Efectos intraoperatorios de una maniobra de reclutamiento alveolar en pacientes sometidos a cirugía laparoscópica de colon / Intraoperative effects of an alveolar recruitment manoeuvre in patients undergoing laparoscopic colon surgery

Introducción: Las atelectasias pulmonares son habituales en pacientes sometidos a cirugía abdominal laparoscópica bajo anestesia general, aumentando el riesgo de complicaciones respiratorias perioperatorias. Las maniobras de reclutamiento alveolar (MRA) permiten la reexpansión del parénquima atelectasiado, aunque no está claramente establecida la duración de su beneficio. El objetivo de este estudio fue determinar la efectividad de una MRA en cirugía de colon laparoscópica, la duración de la respuesta en el tiempo y su repercusión hemodinámica. Métodos: Se incluyeron 25 pacientes sometidos a cirugía de colon laparoscópica. Tras la inducción anestésica e inicio de la cirugía con neumoperitoneo, se realizó una MRA y determinación posterior de la PEEP óptima. Se analizaron variables de mecánica respiratoria y de intercambio gaseoso, así como parámetros hemodinámicos, antes de la maniobra y periódicamente durante los 90 min siguientes. Resultados: Tres pacientes fueron excluidos por causas quirúrgicas. El gradiente alveoloarterial de oxígeno pasó de 94,3 (62,3-117,8) mmHg antes a 60,7 (29,6-91,0) mmHg después de la maniobra (p < 0,05). Esta diferencia se mantuvo durante los 90 min del estudio. La compliance dinámica del sistema respiratorio pasó de 31,3 mL/cmH2O (26,1-39,2) antes de la maniobra, a 46,1 mL/cmH2O (37,5-53,5) tras la misma (p < 0,05). Esta diferencia se mantuvo durante 60 min. No se identificaron cambios significativos en ninguna de las variables hemodinámicas estudiadas. Conclusión: En pacientes sometidos a cirugía laparoscópica de colon, la realización de una MRA intraoperatoria mejora la mecánica del sistema respiratorio y la oxigenación, sin apreciarse un compromiso hemodinámico asociado. El beneficio de estas maniobras se extiende al menos durante una hora.(AU)

Introduction: Pulmonary atelectasis is common in patients undergoing laparoscopic abdominal surgery under general anaesthesia, which increases the risk of perioperative respiratory complications. Alveolar recruitment manoeuvres (ARM) are used to open up the lung parenchyma with atelectasis, although the duration of their benefit has not been clearly established. The aim of this study was to determine the effectiveness of an ARM in laparoscopic colon surgery, the duration of response over time, and its haemodynamic impact. Methods: Twenty-five patients undergoing laparoscopic colon surgery were included. After anaesthetic induction and initiation of surgery with pneumoperitoneum, an ARM was performed, and then optimal PEEP determined. Respiratory mechanics and gas exchange variables, and haemodynamic parameters, were analysed before the manoeuvre and periodically over the following 90 minutes. Results: Three patients were excluded for surgical reasons. The alveolar arterial oxygen gradient went from 94.3 (62.3-117.8) mmHg before to 60.7 (29.6-91.0) mmHg after the manoeuvre (P < .05). This difference was maintained during the 90 minutes of the study. Dynamic compliance of the respiratory system went from 31.3 ml/cmH2O (26.1-39.2) before the manoeuvre to 46.1 ml/cmH2O (37.5-53.5) after the manoeuvre (P < .05). This difference was maintained for 60 minutes. No significant changes were identified in any of the haemodynamic variables studied. Conclusion: In patients undergoing laparoscopic colon surgery, performing an intraoperative ARM improves the mechanics of the respiratory system and oxygenation, without associated haemodynamic compromise. The benefit of these manoeuvres lasts for at least one hour.(AU)

Intraoperative effects of an alveolar recruitment manoeuvre in patients undergoing laparoscopic colon surgery.

