Valoración y tratamiento perioperatorio de los pacientes con síndromes arritmogénicos refractarios a tratamiento médico: a propósito de un caso clínico / Perioperative management of patients with arrhythmogenic syndromes refractory to medical treatment: A clinical case report

Las cardiopatías familiares relacionadas con la muerte súbita son un grupo de enfermedades cardiovasculares (miocardiopatías, canalopatías, enfermedades aórticas…) que requieren familiaridad del anestesiólogo con el tratamiento perioperatorio de los trastornos hemodinámicos complejos, así como con el tratamiento quirúrgico de los mismos1. Presentamos el caso de un varón de 12 años diagnosticado de miocardiopatía hipertrófica no obstructiva, tras una parada cardiorrespiratoria, al que se le practicó una simpatectomía izquierda guiada por videotoracoscopia por síncopes frecuentes, a pesar de tratamiento farmacológico e implantación de un desfibrilador automático implantable. Siempre que se produzca un síncope arrítmico en el contexto de enfermedades cardiacas familiares, la denervación cardiaca izquierda debe considerarse como el siguiente paso en el plan de tratamiento2.(AU)

Family heart diseases related to sudden death are a group of cardiovascular diseases (cardiomyopathies, channelopathies, aortic diseases...) that require familiarity of the anesthesiologist with the perioperative treatment of complex hemodynamic disorders, as well as their surgical treatment1. We present the case of a 12-year-old man diagnosed with non-obstructive hypertrophic cardiomyopathy, after cardiorespiratory arrest, who underwent video-guided thoracoscopy-guided left sympathectomy for frequent syncope, despite pharmacological treatment and implantation of an implantable automatic defibrillator. Whenever arrhythmic syncope occurs in the setting of familial heart disease, left heart denervation should be considered as the next step in the treatment plan2.(AU)

Perioperative management of patients with arrhythmogenic syndromes refractory to medical treatment: A clinical case report.

Family heart diseases related to sudden death are a group of cardiovascular diseases (cardiomyopathies, channelopathies, aortic diseases …) that require familiarity of the anesthesiologist with the perioperative treatment of complex hemodynamic disorders, as well as their surgical treatment.1 We present the case of a 12-year-old man diagnosed with non-obstructive hypertrophic cardiomyopathy (MHNO), after cardiorespiratory arrest (PCR), who underwent video-guided thoracoscopy-guided left sympathectomy (VATS) for frequent syncope, despite pharmacological treatment and implantation of an implantable automatic defibrillator (ICD). Whenever arrhythmic syncope occurs in the setting of familial heart disease, left heart denervation should be considered as the next step in the treatment plan.2.

Perioperative management of patients with arrhythmogenic syndromes refractory to medical treatment: A clinical case report. / Valoración y tratamiento perioperatorio de los pacientes con síndromes arritmogénicos refractarios a tratamiento médico: a propósito de un caso clínico.

Family heart diseases related to sudden death are a group of cardiovascular diseases (cardiomyopathies, channelopathies, aortic diseases...) that require familiarity of the anesthesiologist with the perioperative treatment of complex hemodynamic disorders, as well as their surgical treatment1. We present the case of a 12-year-old man diagnosed with non-obstructive hypertrophic cardiomyopathy, after cardiorespiratory arrest, who underwent video-guided thoracoscopy-guided left sympathectomy for frequent syncope, despite pharmacological treatment and implantation of an implantable automatic defibrillator. Whenever arrhythmic syncope occurs in the setting of familial heart disease, left heart denervation should be considered as the next step in the treatment plan2.

Loss of vision in a patient with major burn injury, including a review of the literature.

Vision loss is a rare complication due to decreased blood flow through the optic nerve, which has been described in certain groups of postoperative patients and as a major complication in polytraumatisms that need massive fluid resuscitation. However it has rarely been described in burned patients. We describe a patient with ischemic optic neuropathy (ION) as a major burn injury complication, focusing on his massive fluid resuscitation and hospital course and comparing it with previous case reports related to burn injuries in the literature. A 37-year-old male was admitted to the Burn Care Unit with an 85% total body surface burn injury caused by high temperature water vapour with traces of caustic soda. He underwent escharotomies the day of admission and sequential enzymatic and surgical debridement. An ophthalmological follow-up was conducted, with no fundoscopy alterations, and ION and vision loss was subsequently diagnosed. ION is an uncommon and currently irreversible condition, prevention therefore being the principal objective. Thus, minimization of risk factors such as anaemia, significant blood loss and massive fluid resuscitation, is advisable.

