Economic impact of improving patient safety using Sugammadex for routine reversal of neuromuscular blockade in Spain.

BACKGROUND: Neuromuscular blocking (NMB) agents are often administered to facilitate tracheal intubation and prevent patient movement during surgical procedures requiring the use of general anesthetics. Incomplete reversal of NMB, can lead to residual NMB, which can increase the risk of post-operative pulmonary complications. Sugammadex is indicated to reverse neuromuscular blockade induced by rocuronium or vecuronium in adults. The aim of this study is to estimate the clinical and economic impact of introducing sugammadex to routine reversal of neuromuscular blockade (NMB) with rocuronium in Spain. METHODS: A decision analytic model was constructed reflecting a set of procedures using rocuronium that resulted in moderate or deep NMB at the end of the procedure. Two scenarios were considered for 537,931 procedures using NMB agents in Spain in 2015: a scenario without sugammadex versus a scenario with sugammadex. Comparators included neostigmine (plus glycopyrrolate) and no reversal agent. The total costs for the healthcare system were estimated from the net of costs of reversal agents and overall cost offsets via reduction in postoperative pneumonias and atelectasis for which incidence rates were based on a Spanish real-world evidence (RWE) study. The model time horizon was assumed to be one year. Costs were expressed in 2019 euros (€) and estimated from the perspective of a healthcare system. One-way sensitivity analysis was carried out by varying each parameter included in the model within a range of +/- 50%. RESULTS: The estimated budget impact of the introduction of sugammadex to the routine reversal of neuromuscular blockade in Spanish hospitals was a net saving of €57.1 million annually. An increase in drug acquisition costs was offset by savings in post-operative pulmonary events, including 4806 post-operative pneumonias and 13,996 cases of atelectasis. The total cost of complications avoided was €70.4 million. All parameters included in the model were tested in sensitivity analysis and were favorable to the scenario with sugammadex. CONCLUSIONS: This economic analysis shows that sugammadex can potentially lead to cost savings for the reversal of rocuronium-induced moderate or profound NMB compared to no reversal and reversal with neostigmine in the Spanish health care setting. The economic model was based on data obtained from Spain and from assumptions from clinical practice and may not be valid for other countries.

Implantación de un protocolo fast-track en cistectomía radical en un hospital terciario / The results of implementing a fast-track protocol in radical cystectomy in a tertiary hospital

Introducción: La cistectomía radical (CR) es el procedimiento urológico asociado a las tasas más altas de morbimortalidad y estancia hospitalaria. La aplicación de programas fast-track pretende acelerar la recuperación posquirúrgica y su aplicación en cistectomía radical ha reportado resultados positivos. Objetivos: Valorar los resultados del protocolo fast-track en CR en nuestro hospital, en términos de morbimortalidad y estancia hospitalaria, comparando dichos resultados con los de los pacientes intervenidos de CR siguiendo el protocolo clásico. Así, averiguar si la aplicación del protocolo fast-track supone una reducción del número y gravedad de complicaciones y una menor estancia hospitalaria. Material y métodos: Estudio de cohortes ambispectivo de pacientes intervenidos de CR, desde enero de 2010 a octubre de 2012, por ambos protocolos, tanto clásico como fast-track. Se analizan las características de los pacientes, las variables intraoperatorias, complicaciones postoperatorias (según clasificación Clavien) y estancia hospitalaria y en reanimación. Resultados: Se incluyeron 99 pacientes, 51 siguiendo el protocolo clásico y 48 el protocolo fast-track, siendo grupos homogéneos. La estancia hospitalaria y en reanimación fue mayor en el grupo clásico que en el fast-track (29 y 2 días respectivamente frente a 17 y 1 días) Hubo menor sangrado intraoperatorio en el grupo fast-track (600 ml) que en el clásico (1.000 ml). De los 99 pacientes, 31 (60,8%) del grupo clásico presentaron alguna complicación postoperatoria mientras que en el fast-track fueron 14 (29,2%), la mayoría menores (grados 1 y 2 Clavien). En el análisis multivariado resultó significativo el tipo de protocolo y el número de comorbilidades. Conclusiones: La implantación del protocolo fast-track en CR se asoció a una disminución significativa de complicaciones intra- y postoperatorias y de estancia hospitalaria

