jueves, 27 de agosto de 2015

Vía aérea difícil/Difficult airway

Agosto 27, 2015. No. 2067
Anestesia y Medicina del Dolor

La vía aérea difícil con recomendaciones para su manejo. Parte 1. Intubación traqueal difícil en el paciente inconsciente/inducido.
The difficult airway with recommendations for management--part 1--difficult tracheal intubation encountered in an unconscious/induced patient.
Can J Anaesth. 2013 Nov;60(11):1089-118. doi: 10.1007/s12630-013-0019-3. Epub 2013 Oct 17.
Abstract
BACKGROUND: Previously active in the mid-1990s, the Canadian Airway Focus Group (CAFG) studied the unanticipated difficult airway and made recommendations on management in a 1998 publication. The CAFG has since reconvened to examine more recent scientific literature on airway management. The Focus Group's mandate for this article was to arrive at updated practice recommendations for management of the unconscious/induced patient in whom difficult or failed tracheal intubation is encountered. METHODS: Nineteen clinicians with backgrounds in anesthesia, emergency medicine, and intensive care joined this iteration of the CAFG. Each member was assigned topics and conducted reviews of Medline, EMBASE, and Cochrane databases. Results were presented and discussed during multiple teleconferences and two face-to-face meetings. When appropriate, evidence- or consensus-based recommendations were made together with assigned levels of evidence modelled after previously published criteria. CONCLUSIONS: The clinician must be aware of the potential for harm to the patient that can occur with multiple attempts at tracheal intubation. This likelihood can be minimized by moving early from an unsuccessful primary intubation technique to an alternative "Plan B" technique if oxygenation by face mask or ventilation using a supraglottic device is non-problematic. Irrespective of the technique(s) used, failure to achieve successful tracheal intubation in a maximum of three attempts defines failed tracheal intubation and signals the need to engage an exit strategy. Failure to oxygenate by face mask or supraglottic device ventilation occurring in conjunction with failed tracheal intubation defines a failed oxygenation, "cannot intubate, cannot oxygenate" situation. Cricothyrotomy must then be undertaken without delay, although if not already tried, an expedited and concurrent attempt can be made to place a supraglottic device.
La vía aérea difícil con recomendaciones para su manejo. Parte 2. La VAD anticipada
The difficult airway with recommendations for management--part 2--the anticipated difficult airway.
Can J Anaesth. 2013 Nov;60(11):1119-38. doi: 10.1007/s12630-013-0020-x. Epub 2013 Oct 17.
Abstract
BACKGROUND: Appropriate planning is crucial to avoid morbidity and mortality when difficulty is anticipated with airway management. Many guidelines developed by national societies have focused on management of difficulty encountered in the unconscious patient; however, little guidance appears in the literature on how best to approach the patient with an anticipated difficult airway. METHODS: To review this and other subjects, the Canadian Airway Focus Group (CAFG) was re-formed. With representation from anesthesiology, emergency medicine, and critical care, CAFG members were assigned topics for review. As literature reviews were completed, results were presented and discussed during teleconferences and two face-to-face meetings. When appropriate, evidence- or consensus-based recommendations were made, and levels of evidence were assigned. PRINCIPAL FINDINGS: Previously published predictors of difficult direct laryngoscopy are widely known. More recent studies report predictors of difficult face mask ventilation, video laryngoscopy, use of a supraglottic device, and cricothyrotomy. All are important facets of a complete airway evaluation and must be considered when difficulty is anticipated with airway management. Many studies now document the increasing patient morbidity that occurs with multiple attempts at tracheal intubation. Therefore, when difficulty is anticipated, tracheal intubation after induction of general anesthesia should be considered only when success with the chosen device(s) can be predicted in a maximum of three attempts. Concomitant predicted difficulty using oxygenation by face mask or supraglottic device ventilation as a fallback makes an awake approach advisable. Contextual issues, such as patient cooperation, availability of additional skilled help, and the clinician's experience, must also be considered in deciding the appropriate strategy. CONCLUSIONS: With an appropriate airway evaluation and consideration of relevant contextual issues, a rational decision can be made on whether an awake approach to tracheal intubation will maximize patient safety or if airway management can safely proceed after induction of general anesthesia. With predicted difficulty, close attention should be paid to details of implementing the chosen approach. This should include having a plan in case of the failure of tracheal intubation or patient oxygenation.
 