INTRODUCTION: Pulmonary atelectasis is common in patients undergoing laparoscopic abdominal surgery under general anaesthesia, which increases the risk of perioperative respiratory complications. Alveolar recruitment manoeuvres (ARM) are used to open up the lung parenchyma with atelectasis, although the duration of their benefit has not been clearly established. The aim of this study was to determine the effectiveness of an ARM in laparoscopic colon surgery, the duration of response over time, and its haemodynamic impact. METHODS: Twenty-five patients undergoing laparoscopic colon surgery were included. After anaesthetic induction and initiation of surgery with pneumoperitoneum, an ARM was performed, and then optimal PEEP determined. Respiratory mechanics and gas exchange variables, and haemodynamic parameters, were analysed before the manoeuvre and periodically over the following 90 min. RESULTS: Three patients were excluded for surgical reasons. The alveolar arterial oxygen gradient went from 94.3 (62.3-117.8) mmHg before to 60.7 (29.6-91.0) mmHg after the manoeuvre (P < .05). This difference was maintained during the 90 min of the study. Dynamic compliance of the respiratory system went from 31.3 ml/cmH2O (26.1-39.2) before the manoeuvre to 46.1 ml/cmH2O (37.5-53.5) after the manoeuvre (P < .05). This difference was maintained for 60 min. No significant changes were identified in any of the haemodynamic variables studied. CONCLUSION: In patients undergoing laparoscopic colon surgery, performing an intraoperative ARM improves the mechanics of the respiratory system and oxygenation, without associated haemodynamic compromise. The benefit of these manoeuvres lasts for at least one hour.

[Fat embolism syndrome after surgery to replace the femoral stem of a hip prosthesis]. / Síndrome de embolia grasa tras recambio de vástago femoral de prótesis de cadera.

A 66-year-old woman developed hemodynamic instability, oliguria, prostration, fever, and coagulopathy 4 hours after surgery to replace the femoral stem component of a hip prosthesis under a combined subarachnoid-epidural block. Dyspnea and tachypnea developed, and a petechial rash appeared 24 hours later. The diagnosis was fat embolism after other possible causes were ruled out. Supplementary oxygen, fluid replacement therapy, and inotropic support were started. The patient's condition improved and she was discharged from the postoperative recovery unit 5 days after admission. Although fat embolism usually appears in young men after large bone fractures, it should be considered when symptoms consistent with this diagnosis arise in patients who have undergone orthopedic surgery so that appropriate treatment can be started early.

Recuperación anestésica inmediata y función psicomotriz de los pacientes tras anestesia prolongada con desflurano, sevoflurano o isoflurano / Recovery and psychomotor function of patients after prolonged anesthesia with desflurane, sevoflurane or isoflurane

OBJETIVOS. Comparar el mantenimiento, la recuperación y la función psicomotriz en el postoperatorio inmediato de los pacientes tras anestesia con desflurano, sevoflurano o isoflurano en cirugía urológica abierta de duración prolongada. PACIENTES Y MÉTODOS. Se seleccionaron 75 pacientes para recibir de forma aleatoria desflurano, sevoflurano o isoflurano con N2O al 60 por ciento durante el mantenimiento de la anestesia. La concentración de estos agentes se ajustó para mantener la presión arterial y la frecuencia cardíaca en ñ 20 por ciento de los valores basales. Al final de la intervención se suprimieron los agentes anestésicos y se registró el tiempo hasta la apertura de ojos de los enfermos, ventilación espontánea, extubación y orientación.En la unidad de recuperación postanestésica (URPA) se evaluaron el test de Newman-Trieger, el test de Aldrete, las náuseas y vómitos, y las necesidades de analgesia de los enfermos en las primeras 24 h. RESULTADOS. No hubo diferencias significativas entre los grupos con respecto a datos demográficos, mantenimiento anestésico, duración de la anestesia o dosis relativas de agentes anestésicos utilizados. Los tiempos de recuperación de los enfermos en quirófano fueron significativamente menores (p < 0,05) tras anestesia con desflurano o sevoflurano que con isoflurano, sin diferencias entre los dos primeros grupos (duración de la anestesia: 198 ñ 90, 171 ñ 67 y 191 ñ 79; apertura de ojos: 7,6 ñ 3,7, 7,8 ñ 3,0 y 11,9 ñ 4,5; tiempo hasta extubación: 7,8 ñ 3,0, 8,3 ñ 3,0 y 11,0 ñ 3,5; desflurano, sevoflurano e isoflurano, respectivamente; todos los datos expresados en min).La recuperación en la URPA no objetivó diferencias significativas entre los tres grupos. CONCLUSIONES. Los tres agentes fueron comparables durante el mantenimiento anestésico. El desflurano y el sevoflurano evidenciaron ventajas sobre el isoflurano durante la recuperación de la anestesia en quirófano. No se encontraron diferencias entre los grupos en la recuperación psicomotriz, náuseas y/o vómitos o requerimientos de analgesia postoperatoria (AU)

[Immediate anesthesia recovery and psychomotor function of patient after prolonged anesthesia with desflurane, sevoflurane or isoflurane]. / Recuperación anestésica inmediata y función psicomotriz de los pacientes tras anestesia prolongada con desflurano, sevoflurano o isoflurano.

