[Paresthesia and spinal anesthesia for cesarean section: comparison of patient positioning]. / Parestesias y anestesia subaracnoidea en cesáreas: estudio comparativo según la posición de la paciente.

OBJECTIVE: To determine the incidence of paresthesia during lumbar puncture performed with the patient in different positions. MATERIAL AND METHODS: A single-blind prospective study of patients scheduled for elective cesarean section, randomized to 3 groups. In group 1 patients were seated in the direction of the long axis of the table, with heels resting on the table. In group 2 they were seated perpendicular to the long axis of the table, with legs hanging from the table. In group 3 they were in left lateral decubitus position. Lumbar punctures were performed with a 27-gauge Whitacre needle. RESULTS: One hundred sixty-eight patients (56 per group) were enrolled. Paresthesia occurred most often in group 3 (P = .009). We observed no differences in blood pressure after patients moved from decubitus position to the assigned position. Nor did we observe between-group differences in blood pressure according to position taken during puncture. CONCLUSION: Puncture undertaken with the patient seated, heels on the table and knees slightly bent, is associated with a lower incidence of paresthesia than puncture performed with the patient seated, legs hanging from the table. Placing the patient's heels on the table requires hip flexion and leads to anterior displacement of nerve roots in the dural sac. Such displacement would increase the nerve-free zone on the posterior side of the sac, thereby decreasing the likelihood of paresthesia during lumbar puncture. A left lateral decubitus position would increase the likelihood of paresthesia, possibly because the anesthetist may inadvertently not follow the medial line when inserting the needle.

Parestesias con diferentes técnicas de anestesia subaracnoidea en la cesárea / Paresthesia in various spinal anesthesia techniques for cesarean section

OBJETIVO: Determinar el porcentaje de parestesiasusando diferentes técnicas de punción subaracnoideacon una aguja Whitacre 27-G.MATERIAL Y MÉTODO: Se realizaron diferentes técnicasde punción subaracnoidea en 224 cesáreas electivas.Estudio simple ciego, prospectivo y aleatorizado distribuido en 4 grupos de 56 pacientes cada uno. Grupo-1: punción epidural-subaracnoidea combinada, usandoaguja espinal con fiador; grupo 2: punción epiduralsubaracnoidea combinada, usando aguja espinal sin fiador; grupo 3: punción subaracnoidea con fiador; grupo 4: punción subaracnoidea con fiador hasta milímetros antes de llegar al saco dural, en que se retira el fiador.RESULTADOS: Los pacientes que presentaron parestesiasfueron 23, 11, 16 y 5 en los grupos 1, 2, 3 y 4 respectivamente. Las parestesias afectaron a diferentes raíces nerviosas. En 2, 11, 29 y 13 casos afectaron a lasraíces nerviosas cuarta y quinta lumbar, primera ysegunda sacra respectivamente. El riesgo de parestesiasfue 7; 2,5 y 4 veces mayor en los grupos 1, 2 y 3 con respecto al grupo 4.CONCLUSIONES: La punción epidural-subaracnoideacombinada presenta mayor número de parestesias que lapunción subaracnoidea simple, posiblemente porque lapunción lumbar se realiza sobre un saco dural, previamente deformado por el “efecto tienda” que origina previamente la aguja epidural. La punción subaracnoidealenta e ininterrumpida, retirando el fiador milímetrosantes de llegar al saco dural origina un menor númerode parestesias

OBJECTIVE: To determine the incidence of paresthesiawith different spinal puncture techniques using a 27-gauge Whitacre needle.MATERIAL AND METHODS: Spinal puncture wasperformed in 224 elective cesarean sections usingdifferent techniques in this single-blind, prospectivetrial. Patients were randomized to 4 groups: group 1,combined epidural and subarachnoid puncture using anintroducer needle; group 2, combined epidural andsubarachnoid puncture without an introducer; group 3,subarachnoid puncture with an introducer; and group 4,subarachnoid puncture with an introducer to within afew millimeters of the dural sac, at which point theintroducer was withdrawn.RESULTS: Paresthesia developed in 23, 11, 16 and 5patients in groups 1, 2, 3 and 4, respectively. Variousnerve roots were affected. In 2 and 11 cases the fourth and fifth lumbar nerve roots were affected; in 29 and 13 cases, the first and second sacral nerve roots were involved. In comparison with group 4, the risk of paresthesia was 7, 2.5 and 4 times greater in groups 1, 2 and 3, respectively.CONCLUSIONS: Combined epidural-subarachnoidpuncture leads to a higher incidence of paresthesia incomparison with simple spinal puncture, probablybecause the lumbar puncture is performed on a duralsac that has been previously deformed due to the "tenteffect" caused by the epidural needle. Fewer cases ofparesthesia occur when the subarachnoid puncture isslow and steady and the introducer needle is withdrawnmillimeters before it reaches the dural sac

