Sevoflurano tópico para alivio inmediato y duradero de agitación postoperatoria extremadamente intensa causada por irritación uretral / Topical sevoflurane for immediate and long-lasting relief of extremely severe postoperative agitation caused by urethral irritation

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Manejo multimodal conservador de material de osteosíntesis ante herida quirúrgica con sobreinfección polimicrobiana, incluyendo Staphylococcus aureus resistente a meticilina. Caso clínico / Conservative multimodal management of osteosynthesis material in surgical wounds with polymicrobial superinfection, including methicillin-resistant Staphylococcus aureus. Clinical case

El tratamiento retentivo de material protésico sobreinfectado por gérmenes resistentes es un desafío, especialmente cuando el agente causal es Staphylococcus aureus resistente a meticilina. Presentamos el manejo conservador satisfactorio de material de osteosíntesis implantado por fractura de tobillo a un paciente añoso y que sufrió sobreinfección por el citado microorganismo, en el que el tratamiento antimicrobiano consistió en la combinación de antibioterapia sistémica guiada por antibiograma (tras un primer ciclo empírico ineficaz), junto a irrigaciones tópicas de sevoflurano, aplicación de crema de sulfadiazina de plata y posteriormente cobertura del defecto cutáneo con terapia de presión negativa. Destacamos el novedoso papel del sevoflurano como analgésico y como antimicrobiano tópico (sumado a la crema de sulfadiazina de plata) en la evolución favorable de la herida, especialmente en el período en el que la antibioterapia empírica era ineficaz y todavía no se había comenzado con terapia de presión negativa

Retentive treatment of prosthetic material superinfected by resistant microorganisms is a challenge, especially when the causative agent is a methicillin-resistant Staphylococcus aureus. We present the successful conservative management of osteosynthesis material implanted due to ankle fracture in an elderly patient who suffered superinfection by the aforementioned microorganism, in which the antimicrobial treatment consisted of the combination of antibiotic-guided systemic antibiotics (after a first ineffective empirical cycle), together with topical irrigations of sevoflurane, applications of silver sulfadiazine cream, and subsequently coverage of the skin defect with negative pressure therapy. We highlight the novel role of sevoflurane as an analgesic and as a topical antimicrobial agent (in addition to silver sulfadiazine) in the favourable evolution of the wound, especially in the period in which the empirical antibiotic therapy was ineffective and negative pressure therapy had not yet been applied

Conservative multimodal management of osteosynthesis material in surgical wounds with polymicrobial superinfection, including methicillin-resistant Staphylococcus aureus. Clinical case. / Manejo multimodal conservador de material de osteosíntesis ante herida quirúrgica con sobreinfección polimicrobiana, incluyendo Staphylococcus aureus resistente a meticilina. Caso clínico.

Retentive treatment of prosthetic material superinfected by resistant microorganisms is a challenge, especially when the causative agent is a methicillin-resistant Staphylococcus aureus. We present the successful conservative management of osteosynthesis material implanted due to ankle fracture in an elderly patient who suffered superinfection by the aforementioned microorganism, in which the antimicrobial treatment consisted of the combination of antibiotic-guided systemic antibiotics (after a first ineffective empirical cycle), together with topical irrigations of sevoflurane, applications of silver sulfadiazine cream, and subsequently coverage of the skin defect with negative pressure therapy. We highlight the novel role of sevoflurane as an analgesic and as a topical antimicrobial agent (in addition to silver sulfadiazine) in the favourable evolution of the wound, especially in the period in which the empirical antibiotic therapy was ineffective and negative pressure therapy had not yet been applied.

