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OBJECTIVES: Novel fascial plane blocks may allow early tracheal extubation and discharge from the intensive care unit (ICU). The present study primarily aimed to determine whether fascial plane blocks, in comparison with intravenous analgesia alone, significantly shortened tracheal extubation times in patients undergoing cardiac surgery. The secondary objectives were to compare each block's performance with that of intravenous analgesia alone in terms of the individual tracheal extubation time and length of ICU stay. DESIGN: Retrospective observational study. SETTING: Single-center study. PARTICIPANTS: Patients who underwent cardiac surgery between 2018 and 2019 were identified from a prospective clinical registry. After obtaining ethics approval, the clinical and electronic records of patients undergoing cardiac surgery in 2018 were analyzed. Data of patients receiving fascial plane blocks (erector spinae plane [ESP], pectoral plane I and II [PECs], and serratus anterior plane [SAP] blocks) with intravenous analgesia were compared with those of patients receiving only intravenous analgesia. A propensity score (PS) model was used to control for differences in the baseline characteristics. Adjusted p < 0.05 was considered statistically significant. MEASUREMENTS AND MAIN RESULTS: Of the 589 patients screened, 532 met the inclusion criteria; 404 received a fascial plane block. After PS matching, weighted linear regression revealed that by receiving a block, the predicted extubation time difference was 9.29 hours (b coefficient; 95% CI: -11.98, -6.60; p = 0.022). Similar results were obtained using PS weighting, with a reduction of 7.82 hours (b coefficient; 95% CI: -11.89, -3.75; p < 0.001) in favor of the block. In the fascial-plane-block group, ESP block achieved the best performance. The length of ICU stay decreased by 1.1 days (b coefficient; 95% CI: -1.43, -0.79; p = 0.0001) in the block group. No complications were reported. CONCLUSIONS: Fascial plane block is associated with reduced extubation times and lengths of ICU stay. ESP block achieved the best performance, followed by PECs and SAP blocks. After PS matching, only ESP block reduced the extubation time.

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Presentamos el tratamiento eficaz de una filtración espontánea de líquido cefalorraquídeo (LCR) asociada a un síndrome de hipoten-sión/hipovolumen de LCR a nivel cervical alto, caracterizado por delirio y hematomas subdurales secundarios, refractarios al drenaje quirúrgico, que se resolvió con dos parches de sangre epidurales cervicales consecutivos.

We present the case of a cerebrospinal fluid (CSF) hypotension/hypovolume syndrome due to a spontaneous CSF fistula at the upper cervical level characterized by loss of consciousness and bilateral subdural hematomas refractory to two drainage surgeries that resolved with two consecutive blood patches on the leak site.

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Resumen El paro cardiorrespiratorio (PCR) en la mujer embarazada es una situación infrecuente, grave y de manejo multidisciplinario. La reanimación cardiopulmonar requiere consideraciones y particularidades propias de la embarazada, centradas en la fisiología y la anatomía, teniendo especial consideración la compresión aortocava, la intubación-ventilación difícil, la presencia de estómago lleno y el hecho que hay dos vidas involucradas. Las principales causas de PCR son las hemorrágicas, seguidas de las embólicas, cardiovasculares, anestésicas e infecciosas. Las principales acciones incluyen activación del código azul obstétrico con respuesta rápida para una eventual realización de histerotomía de emergencia oportuna en el mismo sitio evitando el traslado al quirófano, compresiones torácicas de buena calidad, desviación manual uterina a la izquierda, intubación endotraqueal y manejo avanzado de la vía aérea, todo esto con el fin de mejorar la sobrevida materno-fetal. La cesárea perimortem es un pilar en el manejo, favoreciendo el desenlace materno y eventualmente el fetal. Se debe realizar a los 4 minutos de una reanimación cardiopulmonar no exitosa. Sin embargo, aún hay retardo a la hora de indicarla, por lo que se debe incentivar el entrenamiento, la simulación en resucitación cardiopulmonar materna y las guías clínicas para todo el personal involucrado en la atención de pacientes obstétricas.

Abstract Cardiopulmonary arrest is a rare event during pregnancy and labor. It involves many subspecialties and allied health providers. Besides it requires knowledge of maternal physiology as it relates to resuscitation, particularly aortocaval compression, difficult airway, full stomach and the fact that there are two lives involved. The most frequent causes of cardiac arrest during pregnancy include bleeding, followed by embolism, infection, anesthesia complications and heart failure. The main steps required are: obstetric code activation with appropriate response for performing timely emergent hysterotomy in the same place avoiding the transfer to operating room; good-quality chest compressions; manual uterine displacement to the left, advanced pharmacological and airway management; and optimal care after resuscitation to improve maternal and fetal outcomes. Although current recommendations for maternal resuscitation include the performance of perimortem cesarean section after four minutes of unsuccessful cardiopulmonary resuscitation, deficits in knowledge about this procedure are common. Therefore, training and available evidence-based guidelines should be put in place for all obstetric caregivers.