Background: Radical cystectomy (RC) is the urological procedure associated with the highest rates of morbidity, mortality and hospital stay. The implementation of fast-track programs seeks to speed postsurgical recovery. Its application to radical cystectomy has yielded positive results. Objectives: To assess the results of the fast-track protocol in RC at our hospital, in terms of morbidity, mortality and hospital stay, comparing these results with those of patients who underwent RC following the classic protocol. To thereby ascertain whether the implementation of the fast-track protocol represents a reduced number and severity of complications and shorter hospital stays. Material and methods: Ambispective cohort study of patients who underwent RC between January 2010 and October 2012 by either protocol (classic and fast-track). We analyzed the patient characteristics, intraoperative variables, postoperative complications (according to the Clavien classification), hospital stay and recovery stay. Results: Ninety-nine patients were included, 51 following the classic protocol and 48 following the fast-track protocol. The groups were homogeneous. The hospital stay and recovery stay were longer in the classic group than in the fast-track group (29 and 2 days, respectively, vs. 17 and 1 day). There was less intraoperative bleeding in the fast track group (600 mL) than in the traditional group (1,000 mL). Of the 99 patients, 31 (60.8%) of the classic group presented a postoperative complication, while the fast-track group had 14 (29.2%), most of which were minor (Clavien degrees 1 and 2). In the multivariate analysis, the type of protocol and the number of comorbidities were significant. Conclusions: The implementation of the fast-track protocol in RC was associated with a significant reduction in intraoperative and postoperative complications and hospital stay

The results of implementing a fast-track protocol in radical cystectomy in a tertiary hospital.

BACKGROUND: Radical cystectomy (RC) is the urological procedure associated with the highest rates of morbidity, mortality and hospital stay. The implementation of fast-track programs seeks to speed postsurgical recovery. Its application to radical cystectomy has yielded positive results. OBJECTIVES: To assess the results of the fast-track protocol in RC at our hospital, in terms of morbidity, mortality and hospital stay, comparing these results with those of patients who underwent RC following the classic protocol. To thereby ascertain whether the implementation of the fast-track protocol represents a reduced number and severity of complications and shorter hospital stays. MATERIAL AND METHODS: Ambispective cohort study of patients who underwent RC between January 2010 and October 2012 by either protocol (classic and fast-track). We analyzed the patient characteristics, intraoperative variables, postoperative complications (according to the Clavien classification), hospital stay and recovery stay. RESULTS: Ninety-nine patients were included, 51 following the classic protocol and 48 following the fast-track protocol. The groups were homogeneous. The hospital stay and recovery stay were longer in the classic group than in the fast-track group (29 and 2 days, respectively, vs. 17 and 1 day). There was less intraoperative bleeding in the fast track group (600mL) than in the traditional group (1,000mL). Of the 99 patients, 31 (60.8%) of the classic group presented a postoperative complication, while the fast-track group had 14 (29.2%), most of which were minor (Clavien degrees 1 and 2). In the multivariate analysis, the type of protocol and the number of comorbidities were significant. CONCLUSIONS: The implementation of the fast-track protocol in RC was associated with a significant reduction in intraoperative and postoperative complications and hospital stay.

Análisis de los factores que condicionan el ingreso de los pacientes quirúrgicos en una unidad de críticos. Un estudio prospectivo sobre 764 pacientes intervenidos durante 1 año en un hospital universitario y de referencia / Analysis of factors conditioning admission at the critical care unit of surgical patients. Prospective study of 764 patients operated for 1 year at a university and reference hospital

Objetivo. Valorar qué factores determinan el ingreso de los pacientes quirúrgicos en una unidad de críticos tras la cirugía. Material y métodos. Se incluyó un censo del 10% de todos los pacientes intervenidos por los servicios de Cirugía General, Cirugía Torácica, Cirugía Maxilofacial, Cirugía Vascular, Urología y Otorrinolaringología durante el año 2012. Se realizó un estudio prospectivo, observacional. Se analizaron variables preoperatorias, intraoperatorias y posoperatorias. Se compararon aquellos pacientes ingresados en críticos con los ingresados en planta, y los intervenidos de urgencia con los programados, mediante la χ2 de Pearson con un intervalo de confianza del 95%. Resultados. e introdujeron en el estudio 764 pacientes, siendo ingresados 304 en críticos tras la cirugía y 460 en planta. Los antecedentes patológicos mostraron asociación estadísticamente significativa con el ingreso de los pacientes en críticos, así como el ser marcado con alto riesgo por las escalas de predicción de riesgo quirúrgico. La complejidad y duración de la cirugía mostraron una asociación estadísticamente significativa con el ingreso en críticos, así como el presentar complicaciones intraoperatorias. La cirugía de urgencia no se asoció significativamente con el ingreso en críticos de los pacientes quirúrgicos, aunque estos pacientes sí presentaron significativamente mayor número de complicaciones intraoperatorias y posoperatorias, y más exitus que los sometidos a cirugía programada. Conclusiones. Un mayor índice de ingreso en críticos de los pacientes intervenidos de urgencia se presume disminuiría la morbimortalidad quirúrgica. Protocolos específicos de ingreso para cirugía de urgencia y una mayor disponibilidad de camas podrían ser útiles en este sentido (AU)

