Anesthetic considerations for functional endoscopic sinus surgery in a patient with Kartagener syndrome.

Kartagener's syndrome (KS) is a rare genetic disease characterised by the triad of sinusitis, bronchiectasis, and situs inversus. This syndrome is associated with an increased risk of respiratory complications. Therefore, both the anaesthetic technique and the agents used must be carefully chosen according to the type of intervention and the patient's baseline condition. We present the case of a 48-year-old woman with KS, scheduled for functional endoscopic sinus surgery (FESS) and septoplasty under general anaesthesia. The main anaesthetic considerations in patients with KS are related to anatomical variations, pulmonary and cardiac functions, and respiratory infections. In this case, measures that reduce perioperative complications in KS are reviewed together with the special anaesthetic management in FESS, derived primarily from the need to maintain a bloodless surgical field and the use of induced hypotension techniques.

Anesthetic considerations for functional endoscopic sinus surgery in a patient with Kartagener syndrome. / Consideraciones anestésicas para cirugía endoscópica nasosinusal en una paciente con síndrome de Kartagener.

Kartagener's syndrome (KS) is a rare genetic disease characterized by the triad of sinusitis, bronchiectasis, and situs inversus. This syndrome is associated with an increased risk of respiratory complications. Therefore, both the anesthetic technique and the agents used must be carefully chosen according to the type of intervention and the patient's baseline condition. We present the case of a 48-year-old woman with KS, scheduled for functional endoscopic sinus surgery (FESS) and septoplasty under general anesthesia. The main anesthetic considerations in patients with KS are related to anatomical variations, pulmonary and cardiac functions, and respiratory infections. In this case, measures that reduce perioperative complications in KS are reviewed together with the special anesthetic management in FESS, derived primarily from the need to maintain a bloodless surgical field and the use of induced hypotension techniques.

Imágenes ultrasonográficas de vía aérea superior tras la inserción de mascarilla laríngea: estudio descriptivo y utilidad clínica / Descriptive study of ultrasound images of the upper airway obtained after insertion of laryngeal mask

Objetivo: Evaluar la utilidad clínica de la ecografía de vía aérea superior en la visualización de la mascarilla laríngea correctamente insertada. Material y métodos: Estudio observacional prospectivo en pacientes programados para cirugía abdominal bajo anestesia general, a quienes se aseguraba la permeabilidad de la vía aérea mediante mascarilla Ambu(R)AuraGainTM. Se llevó a cabo un escaneo ecográfico de la vía aérea superior, mediante cortes trasversales en sentido cráneo-caudal y cortes longitudinales en línea media cervical anterior y parasagital, en tres momentos: antes, tras insertar y tras retirar la mascarilla. Las imágenes registradas eran evaluadas en un segundo tiempo por un radiólogo experto en ecografía de la vía aérea. Posteriormente, se relacionaban los datos ecográficos con los clínicos de dificultad de inserción y presencia de fuga aérea. Resultados: Recogimos datos de 30 pacientes (20 mujeres y 10 varones) intervenidos de histerectomía abdominal (15), eventroplastia (6), miomectomía uterina (3) y hernioplastia umbilical (4) e inguinal (2). La inserción a ciegas del dispositivo no presentó dificultades en 24 pacientes (80%). Detectamos fuga aérea en 8 pacientes (26,7%): moderada en 7 casos y grave en uno. Los hallazgos ecográficos confirmaban buena colocación de la mascarilla en 22 pacientes (73,3%). Se objetivaron cambios anatómicos en la vía aérea tras extraer la mascarilla laríngea en 3 pacientes (12%), todos leves. Hubo asociación estadísticamente significativa (p<0,05) entre el grado de dificultad de inserción del dispositivo y el grado de fuga aérea detectado. Conclusiones: La ultrasonografía de la vía aérea superior podría confirmar la colocación correcta de la mascarilla laríngea. No se objetivó edema laríngeo tras la extracción del dispositivo

