Revisiones bibliográficas. Documentación científica en Ortopedia y Traumatología, medicina deportiva, artroscopia, artroplastia y de todas las patologías del sistema Músculo-Esquelético
Falla renal aguda y embarazo: Experiencia en un centro terciario del norte de la India
Acute renal failure in pregnancy: Tertiary centre experience from north Indian population. Patel ML, Sachan R, R, Sachan2 P. Niger Med J [serial online] 2013 [cited 2013 Jul 5];54:191-5. Abstract Background: Obstetrical acute renal failure ARF is now a rare entity in the developed countries but still a common occurrence in developing countries. Delay in the diagnosis and late referral is associated with increased mortality. This study aimed to evaluate the contributing factors responsible for pregnancy-related acute kidney failure, its relation with mortality and morbidity and outcome measures in these patients. Materials and Methods: Total 520 patients of ARF of various aetiology were admitted, out of these 60 (11.5%) patients were pregnancy-related acute renal failure. Results: ARF Acute renal failure occurred in 32 (53.3%) cases in early part of their pregnancy, whereas in 28 (46.7%) cases in later of the pregnancy. Thirty-two (53.3%) patients had not received any antenatal visit, and had home delivery, 20 (33.4%) patients had delivered in hospitals but without antenatal care and eight (13.3%) patients received antenatal care and delivered in the hospitals. Anuria was observed in 23 (38.3%) cases, remaining 37 (61.7%) cases presented with oliguria. Septicemia was present in 25 (41.7%), hypertensive disorder of pregnancy in 20 (33.3%), haemorrhage in eight (13.3%), abortion in 5 (8.3%), haemolysis elevated liver enzymes low platelets counts (HELLP) syndrome in one (1.67%) and disseminated intravascular coagulation in one (1.67%). (61.7%) patients were not dialyzed, 33 (55%) recovered normal renal function with conservative treatment. Complete recovery was observed in 45 (75%) patients, five (8.4%) patients developed irreversible renal failure. Maternal mortality was nine (15%) and foetal loss was 25 (41.7%). Conclusion: Pregnancy-related ARF is usually a consequence of obstetric complications; it carries very high morbidity and mortality. Keywords: Acute renal failure, hemodialysis, partial recovery, pregnancy http://www.nigeriamedj.com/text.asp?2013/54/3/191/114586
El Dr. Alberto Gutiérrez, de Argentina, realizó diversos cursos y trabajos sobre anestesia metamérica epidural y basándose en los estudios de Jansen sobre la presión negativa en el espacio epidural (EE). En 1933 publicó un artículo en el que llamó la atención sobre la importancia de la aspiración de líquidos hacia el EE. De ahí surge el signo conocido como "aspiración de la gota" o "gota pendiente" de Gutiérrez".
Alberto Gutierrez MD from Argentina, conducted several courses and work on metameric epidural anesthesia based on Jansen studies on the negative pressure in the epidural space. In 1933 he published an article in which he called attention to the importance of aspiration of liquid into the epidural space. From this arises the sign known as "aspiration drop" or "Gutierrez drop pending".
Alberto Gutierrez MD da Argentina, realizou vários cursos e trabalho em anestesia epidural metameric com base em estudos Jansen sobre a pressão negativa no espaço epidural. Em 1933, ele publicou um artigo em que ele chamou a atenção para a importância da aspiração de líquido no espaço epidural. Daí surge o sinal conhecido como "drop aspiração" ou "drop Gutierrez pendente".
