[Cerebrospinal fluid drainage in endovascular repair of thoracic aortic lesions: preliminary report of experience with 5 patients]. / Tratamiento endovascular de lesiones en aorta torácica con drenaje de líquido cefalorraquídeo. Experiencia inicial en cinco pacientes.

Endovascular repair of thoracic or thoracoabdominal aortic lesions as an alternative to open surgery, to avoid the high complication and mortality rates associated with the conventional approach, does not eliminate the risk of postoperative paraplegia. We report on a series of 5 patients with different thoracic aortic lesions who underwent endovascular stent-graft repair procedures. We describe measures to drain cerebrospinal fluid to prevent ischemic spinal cord injury. We also review the anesthetic management of patients undergoing this type of surgery.

Tratamiento endovascular de lesiones en aorta torácica con drenaje de líquido cefalorraquídeo. Experiencia inicial en cinco pacientes / Cerebrospinal fluid drainage in endovascular repair of thoracic aortic lesions: preliminary report of experience with 5 patients

El tratamiento endovascular de lesiones a nivel deaorta torácica o toracoabdominal como alternativa a lacirugía abierta convencional (en prevención de la elevadamorbilidad y mortalidad de la misma) no está exentadel riesgo potencial de paraplejía postoperatoria de estaúltima.Presentamos una serie de cinco pacientes, con distintaslesiones a nivel de aorta torácica, sometidos a cirugíaendovascular reparadora por medio de endoprótesis ylas medidas de protección medular desarrolladas con elfin de prevenir una eventual isquemia medular mediantedrenaje de líquido cerfalorraquídeo. Asimismo realizamosuna revisión del manejo anestésico para este tipode abordaje quirúrgico

Endovascular repair of thoracic or thoracoabdominalaortic lesions as an alternative to open surgery, to avoidthe high complication and mortality rates associatedwith the conventional approach, does not eliminate therisk of postoperative paraplegia.We report on a series of 5 patients with different thoracicaortic lesions who underwent endovascular stentgraftrepair procedures. We describe measures to draincerebrospinal fluid to prevent ischemic spinal cordinjury. We also review the anesthetic management ofpatients undergoing this type of surgery

[Severe hemodynamic deterioration during epidural anesthesia for endovascular treatment of thoracic aortic stenosis]. / Deterioro hemodinámico severo durante la anestesia epidural para el tratamiento endovascular de una estenosis de aorta torácica.

A 72-year-old woman diagnosed with critical descending aortic stenosis was scheduled for endovascular treatment by angioplasty and implantation of an aortic stent. Her medical history included arterial hypertension, lipid metabolic disorder, obesity, Takayasu disease, dermatopolymyositis, and alleged allergy to iodine contrast and local anesthetics. After the allergies were ruled out, it was decided to use a regional anesthetic technique to avoid the postoperative complications of general anesthesia and achieve better hemodynamic control during surgery. Surgery was carried out under epidural anesthesia and intravenous sedation. After angioplasty and during self-expansion of the stent, the patient's hemodynamics deteriorated rapidly; she lost consciousness and required orotracheal intubation and immediate resuscitation measures. The literature describes in detail the management of patients with thoracic aortic lesions, including the most appropriate way to provide anesthesia. General anesthesia seems to be preferred, although care is taken to individualize the decision. We analyze this case of a patient with severe thoracic aortic stenosis undergoing endovascular treatment under epidural anesthesia.

Deterioro hemodinámico severo durante la anestesia epidural para el tratamiento endovascular de una estenosis de aorta torácica / Severe hemodynamic deterioration during epidural anesthesia for endovascular treatment of thoracic aortic stenosis

Una mujer de 72 años, diagnosticada de estenosis crítica de aorta torácica descendente, es propuesta para tratamiento endovascular con angioplastia e implante de prótesis aórtica. Como antecedentes personales presentaba: hipertensión arterial, dislipemia, obesidad, enfermedad de Takayasu, dermatopolimiositis y una dudosa alergia a contraste yodado y anestésicos locales. Tras descartar las alergias, se decidió recurrir a una técnica locorregional, con el fin de evitar la morbilidad postoperatoria de la anestesia general y conseguir un mejor control hemodinámico intraoperatorio. La intervención se desarrolló bajo anestesia epidural y sedación intravenosa; tras realizar la angioplastia se procedió a la fijación y autoexpansión de la prótesis, momento en el cual se produjo un deterioro hemodinámico brusco de la paciente, con pérdida de conciencia, que obligó a la intubación orotraqueal y medidas de resucitación inmediatas. La literatura que describe con detalle el manejo y la técnica anestésica más apropiada para el tratamiento endovascular de lesiones a nivel de la aorta torácica, parece decantarse por la anestesia general, aunque siempre individualizando cuidadosamente cada caso. Presentamos una paciente con estenosis aórtica torácica severa, sometida a tratamiento endovascular bajo anestesia epidural

