Secondary use of data extracted from a clinical information system to assess the adherence of tidal volume and its impact on outcomes.

OBJECTIVES: To extract data from clinical information systems to automatically calculate high-resolution quality indicators to assess adherence to recommendations for low tidal volume. DESIGN: We devised two indicators: the percentage of time under mechanical ventilation with excessive tidal volume (>8mL/kg predicted body weight) and the percentage of patients who received appropriate tidal volume (≤8mL/kg PBW) at least 80% of the time under mechanical ventilation. We developed an algorithm to automatically calculate these indicators from clinical information system data and analyzed associations between them and patients' characteristics and outcomes. SETTINGS: This study has been carried out in our 30-bed polyvalent intensive care unit between January 1, 2014 and November 30, 2019. PATIENTS: All patients admitted to intensive care unit ventilated >72h were included. INTERVENTION: Use data collected automatically from the clinical information systems to assess adherence to tidal volume recommendations and its outcomes. MAIN VARIABLES OF INTEREST: Mechanical ventilation days, ICU length of stay and mortality. RESULTS: Of all admitted patients, 340 met the inclusion criteria. Median percentage of time under mechanical ventilation with excessive tidal volume was 70% (23%-93%); only 22.3% of patients received appropriate tidal volume at least 80% of the time. Receiving appropriate tidal volume was associated with shorter duration of mechanical ventilation and intensive care unit stay. Patients receiving appropriate tidal volume were mostly male, younger, taller, and less severely ill. Adjusted intensive care unit mortality did not differ according to percentage of time with excessive tidal volume or to receiving appropriate tidal volume at least 80% of the time. CONCLUSIONS: Automatic calculation of process-of-care indicators from clinical information systems high-resolution data can provide an accurate and continuous measure of adherence to recommendations. Adherence to tidal volume recommendations was associated with shorter duration of mechanical ventilation and intensive care unit stay.

Secondary use of data extracted from a clinical information system to assess the adherence of tidal volume and its impact on outcomes / Uso secundario de los datos del Sistema de Información Clínica para evaluar la adherencia a las guías de práctica clínica respecto al volumen tidal y su impacto en los resultados

Objectives To extract data from clinical information systems to automatically calculate high-resolution quality indicators to assess adherence to recommendations for low tidal volume. Design We devised two indicators: the percentage of time under mechanical ventilation with excessive tidal volume (>8mL/kg predicted body weight) and the percentage of patients who received appropriate tidal volume (≤8mL/kg PBW) at least 80% of the time under mechanical ventilation. We developed an algorithm to automatically calculate these indicators from clinical information system data and analyzed associations between them and patients’ characteristics and outcomes. Settings This study has been carried out in our 30-bed polyvalent intensive care unit between January 1, 2014 and November 30, 2019. Patients All patients admitted to intensive care unit ventilated >72h were included. Intervention Use data collected automatically from the clinical information systems to assess adherence to tidal volume recommendations and its outcomes. Main variables of interest Mechanical ventilation days, ICU length of stay and mortality. Results Of all admitted patients, 340 met the inclusion criteria. Median percentage of time under mechanical ventilation with excessive tidal volume was 70% (23%–93%); only 22.3% of patients received appropriate tidal volume at least 80% of the time. Receiving appropriate tidal volume was associated with shorter duration of mechanical ventilation and intensive care unit stay. Patients receiving appropriate tidal volume were mostly male, younger, taller, and less severely ill. Adjusted intensive care unit mortality did not differ according to percentage of time with excessive tidal volume or to receiving appropriate tidal volume at least 80% of the time (AU)

