Uso del Totaltrack VLM en una vía aérea difícil imprevista en una cesárea urgente / Use of the Totaltrack VLM in unexpected difficult airway in urgent caesarean section

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Obstrucción total del tubo endotraqueal tras intubación nasotraqueal no complicada / No disponible

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Pancreatitis hipertrigliceridémica y embarazo / Hypertriglyceridemic pancreatitis in pregnancy

Una mujer de 33 años, secundípara, con antecedentes de hipertrigliceridemia familiar que se agravó en el embarazo anterior y diabetes gestacional, fue ingresada en la 36 semana de gestación por dolor abdominal difuso, vómitos, febrícula y mal estado general. La muestra de sangre era de aspecto lipémico, lechoso-rosado, con una concentración de triglicéridos plasmáticos de 2173 mg/dl, colesterol de 320 mg/dl, amilasa de 801 U/l, LDH 650 U/l, creatinina 1,5 mg/dl, glucemia de 380 mg/dl y leucocitosis con desviación a la izquierda. Fue diagnosticada de pancreatitis aguda, y por signos de sufrimiento fetal se le realizó una cesárea bajo anestesia general con propofol, succinilcolina, sevoflurano y tras el pinzamiento del cordón rocuronio y fentanilo. El recién nacido nació sano y la paciente evolucionó favorablemente con tratamiento conservador. La incidencia de la pancreatitis en el embarazo es baja, pero de morbimortalidad elevada. La etiología más habitual es la patología del tracto biliar, aunque alteraciones metabólicas poco frecuentes como la hiperlipidemia pueden actuar ocasionalmente como factor desencadenante. Hay que destacar la importancia del diagnóstico y tratamiento precoz de estos procesos como clave para el mejor pronóstico en quirófano y en su seguimiento en la Unidad de Reanimación (AU)

[Early extubation with caudal morphine after pediatric heart surgery]. / Extubación precoz con morfina caudal tras cirugía cardíaca pediátrica.

OBJECTIVES: To analyze the viability of immediate extubation of children after corrective surgery for congenital heart defects with extracorporeal membrane oxygenation using an anesthetic technique involving caudal morphine, and to study the effect on length of stay in the pediatric intensive care unit (PICU) or elsewhere in the hospital. MATERIAL AND METHODS: Twenty-nine ASA I-II patients without coagulation alterations undergoing surgery to correct simple heart defects were selected for extubation after surgery. Anesthesia was provided with with sevoflurane, midazolam, rocuronium, fentanil (maximum dose 10 micrograms/Kg) and a bolus of caudal morphine (50-60 micrograms/Kg) after anesthetic induction. Patient characteristics, type of surgery, times of extracorporeal circulation and of ischemia, arterial blood gases upon arrival in the PICU, postoperative complications and quality of analgesia were the variables analyzed. We also compared length of stay in the PICU and hospital for the study group and for a historical control group of 23 patients who had no received caudal morphine or been selected for early extubation. RESULTS: All patients were extubated satisfactorily in the operating room. None required reintubation or reoperation. Postoperative pain was controlled with metamizol alone for 79.3%. No episodes of respiratory depression or neurological complications were observed. PICU and hospital stays were significantly shorter in the study group than in the control group. CONCLUSIONS: Of patients undergoing simple corrective heart surgery with extracorporeal membrane oxygenation immediate extubation did not increase postoperative morbimortality and shortened the hospital stay. A single dose of caudal morphine provided optimum conditions for extubation and good control of postoperative pain. Strict measures must be taken, however, to avoid postpuncture bleeding.

Extubación precoz con morfina caudal tras cirugía cardíacapediátrica / Early exttubation with caudal morphine after pediatric heart surgery

OBJETIVO: Analizar la viabilidad y la influencia en la estancia en la Unidad de Cuidados Intensivos Pediátricos (UCIP) y en el hospital de la extubación inmediata de niños sometidos a corrección de cardiopatías congénitas bajo circulación extracorpórea (CEC) utilizando una técnica anestésica basada en la administración de morfina caudal. MATERIAL Y MÉTODOS: 29 pacientes ASA I-II, sin alteraciones de la coagulación y sometidos a corrección de una cardiopatía simple, fueron seleccionados para ser extubados tras la intervención. La anestesia se realizó con sevoflurano, midazolam, rocuronio, fentanilo (dosis máxima de 10 µg/Kg) y bolo de morfina caudal (50-60 µg/Kg) tras la inducción anestésica. Se analizaron las variables demográficas, tipo de cirugía, tiempo de CEC y de isquemia, gasometría arterial a su llegada a UCIP, complicaciones postoperatorias y grado de analgesia. Asimismo se compararon las estancias en la UCIP y en el hospital con las de un grupo control histórico de 23 pacientes a los que no se administró morfina caudal ni hubo intencionalidad de conseguir su extubación precoz. RESULTADOS: Todos los pacientes fueron extubados satisfactoriamente en quirófano. Ninguno requirió reintubación o reintervención. En el 79,3 por ciento de los casos el dolor se controló sólo con metamizol durante el postoperatorio. No se registraron episodios de depresión respiratoria ni complicaciones neurológicas. La estancia en UCIP y hospitalaria fueron significativamente más bajas que en el grupo control. CONCLUSIONES: La extubación inmediata de pacientes intervenidos por cardiopatía simple bajo CEC no aumentó la morbimortalidad postoperatoria y acortó la estancia hospitalaria. La morfina caudal en dosis única proporcionó unas condiciones óptimas para la extubación y un buen control del dolor postoperatorio, aunque deben extremarse las precauciones para prevenir un sangrado postpunción (AU)

