Encuesta a los estudiantes tras diez años de enseñanza semipresencial continua de ecocardiografía / Student survey after ten years of continuous blended teaching of echocardiocraphy

Objetivo: Analizar el impacto durante 10 años de nuestro programa de enseñanza semipresencial en ecocardiografía. Métodos y resultados: Se envió una encuesta retrospectiva a todos los médicos especialistas que se graduaron en el programa, desarrollado en la Universidad de Chile, con un equipo docente de Chile y España. Un total de 140 de entre 210 estudiantes, graduados en nuestro programa de 2011 a 2020, respondieron voluntariamente a la encuesta. Entre quienes respondieron, el 53,57% fueron anestesiólogos y el 26,42% intensivistas. Más del 85% de los respondedores indicó que el periodo de enseñanza online cumplió sus expectativas, y el 70,2% indicó que la experiencia práctica cumplió sus objetivos. En un análisis retrospectivo utilizando datos autorreportados, se observaron incrementos significativos en cuanto a frecuencia del uso de ecocardiografía transtorácica y transesofágica del 24,29% al 40,71% y del 13,57% al 27,86%, respectivamente, tras el programa, en comparación con el periodo anterior al mismo. Se usó la ecocardiografía principalmente en el periodo perioperatorio (56,7%) y en cuidados intensivos (32,3%), mientras que solo el 11% de los respondedores la utilizó en unidades de urgencia. Además, el 92,4% de los respondedores reveló que la información aprendida durante el programa había sido muy útil para su práctica posterior. Conclusiones: A lo largo de una década de uso, el programa de aprendizaje semipresencial de ecocardiografía fue evaluado satisfactoriamente por los especialistas que se graduaron en el programa, siendo asociado a un incremento significativo del uso de ecocardiografía en el periodo perioperatorio y en cuidados intensivos. El principal desafío es establecer un periodo más prolongado de práctica, y lograr un mayor alcance en la medicina de urgencias.(AU)

Objective:To analyse the impact of 10 years of blended echocardiography teaching. Methods and results: A questionnaire was emailed to all medical doctors who graduated from the blended learning diploma in echocardiography developed by the University of Chile and taught by a team from Chile and Spain. One hundred and forty of the 210 students who graduated from the program between 2011 and 2020 completed the questionnaire: 53.57% were anaesthesiologists, and 26.42% were intensivists. More than 85% of respondents indicated that the online teaching met their expectations, and 70.2% indicated that the hands-on practice fulfilled the stated objectives. In a retrospective analysis using self-reported data, graduates reported that their use of transthoracic and transoesophageal echocardiography has increased from 24.29% to 40.71% and from 13.57% to 27.86%, repectively, after the programme compared to before the programme. They used echocardiography mainly in the perioperative period (56.7%) and during intensive care (32.3%), while only 11% of respondents used it in emergency care units. Nearly all (92.4%) respondents reported that the skills learned was very useful in their professional practice. Conclusions: Ten years after its launch, the blended learning diploma in echocardiography was well rated by graduate specialists, and is associated with a significant increase in the use of echocardiography in the perioperative period and during intensive care. The main challenges are to establish a longer period of practice and achieve greater implantation in emergency medicine.(AU)

Prognostic factors for deterioration of quality of life one year after admission to ICU for severe SARS-COV2 infection.

PURPOSE: Patients with COVID-19 present long-term symptoms collectively known as "post-COVID syndrome". Long-term manifestations are more frequent in patients requiring admission to Intensive Care Units (ICU), but the risk factors for their development are still unknown. This study explores the quality of life of patients with severe COVID-19 one year after their discharge from ICU. METHODS: Prospective observational study including 106 patients admitted to the ICU of a tertiary care hospital between March and August 2020. We analysed quality of life using the EuroQol-5D index (EQ-5D). We evaluated as possible risk factors associated with a worse value of the EQ-5D index the medical record, the clinical situation at hospital admission, the clinical situation at ICU admission and evolution in the ICU. As a secondary objective, we explored the presence of other frequent symptoms. RESULTS: Most patients (55.4%) reported that their quality of life worsened one year after admission. The mean perceived health status, on the EQ-VAS scale (0-100), was 70.4, with a median of 70 (RI 60-90). The median EQ-5D index was 0.91 (RI 0.76-1). The factors independently related to lower quality of life were female sex and duration of mechanical ventilation. Almost all (91%) of the patients had sequelae one year after discharge from the ICU. The most frequent manifestations were neuropsychiatric (71%). CONCLUSIONS: Critically ill COVID-19 patients worsen their quality of life more than one year after discharge. Female sex and duration of mechanical ventilation predict a lower quality of life assessed by the EQ-5D index.