La perte de vision est une complication rare liée à un bas débit sanguin destiné au nerf optique, décrite en particulier en post opératoire et dans le cadre de polytraumatismes, après remplissage massif. Elle est toutefois peu décrite chez les brûlés. Nous décrivons ici une neuropathie optique ischémique compliquant une brûlure sévère. Nous nous attachons au remplissage massif initial et au séjour hospitalier et le comparons aux cas similaires préalablement rapportés. Un homme de 37 ans est admis pour une brûlure sur 85% SCT par ébouillantement d'eau additionnée de soude caustique (ça sent l'accident agro- alimentaire, NDRLF). Des incisions de décharge ont été initialement nécessaires puis le patient a bénéficié d'un débridement enzymatique. Une névrite optique ischémique, à fond d'oeil normal, a été mise en évidence. Cette complication, rare mais irréversible, doit donc être prévenue, en minimisant les facteurs de risque que sont l'anémie, l'hémorragie massive et le surremplissage.

Scaffolds of Hyaluronic Acid-Poly(Ethyl Acrylate) Interpenetrating Networks: Characterization and In Vitro Studies.

Hyaluronic acid (HA) provides many advantages to regenerative implants through its bioactive properties, but it also has many limitations as a biomaterial if it is not chemically modified. In order to overcome some of these limitations, HA has been combined with poly(ethyl acrylate) in the form of interpenetrating polymeric networks (IPNs), in which the HA network is crosslinked with divinyl sulfone. Scaffolds of this IPN have been produced through a template-leaching methodology, and their properties have been compared with those of single-network scaffolds made of either PEA or crosslinked HA. A fibroblast cell line has been used to assess the in vitro performance of the scaffolds, revealing good cell response and a differentiated behavior on the IPN surface when compared to the individual polymers. Altogether, the results confirm that this type of material offers an interesting microenvironment for cells, which can be further improved toward its potential use in medical implants.

Parada cardiaca relacionada con la anestesia en pediatría. Registro en un hospital infantil terciario / Anesthesia-related cardiac arrest in children. Data from a tertiary referral hospital registry

Objetivos. El objetivo del presente estudio es analizar las paradas cardiacas relacionadas con la anestesia en un hospital infantil terciario, con el fin de identificar factores de riesgo que permitan establecer oportunidades de mejora. Métodos. Estudio retrospectivo de 5 años, sobre las paradas cardiacas relacionadas con la anestesia que ocurrieron en pacientes pediátricos. Se incluyeron todos los procedimientos anestésicos urgentes y electivos realizados por anestesiólogos. Los datos obtenidos incluyeron características del paciente, del procedimiento, la causa probable y la evolución de la parada cardiaca. Se calculó la odds ratio mediante análisis univariante para determinar los factores clínicos asociados a la parada y a la mortalidad. Resultados. Se registraron un total de 15 paradas cardiacas relacionadas con la anestesia en 43.391 procedimientos anestésicos (3,4 por 10.000), con incidencia en niños ASA I-II frente ASA ≥ III de 0,28 y 19,27 por 10.000, respectivamente. Los principales factores de riesgo fueron niños con estado físico ASA ≥ III (p < 0,001), menores de un mes (p < 0,001), menores de un año (p < 0,001), procedimientos urgentes (p < 0,01), procedimientos cardiológicos (p < 0,001) y procedimientos del laboratorio de hemodinamia (p < 0,05). Las principales causas del paro cardiaco fueron cardiovasculares (53,3%), debidas principalmente a hipovolemia, seguidas de causas respiratorias (20%) y por efectos adversos de la medicación (20%). La incidencia de mortalidad y lesión neurológica secundaria a la parada en las primeras 24 h fue de 0,92 y 1,38 por 10.000, respectivamente. La mortalidad en los primeros 3 meses fue de 1,6 por 10.000. Las principales causas de mortalidad fueron ASA ≥ III, edad menor de un año, hipertensión arterial pulmonar, paradas en áreas alejadas del área quirúrgica, duración de la reanimación cardiopulmonar mayor de 20 min y cuando no se aplicó hipotermia tras la parada. Conclusión. Los principales factores de riesgo para la parada cardiaca fueron ASA ≥ III, edad menor de un año, procedimientos urgentes, cardiológicos y los realizados en el laboratorio de hemodinamia. La causa principal de la parada fue cardiovascular, debida principalmente a hipovolemia. Todos los pacientes que fallecieron o tuvieron lesión neurológica eran ASA ≥ III. La hipertensión arterial pulmonar conlleva riesgo de mortalidad relacionada con la anestesia (AU)

[Anesthesia-related cardiac arrest in children. Data from a tertiary referral hospital registry]. / Parada cardiaca relacionada con la anestesia en pediatría. Registro en un hospital infantil terciario.

