Ventilación jet para la extracción de un cuerpo extraño endobronquial en un paciente con neumotórax drenado: Informe de caso

Introduction Even though foreign body aspiration (FBA) is rare in adult patients, they sometimes require the performance of rigid bronchoscopy for its extraction. Ventilation for this procedure is challenging, especially in patients with pulmonary disease. Clinical, diagnostic evaluation and interventions We described the case of a 71-year old man who presented with a FBA in the left upper lobe associated with a controlateral pneumothorax. After the placement of a pleural drainage, the foreign body was extracted, using rigid bronchoscopy under general anaesthesia and high flow jet ventilation with no further haemodynamic or pulmonary complications, suggesting that this technique is safe in patients with pulmonary leaks. Conclusions In the case described, rigid bronchoscopy minimized the risk of aspiration of blood and detritus due to continuous flow of gas upward, and avoided the increase of the air leak through the pneumothorax thank to limited airway pressures, making it a clear indication.Introducción: Aunque la aspiración de cuerpos extraños es rara en adultos, requiere en algunas ocasiones la realización de una broncoscopia rígida para su extracción. El modo ventilatorio para este procedimiento es un reto, especialmente en pacientes con enfermedad pulmonar. Clínica, evaluación diagnóstica e intervenciones: Describimos aquí el caso de un paciente de 71 años con aspiración de un cuerpo extraño enclavado a nivel del lóbulo superior izquierdo asociado a un neumotórax contralateral. Después de insertar un tubo de tórax se extrajo el cuerpo extraño utilizando broncoscopia rígida bajo anestesia general y ventilación jet de alto flujo sin complicaciones hemodinámicas o pulmonares adicionales, sugiriendo que esta técnica es segura en pacientes con fugas pulmonares. Conclusiones: En el presente caso clínico, la broncoscopia rígida minimizó el riesgo de aspiración de sangre y detritus gracias a la inyección de un flujo continuo de gas ascendente, y evitó así el incremento de la fuga a través del neumotórax por las presiones limitadas en la vía aérea, constituyendo una indicación clara de esta técnic

Comparative study of two tecniques for localization of epidural space for analgesia during labour: Loss of resitance with air or saline

Tesis doctoral inédita leída en la Universidad Autónoma de Madrid, Facultad de Medicina, Departamento de Cirugía. Fecha de lectura: 30-06-2015Objetivos: La localización del espacio epidural por pérdida de resistencia con aire (PRA) es controvertida en analgesia obstétrica debido a una supuesta menor eficacia y un mayor riesgo de complicaciones, en comparación con la pérdida de resistencia con suero fisiológico (PRS). Este estudio prospectivo aleatorizado ha comparado la eficacia y la incidencia de las complicaciones más frecuentes de estas dos técnicas de punción epidural para la analgesia obstétrica. Material y métodos: Tras la aprobación del Comité de Ética del Hospital Universitario La Paz (Madrid) y firma del consentimiento informado, 400 parturientas fueron asignadas a 2 grupos para recibir una analgesia epidural con localización del espacio epidural con PRA o PRS. Se inserto un catéter epidural y se inició un protocolo de analgesia estandarizado. Se evaluó la eficacia del bloqueo epidural a los 30 minutos y en el momento del expulsivo. La aparición de efectos adversos durante la punción y a lo largo del trabajo de parto fueron recogidas, así como la necesidad de repunción del bloqueo y la repercusión de la técnica empleada sobre el modo de expulsivo y el feto. A las 24h postparto, se evaluó la incidencia del dolor en el punto de punción (DPP) y la satisfacción de las parturientas en una escala de 0 a 10. Se calculó un tamaño muestral de 177 pacientes por grupo basado en una diferencia del 20% del índice de eficacia a 30 minutos entre grupos (α=0,05 ; β=0,1). Se usaron pruebas paramétricas para variables cuantitativas, y un test Chi-2 o un de Fischer para variables cualitativas. Una p<0,05 fue considerado estadisticamente significativa. Resultados: Once pacientes del grupo PRS y 13 del grupo PRA fueron excluidas del estudio. El nivel de dolor inicial fue similar entre los grupos (p=0,732). La analgesia proporcionada por la PRA y la PRS fue comparable en magnitud tanto 30 minutos después de la punción (p=0,60) como en el momento del expulsivo (p= 0,24). La variación del dolor entre el valor pre-punción y a los 30 minutos fue similar entre los grupos (PRA: 4,7 ± 2,9 /10; PRS: 4,9 ± 3,0 /10; p=0,49). No hubo diferencias a los 30 minutos y en el momento del expulsivo respecto a la intensidad del bloqueo motor (p=0,27 y 0,42 respectivamente) y la eficacia analgésica del bloqueo (p=0,35 y 0,38 respectivamente). No hubo diferencias en la incidencia de las complicaciones de la punción epidural (p=0,31). A los 30 minutos de la punción, la incidencia de bloqueos inadecuados fue comparable entre los grupos (p=0,38), pero hubo una tendencia a una mayor tasa de bloqueos lateralizados en el grupo PRA (p=0,053). A lo largo del trabajo de parto, existió una tendencia a una mayor tasa de bloqueos inadecuados en el grupo PRA (p=0,07). Una re-punción fue necesaria en 9 (4,5%) pacientes del grupo PRA frente a 2 (1,1%) del grupo PRS (p=0,03). No hubo repercusiones de la técnica de punción sobre el modo de expulsivo (p=0,72) ni sobre el feto en términos de índice de Apgar al primer y quinto minuto de vida (p=0,72 y p=0,99 respectivamente) o de tipo de reanimación neonatal (p=0,60). A 24h del parto, el 42,1% de las pacientes del grupo PRA presentó una DPP frente al 31,1% del grupo PRS (p=0,02). La satisfacción fue mayor en las parturientas del grupo PRS (p=0,04). Conclusión: En este estudio, la punción con PRA no afectó la instauración del bloqueo epidural, ni al desarrollo de sus complicaciones más frecuentes. En cambio, la localización del espacio epidural por PRA se asoció a una mayor tasa de re-punción durante el trabajo de parto, una mayor incidencia de DPP a 24h, y una menor satisfacción de las parturienta