Estudio de cohortes para evaluar la prevalencia de QT prolongado y arritmias en pacientes críticos durante la primera fase de la pandemia por COVID-19 / Cohort study to assess the prevalence of prolonged QT and arrhythmias in critically ill patients during the early phase of the COVID-19 pandemic

Antecedentes y objetivo: Los pacientes con infección por SARS-CoV-2 pueden presentar afectación cardiovascular, incluyendo miocarditis, arritmias y prolongación del intervalo QT. Nuestro objetivo fue evaluar el impacto de la COVID-19 y su tratamiento en la repolarización ventricular y el desarrollo de arritmias en pacientes críticos. Material y métodos: Estudio de cohortes retrospectivo de pacientes críticos con infección confirmada por SARS-CoV-2 durante un periodo de 3meses. Se registraron los datos clínicos relevantes y el tratamiento específico administrado para la COVID-19. Se consideró QTc prolongado cuando medía ≥460ms en mujeres y ≥450ms en hombres. Se registró la incidencia y el tipo de arritmias durante el mismo periodo. Resultados: Se evaluaron 77 pacientes con una edad media de 62±13años: 20 mujeres y 57 hombres. El 60% de los pacientes eran hipertensos, el 52% presentaban un IMC>30 y el 70% desarrollaron fracaso renal agudo durante el ingreso. El 56% de los pacientes presentaron prolongación del QTc. El 44% presentaron algún tipo de arritmia durante su estancia en la UCI, siendo en el 21% arritmias auriculares. La mortalidad global fue del 53%, sin diferencias entre los pacientes con o sin QTc prolongado. Conclusiones: En nuestra serie, una elevada proporción de pacientes críticos con COVID-19 han presentado QTc prolongado y arritmias. Los factores implicados se han relacionado con la elevación de biomarcadores cardiacos, la propia afectación miocárdica del virus y la medicación concomitante recibida en la UCI.(AU)

Introduction and objective: Patients with SARS-CoV-2 infection may present cardiovascular involvement including myocarditis, arrhythmias and QT interval prolongation. Our objective was to evaluate the impact of COVID-19 and its treatment on ventricular repolarization and development of arrhythmias in critically ill patients. Material and methods: Retrospective cohort study of critically ill COVID-19 patients during a 3-month period in whom at least one ECG was available. Relevant clinical data and specific treatment administered for COVID-19 were recorded. Prolonged QTc was considered prolonged when it measured ≥460ms in women and ≥450ms in men. The incidence and type of arrhythmias during the same period were recorded. Results: A total of 77 patients with a mean age of 62±13years, 20 women and 57 men, were evaluated. Sixty percent of the patients were hypertensive, 52% had a BMI>30, and 70% developed acute renal failure during admission. Some 56% of the patients presented QTc prolongation. Forty-four percent presented some type of arrhythmia during their stay in the ICU, 21% of which were atrial arrhythmias. Overall mortality was 53%, with no differences between patients with or without prolonged QTc. Conclusions: In our series, a high proportion of critical patients with COVID-19 presented prolonged QTc and arrhythmias. The factors involved have been related to the elevation of cardiac biomarkers, the myocardial involvement of the virus and concomitant medication received in the ICU.(AU)

Cohort study to assess the prevalence of prolonged QT and arrhythmias in critically ill patients during the early phase of the COVID-19 pandemic.