[Postpartum seizures in 2 epileptic patients]. / Crisis convulsiva en el postparto de dos pacientes epilépticas.

We report the cases of 2 women with epilepsy who suffered generalized postpartum seizures on the first day after giving birth. The first had a history of febrile convulsions in childhood and had a seizure in the 36th week of gestation due to sleep deprivation. She had received epidural analgesia for labor pain. The second patient had had her most recent crisis at the beginning of the third trimester of pregnancy. Both patients had low serum levels of antiepileptic drugs. The pharmacokinetics of antiepileptic drugs can change during pregnancy, making seizures more difficult to control. Serum levels of these drugs should therefore be monitored more often, given that a generalized maternal seizure can have devastating consequences for the fetus. More careful planning and management of pregnancy is necessary for epileptic patients to ensure successful outcomes for both mother and fetus.

Implicaciones anestésicas en dos casos de inversión uterina / Anesthetic implications of uterine inversion: 2 cases

No disponible

[Cesarean section in an orthotopic liver transplantation patient]. / Cesárea en una paciente con trasplante hepático ortotópico.

We describe the case of a woman with a functioning orthotopic liver transplant who was receiving cyclosporine treatment. An emergency cesarean section was performed, with epidural analgesia, for prolonged pregnancy and an unfavorable cervix. No complications were recorded either during or after surgery. She gave birth to a healthy boy and both were discharged on the fifth day after delivery. Organ transplantation is an increasingly common procedure, and Spain, which has a large number of organ donors, is the country where the largest number of transplants in Europe is performed. Immunosuppressive therapy has advanced greatly, allowing patients to survive longer and enjoy good quality of life. Many transplanted women in their childbearing years consider pregnancy, which can lead to medical problems, a worsened clinical picture or complications related to pregnancy, putting the lives of both mother and fetus at risk. Perioperative management by an anesthesiologist is necessary, whether delivery is vaginal or cesarean. Whenever immunosuppressive therapy is involved, the use of general or regional anesthetics carries risk, as do pregnancy and delivery themselves.

Cesárea en una paciente con trasplante hepático ortotópico / Cesarean section of a patient with an orthotopic liver transplant

A una embarazada de 36 años, portadora de un trasplante hepático ortotópico normofuncionante y en tratamiento con cilosporina, se le practicó una cesárea urgente bajo anestesia epidural por gestación prolongada y cérvix desfavorable. No presentó complicaciones durante el peroperatorio y dio a luz un varón sano. Fue dada de alta el quinto día del postoperatorio a su domicilio.. El trasplante de órganos es un hecho cada vez más frecuente y España es un país con gran cantidad de donantes de órganos, donde se practica el mayor número de trasplantes de Europa. Además, las técnicas de inmunosupresión han avanzado enormemente , permitiendo una larga supervivencia y una buena calidad de vida. E muchas trasplantadas en edad fértil se plantea el deseo de maternidad. El embarazo puede acarrear problemas médicos a estas pacientes, agravar cuadros clínicos existentes, provocar la aparición de patología asociada al embarazo y poner en riesgo la vida materna y fetal. La terminación del embarazo, vía vaginal o por cesárea, requiere la implicación del anestesiólogo en el manejo perioperatorio. Asimismo hay riesgos asociados al tratamiento inmunosupresor en relación con la anestesia general y regional y riesgos asociados al embarazo y el parto (AU)

Incidencia y factores predictores de inmovilización crónica en ancianos mayores de 75 años que viven en la Comunidad / Incidence and predictors factors of long-term care in a very elderly community-dwelling

