[Anesthesia in a patient with Ellis-van Creveld syndrome]. / Tratamiento anestésico de una paciente con síndrome de Ellis-Van Creveld.

Ellis-van Creveld syndrome is a rare type of developmental chondroectodermal dysplasia. We report the case of a 32-year-old woman with this syndrome who was scheduled for cesarean section. She had no related heart defect. A spinal block was attempted but after confirming that no sensory blockade had been achieved, general anesthesia was administered. Both the operation and the anesthetic procedure were without complications. The clinical manifestations of Ellis-van Creveld syndrome are short-limbed dwarfism, postaxial polydactyly, fingernail dysplasia, cleft palate and lips, and heart defects. Diagnosis is based on clinical manifestations and radiography. Treatment involves correction of heart defects and orthopedic problems. Perioperative airway management problems may develop. A preoperative echocardiogram should be done to assess heart function and ascertain anatomical abnormalities. Thoracic deformities may make mechanical ventilation difficult and there is risk of barotrauma. Intraoperative management requires rapid control of the airway and prevention of bronchial aspiration. Vigilance in preventing hemodynamic instability and myocardial depression is essential. Postoperative analgesia must be managed carefully and adverse cardiorespiratory events avoided.

[Multiple-injection thoracic paravertebral block for reconstructive breast surgery]. / Bloqueo paravertebral torácico con punción múltiple en cirugía reconstructiva de la mama.

OBJECTIVE: To describe the use of multiple-injection thoracic paravertebral blockade, with intravenous sedation, for anesthesia during reconstructive breast surgery. MATERIAL AND METHODS: Descriptive, prospective study in 100 scheduled operations for major reconstructive breast surgery. The paravertebral block was performed by means of 3 injections at the lower edges of the vertebral apophyses at T3-5. We recorded time performing the procedure, latency (time until block onset), dermatomes blocked, degree of effectiveness, conversion to general anesthesia, postoperative complications and pain, and patient satisfaction. RESULTS: Dermatomes T3, T4, and T5 were blocked in 99% of the patients. The block took 7.39 minutes to perform and latency was 7.37 minutes. Postoperative analgesia with anti-inflammatory drugs was adequate for most patients. There were 3 cases of epidural diffusion, 10 patients with hypotension, 12 with postoperative nausea or vomiting, and 3 with symptoms of epidural blockade. Intravascular puncture occurred, without complications, in 3 cases. There were no cases of pneumothorax or intrathecal injection. Ninety-one percent of the patients declared they were satisfied or very satisfied with the technique. CONCLUSIONS: Triple-injection paravertebral blocks, in which 3 fractions of the total anesthetic dose are delivered to block dermatomes T3-5 is an effective technique that is easy to perform and leads to few complications. Most patients express a high degree of satisfaction with this anesthetic technique.

[Sugammadex, a novel drug for neuromuscular blockade reversal]. / Sugammadex. Nuevo fármaco reversor del bloqueo neuromuscular.

Significant progress in the management of aminosteroid nondepolarizing neuromuscular blockers will follow the introduction of sugammadex (Org 25969). Safety and rapid recovery of muscle force will improve and the adverse effects of acetylcholinesterase inhibitors will be avoided. Sugammadex is a modified gamma-cyclodextrin agent developed for the specific reversal of rocuronium and, to a lesser extent, vecuronium. This novel drug functions by means of encapsulation (chelation). Sugammadex was recently approved by the European Medicines Evaluation Agency and became available in Spain in 2009, leading to a series of changes related to patient safety and surgical conditions. We review the literature on sugammadex published to date.

[Anesthetic considerations in sickle cell anemia: a case report]. / Descripción de un caso de drepanocitosis y consideraciones anestésicas.