INTRODUCTION: Patients with SARS-CoV-2 infection may present cardiovascular involvement including myocarditis, arrhythmias and QT interval prolongation. Our objective was to evaluate the impact of COVID-19 and its treatment on ventricular repolarization and development of arrhythmias in critically ill patients. METHODS: Retrospective cohort study of critically ill COVID-19 patients during a 3-month period in whom at least one ECG was available. Relevant clinical data and specific treatment administered for COVID-19 were recorded. Prolonged QTc was considered prolonged when it measured ≥ 460 ms in women and ≥450 ms in men. The incidence and type of arrhythmias during the same period were recorded. RESULTS: A total of 77 patients with a mean age of 62 ±â€¯13 years, 20 women and 57 men, were evaluated. Sixty percent of the patients were hypertensive, 52% had a BMI > 30, and 70% developed acute renal failure during admission. Some 56% of the patients presented QTc prolongation. Forty-four percent presented some type of arrhythmia during their stay in the ICU, 21% of which were atrial arrhythmias. Overall mortality was 53%, with no differences between patients with or without prolonged QTc. CONCLUSIONS: In our series, a high proportion of critical patients with COVID-19 presented prolonged QTc and arrhythmias. The factors involved have been related to the elevation of cardiac biomarkers, the myocardial involvement of the virus and concomitant medication received in the ICU.

Ecocardiografía transesofágica intraoperatoria en cirugía cardiovascular. Documento de consenso de la Sociedad Española de Anestesiología y Reanimación (SEDAR) y Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE) / Intraoperative transesophageal echocardiography in cardiovascular surgery. Consensus document from the Spanish Society of Anesthesia and Critical Care (SEDAR) and the Spanish Society of Endovascular and Cardiovascular Surgery (SECCE)

La ecocardiografía transesfofágica es una técnica semiinvasiva que permite una evaluación de la morfología y función cardiaca a tiempo real y que constituye, a día de hoy, un estándar de calidad en las intervenciones de cirugía cardiovascular. Se ha convertido en una herramienta fundamental tanto de monitorización como de diagnóstico en el perioperatorio que permite la correcta planificación quirúrgica y manejo farmacológico dirigido. El objetivo de este documento es dar respuesta de forma consensuada y avalada por la evidencia científica de cuándo y cómo debe hacerse la ecocardiografía transesfofágica intraoperatoria en cirugía cardiovascular, qué aplicaciones tiene en el intraoperatorio, quién debe realizarla y cómo debe transmitirse la información obtenida durante el estudio. Los autores han hecho una revisión sistemática de las guías internacionales, artículos de revisión y ensayos clínicos para dar respuesta a estas preguntas

Transesophageal echocardiography is a semi-invasive technique that allows an evaluation of cardiac morphology and function in real time and it is a quality standard in cardiovascular surgery. It has become a fundamental tool for both monitoring and diagnosis in the intraoperative period that allows decide the correct surgical planning and pharmacological management. The goal of this document is to answer the questions of when and how the perioperative TEE should be performed in cardiovascular surgery, what are their applications in the intraoperative, who should perform it and how the information should be transmitted. The authors made a systematic review of international guidelines, review articles and clinical trials to answer by consensus to these questions

Intraoperative transesophageal echocardiography in cardiovascular surgery. Consensus document from the Spanish Society of Anesthesia and Critical Care (SEDAR) and the Spanish Society of Endovascular and Cardiovascular Surgery (SECCE). / Ecocardiografía transesofágica intraoperatoria en cirugía cardiovascular. Documento de consenso de la Sociedad Española de Anestesiología y Reanimación (SEDAR) y Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE).

Transesophageal echocardiography is a semi-invasive technique that allows an evaluation of cardiac morphology and function in real time and it is a quality standard in cardiovascular surgery. It has become a fundamental tool for both monitoring and diagnosis in the intraoperative period that allows decide the correct surgical planning and pharmacological management. The goal of this document is to answer the questions of when and how the perioperative TEE should be performed in cardiovascular surgery, what are their applications in the intraoperative, who should perform it and how the information should be transmitted. The authors made a systematic review of international guidelines, review articles and clinical trials to answer by consensus to these questions.