Objetivos Extraer los datos del Sistema de Información Clínica para calcular automáticamente indicadores de calidad de alta resolución para evaluar la adherencia a las recomendaciones sobre el volumen tidal. Diseño Ideamos 2 indicadores: el porcentaje de tiempo en ventilación mecánica con volumen tidal excesivo (>8mL/kg peso ideal) y el porcentaje de pacientes con volumen tidal apropiado (≤8mL/kg peso ideal) al menos el 80% del tiempo en ventilación mecánica. Desarrollamos un algoritmo para calcular automáticamente dichos indicadores con los datos del Sistema de Información Clínica y analizamos su asociación con las características de los pacientes y su evolución. Ambiente El estudio se llevó a cabo en una unidad de cuidados intensivos polivalente de 30 camas desde el 1 enero 2014 hasta el 20 noviembre 2019. Pacientes Se incluyeron en el estudio todos los pacientes ingresados en la unidad de cuidados intensivos conectados a ventilación mecánica>72h. Intervención Usar los datos recogidos automáticamente desde el Sistema de Información Clínica para evaluar la adherencia a las recomendaciones del volumen tidal y sus resultados. Principales variables de interés Días de ventilación mecánica, días de estancia en la unidad de cuidados intensivos y mortalidad. Resultados De todos los pacientes ingresados, 340 cumplieron los criterios de inclusión. El tiempo medio de ventilación mecánica con volumen tidal excesivo fue 70% (23-93%); solo el 22,3% de los pacientes recibió un volumen tidal apropiado al menos el 80% del tiempo. Recibir un volumen tidal apropiado se asoció con menos días de ventilación mecánica y de estancia en la unidad de cuidados intensivos. Los pacientes que recibieron un volumen tidal apropiado fueron más frecuentemente hombres, más jóvenes, más altos y menos graves (AU)

[Evaluation of the effectiveness of the new perioperative model to recover surgical activity during the COVID-19 pandemic]. / Evaluación de la efectividad del nuevo modelo perioperatorio para recuperar la actividad quirúrgica durante la pandemia de COVID-19.

INTRODUCTION: The first wave of the COVID-19 pandemic caused the cancellation of elective interventions. After the improvement of the epidemiological situation, new models of care were applied in hospitals to restart the programmed surgical activity. The aim was to evaluate the effectiveness of the organizational model established to recover surgical activity during the transition period of the COVID-19 pandemic. METHODS: Retrospective observational study comparing patients who underwent schedule surgery from September 1 until October 31, 2020, study group, with a control group of the same period of time corresponding to the year 2019 at the General Hospital from the Vall d'Hebron University Hospital. RESULTS: The total population included 1,825 patients, 888 in the study group and 937 in the control group. Global surgical activity decreased 6.43% during the study period compared to the same period in 2019, with a 25.5% decrease in cancer surgeries. Seven patients became infected with SARS-CoV-2 during their hospital stay. In hospital mortality was 0.9% in the study group compared to 0.7% in control group (p=0.8). The survival rate in cancer patients at 90 days was lower in the study group (95.7% vs 98.7%; p=0.02). CONCLUSIONS: The change in the management model during the transition period of the COVID-19 pandemic allowed the recovery of programmed surgical activity to levels similar to those existing prior to the pandemic with a greater impact on cancer surgery.

Fetal heart rate monitoring during fetoscopic repair of open spinal neural tube defects: a single-centre observational cohort study.

BACKGROUND: During fetal surgery, the haemodynamic stability of the fetus depends on the haemodynamic stability of the mother. The primary objective of this study was to assess changes in fetal heart rate (FHR) throughout the different stages of surgery. The secondary objective was to assess potential changes in maternal physiological parameters and their association with FHR. METHODS: This was a single-center observational cohort study conducted between 2015 and 2019 in 26 women undergoing intra-uterine fetoscopic repair of open spina bifida. The primary outcome was FHR. Maternal physiologic parameters were measured at the beginning, during and after surgery. The linear mixed-effects model fitted by maximum likelihood was used to assess changes in each variable at specific times throughout the surgery, and the repeated measures correlation coefficient was used to study the association between FHR and maternal physiological parameters. RESULTS: One (3.8%) case of fetal bradycardia (FHR <110 beats per minute) required the administration of intramuscular atropine. No other significant FHR changes were observed during surgery. Maternal oesophageal temperature (P <0.001), lactate levels (P=0.002), and mean arterial pressure (P=0.016) changed significantly during surgery, although none of these changes was clinically relevant. The FHR showed a significant association with maternal carbon dioxide tension (r=0.285, 95% CI 0.001 to 0.526) and maternal heart rate (r=0.302, 95% CI 0.025 to 0.535). CONCLUSION: The FHR remained stable during intra-uterine fetoscopic repair of open spina bifida. Maternal carbon dioxide tension and heart rate may have a mild influence on FHR.