Técnicas de identificación del espacio epidural
E. Figueredo
Servicio de Anestesia. Hospital Torrecárdenas. Almería Rev. Esp. Anestesiol. Reanim. 2005; 52: 401-412 Resumen Gran parte del éxito de una anestesia epidural se basa en la correcta identificación del espacio epidural. En los últimos 100 años se han descrito numerosas técnicas intentando localizar el espacio de la manera más simple, efectiva, segura y fiable. Para juzgar las técnicas empleadas para la identificación del espacio epidural, sus ventajas, inconvenientes y/o complicaciones se ha realizado una búsqueda en Medline entrecruzando las palabras clave "epidural analgesia", "epidural anesthesia", "epidural space", "identification" y "loss of resistance". Se analizan las técnicas clásicas de identificación del espacio epidural, así como los principales métodos complementarios o instrumentales. Se evalúan los resultados de los ensayos clínicos en los que se comparan las distintas técnicas de pérdida de resistencia (LOR). Las técnicas basadas en la LOR, mediante el uso de aire, solución salina isotónica o una combinación de ambos, han demostrado ser las más simples y efectivas. Con respecto a la seguridad, la técnica de LOR con aire es la que presenta más complicaciones (neumoencéfalo, embolismo aéreo, analgesia insuficiente, mayor incidencia de punciones durales accidentales, compresión de raíces nerviosas, enfisema subcutáneo). Si a la técnica de LOR con solución salina, se le agrega una pequeña burbuja de aire dentro de la jeringa, la técnica, además de efectiva y segura, resulta más fiable y su enseñanza más didáctica. http://www.csen.com/epid.pdf
Incidencia y predictores de complicaciones inmediatas después punciones epidurales no obstétricas
Incidence and predictors of immediate complications following perioperative non-obstetric epidural punctures. Meyer-Bender A, Kern A, Pollwein B, Crispin A, Lang PM. Department of Anaesthesiology, University Hospital of Munich, Marchioninistr, 15, 81377, Munich, Germany. philip.lang@med.uni-muenchen.de. BMC Anesthesiol. 2012 Dec 10;12:31. doi: 10.1186/1471-2253-12-31. Abstract BACKGROUND: Epidural Anesthesia (EA) is a well-established procedure. The aim of the present study was to evaluate the incidence of immediatecomplications following epidural puncture, such as sanguineous puncture, accidental dural perforation, unsuccessful catheter placement or insufficient analgesia and to identify patient and maneuver related risk factors. METHODS: A total of 7958 non-obstetrical EA were analyzed. The risk of each complication was calculated according to the preconditions and the level of puncture. For probabilistic evaluation we used a logistic regression model with forward selection. RESULTS:The risk of sanguineous puncture (n = 247, 3.1%) increases with both the patient's age (P = 0.013) and the more caudal the approach (P < 0.01). Dural perforation (n = 123, 1.6%) was found to be influenced only by advanced age (P = 0.019). Unsuccessful catheter placement (n = 68, 0.94%) occurred more often in smaller individuals (P < 0.001) and at lower lumbar sites (P < 0.01). Amongst all cases with successful catheter placement a (partial) insufficient analgesia was found in 692 cases (8.8%). This risk of insufficient analgesia decreased with patient's age (P <0 .01), being least likely for punctures of the lower thoracic spine (P < 0.001). CONCLUSIONS:Compared to more cranial levels, EA of the lower spine is associated with an increased risk of sanguineous and unsuccessful puncture. Insufficient analgesia more often accompanies high thoracic and low lumbar approaches. The risk of a sanguineous puncture increases in elderly patients. Gender, weight and body mass index seem to have no influence on the investigated complications.
Puntos de referencia anatómicos para evaluar el nivel espacio intravertebral para la punción lumbar es erróneo en más de 30%
