Extensive extradural pneumorrhachis related to obstetric analgesia.

Iatrogenic extradural pneumorrhachis is a rare clinical entity, but anesthesiologists should be aware of this possibility when using the air technique for the identification of epidural space. Although in most published cases extradural pneumorrhachis is asymptomatic, relevant neurological consequences have been described, such as meningeal irritation, radicular pain, unilateral lower extremity weakness, cauda equina syndrome, paraplegia, and tetraplegia.We describe a very extensive extradural pneumorrachis (T9-S1), related to obstetric analgesia, in a patient with severe and atypical perineal pain after forceps-assisted delivery. Our aim is to synthesize and organize the available scientific evidence, analyzing preventive measures and summarizing the most appropriate diagnostic, follow-up and therapeutic techniques for symptomatic conditions, among which high concentrations of inspired oxygen, hyperbaric oxygen therapy and percutaneous or surgical decompression have been described.

¿Han cambiado los conceptos de analgesia obstétrica en los últimos 100 años? / Have the concepts of obstetric analgesia changed in the last 100 years?

Objetivos: Comparar los conceptos y métodos de analgesia obstétrica actual con los existentes hace 100 años, cuando se publicaron por primera vez Anesthesia & Analgesia (1922) y British Journal of Anaesthesia (1923), que son las dos primeras revistas de anestesia publicadas de forma independiente.Material y métodos: Identificamos y analizamos todos los artículos relacionados con la analgesia obstétrica publicados en estas revistas durante los años 1922 y 1923, y los comparamos con la práctica clínica actual. También buscamos en estos números referencias indirectas a la atención prestada a la analgesia obstétrica en las reuniones científicas de la época.Resultados: En el primer número de Anesthesia & Analgesia que aparece en agosto de 1922, 3 de los 8 artículos publicados están relacionados exclusivamente con la anestesia y analgesia obstétrica, y entre 1922 y 1923 encontramos un alto número de artículos y referencias. El análisis de estos artículos publicados hace un siglo permite objetivar el interés de la época por los resultados, la comparación entre los diferentes métodos anestésicos, la seguridad y la divulgación del conocimiento científico. Son habituales las referencias a la mortalidad, a las complicaciones, al confort y la satisfacción de la paciente, a la influencia de la analgesia obstétrica en la duración del parto, así como al ahorro de tiempo y de gases anestésicos. Resulta obvio que la metodología de investigación actual no puede compararse con la de hace 100 años. Pero existen numerosos aspectos científicos que sentaron algunas de las bases de la investigación actual en obstetricia, entre los que destacan la recogida de amplias series de pacientes durante largos periodos de tiempo, la mención expresa a la publicación de resultados tanto favorables como desfavorables...(AU)

Objectives: To compare current obstetric analgesia concepts and methods with those existing 100 years ago, when Anesthesia & Analgesia (1922) and British Journal of Anaesthesia (1923), the first two independently published anesthesia journals, were first published.Methods: We identified and analyzed all articles related to obstetric analgesia published in these journals during the years 1922 and 1923 and compared them with current clinical practice. We also searched these issues for indirect references to the attention given to obstetric analgesia at scientific meetings of the time.Results: In the first issue of Anesthesia & Analgesia, appearing in August 1922, 3 of the 8 articles published are related exclusively to obstetric anesthesia and analgesia, and between 1922 and 1923 we found a high number of articles and references. The analysis of these articles published a century ago allows us to objectify the interest of the time in the results, the comparison between different anesthetic methods, safety and the dissemination of scientific knowledge. References to mortality, complications, patient comfort and satisfaction, the influence of obstetric analgesia on the duration of labor, as well as savings in time and anesthetic gases are common.It is obvious that today's research methodology cannot be compared with that of 100 years ago. But there are many scientific aspects that laid some of the foundations of current research in obstetrics, including the collection of large series of patients over long periods of time, the express mention of the publication of both favorable and unfavorable results, the references not only to cost but also to cost-effectiveness, as well as the use of specific parameters to measure not only results but also patient satisfaction.Conclusions: It is evident that over the years the outcomes in the practice of anesthesiology have improved, but also that many concepts remain the same 100 years later...(AU)

Síndrome de la cimitarra: manejo anestésico para resección pulmonar del pulmón no afecto / Scimitar syndrome: anaesthetic management for pulmonary resection of the unaffected lung

