Role of VV ECMO tracheal surgery and carinal resection: Two case reports

The aim of this study is to describe the anaesthesia management of two patients undergoing carinal resection under veno-venous extracorporeal membrane oxygenation (VV ECMO). In both cases, anaesthesia was induced and then maintained with inhalational agents during pneumonectomy and mediastinoscopy (respectively). Then the jugular and femoral veins were cannulated and VV ECMO was started after heparinization. One of the patients presented bleeding during surgery, which was treated with low-dose vasopressors (norepinephrine) and transfusion of platelets, fresh frozen plasma, and concentrated red blood cells. During VV ECMO, anaesthesia was maintained with target-controlled infusion of propofol. VV ECMO can be expected to improve surgical conditions in tracheal surgery; however, it is still a novel technique in this context. In selected patients, it would guarantee ventilatory support during carinal resection, but it is essential to carefully plan anaesthesia maintenance and prepare for VV ECMO-related complications. This technique should only be used in tertiary centres with experience in VV ECMO management.

Description of Intensive Care and Intermediate Care resources managed by Anaesthesiology Departments in Spain and their adaptation capacity during the COVID-19 pandemic

INTRODUCTION

It is essential to understand the strategic importance of intensive care resources in the sustainable organisation of healthcare systems. Our objective has been to identify the intensive and intermediate care beds managed by Anaesthesiology and Resuscitation Services (A-ICU and A-IMCU) in Spain, their human and technical resources, and the changes made to these resources during the COVID-19 pandemic.

MATERIAL AND METHODS

Prospective observational study performed between December 2020 and July 2021 to register the number and characteristics of A-ICU and A-IMCU beds in hospitals listed in the catalogue published by the Spanish Ministry of Health.

RESULTS

Data were obtained from 313 hospitals (98% of all hospitals with more than 500 beds, 70% of all hospitals with more than 100 beds). One hundred and forty seven of these hospitals had an A-ICU with a total of 1702 beds. This capacity increased to 2107 (124%) during the COVID-19 pandemic. Three hundred and eight hospitals had an A-IMCU with a total of 3470 beds, 52.9% (2089) of which provided long-term care. The hospitals had 1900 ventilators, at a ratio of 1.07 respirators per A-ICU; 1559 anaesthesiologists dedicated more than 40% of their working time to intensive care. The nurse-to-bed ratio in A-ICUs was 2.8.

DISCUSSION

A large proportion of fully-equipped ICU and IMCU beds in Spanish hospitals are managed by the anaesthesiology service. A-ICU and A-IMCUs have shown an extraordinary capacity to adapt their resources to meet the increased demand for intensive care during the COVID-19 pandemic.

Peripheral VA-ECMO left ventricular dysfunction: A combined biventricular assistance two case-report

We report 2 patients with cardiogenic shock that developed severe left ventricular dysfunction due to a non-opening aortic valve while on peripheral VA-ECMO (Veno-Arterial Extracorporeal Membrane Oxygenator). Patients were managed combining a LV (Left Ventricle) mechanical assist device, and central VA - ECMO to support the right ventricle, thus providing full circulatory and respiratory assistance. Patients were able to bridge to cardiac transplantation. We therefore recommend such combination in patients with severe LV dysfunction while on p-ECMO (peripheral ECMO) support.

Peripheral VA-ECMO left ventricular dysfunction: A combined biventricular assistance two case-report

We report 2patients with cardiogenic shock that developed severe left ventricular dysfunction due to a non-opening aortic valve while on peripheral VA-ECMO (Veno-Arterial Extracorporeal Membrane Oxygenator). Patients were managed combining a LV (Left Ventricle) mechanical assist device, and central VA - ECMO to support the right ventricle, thus providing full circulatory and respiratory assistance. Patients were able to bridge to cardiac transplantation. We therefore recommend such combination in patients with severe LV dysfunction while on p-ECMO (peripheral ECMO) support.