Anatomical landmarks based assessment of intravertebral space level for lumbar puncture is misleading in more than 30%. Duniec L, Nowakowski P, Kosson D, Łazowski T. Department of Teaching Anaesthesiology and Intensive Therapy, Medical University of Warsaw, Poland. dunieclarysa@gmail.com Anaesthesiol Intensive Ther. 2013 Jan-Mar;45(1):1-6. doi: 10.5603/AIT.2013.0001. Abstract BACKGROUND: The anatomical landmark which is used to identify the correct level for lumbar puncture is the line connecting both iliac crests. This crosses the vertebra column at the level of the L4-L5 intervertebral space or L4 vertebra. It can be difficult to determine in a group of orthopaedic patients due to chronic orthopaedic disorders, chronic pain, overweight, or difficulties with positioning for lumbar puncture. The objective of this study was to determine if identification of intervertebral space by a physical exam differs from that of an ultrasound assessment. METHODS:Adult patients scheduled for lower limb surgery under spinal block were enrolled in this study. The intervertebral space suitable for lumbarpuncture was determined by physical exam by an anaesthetist in the sitting or lateral position. This was followed by a lumbar ultrasound. Primarily, a transducer was placed in paramedian sagittal view followed by transverse interlaminar view to confirm the identification of the interlaminar spaces. The 'counting-up' approach starting with the L5-1 space was applied. RESULTS: One hundred and twenty two patients (122) were included in this study. Lumbar intervertebral spaces were identified by ultrasound in all cases. There was concordance of intervertebral space identification (between clinical and ultrasound examination) in 78 cases (64%). Mean deviation of inacuracy was one intervertebral space with no statistical difference among cephalad and caudal direction. There were no statistically significant differences fund in terms of demographic data (sex, age, height, weight, or BMI), positioning for lumbar puncture, or intervertebral space chosen for the puncture between the concordant and the nonconcordant identification groups. The only statistically significant difference found was the difference in the years of experience of the anaesthetist performing the clinical assessment and puncture. CONCLUSIONS:The concordance rate between clinical examination and using assessment of intervertebral space identification for lumbar puncture is 64% among patients undergoing lower limb surgery. No special parameters were found which could make an anaesthetist aware that a patient is at greater risk of inadequate intervertebral space level assessment. Spinal ultrasound can reduce the incidence of inappropriate lumbar puncture level in orthopaedic patients. http://czasopisma.viamedica.pl/ait/article/view/AIT.2013.0001/24858
Uso del ultrasonido para determinar el nivel de punción lumbar en la mujer embarazada
Use of the ultrasound to determine the level of lumbar puncture in pregnant women. Locks Gde F, Almeida MC, Pereira AA.Maternidade Carmela Dutra, Hospital Universitário, Universidade Federal de Santa Catarina. giovanilocks@gmail.com Rev Bras Anestesiol. 2010 Jan-Feb;60(1):13-9. Abstract BACKGROUND AND OBJECTIVES: An imaginary line connecting both iliac crests is used to determine the vertebral level for lumbar puncture. This line crosses the spine at the level of L4 or the L4-L5 space. This anatomical reference can be inaccurate in a large proportion of patients. The objective of the present study was to determine whether the identification of the L3-L4 space by the physical exam differs from that of the ultrasound in obese and non-obese pregnant women. METHODS:Adult patients undergoing elective cesarean sections under spinal block participated in this study. Patients were divided in two groups: obese and non-obese. The L3-L4 space was determined by physical exam with the patient in the sitting position. This was followed by a lumbarultrasound. After the sacrum was identified, the transducer was directed in the cephalad direction to identify the spinous processes of the lumbarvertebrae. The clinically estimated L3-L4 level was recorded. RESULTS: Ninety patients, 43 obese and 47 non-obese, were included in this study. Lumbar intervertebral spaces were identified by ultrasound in all patients. The L3-L4 space clinically identified corresponded to the ultrasound identification in 53% and 49% of the cases in the non-obese and obese groups, respectively. There was no significant difference between groups. CONCLUSIONS:The L3-L4 space is correctly identified in a low percentage of obese and non-obese pregnant women. Spinal ultrasound can reduce the incidence of mistaken identification of the L3-L4 space in obese and non-obese pregnant women. http://www.scielo.br/pdf/rba/v60n1/en_v60n1a02.pdf