Objective. Assess what factors determine the income of surgical patients in critical care unit after surgery. Material and methods. It included a survey of the 10% of all patients operated by the services of General Surgery, Thoracic Surgery, Maxillofacial Surgery, Vascular Surgery, Urology and Otolaryngology during 2012. We performed a prospective, observational study. Pre-, intra-, and post-operative variables were analyzed. Comparisons were made between patients operated under elective and emergency surgery, and between patients admitted in critical care and admitted directly in the ward, using χ2 of Pearson correlation with a confidence interval of 95%. Results. Seven hundred and sixty-four patients were included into the study, 304 were admitted in critical care after surgery and 460 were admitted in the ward. The medical history showed a statistically significant association with intensive care unit admission, well as the fact of being labeled with a high risk for the risk scales. Complexity and duration of the surgery showed a statistically significant association with intensive care unit admission, as well as the fact of present intra-operative complications. Emergency surgery was not significantly associated with intensive care unit admission of surgical patients, although these patients had significantly higher numbers of intra- and post-operative complications, and more exitus than those undergoing elective surgery. Conclusions. A greater incidence of intensive care unit admission of patients undergoing emergency surgery should significantly reduce morbimortality rate. The existence of specific protocols for intensive care unit admission for urgent surgery, and greater availability of beds could be useful in this regard (AU)

[Analysis of factors conditioning admission at the critical care unit of surgical patients. Prospective study of 764 patients operated for 1 year at a university and reference hospital]. / Análisis de los factores que condicionan el ingreso de los pacientes quirúrgicos en una unidad de críticos. Un estudio prospectivo sobre 764 pacientes intervenidos durante 1 año en un hospital universitario y de referencia.

OBJECTIVE: Assess what factors determine the income of surgical patients in critical care unit after surgery. MATERIAL AND METHODS: It included a survey of the 10% of all patients operated by the services of General Surgery, Thoracic Surgery, Maxillofacial Surgery, Vascular Surgery, Urology and Otolaryngology during 2012. We performed a prospective, observational study. Pre-, intra-, and post-operative variables were analyzed. Comparisons were made between patients operated under elective and emergency surgery, and between patients admitted in critical care and admitted directly in the ward, using χ(2) of Pearson correlation with a confidence interval of 95%. RESULTS: Seven hundred and sixty-four patients were included into the study, 304 were admitted in critical care after surgery and 460 were admitted in the ward. The medical history showed a statistically significant association with intensive care unit admission, well as the fact of being labeled with a high risk for the risk scales. Complexity and duration of the surgery showed a statistically significant association with intensive care unit admission, as well as the fact of present intra-operative complications. Emergency surgery was not significantly associated with intensive care unit admission of surgical patients, although these patients had significantly higher numbers of intra- and post-operative complications, and more exitus than those undergoing elective surgery. CONCLUSIONS: A greater incidence of intensive care unit admission of patients undergoing emergency surgery should significantly reduce morbimortality rate. The existence of specific protocols for intensive care unit admission for urgent surgery, and greater availability of beds could be useful in this regard.

Manejo anestésico en el síndrome de Berdon / No disponible

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[Anesthetic management of coagulation factor V deficiency]. / Manejo anestésico en el déficit de factor V de la coagulación.

Factor V deficiency, or Owren's disease, is a rare inherited recessive autonomic disorder that is congenital. The bleeding in patients with this disease depends on plasma levels of factor V. Anesthetic management is similar to that used for patients with other coagulation disorders. On the one hand, it is useful to initiate infusion of plasma if purified concentrates are not available. On the other hand, it is important to monitor hemostasis carefully so that bleeding during postoperative recovery can be prevented. Plasma and antifibrinolytic drugs such as tranexamic acid should continue to be administered in the first few days after surgery. We report the case of a man with homozygotic factor V deficiency who underwent surgery for colon cancer. This article reviews the main aspects of anesthetic management of this coagulation disorder.