Summary of recommendations and key points of the consensus of Spanish scientific societies (SEPAR, SEMICYUC, SEMES; SECIP, SENEO, SEDAR, SENP) on the use of non-invasive ventilation and high-flow oxygen therapy with nasal cannulas in adult, pediatric, and neonatal patients with severe acute respiratory failure

Non-invasive respiratory support (NIRS) in adult, pediatric, and neonatal patients with acute respiratory failure (ARF) comprises two treatment modalities, non-invasive mechanical ventilation (NIMV) and high-flow nasal cannula (HFNC) therapy. However, experts from different specialties disagree on the benefit of these techniques in different clinical settings. The objective of this consensus was to develop a series of good clinical practice recommendations for the application of non-invasive support in patients with ARF, endorsed by all scientific societies involved in the management of adult and pediatric/neonatal patients with ARF. To this end, the different societies involved were contacted, and they in turn appointed a group of 26 professionals with sufficient experience in the use of these techniques. Three face-to-face meetings were held to agree on recommendations (up to a total of 71) based on a literature review and the latest evidence associated with 3 categories: indications, monitoring and follow-up of NIRS. Finally, the experts from each scientific society involved voted telematically on each of the recommendations. To classify the degree of agreement, an analogue classification system was chosen that was easy and intuitive to use and that clearly stated whether the each NIRS intervention should be applied, could be applied, or should not be applied.

Summary of recommendations and key points of the consensus of Spanish scientific societies (SEPAR, SEMICYUC, SEMES; SECIP, SENEO, SEDAR, SENP) on the use of non-invasive ventilation and high-flow oxygen therapy with nasal cannulas in adult, pediatric, and neonatal patients with severe acute respiratory failure

Non-invasive respiratory support (NIRS) in adult, pediatric, and neonatal patients with acute respiratory failure (ARF) comprises two treatment modalities, non-invasive mechanical ventilation (NIMV) and high-flow nasal cannula (HFNC) therapy. However, experts from different specialties disagree on the benefit of these techniques in different clinical settings. The objective of this consensus was to develop a series of good clinical practice recommendations for the application of non-invasive support in patients with ARF, endorsed by all scientific societies involved in the management of adult and pediatric/neonatal patients with ARF. To this end, the different societies involved were contacted, and they in turn appointed a group of 26 professionals with sufficient experience in the use of these techniques. Three face-to-face meetings were held to agree on recommendations (up to a total of 71) based on a literature review and the latest evidence associated with 3 categories: indications, monitoring and follow-up of NIRS. Finally, the experts from each scientific society involved voted telematically on each of the recommendations. To classify the degree of agreement, an analogue classification system was chosen that was easy and intuitive to use and that clearly stated whether the each NIRS intervention should be applied, could be applied, or should not be applied.

Clinical Consensus Recommendations Regarding Non-Invasive Respiratory Support in the Adult Patient with Acute Respiratory Failure Secondary to SARS-CoV-2 infection

Coronavirus disease 2019 (COVID-19) is a respiratory tract infection caused by a newly emergent coronavirus, that was first recognized in Wuhan, China, in December 2019. Currently, the World Health Organization (WHO) has defined the infection as a global pandemic and there is a health and social emergency for the management of this new infection. While most people with COVID-19 develop only mild or uncomplicated illness, approximately 14% develop severe disease that requires hospitalization and oxygen support, and 5% require admission to an intensive care unit. In severe cases, COVID-19 can be complicated by the acute respiratory distress syndrome (ARDS), sepsis and septic shock, and multiorgan failure. This consensus document has been prepared on evidence-informed guidelines developed by a multidisciplinary panel of health care providers from four Spanish scientific societies (Spanish Society of Intensive Care Medicine [SEMICYUC], Spanish Society of Pulmonologists [SEPAR], Spanish Society of Emergency [SEMES], Spanish Society of Anesthesiology, Reanimation, and Pain [SEDAR]) with experience in the clinical management of patients with COVID-19 and other viral infections, including SARS, as well as sepsis and ARDS. The document provides clinical recommendations for the noninvasive respiratory support (noninvasive ventilation, high flow oxygen therapy with nasal cannula) in any patient with suspected or confirmed presentation of COVID-19 with acute respiratory failure. This consensus guidance should serve as a foundation for optimized supportive care to ensure the best possible chance for survival and to allow for reliable comparison of investigational therapeutic interventions as part of randomized controlled trials.