Evaluación de ultrasonido del nivel vertebral de la línea intercristal en el embarazo. Ultrasound assessment of the vertebral level of the intercristal line in pregnancy. Lee AJ, Ranasinghe JS, Chehade JM, Arheart K, Saltzman BS, Penning DH, Birnbach DJ. Department of Anesthesiology, University of Miami, Jackson Memorial Hospital, 1611 NW 12th Ave. (C-301), Miami, FL 33136, USA. alee@med.miami.edu Anesth Analg. 2011 Sep;113(3):559-64. doi: 10.1213/ANE.0b013e318222abe4. Epub 2011 Jun 16. Abstract BACKGROUND: The intercristal line is known to most frequently cross the L4 spinous process or L4-5 interspace; however, it is speculated to be positioned higher during pregnancy because of the exaggerated lumbar lordosis. Clinical estimation of vertebral levels relying on the use of the intercristal line has been shown to often be inaccurate. We hypothesized that the vertebral level of the intercristal line determined by palpation would be higher than the level determined by ultrasound in pregnant women. METHODS: Fifty-one term pregnant patients were recruited. Two experienced anesthesiologists performed estimates of the position of the intercristal line by palpation. Using ultrasound, another anesthesiologist who was blinded to the clinical estimates, determined the position of the superior border of the iliac crest in the transverse and longitudinal planes and then identified the lumbar vertebral levels. The vertebral level at which the clinical estimates of the intercristal line crossed the spine was recorded and compared with the ultrasound-determined level of the superior border of the iliac crest. RESULTS: The clinical estimates of the spinal level of the intercristal line agreed with the ultrasound measurement 14% of the time (14 of 101; 95% confidence interval [CI]: 8%, 22%). The clinical estimates were 1 level higher than the ultrasound measurement 23% of the time (23 of 101; 95% CI: 16%, 32%) and >1 level higher 25% of the time (25 of 101; 1-tailed 95% CI: >18%). The distribution of the clinical estimates found clinicians locating the intercristal line at L3 or L3-4 54% of the time (54 of 101; 95% CI: 44%, 63%) and at L2-3 or higher 27% of the time (27 of 101; 1-tailed 95% CI: >20%). CONCLUSION: The anatomical position of the intercristal line was at L3 or higher in at least 6% of term pregnant patients using ultrasound. Clinical estimates were found to be ≥1 vertebral level higher than the anatomical position determined by ultrasound at least 40% of the time. This disparity may contribute to misidentification of lumbar interspaces and increased risk of neurologic injury during neuraxial anesthesia.
Libro sobre Hipertensión Pulmonar Pulmonary Hypertension Edited by Jean M. Elwing and Ralph J. Panos, ISBN 978-953-51-1165-8, Hard cover, 233 pages, Publisher: InTech, Chapters published July 17, 2013 under CC BY 3.0 license DOI: 10.5772/45912
This volume presents overviews as well as in depth reviews of many aspects of the clinical presentation, pathophysiology, and treatment of Pulmonary Hypertension (PH) especially PH related to thromboembolic disease. Saleem Sharieff presents a comprehensive synopsis of the epidemiologic, clinical, histopathologic, and therapy of PAH. Next, Dimitar Sajkov, Bliegh Mupunga, Jeffrey J. Bowden, and Nikolai Petrovsky comprehensively review World Health Organization group III PH. The cellular and biochemical pathophysiology of PH are summarized by Rajamma Mathew. Specific mechanisms implicated in the pathogenesis of PH are presented by Junko Maruyama, Ayumu Yokochi, Erquan Zhang, Hirohumi Sawada, Kazuo Maruyama; and Aureliano Hernandez and Rafael A. Areiza. Jean Elwing and Ralph Panos discuss PH associated with acute thromboembolism. Mehdi Badidi and M Barek Naz discuss PH caused by chronic thromboembolic disease. Juan C. Grignola, Maria J. Ruiz-Cano, Juan P. Salisbury, Gabriela Pascal, Pablo Curbelo, and Pilar Escribano present the physiologic assessment of patients with chronic thromboembolic disease prior to surgical pulmonary endarterectomy and, finally, Henry Liu, Philip L. Kalarickal, Yiru Tong, Daisuke Inui, Michael J Yarborough, Kavitha A. Mathew, Amanda Gelineau, and Charles Fox comprehensively review the clinical perioperative evaluation and management of patients with PH due to chronic thromboembolic disease.