Eficacia analgésica del sevoflurano tópico en heridas / Analgesic efficacy of topical sevoflurane on wounds

El sevoflurano es un anestésico derivado halogenado del éter dietílico que se presenta como un líquido volátil. Es ampliamente utilizado por vía inhalatoria para la inducción y el mantenimiento de la anestesia general, pues su perfil de seguridad es muy bueno. Además de su acción hipnótica, diversas experiencias preclínicas muestran que el sevoflurano y otros derivados halogenados del éter producen un efecto analgésico/anestésico importante cuando son administrados en su formulación líquida directamente al sistema nervioso central, concretamente a la médula espinal, pero clásicamente se les considera carentes de efecto analgésico a nivel periférico. Sin embargo, en los últimos años se están comunicando experiencias clínicas en las que el sevoflurano produce un efecto analgésico importante sobre heridas dolorosas cuando es irrigado en su presentación líquida sobre el lecho de dichas heridas. Este efecto analgésico se caracteriza por instaurarse en escasos minutos, ser lo bastante intenso como para permitir el desbridamiento mecánico de las heridas, y extenderse por espacio de varias horas. Referido a efectos adversos, hasta ahora no ha sido comunicado ninguno a nivel sistémico, y el efecto local más frecuentemente referido por los pacientes es prurito leve y transitorio. Hasta ahora las comunicaciones clínicas se limitan a casos clínicos aislados y series de casos, y es obvio que se precisa la realización de los pertinentes ensayos clínicos para establecer adecuadamente su papel en el tratamiento analgésico de las heridas dolorosas. Pero mientras estos ensayos clínicos se realizan, el empleo fuera de indicación de sevoflurano irrigado tópicamente sobre el lecho de heridas dolorosas es una alternativa analgésica de rescate a tener en cuenta en aquellas heridas de dolor refractario a los tratamientos habituales

Sevoflurane is a halogenated anesthetic derived from diethyl ether, which is presented as a volatile liquid. Administered by inhalation, it is widely used for the induction and maintenance of general anesthesia, as its safety profile is very good. In addition to their hypnotic action, various preclinical experiences show that sevoflurane and other halogenated ether derivatives produce an important analgesic/ anesthetic effect when administered in their liquid form directly to the central nervous system, specifically to the spinal cord. However, it is classically thought they lack analgesic effect at peripheral level. However, clinical experiences in which sevoflurane had an important analgesic effect on painful wounds when it was irrigated in its liquid presentation on the bed of such wounds have been reported in recent years. Such analgesic effect is characterized by being established in a few minutes, be intense enough to allow sharp debridement of the wounds, and last for several hours. Concerning adverse effects, it has been reported so far no case of systemic adverse events; only local adverse effects have been reported, the most frequently reported one being mild and transitory itching. For the moment, clinical communications are limited to isolated clinical cases and case series of patients; obviously, relevant clinical trials are required to adequately establish the role of topical sevoflurane in the analgesic treatment of painful wounds. But while conducting these clinical trials, the off-label use of topical sevoflurane irrigated on the bed of painful wounds may be an alternative option for the analgesic treatment of wounds with pain refractory to usual treatments

Antibacterial effect of sevoflurane and isoflurane.

OBJECTIVE: Multidrug resistant bacteria are increasing worldwide and therapeutic options are limited. Some anaesthetics have shown antibacterial activity before. In this study, we have investigated the antibacterial effect of the halogenated anaesthetic agents sevoflurane and isoflurane against a range of resistant pathogens. METHODS: Two experiments were conducted. In the first, bacterial suspensions of both ATCC and resistant strains of Staphylococcus aureus, Escherichia coli and Pseudomonas aeruginosa were exposed to liquid sevoflurane and isoflurane during 15, 30 and 60 minutes. In the second experiment clinical resistant strains of E. coli, Klebsiella pneumoniae, Enterobacter cloacae, P. aeruginosa, Acinetobacter baumannii, S. aureus, and Enterococcus faecium were studied. Previously inoculated agar plates were irrigated with the halogenated anaesthetic agents and these were left to evaporate before the plates were incubated. In both experiments colony forming units were counted in resultant plates. RESULTS: In the first experiment, isoflurane showed faster and higher antimicrobial effect than sevoflurane against all the strains studied. Gram-negative organisms were more susceptible. In the second experiment, E. faecium was found to be resistant to both halogenated agents; only isoflurane showed statistically significant activity against the rest of the strains studied. CONCLUSIONS: Both halogenated agents, but particularly isoflurane, showed in vitro antibacterial activity against pathogens resistant to conventional antibiotics. Further investigation is required to determine whether or not they also exhibit this property in vivo. This might then allow these agents to be considered as rescue treatment against multidrug resistant pathogens, including a topical use in infected wounds.