A 72-year-old woman diagnosed with critical descending aortic stenosis was scheduled for endovascular treatment by angioplasty and implantation of an aortic stent. Her medical history included arterial hypertension, lipid metabolic disorder, obesity, Takayasu disease, dermatopolymyositis, and alleged allergy to iodine contrast and local anesthetics. After the allergies were ruled out, it was decided to use a regional anesthetic technique to avoid the postoperative complications of general anesthesia and achieve better hemodynamic control during surgery. Surgery was carried out under epidural anesthesia and intravenous sedation. After angioplasty and during self-expansion of the stent, the patient's hemodynamics deteriorated rapidly; she lost consciousness and required orotracheal intubation and immediate resuscitation measures. The literature describes in detail the management of patients with thoracic aortic lesions, including the most appropriate way to provide anesthesia. General anesthesia seems to be preferred, although care is taken to individualize the decision. We analyze this case of a patient with severe thoracic aortic stenosis undergoing endovascular treatment under epidural anesthesia

[Refractory hypotension sustained during general anesthesia due to chronic treatment with angiotensin-converting enzyme inhibitors]. / Hipotensión refractaria y sostenida durante una anestesia general asociada al tratamiento crónico con inhibidores de la enzima conversiva de la angiotensina.

Perioperative management of angiotensin-converting enzyme inhibitors (ACEI) is controversial because of associated hypertensive episodes during induction and maintenance of anesthesia. A 71-year-old woman with a non-functioning thyroid node was scheduled for thyroid lobectomy. Her medical history included high blood pressure and she was being chronically treated with ACEI, which were taken until the morning of surgery. After induction of anesthesia, arterial hypotension refractory to crystalloid therapy developed and worsened in spite of administration of a gelatin-type colloid (Gelafundina). The patient did not respond to ephedrine or dopamine and required stabilization with adrenalin in continuous perfusion for 12 hours. Later evolution was satisfactory and recovery took place without sequelae. We discuss the anesthetic implications of chronic ACEI treatment and possible hemodynamic repercussions of associated administration with gelatin-type solutions or human albumin.

Hipotensión refractaria y sostenida durante una anestesia general asociada al tratamiento crónico con inhibidores de la enzima conversiva de la angiotensina / Sustained, refractory hypotension during general anesthesia of a patient chronically treated with angiotensin-converting enzyme inhibitors

El manejo perioperatorio de los fármacos inhibidores de la enzima conversiva de la angiotensina (IECA) es controvertido por su asociación a episodios hipotensivos durante la inducción y el mantenimiento anestésico.Una paciente de 71 años fue programada para lobectomía tiroidea por nódulo tiroideo no funcionante; tenía antecedentes de hipertensión arterial y estaba en tratamiento crónico con un IECA, que se mantuvo hasta la mañana de la intervención. Tras la inducción anestésica la paciente desarrolló un cuadro de hipotensión arterial que no respondió a fluidoterapia con cristaloides y se fue acentuando, a pesar de la administración de una solución coloide tipo gelatina (Gelafundina®). No hubo respuesta a la efedrina ni a la dopamina, precisando para su estabilización adrenalina en perfusión continua durante 12 h. La evolución de la paciente fue satisfactoria y la recuperación, completa sin secuelas.Se comentan las implicaciones anestésicas del tratamiento crónico con fármacos IECA y la posible repercusión hemodinámica que puede suponer su asociación a soluciones tipo gelatina o albúmina humana (AU)

Trasplante pulmonar y hemofilia. Consideraciones perioperatorias / Lung transplantation and hemophilia. Perioperative considerations

El trasplante pulmonar es una indicación terapéutica para pacientes seleccionados con enfermedad pulmonar terminal.Presentamos el caso clínico de un trasplante pulmonar unipulmonar izquierdo en una paciente de 16 años con hemofilia B y diagnóstico de fibrosis pulmonar idiopática, con antecedentes de desnutrición, osteoporosis, escoliosis severa, serología VHC positiva y neumotórax bilateral recidivante.La terapia sustitutiva con factor IX ultrapuro se inició en el momento en que se dispuso del pulmón donante y se mantuvo hasta 37 días postintervención. Los valores plasmáticos de factor IX se mantuvieron próximos al 100 por ciento durante el acto quirúrgico y postoperatorio inmediato, y por encima del 40 por ciento pasado éste, lo que permitió una correcta hemostasia durante todo el proceso, sin precisar la administración de hemoderivados.La evolución de la paciente fue favorable, con una estancia en la unidad de reanimación de 17 días, dándose el alta hospitalaria a los 40 días del trasplante.Se comentan las consideraciones de la hemofilia con respecto al trasplante pulmonar, y la influencia que tienen sobre éste la malnutrición, el tratamiento crónico esteroide y la osteoporosis (AU)

[Lung transplantation and hemophilia. Preoperative considerations]. / Trasplante pulmonar y hemofilia. Consideraciones perioperatorias.

