Inician Jornadas Académicas en el marco del 51 Aniversario del “Aurelio Valdivieso”

Inician Jornadas Académicas en el marco del 51 Aniversario del “Aurelio Valdivieso”

Arterias medulares / Spinal arteries

Mayo 16, 2016. No. 2328

Avances  en angiografía-resonancia magnética de la médula espinal Advances in spinal cord MR angiography. Backes WH1, Nijenhuis RJ. AJNR Am J Neuroradiol. 2008 Apr;29(4):619-31. doi: 10.3174/ajnr.A0910. Epub 2008 Jan 17. Abstract Novel developments in MR angiography are reviewed that enable non-invasive clinical imaging of normal and abnormal vessels of the spinal cord. Current fast contrast-enhanced MR techniques are able 1) to visualize vessels supplying or draining the spinal cord and 2) to differentiate spinal cord arteries from veins. The localization of the Adamkiewicz artery, the largest artery supplying the thoracolumbar spinal cord, has become possible in a reproducible and reliable manner. Knowledge of the anatomic location of this artery and its arterial supplier may be of benefit in the work-up for aortic aneurysm surgery to reduce incidences of ischemic injury. Spinal cord MR angiography is ready to become a diagnostic tool that can compete with catheter angiography for detecting and localizing arterial feeders of vascular lesions and is strongly advised for use prior to invasive catheter angiography. Successful clinical application strongly relies on in depth knowledge of the complex spinal cord vasculature and skills in image postprocessing. PDF   El embolismo emergiendo como una de las principales causas de lesión de la médula espinal después de la reparación aórtica descendente y toracoabdominal con un enfoque contemporáneo: hallazgos en resonancia magnética de lesiones de la médula espinal. Embolism is emerging as a major cause of spinal cord injury after descending and thoracoabdominal aortic repair with a contemporary approach: magnetic resonance findings of spinal cord injury. Tanaka H1, Minatoya K2, Matsuda H2, Sasaki H2, Iba Y2, Oda T2, Kobayashi J2. Interact Cardiovasc Thorac Surg. 2014 Aug;19(2):205-10. doi: 10.1093/icvts/ivu148. Epub 2014 May 14. Abstract OBJECTIVES: We reviewed magnetic resonance (MR) findings of the spinal cord in patients who had a spinal cord injury after descending and thoracoabdominal aortic repair, to speculate the specific cause of the injury. METHODS: Between 2000 and 2012, 746 patients underwent descending or thoracoabdominal aortic surgery: 480 received an open repair with adjuncts of spinal cord protection [distal perfusion, cerebrospinal fluid (CSF) drainage, reattachment of intercostal arteries and hypothermia] and 266 received an endovascular repair. Twenty-six (3.5%) suffered a spinal cord injury. Of these, 18 (14 open repair and 4 endovascular repair) underwent postoperative spinal cord MRI. Preoperative identification of the Adamkiewicz artery (ARM) was obtained in all patients except 1. Aortic pathology was dissection in 2 and non-dissection in 16 patients. RESULTS: There were 3 types MRI finding: sporadic infarction involving a range of spinal cord (sporadic); focal and asymmetrical infarction within a few segments of vertebra (focal); and diffuse and symmetrical infarction around the level of the ARM (diffuse). In endovascular repair, sporadic infarction was observed in all patients (4 of 4). In open repair, sporadic infarction was observed in 3 (21%), focal infarction in 7 (50%) and diffuse infarction in 4 (29%). In all patients who had sporadic or focal infarction, the aortic pathology was non-dissection. CONCLUSIONS: From these findings, embolism is 1 of the major causes of spinal cord injury in the era of adjuncts to optimize spinal cord haemodynamics during aortic repair. PDF  Ubicación intraforaminal de las arterias medulares anteriores toracolumbares. Intraforaminal location of thoracolumbar anterior medullary arteries. Kroszczynski AC1, Kohan K, Kurowski M, Olson TR, Downie SA. Pain Med. 2013 Jun;14(6):808-12. doi: 10.1111/pme.12056. Epub 2013 Feb 25. Abstract BACKGROUND: Transforaminal epidural steroid injection (TFESI) is a widely utilized interventional pain technique for radicular pain. Although the six o'clock position of the pedicle in the so-called "safe triangle" has been used as a target location, there have been a number of reported catastrophic complications of this procedure, including paraplegia. The mechanism of this has been attributed to the intravascular injection of steroids. The goal of this study was to examine the intraforaminal location of thoracolumbar medullary arteries which would help guide pain physicians in developing safer techniques and guidelines. METHODS: Twenty-four (24) embalmed cadavers were dissected and examined for the presence and distribution of thoracolumbar anterior medullary arteries. Access to the anterior surface of the spinal cord was made via anterior corpectomy from C2 to S5. Each medullary artery's course was determined by dissection from its origin, the anterior spinal artery, through the intervertebral foramen. The foramen was subsequently opened in the coronal plane, and the intraforaminal location of the artery, its diameter, and its relation to other foraminal structures were examined and measured. RESULTS: In the thoracolumbar foramina (T4-L2), 39 anterior medullary arteries were found, including 23 great medullary arteries (Adamkiewicz artery). One Adamkiewicz artery was found to be located in the left S2 foramen and was not included in the statistical analysis. Of the analyzed 39 anterior medullary arteries, 29 (74%) were located in the upper 1/3 of the foramen, 9 (23%) were located in the middle, and 1 (3%) artery was located in the lower 1/3. In relation to the dorsal root ganglion--ventral root complex, 21 (54%) arteries were located anterosuperiorly, 16 (41%) anteriorly, and 2 (5%) anteroinferiorly. The average intraforaminal artery diameter was 1.20 mm (0.84-1.91 mm). At thoracolumbar levels, theartery is almost always (92% ± 15%) located anterosuperior to the nerve. At typical thoracic levels, it is less often anterosuperior (38% ± 19%), but more often anterior to the nerve. CONCLUSIONS: At thoracolumbar levels, if needles were to encounter an artery, they are most likely to do so if placed anterosuperior to the nerve. Encountering an artery anterosuperior to the nerve is less likely at typical thoracic levels, but the likelihood is far from negligible. Pain physicians should be cognizant of this when considering optimal needle placement during transforaminal epidural steroid injections. PDF VIII Foro Internacional de Medicina del Dolor y Paliativa  Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán Junio 9-11, Ciudad de México Dra. Argelia Lara Solares Tel. 5513 3782  www.dolorypaliativos.org