Awareness and use of mouthguards in risk sports by Spanish children between 6 and 18 years of age.

AIM: To investigate awareness and frequency of use of mouthguards in children and adolescents who engage in high-risk sports in various federated sports clubs in different provinces of Catalonia (Spain). MATERIALS: A total of 207 athletes aged between 6 and 18 years who belonged to one of the various official sports clubs across Catalonia (Spain) took part in the study. The participants completed a survey that included 13 anonymous questions to assess their awareness and use of a mouthguard while engaging in high-risk sports, the person who recommended its use, and among other variables, the dental history of sports-related injuries. Statistical analysis was performed using the chi-square test; Fisher's exact test and analysis of variance (ANOVA) were used to determine the relationships among the variables. A p-value of 0.05 and a 95% reliability were considered statistically significant. CONCLUSION: Use of a mouthguard as a preventive measure in sport was very low. One of the main reasons for this was the large amount of disinformation about this type of protection. It would be beneficial to enforce mandatory use of mouthguards in all high-risk sports.

Recomendaciones prácticas en la paciente obstétrica con infección por COVID-19 / Practical recommendations in the obstetrical patient with a COVID-19 infection

La infección por COVID-19 afecta también a las pacientes obstétricas. La atención obstétrica habitual ha continuado a pesar de la pandemia. Existen series de casos de pacientes obstétricas. Parece que las técnicas neuroaxiales son seguras y es importante asegurarse que los bloqueos funcionen correctamente antes de una cesárea. Es por esto que se recomienda que los bloqueos sean realizados por anestesiólogos expertos. La protección y seguridad de los profesionales es un punto fundamental y, en caso de anestesia general, también se recomienda acudir al anestesiólogo más experto. Las pacientes gravemente enfermas deben reconocerse rápida y precozmente, para poder suministrarles el tratamiento adecuado lo antes posible. La susceptibilidad a las trombosis hace que la anticoagulación profiláctica sea prioritaria

COVID-19 infection also affects obstetric patients. Regular obstetric care has continued despite the pandemic. Case series of obstetric patients have been published. Neuroaxial techniques appear to be safe and it is important to obtain the highest possible rate of success of the blocks before a cesarean section. For this reason, it is recommended that the blocks be carried out by senior anesthesiologists. The protection and safety of professionals is a key point and in case of general anesthesia, so it is also recommended to call to the most expert anesthesiologist. Seriously ill patients should be recognized quickly and early, in order to provide them with the appropriate treatment as soon as possible. Susceptibility to thrombosis makes prophylactic anticoagulation a priority

Practical recommendations in the obstetrical patient with a COVID-19 infection. / Recomendaciones prácticas en la paciente obstétrica con infección por COVID-19.

COVID-19 infection also affects obstetric patients. Regular obstetric care has continued despite the pandemic. Case series of obstetric patients have been published. Neuroaxial techniques appear to be safe and it is important to obtain the highest possible rate of success of the blocks before a cesarean section. For this reason, it is recommended that the blocks be carried out by senior anesthesiologists. The protection and safety of professionals is a key point and in case of general anesthesia, so it is also recommended to call to the most expert anesthesiologist. Seriously ill patients should be recognized quickly and early, in order to provide them with the appropriate treatment as soon as possible. Susceptibility to thrombosis makes prophylactic anticoagulation a priority.

Fetoscopic two-layer closure of open neural tube defects.