Experience in anaesthetic management of non-cardiac surgery in patients with ventricular assist devices

Heart failure (HF) is a syndromic condition with a high incidence in current medicine. When the symptoms of HF progress, and become refractory, cardiac transplant is the best therapeutic option. However, due to the shortage of donors and the long waiting lists, many of those patients are candidates for implantation of ventricular assist devices as a bridge to the cardiac transplant, or when this is not an option, as a definitive therapy. A series of four clinical cases of patients with ventricular assist devices that required surgical intervention, is presented. Three of them were assisted with long-term care: two EXCOR (pulsatile and para-corporeal) and one HEARTWARE (non-pulsatile and intra-corporeal), and the last one with short-term assistance; CentriMag biventricular Levitronix. There is no significant literature on the peri-operative implications of these patients when they undergo urgent or scheduled surgery. The experience in our centre leads us to raise the need to determine a series of aspects: operation of each device, emphasising the correct placement of the cannulas during the surgery; the proper management of any medication, emphasising the importance of anticoagulant and anti-platelet therapies; the Pathophysiological changes at cardiopulmonary level due to the implantation of these devices; and the importance of the administration of a correct antibiotic therapy. Given the complexity of these cases, the limited experience in this field, and the few cases that exist in these situations, it is recommended to create protocols to ensure their proper management.

[Cerebral oximetry in pulmonary thromboendarterectomy with circulatory arrest]

Pulmonary thromboendarterectomy is an uncommon procedure and should be performed with circulatory arrest. One of the major concerns is the postoperative central neurological injuries. Perioperative brain oxygen monitoring is advisable in this surgical procedure for the early detection of brain hypoperfusion episodes and their intensity as well as any other postoperative episodes that can deteriorate the neurological outcome.

Reappraisal of classical electrocardiographic criteria in detecting accessory pathways with a strict para-Hisian location

BACKGROUND

Identification of electrocardiographic (ECG) criteria for para-Hisian accessory pathways (APs) is based on a small series of patients. The presence of a negative delta wave in leads V(1) and V(2) has been suggested as an ECG marker of this AP location.

OBJECTIVE

To validate these ECG findings in a large series of patients with strict invasive criteria for that location.

METHODS

We included 105 patients (39 women, 66 men; mean age 26 ± 12 years, range 5-82 years) with an ECG pattern compatible with preexcitation through an anteroseptal or midseptal AP following established ECG criteria. A para-Hisian AP was defined when the location of its successful catheter ablation coincided with either the largest recordable His bundle electrogram or a His bundle potential of>0.1 mV. Patients without that definition were included in the control group.

RESULTS

A para-Hisian location of the AP was found in 52 patients. AP locations of the remaining 53 patients (control group) were anteroseptal (n = 39), midseptal (n = 9), and fasciculoventricular (n = 5). A negative delta wave in leads V(1) and V(2) was observed in 13 patients with para-Hisian APs (sensitivity 25%; specificity 92%). However, the sum of initial r-wave amplitudes in those leads was<0.5 mV in 44 of the patients with para-Hisian APs and in 13 patients of the control group (sensitivity 85%; specificity 75.5%; area under receiver-operator characteristic curve 0.85).

CONCLUSIONS

The presence of negative delta waves in leads V(1) and V(2) indicates a poor sensitivity and high specificity to detect APs with a strict definition of para-Hisian location. The sum of initial r-wave amplitudes in those ECG leads could be a useful, adjunctive marker in the noninvasive identification of these challenging APs.

[Retrospective comparative study between sevoflurane and propofol in maintaining anaesthesia during liver transplant: Effects on kidney and liver function]

OBJECTIVE

To compare the post-operative effects of sevoflurane versus propofol on liver and kidney function while maintaining anaesthesia in the orthotopic liver transplant (OLT), as well as to analyse the short-term survival as regards these functions.