OBJECTIVES: The aim of this study is to analyze the cardiac arrests related to anesthesia in a tertiary children's hospital, in order to identify risk factors that would lead to opportunities for improvement. METHODS: A 5-year retrospective study was conducted on anesthesia related cardiac arrest occurring in pediatric patients. All urgent and elective anesthetic procedures performed by anesthesiologists were included. Data collected included patient characteristics, the procedure, the probable cause, and outcome of the cardiac arrest. Odds ratio was calculated by univariate analysis to determine the clinical factors associated with cardiac arrest and mortality. RESULTS: There were a total of 15 cardiac arrests related to anesthesia in 43,391 anesthetic procedures (3.4 per 10,000), with an incidence in children with ASA I-II versus ASA≥III of 0.28 and 19.27 per 10,000, respectively. The main risk factors were children ASA≥III (P<.001), less than one month old (P<.001), less than one year old (P<.001), emergency procedures (P<.01), cardiac procedures (P<.001) and procedures performed in the catheterization laboratory (P<.05). The main causes of cardiac arrest were cardiovascular (53.3%), mainly due to hypovolemia, and cardiovascular depression associated with induction of anesthesia, followed by respiratory causes (20%), and medication causes (20%). The incidence of mortality and neurological injury within the first 24h after the cardiac arrest was 0.92 and 1.38 per 10,000, respectively. The mortality in the first 3 months was 1.6 per 10,000. The main causes of death were ASA≥III, age under one year, pulmonary arterial hypertension, cardiac arrest in areas remote from the surgery area, a duration of cardiopulmonary resuscitation over 20min, and when hypothermia was not applied after cardiac arrest. CONCLUSION: The main risk factors for cardiac arrest were ASA≥III, age under one year, emergency procedures, cardiology procedures and procedures performed in the catheterization laboratory. The main cause of the cardiac arrest was due mainly to cardiovascular hypovolemia. All patients who died or had neurological injury were ASA≥III. Pulmonary arterial hypertension is a risk of anesthesia-related mortality.

La ciclópea obra del Dr. Charles D. Kelman / The cyclopean work of Dr. Charles D. Kelman

Se hace un recorrido por la vida del Dr. Kelman, el padre de la facoemulsificación, desde su nacimiento en Nueva York hasta su fallecimientoen Boca Ratón, repasando lo más importante de su trayectoria investigadora en el desarrollo de la tecnología quirúrgica ocular; así como su estancia en Europa, donde estudió medicina en Ginebra y su lucha contra el poder oftalmológico establecido desde sus inicios en el tratamiento del desprendimiento de retina por medio de la crio-coagulación, con la extirpación del cristalino por medio de la crio-extracción o su máxima aportación a la oftalmología al desarrollar la facoemulsificación en la cirugía de la catarata (AU)

The article takes us through the life of Dr. Kelman, father of phacoemulsification, since his birth in New York until his death in Boca Raton reviewing the most important of his research career in the development of ocular surgical technology, as well as his pass through Europe where he studied medicine in Geneva and his fight against the established ophthalmologic power. It also reviews his beginning in the treatment of retinal detachment by means of cryocoagulation, with removal of the lens by means of cryoextraction and his maximum contribution to ophthalmology in developing the phacoemulsification cataract surgery (AU)

[Anesthetic induction with nitrous-oxide-free sevoflurane in pediatric patients]. / Inducción anestésica con sevoflurano libre de óxido nitroso en pediatría.

OBJECTIVE: To evaluate the pediatric use of inhaled nitrous oxide (N2O)-free induction with sevoflurane for the purpose of protecting staff from exposure to workplace air pollution. PATIENTS AND METHODS: Prospective, randomized trial in ASA class 1-2 children in whom a tidal breathing technique was used for anesthetic induction in a variety of surgical procedures. Patients were allocated to 2 groups. The sevo-N2O group inhaled 8% sevoflurane in a 60/40% mixture of oxygen and N2O. The sevo-air group received 8% sevoflurane in a mixture of oxygen and air (inspired oxygen fraction, 40%). We recorded mean arterial pressure (MAP), heart rate, oxygen saturation by pulse oximetry (SpO2), limb response to venous puncture, alveolar concentration of sevoflurane, and incidence of adverse events. RESULTS: Twenty-two patients were assigned to each group. The vein was catheterized in all patients without a pain reflex in the limb, and there were no statistically significant differences in MAP, heart rate, SpO2, or incidence of adverse events. Mean (SD) alveolar concentration of sevoflurane, however, differed between the 2 groups: 53% (0.51%) in the sevo-N2O group and 4.91% (0.41%) in the sevo-air group (P = .028). CONCLUSIONS: N2O-free anesthetic induction by tidal breathing of 8% sevoflurane provides similar anesthetic conditions (efficacy, safety, and rapid onset) without a higher incidence of adverse events. The use of N2O can therefore be avoided.