Modulo CEEA Leon, Gto. 

          
Anestesiología y Medicina del Dolor
52 664 6848905
vwhizar@anestesia-dolor.org
anestesia-dolor.org

Copyright © 2015

miércoles, 26 de agosto de 2015

Conoce las 5 enfermedades que se pueden mejorar con una cirugía bariátrica


Fuente
Este artículo es originalmente publicado en:
http://www.entornointeligente.com/articulo/6784812/CHILE-Conoce-las-5-enfermedades-que-se-pueden-mejorar-con-una-cirugiacute;a-bariaacute;trica-24082015

Conoce las 5 enfermedades que se pueden mejorar con una cirugía bariátrica


CHILE: Conoce las 5 enfermedades que se pueden mejorar con una cirugía bariátrica / Emol / La obesidad -que en Chile afecta a siete de cada diez mayores de 15 años, y a cuatro de cada diez niños- es una enfermedad que suele asociarse a un tema estético y de imagen. Sin embargo, quizás más importante aún es que se trata de un mal que puede afectar fuertemente la calidad y la esperanza de vida, ya que impacta en el funcionamiento del cuerpo, dando origen a una serie de problemas de salud.

Concretamente, cinco son las enfermedades que puede presentar una persona obesa:

1.- Diabetes tipo 2: mal crónico que se caracteriza por altos niveles de azúcar en sangre. Es de lento desarrollo y aunque afecta a personas con obesidad o sobrepeso, también puede presentarse en personas delgadas.

2.- Hígado graso: consiste en la acumulación excesiva de grasa en las células del hígado. No produce síntomas, de ahí que sea considerada una enfermedad "silenciosa". Por esta razón, muchos pacientes que la padecen pueden llegar a presentar hepatitis, fibrosis y hasta cirrosis.

3.- Síndrome de apnea del sueño: es un trastorno común, en el que la persona hace una o más pausas en la respiración durante el dormir. Sus consecuencias son diversas y van desde tener un sueño de mala calidad, hasta aumentar el riesgo de sufrir hipertensión arterial, infarto cardíaco, accidente cerebrovascular, etc.

4.- Hipertensión arterial: patología crónica que consiste en el aumento de la presión arterial. Su síntoma principal es la cefalea, aunque no siempre se da en todas las personas. Es una enfermedad controlable, pero si no es tratada a tiempo puede derivar en complicaciones graves.

5.- Problemas osteoarticulares: involucran el deterioro y disfunción del sistema óseo y articular del cuerpo. Tiene dos síntomas principales: dolor y dificultad para el funcionamiento de alguna articulación. Es importante tratarlos, ya que de lo contrario acarrean disfuncionalidad en la vida del paciente.

Cirugía bariátrica, la solución

"Es importante que el paciente con obesidad sea evaluado por un profesional, para definir si algunas de estas enfermedades ya están presentes; de ser así, es fundamental realizar un tratamiento", explica Jorge León, médico del Programa de Obesidad y Diabetes de la Clínica de la Universidad de Los Andes.

En este sentido, la mejor opción la tiene la denominada cirugía bariátrica, la cual mejora y puede llegar a eliminar estas patologías, transformando considerablemente la calidad de vida de quienes las sufren.

La cirugía bariátrica contempla varias técnicas, de las cuales las de mayor uso actualmente son la gastrectomía vertical, conocida como manga gástrica, y el bypass gástrico. Ambos procedimientos se hacen por vía laparoscópica, es decir pequeñas incisiones en la pared abdominal que permite una rápida recuperación general del paciente.