PATIENTS AND METHODS

A retrospective analysis was conducted on patients subjected to an OLT between January 2002 and December 2009. Patients on pre-transplant haemodialysis, re-transplants, and hepatorenal transplants were excluded. The incidence of acute renal failure, initial dysfunction of the graft, reperfusion syndrome, rejection, and the transaminase peak depending value depending on the hypnotic used, were recorded.

RESULTS

About one-third (31.2%) of the patients developed acute renal failure and 11.9% an initial dysfunction, with no differences between the groups. There was a tendency for a lower incidence of initial dysfunction of the graft in the sevoflurane group (8.6% compared to 12.8%), a lower transaminase peak (greater than 2000 U/L, 12.1% versus 15.9%), and a lower incidence of reperfusion syndrome (10.3% compared to 21.6%).

CONCLUSIONS

Despite the fact that the renal metabolism sevoflurane is elevated, we did not find any higher incidence of acute renal failure. Sevoflurane in the liver transplant anaesthesia is as least equally as safe propofol as regards renal function and liver function. New prospective studies are needed to clarify the possible effects of the hypnotic in liver transplant.

[Bispectral index during induction and awakening from sedation with sevoflurane for magnetic resonance imaging in children]

OBJECTIVES

To determine the bispectral (BIS) index during induction of sedation with sevoflurane and awakening in children undergoing magnetic resonance imaging (MRI).

MATERIAL AND METHODS

We studied 50 pediatric patients sedated only with 2% sevoflurane in oxygen and air administered through a face mask. BIS was monitored during induction, before MRI, after MRI, during awakening, upon first movement, and upon eye opening or first cry.

RESULTS

The scan was performed successfully in all patients (none moved during the procedure) even though there was great variability in BIS indices (before MRI, 59.5 [SD, 11.1]; after MRI, 52.8 [13.7]). BIS indices before and after MRI were correlated, although the index after MRI was significantly lower than the index before the scan (P<0.01), indicating that hypnosis became deeper during the procedure. The first spontaneous movement and crying or eye opening produced significantly higher BIS indices (P<0.01) (movement, 75.4 [15.9]; crying, 79.8 [15.6]), although variation was also greater. The BIS index did not exceed 70 for 15 patients (31.3%) upon eye opening and for 12 (27.3%) at the first cry. Children under 6 months of age had significantly lower BIS indices before and after MRI scans than did the older children (P<0.01).

CONCLUSIONS

In the absence of painful stimuli, the BIS index reflects the patient's level of hypnosis but does not predict recovery of consciousness.

[Jehovah's Witnesses refusal of blood: religious, legal and ethical aspects and considerations for anesthetic management]

The refusal of Jehovah's Witnesses to agree to blood or blood product transfusion based on religious beliefs is one of the most challenging conflictive issues health care givers have to face today. Such conflict is a by product of the ideological and religious diversity in society today. The perioperative care of such patients constitutes a genuine challenge for anesthesiologists and surgeons from technical, scientific, ethical, and legal perspectives. We review the reasons why Jehovah's Witnesses refuse transfusion and discuss the ethical, legal, and anesthetic aspects of their care. The literature up to August 2005 was reviewed by MEDLINE search. The following search terms were used: Jehovah's Witnesses, anesthesia (and anaesthesia), legislation and jurisprudence, ethics, blood transfusion, alternatives, anemia (and anaemia), erythropoietin, trigger, and critical care. To further cover ethical and legal aspects, we reviewed current laws in Spain and similar practice settings.

A new successful therapy for fetal chylothorax by intrapleural injection of maternal blood

We present two cases of fetal chylothorax and hydrops diagnosed at 20 weeks' gestation, both of which underwent successful intrauterine treatment. In Case 1, a transient, near total resolution began 2 weeks after an iatrogenic hemothorax following a second thoracocentesis performed at 24 + 6 weeks. Because of pleural fluid reaccumulation, a Cesarean section was performed at 36 weeks. The 3805-g female neonate was admitted to neonatal intensive care but was discharged 50 days later in a healthy condition. In Case 2, resolution occurred after a third thoracocentesis and a second pleural injection of maternal blood, performed at 26 weeks. A 2660-g female neonate was delivered vaginally at 38 weeks. The infant remained asymptomatic and was discharged aged 4 days. Our experience suggests a possible useful role of intrapleural blood injection for the treatment of fetal chylothorax.