Perforación de la pared del ventrículo izquierdo por catéter de arteria pulmonar Swan-Ganz. A propósito de un caso / Perforation of the left ventricle wall due to the insertion of a pulmonary artery catheter. A case report

A pesar de la extendida y frecuente utilización del catéter de arteria pulmonar en nuestro medio para el manejo hemodinámico en pacientes críticos y particularmente en pacientes tras cirugía cardiaca, en la actualidad siguen planteándose dudas sobre la necesidad de su uso. Es preciso valorar el riesgo/beneficio de su colocación y tener en cuenta sus posibles complicaciones, que aun siendo poco frecuentes, pueden llegar a ser potencialmente graves. En este artículo exponemos una complicación muy poco frecuente ocurrida en nuestro centro sobre el uso del catéter de arteria pulmonar de la que no teníamos constancia hasta ahora. Se trata de una perforación del tabique interventricular y de la pared libre del ventrículo izquierdo debido a una acodadura firme del catéter de arteria pulmonar, que no fue sospechada ni diagnosticada salvo por la visión directa del corazón, tras la esternotomía, durante la cirugía cardiaca. La mejora de la seguridad del paciente implica reflexionar sobre el valor de los eventos adversos, de manera que al aumentar la conciencia de la situación y del mecanismo por el que se producen, pueda reducirse la probabilidad de repetición

Despite the widespread and frequent use in our setting of pulmonary artery catheters for haemodynamic management in critically ill patients, particularly after heart surgery, some experts continue to question the need for these devices. Clinicians need to weigh up the risks and benefits of pulmonary artery catheters placement and bear in mind the potential complications which, though rare, can be potentially fatal. We present a pulmonary artery catheters-related complication not hitherto described in the literature, involving perforation of the interventricular septum and left ventricular free wall caused by a kink in the pulmonary artery catheters that was not suspected, and only diagnosed by direct vision of the heart after pericardial opening. In the interest of patient safety, we must consider the impact of adverse events; improving our situational awareness and our understanding of the mechanisms behind such events can help reduce the likelihood of repetitions in the future

Perforation of the left ventricle wall due to the insertion of a pulmonary artery catheter. A case report. / Perforación de la pared del ventrículo izquierdo por catéter de arteria pulmonar Swan-Ganz. A propósito de un caso.

Despite the widespread and frequent use in our setting of pulmonary artery catheters for haemodynamic management in critically ill patients, particularly after heart surgery, some experts continue to question the need for these devices. Clinicians need to weigh up the risks and benefits of pulmonary artery catheters placement and bear in mind the potential complications which, though rare, can be potentially fatal. We present a pulmonary artery catheters-related complication not hitherto described in the literature, involving perforation of the interventricular septum and left ventricular free wall caused by a kink in the pulmonary artery catheters that was not suspected, and only diagnosed by direct vision of the heart after pericardial opening. In the interest of patient safety, we must consider the impact of adverse events; improving our situational awareness and our understanding of the mechanisms behind such events can help reduce the likelihood of repetitions in the future.

Routine aspiration of subglottic secretions after major heart surgery: impact on the incidence of ventilator-associated pneumonia.

Aspiration of subglottic secretions (ASS) is recommended in patients requiring mechanical ventilation for ≥48h. We assessed the impact of the introduction of ASS routinely in all patients after major heart surgery in an ecological study comparing ventilator-acquired pneumonia (VAP) incidence, days of mechanical ventilation, and cost of antimicrobial agents before and after the implementation of ASS. Before and after the intervention the results (per 1000 days) were: VAP incidence, 23.92 vs 16.46 (P = 0.04); cost of antimicrobials, €71,384 vs €63,446 (P = 0.002); and days of mechanical ventilation, 507.5 vs 377.5 (P = 0.009). From the moment of induction of anaesthesia all patients undergoing major heart surgery should routinely receive ASS.

Nasal carriage of S. aureus increases the risk of surgical site infection after major heart surgery.

Staphylococcus aureus is the main cause of surgical site infection (SSI) after major heart surgery (MHS), with the patient's endogenous flora as the principal source. However, the influence of nasal carriage of S. aureus on the development of SSI after MHS has not been established and Centers for Disease Control and Prevention guidelines do not make a recommendation for or against decolonisation. We performed a one-year observational study in which patients undergoing MHS were screened for nasal carriage of S. aureus before surgery. Cases of SSI were recorded and the risk factors of patients with and without SSI were analysed. During the study period, 357 patients were included in the protocol. Ninety-six patients (27%) were found to be nasal carriers of S. aureus and nine (9.4%) of these had meticillin-resistant (MRSA) strains. The overall incidence of SSI was 6.4%, with 4.2% for mediastinitis and 2.2% for superficial SSI. Nasal carriers of S. aureus had a significantly higher incidence of SSI than non-carriers (12.5% vs 5%, P=0.01). Among MRSA carriers, the incidence of SSI reached 33% (P<0.001). S. aureus was responsible for 64% of SSIs. Multivariate analysis showed that the independent factors for SSI were S. aureus nasal carriage [relative risk (RR): 3.1; 95% confidence interval (CI): 1.4-7.3; P=0.009], reoperation (RR: 3.1; 95% CI: 1.8-19.2; P=0.04) and diabetes mellitus (RR: 5.9; 95% CI: 1.8-19.2; P=0.003). Nasal carriage of S. aureus significantly increases the rate of nosocomial SSI after MHS and decolonisation strategies should be implemented in this population.