El síndrome de la cimitarra es una rara anomalía congénita caracterizada por drenaje anómalo de las venas pulmonares derechas en cava inferior, asociado frecuentemente a hipoplasia del pulmón y arteria pulmonar derecha, dextrocardia y aporte arterial sistémico anómalo al lóbulo inferior. La resección sobre el pulmón sano resulta excepcional, y no conocemos antecedentes publicados. Un varón con síndrome de la cimitarra es diagnosticado de nódulo pulmonar maligno del pulmón contralateral. Esta situación conlleva una enorme complejidad anestésica, fundamentalmente para la ventilación intraoperatoria. Aunque la espirometría y la prueba de esfuerzo no contraindicaban la lobectomía prevista, la gammagrafía objetivó un pulmón derecho hipoplásico con captación por debajo del 15%. Descartamos la ventilación selectiva del pulmón derecho, ya que el shunt lo hacía funcionalmente inexistente, y planteamos 4 posibilidades anestésicas. Tras la colocación de un catéter epidural e intubación selectiva izquierda, la toracoscopia con apneas intermitentes fue nuestra primera elección (AU)

Scimitar syndrome is a rare congenital anomaly characterized by anomalous drainage of the right pulmonary veins in the inferior vena cava, frequently associated with right lung and pulmonary artery hypoplasia, dextrocardia and abnormal systemic arterial supply to the lower lobe. Pulmonary resection surgery on healthy lung is exceptional, and there are no published records of it, as far as we know. A man with scimitar syndrome diagnosed with a lung nodule with malignant features in the contralateral lung. This situation implies huge anaesthetic complexity, mainly for intraoperative ventilation. Although spirometry and stress test did not contraindicate the planned lobectomy, scintigraphy showed a hypoplastic right lung with an uptake of 15%. From an anaesthetic point of view we discarded selective ventilation of the right lung, since the shunt made it functionally non-existent. In consequence we proposed four anaesthetic possibilities. After the placement of an epidural catheter and left selective intubation, thoracoscopy with intermittent apnoeas was our first choice, and we could complete the extirpation and avoid excessive complexity (AU)

Pacientes reto: antiagregantes y nuevos anticoagulantes / No disponible

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Scimitar syndrome: Anaesthetic management for pulmonary resection of the unaffected lung. / Síndrome de la cimitarra: manejo anestésico para resección pulmonar del pulmón no afecto.

Scimitar syndrome is a rare congenital anomaly characterized by anomalous drainage of the right pulmonary veins in the inferior vena cava, frequently associated with right lung and pulmonary artery hypoplasia, dextrocardia and abnormal systemic arterial supply to the lower lobe. Pulmonary resection surgery on healthy lung is exceptional, and there are no published records of it, as far as we know. A man with scimitar syndrome diagnosed with a lung nodule with malignant features in the contralateral lung. This situation implies huge anaesthetic complexity, mainly for intraoperative ventilation. Although spirometry and stress test did not contraindicate the planned lobectomy, scintigraphy showed a hypoplastic right lung with an uptake of 15%. From an anaesthetic point of view we discarded selective ventilation of the right lung, since the shunt made it functionally non-existent. In consequence we proposed four anaesthetic possibilities. After the placement of an epidural catheter and left selective intubation, thoracoscopy with intermittent apnoeas was our first choice, and we could complete the extirpation and avoid excessive complexity.

Seguimiento del protocolo de profilaxis de náuseas y vómitos postoperatorios en un hospital regional / Monitoring the protocol for postoperative nausea and vomiting prophylaxis in a regional hospital

Introducción: Las náuseas y vómitos postoperatorios (NVPO) tienen una incidencia de hasta el 80%, por lo que es necesario identificar a los pacientes que necesitan profilaxis, e instaurar medidas en función del riesgo. Nuestro objetivo es valorar el grado de adhesión al protocolo de profilaxis de NVPO de nuestro Hospital, tratando de identificar si existen factores que dificultan su cumplimiento. Material y Método: Estudio retrospectivo sobre 100 pacientes durante su estancia en la Unidad de Recuperación Postanestésica, tras ser sometidos a anestesia general. Se identifica el porcentaje de profilaxis no realizada correctamente y sus causas. Resultados: El 76 % de los pacientes recibieron algún fármaco antiemético. El cumplimiento del protocolo has sido únicamente del 15 %, siendo las causas la administración de un mayor número de fármacos de los indicados (48), seguido de la administración de un fármaco inadecuado (17), utilizar menos fármacos de los necesarios (14) y el momento inadecuado de la administración de la profilaxis (14). En algunos casos se han solapado al menos dos procedimientos incorrectos. Conclusiones. El porcentaje de cumplimento del protocolo es bajo. Sin embargo, en la mayoría de los casos se debe a un exceso de fármacos lo que indica una buena concienciación de la necesidad de profilaxis y una alta preocupación de los anestesiólogos de nuestro Hospital por este problema. La valoración de NVPO debería incluirse de forma rutinaria en la valoración preanestésica, mediante protocolos actualizados