Inducción anestésica con sevoflurano libre de óxido nitrosoen pediatría / Anesthetic induction with nitrous oxide-free sevoflurane in pediatric patients

OBJETIVO: Evaluación de la inducción inhalatoria consevoflurano en ausencia de óxido nitroso (N2O) en pediatría,como estrategia antipolución en el personal laboralexpuesto.PACIENTES Y MÉTODOS: Estudio prospectivo y aleatorizadoen niños ASA I-II, que recibieron inducción inhalatoriaa volumen corriente para distintos procedimientosquirúrgicos. Se distribuyeron en 2 grupos, grupo sevo-N2O (sevoflurano al 8% en O2/N2O al 60/40%) y gruposevo-aire (sevoflurano al 8% en O2/aire con FiO2 del40%). Se registraron la presión arterial media (PAM),frecuencia cardiaca (FC), pulsioximetría (SpO2), la respuestade retirada del miembro a la punción venosaperiférica, la concentración alveolar (FA) de sevofluranoy la incidencia de los fenómenos adversos.RESULTADOS: Se recogieron 22 pacientes en cada grupo,en todos se canalizó la vía venosa periférica sin retiradadel miembro, no hubo diferencias estadísticamentesignificativas en PAM, FC, SpO2 ni en los fenómenosadversos; sí se encontraron diferencias estadísticamentesignificativas en la FA de sevoflurano (sevo-N2O = 5,3 ±0,51%; sevo-aire = 4,91 ± 0,41%, p = 0,028).CONCLUSIONES: La ausencia del N2O en la induccióninhalatoria a volumen corriente con sevoflurano al 8%se asocia a similares condiciones anestésicas (eficacia,seguridad y rapidez), sin mayor incidencia de fenómenosadversos, por lo que el N2O puede ser evitado (AU)

OBJECTIVE: To evaluate the pediatric use of inhalednitrous oxide (N2O)-free induction with sevoflurane forthe purpose of protecting staff from exposure toworkplace air pollution.PATIENTS AND METHODS: Prospective, randomized trialin ASA class 1-2 children in whom a tidal breathingtechnique was used for anesthetic induction in a varietyof surgical procedures. Patients were allocated to 2groups. The sevo-N2O group inhaled 8% sevoflurane ina 60/40% mixture of oxygen and N2O. The sevo-airgroup received 8% sevoflurane in a mixture of oxygenand air (inspired oxygen fraction, 40%). We recordedmean arterial pressure (MAP), heart rate, oxygensaturation by pulse oximetry (SpO2), limb response tovenous puncture, alveolar concentration of sevoflurane,and incidence of adverse events.RESULTS: Twenty-two patients were assigned to eachgroup. The vein was catheterized in all patients withouta pain reflex in the limb, and there were no statisticallysignificant differences in MAP, heart rate, SpO2, orincidence of adverse events. Mean (SD) alveolarconcentration of sevoflurane, however, differed betweenthe 2 groups: 5.3% (0.51%) in the sevo-N2O group and4.91% (0.41%) in the sevo-air group (P=.028).CONCLUSIONS: N2O-free anesthetic induction by tidalbreathing of 8% sevoflurane provides similar anestheticconditions (efficacy, safety, and rapid onset) without ahigher incidence of adverse events. The use of N2O cantherefore be avoided (AU)

Efectos electrofisiológicos del sevoflurano versus propofol en niños con síndrome de Wolff-Parkinson-White / Electrophysiological effects of sevoflurane in comparison with propofol in children with Wolff-Parkinson-White syndrome

OBJETIVOS: Evaluar los efectos electrofisiológicos delsevoflurano en niños con síndrome de Wolff-Parkinson-White (WPW) sometidos a ablación por radiofrecuencia(RF).MÉTODOs: Se estudiaron de forma prospectiva 15pacientes con síndrome de WPW, programados paraestudio electrofiosológico (EEF) y ablación por RF.La inducción anestésica se realizó con fentanilo (2 μkg–1), propofol (3 mg kg–1) y vecuronio (0,1 mg kg–1) y el mantenimiento con propofol (100 μ kg–1 min–1), bolus de fentanilo y vecuronio según necesidades. El EEF(EEFpropofol) se practicó mediante la introducción de cuatro electrocatéteres intracardiacos. Se determinaron la función del nodo sinusal, la conducción sinoatrial, períodos refractarios (auricular, nodo AV, anterógrado y retrógrado de la vía accesoria, ventricular)y características de la taquicardia ortodrómicainducida. Posteriormente, se intercambió propofol por sevoflurano (1 MAC según edad) repitiendo las mediciones(EEFsevoflurano). Los parámetros EEFpropofol y EEFsevoflurano se compararon mediante el test de Wilcoxon. RESULTADOS: La edad media fue de 9,3 ± 6 años. Trasla administración de sevoflurano se produjo un alargamiento del período refractario efectivo anterógrado de la vía accesoria (EEFpropofol 283 ± 22 ms; EEFsevoflurano 298 ± 25 ms; p = 0,004), y del ciclo mínimo de estimulación con conducción ventrículo-atrial 1:1 (EEFpropofol 244 ± 41 ms; EEFsevoflurano 273 ± 28 ms; p = 0,028). No hubo cambios significativosen el resto de los parámetros. En todos lospacientes se consiguió la ablación de la vía accesoria.CONCLUSIONES: El sevoflurano modificó parcialmentelas propiedades de la vía accesoria, aunque esto no impidióla ablación de la misma