[Sudden death in a normal heart. Idiopathic ventricular fibrillation. Review of the literature concerning one case]

Idiopathic ventricular fibrillation is that which is produced in the absence of structural cardiac disease and of other identifiable causes of ventricular fibrillation such as cardiotoxicity, electrolytical alterations or hereditary predisposition. The case of a healthy male, aged 37, who was asymptomatic until the day he was admitted to hospital where he showed numerous episodes of ventricular fibrillation without any previous triggering, is discussed. In the examination no cause was found to explain this, and an automatic defibrillator was implanted. The requirements for its diagnosis, risk stratification and the usefulness of the tests employed, as well as the treatments proposed are discussed.

[The midterm evolution in the percutaneous closure of ductus arteriosus with the Rashkind prosthesis]

Background percutaneous PDA occlusion has been proposed as a valid therapeutic alternative to surgical closure. Between April 1990 and July 1994, 44 patients underwent percutaneous PDA occlusion. Thirteen patients were less than 18 months old and weighed 8.7 +/- 3.2 Kg (Group I). Thirty-one patients, older than 18 months of age, had a mean weight of 36.8 +/- 20.6 Kg (Group II). Four patients in group I and two in group II had associated cardiac anomalies Residual shunt after percutaneous occlusion was studied by color Doppler. Fifty-one occluding devices were used. Forty-nine were implanted and there were two device embolizations. Twelve devices were implanted in group I. One device needed surgical removal from the right ventricle where it had embolized. In group II, 31 devices were implanted and one embolized to the descending aorta and was percutaneously removed through the femoral artery sheath. In two patients of group I and four of group II, a second device was implanted. The total occlusion rate immediately after implantation at 24 hours and at 6 months was 75%, 83% and 83% in group I and 64.5%, 77% and 84% in group II. After implantation of a second device the total occlusion rate without residual shunt reached 100% in group I (after 16 +/- 12 months follow-up) and 97% in group II (after 23 +/- 16 months of follow-up). We conclude that percutaneous ductal occlusion with a Rashkind device is a valid therapeutic alternative to surgical closure in all age groups.

Scanning electron microscopy of the wild boar and pig lingual papillae

Lingual papillae of wild boar and pig were studied by means of scanning electron microscopy (SEM). Vallate papillae appear with the typical circumvallate morphology. Their papillary bodies show conical or fungiform-like and spicule-like pseudopapillae in both animals. Taste pores were seen in the papillary grooves. Microplicae or pits are visible at high magnification. In pig and wild boar similar foliate papillae were observed. Pig has less but wider leaves than wild boar. Taste pores on papillary walls were viewed. At high magnification microplicae were seen. Morphologically, fungiform papillae correspond with their denomination. Taste pores open onto the upper surface and they are easily identifiable by SEM. The rostral and lateral regions contain the major number of fungiform papillae. The lateral papillae of wild boar and pig show a high number of pores per papilla. These regions must be considered important in taste sensitivity. Lateral papillae in both animals could provide a source of taste buds for study. In both animals the fungiform papillary epithelium showed a pitted appearance as a consequence of keratinization by food environmental stress. The filiform papillae can be both simple and compound (with body and hairs). Large conical papillae are located caudally and curved in the same direction. Filiform and conical papillae have a function in food mastication, handling and deglutition.

Fungiform papillae of the pig and the wild boar analyzed by scanning electron microscopy

Fungiform papillae of wild boar and pig were studied by scanning electron microscopy (SEM). Four regions were defined on the tongue: rostral, medial and caudal thirds and lateral sides. Morphologically the fungiform papillae correspond with their denomination. Rostral and lateral tongue regions presented the largest average number of fungiform papillae. Taste pores opened onto the upper surface of the papillae and were easily identifiable by SEM. The total number of fungiform taste pores from both animals was the highest reported in the literature. The lateral papillae of wild boar and pig contained the largest average number of pores per papilla. This region must be important in taste sensitivity. Lateral and rostral papillae from both animals can provide a source of taste buds for study since each fungiform papilla presents numerous taste buds and these papillae are very abundant.

