[Comparison of the effect of desflurane with isoflurane in patients over 65 years of age: multicenter study]. / Comparación de los efectos del desflurano con el isoflurano en los pacientes mayores de 65 años: estudio multicéntrico.

OBJECTIVE: To compare the effects of desflurane (DES) and isoflurane (ISO) in patients over 65 years of age based on recovery, hemodynamic variables, need for additional drugs and postoperative rates of nausea and vomiting. PATIENTS AND METHODS: Ninety-eight patients were anesthetized with DES (n = 51) at an inspired concentration of 3% or ISO (n = 47) at a concentration of 0.5%, both combined with 60% nitrous oxide. Anesthetic concentration was later adjusted to maintain hemodynamic variables within 20% above or below baseline. Analgesia was provided with fentanyl and neuromuscular relaxation with atracurium. After surgery, anesthetic gases were withdrawn. We then recorded variables related to anesthetic recovery, postoperative analgesia and the rates of nausea and vomiting. RESULTS: Mean time (+/- SD) until eye opening was 7.6 +/- 5.5 minutes for patients anesthetized with DES and was significantly less than the 14.4 +/- 8.9 minutes taken by patients anesthetized with ISO (p < 0.01). Patients anesthetized with DES spent 23 minutes less time in the recovery room than did patients anesthetized with ISO (p < 0.05). There were no significant differences in need for fentanyl, atracurium, postoperative analgesia, hemodynamic variables or rates of nausea or vomiting. CONCLUSIONS: Patients over 65 years of age anesthetized with DES recovered in half the time of patients anesthetized with ISO. DES is a safe anesthetic for elderly patients and may offer clinical advantages.

[Paraplegia after surgery for aneurysm of the descending thoracic aorta]. / Paraplejía tras cirugía de aneurisma de aorta torácica descendente.

Postoperative paraplegia caused by ischemic injury of the spinal cord is the most disabling complication of thoracoabdominal surgery, particularly when repair of the descending thoracic aorta is involved. We describe the case of a 59-year-old man who underwent emergency surgery for placement of a Dacron prosthesis to repair a ruptured descending thoracic aorta aneurysm, using an aortic cross-clamping technique plus aortic-femoral partial bypass with normothermia and an ischemic time of 165 minutes. The early postoperative course included complete spinal syndrome with motor and sensory loss below T5, with consequent respiratory insufficiency of neuromuscular origin. The result was a difficult postoperative course including prolonged mechanical ventilation and recurrent respiratory infections. Possible causes include prolonged time of ischemia, inadequate monitoring of distal aortic pressure and inappropriate surgical technique related to the absence of angiographic data on spinal vascularization. We conclude that ischemic time should be kept to under 30 minutes whenever possible. In cases of prolonged ischemia, bypass techniques with outflow to the distal aortic segment are more effective whenever mean blood pressure at this point rises to 60 mmHg or more. Vasodilator use should be reserved for cases of severe arterial hypertension and left ventricular failure and/or life-threatening increases in aortic wall stress even if not leading to dangerous decreases in distal aortic pressure. Finally, angiographic study to obtain anatomical details of spinal blood flow is advisable.

[Lung transplantation and hemophilia. Preoperative considerations]. / Trasplante pulmonar y hemofilia. Consideraciones perioperatorias.

Lung transplantation is indicated in certain patients with terminal pulmonary disease. We report a case in which a single lung (left) was transplanted to a 16-year-old girl with hemophilia B; she also suffered idiopathic pulmonary fibrosis and had a history of malnutrition, osteoporosis, severe scoliosis, hepatitis C positivity and recurrent bilateral pneumothorax. Treatment with pure factor IX was started the moment the donor lung was available and was continued for 37 days after surgery. Plasma levels of factor IX were kept at 100% during surgery and in the early postoperative period, and over 40% after that time. Correct hemostasis was thus achieved throughout the procedure, with no need for blood products. Patient outcome was satisfactory. The stay in the intensive care recovery ward was 17 days and discharge was 40 days after transplantation. We discuss aspects of hemophilia and lung transplantation, and the influence on malnutrition, chronic steroid treatment and osteoporosis.

Trasplante pulmonar y hemofilia. Consideraciones perioperatorias / Lung transplantation and hemophilia. Perioperative considerations

El trasplante pulmonar es una indicación terapéutica para pacientes seleccionados con enfermedad pulmonar terminal.Presentamos el caso clínico de un trasplante pulmonar unipulmonar izquierdo en una paciente de 16 años con hemofilia B y diagnóstico de fibrosis pulmonar idiopática, con antecedentes de desnutrición, osteoporosis, escoliosis severa, serología VHC positiva y neumotórax bilateral recidivante.La terapia sustitutiva con factor IX ultrapuro se inició en el momento en que se dispuso del pulmón donante y se mantuvo hasta 37 días postintervención. Los valores plasmáticos de factor IX se mantuvieron próximos al 100 por ciento durante el acto quirúrgico y postoperatorio inmediato, y por encima del 40 por ciento pasado éste, lo que permitió una correcta hemostasia durante todo el proceso, sin precisar la administración de hemoderivados.La evolución de la paciente fue favorable, con una estancia en la unidad de reanimación de 17 días, dándose el alta hospitalaria a los 40 días del trasplante.Se comentan las consideraciones de la hemofilia con respecto al trasplante pulmonar, y la influencia que tienen sobre éste la malnutrición, el tratamiento crónico esteroide y la osteoporosis (AU)