[Hypertriglyceridemic pancreatitis and pregnancy]. / Pancreatitis hipertrigliceridémica y embarazo.

A 33-year-old secundipara with a history of gestational diabetes and familial hypertriglyceridemia exacerbated during her previous pregnancy was admitted in the 36th week of gestation with diffuse abdominal pain, vomiting, low-grade fever, and general malaise. A blood sample had a lipemic, milky-pink appearance and plasma concentrations were as follows: triglycerides 2173 mg/dL, cholesterol 320 mg/dL, amylase 801 U/L, lactate dehydrogenase 650 U/L, creatinine 1.5 mg/dL, glucose 380 mg/dL, and left-shifted white cells. Acute pancreatitis was diagnosed and owing to signs of fetal distress, a cesarean was performed under light general anesthesia with propofol, succinylcholine, and sevoflurane. After the umbilical cord was cut, rocoronium and fentanyl were administered. The neonate was healthy and the patient's condition evolved favorably with conservative treatment. The incidence of pancreatitis during pregnancy is low but related morbidity and mortality are high. The usual cause is biliary tract disease, although rare metabolic alterations such as hyperlipidemia may occasionally act as the trigger. Early diagnosis and treatment are the keys to successful surgery and postoperative recovery.

[Transfusion needs during intraoperative and immediate postoperative periods in arthroplasty of the hip and knee]. / Necesidades transfusionales durante el intra y postoperatorio inmediato de la artroplastia de cadera y rodilla. Incidencia y factores asociados.

OBJECTIVES: To determine the factors associated with immediate perioperative transfusion requirements of hip or knee arthroplasty patients who have not been enrolled in a blood salvage program. PATIENTS AND METHODS: This prospective study collected demographic (age, sex, weight, height, etc.), physiological (hemoglobin levels, coagulation times, preoperative platelet counts, etc.), clinical history and anesthetic and surgical data (type of anesthesia, surgical diagnosis, duration of procedure) in 112 patients undergoing orthopedic surgery: 19 cases of primary knee arthroplasty, 77 cases of hip arthroplasty and 16 replacements of hip arthroplasty. Logistic regression analysis of the aforementioned variables was performed to search for factors related to transfusional needs during and after hip arthroplasty or after knee arthroplasty, which was performed with a tourniquet applied to render intraoperative transfusion unnecessary. RESULTS: The variables that increased the risk of transfusion during surgery were duration of procedure exceeding 120 min (OR 15.24; p = 0.01) and loss of over 500 ml of blood during surgery (OR 11.4; p = 0.02). The variables associated with perioperative transfusion were loss of over 500 ml in the postanesthetic recovery room (OR 12.6; p < 0.0001), hypotensive episodes during recovery (OR 11.7; p = 0.0001), prosthetic replacement (OR 6.33; p = 0.005), height < 160 cm (OR 5.03; p = 0.02), preoperative hemoglobin level < 13.5 g/dl (OR 4.97; p = 0.02), and surgery for reasons other than osteoarthritis (arthritis, pathological fractures, etc.) (OR 4.60; p = 0.04). Variables associated with transfusion of over two units of packed red cells were a history of neoplastic disease unrelated to arthroplasty (OR 378.67; p = 0.005), prosthetic replacement (OR 49.71; p = 0.009), diabetes (OR 36.49; p = 0.02) and a hypotensive event while in the postanesthetic recovery room (OR 29.12; p = 0.02). CONCLUSION: These results suggest that certain modifiable factors increase the risk of blood transfusion in knee and hip arthroplasty. Specifically, they are duration of surgery, intra- and postoperative bleeding, preoperative hemoglobin level and instances of perioperative hypotension. Other factors outside our control are height or patient clinical history.