Estudio comparativo de la respuesta metabólica e inmunológica de la morfina administrada vía subaracnoidea frente a morfina endovenosa para el control del dolor postoperatorio en prostatectomía radical / Metabolic and immune response to spinal vs intravenous morphine for analgesia after radical prostatectomy

OBJETIVO: Estudiar las diferencias en la respuesta endocrino-metabólica e inmunológica asociadas al uso endovenoso o subaracnoideo de la morfina utilizada como analgésico postoperatorio en cirugía de prostatectomía radical. MATERIAL Y MÉTODOS: Estudio prospectivo de 60 pacientes incluidos aleatoriamente en dos grupos: Grupo A(n=30): analgesia postoperatoria con morfina endovenosa. Grupo B (n=30): analgesia postoperatoria con morfina subaracnoidea. Para el estudio de la respuesta inmunológica celular se analizó la evolución de las poblaciones leucocitarias y subpoblaciones linfocitarias en sangre periférica y a nivel del drenaje quirúrgico. Como marcadores de la respuesta metabólica e inmunológica humoral se midieron los niveles de cortisol, ACTH, GH, glucosa e inmunoglobulinas en sangre periférica. RESULTADOS: Ambos grupos presentaron linfopenia en sangre periférica. El grupo tratado con morfina subaracnoidea presentó recuentos de linfocitos CD4 significativamente más bajos en sangre periférica, p<0,05. A nivel local no se encontraron diferencias en la respuesta leucocitaria de ambos grupos. Se encontraron diferencias significativas, p<0,05, en el número de células NK y CD4 a nivel local y el encontrado en sangre periférica. En ambos grupos se encontró inmunosupresión de la respuesta humoral, siendo significativamente mayor, p<0,05 en el grupo tratado con morfina subaracnoidea. La respuesta metabólica fue superior en el grupo tratado con morfina endovenosa. CONCLUSIÓN: El grupo tratado con morfina subaracnoidea presentó una respuesta endocrino-metabólica menor. Aunque la respuesta celular a nivel local fue similar en ambos grupos, la respuesta encontrada a nivel periférico fue distinta, pudiendo ser reflejo de diferentes vías centrales de modulación de la respuesta inflamatoria a estrés

OBJETIVE: To study differences between the endocrine– metabolic and immune cell responses to spinal or intravenous administration of morphine for analgesia after radical prostatectomy. MATERIAL AND METHODS: Prospective study of 60 patients randomized to 2 groups: in group A (n=30) morphine for postoperative analgesia was infused intravenously and in group B (n=30) morphine was infused into the spinal canal. Changes in leukocyte populations and lymphocyte subpopulations in peripheral blood and blood from surgical drains (local) were analyzed to study immune cell response to morphine administration. Cortisol, corticotropin, growth hormone, glucose, and immunoglobulin levels in peripheral blood were measured as indicators of metabolic and humoral immune responses. RESULTS: Both groups developed lymphopenia in peripheral blood. The group treated with spinal morphine had significantly lower CD4+ cell counts in peripheral blood P<0.05. No differences were found in the local leukocyte response in either group. Significant differences were found in natural killer and CD4+ cell counts both locally and in peripheral blood P<0.05. There was humoral immune response suppression in both groups; however, it was more marked in the group treated with spinal morphine and the difference was significant P<0.05. The metabolic response was greater in the group treated with intravenous morphine. CONCLUSION: Patients who received morphine by spinal infusion had a less marked endocrine-metabolic response. Although local cell responses were similar in the 2 groups, the response in peripheral blood was different, possibly reflecting different mechanisms of central modulation of the inflammatory response to stress

Cardiografía por impedancia torácica en un caso de drenaje anómalo de vena cava superior en seno coronario / Thoracic impedance cardiography in a case of anomalous drainage of the superior vena cava into the coronary sinus

