Introduction and objectives: The occurrence of a difficult airway during intubation is a critical event in anaesthesia. Despite the usefulness of clinical predictors, difficult intubation frequently arises unexpectedly. The aim of this study was to determine the utility of airway ultrasound in detecting these patients. Materials and methods: This was a case-control study. The patients in the case group were identified from the registry of patients with reports of difficult laryngoscopy (Cormack III and IV). The controls were selected from among patients classed as Cormack I who underwent surgery under general anaesthesia. Fifty patients (25 cases and 25 controls) participated in the study. All patients underwent ultrasound to obtain 3 measurements: distance from the skin to the hyoid bone, distance from the skin to the epiglottis, and distance from the skin to the vocal cords. Results: A skin-to-hyoid bone distance greater than 9.8 mm (50% of the sample) generated an odds ratio of 5.46 (p = 0.005); a skin-to-epiglottis distance greater than 21.3 mm (50% of the sample) generated an odds ratio of 6.62 (p = 0.002). There was no significant difference in the skin-to-vocal cords distance. Conclusions: Ultrasound has proven to be a useful tool for predicting difficult laryngoscopy. Despite the low sensitivity of clinical predictors, they appear to improve the detection of patients with difficult laryngoscopy when integrated into predictive models alongside ultrasound values. (c) 2024 The Author(s). Published by Elsevier Espana, S.L.U. on behalf of Sociedad Espanola de Anestesiolog& imath;a, Reanimacion y Terapeutica del Dolor. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Introducción y objetivos La incidencia de la vía aérea difícil durante la intubación es un episodio crítico en anestesia. A pesar de la utilidad de los indicadores predictivos clínicos, dicho episodio surge a menudo de manera inesperada. El objetivo de este estudio fue determinar la utilidad de la ecografía de la vía aérea para detectar a estos pacientes. Materiales y métodos Estudio de casos y controles. Los pacientes del grupo de casos fueron identificados a partir del registro de pacientes con informes de laringoscopia difícil (Cormack III y IV). Los controles fueron seleccionados entre los pacientes sometidos a cirugía con anestesia general identificados como Cormack I. Cincuenta pacientes (25 casos y 25 controles) participaron en el estudio. Se realizó ecografía a todos los pacientes para determinar tres medidas: distancia de la piel al hueso hioides, distancia de la piel a la epiglotis y distancia de la piel a las cuerdas vocales. Resultados Tener una distancia de la piel al hueso hioides superior a 9,8mm (50% de percentil de la muestra) generó un odds ratio de 5,46 (p=0,005). Tener una distancia de la piel a la epiglotis superior a 21,3mm (50% de percentil de la muestra) generó un odds ratio de 6,62 (p=0,002). No existió diferencia significativa en la medida de la distancia de la piel a las cuerdas vocales. Conclusiones La ecografía ha demostrado ser una herramienta útil para la predicción de la laringoscopia difícil. A pesar de la baja sensibilidad de los indicadores predictivos clínicos, estos parecen ayudar a mejorar la detección de los pacientes con laringoscopia difícil cuando se integran en modelos predictivos junto con los valores ecográficos.

Thrombotic microangiopathies (TMA) are a group of clinical syndromes associated with haemolytic anaemia, thrombocytopenia and organ dysfunction, mainly renal or neurological. They are associated with significant morbidity and mortality, so early diagnosis and treatment are essential. In this article we report two cases of TMA; a patient with thrombotic thrombocytopenic purpura (TTP) and a patient with atypical haemolytic uraemic syndrome (aHUS).

Introduction: Respiratory muscle function in the postoperative period is a key to whether a patient develops Postoperative Respiratory Failure (PRF) or not. PRF occurs when the gas exchange does not meet metabolic needs. ipsilateral paralysis of the hemidiaphragm after interscalenic brachial plexus block (ISB) causes an acute reduction of respiratory muscle function. This reduction does not cause PRF when the contralateral hemidiaphragm generates enough gas exchange to meet metabolic demands. Objectives: To study the evolution of hemidiaphragmatic muscle function during the perioperative period with diaphragmatic ultrasound (D-POCUS), and use it as an innovative tool to predict PRF, assessing the contralateral hemidiaphragm in the event of acute hemidiaphragm paralysis. Methods: Patients considered high risk, scheduled for shoulder surgery with ISB are studied. Both hemidiaphragms were evaluated by ultrasound, before and after the procedure, measuring Thickening Fraction (TF) and Diaphragmatic Excursion (DE). PACU patients with PRF were registered. Results: There was a significant reduction in the TF and DE of the ipsitateral hemidiaphragm in the six patients studied. Only 1/6 patients showed signs of PRF. The evaluation of the contralateral hemidiaphragm during the postoperative period showed that in the five patients without signs of PRF, there were no significant changes in the function of the contralateral hemidiaphragm. The patient, who showed a reduction in contralateral hemidiaphragm function, was the only one who suffered PRF. Conclusions: In this case series, D-POCUS allows to know the perioperative function of the diaphragm in high-risk patients. Alt patients suffered an acute reduction of hemidiaphragm function after ISB; however, these patients did not develop PRF when the contralateral hemidiaphragm function was preserved. (C) 2020 Sociedad Espanola de Anestesiologia, Reanimacion y Terapeutica del Dolor. Published by Elsevier Espana, S.L.U. All rights reserved.