OBJECTIVE: To evaluate the electrophysiologicaleffects of sevoflurane in children with Wolff-Parkinson-White (WPW) syndrome undergoing radiofrequencyablation.METHODS: We performed a prospective study of 15patients with WPW syndrome who were scheduled foran electrophysiological study (EPS) and radiofrequencyablation.Anesthesia was induced with fentanyl (2 μg/kg),propofol (3 mg/kg), and vecuronium (0.1 mg/kg), andinitially maintained using propofol (100 μg/kg), withbolus administration of fentanyl and vecuronium asrequired. Four intracardiac catheters were introducedfor the EPSpropofol, which included measurements ofsinus-node function, sinoatrial-node conduction,refractory periods (atrial, AV-node, accessory pathwayanterograde and retrograde, and ventricular), and thecharacteristics of induced orthodromic tachycardia.The propofol was then replaced with sevoflurane (1MAC adjusted for age) and the measurements wererepeated (EPSsevoflurane). The EPSpropofol and EPSsevoflurane data were compared using the Wilcoxon signed-rank test.RESULTS: The mean (SD) age was 9.3 (6 ) years. Afteradministration of sevoflurane, the duration of the antegrade effective refractory period of the accessory pathway increased (EPSpropofol, 283 (22) ms; EPSsevoflurane, 298 (25) ms; P = .004), as did the duration of the minimum pacing cycle with 1:1 atrioventricular conduction (EPSpropofol, 244 (41) ms; EPSsevoflurane, 273 (28) ms; P = .028). No significant changes were observed in the other parameters. Ablation of the accessory pathway was achieved in all patients.CONCLUSIONS: Sevoflurane partially modified the properties of the accessory pathway but did not prevent ablation

[Effect of tranexamic acid on postoperative bleeding in pediatric heart surgery]. / Efecto del ácido tranexáimico en el sangrado postoperatorio de cirugía cardiaca en pediatría.

OBJECTIVE: To assess the effects of a single dose of tranexamic acid on bleeding and requirement for blood product transfusion in children undergoing cardiac surgery with cardiopulmonary bypass. PATIENTS AND METHODS: A prospective study of closed cohorts undergoing pediatric heart surgery was carried out. The children weighed between 4 and 10 kg. Reoperated and cyanotic patients were included in the sample. The treatment group received 50 mg x kg(-1) of tranexamic acid before surgery. Analyzed data collected during the first 24 hours after surgery were biochemical parameters, bleeding, use of blood products, and D-dimer levels. RESULTS: Fifty-three patients, 25 in the treatment group, were enrolled. Patients on treatment had 24.8% less bleeding in the first 24 hours after surgery (P = .02). The transfusion of blood products was 20% less in the treatment group, although the difference was not significant except in the subgroup of patients who were reoperated. In that group the amount of blood products transfused was 72% less than in the control group (P = .05). D-dimer levels were also lower in the treatment group (P = .003). No adverse effects attributable to the treatment were observed. CONCLUSIONS: A single preoperative dose of tranexamic acid to inhibit fibrinolysis reduces bleeding 24.8% in pediatric patients undergoing heart surgery with cardiopulmonary bypass. The effect is greater in reoperated patients, leading to a reduction in their requirement for transfusion. The use of this therapy in these patients is therefore highly justified.

Exposición laboral a los anestésicos inhalatorios: medidas de control / Labour exposure to the inhalatory anaesthetic gases: control measurements

La exposición laboral a los residuos ambientales anestésicos durante la anestesia inhalatoria supone un riesgo importante para la salud, cuando los niveles de exposición superan los límites recomendados. La medición ambiental periódica junto con una metodología adecuada en el manejo de la anestesia inhalatoria y en el mantenimiento de las instalaciones son estrategias fundamentales para control de contaminación ambiental y exposición laboral. De estas medidas destacan por su eficacia la ventilación adecuada de los quirófanos y el empleo de sistemas de evacuación de gases anestésicos, ya que reducen el nivel de exposición un 50 y 90% respectivamente

The labour exposure to the environmental anaesthetic residues during the inhalatory anaesthesia means a risk for health if exposure levels overcome the recommended limits. A periodical analysis of environmental conditions, an adequate methodology during the inhalatory anaesthesia, and an appropriate maintenance of the facilities are necessary strategies to control the environmental pollution and therefore the labour exposure. Some of the most efficient actions to take are a suitable ventilation of the operating room and the use of an anaesthetic gases evacuation system since they may reduce the exposure levels 50 and 90 % respectively

Efecto del ácido tranexámico en el sangrado postoperatorio de cirugía cardiaca en pediatría / Effect of tranexamic acid on postoperative bleeding in pediatric heart surgery