Sickle cell anemia is the most common hemoglobinopathy. Advances in therapeutic techniques and anesthetic procedures have led to a considerable increase in the success of surgical procedures in these patients. We report the case of a 16-year-old black boy diagnosed with sickle cell anemia and beta-thalassemia who presented with chronic osteomyelitis of the tibia. He was scheduled for debridement of the lesion and musculocutaneous flap repair. We emphasize the importance of communication between anesthesiologists, surgeons, and hematologists in the perioperative period in order to determine the risk of complications and anticipate them.

Combination of thoracic blocks as a main anesthetic tecnique in modified radical mastectomy for patients with severe respiratory disease. / Combinación de bloqueos torácicos como método anestésico principal en mastectomía radical modificada para pacientes con compromiso respiratorio severo.

The addition of ultrasound to locoregional anaesthesia in the last few years has led to the description of various fascial thoracic blocks with analgesic purposes: PECS 1 and 2 block, serratus plane block, serratus intercostal fascial block, blockade in the plane of the thoracic transverse muscle..., which have been added to other well-known nerve blocks, such as thoracic paravertebral block or intercostal block. In this sense, locoregional anaesthesia has been universally recommended in patients with severe respiratory processes in order to avoid ventilatory support and subsequent weaning that considerably increases postoperative morbidity and mortality rates. However, as regards thoracic wall and axillary hollow, there are very few references which detail the use of nerve or fascial blocks as a main anaesthetic method. Two extreme cases are presented of multi-pathological patients with serious respiratory disease who successfully underwent a modified radical mastectomy plus surgery in the axillary space using a combination of ultrasound-guided thoracic blocks that allowed surgery without general anaesthesia, avoiding mechanical ventilation, and maintaining spontaneous breathing throughout the surgical procedure. The main indications of the anaesthetic blocks used are described, focusing on the performance of the technique and underlining, in a novel way, the possibility of facing aggressive surgery at the level of the armpit with only locoregional anaesthesia.

[Abdominal compartment syndrome]. / Síndrome compartimental abdominal.

The measurement of intra-abdominal pressure (IAP) is gaining importance in critical care units because of its prognostic value. The standard method of measurement is intravesical. When the IAP is high, the condition is referred to as intra-abdominal hypertension. The elevation may be compensated for if it is not excessive or if the increase was not rapid, or it might have various repercussions, in which case abdominal compartment syndrome (ACS) is diagnosed. The pathogenic mechanism that underlies ACS is the response of a territory predisposed to a process of ischemia and reperfusion, with release of inflammatory cytokines and formation of free radicals (anaerobic metabolism). Clinical manifestations comprise elevated IAP, oliguria, difficult mechanical ventilation with hypoxia and hypercapnia, and diminished cardiac output. ACS leads to multisystem dysfunction and, if not treated, to multiple organ failure and death. The rapid establishment of appropriate treatment measures is important. The first line of treatment is medical but definitive surgical treatment should not be delayed.

[Obesity and bariatric surgery: anesthesia implications]. / Obesidad y cirugía bariátrica: implicaciones anestésicas.

Over the last few years, obesity has been constantly increasing, thus turning it into a serious public health problem, with the subsequent impact on health-related expenditure, particularly in developed countries. The main peculiarity of obesity is its association with numerous pathologies (respiratory disease, cardiovascular problems, endocrinological or metabolic disorders, etc.) that leads it to be related with high levels of mortality and morbidity, affecting both the quality and duration of the life of sufferers. The attempts to prevent obesity and, when these fail, the treatments that can be resorted to cover many aspects: behavioural, dietary and medical. But these are frequently doomed to failure because of their potentially very demanding nature, at which times, after complying with certain minimal requirements and a detailed assessment, it is possible to move on to the next step: bariatric surgery. This is a part of the therapeutic armoury that is enjoying a constant boom, with very favourable results that mean the physiopathology of this condition should be known in greater detail by all of the multidisciplinary team dealing with the problem: GPs, endocrinologists, psychiatrists, general surgeons and anaesthesiologists, with the latter being involved in all of the peri-surgical activity (pre-, intra- and post-operative stages, in the reanimation units). From the standpoint of anaesthesia (the focus of this paper as it is the least well-known of those mentioned), obese individuals are at a disadvantage with respect to other non-obese patients as the process is complicated and the risk increases. With this review of the subject, it is intended to recall the physiopathological changes produced by obesity as well as the anaesthetic implications within the framework of bariatric surgery, so as to achieve the most favourable possible results from the surgery.