Introduction: Postoperative nausea and vomiting (PONV) have a high incidence, so it is necessary to identify the patients who need prophylaxis, establishing risk-based measures. Our objetive is to assess the degree of adherence to the protocol for PONV prophylaxis in our Hospital, trying to identify if there are factors that hinder the accomplishment. Material and Methods: We realized a retrospective study with 100 patients after general anesthesia, during their stay in the post-anesthesia recovery unit. We identified the percentage of prophylaxis not performed correctly and their causes. Results: 76% of patients received antiemetic drugs. The protocol accomplishment has been only 15%, and the causes were the administration of more drugs than indicated (48), the administration of an inappropriate drug (17), the use of fewer drugs than required (14) and the inappropriate timing of administration (14). In some cases they have overlapped at least two incorrect procedures. Conclusions: The acomplisment with our protocol was low. However, in most cases it was due to an excess of drugs, indicating that the anesthesiologists in our Hospital have a high concern for this problem. The assessment of PONV should be included routinely in the pre-anesthetic assessment, using updated protocols

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[Severe perioperative thrombocytosis in a patient undergoing lung resection]. / Trombocitosis severa perioperatoria en un caso de resección pulmonar.

Severe thrombocytosis (platelet count > 1,000,000 microL(-1)) is a rare, usually reactive, process and few perioperative cases have been reported. We describe the management of a patient who developed severe reactive thrombocytosis in the preoperative period before undergoing segmentectomy to remove a malignant nodule. A platelet count of 2,086,000 microL(-1) was observed during the first few days after surgery; we therefore started antiplatelet therapy to prevent thrombotic complications. We analyze the factors that might have contributed to the development of severe thrombocytosis in this case and discuss the different treatment options that may affect perioperative outcomes in these patients.

Trombocitosis severa perioperatoria en un caso de resección pulmonar / Severe perioperative thrombocytosis in a patient undergoing lung resection

La trombocitosis severa, definida como una cifra deplaquetas superior a 1.000.000 mL-1, es una entidad infrecuenteque generalmente tiene un origen reactivo, y de lacual se han publicado pocos casos relacionados con elperiodo perioperatorio. Describimos el manejo de unpaciente intervenido de resección pulmonar segmentariapor nódulo maligno que ya en el preoperatorio presentabatrombocitosis reactiva severa. En los primeros díastras la intervención alcanzó un máximo de 2.086.000 plaquetasmL-1, por lo que iniciamos tratamiento antiagregantepara intentar prevenir complicaciones trombóticas.Se analizan las causas que pudieron contribuir aldesarrollo de esta trombocitosis severa y las distintasopciones terapéuticas que pueden tener influencia en elresultado perioperatorio de los pacientes afectos de estaentidad clínica(AU)

Severe thrombocytosis (platelet count >1 000 000 mL-1)is a rare, usually reactive, process and few perioperativecases have been reported. We describe the managementof a patient who developed severe reactivethrombocytosis in the preoperative period beforeundergoing segmentectomy to remove a malignantnodule. A platelet count of 2 086 000 mL-1 was observedduring the first few days after surgery; we thereforestarted antiplatelet therapy to prevent thromboticcomplications. We analyze the factors that might havecontributed to the development of severe thrombocytosisin this case and discuss the different treatment optionsthat may affect perioperative outcomes in these patients(AU)

Comentarios a "Sleepless in the operating theater: chronic fatigue and Burnout in anesthesia" / Comment "Sleepless in the operating theater: chronic fatigue and Burnout in anesthesia"

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Réplica a la carta al director "Sobre el síndrome de quemarse por el trabajo en anestesiología" / Comments on the letter to the editor "On burnout syndrome in anesthesiology"

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Utilidad y fiabilidad de los laringoscopios desechables / Usefulness and reliability of disposable laryngoscopes

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[Obstetric analgesia for a patient with a history of 3 previous operations on the spine]. / Analgesia obstétrica en una paciente con tres cirugías previas de columna.

A history of spinal surgery is not currently considered a contraindication for regional obstetric analgesia. However, there are highly complex cases in which choosing the best analgesic technique presents genuine problems. We report the case of a woman in labor at full-term with 4-cm dilatation of the cervix who had undergone 3 operations for scoliosis and a herniated disk treated by T5-L4 and L4-sacral arthrodesis, laminectomy, and diskectomy. No previous anesthetic plan was in place, so we chose intravenous patient-controlled analgesia for labor and vaginal delivery and spinal anesthesia for a cesarean delivery. However, general anesthesia became necessary because it was impossible to reach the dura mater. The literature was reviewed to assess alternative forms of obstetric analgesia for patients who have undergone scoliosis surgery.