OBJECTIVE: Fetoscopy for closure of open neural tube defects (NTD) remains controversial, as the use of patches or single-layer closure is not considered to meet the standards of good neurosurgical reconstruction. In this study, we describe a fetoscopic two-layer (myofascial and skin) closure technique for the treatment of NTD in five patients and report the preliminary anatomical outcome at birth. METHODS: From February to September 2017, five pregnant women with a fetus with a NTD, including three cases of myelomeningocele and two cases of myelocele, were operated on using a fetoscopic two-layer closure technique. In this technique, with the uterus exteriorized and using three 10-Fr ports, the placode is dissected from the surrounding tissue and detethered, removing the cystic tissue. The skin is undermined by blunt dissection and the defect is sutured to the midline in two layers (myofascial and skin) using a running 4/0 resorbable barbed suture. RESULTS: Median gestational age at the procedure was 24 + 3 (range, 23 + 5 to 27 + 3) weeks. Surgery was successful in all cases, without any intraoperative complications. Median time in surgery was 180 (range, 140-180) min and median time for fetoscopy was 105 (range, 65-120) min. In terms of obstetric complications, three cases of premature rupture of membranes and one case of chorioamnionitis were recorded. Median gestational age at delivery was 34 + 1 (range, 25 + 4 to 37 + 2) weeks and two patients delivered vaginally. The closed defect was watertight with good quality tissue in all cases. CONCLUSION: Fetoscopic two-layer closure of NTD may improve the quality of the tissue covering the defect, diminishing the need for postnatal surgical revision, and preserving the well-documented beneficial effects of prenatal closure on the neural tissue and hindbrain herniation. However, this technique may not be appropriate for those cases with wide diastasis of the myofascial layer or with a low quantity of available tissue. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Cardiac complications during pregnancy are better predicted with the modified WHO risk score.

BACKGROUND/OBJECTIVE: Several risk scores (RSs) have been used to stratify risk of cardiac complications (CCs) in pregnant patients with heart disease. We aimed to compare and contrast the accuracy of several RSs for predicting CC in this population. METHODS: Prospective inclusion of all consecutive pregnant patients with heart disease, and follow-up until 6 months postpartum. CCs were defined as primary if admission was required due to heart failure, arrhythmia or thromboembolic events, and secondary if the decline in NYHA class compared with baseline was >2 or urgent invasive cardiac procedures were needed. The discriminatory power of each RS was assessed by the area-under-the receiver-operating characteristic (ROC) curve (AUC). RESULTS: 179 patients, mean age: 32 years, accounted for 13.4% of CC (primary 11.7%, secondary 1.7%); the main diagnosis was congenital heart disease (CHD) in 68% followed by valvulopathies in 16%, arrhythmia in 7% and myocardiopathies in 5%. 22% (n=40) were classified as mWHO=1, 59% (n=105) mWHO=2 including subgroup 2-3, 14% (n=26) mWHO=3 and 4%(n=7) mWHO=4; 1 patient was unclassifiable. mWHO showed a better AUC (0.763) than CARPREG (0.67). For the CHD population, ZAHARA RS showed an AUC of 0.74, and Khairy an AUC of 0.632. CONCLUSIONS: mWHO was better at predicting CC than CARPREG; mWHO was also better at predicting CC than the specific CHD RS in the CHD subgroup. PRACTICE: There are an increasing number of pregnant women with HD. IMPLICATIONS: Improved prediction of CC risk during pregnancy can provide better preconception assessment in women with HD.

Tratamiento anestésico para cesárea en una paciente con epidermolisis bullosa distrófica recesiva / Anesthesia for cesarean section in a patient with recessive dystrophic epidermolysis bullosa

La epidermolisis bullosa distrófica recesiva es unaenfermedad cutánea genéticamente determinada, debaja incidencia, y que consiste en la formación deampollas en la dermis. Describimos el tratamiento anestésicode una gestante de 39 años con epidermolisisbullosa distrófica recesiva que se iba a someter a unacesárea electiva a las 37 semanas de gestación. Presentabalesiones cutáneas generalizadas, pérdida de dedosen manos y estenosis esofágica. Se realizó la cesárea conanestesia subaracnoidea sin incidencias. La epidermolisisbullosa distrófica recesiva requiere un tratamientoanestésico adaptado, con control postural y manipulacióncuidadosa, así como adecuación del material demonitorización y de los accesos venosos a las deformidadesy lesiones cutáneas(AU)