OBJETIVO: Valorar los efectos de una única dosis de ácido tranexámico (AT) sobre el sangrado y las necesidades de hemoderivados en niños sometidos a cirugía cardiaca con circulación extracorpórea (CEC). PACIENTES Y MÉTODOS: Estudio prospectivo de cohortes cerradas en pacientes sometidos a cirugía cardiaca infantil con pesos comprendidos entre 4 y 10 kg. La muestra incluyó pacientes reintervenidos y cianóticos. El grupo tratado recibió 50 mg kg–1 de AT previo a la cirugía. Durante las primeras 24 horas del postoperatorio se analizaron datos bioquímicos, sangrado, uso de hemoderivados y niveles de D-dímero. RESULTADOS: Se incluyeron 53 pacientes, 25 en el grupo que recibió AT. En ellos se observó una disminución en un 24,8% del volumen de sangrado en las primeras 24 horas del postoperatorio (p=0,02). El consumo de concentrados de hematíes descendió un 20% en el grupo tratado pero sin relevancia estadística, salvo en los enfermos reintervenidos donde se observó una reducción del 72% en la transfusión de concentrados de hematíes respecto al control (p=0,05). Los niveles de D-dímero fueron menores en el grupo tratado (p=0,003). No se observaron efectos adversos atribuibles al fármaco. CONCLUSIONES: La administración preoperatoria de una única dosis de AT disminuye el sangrado un 24,8% en pacientes pediátricos sometidos a cirugía cardiaca con CEC, esto por inhibición de la fibrinolisis asociada. En los pacientes reintervenidos, el efecto es mayor, lo cual se relaciona con una disminución en la necesidad de transfusión, por lo que su uso estaría muy justificado en este grupo de enfermos

OBJECTIVE: To assess the effects of a single dose of tranexamic acid on bleeding and requirement for blood product transfusion in children undergoing cardiac surgery with cardiopulmonary bypass. PATIENTS AND METHODS: A prospective study of closed cohorts undergoing pediatric heart surgery was carried out. The children weighed between 4 and 10 kg. Reoperated and cyanotic patients were included in the sample. The treatment group received 50 mg.kg–1 of tranexamic acid before surgery. Analyzed data collected during the first 24 hours after surgery were biochemical parameters, bleeding, use of blood products, and D-dimer levels. RESULTS: Fifty-three patients, 25 in the treatment group, were enrolled. Patients on treatment had 24.8% less bleeding in the first 24 hours after surgery (P=.02). The transfusion of blood products was 20% less in the treatment group, although the difference was not significant except in the subgroup of patients who were reoperated. In that group the amount of blood products transfused was 72% less than in the control group (P=.05). D-dimer levels were also lower in the treatment group (P=.003). No adverse effects attributable to the treatment were observed. CONCLUSIONS: A single preoperative dose of tranexamic acid to inhibit fibrinolysis reduces bleeding 24.8% in pediatric patients undergoing heart surgery with cardiopulmonary bypass. The effect is greater in reoperated patients, leading to a reduction in their requirement for transfusion. The use of this therapy in these patients is therefore highly justified

Exposición laboral al óxido nitroso y sevoflurano durante la anestesia en pediatría: evaluación de un dispositivo de extracción de gases anestésicos / Occupational exposure to nitrous oxide and sevoflurane during pediatric anesthesia: evaluation of an anesthetic gas extractor

OBJETIVOS: Determinar el grado de exposición laboral alos gases anestésicos en ausencia de extracción de gases y evaluarla efectividad de un sistema extractor, original y diseñadoal efecto, durante la anestesia inhalatoria en pediatría.MÉTODOS: Veinticuatro niños sometidos a adenoamigdalectomía.En grupo ASP se aplicó extracción de gasesanestésicos (n=12) y grupo No ASP no se aplicó (n=12).Se hizo inducción inhalatoria mediante circuito MaplesonC con sevoflurano 8%, N2O 60%, oxígeno 40% y flujode gas 8 l.min-1. El mantenimiento se hizo con sevoflurano2% con el mismo flujo y mezcla anestésica, enventilación espontánea con tubo endotraqueal y circuitoMapleson D. Los circuitos disponen de válvula APL (airwaypressure-limiting) que permite la conexión al extractorde gases anestésicos. Se midieron niveles ambientalesde sevoflurano y N2O en la zona respiratoria del anestesiólogo.Se realizó encuesta a cirujano y enfermera sobresíntomas relacionados con la exposición laboral.RESULTADOS: Durante el periodo anestésico el promediode exposición al N2O y sevoflurano fue en No ASP:423±290 y 12±10,9 ppm respectivamente; disminuyendoun 94% y 91% en ASP: 24,7±26 y 1,1±1 ppm; p<0,001.Se detectó más incidencia de “olor a gas” en NoASP:87% frente ASP:11% (p=0,003), malestar general:62% versus 11% (p=0,05), náuseas: 62% versus 0%(p=0,009) y cefalea: 62% versus 0% (p=0,009).CONCLUSIONES: La extracción de gases disminuyó hastaun 94% el nivel de exposición, consiguiendo nivelesinferiores a los límites recomendados y reduciendo intensamentelos riesgos para la salud de los trabajadores