La Cardiografía por Impedancia Torácica es una técnica de monitorización hemodinámica no invasiva. Se basa en el principio físico de impedancia, que puede definirse como la resistencia al flujo de una corriente eléctrica. Presentamos un caso de un paciente que fue sometido a trasplante cardiaco ortótopico, en el que se halló intraoperatoriamete la existencia de una vena cava superior con drenaje en el seno coronario. Ante la imposibilidad de una monitorización hemodinámica invasiva a través de catéter de Swan-Ganz, se optó por cardiografía por impedancia torácica. Se revisan las principales aplicaciones de esta técnica y la descripción de esta rara anomalía vascular

Thoracic impedance cardiography is a noninvasive hemodynamic monitoring technique based on the physical principal of impedance, which can be defined as resistance to electrical flow. We report the case of a man who underwent orthotopic heart transplantation, during which the superior vena cava was found to drain into the coronary sinus. Impedance cardiography was used because hemodynamics could not be monitored invasively with a Swan-Ganz catheter. We describe the main applications of impedance cardiography and the characteristics of this rare vascular anomaly

Lidocaína endovenosa como coadyuvante en el tratamiento inicial de la neuralgia postherpética. Bases fisiopatológicas del uso de anestésicos locales en el tratamiento del dolor neuropático / Endovenous lidocaine as co-adjuvant in the initial treatment of post-herpetic neuralgia. Physiopathological basis of the use of local anesthetics for the treatment of neuropathic pain

Introducción:La neuralgia postherpética es el cuadro álgico que permanecetras desaparecer las vesículas del episodio agudodel herpes zóster, habiendo pasado un periodo mínimo detiempo de 8-12 semanas. Hasta un 50% de los pacientescon edad superior a 70 años, lo desarrollará tras el episodio agudo de herpes zóster. Sus bases fisiopatológicas nohan sido aclaradas, por lo que su prevención es difícil y sutratamiento sintomático.Material y métodos:Se estudiaron 100 pacientes incluidos de forma aleatoriaen uno de los grupos diseñados (n = 25): grupo A1, pacientesmenores de 70 años, tratados con gabapentina adosis crecientes; grupo A2, pacientes mayores de 70 años,tratados con gabapentina a dosis crecientes; grupo B1, pacientesmenores de 70 años tratados con gabapentina y lidocaínaendovenosa; grupo B2, pacientes mayores de 70años tratados con gabapentina y lidocaína endovenosa. Seevaluó el dolor referido por el paciente en cuatro momentosa lo largo de las cuatro primeras semanas.Resultados:Se observaron diferencias estadísticamente significativas,p < 0,05, en las medias de EVA referido por los pacientes,presentando una EVA menor los grupos tratadoscon lidocaína endovenosa y pacientes menores de 70 añosen ambos grupos.Conclusiones:El tratamiento de la neuralgia postherpética es un tratamientosintomático. Los anestésicos locales han sido utilizadoscon éxito en algunos tipos de dolor neuropático. Lalidocaína endovenosa puede ser útil como coadyuvante enel periodo inicial del tratamiento de la neuralgia posthetpética,al reducir significativamente la EVA referida por lospacientes. Los pacientes de edad avanzada respondieronpeor al uso de lidocaína, aunque presentaron medias deEVA inferiores a los pacientes a los que no se administró lidocaína

Introduction:Post-herpetic neuralgia is the algic condition that remainswhen the vesicles of an acute episode of herpeszoster have disappeared after a minimum period of 8-12weeks. Up to 50% of patients older than 70 years will developthis condition after an acute episode of herpes zoster.Its physiopathological basis is still unclear, so its preventionis difficult and its treatment is aimed to symptoms.Materials and methods:One hundred patients were randomized to one of thestudy groups (n = 25): group A1, patients 70 years of age treated with gabapentin and endovenouslidocaine; group B2, patients > 70 years of agetreated with gabapentin and endovenous lidocaine. Painreported by the patient was assessed at four time pointsduring the first four weeks.Results:Statistically significant differences were observed (p <0,05) in the mean VAS scores reported by the patients,with a lower VAS score within the groups treated with endovenouslidocaine and in patients < 70 years of age inboth groups.Conclusions:The treatment of post-herpetic neuralgia is aimed tosymptoms. Local anesthetics have been successfully usedfor some types of neuropathic pain. Endovenous lidocainecan be useful as co-adjuvant during the initial treatment ofpost-herpetic neuralgia, since it significantly reduces theVAS score reported by patients. Aged patients had a poorerresponse to the use of lidocaine, as well as lower meanVAS scores, compared to patients that did not received lidocaine