Pediatric cuffed endotracheal tubes: an evolution of care. Taylor C, Subaiya L, Corsino D. Department of Anesthesiology, Ochsner Clinic Foundation, New Orleans, LA. Ochsner J. 2011 Spring;11(1):52-6. Abstract PURPOSE: To examine the history of pediatric endotracheal intubation and the issues surrounding the change from uncuffed endotracheal tubes to cuffed endotracheal tubes, including pediatric airway anatomy, endotracheal tube design, complications, and safety concerns. METHOD:Review of the literature. CONCLUSIONS:Although the use of cuffed endotracheal tubes in infants and children remains a topic of debate, the literature supports this change in practice. Meticulous attention must be given to intracuff pressure. Cuffed endotracheal tubes designed especially for the pediatric patient may increase the margin of safety. KEYWORDS:Cuffed endotracheal tube, equipment design, pediatric airway, stridor, subglottic stenosis, tracheal intubation, ventilation
Influencias del proceso de envejecimiento sobre el dolor perioperatorio en el viejo y en pacientes con daño cognitivo
Influences of the aging process on acute perioperative pain management in elderly and cognitively impaired patients. Halaszynski T. Department of Anesthesiology, Yale University School of Medicine, New Haven, CT. Ochsner J. 2013 Summer;13(2):228-47. Abstract BACKGROUND: The aging process results in physiological deterioration and compromise along with a reduction in the reserve capacity of the human body. Because of the reduced reserves of mammalian organ systems, perioperative stressors may result in compromise of physiologic function or clinical evidence of organ insult secondary to surgery and anesthesia. The purpose of this review is to present evidence-based indications and best practice techniques for perioperative pain management in elderly surgical patients. RESULTS: In addition to pain, cognitive dysfunction in elderly surgical patients is a common occurrence that can often be attenuated with appropriate drug therapy. Modalities for pain management must be synthesized with intraoperative anesthesia and the type of surgical intervention and not simply considered a separate entity. CONCLUSIONS: Pain in elderly surgical patients continues to challenge physicians and healthcare providers. Current studies show improved surgical outcomes for geriatric patients who receive multimodal therapy for pain control. KEYWORDS: Aging, pain management, perioperative care http://www.ochsnerjournal.org/doi/pdf/10.1043/1524-5012-13.2.228
Uso de sugammadex en situación de no poder intubar-no poder ventilar
Use of sugammadex in a 'can't intubate, can't ventilate' situation. Curtis R, Lomax S, Patel B. Department of Anaesthesia, Royal Surrey County Hospital, Guildford GU2 7XX, UK. Br J Anaesth. 2012 Apr;108(4):612-4. doi: 10.1093/bja/aer494. Epub 2012 Jan 26. Abstract A 78-yr-old woman presented for a panendoscopy to investigate dysphonia and dysphagia. Intubation was anticipated to be difficult but possible, and mask ventilation was anticipated to be possible. After induction of anaesthesia and after three attempts at intubation, a 'can't intubate, can ventilate' situation deteriorated to a 'can't intubate, can't ventilate' (CICV) situation. Rocuronium-induced neuromuscular block was successfully reversed with sugammadex, as evidenced by the restoration of diaphragmatic movement, the ability of the patient to move her limbs, and the presence of a train-of-four nerve stimulation with no fade; however, ventilation was still not possible. A cricothyroid puncture using a Ravussin needle was performed successfully to provide emergency oxygenation. A tracheostomy was performed to allow the panendoscopy. CICV situations are rare anaesthetic emergencies. While sugammadex can be relied upon to reverse rocuronium-induced neuromuscular block, it should not be relied upon to rescue all CICV events, especially where airway instrumentation has led to airway swelling. The availability of sugammadex does not obviate the need for emergency tracheal access in the event of failed oxygenation. The presence of head and neck pathology should lead to the consideration of securing the airway awake. http://bja.oxfordjournals.org/content/108/4/612.full.pdf
Uso exitoso de sugammadex en el caso de no poder ventilar