Toxicidad neurológica severa por bupivacaína durante analgesia para el trabajo de parto / Severe neurologic toxicity induced by bupivacaine for labor analgesia

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Escasa notificación de las dosis de los antiinfecciosos de uso sistémico en los casos clínicos comunicados a la Revista Española de Anestesiología y Reanimación / Doses of anti-infectives for systemic use are scarcely notified in clinical cases reported to the Revista Española de Anestesiología y Reanimación

Objetivo: Describir las frecuencias de notificación de las dosis de los antiinfecciosos de uso sistémico en los casos clínicos comunicados a la Revista Española de Anestesiología y Reanimación . Material y método: Revisión de los casos clínicos individualizados aparecidos en las secciones «Caso clínico» o «Carta al Director» de la citada revista en los años 2010 a 2012 e identificación de los principios activos y sus pautas terapéuticas aparecidos en dichas comunicaciones, siendo la notificación de la dosis la variable principal. Los principios activos han sido clasificados según el Sistema de Clasificación Anatómica Terapéutica Química. Resultados: Fueron identificados 182 pacientes en 167 comunicaciones, en las que 1.135 principios activos fueron citados 1.317 veces; de ellas, 73 citaciones (5,6%) correspondieron a principios activos del grupo J (Antiinfecciosos para uso sistémico), divididas en profilaxis perioperatoria (n = 15) y tratamiento activo (n = 58). El porcentaje de notificación de las dosis fue pequeño para el conjunto del grupo J (27,4%), pero especialmente considerando el empleo como tratamiento activo (17,2%) frente al empleo de antiinfecciosos como profilaxis perioperatoria (66,7%); este último valor fue similar al hallado para los porcentajes de notificación de las dosis de algunos fármacos considerados anestésicos clásicos (fentanilo: 86,6%; remifentanilo: 70,5%; sevoflurano: 78%; propofol: 79%; rocuronio:79,6%; cisatracurio: 68,4%) e incluso de los empleados para la profilaxis emética (ondansetrón: 92,3%; dexametasona: 84,6%). Conclusiones: Las comunicaciones de casos clínicos son susceptibles de mejora incluyendo la descripción de las pautas terapéuticas de los antiinfecciosos empleados (AU)

Objective: To describe the frequency of dose notification of antiinfectives for systemic use in clinical cases published in Revista Española de Anestesiología y Reanimación. Material and method: Review of individualized clinical cases published in the sections «Clinical case» or «Letter to the Editor» of the above mentioned journal from year 2010 to 2012, and identification of the drugs and their therapeutic regimens cited in such publications, being dose notification the main variable. Drugs have been classified according to the Anatomical Therapeutic Chemical Classification System. Results: One thousand one hundred and thirty-five drugs cited 1,317 times were identified in 167 articles describing the clinical pictures of 182 patients, 73 of the citations (5.6%) regarding to drugs belonging to group J (Antiinfectives for systemic use) which were divided into perioperative prophylaxis (n=15) and active treatment (n=58). Doses were scarcely notified for group J drugs as a whole (27.4%), but especially for active treatment (17.2%) compared to perioperative prophylaxis (66.7%), percentage which was similar to those more classical anesthetic drugs (fentanyl: 86.6%; remifentanil: 70.5%; sevoflurane: 78%; propofol: 79%; rocuronium:79.6%; cisatracurium: 68.4%) or even for antiemetics (ondansetron: 92.3%; dexamethasone: 84.6%). Conclusions: Quality of case reports could be improved by including dose notification for antiinfective agents

[Doses of anti-infectives for systemic use are scarcely notified in clinical cases reported to the Revista Española de Anestesiología y Reanimación]. / Escasa notificación de las dosis de los antiinfecciosos de uso sistémico en los casos clínicos comunicados a la Revista Española de Anestesiología y Reanimación.