Réplica a "consideraciones sobre la conversión de tubo nasotraqueal a orotraqueal" / Author's reply to "on conversion from nasotracheal to orotracheal intubation

No disponible

No disponible

Manejo anestésico en el déficit de factor V de la coagulación / Anesthetic management of coagulation factor V deficiency

El déficit del factor V o enfermedad de Owren en un raro trastorno congénito de herencia autonómica recesiva. La clínica hemorrágica que presentan los pacientes, está en función de los niveles plasmáticos de factor V. La conducta anestésica a seguir será similar a la utilizada en pacientes con otros tipos de coagulopatías. Por un lado, es conveniente iniciar un protocolo de administración de plasma, en aquellos déficits en los que no se disponga de concentrados purificados. Por otro lado, es importante un control estricto de los parámetros hemostáticos, con el fin de prevenir el riego hemorrágico en el postoperatorio inmediato. En los primeros días del postoperatorio, se continuará la administración de plasma y fármacos antifibrinólicos como el ácido tranexámico. Se presenta el caso de un paciente varón, intervenido de cirugía oncológica de colon, homocigoto para el déficit de factor V. En el presente trabajo se revisan los principales puntos de la actuación anestésica en este tipo de pacientes (AU)

Factor V deficiency, or Owren's disease, is a rare inherited recessive autonomic disorder that is congenital. The bleeding in patients with this disease depends on plasma levels of factor V. Anesthetic management is similar to that used for patients with other coagulation disorders. On the one hand, it is useful to initiate infusion of plasma if purified concentrates are not available. On the other hand, it is important to monitor hemostasis carefully so that bleeding during postoperative recovery can be prevented. Plasma and antifibrinolytic drugs such as tranexamic acid should continue to be administered in the first few days after surgery. We report the case of a man with homozygotic factor V deficiency who underwent surgery for colon cancer. This article reviews the main aspects of anesthetic management of this coagulation disorder (AU)

[Anesthesia in intrahepatic cholestasis: Alagille syndrome]. / Anestesia en la colestasis intrahepática. Síndrome de Alagille.

A 42-year-old patient, diagnosed with Alagille syndrome when he was 1 month old, was admitted to the general surgery department to undergo right hepatectomy for right lobe carcinoma. Alagille syndrome, also known as biliary duct hypoplasia, is an extremely rare genetic condition with multiorganic implications. Liver and heart dysfunction will play key roles in the course of the disease and its prognosis. An exhaustive preoperative assessment of liver and heart function, blood chemistry and the skeleton will be essential for managing these patients. This article reviews the main principles underlying the anesthetic management of patients with Alagille syndrome.

Anestesia en la colestasis intrahepática. Síndrome de Alagille / Anesthesia in intrahepatic cholestasis: Alagille syndrome

Paciente de 42 años, diagnosticada de Síndrome de Alagille en el primer mes de vida. Ingresa en el Servicio de Cirugía General con diagnóstico de hepatocarcinoma de lóbulo derecho, para la realización de hepatectomía derecha. El Síndrome de Alagille, también conocido como Síndrome de escasez de conductos biliares, es una enfermedad genética extremadamente rara, de afectación multiorgánica. La disfunción hepática y cardíaca será fundamental para la evolución y pronóstico de la enfermedad. Un estudio preoperatorio exhaustivo de la función hepática, cardiológico, hematológica y ósea se antoja funda- mental para el manejo de estos pacientes. En el presente trabajo se revisan los principales pun- tos de la actuación anestésica en los pacientes portado- res de este síndrome

A 42-year-old patient, diagnosed with Alagille syndrome when he was 1 month old, was admitted to the general surgery department to undergo right hepatectomy for right lobe carcinoma. Alagille syndrome, also known as biliary duct hypoplasia, is an extremely rare genetic condition with multiorganic implications. Liver and heart dysfunction will play key roles in the course of the disease and its prognosis. An exhaustive preoperative assessment of liver and heart function, blood chemistry and the skeleton will be essential for managing these patients. This article reviews the main principles underlying the anesthetic management of patients with Alagille syndrome

[Exchanging and maintaining the airway in hyoid surgery: using a flexible exchanger during new surgical treatments for obstructive sleep apnea syndrome]. / Modificación y mantenimiento de la vía aérea en la cirugía del hioides. Empleo de un intercambiador flexible en las nuevas técnicas quirúrgicas del síndrome de apnea obstructiva del sueño.