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015

Medicación preanestésica / Anesthetic premedication Victor Whizar-Lugo Para bibliomanazteca@yahoo.com.mx abr 8 a las 9:11 A.M. Abril 8, 2016. No. 2290 Estimad@ Dr@ Víctor Valdés: Premedicación anestésica. Nuevos horizontes de una vieja práctica Anesthetic premedication: new horizons of an old practice. Sheen MJ, Chang FL, Ho ST. Acta Anaesthesiol Taiwan. 2014 Sep;52(3):134-42. doi: 10.1016/j.aat.2014.08.001. Epub 2014 Oct 7. Abstract The practice of anesthetic premedication embarked upon soon after ether and chloroform were introduced as general anesthetics in the middle of the 19(th) century. By applying opioids and anticholinergics before surgery, the surgical patients could achieve a less anxious state, and more importantly, they would acquire a smoother course during the tedious and dangerous induction stage. Premedication with opioids and anticholinergics was not a routine practice in the 20(th) century when intravenous anesthetics were primarily used as induction agents that significantly shorten the induction time. The current practice of anesthetic premedication has evolved into a generalized scheme that incorporates several aspects of patient care: decreasing preoperative anxiety, dampening intraoperative noxious stimulus and its associated neuroendocrinological changes, and minimizing postoperative adverse effects of anesthesia and surgery. Rational use of premedication in modern anesthesia practice should be justified by individual needs, the types of surgery, and the anesthetic agents and techniques used. In this article, we will provide our readers with updated information about premedication of surgical patients with a focus on the recent application of second generation serotonin type 3 antagonist, antidepressants, and anticonvulsants. KEYWORDS: anticonvulsants; antidepressive agents; antiemetics; benzodiazepines; clonidine; dexmedetomidine; midazolam; neurokinin 1 receptor antagonists; premedication; serotonin 5-HT3 receptor antagonists PDF CEEA Veracruz Like us on Facebook Follow us on Twitter Find us on Google+ View our videos on YouTube Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org

