The erector spinae plane block in 4 cases of video-assisted thoracic surgery. / Bloqueo del plano del músculo erector de la columna en 4 casos de cirugía torácica videoasistida.

Multimodal anaesthesia, combining epidural catheter and general anaesthesia, is a common technique in thoracic surgery, however, epidural catheter placement is not always possible. Recently, erector spinae plane block has been described, which provides analgesia like that of the epidural block, although unilateral, and which has been used in various procedures at thoracic level. At present, there are no studies comparing the efficacy or safety of this block with those commonly used in thoracic surgery. However, its safety profile and contraindications seem different from those of the epidural catheter, since its placement is done under ultrasound view, the needle introduction is done in plane and the ultrasound target, the transverse process, is easily identifiable and is relatively remote from major neural or vascular structures and the pleura. Unlike other blockages made by anatomical references, erector spinae plane block can be done with the patient in different positions. We describe our experience with erector spinae plane block as part of a multimodal anaesthetic approach in thoracic surgery.

Effects of inhalational anaesthesia with low tidal volume ventilation on end-tidal sevoflurane and carbon dioxide concentrations: prospective randomized study / Efectos de la anestesia inhalatoria con baja concentración final de volumen corriente de sevoflurano y dióxido de carbono: estudio prospectivo aleatorizado

Objective. We investigated how ventilation with low tidal volumes affects the pharmacokinetics of sevoflurane uptake during the first minutes of inhaled anaesthesia. Methods. Forty-eight patients scheduled for lung resection were randomly assigned to three groups. Patients in group 1, 2 and 3 received 3% sevoflurane for 3 min via face mask and controlled ventilation with a tidal volume of 2.2, 8 and 12 ml kg−1, respectively (Phase 1). After tracheal intubation (Phase 2), 3% sevoflurane was supplied for 2 min using a tidal volume of 8 ml kg−1 (Phase 3). Results. End-tidal sevoflurane concentrations were significantly higher in group 1 at the end of phase 1 and lower at the end of phase 2 than in the other groups as follows: median of 2.5%, 2.2% and 2.3% in phase 1 for groups 1, 2 and 3, respectively (P < 0.001); and 1.7%, 2.1% and 2.0% in phase 2, respectively (P < 0.001). End-tidal carbon dioxide values in group 1 were significantly lower at the end of phase 1 and higher at the end of phase 2 than in the other groups as follows: median of 16.5, 31 and 29.5 mmHg in phase 1 for groups 1, 2 and 3, respectively (P < 0.001); and 46.2, 36 and 33.5 mmHg in phase 2, respectively (P < 0.001). Conclusion. When sevoflurane is administered with tidal volume approximating the airway dead space volume, end-tidal sevoflurane and end-tidal carbon dioxide may not correctly reflect the concentration of these gases in the alveoli, leading to misinterpretation of expired gas data (AU)

Objetivo. Investigamos cómo la ventilación controlada con volúmenes corrientes bajos afecta a la farmacocinética del sevoflurano durante los primeros minutos de anestesia inhalada. Métodos. Cuarenta y ocho pacientes programados para cirugía de resección pulmonar fueron distribuidos al azar en tres grupos. Los pacientes del grupo 1, 2 y 3 recibieron sevoflurano al 3% durante 3 minutos mediante ventilación controlada a través de mascarilla con un volumen corriente de 2,2, 8 y 12 ml kg−1, respectivamente (Fase 1). Después de la intubación traqueal (Fase 2), se administró sevoflurano al 3% durante 2 minutos usando un volumen corriente de 8 ml kg−1 (Fase 3). Resultados. las concentraciones finales de sevoflurano fueron significativamente superiores en el grupo 1 al final de la fase I e inferiores al final de la fase II con respecto a los otros grupos: mediana del 2,5%, 2,2% y 2,3% en la fase I para los grupos 1, 2 y 3, respectivamente (P < 0,001), y 1,7%, 2,1% y 2,0% en la fase II, respectivamente (P < 0,001). Los valores de dióxido de carbono en el grupo 1 fueron significativamente inferiores al final de la fase I y superiores al final de la fase II frente a los otros grupos: mediana de 16,5, 31 y 29,5 mmHg en la fase I para los grupos 1, 2 y 3, respectivamente (P < 0,001), y 46,2 36, y 33,5 mmHg en fase II, respectivamente (P < 0,001). Conclusión. Cuando el sevoflurano se administra mediante volúmenes corrientes cercanos al volumen de espacio muerto de la vía aérea, las concentraciones finales de sevoflurano y dióxido de carbono pueden no reflejar correctamente la concentración de estos gases en los alvéolos, lo que puede conducir a una interpretación incorrecta de los gases expirados (AU)

Effects of inhalational anaesthesia with low tidal volume ventilation on end-tidal sevoflurane and carbon dioxide concentrations: prospective randomized study.

