Intraoperative high flow oxygen therapy for tubeless anaesthesia in thoracoscopic surgery.

Tubeless anaesthesia has become widespread in videothoracoscopic surgery, even in major procedures such as lobectomies. There are several advantages in avoiding general anaesthesia and one-lung mechanical ventilation, such as faster recovery and shorter hospital stays. However, hypoxaemia and hypercapnia are the most reported causes of conversion to general anaesthesia. High Flow Oxygen Therapy (HFOT) generates flow-dependent positive end-expiratory pressure, improves oxygenation and also carbon dioxide washout by flow-dependent dead space flushing. For this reason, intraoperative HFOT may reduce the rate of conversion to general anaesthesia. We report our experience with intraoperative HFOT in a 71-year-old female with lung adenocarcinoma undergoing VATS upper left lobectomy.

Non intubated video-assisted thoracoscopic lung resections (NI-VATS) in COVID times.

The emergence of epidemic Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in December 2019 in Wuhan, China causing Coronavirus Disease 2019 (COVID-19) and its rapid expansion around the world, leading to a global pandemic of dimensions not observed at least since the "Spanish influenza" pandemic in 1917-18, has had great consequences at all levels, including social, health and economic spheres. This pandemic situation forces us, as health care workers, to redefine our medical and surgical actions to adapt them to this new reality. It is important, when the rules of the game change, to rethink and to reevaluate if the balance between risk and benefit have moved to a different point of equilibrium, and if our indications of certain surgical interventions need to be redefined. In this article we try to answer the doubts that arise about the suitability of the NI-VATS technique and assess whether its use in these new pandemic circumstances might add advantages, especially in relation to minimize the risks of virus contagion between patients and all healthcare personnel during the surgical procedure, as well as the known advantages described in many articles the last ten years.

[Remifentanil in heart surgery]. / Remifentanilo en cirugía cardíaca.

The contributions of remifentanil to anesthesia for heart surgery is described. The pharmacokinetic properties are described along with our clinical experience with the various modes and doses of perfusion for induction as well as during and after surgery.

[The use of high-frequency jet ventilation for ventilatory support in an extreme case]. / Utilidad de la ventilación con jet a alta frecuencia como soporte ventilatorio alternativo en un caso extremo.

We report the case of a 27-year old man given a left lateral thoracotomy for emergency repair of the aortic isthmus, which had partially ruptured as a consequence of chest trauma. The patient also suffered serious trauma to the right lung, such that selective ventilation of that lung had to be applied with the left lung collapsed to allow the surgeon access to the descending aorta. Rapid decrease in SpO2 occurred, with excessively high airway pressures, requiring reinstatement of conventional ventilation of both lungs and interruption of surgery. Conventional ventilation was then replaced by high frequency jet ventilation to both lungs. That technique, combined with intermittent inflation of the left lung (inclined), provided sufficient oxygen as well as a wide and sufficiently immobile surgical field.

[Quantification of dehydration of soda lime in clinical circumstances]. / Cuantificación de la desecación de la cal sodada en circunstancias clínicas.

HYPOTHESIS AND OBJECTIVES: When the CO2 absorbents, soda lime and baralime, have lost their normal level of hydration, they may react with certain halogenated anesthetics to produce appreciable levels of carbon monoxide. The degree of absorbent desiccation has been considered the limiting factor for this phenomenon. This study quantifies the level of dehydration of lime produced under clinical conditions and the influence of several factors. MATERIAL AND METHOD: Desiccation was determined: 1) at set periods of time (3, 7 and 14 days) after clinical use of fresh soda lime in general anesthesia using a fresh gas flow (FGF) of 6 l/min, and 2) after gas had been crossing the continuous flow (CF) oxygen reservoir at 7 l/min for 17 and 65 hours. Two anesthetic systems were used: a) the Ohmeda Excel-210, in which the continuous FGF did not cross the reservoir and b) the Siemens Ventilator 710, in which the FGF did cross the reservoir. The experiments were repeated with three types of lime. RESULTS: The clinical use of lime for 3, 7 and 14 days caused different levels of desiccation, with decreases in hydration of up to 50% and 14 days. Nevertheless, water content was always over 5%, a level at which no reaction with halogenated agents takes place. After 17 and 65 hours of CF in the circuit where continuous FGF did not pass through the canister, the water content did not change. With the Siemens 710 circuit, in which the continuous FGF crossed the canister, the dehydration level was 1.2 +/- 0.3% after 17 hours and 0.7 +/- 0.3% after 65 hours, a level that can produce CO upon reaction between lime and halogenated gases. The type of lime used had little effect. CONCLUSIONS: Lime does not desiccate to levels able to produce CO in daily use, regardless of the FGF system used. The phenomenon of desiccation depends on two factors: 1) use of anesthetic equipment in which continuous FGF conditions require gas to pass through the canister, and 2) the maintenance of CF for a sufficient period of time.

[Epidural abscess secondary to the implantation of a thoracic catheter]. / Absceso epidural secundario a la implantación de un catéter torácico.

Spinal compression related to the formation of an epidural abscess after epidural blockade is a rare but serious complication. We report the case of a male patient in whom a thoracic epidural catheter was implanted to provide analgesia after trauma involving fracture ribs. The patient developed an epidural abscess within one week of implantation. Delay in diagnosis led to persistent neurogenic bladder symptoms in spite of aggressive treatment. We review causal factors, mechanisms of formation, pathogenesis, diagnosis and management, as well as possible relation between injury and abscess formation. We also emphasize the importance of adequate vigilance as well as rapid diagnosis and adoption of therapeutic measures in order to avoid permanent sequelae such as paresis, sensory deficits or mechanical sphincter dysfunction.