La infección por SARS-CoV-2 ha evolucionado hasta convertirse progresivamente en una pandemia y en una emergencia de salud pública de importancia internacional que ha obligado a las organizaciones de salud a nivel mundial, regional y local a adoptar una serie de medidas para hacer frente a la COVID-19 e intentar disminuir su impacto, no solo en el ámbito social sino también en el ámbito sanitario, modificándose las pautas de actuación en los servicios de salud. Dentro de estas recomendaciones, que incluyen las unidades de tratamiento del dolor, los pacientes con sospecha o infección confirmada por SARS-CoV-2 pueden encontrase en situación de espera para consulta médica o técnicas invasivas para el manejo de dolor crónico refractario a otras terapias. Se recogen en este manuscrito una serie de pautas encaminadas a disminuir el riesgo de infección del personal de salud, de otros pacientes y de la comunidad.

IntroductionInterventions performed in thoracic surgery are associated with moderate to severe postoperative pain, and has a high risk of developing chronic pain after thoracic surgery (CPATS). The main analgesic techniques are thoracic epidural analgesia (TEA), paravertebral block (PVB) and opioid management. Although it has been seen that there are no significant differences in postoperative analgesia between TEA and PVB [1,2], the comparison between both techniques in the prevention of CPATS has not been sufficiently investigated[2,3] and needs more evidence.MethodsIt is an observational, descriptive, retrospective study. The patient selection algorithm is shown in Figure 1. We made phone calls to patients. With the data collected we developed a database that included the variables: sex, age, type of intervention, intraoperative analgesic technique, analog visual pain scale (VAS) upon admission to the ICU, presence of chronic pain, VAS current and modified DN4 scale (table 1).ResultsThe variables analyzed are shown in table 2. The risk of CPATS in this sample was higher in women (40.38%) than in men (29.01%) OR 1.39 95% CI [0.91-2.13]. In relation to age, the risk of CPATS in those under 60 was 44.07%, and in those over 60, 26.61%; with those under 60, 17.45% [2.6-32] of greater risk: OR 2.163 [1.12-4.17] (p = 0.01). The patients presented the same risk of chronic pain using regional analgesia (RA) 32.35% versus opioid management (32.41%). The incidence of neuropathic pain was 31.9% when RA was used versus 33.3% when opioid analgesia was used. In relation to the surgical technique, the risk of chronic pain in those undergoing thoracotomy was 40.42%, and in those subjected to VATS of 22.99%; the patients undergoing thoracotomy had 17.43% [4.14-30.72] of greater risk: OR 2.23 [1.18-4.38] (p = 0.006). Regarding the RA technique, the risk of CPATS in those undergoing TEA was 27.72%, and in those undergoing PVB 45%: OR 0.61 [0.38-0.98] (p = 0.048). The mean VAS at admission among patients receiving TEA and PVB was 2.62 ± 2.04 vs. 3.15 ± 1.98 (p = 0.167).DiscussionThe comparison of RA techniques in thoracic surgery has been widely studied, especially TEA and PVB. In our study, we observed no differences between RA techniques with respect to postoperative analgesia. The RA technique in relation to the development of CPATS has been much less studied. We have observed in our study that the use of epidural is a protective factor compared to patients undergoing paravertebral analgesia (p = 0.048). Although this fact may be due to a higher failure rate in performing the PVB technique in our environment.