Intérêt de l'association pré-opératoire d'une administration orale de Gabapentine au Bloc Plexique Cervical Superficiel en chirurgie thyroïdienne (une étude randomisée double aveugle contre placebo)

LILLE2-BU Santé-Recherche (593502101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Levosimendan as a treatment for acute renal failure associated with cardiogenic shock after hip fracture

Abstract Inotropic drugs are part of the treatment of heart failure; however, inotropic treatment has been largely debated due to the increased incidence of adverse effects and increased mortality. Recently levosimendan, an inotropic positive agent, has been proved to be effective in acute heart failure, reducing the mortality and improving cardiac and renal performance. We report the case of a 75-year-old woman with history of heart and renal failure and hip fracture. Levosimendan was used in preoperative preparation as an adjuvant therapy, to improve cardiac and renal function and to allow surgery

Levosimendan as a treatment for acute renal failure associated with cardiogenic shock after hip fracture

Abstract Inotropic drugs are part of the treatment of heart failure; however, inotropic treatment has been largely debated due to the increased incidence of adverse effects and increased mortality. Recently levosimendan, an inotropic positive agent, has been proved to be effective in acute heart failure, reducing the mortality and improving cardiac and renal performance. We report the case of a 75-year-old woman with history of heart and renal failure and hip fracture. Levosimendan was used in preoperative preparation as an adjuvant therapy, to improve cardiac and renal function and to allow surgery

Análise do contorno do pulso calibrado por termodiluição transpulmonar (Picco Plus®) para o manejo perioperatório de cesariana em paciente com miocardiopatia grave

ResumoJustificativaO parto em pacientes cardíacas é um desafio para o anestesiologista, para o qual o bem‐estar tanto da mãe quanto do feto é a questão principal. Em caso de cesariana, o monitoramento avançado permite melhorar a condição hemodinâmica e diminuir a morbidade e mortalidade.ObjetivoDescrever o uso da análise do contorno do pulso calibrado por termodiluição transpulmonar (Picco Plus®) para o manejo perioperatório de cesariana em paciente com miocardiopatia grave.Relato de casoDescrevemos o caso de uma paciente de 28 anos com uma doença cardíaca congênita, submetida a uma cesariana sob anestesia geral devido a afecção materna e apresentação fetal pélvica. O manejo nos períodos intraoperatório e pós‐operatório foi aprimorado por monitoração hemodinâmica avançada obtida pela análise do contorno da onda de pulso e calibração por termodiluição (monitor Picco Plus®). As informações sobre pré‐carga, pós‐carga e contratilidade miocárdica foram úteis para orientar a reposição hídrica e o uso de medicamentos vasoativos.ConclusãoEste relato de caso ilustra a importância da monitoração hemodinâmica avançada com dispositivo aceitavelmente invasivo em pacientes obstétricas com alto risco cardíaco. O aumento do conhecimento no manejo hemodinâmico avançado provavelmente possibilitará a redução da morbidade e mortalidade de pacientes obstétricas no futuro.AbstractBackgroundThe delivery of cardiac patients is a challenge for the anaesthesiologist, to whom the welfare of both the mother and the foetus is a main issue. In case of caesarean section, advanced monitoring allows to optimize haemodynamic condition and to improve morbidity and mortality.ObjectiveTo describe the use of pulse contour analysis calibrated by Trans‐pulmonar thermodilution (Picco Plus®) for the perioperative management of a caesarean section in a patient with severe cardiomyopathy.Case reportWe describe the case of a 28‐year‐old woman with a congenital heart disease who was submitted to a caesarean section under general anaesthesia for maternal pathology and foetal breech presentation. Intra‐ and post‐operative management was optimized by advanced haemodynamic monitorization obtained by pulse contour wave analysis and thermodilution calibration (Picco Plus® monitor). The information about preload, myocardial contractility and postcharge was useful in guiding the fluid therapy and the use of vasoactive drugs.ConclusionThis case report illustrates the importance of advanced haemodynamic monitoring with an acceptably invasive device in obstetric patients with high cardiac risk. The increasing experience in advanced haemodynamic management will probably permit to decrease morbidity and mortality of obstetric patients in the future

