con epidermolisisbullosa distrófica recesiva que se iba a someter a unacesárea electiva a las 37 semanas de gestación. Presentabalesiones cutáneas generalizadas, pérdida de dedosen manos y estenosis esofágica. Se realizó la cesárea conanestesia subaracnoidea sin incidencias. La epidermolisisbullosa distrófica recesiva requiere un tratamientoanestésico adaptado, con control postural y manipulacióncuidadosa, así como adecuación del material demonitorización y de los accesos venosos a las deformidadesy lesiones cutáneas(AU)

Recessive dystrophic epidermolysis bullosa isinherited as a rare autosomal disorder which causesblisters to form in the skin. We describe the treatmentof a 39-year-old parturient with this condition. She wasscheduled for elective cesarean section at 37 weeks'gestation. The patient had widespread skin lesions, hadlost fingers, and had esophageal stenosis. The cesareanwas performed under spinal anesthesia withoutcomplications. Recessive dystrophic epidermolysisbullosa requires adaptation of anesthetic technique thatincludes control over posture and careful handling of theskin. Material for attaching monitoring devices andinserting venous lines must be adapted to the particulardeformities and skin lesions present(AU)

[Anesthesia for cesarean section in a patient with recessive dystrophic epidermolysis bullosa]. / Tratamiento anestésico para cesárea en una paciente con epidermolisis bullosa distrófica recesiva.

Recessive dystrophic epidermolysis bullosa is inherited as a rare autosomal disorder which causes blisters to form in the skin. We describe the treatment of a 39-year-old parturient with this condition. She was scheduled for elective cesarean section at 37 weeks' gestation. The patient had widespread skin lesions, had lost fingers, and had esophageal stenosis. The cesarean was performed under spinal anesthesia without complications. Recessive dystrophic epidermolysis bullosa requires adaptation of anesthetic technique that includes control over posture and careful handling of the skin. Material for attaching monitoring devices and inserting venous lines must be adapted to the particular deformities and skin lesions present.

[Fetoscopic tracheal occlusion for the treatment of severe congenital diaphragmatic hernia: preliminary results]. / Oclusión traqueal fetoscópica (FETO) para el tratamiento de la hernia diafragmática congénita severa: resultados preliminares.

OBJECTIVES: To evaluate survival and lung growth in fetuses with severe congenital diaphragmatic hernia (CDH) treated with fetoscopic tracheal occlusion (FETO) compared with control fetuses and to analyze possible complications of the anesthetic techniques used. PATIENTS AND METHODS: This prospective study was performed on fetuses with CDH. FETO was undertaken before the 29th week of gestation on fetuses with a lung-to-head ratio (LHR) less than 1. FETO was not performed on fetuses with an LHR between 1.0 and 1.5 or those with an LHR less than 1 where consent was not given. Lung growth was monitored by means of LHR. FETO was performed under fetal intramuscular anesthesia and maternal epidural anesthesia and sedation with remifentanil. RESULTS: Seventeen fetuses were included in the study. FETO was performed on 11 fetuses and was effective in 9. The median percentage difference between LHR at diagnosis and prior to FETO was 1.15% (P=.183); between diagnosis and before removing the balloon, the difference was 130.5% (P=.003); and between diagnosis and before delivery, 90.18% (P=.003). In the control group (n=6), the median percentage difference between LHR at diagnosis and before delivery was 49.25% (P=.028). No significant hemodynamic or respiratory changes occurred in either mother or fetus during fetoscopy. All the fetuses in the control group died; 45.5% of those in the FETO group survived. CONCLUSIONS: The use of FETO in cases of CDH appears to increase survival and lung growth. Fetal anesthesia in association with maternal epidural anesthesia and sedation makes it possible to place and remove the endotracheal balloon via fetoscopy with acceptable maternal comfort and without notable complications.

Oclusión traqueal fetoscópica (FETO) para el tratamiento de lahernia diafragmática congénita severa: resultados preliminares / Fetoscopic tracheal occlusion for the treatment of severe congenital diaphragmatic hernia: preliminary results

OBJETIVOS: Evaluar la supervivencia y crecimientopulmonar de fetos con hernia diafragmática congénitasevera (HDCs) tratados con oclusión traqueal fetoscópica(FETO) comparado con aquellos en que no se realizóy analizar posibles complicaciones de las técnicas anestésicas.PACIENTES Y MÉTODOS: Estudio prospectivo en fetoscon HDCs. FETO fue realizada antes de la 29 SG a fetoscon un lung head ratio (LHR) < 1. No se realizó FETO alos pacientes con LHR entre 1,0 y 1,5 o con LHR<1 queno dieron consentimiento. El crecimiento pulmonar fuemonitorizado con el LHR. Las fetoscopias se realizaronbajo anestesia intramuscular fetal asociada a anestesiaepidural y sedación materna con remifentanilo.RESULTADOS: Se incluyeron 17 fetos. En 11 se realizóFETO que fue efectiva en 9, la mediana de la diferenciade porcentajes del LHR respecto al diagnóstico fue1,15% (p = 0,183) previamente FETO, 130,5% (p =0,003) antes de retirar el balón y 90,18% (p = 0,003)antes del parto. En los “no FETO” (n=6) la diferencia deporcentajes del LHR antes del parto respecto al diagnósticofue 49,25% (p = 0,028). Durante las fetoscopiasno se produjeron cambios significativos hemodinámicoso respiratorios maternos ni fetales. En el grupo "FETO" 45,5% sobrevivieron mientras que en el "no FETO" todos murieron. CONCLUSIONES: FETO en la HDCs parece aumentar lasupervivencia y el crecimiento pulmonar. La anestesiafetal asociada a anestesia epidural y sedación maternapermiten colocar y retirar el balón endotraqueal fetoscópicamentecon buena confortabilidad materna sin complicacionesimportantes (AU)