Cada técnica tiene que indicarse de acuerdo a las características del paciente y deben ser discutidas en un grupo multidisciplinario dedicado a la obesidad.

Después de una cirugía bariátrica, los cuidados más importantes son:

1.- Seguir la pauta de alimentación entregada.

2.- Hacer la vida en pie, no mantenerse en cama, pero sin realizar actividad física ni levantar pesos.

3.- Tomar los medicamentos prescritos por el médico.

4.- Realizar los controles indicados.

5.- Mantener contacto con el médico ante cualquier problema en su evolución.

Con Información de Emol

www.entornointeligente.com

Medwave. Agosto 2015

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Intubacion con paciente despierto/Awake intubation

Anestesia y Medicina del Dolor

La anestesia tópica de la vía aérea es mandatoria para realizar la intubación con paciente despierto y por lo general se lleva a cabo con lidocaína tópica en aerosol, sin vasoconstrictores. El propósito principal de esta "topicalización" es tener un paciente que tolere el uso de un dispositivo para la vía oral que facilite la intubación traqueal. La intubación nasal requiere topicalización adicional de las vías nasales en combinación con un vasoconstrictor. La mayoría de los anestesiólogos usan sedación cuidadosa cuando se lleva a cabo intubación con paciente despierto.
 
Topical anesthesia of the airway is a required to perform awake intubation and is typically accomplished with topical lidocaine in spray, without vasoconstrictors. The main purpose of this "topicalization" is to have a patient accepting the use of an oral airway used to facilitate awake oral intubation. Nasal intubation requires additional topicalization of the nasal ways in combination with a vasoconstrictor. Most anesthesiologist use cautious sedation when awake intubation is carried out.
Intubación con paciente despierto usando el laringoscopio (Pentax airway scope) en 30 pacientes.
Awake tracheal intubation using Pentax airway scope in 30 patients: A Case series.
Indian J Anaesth. 2014 Jul;58(4):447-51. doi: 10.4103/0019-5049.138987.
Abstract
BACKGROUND AND AIMS: Pentax airway scope (AWS) has been successfully used for managing difficult intubations. In this case series, we aimed to evaluate the success rate and time taken to complete intubation, when AWS was used for awake tracheal intubation. METHODS: We prospectively evaluated the use of AWS for awake tracheal intubation in 30 patients. Indication for awake intubation, intubation time, total time to complete tracheal intubation, laryngoscopic view (Cormack and Lehane grade), total dose of local anaesthetic used, anaesthetists rating and patient's tolerance of the procedure were recorded. RESULTS: The procedure was successful in 25 out of the 30 patients (83%). The mean (standard deviation) intubation time and total time to complete the tracheal intubation was 5.4 (2.4) and 13.9 (3.7) min, respectively in successful cases. The laryngeal view was grade 1 in 24 and grade 2 in one of 25 successful intubations. In three out of the five patients where the AWS failed, awake tracheal intubation was successfully completed with the assistance of flexible fibre optic scope (FOS). CONCLUSION: Awake tracheal intubation using AWS was successful in 83% of patients. Success rate can be further improved using a combination of AWS and FOS. Anaesthesiologists who do not routinely use FOS may find AWS easier to use for awake tracheal intubation using an oral route.
KEYWORDS: Awake fibreoptic intubation; awake intubation; pentax airway scope; video laryngoscope
Preparación para realizar intubación fibroscópica con paciente despierto
Preparing to perform an awake fiberoptic intubation.
Yale J Biol Med. 1998 Nov-Dec;71(6):537-49.
Abstract
Fiberoptically guided tracheal intubation represents one of the most important advances in airway management to occur in the past thirty years. Perhaps its most important role is in management of the anticipated difficult airway. This is a situation in which the dangers of encountering the life-threatening "can't intubate, can't ventilate" situation can be avoided by placement of an endotracheal tube while the patient is awake. Although skill at the procedure of endoscopy is obviously necessary in this setting, these authors hold that success or failure of the technique frequently depends on the adequacy of preparation. These measures include 1) pre-operative assessment of the patient; 2) careful explanation of what lies in store; 3) "setting the stage"; 4) preparing the equipment to be used; and 5) preparing the patient (antisialogue, sedation, application of topical anesthesia to the upper airway). If these preparatory measures are carried out meticulously, the likelihood of performing a successful and comfortable awake fiberoptic tracheal intubation is greatly increased.
PDF 
Inserción con paciente despierto  del fibroscopio Bonfil retromolar en 5 pacientes con vía aérea difícil
Awake insertion of the Bonfils Retromolar Intubation Fiberscope in five patients with anticipated difficult airways.
Anesth Analg. 2008 Apr;106(4):1215-7, table of contents. doi: 10.1213/ane.0b013e318167cc7c.
Abstract
Traditionally, an awake intubation is performed by flexible fiberoptic laryngoscopy. However, many new devices have been developed to assist anesthesiologists with both routine and difficult airway management, one of which is the Bonfils Retromolar Intubation Fiberscope. This device may be more beneficial than the flexible fiberoptic laryngoscope since it can readily navigate through soft tissue and physically lift airway structures, is more affordable, durable, and easier to clean. This case series demonstrates successful use of the Bonfils Scope in five patients for awake orotracheal intubation with anticipated difficult airways.
 