OBJECTIVE: To assess the level of intubation difficulty and anatomical changes after hyoid surgery. To evaluate the difficulty of switching from nasotracheal to orotracheal intubation after hyoid and palatopharyngeal surgery using an exchanger. MATERIAL AND METHODS: Prospective study enrolling 30 patients undergoing surgery for obstructive sleep apnea syndrome (OSAS) in 2 consecutive phases. Anatomical features suggesting risk of difficult intubation, anatomical changes caused by surgery, the incidence of failure to intubate upon first attempt during the first surgical session, and upon switching from nasal to oral intubation, and the time required to intubate were recorded. The rate of complications during and after surgery was also noted. RESULTS: The incidence of difficult intubation was 15% and no complications developed in the switch from nasotracheal to orotracheal intubation (100% success rate). CONCLUSION: New surgical treatments for the OSAS patient require new anesthetic maneuvers such as nasotracheal-orotracheal intubation exchange after hyoid surgery. The exchanger used in the present study offers a valid way to achieve airway management in this situation.

[Anesthetic management in mastocytosis]. / Manejo anestésico en la mastocitosis.

Mastocytosis is a heterogeneous grouping of entities characterized by proliferation of mast cells in one or more organs or tissues. The skin is the most frequently affected organ, followed by bone marrow. The relevance of this disease to anesthesia lies in the fact that many drugs used can trigger massive release of chemical mediators of mast cells. We report the case of a patient diagnosed with cutaneous mastocytosis who underwent testicular biopsy with intradural anesthesia. We review the fundamental aspects of the disease and the principles of anesthetic management.

Modificación y mantenimiento de la vía aérea en la cirugía del hioides. Empleo de un intercambiador flexible en las nuevas técnicas quirúrgicas del síndrome de apnea obstructiva del sueño / Exchanging and maintaining the airway in hyoid surgery: using a flexible exchanger during new surgical treatments for obstructive sleep apnea syndrome

OBJETIVO: Establecer el grado de dificultad de intubación así como las alteraciones anatómicas tras la cirugía hioidea. Valorar la dificultad que plantea el cambio de intubación nasotraqueal a orotraqueal tras la cirugía hioidea y palatofaríngea empleando un intercambiador. MATERIALES Y MÉTODOS: Estudio prospectivo en el que se incluyeron 30 pacientes intervenidos de cirugía del Síndrome de Apnea Obstructiva del Sueño (SAOS) en dos tiempos quirúrgicos consecutivos. Se recogieron variables anatómicas predictivas de intubación difícil, los cambios anatómicos producidos por la cirugía, la incidencia de intubaciones fallidas en el primer tiempo quirúrgico y en el cambio de intubación nasal a oral, recogiéndose el tiempo empleado en dicho cambio. También se recogieron las complicaciones intra y postoperatorias. RESULTADOS: La incidencia de intubación difícil fue de un 15%, ninguno de los cambios de intubación nasotraqueal a orotraqueal presentó complicaciones, obteniéndose un 100% de intubaciones exitosas. CONCLUSIÓN: Las nuevas técnicas quirúrgicas en el paciente con SAOS, implican nuevas actuaciones anestésicas, como el cambio de intubación nasotraqueal a orotraqueal necesario tras la cirugía hioidea. El intercambiador empleado en el presente trabajo plantea una alternativa valida para el manejo de la vía aérea en esa situación

OBJECTIVE: To assess the level of intubation difficulty and anatomical changes after hyoid surgery. To evaluate the difficulty of switching from nasotracheal to orotracheal intubation after hyoid and palatopharyngeal surgery using an exchanger. MATERIAL AND METHODS: Prospective study enrolling 30 patients undergoing surgery for obstructive sleep apnea syndrome (OSAS) in 2 consecutive phases. Anatomical features suggesting risk of difficult intubation, anatomical changes caused by surgery, the incidence of failure to intubate upon first attempt during the first surgical session, and upon switching from nasal to oral intubation, and the time required to intubate were recorded. The rate of complications during and after surgery was also noted. RESULTS: The incidence of difficult intubation was 15% and no complications developed in the switch from nasotracheal to orotracheal intubation (100% success rate). CONCLUSION: New surgical treatments for the OSAS patient require new anesthetic maneuvers such as nasotracheal- orotracheal intubation exchange after hyoid surgery. The exchanger used in the present study offers a valid way to achieve airway management in this situation