OBJECTIVE: To describe the frequency of dose notification of antiinfectives for systemic use in clinical cases published in Revista Española de Anestesiología y Reanimación. MATERIAL AND METHOD: Review of individualized clinical cases published in the sections «Clinical case¼ or «Letter to the Editor¼ of the above mentioned journal from year 2010 to 2012, and identification of the drugs and their therapeutic regimens cited in such publications, being dose notification the main variable. Drugs have been classified according to the Anatomical Therapeutic Chemical Classification System. RESULTS: One thousand one hundred and thirty-five drugs cited 1,317 times were identified in 167 articles describing the clinical pictures of 182 patients, 73 of the citations (5.6%) regarding to drugs belonging to group J (Antiinfectives for systemic use) which were divided into perioperative prophylaxis (n=15) and active treatment (n=58). Doses were scarcely notified for group J drugs as a whole (27.4%), but especially for active treatment (17.2%) compared to perioperative prophylaxis (66.7%), percentage which was similar to those more classical anesthetic drugs (fentanyl: 86.6%; remifentanil: 70.5%; sevoflurane: 78%; propofol: 79%; rocuronium:79.6%; cisatracurium: 68.4%) or even for antiemetics (ondansetron: 92.3%; dexamethasone: 84.6%). CONCLUSIONS: Quality of case reports could be improved by including dose notification for antiinfective agents.

Bacteriemia por Salmonella enteritidis como debut clínico de síndrome de inmunodeficiencia adquirida / Salmonella enteritidis bacteraemia as clinical onset of acquired immune deficiency syndrome

Presentamos un caso de una paciente de 38 años, que acudió a urgencias por cuadro de insuficiencia respiratoria aguda severa y fue ingresada en la Unidad de Cuidados Críticos con la sospecha diagnóstica inicial de neumonía adquirida en la comunidad producida por gérmenes atípicos, que se complicó con un síndrome de distrés respiratorio agudo. Este pudo ser tratado con ventilación mecánica no invasiva. A las 48h de su ingreso se informó del crecimiento de bacilos gramnegativos en los hemocultivos, identificados posteriormente como Salmonella enteritidis. Esta información, unida a la linfopenia que presentaba la paciente, sugería un estado de inmunodepresión, por lo que se realizaron pruebas serológicas que resultaron positivas para VIH. Fueron instaurados tratamientos antimicrobianos basados en los hallazgos microbiológicos y la evolución clínica de la paciente fue favorable(AU)

The case is presented of a 38 year-old patient who was admitted in the Emergency Department due to a severe acute respiratory failure and who was transferred to the Critical Care Unit with a suspected initial diagnosis of community acquired pneumonia caused by an atypical microorganism, which was complicated with an acute respiratory distress syndrome. This was able to be treated with non-invasive mechanical ventilation. At 48hours after admission, the growth of Gram negative bacilli in the blood culture was reported, which was subsequently identified as Salmonella enteritidis. This information, along with the lymphopenia suffered by the patient, suggested an immunodepressed state, thus serological tests were performed which showed positive for HIV. Antibiotic treatment was started based on the microbiological findings, with a favourable clinical outcome for the patient(AU)

[Salmonella enteritidis bacteraemia as clinical onset of acquired immune deficiency syndrome]. / Bacteriemia por Salmonella enteritidis como debut clínico de síndrome de inmunodeficiencia adquirida.

The case is presented of a 38 year-old patient who was admitted in the Emergency Department due to a severe acute respiratory failure and who was transferred to the Critical Care Unit with a suspected initial diagnosis of community acquired pneumonia caused by an atypical microorganism, which was complicated with an acute respiratory distress syndrome. This was able to be treated with non-invasive mechanical ventilation. At 48 hours after admission, the growth of Gram negative bacilli in the blood culture was reported, which was subsequently identified as Salmonella enteritidis. This information, along with the lymphopenia suffered by the patient, suggested an immunodepressed state, thus serological tests were performed which showed positive for HIV. Antibiotic treatment was started based on the microbiological findings, with a favourable clinical outcome for the patient.