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Pregnancy induces changes in almost every body system, pushing their reserves to the limit. There is a decrease in systemic vascular resistance, a progressive increase in blood volume, heart rate and myocardial size, resulting in an increased cardiac output. It reduces the functional residual capacity and increases the tidal volume. Oxygen consumption increases, leading to a decrease in oxygen reserves and increased risk of hypoxemia under hypoventilation or apnea (more frequent due to difficult airway management as a result of edema). Important changes are also observed at the hematological, renal and intestinal levels. Uterineplacental blood flow increases progressively during pregnancy, elevating the risk of massive hemorrhage. When intrauterine resuscitation does not resolve acute fetal distress, urgent cesarean section should be performed. Neuraxial over general anesthesia is recommended. In emergency situations, general anesthesia or "Rapid Sequence Spinal Anesthesia" is suggested as an alternative. The requirements of both, hypnotics and inhalation agents, decrease during pregnancy. Obstetric hemorrhage may be the result of bleeding from placenta or a consequence of trauma to the genital tract during delivery. The most severe cases present hypovolemic shock. Along with controlling the source of bleeding, the treatment goals are: treat hypovolemia and acute trauma coagulopathy, preserve oxygen transport capacity, repair the endothelium and prevent dilutional coagulopathy. Management of placenta accreta must be multidisciplinary. Preoperative diagnosis is essential for adequate preparation. Combined spinal-epidural technique is recommended. When hysterectomy becomes necessary, conversion to general anesthesia should be considered. Amniotic fluid embolism in its early stage produces right ventricular dysfunction due to acute pulmonary hypertension and, in its late stage, left ventricular dysfunction. In 40% of cases, multifactorial coagulopathy is observed. The diagnostic criteria are: 1) hypotension or cardiac arrest, hypoxia and coagulopathy; 2) during labor, caesarean section, uterine curettage or in the first 30 minutes postpartum; 3) in the absence of another diagnosis that explains the symptoms. Treatment is supportive, besides termination of pregnancy. Resuscitation during pregnancy must be led by a professional who understands the complexities of the situation. Maternal well-being is the best predictor of fetal well-being. A perimortem cesarean may become necessary.

El embarazo induce cambios en casi todos los sistemas corporales, llevando al límite las reservas a cada uno de ellos. Hay disminución de la resistencia vascular sistémica, aumento progresivo de la volemia, frecuencia cardiaca y tamaño miocárdico, lo que produce un aumento del débito cardiaco. Se reduce de la capacidad residual funcional y aumenta del volumen corriente. Aumenta el consumo de oxígeno, lo que conlleva disminución de la reserva de oxígeno y aumenta el riesgo de hipoxemia frente a hipoventilación o apnea (más frecuente dificultad en el manejo de vía aérea por edema). También se observan importantes cambios a nivel hematológico, renal e intestinal. El aumento progresivo de flujo úteroplacentario propicia el desarrollo de hemorragias masivas. Cuando la reanimación intrauterina no resuelve el sufrimiento fetal agudo se debe proceder a la cesárea de urgencia. En dicho caso, se privilegia la anestesia neuroaxial por sobre la general. En la cesárea de emergencia se recomienda anestesia general o "anestesia espinal en secuencia rápida" como alternativa. Los requerimientos tanto de hipnóticos como de agentes inhalatorios disminuyen en el embarazo. La hemorragia obstétrica resulta del sangrado del lecho placentario o como consecuencia del traumatismo al tracto genital durante el parto. La forma de presentación de los casos graves generalmente es con hipovolémico. Junto con controlar la fuente del sangrado los objetivos son: tratar la hipovolemia, tratar la coagulopatía aguda del trauma, preservar la capacidad de transporte de oxígeno, reparar el endotelio y prevenir la coagulopatía dilucional. El manejo de la placenta acreta es multidisciplinario. El diagnóstico preoperatorio es imprescindible para la adecuada preparación. Es recomendable una técnica combinada espinal-epidural y conversión a anestesia general en caso de histerectomía. La embolia de líquido amniótico en su etapa temprana produce disfunción ventricular derecha, por hipertensión pulmonar aguda y en su etapa tardía, disfunción ventricular izquierda. En el 40% de los casos, se observa coagulopatía multifactorial. Los criterios diagnósticos son: 1) hipotensión o paro cardíaco, hipoxia y coagulopatía; 2) durante el trabajo de parto, cesárea, legrado uterino o en los primeros 30 min posparto; 3) en ausencia de otro cuadro que explique los síntomas. El tratamiento es de soporte y la interrupción del embarazo. La reanimación durante el embarazo debe ser liderada por un profesional que conozca las particularidades del manejo. El bienestar materno es el mejor predictor de bienestar fetal. Una cesárea puede ser necesaria.