OBJECTIVE: We investigated how ventilation with low tidal volumes affects the pharmacokinetics of sevoflurane uptake during the first minutes of inhaled anaesthesia. METHODS: Forty-eight patients scheduled for lung resection were randomly assigned to three groups. Patients in group 1, 2 and 3 received 3% sevoflurane for 3 min via face mask and controlled ventilation with a tidal volume of 2.2, 8 and 12 ml kg(-1), respectively (Phase 1). After tracheal intubation (Phase 2), 3% sevoflurane was supplied for 2 min using a tidal volume of 8 ml kg(-1) (Phase 3). RESULTS: End-tidal sevoflurane concentrations were significantly higher in group 1 at the end of phase 1 and lower at the end of phase 2 than in the other groups as follows: median of 2.5%, 2.2% and 2.3% in phase 1 for groups 1, 2 and 3, respectively (P<0.001); and 1.7%, 2.1% and 2.0% in phase 2, respectively (P<0.001). End-tidal carbon dioxide values in group 1 were significantly lower at the end of phase 1 and higher at the end of phase 2 than in the other groups as follows: median of 16.5, 31 and 29.5 mm Hg in phase 1 for groups 1, 2 and 3, respectively (P<0.001); and 46.2, 36 and 33.5 mm Hg in phase 2, respectively (P<0.001). CONCLUSION: When sevoflurane is administered with tidal volume approximating the airway dead space volume, end-tidal sevoflurane and end-tidal carbon dioxide may not correctly reflect the concentration of these gases in the alveoli, leading to misinterpretation of expired gas data.

[The objective structured clinical evaluation of teaching in anaesthesiology and resuscitation]. / La evaluación clínica objetiva estructurada en la docencia en Anestesiología y Reanimación.

OBJECTIVES: To find out the acquirement of professional competencies of Anaesthesiology and Resuscitation medical residents at the end of their training period using the Objective Structured Clinical Evaluation (OCSE) tool. MATERIAL AND METHODS: Six competency components to evalúate were defined as follows: clinical interview (communication), technical ability and relationship abilities (leadership, decision making, work in a team), diagnostic assessment, therapeutic management, and medical records. Different methodologies were determined depending on the knowledge and skills to evaluate. Twelve clinical cases were developed that were performed in 12 stations. A total of 107 Ítems, specified within the stations, evaluated the competency components. A total of 43 residents were invited to participate in the last 4 months of their training in hospitals in Andalusia and Extremadura. RESULTS: A total of 33 residents participated. The overall mean of the classifications obtained in the 12 stations was 64.2 out of a maximum of 100. The medical residents demonstrated higher competency in obstetrics, paediatric anaesthesia, and that associated with difficult airway. The main competency gaps were detected in the area of one-day surgery, chronic pain, and literature management, in which approximately half passed the test. CONCLUSIONS: We believe that training evaluations, such as the OCSE, help in determining the skill levels of the medical resident, making it easier to continually improve the training of the future anaesthesiologist.

[Psychological profile of anesthesia residents in the province of Andalucia]. / Perfil psicológico de la población de médicos residentes de anestesiología en una provincia de Andalucía.

OBJECTIVES: To describe the personality traits and value systems of the population of residents in anesthesiology of a province in Andalusia and to analyze what the ideal profile of an anesthesiologist in training would be. SUBJECTS AND METHOD: Forty-four residents in anesthesiology were invited to participate, of whom 22 accepted. The participants voluntarily completed anonymous written questionnaires with 232 items: the sixteen personality factors questionnaire, form A (R.B. Cattell), and the survey of interpersonal values (L.V. Gordon). RESULTS: The residents scored high on primary factors of intelligence (B), self-sufficiency (Q2) and conservatism (Q1). High scores were also recorded on the secondary factors of anxiety (QI) and socialization (QIII); low scores were seen for independence (QIV). Four theoretical personality models (alpha, beta, gamma and delta) were established based on the data. Four residents were alphas (18%), 10 were betas (45%), 6 were gammas (27%) and 2 were deltas (10%). CONCLUSIONS: An ideal personal profile for residents in anesthesiology by American authors has been available since the 1960s. An ideal resident should be independent, calm, aware, stable, secure, self-disciplined and alert; moreover, he or she should enjoy team work. The residents with alpha personalities were ideal. At present, the training of residents and the selection criteria for access to specialized training based on a personality test are scarcely valued in our discipline.