Abril 8, 2016. No. 2290

Premedicación anestésica. Nuevos horizontes de una vieja práctica Anesthetic premedication: new horizons of an old practice. Sheen MJ, Chang FL, Ho ST. Acta Anaesthesiol Taiwan. 2014 Sep;52(3):134-42. doi: 10.1016/j.aat.2014.08.001. Epub 2014 Oct 7. Abstract The practice of anesthetic premedication embarked upon soon after ether and chloroform were introduced as general anesthetics in the middle of the 19(th) century. By applying opioids and anticholinergics before surgery, the surgical patients could achieve a less anxious state, and more importantly, they would acquire a smoother course during the tedious and dangerous induction stage. Premedication with opioids and anticholinergics was not a routine practice in the 20(th) century when intravenous anesthetics were primarily used as induction agents that significantly shorten the induction time. The current practice of anesthetic premedication has evolved into a generalized scheme that incorporates several aspects of patient care: decreasing preoperative anxiety, dampening intraoperative noxious stimulus and its associated neuroendocrinological changes, and minimizing postoperative adverse effects of anesthesia and surgery. Rational use of premedication in modern anesthesia practice should be justified by individual needs, the types of surgery, and the anesthetic agents and techniques used. In this article, we will provide our readers with updated information about premedication of surgical patients with a focus on the recent application of second generation serotonin type 3 antagonist, antidepressants, and anticonvulsants. KEYWORDS: anticonvulsants; antidepressive agents; antiemetics; benzodiazepines; clonidine; dexmedetomidine; midazolam; neurokinin 1 receptor antagonists; premedication; serotonin 5-HT3 receptor antagonists PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015