Lung transplantation is indicated in certain patients with terminal pulmonary disease. We report a case in which a single lung (left) was transplanted to a 16-year-old girl with hemophilia B; she also suffered idiopathic pulmonary fibrosis and had a history of malnutrition, osteoporosis, severe scoliosis, hepatitis C positivity and recurrent bilateral pneumothorax. Treatment with pure factor IX was started the moment the donor lung was available and was continued for 37 days after surgery. Plasma levels of factor IX were kept at 100% during surgery and in the early postoperative period, and over 40% after that time. Correct hemostasis was thus achieved throughout the procedure, with no need for blood products. Patient outcome was satisfactory. The stay in the intensive care recovery ward was 17 days and discharge was 40 days after transplantation. We discuss aspects of hemophilia and lung transplantation, and the influence on malnutrition, chronic steroid treatment and osteoporosis.

[A case of malignant hyperthermia: anesthesia and recovery]. / Un caso de hipertermia maligna: anestesia y reanimación.

We report the case of a 29-years-old woman with Menière's syndrome undergoing surgery to drain the endolymphatic sack. After anesthetic induction trismus developed but tubes were inserted without difficulty. Tachycardia began 15 min after start of balanced anesthesia with isoflurane, as arterial oxygen saturation and CO2 pressure decreased and temperature increased. These symptoms responded favorably to immediate treatment with dantrolene sodium, which was continued for 30 h in the ward for postoperative intensive care. Blood chemistry reports showed high enzyme levels that peaked at 24 h. We stress the importance of monitoring end tidal CO2 pressure and of rapidly starting specific treatment with dantrolene for correction of the clinical picture described.

[Selection and maintenance of lung donors]. / Particularidades de la selección y mantenimiento del donante pulmonar.

Lung transplantation is a relatively modern procedure that can afford improvement in quality of life to certain terminal patients with irreversible respiratory failure. Selection of the donor and the recipient must be both strict and flexible, as we apply criteria that are constantly being revised and extended. The care afforded the donor must include certain elements: exhaustive monitorization that serves to guide the intravenous replacement of fluids and maintenance of hemodynamic stability; assisted ventilation with PEEP, FiO2 under 0.4 and adequate flow volumes; prevention and treatment of neurogenic pulmonary edema; and prevention of infections through careful airways management involving appropriate antibiotic prophylaxis. The same protocol must be maintained while the organ is being extracted and the organ itself must be properly preserved until implanted. The anesthesiologist is fully involved in optimum management of the lung donor. We consider that such care is essential for achieving more and better quality lung donations.

Biomechanical consequences of callus development in Hoffmann, Wagner, Orthofix and Ilizarov external fixators.

A theoretical analysis by a finite elements model (FEM) of some external fixators (Hoffmann, Wagner, Orthofix and Ilizarov) was carried out. This study considered a logarithmic progress of callus elastic characteristics. A standard configuration of each fixator was defined where design and application characteristics were modified. A comparison among standard configurations and influence of every variation was made with regard to displacement and load transmission at the fracture site. An experimental evaluation of standard configurations was performed with a testing machine. After experimental validation of the theoretical model was achieved, an application of physiological loads which act on a fractured limb during normal gait was analysed. A minimal contribution from an external fixator to the total rigidity of the bone-callus-fixator system was assessed when a callus showing minimum elastic characteristics had just been established. Insufficient rigidity from the fixation devices to assure an adequate immobilization during the early stages of fracture healing was verified. However, regardless of the external fixator, callus development was the overriding element for the rigidity of the fixator-bone system.

[Application of continuous positive pressure to the uppermost lung in patients ventilated through a single lung]. / Aplicación de presión positiva continua al pulmón proclive en pacientes ventilados a un solo pulmón.

We have studied the oxygenation process in a series of 20 patients who underwent thoracic surgery and were ventilated through a single lung. There were 19 men and one woman with a mean age (+/- SD) of 63 +/- 10.5 years, a mean height of 166 +/- 37.9 cm and a mean weight of 67 +/- 14.1 kg. Premedication and anesthesia were comparable among all patients. Endotracheal intubation was performed with a double lumen Robersthaw cannula. After anesthetic induction the radial and pulmonary arteries were catheterized to obtain samples for gasometric investigation in arterial and venous mixed blood before and after exclusion of one lung with continuous positive pressure (CPAP). Gasometric analysis was also performed during the immediate postoperative period. All patients were ventilated with 100% oxygen concentration 20 min before blood sampling in order to remove the alveolar nitrogen. During single lung ventilation and during application of CPAP (5 cm H20) to the upright sided lung we observed a 50% increase in arterial p02 (Pa02) (p less than 0.001) without any change in mean alveolar p02 (PA02). There was also a 17% decrease in alveolo-arterial oxygen difference (D[A-a]02) (p less than 0.001) and a 16.6% reduction in the intrapulmonary shunt (Qs/Qt) (p less than 0.001). Improvement of oxygenation was attributed to a beneficial effect of CPAP applied to the upright sided lung while intermittent positive pressure was maintained in the recumbent lung.