Recessive dystrophic epidermolysis bullosa isinherited as a rare autosomal disorder which causesblisters to form in the skin. We describe the treatmentof a 39-year-old parturient with this condition. She wasscheduled for elective cesarean section at 37 weeks'gestation. The patient had widespread skin lesions, hadlost fingers, and had esophageal stenosis. The cesareanwas performed under spinal anesthesia withoutcomplications. Recessive dystrophic epidermolysisbullosa requires adaptation of anesthetic technique thatincludes control over posture and careful handling of theskin. Material for attaching monitoring devices andinserting venous lines must be adapted to the particulardeformities and skin lesions present(AU)

[Anesthesia for cesarean section in a patient with recessive dystrophic epidermolysis bullosa]. / Tratamiento anestésico para cesárea en una paciente con epidermolisis bullosa distrófica recesiva.

Recessive dystrophic epidermolysis bullosa is inherited as a rare autosomal disorder which causes blisters to form in the skin. We describe the treatment of a 39-year-old parturient with this condition. She was scheduled for elective cesarean section at 37 weeks' gestation. The patient had widespread skin lesions, had lost fingers, and had esophageal stenosis. The cesarean was performed under spinal anesthesia without complications. Recessive dystrophic epidermolysis bullosa requires adaptation of anesthetic technique that includes control over posture and careful handling of the skin. Material for attaching monitoring devices and inserting venous lines must be adapted to the particular deformities and skin lesions present.

[Fetoscopic tracheal occlusion for the treatment of severe congenital diaphragmatic hernia: preliminary results]. / Oclusión traqueal fetoscópica (FETO) para el tratamiento de la hernia diafragmática congénita severa: resultados preliminares.

OBJECTIVES: To evaluate survival and lung growth in fetuses with severe congenital diaphragmatic hernia (CDH) treated with fetoscopic tracheal occlusion (FETO) compared with control fetuses and to analyze possible complications of the anesthetic techniques used. PATIENTS AND METHODS: This prospective study was performed on fetuses with CDH. FETO was undertaken before the 29th week of gestation on fetuses with a lung-to-head ratio (LHR) less than 1. FETO was not performed on fetuses with an LHR between 1.0 and 1.5 or those with an LHR less than 1 where consent was not given. Lung growth was monitored by means of LHR. FETO was performed under fetal intramuscular anesthesia and maternal epidural anesthesia and sedation with remifentanil. RESULTS: Seventeen fetuses were included in the study. FETO was performed on 11 fetuses and was effective in 9. The median percentage difference between LHR at diagnosis and prior to FETO was 1.15% (P=.183); between diagnosis and before removing the balloon, the difference was 130.5% (P=.003); and between diagnosis and before delivery, 90.18% (P=.003). In the control group (n=6), the median percentage difference between LHR at diagnosis and before delivery was 49.25% (P=.028). No significant hemodynamic or respiratory changes occurred in either mother or fetus during fetoscopy. All the fetuses in the control group died; 45.5% of those in the FETO group survived. CONCLUSIONS: The use of FETO in cases of CDH appears to increase survival and lung growth. Fetal anesthesia in association with maternal epidural anesthesia and sedation makes it possible to place and remove the endotracheal balloon via fetoscopy with acceptable maternal comfort and without notable complications.

Oclusión traqueal fetoscópica (FETO) para el tratamiento de lahernia diafragmática congénita severa: resultados preliminares / Fetoscopic tracheal occlusion for the treatment of severe congenital diaphragmatic hernia: preliminary results