Obesidad y vía aérea / Obesity and airway management

Abril 19, 2016. No. 2301

Intubación difícil en pacientes obesos: incidencia, factores de riesgo y complicaciones en la sala de operaciones y en la UCI Difficult intubation in obese patients: incidence, risk factors, and complications in the operating theatre and in intensive care units. De Jong A1, Molinari N2, Pouzeratte Y1, Verzilli D1, Chanques G1, Jung B3, Futier E1, Perrigault PF4, Colson P5, Capdevila X6, Jaber S7. Br J Anaesth. 2015 Feb;114(2):297-306. doi: 10.1093/bja/aeu373. Epub 2014 Nov 27. Abstract BACKGROUND: Intubation procedure in obese patients is a challenging issue both in the intensive care unit (ICU) and in the operating theatre (OT). The objectives of the study were (i) to compare the incidence of difficult intubation and (ii) its related complications in obese patients admitted to ICU and OT. METHODS: We conducted a multicentre prospective observational cohort study in ICU and OT in obese (BMI≥30 kg m(-2)) patients. The primary endpoint was the incidence of difficult intubation. Secondary endpoints were the risk factors for difficult intubation, the use of difficult airway management techniques, and severe life-threatening complications related to intubation (death, cardiac arrest, severe hypoxaemia, severe cardiovascular collapse). RESULTS: In cohorts of 1400 and 11 035 consecutive patients intubated in ICU and in the OT, 282 (20%) and 2103 (19%) were obese. In obese patients, the incidence of difficult intubation was twice more frequent in ICU than in the OT (16.3% vs 8.2%, P<0.01). In both cohorts, risk factors for difficult intubation were Mallampati score III/IV, obstructive sleep apnoea syndrome, and reduced mobility of cervical spine, while limited mouth opening, severe hypoxaemia, and coma appeared only in ICU. Specific difficult airway management techniques were used in 66 (36%) cases of difficult intubation in obese patients in the OT and in 10 (22%) cases in ICU (P=0.04). Severe life-threatening complications were significantly more frequent in ICU than in the OT (41.1% vs 1.9%, relative risk 21.6, 95% confidence interval 15.4-30.3, P<0.01). CONCLUSIONS: In obese patients, the incidence of difficult intubation was twice more frequent in ICU than in the OT and severe life-threatening complications related to intubation occurred 20-fold more often in ICU. PDF Problemas de manejo de la vía aérea en pacientes con procedimientos de banda gástrica Airway management concerns in patient with gastric banding procedures. Koolwijk J1, Schors M, el Bouazati S, Noordergraaf GJ. BMJ Case Rep. 2013 Sep 19;2013. pii: bcr2013201009. doi: 10.1136/bcr-2013-201009. Abstract Laparoscopic adjustable gastric band (LAGB) is considered a relatively safe and effective treatment for obesity. Even after weight loss patients with LAGB are at increased risk of pulmonary aspiration during induction of general anaesthesia, possibly due to LAGB-induced anatomical and functional changes. We present a case of aspiration in a patient with LAGB following significant weight loss and 14 h of preoperative fasting and review the literature. In the presence of LAGB we propose specific anaesthesia management at least consisting of anti-Trendelenburg positioning; avoidance of mask-ventilation; use of the local rapid sequence induction strategy with endotracheal intubation and fully awake extubation. PDF Manejo de la vía aérea en el obeso Airway management in obese patient. Langeron O1, Birenbaum A, Le Saché F, Raux M. Minerva Anestesiol. 2014 Mar;80(3):382-92. Epub 2013 Oct 14. Abstract Oxygenation maintenance is the cornerstone of airway management in the obese patient related to anatomic and pathophysiologic issues. Difficult mask ventilation (DMV) risk is increased in obese patients according recognized predictors (Body Mass Index [BMI]>26 kg/m2, age >55 years, jaw protrusion severely limited, lack of teeth, snoring, beard, Mallampati class III or IV) and should systematically search. Difficult tracheal intubation(DTI) risk may be increased and risk should be assessed in a careful manner. Increased neck circumference and high BMI (>35 kg/m2) should be added to "standard" preoperative airway assessment including:Mallampati class, mouth opening and thyromental distance. In obese patients, preoxygenation is mandatory by 25° head-up position achieving better gas exchange than in supine position. In addition, to prevent early arterial oxygen desaturation related to a reduced functional residual capacity (FRC), atelectasis formation during anesthetic induction and after trachealintubation, non invasive positive pressure ventilation and application of PEEP throughout this period are recommended. Airway management inobese patients has to consider: the anesthesia technique with maintenance or not of spontaneous ventilation, the available oxygenation technique in case of anticipated DMV, and the appropriate tracheal intubation technique (fiberoptic intubation technique or videolaryngoscope) according to the patient status and will. In unexpected difficult airway, the very first priority is oxygenation and a predefined strategy has to be implemented with oxygenation devices first (supraglottic devices or ILMA). Lastly, the final step of the obese airway management is tracheal extubation and recovery. A strategy with a fully awake patient, without residual paralysis, and a 25° head-up position is mandatory. PDF Committee for European Education in Anaesthesiology (CEEA) Colegio de Anestesiólogos de León AC MÓDULO V: Sistema nervioso, fisiología, anestesia locoregional y dolor. Reconocimientos de: CEEA, CLASA, Consejo Nacional Mexicano de Anestesiología.   En la Ciudad de Léon, Guanajuato. México del 6 al 8 de Mayo, 2016. Informes en el tel (477) 716 06 16 y con el Dr. Enrique Hernández kikinhedz@gmail.com

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