Manejo urgente de la vía aérea en un caso con fibrodisplasia osificante progresiva
Emergent airway management in a case of fibrodysplasia ossificans progressiva.
J Anaesthesiol Clin Pharmacol. 2014 Oct;30(4):565-7. doi: 10.4103/0970-9185.142865.
Abstract
Fibrodysplasia ossificans progressiva (FOP), or Stone man syndrome, is rare and one of the most disabling genetic conditions of the connective tissue due to progressive extraskeletal ossification. It usually presents in the first decade of life as painful inflammatory swellings, either spontaneously or in response to trauma, which later ossify and lead to severe disability. Progressive spinal deformity including thoracolumbar kyphoscoliosis leads to thoracic insufficiency syndrome, increasing the risk for pneumonia and right sided heart failure. We present the airway management in a 22-year-old male, diagnosed with FOP with severe disability, who required urgent airway intervention as a result of respiratory failure from pnuemonia. Tracheostomy triggers ossification and consequent airway obstruction at the tracheostomy site and laryngoscopy triggers temporomandibular joint ankylosis. Therefore, awake fiber-optic endotracheal intubation is recommended in these patients. Use of an airway endoscopy mask enabled us to simultaneously maintain non-invasive ventilation and intubate the patient in a situation where tracheostomy needed to be avoided.
KEYWORDS: Airway endoscopy mask; airway management; fibrodysplasia ossificans progressiva
Dexmedetomidina para intubación con paciente despierto en una parturienta con síndrome de Klippel-Feil y malformación de Arnold Chiari tipo I
Dexmedetomidine for an awake fiber-optic intubation of a parturient with Klippel-Feil syndrome, Type I Arnold Chiari malformation and status post released tethered spinal cord presenting for repeat cesarean section.
Clin Pract. 2011 Jul 1;1(3):e57. doi: 10.4081/cp.2011.e57. eCollection 2011.
Abstract
Patients with Klippel-Feil Syndrome (KFS) have congenital fusion of their cervical vertebrae due to a failure in the normal segmentation of the cervical vertebrae during the early weeks of gestation and also have myriad of other associated anomalies. Because of limited neck mobility, airway management in these patients can be a challenge for the anesthesiologist. We describe a unique case in which a dexmedetomidine infusion was used as sedation for an awake fiber-optic intubation in a parturient with Klippel-Feil Syndrome, who presented for elective cesarean delivery. A 36-year-old female, G2P1A0 with KFS (fusion of cervical vertebrae) who had prior cesarean section for breech presentation with difficult airway management was scheduled for repeat cesarean delivery. After obtaining an informed consent, patient was taken in the operating room and non-invasive monitors were applied. Dexmedetomidine infusion was started and after adequate sedation, an awake fiber-optic intubation was performed. General anesthetic was administered after intubation and dexmedetomidine infusion was continued on maintenance dose until extubation. Klippel-Feil Syndrome (KFS) is a rare congenital disorder for which the true incidence is unknown, which makes it even rare to see a parturient with this disease. Patients with KFS usually have other congenital abnormalities as well, sometimes including the whole thoraco-lumbar spine (Type III) precluding the use of neuraxial anesthesia for these patients. Obstetric patients with KFS can present unique challenges in administering anesthesia and analgesia, primarily as it relates to the airway and dexmedetomidine infusion has shown promising result to manage the airway through awake fiberoptic intubation without any adverse effects on mother and fetus.
KEYWORDS: Klippel-Feil syndrome; awake fiberoptic intubation; cesarean section.; dexmedetomidine
PDF 
Modulo CEEA Leon, Gto. 