Objective: To evaluate clinical usefulness of ultrasound images of the upper airway in order to check correct laryngeal mask placement. Material and methods: A prospective observational study was conducted on patients scheduled for abdominal surgery under general anaesthesia, in whom the patency of the upper airway was ensured using an Ambu(R)AuraGainTM laryngeal mask. An ultrasound scan was performed of the upper-airway in the cranio-caudal direction and with longitudinal scans in the anterior midline and parasagittal axis, in three moments: before, after inserting and after removing the mask. All recorded images were evaluated in a second time by a radiologist-expert in upper airway ultrasound. Subsequently, the ultrasound data were related to the clinical difficulty of the insertion and presence of air leaks. Results: Data was collected from 30 patients (20 females and 10 males) being operated on for abdominal hysterectomy (15), eventroplasty (6), uterine myomectomy (3), and umbilical (4) and inguinal herniorrhaphy (2). The blind insertion of the masks did not present difficulties in 24 (80%) patients. Air leakage was detected in 8 (26.7%) patients, which was moderate in 7 cases and severe in one of them. The ultrasound findings confirmed good mask placement in 22 (73.3%) patients. Anatomical airway changes after laryngeal mask extraction were only observed in 3 (12%) patients, all of them minor. There was a statistically significant association (P<.05) between difficulty in inserting the device and the level of air leakage. Conclusions: Upper airway ultrasound is a useful diagnostic method to evaluate laryngeal mask placement. Laryngeal oedema was not observed after removal of the device

Tratamiento anestésico en una paciente pediátrica con miopatía congénita por desproporción del tipo de fibras / Anaesthetic management of a paediatric patient with congenital fibre type disproportion myopathy

La desproporción congénita del tipo de fibras (DCTF) es un raro tipo de miopatía caracterizado por debilidad muscular e hipotonía durante la infancia. Las características clínicas incluyen retraso motor, dificultades en la alimentación, debilidad de las extremidades, contracturas articulares y escoliosis. Se describe el tratamiento anestésico de una paciente de 3 años con miopatía DCTF asociada a mutación del gen TPM3, programada para realización de adenoamigdalectomía por presentar un síndrome de apnea-hipopnea obstructiva del sueño (SAHOS). Nuestras principales preocupaciones fueron la posible susceptibilidad a la hipertermia maligna, el riesgo de rabdomiólisis inducida por anestesia, una mayor sensibilidad a los relajantes musculares no despolarizantes y la presencia de SAHOS. La anestesia total intravenosa con propofol y el empleo de rocuronio/sugammadex parecen ser opciones seguras. Dado el alto riesgo de compromiso respiratorio y otras complicaciones, los pacientes deben controlarse estrechamente en el periodo postoperatorio

Congenital fibre type disproportion (CFTD) is a rare type of myopathy that is characterised by muscle weakness and hypotonia during childhood. Clinical features include motor delay, feeding difficulties, limb weakness, joint contractures, and scoliosis. A report is presented of the anaesthetic management of a 3-year-old girl with CFTD myopathy associated with a mutation of the TPM3 gene, scheduled for adenotonsillectomy because of obstructive sleep apnoea hypopnoea syndrome (OSAHS). The main concerns were the possible susceptibility to malignant hyperthermia, the risk of anaesthesia-induced rhabdomyolysis, a greater sensitivity to non-depolarising muscle relaxants, and the presence of OSAHS. Total intravenous anaesthesia with propofol and the use of rocuronium/sugammadex appear to be safe options. Given the high risk of respiratory compromise and other complications, patients should be closely monitored in the post-operative period

Descriptive study of ultrasound images of the upper airway obtained after insertion of laryngeal mask. / Imágenes ultrasonográficas de vía aérea superior tras la inserción de mascarilla laríngea: estudio descriptivo y utilidad clínica.