OBJETIVES: To determine the level of occupationalexposure to anesthetic gases in the absence of anextractor during pediatric anesthesia and to assess theefficacy of a purpose-built extraction system.METHODS: The patients were 24 children undergoingtonsillectomy and adenoidectomy. Gases were extractedfrom the room for 1 group and were not extracted forthe other group (n=12 in each group). Induction waswith 8% sevoflurane, 60% nitrous oxide (N2O), 40%oxygen at a flow rate of 8 L·min–1 through a Mapleson Ccircuit. Maintenance was with 2% sevoflurane at thesame flow rate and gas mixture under spontaneousventilation with an endotracheal tube and a Mapleson Dcircuit. The circuits were equipped with an airwaypressure-limiting valve to allow connection to ananesthetic gas extractor. Ambient levels of sevofluraneand N2O were measured in the breathing area aroundthe anesthesiologist. The surgeon and the nurse wereasked about symptoms related to occupational exposure.RESULTS: The mean (SD) exposure to N2O andsevoflurane in the group without an extractor was 423(290) and 12 (10.9) parts per million (ppm), respectively.In the group working with the extractor, exposure was94% and 91% lower: 24.7 (26) and 1.1 (1) ppm (P<.001).A higher incidence of noticing a "smell of gas" wasregistered for the group without an extractor (87% vs11% in the extractor group, P=.003). Higher rates werealso found for general discomfort (62% vs 11%, P=.05),nausea (62% vs 0%, P=.009), and headache (62% vs0%, P=.009) in the absence of the extractor.CONCLUSIONS: Gas extraction decreased the level ofexposure by up to 94%, achieving levels that were belowthe recommended limits and greatly reducing occupationalrisk

Exposición laboral a los anestésicos inhalatorios: riesgos para la salud, monitorización ambiental y legislación / Labour exposure to the anesthetic gases: risks for the health, environmental monitoring, and legislation

La exposición laboral a los residuos ambientales anestésicos durante la anestesia inhalatoria puede suponer un riesgo para la salud de los trabajadores expuestos que requiere la planificación e implantación de medidas de prevención efectivas. Cuando los niveles de exposición superan los límites recomendados se produce mayor incidencia de cefalea, náuseas, descenso del tiempo de reacción y de la habilidad motora, y en la exposición crónica mayor incidencia de aborto espontáneo y alteraciones en la función reproductora. El óxido nitroso es el principal agente involucrado en dichas alteraciones, con un mecanismo de toxicidad conocido y de peor control en las estrategias antipolución. Las principales fuentes de contaminación son la ventilación con mascarilla, la no utilización del extractor de gases, la anestesia pediátrica y fugas por inadecuado mantenimiento de las instalaciones. Establecer un plan preventivo que incluya, la vigilancia y control de la salud de los trabajadores, la medición ambiental periódica para identificar y solucionar las posibles fugas, implantar medidas correctoras y comprobar la eficacia de las medidas antipolución instauradas, cuyo objetivo será no sobrepasar los valores límite recomendados, hasta la fecha, por el Instituto Nacional de Seguridad e Higiene en el Trabajo siguiendo la Ley de Prevención de Riesgos Laborales y normativa que la desarrolla. Además es necesaria la creación de una Comisión de Vigilancia de los Gases para asegurar que se siguen las normativas vigentes de prevención y se instauran los avances científicos en este campo

The labour exposure to the environmental anaesthetic residue during the inhalatory anaesthesia supposes an important risk for the health without solution at present time. Among these risks, we may emphasize: headache, nauseas, decrement of the reactiontime and motor ability. Additionally, greater incidence inspontaneous abortion and alterations in the reproductive function may arise when the exposure levels overcome the recommended limits. The nitrous oxide is the main agent involved in the above mentioned alterations. Although its toxicity mechanism is wellknown, antipollution strategies are difficult to implement. The main pollution sources are the ventilation with face mask, no useof the gas extractor, the paediatric anaesthesia and the gas escapes due to an inadequate maintenance of the facilities. A periodical analyse of environmental conditions is basic to identify and to solve the escapes, and should be also used to check the efficiency of the antipollution measures implemented which should not exceed the recommended limits following the Law of Prevention for Labour Risks. Besides, it is necessary to create a commission which would be in charge of assuring the norms in use and also the accomplishment of the latest scientific advances

[Occupational exposure to nitrous oxide and sevoflurane during pediatric anesthesia: evaluation of an anesthetic gas extractor]. / Exposición laboral al óxido nitroso y sevoflurano durante la anestesia en pediatráa: evaluación de un dispositivo de extracción de gases anestésicos.