        
Anestesiología y Medicina del Dolor
52 664 6848905
vwhizar@anestesia-dolor.org
anestesia-dolor.org

Copyright © 2015

martes, 25 de agosto de 2015

Anestesia general/General anaesthesia

Anestesia y Medicina del Dolor
  
Anestesia general y riesgo de demencia en ancianos: conocimientos actuales
General anesthetic and the risk of dementia in elderly patients: current insights.
Clin Interv Aging. 2014 Sep 24;9:1619-28. doi: 10.2147/CIA.S49680. eCollection 2014.
Abstract
In this review, we aim to provide clinical insights into the relationship between surgery, general anesthesia (GA), and dementia, particularly Alzheimer's disease (AD). The pathogenesis of AD is complex, involving specific disease-linked proteins (amyloid-beta [Aβ] and tau), inflammation, and neurotransmitter dysregulation. Many points in this complex pathogenesis can potentially be influenced by both surgery and anesthetics. It has been demonstrated in some in vitro, animal, and human studies that some anesthetics are associated with increased aggregation and oligomerization of Aβ peptide and enhanced accumulation and hyperphosphorylation of tau protein. Two neurocognitive syndromes that have been studied in relation to surgery and anesthesia are postoperative delirium and postoperative cognitive dysfunction, both of which occur more commonly in older adults after surgery and anesthesia. Neither the route of anesthesia nor the type of anesthetic appears to be significantly associated with the development of postoperative delirium or postoperative cognitive dysfunction. A meta-analysis of case-control studies found no association between prior exposure to surgery utilizing GA and incident AD (pooled odds ratio =1.05, P=0.43). The few cohort studies on this topic have shown varying associations between surgery, GA, and AD, with one showing an increased risk, and another demonstrating a decreased risk. A recent randomized trial has shown that patients who received sevoflurane during spinal surgery were more likely to have progression of preexisting mild cognitive impairment compared to controls and to patients who received propofol or epidural anesthesia. Given the inconsistent evidence on the association between surgery, anesthetic type, and AD, well-designed and adequately powered studies with longer follow-up periods are required to establish a clear causal association between surgery, GA, and AD.
 
Técnica de anestesia, mortalidad, y tiempo de estancia después de cirugía de cadera
Anesthesia technique, mortality, and length of stay after hip fracture surgery.
JAMA. 2014 Jun 25;311(24):2508-17. doi: 10.1001/jama.2014.6499.
PDF 
Modulo CEEA Leon, Gto. 

          
Anestesiología y Medicina del Dolor
52 664 6848905
vwhizar@anestesia-dolor.org
anestesia-dolor.org

Copyright © 2015