OBJETIVOS: Evaluar la supervivencia y crecimientopulmonar de fetos con hernia diafragmática congénitasevera (HDCs) tratados con oclusión traqueal fetoscópica(FETO) comparado con aquellos en que no se realizóy analizar posibles complicaciones de las técnicas anestésicas.PACIENTES Y MÉTODOS: Estudio prospectivo en fetoscon HDCs. FETO fue realizada antes de la 29 SG a fetoscon un lung head ratio (LHR) < 1. No se realizó FETO alos pacientes con LHR entre 1,0 y 1,5 o con LHR<1 queno dieron consentimiento. El crecimiento pulmonar fuemonitorizado con el LHR. Las fetoscopias se realizaronbajo anestesia intramuscular fetal asociada a anestesiaepidural y sedación materna con remifentanilo.RESULTADOS: Se incluyeron 17 fetos. En 11 se realizóFETO que fue efectiva en 9, la mediana de la diferenciade porcentajes del LHR respecto al diagnóstico fue1,15% (p = 0,183) previamente FETO, 130,5% (p =0,003) antes de retirar el balón y 90,18% (p = 0,003)antes del parto. En los “no FETO” (n=6) la diferencia deporcentajes del LHR antes del parto respecto al diagnósticofue 49,25% (p = 0,028). Durante las fetoscopiasno se produjeron cambios significativos hemodinámicoso respiratorios maternos ni fetales. En el grupo "FETO" 45,5% sobrevivieron mientras que en el "no FETO" todos murieron. CONCLUSIONES: FETO en la HDCs parece aumentar lasupervivencia y el crecimiento pulmonar. La anestesiafetal asociada a anestesia epidural y sedación maternapermiten colocar y retirar el balón endotraqueal fetoscópicamentecon buena confortabilidad materna sin complicacionesimportantes (AU)

OBJECTIVES: To evaluate survival and lung growth infetuses with severe congenital diaphragmatic hernia(CDH) treated with fetoscopic tracheal occlusion(FETO) compared with control fetuses and to analyzepossible complications of the anesthetic techniques used.PATIENTS AND METHODS: This prospective study wasperformed on fetuses with CDH. FETO was undertakenbefore the 29th week of gestation on fetuses with a lungto-head ratio (LHR) less than 1. FETO was notperformed on fetuses with an LHR between 1.0 and 1.5or those with an LHR less than 1 where consent was notgiven. Lung growth was monitored by means of LHR.FETO was performed under fetal intramuscularanesthesia and maternal epidural anesthesia andsedation with remifentanil.RESULTS: Seventeen fetuses were included in thestudy. FETO was performed on 11 fetuses and waseffective in 9. The median percentage difference betweenLHR at diagnosis and prior to FETO was 1.15%(P=.183); between diagnosis and before removing theballoon, the difference was 130.5% (P=.003); andbetween diagnosis and before delivery, 90.18% (P=.003).In the control group (n=6), the median percentagedifference between LHR at diagnosis and before deliverywas 49.25% (P=.028). No significant hemodynamic orrespiratory changes occurred in either mother or fetusduring fetoscopy. All the fetuses in the control groupdied; 45.5% of those in the FETO group survived. CONCLUSIONS: The use of FETO in cases of CDHappears to increase survival and lung growth. Fetalanesthesia in association with maternal epidural anesthesiaand sedation makes it possible to place and remove theendotracheal balloon via fetoscopy with acceptablematernal comfort and without notable complications (AU)

[Two cases of congenital airway obstruction managed with ex utero intrapartum treatment procedures: anesthetic implications]. / Dos casos de obstrucción congénita de la vía aérea sometidos a E.X.I.T. ("ex-utero intrapartum treatment"): implicaciones anestésicas.

An ex utero intrapartum treatment (EXIT) procedure provides sufficient time to gain control of the potentially obstructed fetal upper airway while uterine placental circulation is maintained during cesarean section. We report 2 cases in which fetal congenital upper airway obstruction was managed without complications during EXIT procedures. We also discuss general considerations concerning the obstetric patient and the performance of intramuscular fetal anesthesia. Before the hysterotomy, sevoflurane at 1.5 minimum alveolar concentration was administered to assure sufficient uterine relaxation during EXIT. The 2 parturients remained hemodynamically stable during the procedure and uterine and placental perfusion was adequate. Nasotracheal intubation was possible in 1 fetus after a cervical mass was dissected. In the other, a tracheostomy was created. After the umbilical cord was clamped, the concentration of sevoflurane anesthetic gas was reduced and oxytocin and methylergometrine were administered to induce adequate uterine contractions within a few minutes. Both neonates survived the EXIT procedure with no complications.