OBJETIVOS: Estimar la incidencia acumulada anual de inmovilización crónica y los factores asociados con la misma, en población de 75 o más años, no institucionalizada ni inmovilizada que vive en la comunidad. MÉTODOS: Estudio longitudinal, en una muestra representativa de la población de 75 o más años (n= 615) no inmovilizada que vive en su domicilio en la 10 área sanitaria, con tres distritos urbanos (Getafe, Parla y Pinto) y uno rural (Griñón). En 1997 se identificó la situación basal: a) Funcional. b) Mental. c) Sociodemográfica d) Condiciones crónicas. e) Alteraciones sensoriales y f) Apoyo social. Durante un año, en cuatro ocasiones, se investigó la situación de: a) Inmovilización 'Caso'. b) Muerte. c) Institucionalización. d) Pérdidas. e) 'Caso' vivo. f) 'Caso' muerto. g) Fecha del cambio de situación. Mediante un modelo de riesgos proporcionales de Cox se analizó el valor predictivo de las variables identificadas en 1997, sobre la situación de Inmovilización al año. RESULTADOS: La incidencia acumulada de ancianos inmovilizados a lo largo de un año fue del 4,1 por ciento (IC 95 por ciento 2,4-5,6). Los factores que presentaron asociación independiente con la situación de inmovilización en el análisis multivariante fueron: edad avanzada, Odds Ratio (OR) 4,3 (IC 95 por ciento 1,4-13,3). Puntuaciones en Test de Pfeiffer (SPMSQ) > 4, OR 2,5 (IC 95 por ciento 1,0-6,2). Dependencia para una o más actividades básicas de la vida diaria (ABVD), OR 2,8 (IC 95 por ciento 1,1-6,8). El diagnóstico de bronquitis crónica (BOC) y/o asma, OR 3,2 (IC 95 por ciento 1,3-7,5) CONCLUSIONES: Este estudio identifica factores de riesgo de inmovilización crónica en población anciana. Algunos de estos factores son modificables. Futuros estudios son necesarios para determinar la efectividad de intervenciones precoces en la prevención de la incapacidad crónica o inmovilización entre la población anciana con elevado grado funciona (AU)

[Cognitive deficit, its prevalence and associated factors in the population over 74]. / Déficit cognitivo, prevalencia y factores asociados en la población mayor de 74 años.

OBJECTIVE: To know the proportion of people older than 74, who are not institutionalized and not immobilized with cognitive alteration and to analyze if there is any association with social demographic characteristics and health factors. DESIGN: Cross-sectional descriptive study, made by interview. LOCATION: In an urban environment: Getafe, Parla, Pinto and rural environment: Griñón. PARTICIPANTS: The study population included all the people older than 74, that was registered in data base of individual health card, INSALUD. The sample, consisted by 704 elderly, who compliment including criterion, accuracy +/- 3.4%, p < 0.05 It's evaluated 615 persons. MEASUREMENTS AND MAIN RESULTS: It's made by questionnaire that included social demographic variables, information about the necessity of help for basic activities in daily life (ADLs), perceived health status, illness, sensorial alterations, falls, stay in hospital, social support, rotation, architectonics obstacles. For evaluating the likely cognitive deterioration, it was used the Short Potable Mental Questionnaire (SPSMQ) with 2 cutting points: 2-4 errors and > 4 errors. The proportion of elderly people with cognitive deterioration (SPSMQ > 2) was 19% (95% CI, 16.2-22.4). This proportion grew with age, the same as men as in women (p < 0.0001), 11% (95% CI, 8-15) in < 80 years, 29% (95% CI, 23.8-34.8) in > 79 years. It's proved a significant statistically association between cognitive deficit (SPSMQ > 4), in age > 84 years OR = 4.1 (95% CI, 1.7-9.7), dependence degree for ADLs OR = 4.4 (95% CI, 2.2-8.8), and low cultural level, OR = 6.2 (95% CI, 2-18). CONCLUSION: The prevalence of cognitive deficit in elderly population who lives in community environment, it's associated with the degree of functional damage, advanced age and the absence of studies, without any difference between urban and rural environment.