Evaluación de la lesión neurológica y complicaciones médicas en una cohorte histórica de pacientes con lesión medular aguda traumática tras tratamiento con megadosis de metilprednisolona / Assessment of neurologic function and complications in a retrospective cohort of patients with acute spinal cord injury due to trauma treated with large-dose methylprednisolone

Introducción: El uso de metilprednisolona para el tratamiento de lesiones traumáticas de médula espinal se utilizó para mejorar la recuperación neurológica en The National Acute Spinal Corel Injury Studies-NASClS. La controversia sobre este protocolo, llevó a investigaciones posteriores y un informe de 2002, lo considera de una evidencia insuficiente para ser considerado un estándar de tratamiento. Nuestro objetivo fue valorar retrospectivamente su aplicación en una cohorte de pacientes con trauma medular. Métodos: Estudio retrospectivo de una cohorte de pacientes ingresados en una unidad de críticos entre 1997-2007 con diagnóstico de lesión de médula espinal traumática. Los pacientes fueron agrupados de acuerdo con el tratamiento médico recibido (grupo metilprednisolona frente a grupo no-metilprednisolona). Se evaluó la variación de la función neurológica mediante la escala ASIA al ingreso y alta, así como la aparición de complicaciones médicas en función del tratamiento con o sin metilprednisobna. Se realizó estudio estadístico mediante regresión múltiple de Cox para el tratamiento o no con el fármaco. Resultados: No hubo diferencias entre grupos de tratamiento en la evolución neurológica al alta de la unidad de cuidados críticos (OR = 1,57, IC 95%: 0,69 a 3,54). El grupo metilprednisolona presentó un aumento de complicaciones médicas como hiperglucemia (OR = 5,67, IC 95%: 1,85-17,31) y hemorragia gastrointestinal (OR = 19,16, IC 95%: 1,64-223,30) en comparación con el grupo no tratado con metalprednisolona. Conclusiones: En este estudio retrospectivo, el uso de metilprednisolona en pacientes con lesión aguda de la médula espinal no se asocia con una mejoría en el resultado de la función neurológica al alta en la unidad de críticos y un mayor riesgo de complicaciones metabólicas (AU)

BACKGROUND AND OBJECTIVE: Methylprednisolone was used to improve neurologic recovery from spinal cord injury in the National Acute Spinal Cord Injury Studies (NASCIS). Debate over this use led to further research and a 2002 report stating that there was insufficient evidence to support this application as a standard therapy. Our aim was to retrospectively assess this application in a cohort of patients with spinal cord injury. METHODS: Retrospective cohort study of patients admitted to the intensive care unit (ICU) between 1997 and 2007 with a diagnosis of spinal cord injury due to trauma. The patients were grouped according to medical treatment received into a methylprednisolone group and a no-methylprednisolone group. We assessed change in neurologic function on the impairment scale of the American Spinal Injury Association on ICU admission and on discharge. We also recorded medical complications in each group. Cox multiple regression analysis was used to analyze differences between treatments. RESULTS: No significant differences were detected in neurologic outcome on discharge from the ICU (odds ratio [OR], 1.57; 95% confidence interval [CI], 0.69-3.54). The methylprednisolone-treated patients had more medical complications such as hyperglycemia (OR, 5.67; 95% CI, 1.85-17.31) or gastrointestinal bleeding (OR, 19.16; 95% CI, 1.64-223.30) than the patients who did not receive methylprednisolone. CONCLUSIONS: In this retrospective study, methylprednisolone was unrelated to improvement in neurologic outcome after acute spinal cord injury on ICU discharge although the patients treated with this drug were at greater risk of metabolic complications (AU)

Reversión del bloqueo neuromuscular con sugammadex en un paciente con miastenia gravis intervenido de timectomía / Sugammadex reversal of neuromuscular blockade for thymectomy in a patient with myasthenia gravis

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[Assessment of neurologic function and complications in a retrospective cohort of patients with acute spinal cord injury due to trauma treated with large-dose methylprednisolone]. / Evaluación de la lesión neurológica y complicaciones médicas en una cohorte histórica de pacientes con lesión medular aguda traumática tras tratamiento con megadosis de metilprednisolona.