[Body temperature variations during laparoscopic cholecystectomies]. / Variaciones de la temperatura corporal en el curso de colecistectomías laparoscópicas.

OBJECTIVE: To study changes over time in body temperature related to insufflation of CO2. PATIENTS AND METHOD: Fifty patients were randomly assigned to 2 groups of 25 to undergo cholecystectomy by either laparoscopy or laparotomy. Total intravenous anesthesia with propofol, pancuronium and fentanyl was used in both groups. Ventilation was maintained at 0.5 FiO2. Central temperature was continuously measured by a distal esophageal thermometer and results were recorded every 10 minutes in both groups. All operations lasted approximately 80 min. RESULTS: We found that temperature gradually decreased over time in both groups. In the laparotomy group the decrease reached 0.20 degree C (SD 0.03) at 80 min. During laparoscopy the temperature decrease was 0.43 degree C (SD 0.04) for the same time period. The differences were statistically significant. We observed no pathophysiologic repercussions associated with these results. CONCLUSIONS: Laparoscopic surgery, even when the abdominal cavity is not exposed to room air, induces a loss of temperature that is greater than that of laparotomy, because of insufflation of CO2 at 4 degrees C. The decrease was 0.4 degree C for every 50 l of CO2 insufflated during the study.

[Adrenergic response during general anesthesia with propofol as maintenance agent]. / Respuesta adrenérgica durante la anestesia general con propofol como agente de mantenimiento.

To determine plasma catecholamine levels during the use of propofol for maintenance of anesthesia. We studied 20 randomly chosen patients undergoing elective orthopedic surgery under general intravenous anesthesia with propofol as the agent of maintenance along with pancuronium and fentanyl. Plasma concentrations of dopamine, noradrenalin and adrenalin were measured at the following times: baseline, after intubation and every 15 min during surgery. The levels obtained for the different samples were compared with baseline levels. At the doses used in our study, there were no significant differences in the way dopamine plasma levels varied. This was not the case with the other two hormones, however. Adrenalin levels were significantly higher at the first 3 extractions (post-intubation, 15 min and 30 min), and noradrenalin was significantly higher (p < 0.05) at all extraction times. Total intravenous anesthesia with propofol is associated with a significant increase in plasma concentrations of adrenalin and noradrenalin. Adrenalin returns to baseline levels 45 min after induction.

[Utility of premedication with different regimens of omeprazole and ranitidine in the prevention of acid broncho-aspiration syndrome]. / Utilidad de la premedicación con distintas pautas de omeprazol y ranitidina en la profilaxis del síndrome de broncoaspiración ácida.

OBJECTIVE: To study the usefulness of several omeprazole regimens on gastric fluid volume and pH in patients undergoing elective surgery. MATERIAL AND METHODS: We analyzed 105 patients undergoing to elective surgery who received prophylactic treatment for the acid aspiration syndrome. They were randomly allocated into 7 homogeneous groups according to the therapeutic regime. Placebo (group 1), oral omeprazole (20 mg) the night prior to surgery (group 2), oral ranitidine (150 mg) the night before (group 6), two doses (the previous night and before surgery) in the remaining three groups: 20 mg of omeprazole (group 4), 40 mg of omeprazole (group 5) or 150 mg of ranitidine (group 7). In all patients we measured pH and volume of the gastric content after induction of anesthesia and one hour thereafter. RESULTS: There were no statistically significant differences in mean pH values and gastric volume content among groups 1.2,3, and 6 (2.1 (pH) and 27 ml (gastric volume) in group 1, 2.1 and 23 ml in group 2, 2.6 and 19 ml in group 3, and 2.2 and 32 ml in group 6). With repeated doses of 40 mg omeprazol (group 5), mean pH values were comparable to those found with the two doses of ranitidine (4.1 +/- 1.8 vs 4.1 +/- 3.6) although gastric volumes were significantly less (12 +/- 2.6 ml vs 20 +/- 4.8 ml). These two groups showed significantly greater mean pH values and less gastric volumes than the remaining patients. CONCLUSIONS: The incidence of patients with gastric content deemed at risk for acid aspiration (pH less than 2.5 and gastric volume greater than 25 ml) was less after premedication with two oral doses of omeprazole (40 mg) than either two doses of ranitidine (150 mg) or smaller doses of both drugs.