Reflexión sobre la situación actual de los tutores docentes y la docencia de anestesiología y reanimación en nuestro país / No disponible

No disponible

Prevalence of peripheral arterial disease and prior stroke in octogenarians with symptomatic severe aortic stenosis or severe coronary artery disease: influence in management and outcome.

AIM: Severe aortic stenosis (SAS) and severe coronary artery disease (SCAD) are the most frequent reasons to perform cardiac surgery in octogenarians. Non-coronary vascular disease is frequently present in these patients. METHODS: We assessed the prevalence and impact of previous stroke (PS) and peripheral arterial disease (PAD) on the management and outcome of 130 consecutive symptomatic patients (80 years old with SAS or SCAD. RESULTS: Mean age was 82.8+/-3.1 years. PS was present in 24 patients (18.5%) and PAD in 15 (11.5%). We found a non-significant trend to a higher prevalence of PAD in patients with SCAD than in patients with SAS (14.5% vs 6.4%, P=0.13), while no relevant differences were seen for PS prevalence (19.3% vs 17%, P=0.75). Patients with PS tended to be operated less frequently than patients without PS (20.8% vs 37.7%, P=0.08), while no relevant differences were seen for patients with and without PAD (26.7% vs 35.7%, P=0.5). Thirty-nine patients (30%) died during follow-up, mean of 1.1(0.7 years (median 1 years; 100% complete). There was a trend to a worse prognosis in patients with PAD (adjusted hazard ratio [HR] 2.2; 95% confidence interval [CI] 0.96-4.8; P=0.06), while PS showed no independent influence on survival (adjusted HR 1.3, 95% CI 0.6-2.8, P=0.53). CONCLUSIONS: PS and PAD are frequently present in octogenarians with SAS or SCAD. Patients with PS show a similar long-term mortality, but tend to be operated less frequently. On the other hand, PAD did not influence the decision of surgical treatment, but is associated with a lower survival rate.

Postoperative infections after major heart surgery and prevention of ventilator-associated pneumonia: a one-day European prevalence study (ESGNI-008).

Few data have been published on the prevalence of postoperative infection in patients undergoing major heart surgery (MHS). The degree of compliance with standard measures used to prevent them is unknown. This study assessed the prevalence of infections, particularly ventilator-associated pneumonia (VAP), in patients undergoing MHS in 42 institutions from 13 European countries. On the study day, there were 321 postoperative MHS patients, of whom 164 (51%) were mechanically ventilated. The overall prevalence of infection was 26.8%. Lower respiratory tract infections represented 57% of all the infections present on the study day. Other infections included intravenous-catheter-related bloodstream infections (2.8%), surgical site infections (2.2%), urinary tract infections (0.9%) and postoperative mediastinitis (0.9%). Of the mechanically ventilated patients, 55 (33.5%) were not being nursed in a semi-recumbent position, 36 (22%) had heat-moisture exchangers with no antibacterial filters, and intracuff pressure was not monitored in 78 patients (47.6%). Only 13 patients (8%) were given continuous subglottic suctioning, 64 patients (39%) did not receive postural oscillation, and gastric overdistension was not actively prevented in 23 patients (14%). In conclusion, these data from intensive care units across Europe provide information on postoperative infections in an important subset of the patient population, and stress the need for active interventions to prevent VAP in patients undergoing MHS.

Infections following major heart surgery in European intensive care units: there is room for improvement (ESGNI 007 Study).