OBJECTIVE: To evaluate clinical usefulness of ultrasound images of the upper airway in order to check correct laryngeal mask placement. MATERIAL AND METHODS: A prospective observational study was conducted on patients scheduled for abdominal surgery under general anaesthesia, in whom the patency of the upper airway was ensured using an Ambu®AuraGainTM laryngeal mask. An ultrasound scan was performed of the upper-airway in the cranio-caudal direction and with longitudinal scans in the anterior midline and parasagittal axis, in three moments: before, after inserting and after removing the mask. All recorded images were evaluated in a second time by a radiologist-expert in upper airway ultrasound. Subsequently, the ultrasound data were related to the clinical difficulty of the insertion and presence of air leaks. RESULTS: Data was collected from 30 patients (20 females and 10 males) being operated on for abdominal hysterectomy (15), eventroplasty (6), uterine myomectomy (3), and umbilical (4) and inguinal herniorrhaphy (2). The blind insertion of the masks did not present difficulties in 24 (80%) patients. Air leakage was detected in 8 (26.7%) patients, which was moderate in 7 cases and severe in one of them. The ultrasound findings confirmed good mask placement in 22 (73.3%) patients. Anatomical airway changes after laryngeal mask extraction were only observed in 3 (12%) patients, all of them minor. There was a statistically significant association (P<.05) between difficulty in inserting the device and the level of air leakage. CONCLUSIONS: Upper airway ultrasound is a useful diagnostic method to evaluate laryngeal mask placement. Laryngeal oedema was not observed after removal of the device.

Anaesthetic management of a paediatric patient with congenital fibre type disproportion myopathy. / Tratamiento anestésico en una paciente pediátrica con miopatía congénita por desproporción del tipo de fibras.

Congenital fibre type disproportion (CFTD) is a rare type of myopathy that is characterised by muscle weakness and hypotonia during childhood. Clinical features include motor delay, feeding difficulties, limb weakness, joint contractures, and scoliosis. A report is presented of the anaesthetic management of a 3-year-old girl with CFTD myopathy associated with a mutation of the TPM3 gene, scheduled for adenotonsillectomy because of obstructive sleep apnoea hypopnoea syndrome (OSAHS). The main concerns were the possible susceptibility to malignant hyperthermia, the risk of anaesthesia-induced rhabdomyolysis, a greater sensitivity to non-depolarising muscle relaxants, and the presence of OSAHS. Total intravenous anaesthesia with propofol and the use of rocuronium/sugammadex appear to be safe options. Given the high risk of respiratory compromise and other complications, patients should be closely monitored in the post-operative period.

Intubación con laringoscopio Airtraq® en paciente con quiste de vallécula gigante / Intubation with laryngoscope Airtraq in a patient with a giant vallecular cyst

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[Implantable pacemakers and defibrillators: implications for anesthesia and perioperative management]. / Marcapasos y desfibriladores automáticos implantables: implicaciones anestésicas y manejo perioperatorio.

The technological complexity of implantable devices for managing arrhythmias, specifically pacemakers and defibrillators, has increased spectacularly since their introduction a few decades ago. A growing number of patients with these devices are undergoing surgery and it is therefore essential to understand how they work and what the real associated risks are. Manuals and reference works on anesthesia may provide little information on these devices and their perioperative management. It is no longer satisfactory to place a magnet over these devices during surgery and assume that this action will protect the patient from the possible effects of electromagnetic interference. This review examines the basic principles and operation of implantable pacemakers and defibrillators, the relevant nomenclature, and the sources and effects of electromagnetic interference; the current recommendations for the perioperative management of patients fitted with these devices are also discussed.