[Obesity, anesthesia and bariatric surgery]. / Obesidad, anestesia y cirugía bariátrica.

Obesity is increasingly prevalent, particularly in developed countries, and has come to represent a serious threat to public health, with consequent repercussions on health care expenditure. Bariatric surgery is a great advance in the treatment of obese patients. Applied when all other measures have failed, this therapeutic option is achieving very favorable outcomes and is therefore being carried out with increasing frequency. Obese patients are at a disadvantage during anesthesia, given that techniques are more difficult to perform and risk increases. It therefore becomes particularly important to understand the pathophysiological changes that obesity brings about as well as the implications for anesthesia in the context of bariatric surgery so that outcomes can be as favorable as possible.

[Management of peri-operative hypothermia]. / Manejo de la hipotermia perioperatoria.

Hypothermia (body temperature under 36°C) is the thermal disorder most frequently found in surgical patients, but should be avoided as a means of reducing morbidity and costs. Temperature should be considered as a vital sign and all staff involved in the care of surgical patients must be aware that it has to be maintained within normal limits. Maintaining body temperature is the result, as in any other system, of the balance between heat production and heat loss. Temperature regulation takes place through a system of positive and negative feedback in the central nervous system, being developed in three phases: thermal afferent, central regulation and efferent response. Prevention is the best way to ensure a normal temperature. The active warming of the patient during surgery is mandatory. Using warm air is the most effective, simple and cheap way to prevent and treat hypothermia.

[Thoracic paravertebral block compared to thoracic paravertebral block plus pectoral nerve block in reconstructive breast surgery]. / Bloqueo paravertebral torácico frente al bloqueopararavertebral torácico más bloqueo de nervios pectoralesen cirugía reconstructiva de mama.

INTRODUCTION: Major breast surgery was usually performed under general anaesthesia until the first patient series with thoracic paravertebral block was published. This block was introduced into our Hospital, and with the purpose of obtaining a more comfortable perioperative period, it was combined with blocking the pectoral nerves. In this study, both anaesthetic techniques are compared, as regards control of postoperative pain, incidence of postoperative nausea and vomiting, and sedation requirements. MATERIAL AND METHODS: An observational study was conducted with 60 patients scheduled for breast surgery with subpectoral implants (augmentation and /or prosthesis). Two groups were studied. The first (Group I) was randomly selected from a patient records data base to have thoracic paravertebral block and sedation. In the second (Group II), a pectoral nerve block was performed combined with a thoracic paravertebral block. RESULTS: In Group I, 33.3% of the patients had a score of ≤ 3 on the visual analogue scale (VAS) at 8 hours, and 66.7% had a VAS score of ≥ 4 at 24h, compared to 80% of the Group II patients who had a VAS score of ≤ 3 at 8 hours and 20% with a VAS score ≥ 4 at 24h. The mean difference in the VAS scores at 8 hours between the two groups was statistically significant: mean VAS score at 8 hours in Group I, 4.23 ± 2.4 compared to 1.77 ± 2.2 in Group II. There was no difference in the VAS scores at 24 hours. No statistically significant differences were found between the two groups in the incidence of postoperative nausea and vomiting. The need for intra-operative sedation supplements with propofol boluses was less in Group II, 40% compared to 90% in Group II. CONCLUSIONS: Pectoral nerve block is a technique that improves the results obtained with thoracic paravertebral block in reconstructive breast surgery, with better post-operative analgesic control in the immediate post-operative period and a lower requirement for sedation.