OBJECTIVES: To determine the level of occupational exposure to anesthetic gases in the absence of an extractor during pediatric anesthesia and to assess the efficacy of a purpose-built extraction system. METHODS: The patients were 24 children undergoing tonsillectomy and adenoidectomy. Gases were extracted from the room for 1 group and were not extracted for the other group (n=12 in each group). Induction was with 8% sevoflurane, 60% nitrous oxide (N2O), 40% oxygen at a flow rate of 8 L x min(-1) through a Mapleson C circuit. Maintenance was with 2% sevoflurane at the same flow rate and gas mixture under spontaneous ventilation with an endotracheal tube and a Mapleson D circuit. The circuits were equipped with an airway pressure-limiting valve to allow connection to an anesthetic gas extractor. Ambient levels of sevoflurane and N2O were measured in the breathing area around the anesthesiologist. The surgeon and the nurse were asked about symptoms related to occupational exposure. RESULTS: The mean (SD) exposure to N2O and sevoflurane in the group without an extractor was 423 (290) and 12 (10.9) parts per million (ppm), respectively. In the group working with the extractor, exposure was 94% and 91% lower: 24.7 (26) and 1.1 (1) ppm (P<.001). A higher incidence of noticing a "smell of gas" was registered for the group without an extractor (87% vs 11% in the extractor group, P=.003). Higher rates were also found for general discomfort (62% vs 11%, P=.05), nausea (62% vs 0%, P=.009), and headache (62% vs 0%, P=.009) in the absence of the extractor. CONCLUSIONS: Gas extraction decreased the level of exposure by up to 94%, achieving levels that were below the recommended limits and greatly reducing occupational risk.

Repercusión de la infección de vía respiratoria alta en niños sobre la programación quirúrgica en un hospital infantil / Upper respiratory tract infections in children: impact on surgical scheduling at a pediatric hospital

OBJETIVO: Detectar la incidencia de suspensiones de intervenciones quirúrgicas programadas por infección de vía respiratoria superior (IRA) en nuestro medio y analizar la repercusión sobre estas suspensiones de la instauración de un protocolo basado en sucesivas revisiones bibliográficas y en una adecuada información a los padres. MATERIAL Y MÉTODOS: Estudiamos de manera retrospectiva las causas de suspensión de las intervenciones quirúrgicas programadas del quirófano de otorrinolaringología pediátrica (ORL) durante los años 2001, 2002, 2003 y 2004. El estudio estadístico se realizó utilizando el test estadístico del Chi cuadrado. RESULTADOS: En el periodo de estudio del 2001 se suspendieron el 24% de los 641 pacientes programados, suspendiéndose por IRA el 12,9%. Tras la instauración del protocolo, en el 2002 se suspendieron el 15% de los 751 pacientes programados, suspendiéndose por IRA el 4,9% (p<0,0001 respecto al 2001). En el 2003 se suspendieron el 14,3% de los 760 pacientes programados, suspendiéndose por IRA el 6,5% (p<0,0001 respecto al 2001). En el 2004 se suspendieron el 12,2% de los 692 pacientes programados, suspendiéndose por IRA el 7,2% (p<0,0001 respecto al 2001). Durante los meses de otoño-invierno / primavera- verano se suspendieron el 28,2% /19,8% en el 2001, 17,1% /12,7% en el 2002, 16,6% /11,8% en el 2003 y 13,8% /11,1% en el 2004. CONCLUSIONES: La IRA provoca una alta tasa de suspensiones de intervenciones quirúrgicas programadas, sobre todo en estaciones frías. Para optimizar los resultados es necesario disponer de protocolos de actuación basados en sucesivas revisiones bibliográficas y en una adecuada información a los padres

OBJECTIVE: To determine the rate of cancelation of scheduled surgical procedures attributable to upper respiratory tract infection (URTI) in our university pediatric hospital in Madrid and to analyze the effect that literature reviews and appropriate counseling of parents would have on cancelations. MATERIAL AND METHODS:We carried out a retrospective study of the reasons for canceling scheduled pediatric ear, nose, or throat operations in 2001, 2002, 2003, and 2004. Statistical comparisons were performed with the chi2 test. RESULTS: In 2001, 24% of the 641 procedures scheduled were canceled, 12.9% of them because of URTIs. After applying criteria based on a review of the literature, 15% of the 751 procedures were canceled in 2002, 4.9% of them because of URTIs (P<0.0001 in comparison with 2001). In 2003 14.3% of the 760 scheduled procedures were canceled, 6.5% because of URTIs (P<0.0001 in the comparison with 2001). In 2004 12.2% of the 692 scheduled procedures were canceled, 7.2% because of URTIs (P<0.0001 in comparison with 2001). Cancelations in autumn–winter or in spring–summer seasons amounted to 28.2% vs 19.8% in 2001, 17.1% vs 12.7% in 2002, 16.6% vs 11.8% in 2003, and 13.8% vs 11.1% in 2004. CONCLUSIONS: URTIs are responsible for a high rate of cancelations of scheduled operations, particularly in colder seasons of the year. To obtain optimal results, criteria based on up-to-date literature reviews should be put into effect and parents should be given appropriate information