Efectividad del uso de ketamina perioperatoria en pacientes sometidos a cirugía de raquis en tratamiento crónico con opioides / Postoperative ketamine efficacy in patients receiving chronic opioids undergoing spinal surgery

Introducción: El número de pacientes en tratamiento con opioides de forma crónica sometidos a una cirugía espinal ha aumentado en los últimos años. Los registros de dolor mediante la escala visual analógica (EVA) y el consumo de opioides durante el postoperatorio son más elevados en esta clase de pacientes.Material y métodos: Siguiendo las recomendaciones de la American Pain Society (APS), en 2018 se diseñó un nuevo protocolo analgésico intra y postoperatorio basado en el uso de ketamina. En el intraoperatorio, se administró un bolus de 0,5 mg/kg de ketamina, seguido por una perfusión a dosis de 0,2 mg/kg/h hasta el cierre de la herida. Durante las 48 horas postoperatorias, se mantuvo una bomba de analgesia controlada por el paciente (PCA) de morfina-ketamina junto con un régimen de analgesia multimodal con paracetamol y dexketoprofeno. Se realizó un análisis de la efectividad del nuevo protocolo (grupo ketamina) comparándolo con el protocolo seguido el año anterior (grupo control), basado en el uso de tramadol 100 mg/6 h o PCA de morfina. Se analizaron los registros de dolor mediante la escala verbal numérica (EVN) durante las primeras 48 horas postoperatorias, la necesidad de administración de bolus puntuales de morfina y la necesidad de iniciar una perfusión continua de morfina (grupo control) o morfina ketamina (grupo ketamina). Resultados: Los pacientes del grupo ketamina presentaron EVN inferiores a los del grupo control durante las dos primeras horas postoperatorias (p = 0,001) y menores necesidades de rescates de morfina en el segundo día postoperatorio (p = 0,003). La necesidad de perfusión continua de morfina-ketamina fue significativamente inferior a la necesidad de inicio de perfusión continua de morfina en el grupo control (p = 0,011). Conclusión: El protocolo basado en el uso de ketamina consiguió mejorar el control del dolor postoperatorio y reducir de forma significativa el consumo de opioides en las primeras 48 horas...(AU)

Introduction: The number of patients receiving chronic opioids undergoing spinal surgery has increased lately. Elevate records in visual analog scale (VAS) and opioid consumption are higher in this group of patients. Material and methods: Following the recommendations of the American Pain Society (APS), a new intra and postoperative analgesic protocol based on the use of ketamine was designed in 2018. Intraoperatively, a bolus of 0.5 mg/kg of ketamine was administered, followed by a dose infusion of 0.2 mg/kg/h until the surgical wound was closed. During the first 48 post­operative hours, a patient-controlled analgesia pump (PCA) of morphine-ke­tamine was maintained along with a multimodal analgesia regimen with paracetamol and dexketoprofen. An effectiveness analysis comparing the new protocol (ketamine group) with the previous one (control group), based on the use of tramadol 100 mg / 6h or PCA morphine, was done. During the first 48 postoperative hours, NVS records, need of rescue analgesia, morphine bolus or continuous morphine infusion (control group) or ketamine morphine infusion (ketamine group) were analyzed. Results: The patients in the ketamine group had lo­­wer NVS records than those in the control group during the first two postoperative hours (p = 0.001) and lower morphine rescues needs on the second postoperative day (p = 0.003). The need for continuous morphine-ke­tamine perfusion was significantly lower than the need for continuous morphine perfusion on the control group (p = 0.011). Conclusion: The protocol based on the use of ke­tamine, managed to improve the control of postoperative pain and significantly reduce the consumption of opioids in the first 48 hours after the intervention.(AU)

Clevidipino como antihipertensivo en la cirugía de feocromocitoma / Clevidipine for hypertension treatment in pheochromocytoma surgery

El feocromocitoma es un tumor productor de catecolaminas y su tratamiento de elección es la adrenalectomía laparoscópica. Durante la insuflación del neumoperitoneo y la manipulación tumoral hay alto riesgo de liberación masiva de catecolaminas y crisis hipertensivas. Tras la exéresis tumoral es frecuente la hipotensión arterial grave por vasodilatación relativa y por el efecto residual de los fármacos antihipertensivos utilizados. Presentamos el caso clínico de un paciente con feocromocitoma intervenido de adrenalectomía laparoscópica. Durante la manipulación quirúrgica hubo un pico hipertensivo brusco que pudo controlarse rápidamente con clevidipino en perfusión. Tras la resección tumoral se detuvo la perfusión y no se produjo hipotensión arterial en ningún momento. El clevidipino es un nuevo antagonista del calcio intravenoso con inicio de acción rápido y vida media corta que no tiene efecto residual y no causa hipotensión tras la resección tumoral, por lo que puede ser un fármaco de primera elección esta cirugía

Pheochromocytoma is a catecholamine-producing tumour and laparoscopic adrenalectomy is its treatment of choice. During pneumoperitoneum insufflation and tumour handling there is a high risk of massive catecholamine release and hypertensive crisis. After tumour excision, severe arterial hypotension is a common effect, due to relative vasodilation and the residual effect of antihypertensive drugs. We report the case of a patient with pheochromocytoma who was treated with laparoscopic adrenalectomy. During surgical manipulation there was a sudden hypertensive peak that could be controlled quickly with clevidipine infusion. After tumour resection, clevidipine perfusion was stopped and there were no arterial hypotension episodes. Clevidipine is a new intravenous calcium antagonist with rapid onset of action and short half-life that has no residual effect and does not produce arterial hypotension after tumour resection. For these reasons, it can be a first-choice drug for this kind of surgery

Clevidipine for hypertension treatment in pheochromocytoma surgery. / Clevidipino como antihipertensivo en la cirugía de feocromocitoma.