Patients undergoing major heart surgery (MHS) may be at increased risk for nosocomial infections. To assess the incidence and type of infections in MHS patients in European intensive care units (ICUs) and their quality of care, a questionnaire was sent to a selection of MHS ICUs in Europe. Seventeen hospitals from seven European countries participated. Overall, 53% of the ICUs received patients only for MHS and the other 47% were mixed. During the study period, 11 915 patients underwent MHS and 1181 (9.9%) developed one or more nosocomial infections. Ventilator-associated pneumonia (VAP) was the most common infection [median 3.8%; interquartile range (IQR) 1.8-4.9], followed by surgical wound infection (median 1.6%; IQR 0.8-2.3), catheter-related bloodstream infection (median 1.3%; IQR 0.8-2.1), mediastinitis (median 1.1%; IQR 0.4-1.6), urinary tract infection (median 0.6; IQR 0.4-1.4) and nosocomial endocarditis (median 0.2%; IQR 0.0-0.9). Median mortality was 4.7% (IQR 2.7-8.4) and median infection-related mortality was 1% (IQR 0.5-2.7). Regarding VAP, 18% of the ICUs did not routinely pursue a diagnosis. Microbiological information was quantitative in 35% of cases and exclusively qualitative in 65% of cases. An infectious disease specialist was regularly involved in VAP management in only 35% of the ICUs, and the therapeutic approach to VAP involved de-escalation in 59% of the ICUs. MHS ICUs in Europe still have a high rate of postoperative infections. Well-recognized routine practices for the diagnosis and treatment of VAP are not implemented regularly in many European institutions.

[Aortic coarctation and postcoarctation mycotic aneurysm in a woman 20 weeks pregnant: anesthetic management]. / Coartación aórtica y aneurisma micótico postcoartación en gestante de 20 semanas: manejo anestésico.

A 28-year-old woman, 20 weeks pregnant, was diagnosed with aortic coarctation and postcoarctation mycotic aneurysm. After anesthetic induction, blood pressure was monitored in the radial artery of the right arm and the femoral artery of the right leg for two purposes: to verify hemodynamic stability as required in this type of operation and to determine the pressure gradient between the upper and lower limbs, which was approximately 40 mm Hg. To prevent spinal cord ischemia, an intradural catheter was inserted into the fourth and fifth lumbar space for spinal fluid drainage. A double lumen tube was used for intubation so that the left lung could be blocked, and a centrifugal pump was used instead of extracorporeal circulation. The aneurysm was resected through a left thoracotomy and an aortic prosthesis was placed. Satisfactory outcome was indicated by resolution of the pressure gradient, and fetal viability was verified by ultrasound. The mother suffered no neurological complications and the pregnancy continued to term uneventfully. We review the anesthetic procedure to follow in such cases.

Coartación aórtica y aneurisma micótico postcoartación en gestante de 20 semanas: manejo anestésico / Aortic coarctation and postcoarctation mycotic aneurysm in a woman 20 weeks pregnant: anesthetic management

Presentamos el caso de una paciente de 28 años de edad, gestante de 20 semanas, diagnosticada de coartación aórtica y aneurisma micótico post-coartación. Una vez realizada la inducción anestésica, se monito-rizó la arteria radial en el miembro superior derecho así como la arteria femoral en el miembro inferior derecho con el doble objetivo de tener la monitorización hemodinámica requerida siempre en este tipo de intervenciones y observar el gradiente de presión existente entre miembros superiores e inferiores, que era de unos 40 mmHg. Para intentar evitar la isquemia medular, se colocó un catéter intradural en el espacio L4-L5, para drenaje de líquido cefalorraquídeo. Se realizó intubación con tubo de doble luz, para bloqueo de pulmón izquierdo. Se usó bomba centrífuga en lugar de circulación extracorpórea. La resección aneurismática fue por toracotomía izquierda, colocándose una prótesis aórtica. El resultado final fue satisfactorio, pues desapareció el gradiente de presión y se demostró la viabilidad fetal por la ecografía. La paciente no presentó ninguna secuela neurológica y el embarazo finalizó sin problemas. Revisamos la conducta anestésica a seguir en estos casos