OBJECTIVE: To compare the anesthetic maintenance and early postoperative recovery and psychomotor function in patients who have been anesthestized with desflurane, sevoflurane or isoflurane during prolonged open urological surgery. PATIENTS AND METHODS: Seventy-five patients were randomly assigned to receive desflurane, sevoflurane or isoflurane with N2O 60% for anesthetic maintenance. The concentration of each drug was adjusted to maintain arterial pressure and heart rate +/- 20% of baseline. After the operation the anesthetics were discontinued and times until eye opening, spontaneous breathing, extubation and orientation were recorded. In the post-anesthesia recovery ward we applied the Newman-Trieger and Aldrete tests and recorded instances of nausea and vomiting and need for analgesia during the first 24 hours after surgery. RESULTS: The groups were similar with regard to demographic features, anesthetic maintenance, duration of anesthesia and relative doses of the anesthetics used. Recovery times in the operating room were significantly shorter (p < 0.05) after anesthesia with desflurane and sevoflurane than with isoflurane, with no significant differences between the desflurane and sevoflurane groups (duration of anesthesia 198 +/- 90, 171 +/- 67 and 191 +/- 79; eye opening 7.6 +/- 3.7, 7.8 +/- 3.0 and 11.9 +/- 4.5; time until extubation 7.8 +/- 3.0, 8.3 +/- 3.0 and 11.0 +/- 3.5 for desflurane, sevoflurane and isoflurane, respectively; all data in minutes). Recovery in the post-anesthetic recovery ward was similar for all three groups. CONCLUSIONS: Anesthetic maintenance was comparable with all three drugs. Desflurane and sevoflurane demonstrated advantages over isoflurane during recovery from anesthesia in the operating theater. No significant differences were found in psychomotor recovery, nausea and/or vomiting or requirements for postoperative analgesia.

[Anesthetic treatment of periodic familial hypokalemic paralysis. Report of a case]. / Tratamiento anestésico de la parálisis periódica familiar hipopotasémica. A propósito de un caso.

Periodic familiar hypopotassemic paralysis (PFHP) is a rare dominant autosomally transmitted genetic disease characterized by intermittent attacks of muscle weakness. A patient with PFHP was successfully given general anesthesia for 2 operations using atracurium as the muscle relaxant. For a third operation he was given a paravertebral block.

[Anesthesia for brain tumor surgery during pregnancy: presentation of a case]. / Anestesia para cirugía de un tumor cerebral durante el embarazo: a propósito de un caso.

We report the case of a 26th-week pregnant woman undergoing craniotomy for excision of brain tumor. Main considerations for anesthetic management of pregnant women undergoing surgical operations are the following: Each pregnant women patient should be considered as "full stomach" regardless fasting period. All measures should be taken to ensure fetal oxigenation by maintaining an optimal placental blood flow. There is no evidence of teratogenesis of anesthesic agents except for nitrous oxide which should be avoided during first and second trimesters. Fetal monitoring should be instituted from week 16 on as well as uterine dynamics periods whenever possible because of the greater frequency of premature labor or abortion. In Neurosurgery, an exhaustive control of blood pressure and PaCO2 of the mother should be carried out and osmotic diuretic agents should be cautiously administered.

[Effects of postoperative pain on lung volume in patients undergoing aortic surgery]. / Repercusión del dolor postoperatorio sobre los volúmenes pulmonares en pacientes sometidos a cirugía aórtica.

To evaluate the potential advantages of the administration of extradural morphine to control postoperative pain and its effects on respiratory function, 39 patients were randomly assigned to one of two groups before aortic surgery. The first group (20 patients) received intravenous analgesia as required (control group). The second group (19 patients) received extradural morphine in a programmed fashion. During the immediate postoperative period the following parameters were measured in both groups: respiratory rate, vital capacity, peak expiratory volume in the first second, PaO2, PaCO2, arterial pH, heart rate, and systolic and diastolic blood pressure. In the group treated with morphine the postoperative increase in heart and respiratory rate was significantly smaller than in the control group (p less than 0.01). Postoperative forced pulmonary volumes were higher in the morphine group (p less than 0.01). However, there were no differences in time of hospitalization between both groups. There were more complications in the control group, but the difference did not reach statistical significance.

[Obturator nerve block in transurethral surgery]. / Bloqueo del nervio obturador en la cirugía transuretral.

The obturator nerve passes in close proximity to the bladder as it courses through the pelvis. During transurethral operations, resection may result in stimulation of the obturator nerve, causing violent adductor contraction. Bladder perforation and incomplete tumor resection are the most important complications. All techniques proposed since transurethral surgery began, until nowadays are reviewed: neuromuscular blockade, electric circuit modifications, transparietal endoscopic blockade, periprostatic and subvesical infiltration, obturator nerve blockade and the "3 in 1 block" described by Winnie. Practical advices are proposed finally.