BACKGROUND AND OBJECTIVE: Methylprednisolone was used to improve neurologic recovery from spinal cord injury in the National Acute Spinal Cord Injury Studies (NASCIS). Debate over this use led to further research and a 2002 report stating that there was insufficient evidence to support this application as a standard therapy. Our aim was to retrospectively assess this application in a cohort of patients with spinal cord injury. METHODS: Retrospective cohort study of patients admitted to the intensive care unit (ICU) between 1997 and 2007 with a diagnosis of spinal cord injury due to trauma. The patients were grouped according to medical treatment received into a methylprednisolone group and a no-methylprednisolone group. We assessed change in neurologic function on the impairment scale of the American Spinal Injury Association on ICU admission and on discharge. We also recorded medical complications in each group. Cox multiple regression analysis was used to analyze differences between treatments. RESULTS: No significant differences were detected in neurologic outcome on discharge from the ICU (odds ratio [OR], 1.57; 95% confidence interval [CI], 0.69-3.54). The methylprednisolone-treated patients had more medical complications such as hyperglycemia (OR, 5.67; 95% CI, 1.85-17.31) or gastrointestinal bleeding (OR, 19.16; 95% CI, 1.64-223.30) than the patients who did not receive methylprednisolone. CONCLUSIONS: In this retrospective study, methylprednisolone was unrelated to improvement in neurologic outcome after acute spinal cord injury on ICU discharge although the patients treated with this drug were at greater risk of metabolic complications.

[Pulmonary torsion complicating lobectomy: report of 2 cases]. / Torsión pulmonar como complicación de una lobectomía pulmonar, descripción de dos casos.

We report 2 cases of pulmonary torsion discovered during the early postoperative recovery of patients who had undergone lobectomy. Early diagnosis, based on chest radiography and confirmed by computed tomography, meant we were able to avoid major surgical resection and the development of further complications. Pulmonary torsion is a rare but potentially serious abnormality. Prompt diagnosis is the key to preventing tissue injury and complications such as necrotizing pneumonitis, thromboembolic disease, or septic shock. Among the diagnostic tests that can be carried out if there is good reason to suspect torsion, we emphasize simple chest radiography and fiberoptic bronchoscopy, supported by computed tomography or arteriography, even though a firm diagnosis requires surgical exploration of the affected lung. Definitive treatments range from reversing the torsion and securing the lung to resecting the lung if the parenchymal tissue has been fully compromised.

Torsión pulmonar como complicación de una lobectomía pulmonar, descripción de dos casos / Pulmonary torsion complicating lobectomy: report of 2 cases

Descripción de dos casos de torsión pulmonar enpacientes intervenidos de lobectomía por neoplasia pulmonar.Se muestran dos pacientes que sufrieron complicaciónde torsión de lóbulo pulmonar tras realizarselobectomía pulmonar aparecida en el postoperatorioinmediato. Se realizó el diagnóstico precoz mediante unaradiografía del tórax y la confirmación mediante unTAC, que indicó la toracotomía la cual evitó mayorresección quirúrgica y aparición de otras complicaciones.La torsión pulmonar es una alteración infrecuentepero de potencial gravedad. El diagnóstico precoz es devital importancia para evitar el compromiso tisular yprevenir complicaciones como neumonitis necrotizante,enfermedad tromboembólica o shock séptico. Entre laspruebas diagnósticas que pueden llevar a la alta sospechadiagnóstica destacamos la radiología simple de tóraxy fibrobroncoscopia, apoyadas por la tomografía axial ola arteriografía, aunque el diagnóstico definitivo es laexploración quirúrgica del parénquima afecto. El tratamientodefinitivo abarca desde la simple detorsión y fijacióndel pulmón, hasta resección pulmonar o neumonectomíasi el compromiso tisular es completo(AU)

We report 2 cases of pulmonary torsion discoveredduring the early postoperative recovery of patients whohad undergone lobectomy. Early diagnosis, based onchest radiography and confirmed by computedtomography, meant we were able to avoid major surgicalresection and the development of further complications.Pulmonary torsion is a rare but potentially seriousabnormality. Prompt diagnosis is the key to preventingtissue injury and complications such as necrotizingpneumonitis, thromboembolic disease, or septic shock.Among the diagnostic tests that can be carried out ifthere is good reason to suspect torsion, we emphasizesimple chest radiography and fiberoptic bronchoscopy,supported by computed tomography or arteriography,even though a firm diagnosis requires surgicalexploration of the affected lung. Definitive treatmentsrange from reversing the torsion and securing the lungto resecting the lung if the parenchymal tissue has beenfully compromised(AU)