OBJECTIVES: To evaluate survival and lung growth infetuses with severe congenital diaphragmatic hernia(CDH) treated with fetoscopic tracheal occlusion(FETO) compared with control fetuses and to analyzepossible complications of the anesthetic techniques used.PATIENTS AND METHODS: This prospective study wasperformed on fetuses with CDH. FETO was undertakenbefore the 29th week of gestation on fetuses with a lungto-head ratio (LHR) less than 1. FETO was notperformed on fetuses with an LHR between 1.0 and 1.5or those with an LHR less than 1 where consent was notgiven. Lung growth was monitored by means of LHR.FETO was performed under fetal intramuscularanesthesia and maternal epidural anesthesia andsedation with remifentanil.RESULTS: Seventeen fetuses were included in thestudy. FETO was performed on 11 fetuses and waseffective in 9. The median percentage difference betweenLHR at diagnosis and prior to FETO was 1.15%(P=.183); between diagnosis and before removing theballoon, the difference was 130.5% (P=.003); andbetween diagnosis and before delivery, 90.18% (P=.003).In the control group (n=6), the median percentagedifference between LHR at diagnosis and before deliverywas 49.25% (P=.028). No significant hemodynamic orrespiratory changes occurred in either mother or fetusduring fetoscopy. All the fetuses in the control groupdied; 45.5% of those in the FETO group survived. CONCLUSIONS: The use of FETO in cases of CDHappears to increase survival and lung growth. Fetalanesthesia in association with maternal epidural anesthesiaand sedation makes it possible to place and remove theendotracheal balloon via fetoscopy with acceptablematernal comfort and without notable complications (AU)

Lung transplantation in young infants with interstitial pneumonia.

OBJECTIVES: We describe our experience with infants suffering from interstitial pneumonia referred for lung transplantation. METHODS: From April 1998 to December 2000, three infants were admitted to our lung transplantation program: a 9-month-old girl (patient 1) suffering from surfactant protein C deficiency who had high oxygen requirements (fraction of inspired oxygen: 70% to 90%), and two boys, ages 2 (patient 2) and 9 months (patient 3), who were ventilator-dependent due to chronic pneumonitis of infancy. RESULTS: Patients were transplanted at the age of 5 months (patient 2) and 13 months (patients 1 and 3) at 87 to 105 days after being accepted for lung transplantation. All cases underwent a sequential double lung transplant on cardiopulmonary bypass. The immunosuppressive regime included tacrolimus, prednisone, and azathioprine. Patients 2 and 3 also received basiliximab. Two cases suffered a mild rejection episode that responded to high-dose steroids. Patient 2 was ventilator-dependent for 8 months after transplant, owing to severe bronchomalacia and left main bronchus stenosis. Bronchial stenosis resolved after pneumatic dilatation and endobronchial stenting. This patient also presented with a pulmonary artery anastomosis stricture that required percutaneous balloon dilatation. All three patients are at home, carrying out normal activities for their age, with no respiratory symptoms after a period of 8 to 29 months of follow-up. CONCLUSIONS: Interstitial pneumonia of infancy is a rare disease with a bad prognosis and no specific treatment; therefore, lung transplantation represents a good therapeutic option for these infants.

Respiratory depression following epidural morphine in an infant of three months of age.

Epidural administration of combinations of opioids and a local anaesthetic provides prompt and effective analgesia and is increasingly used in paediatric anaesthesia. However, respiratory depression by rostral spread of opioid in the CSF is by far the greatest concern after epidural morphine. An infant of three months of age underwent portoenterostomy (Kasai's operation) for extrahepatic biliary duct atresia. A median approach at the L3-L4 epidural interspace was used and a dose of 1 ml.kg-1 of 0.125% bupivacaine with adrenaline 1:400000 mixed with 50 micrograms.kg-1 morphine was injected using a 19 gauge Tuohy needle. Six h after epidural morphine, the infant developed respiratory depression with an increase in drowsiness, miosis and decreased respiratory rate. Low arterial saturation (SpO2) was detected by pulse oximetry and confirmed by blood gas analysis. An intravenous bolus of 5 micrograms.kg-1 naloxone followed by a 3-h infusion of 2 micrograms.kg-1.h-1 resulted in complete reversal of signs and symptoms of respiratory depression. Epidural opioids should be limited to paediatric patients admitted to specialized recovery units for the first postoperative day.