Dos casos de obstrucción congénita de la vía aérea sometidos a E.X.I.T. ("ex-utero intrapartum treatment"): implicaciones anestésicas / Two cases of congenital airway obstruction managed with ex utero intrapartum treatment procedures: anesthetic implications

El procedimiento E.X.I.T. (“Ex-Utero Intrapartum Treatment”) proporciona un tiempo adecuado para conseguir el control de una vía aérea fetal potencialmente obstruida mientras se mantiene la circulación útero-placentaria durante la cesárea. Describimos dos casos clínicos de fetos con obstrucción congénita de la vía aérea alta en los que la estrategia E.X.I.T. permitió permeabilizar con éxito y sin complicaciones en la vía aérea. Además de tomarse las consideraciones generales de la paciente obstétrica y de realizarse anestesia fetal intramuscular, previamente a la histerotomía se administró sevofluorano a 1,5 CAM para conseguir una adecuada relajación uterina durante el procedimiento. Las dos gestantes permanecieron hemodinámicamente estables durante el procedimiento con una adecuada perfusión útero-placentaria. En un feto la intubación nasotraqueal fue posible tras disecar la masa cervical mientras que en el otro se realizó una traqueostomía. Tras el clampaje del cordón umbilical se redujo la concentración de halogenado y se administraron oxitocina y metilergometrina para conseguir una contracción uterina adecuada en pocos minutos. Ambos neonatos sobrevivieron al procedimiento sin complicaciones

An ex utero intrapartum treatment (EXIT) procedure provides sufficient time to gain control of the potentially obstructed fetal upper airway while uterine placental circulation is maintained during cesarean section. We report 2 cases in which fetal congenital upper airway obstruction was managed without complications during EXIT procedures. We also discuss general considerations concerning the obstetric patient and the performance of intramuscular fetal anesthesia. Before the hysterectomy, sevoflurane at 1.5 minimum alveolar concentration was administered to assure sufficient uterine relaxation during EXIT. The 2 parturients remained hemodynamically stable during the procedure and uterine and placental perfusion was adequate. Nasotracheal intubation was possible in 1 fetus after a cervical mass was dissected. In the other, a tracheostomy was created. After the umbilical cord was clamped, the concentration of sevoflurane anesthetic gas was reduced and oxytocin and methylergometrine were administered to induce adequate uterine contractions within a few minutes. Both neonates survived the EXIT procedure with no complications

Cerebral hemodynamic changes during sustained hypocapnia in severe head injury: can hyperventilation cause cerebral ischemia?

Hyperventilation (HV) is routinely used in the management of increased intracranial pressure (ICP) in severe head injury. However, this treatment continues to be controversial because it has been reported that long-lasting reduced cerebral blood flow (CBF) due to profound sustained hypocapnia may contribute to the development or deterioration of ischemic lesions. Our goal in this study was to analyze the effects of sustained hyperventilation on cerebral hemodynamics (CBF, ICP) and metabolism (arterio jugular differences of lactates = AVDL). CO2-reactivity and CBF was estimated using AVDO2 (arteriojugular differences of oxygen content). Global cerebral ischemia and increased anaerobic metabolism were considered according to AVDO2 and AVDL respectively. Thirty-three patients with severe and moderate head injury and increased ICP were included. Within 72 hours after accident, patients were hyperventilated for a period of 4 hours. During this time jugular oxygen saturation (SjO2), arterial oxygen saturation (SaO2), ICP, mean arterial blood pressure (MABP), AVDO2 and AVDL were recorded. In our study, most patients preserved CO2-reactivity (88.2%). In these cases HV was very effective in lowering ICP. Our findings showed that this reduction was due to a CBF decrease. According to basal AVDO2 twenty-five patients (75.7%) were considered as hyperemic and eight (24.2%) as not hyperemic. Global ischemia and increased anaerobic metabolism were detected in one case in the non-hyperemic group. According to AVDO2 and AVDL, no adverse effects were found during four hours of HV in hyperemic patients. Nevertheless, AVDO2 and AVDL are global measurements and might not detect regional ischemia surrounding focal lesions such as contusions and haematomas. We suggest that monitoring of AVDO2 or other haemometabolic variables should be mandatory when sustained HV is used in the management of head injury patients.