Pulse contour analysis calibrated by Trans-pulmonar thermodilution (Picco Plus ® ) for the perioperative management of a caesarean section in a patient with severe cardiomyopathy

ABSTRACT BACKGROUND: The delivery of cardiac patients is a challenge for the anaesthesiologist, to whom the welfare of both the mother and the foetus is a main issue. In case of caesarean section, advanced monitoring allows to optimize haemodynamic condition and to improve morbidity and mortality. OBJECTIVE: To describe the use of pulse contour analysis calibrated by Trans-pulmonar thermodilution (Picco Plus® for the perioperative management of a caesarean section in a patient with severe cardiomyopathy. CASE REPORT: We describe the case of a 28-year-old woman with a congenital heart disease who was submitted to a caesarean section under general anaesthesia for maternal pathology and foetal breech presentation. Intra- and post-operative management was optimized by advanced haemodynamic monitorization obtained by pulse contour wave analysis and thermodilution calibration (Picco Plus® monitor). The information about preload, myocardial contractility and postcharge was useful in guiding the fluid therapy and the use of vasoactive drugs. CONCLUSION: This case report illustrates the importance of advanced haemodynamic monitoring with an acceptably invasive device in obstetric patients with high cardiac risk. The increasing experience in advanced haemodynamic management will probably permit to decrease morbidity and mortality of obstetric patients in the future

Post-anaesthesia pulmonary complications after use of muscle relaxants (POPULAR): a multicentre, prospective observational study

Background Results from retrospective studies suggest that use of neuromuscular blocking agents during general anaesthesia might be linked to postoperative pulmonary complications. We therefore aimed to assess whether the use of neuromuscular blocking agents is associated with postoperative pulmonary complications. Methods We did a multicentre, prospective observational cohort study. Patients were recruited from 211 hospitals in 28 European countries. We included patients (aged ≥18 years) who received general anaesthesia for any in-hospital procedure except cardiac surgery. Patient characteristics, surgical and anaesthetic details, and chart review at discharge were prospectively collected over 2 weeks. Additionally, each patient underwent postoperative physical examination within 3 days of surgery to check for adverse pulmonary events. The study outcome was the incidence of postoperative pulmonary complications from the end of surgery up to postoperative day 28. Logistic regression analyses were adjusted for surgical factors and patients’ preoperative physical status, providing adjusted odds ratios (ORadj) and adjusted absolute risk reduction (ARRadj). This study is registered with ClinicalTrials.gov, number NCT01865513. Findings Between June 16, 2014, and April 29, 2015, data from 22803 patients were collected. The use of neuromuscular blocking agents was associated with an increased incidence of postoperative pulmonary complications in patients who had undergone general anaesthesia (1658 [7·6%] of 21694); ORadj 1·86, 95% CI 1·53–2·26; ARRadj –4·4%, 95% CI –5·5 to –3·2). Only 2·3% of high-risk surgical patients and those with adverse respiratory profiles were anaesthetised without neuromuscular blocking agents. The use of neuromuscular monitoring (ORadj 1·31, 95% CI 1·15–1·49; ARRadj –2·6%, 95% CI –3·9 to –1·4) and the administration of reversal agents (1·23, 1·07–1·41; –1·9%, –3·2 to –0·7) were not associated with a decreased risk of postoperative pulmonary complications. Neither the choice of sugammadex instead of neostigmine for reversal (ORadj 1·03, 95% CI 0·85–1·25; ARRadj –0·3%, 95% CI –2·4 to 1·5) nor extubation at a train-of-four ratio of 0·9 or more (1·03, 0·82–1·31; –0·4%, –3·5 to 2·2) was associated with better pulmonary outcomes. Interpretation We showed that the use of neuromuscular blocking drugs in general anaesthesia is associated with an increased risk of postoperative pulmonary complications. Anaesthetists must balance the potential benefits of neuromuscular blockade against the increased risk of postoperative pulmonary complications