Marcapasos y desfibriladores automáticos implantables: implicaciones anestésicas y manejo perioperatorio / Implantable pacemakers and defibrillators: implications for anesthesia and perioperative management

La complejidad tecnológica de los dispositivosimplantables para el manejo de las arritmias, concretamentede marcapasos y desfibriladores, ha aumentadode forma espectacular desde su introducción hace solamenteunas pocas décadas. Un número cada vez mayorde pacientes con estos dispositivos va a ser intervenidoquirúrgicamente, por lo que es primordial saber cómofuncionan y cuáles son los riesgos reales. Los manuales yreferencias de anestesia pueden proporcionar pocainformación sobre este tipo de aparatos y su manejoperioperatorio. Ya no es satisfactorio colocar durante lacirugía un imán encima de estos dispositivos y suponerque esta acción protege al paciente de los posibles efectosde las interferencias electromagnéticas. Este artículorevisa los principios básicos y el funcionamiento de estosequipos, la nomenclatura, las fuentes de interferenciaelectromagnética y sus efectos, así como las recomendacionesactuales para el manejo perioperatorio delpaciente portador de un marcapasos o un desfibriladorimplantable(AU)

The technological complexity of implantable devicesfor managing arrhythmias, specifically pacemakers anddefibrillators, has increased spectacularly since theirintroduction a few decades ago. A growing number ofpatients with these devices are undergoing surgery and itis therefore essential to understand how they work andwhat the real associated risks are. Manuals and referenceworks on anesthesia may provide little information onthese devices and their perioperative management. It is nolonger satisfactory to place a magnet over these devicesduring surgery and assume that this action will protectthe patient from the possible effects of electromagneticinterference. This review examines the basic principlesand operation of implantable pacemakers anddefibrillators, the relevant nomenclature, and the sourcesand effects of electromagnetic interference; the currentrecommendations for the perioperative management ofpatients fitted with these devices are also discussed(AU)

[Percutaneous tracheotomy with the Ciaglia Blue Rhino technique: a critical analysis after 1 year]. / Traqueotomía percutánea con la técnica de Ciaglia Blue Rhino: un análisis crítico tras un año de experiencia.

OBJECTIVES: To report our experience during a learning period with the Ciaglia Blue Rhino (William Cook Europe) kit for percutaneous tracheotomy. PATIENTS AND METHODS: This prospective, observational study included 38 adult patients who underwent elective placement of a percutaneous tracheostomy tube with the Ciaglia Blue Rhino introducer kit. The study was carried out from April 2002 to May 2003. The main variables analyzed were duration of the procedure, level of difficulty (easy, moderately difficult, difficult), and complications while the procedure was being performed. RESULTS: The mean time of orotracheal intubation was 13.5 days (range, 2-28 days). The mean duration of the procedure was 12 minutes 36 seconds (range, 4 minutes 30 seconds-29 minutes; 95% confidence interval, 10 minutes 30 seconds-14 minutes 36 seconds). The procedure was rated easy in 60.5% of the cases, moderately difficult in 31.6%, and difficult in 7.9%. Some form of complication occurred in 28 patients (73.6%), the most common being puncture of the orotracheal tube (28.9%) and slight bleeding (26.3%). Two patients (5.2%) died, from massive hemorrhage in 1 case and pneumothorax in the other. CONCLUSIONS: The Ciaglia Blue Rhino technique for percutaneous tracheotomy is useful, rapid, and easy but not free of risk. There is a learning curve that calls for caution and an experienced physician to perform the maneuvers, given that potentially fatal complications can occur.

Traqueotomía percutánea con la técnica de Ciaglia Blue Rhino®: un análisis crítico tras un año de experiencia / Percutaneous tracheotomy with the Ciaglia Blue Rhino® technique: a critical analysis after 1 year