Pheochromocytoma is a catecholamine-producing tumour and laparoscopic adrenalectomy is its treatment of choice. During pneumoperitoneum insufflation and tumour handling there is a high risk of massive catecholamine release and hypertensive crisis. After tumour excision, severe arterial hypotension is a common effect, due to relative vasodilation and the residual effect of antihypertensive drugs. We report the case of a patient with pheochromocytoma who was treated with laparoscopic adrenalectomy. During surgical manipulation there was a sudden hypertensive peak that could be controlled quickly with clevidipine infusion. After tumour resection, clevidipine perfusion was stopped and there were no arterial hypotension episodes. Clevidipine is a new intravenous calcium antagonist with rapid onset of action and short half-life that has no residual effect and does not produce arterial hypotension after tumour resection. For these reasons, it can be a first-choice drug for this kind of surgery.

Situación actual del dolor postoperatorio en el "Año Global Contra el Dolor Agudo" / No disponible

No disponible

Enfermedad tromboembólica en la embarazada: estrategias de profilaxis y tratamiento / No disponible

No disponible

Síndrome de hiperestimulación ovárica: fisiopatología y repercusiones sistémicas / No disponible

No disponible

Rotura traqueal yatrogénica / No disponible

No disponible

[Update on the anesthetic management of patients with malignant carcinoid syndrome]. / Actualización del manejo anestésico de un paciente con síndrome carcinoide.

Carcinoid crisis during surgery can lead to severe hemodynamic alterations (hypo- and hypertension) and bronchospasm. Intravenous infusion of octreotide, preceded by preoperative subcutaneous administration, can allow such crises to be brought under control quickly. Given the high prevalence of carcinoid cardiopathy, which increases the risk of a crisis in these patients, a preoperative echocardiogram should be performed. General anesthesia combined with epidural blockade is effective in this context. Block onset should be gradual to avoid the development of hypotension, which is difficult to treat. The pharmacodynamic profile of remifentanil, its elevated potency, and low histamine releasing potential mean that this opioid offers novel advantages during general anesthesia.

Actualización del manejo anestésico de un paciente con síndrome carcinoide / Update on the anesthetic management of patients with malignant carcinoid syndrome

Las crisis carcinoides durante el intraoperatorio pueden dar lugar a severas alteraciones hemodinámicas (hipo e hipertensión)y broncospasmo. La administración de octeótrida endovenosa para el control de las crisis, precedido de su administración subcutánea preoperatoria, permite un rápido control. Dada la elevada frecuencia de cardiopatía carcinoide en estos pacientes, debe realizarse un ecocardiograma preoperatoriamente en todos. Su presencia supone un factor de riesgo para la presentación de las crisis. La anestesia general combinada con bloqueo epidural supone una alternativa eficaz en estos pacientes. Se debe instaurar el bloqueo progresivamente para evitar la aparición de hipotensión, de difícil tratamiento. El empleo del remifentanilo como opioide durante la anestesia general nos ofrece nuevas ventajas en este tipo de pacientes, gracias a su perfil farmacocinético, elevada potencia y bajo potencial histaminoliberador, dando buenos resultados

Carcinoid crisis during surgery can lead to severe hemodynamic alterations (hypo-and hypertension)and bronchospasm. Intravenous infusion of octreotide, pre- ceded by preoperative subcutaneous administration, can allow such crises to be brought under control quickly. Given the high prevalence of carcinoid cardiopathy, which increases the risk of a crisis in these patients, a preoperative echocardiogram should be performed. General anesthesia combined with epidural blockade is effective in this context. Block onset should be gradual to avoid the development of hypotension, which is difficult to treat. The pharmacodynamic profile of remifentanil, its elevated potency, and low histamine releasing potential mean that this opioid offers novel advantages during general anesthesia

Awareness detected by auditory evoked potential monitoring.

We report a case of awareness detected by the Alaris AEP Monitor, a device that measures anaesthesia by tracking changes of the waveform of the mid-latency auditory evoked potential.

[Degrees of acceptance of local regional anesthetic techniques among hospital physicians]. / Grado de aceptación de las técnicas de anestesia locorregional entre los médicos hospitalarios.

We have evaluated the acceptance of local regional anesthetic techniques (LRA) among the physicians of our hospital by means of an anonymous questionnaire. The people addressed had to choose, as if they were hypothetical patients, the type of anesthesia (general or local regional anesthesia) in four clinical hypothetical situations: interventions on upper limb (UL), on lower limb (LL), in an emergency situation and in a scheduled situation. We obtained 109 answers: 58 from medical specialities (cardiology, gastroenterology, internal medicine, pneumology, and radiology) and 51 from surgical specialities (general surgery, gynecology, ear, nose and throat, and traumatology). Local regional anesthetic techniques were the most frequently selected (p less than 0.001) and the main reason for selection was safety. Surgeons choose LRA more frequently than medical specialists but the difference was not significant. More information on such techniques does contribute to an increase in its acceptance, a fact which is clearly reflected in the medical staff of our hospital.

[Malignant hyperthermia. Apropos of a case]. / Hipertermia maligna. A propósito de un caso.

We present the clinical case of a thirteen-year-old male patient who suffered a malignant hyperthermia syndrome after an adenoidectomy under general anaesthesia. The recovery of the patient was successful with the specific treatment of dantrolene. We believe it is interesting to publish all the cases of malignant hyperthermia in order to have a better knowledge of the real incidence in our country.