A 28-year-old woman, 20 weeks pregnant, was diagnosed with aortic coarctation and postcoarctation mycotic aneurysm. After anesthetic induction, blood pressure was monitored in the radial artery of the right arm and the fem-oral artery of the right leg for two purposes: to verify hemodynamic stability as required in this type of operation and to determine the pressure gradient between the upper and lower limbs, which was approximately 40 mm Hg. To prevent spinal cord ischemia, an intradural catheter was inserted into the fourth and fifth lumbar space for spinal fluid drainage. A double lumen tube was used for intubation so that the left lung could be blocked, and a centrifugal pump was used instead of extracorporeal circulation. The aneurysm was resected through a left thoracotomy and an aortic prosthesis was placed. Satisfactory outcome was indicated by resolution of the pressure gradient, and fetal viability was verified by ultrasound. The mother suffered no neurological complications and the pregnancy continued to term uneventfully. We review the anesthetic procedure to follow in such cases

Differential effects of dietary fat on chick plasma and liver composition and HMG-CoA reductase activity.

The comparative effects of diet supplementation with 10% saturated fat rich in 12:0 and 14:0 fatty acids (coconut oil), without and with 1% added cholesterol, and with 10% unsaturated fat rich in n-3 polyunsaturated fatty acids (menhaden oil) on cholesterol metabolism in neonatal chicks were examined to clarify the different mechanisms of their hyper- and hypolipidemic action. Supplementation of coconut oil produced a significant hypercholesterolemia after 7 days of treatment, with a similar increase in the amount of both free and esterified cholesterol. Supplementation of coconut oil plus cholesterol produced a higher increase of plasma cholesterol levels (approximately two to three times higher than those found with standard diet). However, supplementation of menhaden oil induced a significant decrease in total cholesterol after only 2 weeks of treatment. Levels of plasma triglycerides did not change by coconut oil addition to the diet, but a significant increase was observed after coconut oil plus cholesterol feeding. Menhaden oil produced a transient decrease in plasma triglycerides. Hepatic 3-hydroxy-3-methylglutaryl-CoA reductase activity did not change with coconut oil treatment. However, both coconut oil plus cholesterol and menhaden oil supplemented diets drastically decreased reductase activity after 1 week of dietary manipulation. These results show that different nutrients with the same inhibitory effect on reductase activity produced opposite effects on plasma cholesterol content, suggesting the existence of important differences in the regulatory mechanisms implied in cholesterol biosynthesis and its accumulation in plasma.

Synergism between the effects of dietary cholesterol and coconut oil on plasma, liver and lipoprotein composition of neonatal chick.

The nature of the synergism between dietary factors and the development of atherosclerosis has not been fully defined. Our studies showed that simultaneous supplementation of 10% saturated fat rich in 12:0 and 14:0 fatty acids (coconut oil) plus 1% cholesterol to the diet produced a sharp increase of plasma cholesterol, indicating a synergic influence of both dietary constituents. This increase was especially patent in the VLDL fraction, modifying the distribution of other lipid components between the core and the surface of these particles. These changes are consistent with the atherogenic function of VLDL and its responsiveness to dietary manipulation.

Coconut oil affects lipoprotein composition and structure of neonatal chicks.

Supplementation of 10 or 20% coconut oil in the diet for 1-2 weeks produced a significant hypercholesterolemia in neonatal chicks. Plasma triacylglycerol concentration significantly increased after the addition of 20% coconut oil for 2 weeks. These results show that newborn chicks are more sensitive to saturated fatty acids from coconut oil than adult animals. The effects of this saturated fat on lipoprotein composition were studied for the first 1-2 weeks of neonatal chick life. Coconut oil supplementation in the diet (20%) for 2 weeks increased cholesterol concentration in all the lipoprotein fractions, while 10% coconut oil only increased cholesterol in low-density and very-low-density lipoproteins, an increase that was significant after 1 week of treatment. Similar results were obtained for triacylglycerol concentration after 2 weeks of treatment. Changes in phospholipid and total protein levels were less profound. Coconut oil decreased low-density and very-low-density lipoprotein fluidity, measured as total cholesterol/phospholipid ratio. Changes in esterified cholesterol/phospholipid and triacylglycerol/phospholipid ratios suggest that coconut oil affects the distribution of lipid components in the core of very-low-density particles. Likewise, the esterified cholesterol/triacylglycerol ratio was clearly increased in the low-density, and especially in the very-low-density, fraction after the first week of coconut oil feeding. Our results show that neonatal chick provides a suitable model in which to study the role of very-low-density lipoproteins in atherogenesis and the rapid response to saturated fatty acids with 12-14 carbons.