OBJETIVOS: Presentar nuestra experiencia con el set Ciaglia Blue Rhino® para traqueotomía percutánea durante el periodo de aprendizaje de la técnica. PACIENTES Y MÉTODOS: Se ha realizado un estudio observacional prospectivo en 38 pacientes adultos a los que se les realizó una traqueotomía percutánea electiva con el equipo introductor Ciaglia Blue Rhino® (William Cook Europe). El estudio se realizó entre los meses de abril de 2002 y mayo de 2003. Las variables primarias analizadas fueron la duración del procedimiento, la graduación del nivel de dificultad (fácil, dificultad media, difícil), así como las complicaciones durante la realización de la técnica. RESULTADOS: El tiempo medio de intubación orotraqueal previo a la traqueotomía fue de 13,5 días (rango: 2-28 días). El procedimiento se realizó en un tiempo medio de 12 min 36 s (rango: 4 min 30 s-29 min; Intervalo de Confianza (IC) 95%: 10 min 30 s-14 min 36 s). El 60,5% de los casos fueron fáciles, el 31,6%, de dificultad media y sólo 3 se consideraron difíciles (7,9%). Existió algún tipo de complicación en 28 pacientes (73,6%), siendo las más frecuentes la punción del tubo orotraqueal (28,9%) y la aparición de hemorragia leve (26,3%). Hubo dos fallecimientos (5,2%). Las causas de estas muertes fueron una hemorragia incoercible y un neumotórax a tensión. CONCLUSIONES: Es una técnica útil, fácil y rápida, pero no está exenta de riesgos. Hay una curva de aprendizaje que demanda precaución y experiencia por parte del médico que está ejecutando la técnica, ya que las complicaciones potencialmente fatales pueden ocurrir

OBJECTIVES: To report our experience during a learning period with the Ciaglia Blue Rhino® (William Cook Europe) kit for percutaneous tracheotomy. PATIENTS AND METHODS: This prospective, observational study included 38 adult patients who underwent elective placement of a percutaneous tracheostomy tube with the Ciaglia Blue Rhino® introducer kit. The study was carried out from April 2002 to May 2003. The main variables analyzed were duration of the procedure, level of difficulty (easy, moderately difficult, difficult), and complications while the procedure was being performed. RESULTS: The mean time of orotracheal intubation was 13.5 days (range, 2–28 days). The mean duration of the procedure was 12 minutes 36 seconds (range, 4 minutes 30 seconds–29 minutes; 95% confidence interval, 10 minutes 30 seconds–14 minutes 36 seconds). The procedure was rated easy in 60.5% of the cases, moderately difficult in 31.6%, and difficult in 7.9%. Some form of complication occurred in 28 patients (73.6%), the most common being puncture of the orotracheal tube (28.9%) and slight bleeding (26.3%). Two patients (5.2%) died, from massive hemorrhage in 1 case and pneumothorax in the other. CONCLUSIONS: The Ciaglia Blue Rhino® technique for percutaneous tracheotomy is useful, rapid, and easy but not free of risk. There is a learning curve that calls for caution and an experienced physician to perform the maneuvers, given that potentially fatal complications can occur

[Patient-controlled analgesia (PCA) with variable doses: an alternative to conventional PCA?]. / Analgesia controlada por el paciente (PCA) a dosis variables: una alternativa a la PCA convencional?

We have prospectively studied the effects of three types of patient controlled anesthesia (PCA) in 30 patients who underwent elective upper abdominal surgery. Patients were allocated into three groups of 10. The first group received postoperative anesthesia by means of intravenous conventional PCA at fixed demand doses (PCADF). A second group was treated with demand doses that were varied in each bolus according to the intensity of pain (PCADV). A third group received continuous infusion with additional demand doses in variable bolus (PCAC + DV). The analgesic agent used in this study was morphine chloride. The total accumulated doses of morphine in PCADV group were lower than those of the other two groups. These differences were statistically significant when they were compared with PCADF group (p less than 0.01 at 2 and 6 hours; p less than 0.05 at 12 and 24 hours) and with PCAC + DV group (p less than 0.01 at 2, 6, 12, and 24 hours). Differences in morphine consumption during the different time intervals were markedly significant between 0 and 2 hours after the onset of PCA. PCADV required lower doses (p less than 0.01). After the first 2 hours, patients of PCADV group continued using lower morphine doses, but these differences were not significant when compared with PCADF group, although were present with respect to patients of PCAC + DV group (p less than 0.01). The incidence of secondary effects was not significantly different among the three groups. Based on these results we propose a modification in present PCA pumps.