Successful use of sugammadex in a 'can't ventilate' scenario L. Paton, S. Gupta, and D. Blacoe Anaesthetic Department, Monklands Hospital, Airdrie, UK Anaesthesia 2013, 68, 861-864 Summary A 53-year-old man with hypopharyngeal stenosis following curative chemoradiotherapy for a tongue base tumour presented three years later for an attempt at pharyngeal dilatation. The first attempt 6 months previously was abandoned when awake fibreoptic intubation failed due to partial airway obstruction and desaturation when the fibrescope was advanced. As mask ventilation was anticipated to be possible, a further attempt at intubation after induction of anaesthesia was judged appropriate. The backup plan was jet ventilation via a cricothyroid cannula sited pre-induction. However, neither mask nor jet ventilation proved possible after the induction of anaesthesia and neuromuscular blockade with rocuronium. Swift administration of sugammadex on a background of thorough pre-oxygenation allowed return of spontaneous breathing before the development of hypoxia and so avoided the need for surgical airway rescue. This case demonstrates the utility of sugammadex in restoring spontaneous respiration in a 'can't ventilate'scenario, provided that the airway has not been traumatised by instrumentation http://onlinelibrary.wiley.com/doi/10.1111/anae.12338/pdf
Reversión del bloqueo neuromuscular con sugammadex en un obeso mórbido con miastenia gravis Neuromuscular block reversal with sugammadex in a morbidly obese patient with myasthenia gravis. Jakubiak J, Gaszyński T, Gaszyński W. jakubiakj@yahoo.com. Anaesthesiol Intensive Ther. 2012 Jan-Mar;44(1):28-30. Abstract BACKGRAOUND: Myasthenia gravis is a rare immunological illness that impairs neuromuscular transmission. Myasthenic patients are usually hypersensitive to non-depolarising muscle relaxants, and reversal with neostigmine is rarely effective. We report the successful reversal of rocuroniuminduced neuromuscular block in a morbidly obese myasthenic patient. CASE REPORT: A 38-year-old morbidly obese (body weight 160 kg, BMI 48.8 kg m²) woman was scheduled for elective laparoscopic gastric banding. She was anaesthetised with propofol-based TIVA; intubation was facilitated by 24 mg of rocuronium. After spontaneous recovery of T1, she received 200 mg of sugammadex, which completely restored the NMT ratio (TOF=100%) within 2 min and 48 sec., and she was extubated. No postoperative complications were observed. CONCLUSION: Sugammadex can be successfully used in myasthenic patients, allowing for the safe use of muscle relaxants in these patients.
descubrimiento del manuscrito macarrónico de la biblioteca de la ... José Miguel Domínguez Leal El poema macarrónico, inédito, atribuido a Francisco Pacheco nos ha sido transmitido, según se creía hasta hace poco, en dos manuscritos del s. XVI.LA POESÍA MACARRÓNICA EN ESPAÑA
Dexmedetomidine, morphine, propofol vs midazolam, morphine, propofol for conscious sedation in rhinoplasty under local anesthesia. A prospective, randomized study Ashraf Ragab, Hossam El Shamaa, Mohamed Ibrahim Egyptian Journal of Anaesthesia (2013) 29, 181-187 Abstract Background. Monitored anesthesia care (MAC) has been proposed as one of the suitable techniques for rhinoplasty. In this study our aim was to compare the effects of dexmedetomidine with morphine and propofol vs benzodiazepines with morphine and propofol as adjuncts to local anesthesia - on analgesia, sedation, respiratory and hemodynamics variables and surgeon and patient satisfaction. Methods. In this prospective, double-blind, comparative study, 60 patients undergoing rhinoplasty by local anesthesia randomly received intravenous sedation of either: dexmedetomidine (Dex group) or midazolam (Mid group) in combination with morphine and propofol. Level of sedation was assessed by using the Observer's Assessment Alertness/Sedation Scale (OAA/S). Pain on local anesthesia injection was assessed by a visual analog scale. Surgeon's satisfaction also can be assessed by using a 3-grades score, the surgeon assessed the quality of surgical bleeding. Mean Arterial Pressure (MAP) and heart rate (HR) were assessed and recorded. Patients' satisfaction, visual analog scale for intraoperative pain, and total amount of propofol used intraoperatively. Adverse effects were also recorded. Results. In Mid group patients were earlier to reach adequate sedation level than in Dex group, but they felt more pain either on local anesthetic injection or during operation. Intraoperative mean arterial blood pressure and heart rate in Dex group were lower than their baseline values and the corresponding values in Mid group. The total amount of propofol needed for Mid group was much higher than in Dex group. Patient satisfaction was higher in Dex group. Time of surgery was longer in Mid group. Both groups were similar in sedation recovery and ward discharge times, as well as, incidence of side effects.Conclusion. Dexmedetomidine sedation with morphine and propofol in rhinoplasty performed under local anesthesia was associated with shorter surgery time, greater patient and surgeon satisfaction, and lower pain scores with no adverse effects, when compared to midazolam sedation with morphine and propofol. Keywords: Dexmedetomidine, Midazolam, Rhinoplasty, Local anesthesia