Low-flow anesthesia and reduced animal size increase carboxyhemoglobin levels in swine during desflurane and isoflurane breakdown in dried soda lime.

UNLABELLED: After institutional approval, we studied the effect of animal size, anesthetic concentration, and fresh gas flow (FGF) rate on inspired carbon monoxide (CO) and carboxyhemoglobin (COHb) during anesthesia in swine, using soda lime previously dried to 1 +/- 0.1% water content. To ascertain the effect of anesthesia, eight adult pigs were anesthetized with either 1 minimum alveolar anesthetic concentration (MAC) desflurane or isoflurane and, to characterize the effect of the FGF rate, it was doubled in four pigs. To determine the effect of animal size, four small and four large pigs received 1 MAC desflurane or isoflurane, and to determine the effect of the anesthetic concentration, a group of four swine was exposed to 0.5 MAC. CO and COHb concentrations were larger with desflurane (5500 +/- 980 ppm and 57.90% +/- 0.50%, respectively) than with isoflurane (800 ppm and 17.8% +/- 2.14%, respectively), especially in the small animals. Increasing the FGF rate significantly reduced peak CO and COHb concentrations resulting from both anesthetics; however, when each anesthetic was reduced to 0.5 MAC, the concentrations obtained were similar. We conclude that CO intoxication is more severe with desflurane than with isoflurane, that small animals are at higher risk for CO poisoning, and that low FGF can increase COHb concentrations. IMPLICATIONS: The present study shows that the use of desflurane with desiccated carbon dioxide absorbents in pediatric anesthesia can produce a dangerous carbon dioxide intoxication, especially with low-flow anesthesia.

Remifentanilo en cirugía cardíaca / Remifentanil in heart surgery

Se describe la aportación que ha incorporado el remifentanilo a las técnicas anestésicas empleadas en cirugía cardíaca. Se detallan las características farmacocinéticas, así como nuestra experiencia clínica en distintos modos y dosis de perfusión, tanto en la inducción como en el intra y postoperatorio (AU)

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Comparación de dos pautas analgésicas para el tratamiento del dolor postoperatorio tras reconstrucción de los ligamentos de la rodilla en programas de cirugía mayor ambulatoria / Comparison between two analgesic regimes for the management of postoperative pain after reconstruction of knee ligaments in programs of major outpatient surgery

Introducción: Durante la última década la CMA aumentó el número, la diversidad y la complejidad de las intervenciones realizadas, fracasando las técnicas analgésicas convencionales en el objetivo de conseguir una analgesia postoperatoria óptima. Un 30-40 por ciento de los pacientes dados de alta en una unidad de CMA pueden tener dolor de moderado a severo. La complicación más frecuente en cirugía de reconstrucción de los ligamentos de la rodilla, vía artroscópica, es el dolor severo, por lo que para realizar con éxito estas intervenciones en programas de CMA, debemos garantizar una buena analgesia postoperatoria. Objetivo: El objetivo de este estudio es valorar la eficacia y efectividad de la analgesia postoperatoria, los efectos secundarios y el grado de satisfacción en un programa de CMA, de la administración de analgesia endovenosa continua, mediante infusores tipo elastoméricos, frente al método convencional de tratamiento vía oral. Material y método: Estudio prospectivo, randomizado de 50 pacientes, programados para cirugía de reconstrucción de ligamentos de la rodilla, vía artroscópica. En todos se realiza un manejo multimodal del dolor postoperatorio (AINE, anestésicos locales y opiáceos) y se emplea una técnica anestésica similar.Los pacientes fueron distribuidos de forma aleatoria en dos grupos en función del tipo de analgesia postoperatoria administrada. Grupo A: metamizol endovenoso mediante infusor continuo a 2 ml.h-1, 6 g.día-1. Grupo B: metamizol vía oral 575 mg cada 6 horas. Todos recibieron instrucciones previas al alta hospitalaria y en su domicilio evalúan la intensidad del dolor en las primeras 48 horas en 6 intervalos de tiempo diferentes, efectos adversos, alteraciones del patrón de sueño, requerimientos de analgésicos de rescate y grado de satisfacción. Resultados: Se incluyen 50 pacientes distribuidos en dos grupos de tratamiento. En ambos grupos el dolor postoperatorio más elevado fue en T2 y T3 (24 y 32 h), sin embargo sólo existen diferencias significativas en T1 y T3 (16 y 24 h). El 34 por ciento de los pacientes no presentó dolor postoperatorio, siendo significativa la diferencia entre el grupo A (44 por ciento) y el B (24 por ciento); el 52 por ciento refirió un dolor leve y el 14 por ciento presentó dolor moderado. En el grupo B, un 12 por ciento presenta episodios de despertar nocturno asociados a dolor, y la necesidad de tratamiento de rescate e incidencia de náuseas y/o vómitos fue significativamente superior. El grado de satisfacción fue similar en ambos grupos. Conclusión: Ninguna de las dos pautas analgésicas proporciona analgesia adecuada a todos los pacientes (20 por ciento de pacientes requieren tratamiento de rescate), pero la administración de analgesia mediante infusores elastoméricos es un método seguro y eficaz que proporciona más confort al paciente (mejor control del dolor, menores necesidades de tratamiento de rescate y más horas de sueño) con un número de efectos secundarios menor. Son necesarios más estudios, para demostrar los beneficios de estas técnicas analgésicas en el contexto de la CMA. © 2003 Sociedad Española del Dolor. Publicado por Arán Ediciones, S.L (AU)

Diagnóstico diferencial de meningitis postoperatoria tras anestesia subaracnoidea / Differential diagnosis of postoperative meningitis following subaracnoid anesthesia

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