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We present the analysis and comments of a review of evidence of the impact of obstetric anesthesia on maternal and neonatal outcomes, based on an article previously published by Lim et al.[1]. The advances in obstetric anesthesia on analgesia and anesthesia for labor and delivery, anesthesia for cesarean section and outcomes in obstetric anesthesia.

Se presenta el análisis y comentarios de una revisión de evidencia del impacto de la anestesia obstétrica en los desenlaces maternos y neonatales, basado en un artículo previamente publicado por Lim y cols.[1]. Se analizan los avances en la anestesiología obstétrica sobre analgesia y anestesia para el parto, anestesia para cesárea y desenlaces en anestesia obstétrica.

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BACKGROUND: Cannulation of a peripheral venous access is a routine procedure in pediatric patients admitted to the hospital. 50% of the time cannulation on the first attempt is not feasible, so it is necessary to repeat the puncture, resulting in a complex and frustrating procedure. Half of the children admitted to the hospital have a difficult venous access (DIVA). OBJECTIVE: To carry out a review, which provides information about DIVA in pediatrics, how to evaluate and proceed in these patients. DESIGN: DIVA Score considers vein palpability, vein visibility, age and history of prematurity. The score ranges from 0 to 10 points. Values greater than 4 are associated with difficult venous access. There are associated risk factors: obesity, musculoskeletal malformations, chemotherapy treatment, diabetes mellitus, patients on dialysis, limb edema, moderate to severe dehydration, history of difficult venous access, anxiety of the patient and/or parents report that the child is less likely to cooperate. When making the decision to establish a venous access, it should be evaluated whether it is an emergency or not, the characteristics of the medications and infusions, the time of therapy and the anatomical sites for puncture. Ultrasound and transillumination techniques decrease the time to obtain a venous access and increase the success rate on the first attempt. CONCLUSION: The decision to obtain a venous access must take into account the criteria and risk factors for DIVA. The most recognized scale is the DIVA Score.

INTRODUCCIÓN: La canulación de un acceso venoso periférico es un procedimiento rutinario en los pacientes pediátricos que ingresan al hospital. 50% de las veces la canulación al primer intento es frustra, por lo que es necesario repetir la punción resultando el procedimiento complejo y frustrante. La mitad de los niños que ingresa al hospital presentan un acceso venoso difícil (DIVA, sigla derivada de "difficult intravenous access"). OBJETIVO: Realizar una revisión, que entrega información acerca de DIVA en pediatría, cómo evaluar y proceder en estos pacientes. DESARROLLO: DIVA Score considera palpabilidad y visibilidad venosa, edad y antecedente de prematurez. El puntaje va desde 0 a 10 puntos. Valores mayores a 4 se asocian a acceso venoso difícil. Existen factores de riesgo asociados: obesidad, malformaciones osteomusculares, tratamiento con quimioterapia, diabetes mellitus, pacientes en diálisis, edema de extremidades, deshidratación moderada a severa, historia de acceso venoso difícil, ansiedad del paciente y/o padres que refieren que el niño es poco probable que coopere. Al tomar la decisión de establecer un acceso venoso se debe evaluar si es urgencia o no, las características de los medicamentos e infusiones, tiempo de terapia y los sitios anatómicos para punción. La ultrasonografía y las técnicas de transiluminación disminuyen el tiempo de obtención del acceso venoso e incrementan la tasa de éxito en el primer intento. CONCLUSIÓN: En la decisión de obtener un acceso venoso se deben tener en cuenta los criterios y factores de riesgo de acceso venoso difícil. La escala más reconocida es el DIVA Score.

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Anesthesiology became the first Chilean medical specialty certification board to incorporate an objective structured clinical examination (OSCE) into its certification system. The main reason for the introduction of an OSCE is to include an evaluation that allow candidates to demonstrate what they really "do" in clinical practice domains. Inherent in this justification is that the OSCE detects competences that are not well evaluated in current written and oral exams. This article describes the process of implementing an OSCE in Anesthesiology certification and a description of its application after one year of operation.

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Anesthesiology became the first Chilean medical specialty certification board to incorporate an objective structured clinical examination (OSCE) into its certification system. The main reason for the introduction of an OSCE is to include an evaluation that allow candidates to demonstrate what they really "do" in clinical practice domains. Inherent in this justification is that the OSCE detects competences that are not well evaluated in current written and oral exams. This article describes the process of implementing an OSCE in Anesthesiology certification and a description of its application after one year of operation.

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