A study of the chick thymus microenvironment during development: analysis by monoclonal antibodies against thymic epithelium

The process of T-lymphocyte differentiation within the thymus involves a series of molecular interactions. In this work we have carried out an analysis of the chick thymus microenvironment in order to evaluate its heterogeneity during development. We have produced 11 monoclonal antibodies whose staining patterns detected by the immunoperoxidase technique allowed us to divide them into five groups. A first group (E19-E2, P0-E5, and P15-T1) binds to thymic medullary stroma showing a reticular pattern on medullary epithelial cells and whose significance would be related to thymic stromal secretion. The second group of monoclonal antibodies (P15-T3) stains thymic corpuscles of 10- and 15-day chicks. The third group of antibodies includes P0-E1, P0-E3, P5-A6, and P15-T2 whose staining pattern is both medullary and cortical. The fourth group (P10-HB1 and P10-HB2) binds to thymic stromal and cortical thymocytes, and the fifth group (P5-A1) is characterized by the staining of medullary vessels of 5-day chicks. These five groups of monoclonal antibodies corroborate the existence of an antigenic diversity of the chick thymus microenvironment. Their possible relationships with T-cell differentiation and stromal-thymocyte interactions are discussed.

[Heptatodiaphragmatic interposition of the colon (Chilaiditi's syndrome)]

A case of heptatodiaphragmatic interposition of colon is described in a school-age boy with malnutrition, appendicitis and mesenteric adenitis subsequent to typhoid fever. Historical, etiological, clinical and therapeutic considerations are made.

Simultaneous determination of toluene and xylene metabolites in urine by gas chromatography

A gas chromatographic method for simultaneous determination of hippuric and o-, m-, and p-methylhippuric acids (metabolites of toluene and xylene) in urine is described. The analytical procedure is based on the extraction of the aromatic metabolites with ethyl acetate containing the internal standard and on a methylation with 3-methyl-1-p-tolyltriazene. With this method, which does not require much time and handling, the different acids can be satisfactorily determined with high sensitivity and specificity. A statistical study shows a good reproducibility for the determination of hippuric and o-, m-, and p-methylhippuric acids. The coefficient of variation for 10 determinations in all cases was less than 5%.

Direct evidence of luteal insufficiency in women with habitual abortion

Plasma levels of progesterone were measured during the luteal phase in 10 of 15 women with clinical histories of at least three spontaneous abortions in the last three gestations, and in 15 healthy nonpregnant women during the same phase of the ovarian cycle. Progesterone values found in the women with habitual abortion were lower (P less than 0.05-0.005) than in the nonpregnant group almost throughout the period of observation. The habitually aborting women who became pregnant again aborted between the seventh and 12th weeks. Their progesterone concentrations were less than 6 ng/ml, 48-72 hours before vaginal bleeding or abortion. These values were compared with those found during the first 12 weeks in normal pregnancy (P less than 0.001). The results suggest a useful method of evaluating the treatment of habitual abortion.

Trichloroethylene exposure. Simulation of uptake, excretion, and metabolism using a mathematical model

The absorption, distribution, and excretion of trichloroethylene, as well as the kinetics of formation and elimination of trichloroethanol (TCE) and trichloroacetic acid (TCA) were simulated by a mathematical model. The results of this model have been satisfactorily compared with those obtained experimentally from pulmonary elimination of the solvent and from urinary excretion of the metabolites. The model permitted a study of the distribution of the solvent in the different tissues of the organism as well as an evaluation of the body burden of TCE and TCA. The influence of the duration and repetition of the exposure on the urinary eliminations of TCE and TCA was studied, and showed that the excretion of the first metabolite represents the most recent exposure while that of the second is related to the average exposure of the preceding days. The study of the pulmonary elimination of trichloroethylene during single or repeated exposures showed a linear relationship between the alveolar concentration of the solvent approximately 15 hours after the end of the exposure and the quantity of trichloroethylene accumulated in the fatty tissues.