La función muscular respiratoria en el período postoperatorio es clave para determinar si un paciente desarrollará insuficiencia respiratoria postoperatoria (IRP) o no. La IRP ocurre cuando el intercambio de gases no satisface las necesidades metabólicas. La parálisis ipsilateral del hemidiafragma después del bloqueo del plexo braquial interescalénico (BPBI) provoca una reducción aguda de la función muscular respiratoria. Esta reducción no causa IRP cuando el hemidiafragma contralateral genera suficiente intercambio de gases para satisfacer las demandas metabólicas. Estudiar la evolución de la función muscular hemidiafragmática durante el perioperatorio mediante ecografía diafragmática (D-POCUS) y usarlo como una herramienta innovadora de predicción de IRP valorando el hemidiafragma contralateral en caso de que ocurra una parálisis hemidiafragmática aguda. Se estudian pacientes considerados de alto riesgo programados para cirugía de hombro con BPBI. Se evalúan ecográficamente ambos hemidiafragmas, antes y después del procedimiento, mediante fracción de acortamiento (FA) y excursión diafragmática (ED). Se registró en URPA los pacientes con IRP. En los 6 pacientes estudiados se produjo una reducción significativa de la FA y la ED del hemidiafragma ipsilateral. Solo 1/6 mostró signos de IRP. La evaluación del hemidiafragma contralateral durante el postoperatorio mostró que en los 5 pacientes sin signos de IRP no existieron cambios significativos en la función del hemidiafragma contralateral. El único paciente que mostró una caída de la función hemidiafragmática contralateral fue el único paciente que padeció IRP. En esta serie de casos D-POCUS permite conocer la función perioperatoria del diafragma en pacientes de alto riesgo. Todos los pacientes sufrieron una reducción de la FA y la excursión hemidiafragmática aguda tras BPBI; sin embargo, estos pacientes no desarrollaron IRP cuando la función del hemidiafragma contralateral estaba conservada. Respiratory muscle function in the postoperative period is a key to whether a patient develops Postoperative Respiratory Failure (PRF) or not. PRF occurs when the gas exchange does not meet metabolic needs. Ipsilateral paralysis of the hemidiaphragm after interscalenic brachial plexus block (ISB) causes an acute reduction of respiratory muscle function. This reduction does not cause PRF when the contralateral hemidiaphragm generates enough gas exchange to meet metabolic demands. To study the evolution of hemidiaphragmatic muscle function during the perioperative period with diaphragmatic ultrasound (D-POCUS), and use it as an innovative tool to predict PRF, assessing the contralateral hemidiaphragm in the event of acute hemidiaphragm paralysis. Patients considered high risk, scheduled for shoulder surgery with ISB are studied. Both hemidiaphragms were evaluated by ultrasound, before and after the procedure, measuring Thickening Fraction (TF) and Diaphragmatic Excursion (DE). PACU patients with PRF were registered. There was a significant reduction in the TF and DE of the ipsilateral hemidiaphragm in the six patients studied. Only 1/6 patients showed signs of PRF. The evaluation of the contralateral hemidiaphragm during the postoperative period showed that in the five patients without signs of PRF, there were no significant changes in the function of the contralateral hemidiaphragm. The patient, who showed a reduction in contralateral hemidiaphragm function, was the only one who suffered PRF. In this case series, D-POCUS allows to know the perioperative function of the diaphragm in high-risk patients. All patients suffered an acute reduction of hemidiaphragm function after ISB; however, these patients did not develop PRF when the contralateral hemidiaphragm function was preserved.

SARS-CoV-2 infection has evolved into a pandemic declares by the World Health Organization (WHO) that has forced health organizations at the global, regional and local levels to adopt a series of measures to address to COVID-19 and try to reduce its impact, not only in the social sphere but also in the health sphere, modifying the guidelines for action in the health services. Within these recommendations that include the Pain Treatment Units, patients with suspected or confirmed SARS-CoV-2 infection may be waiting for intervention for implantation or revision of electronic devices for the management of chronic pain refractory to other therapies. Sugerences aimed at reducing the risk of infection of health personnel, other patients and the community are included in this manuscript. (C) 2020 Sociedad Espanola de Anestesiologia, Reanimacion y Terapeutica del Dolor. Published by Elsevier Espana, S.L.U. All rights reserved.

SARS-CoV-2 infection has evolved into a pandemic and a Public Health Emergency of International Importance that has forced health organizations at the global, regional and local levels to adopt a series of measures to address to COVID-19 and try to reduce its impact, not only in the social sphere but also in the health sphere, modifying the guidelines for action in the health services. Within these recommendations that include the Pain Treatment Units, patients with suspected or confirmed SARS-CoV-2 infection may be waiting for medical consult or interventional procedures for the management of chronic pain refractory to other therapies. A series of guidelines aimed at reducing the risk of infection of health personnel, other patients and the community are included in this manuscript.

Background and aims Knee osteoarthritis is a chronic condition characterized by progressive destruction of the cartilage and alteration of the synovial fluid and causes pain and severely limiting the daily activity and quality of life. Patients can be treated with conservative non-pharmacologic options, pharmacologic therapies and intraarticular injections of corticosteroids or hyaluronic acid (HA). The aim of this study is to evaluate the long-term efficacy of intraarticular infiltration of HA in patients with knee osteoarthritis. Methods 22 patients treated with HA in 2018 were included in our restrospective study. All patients had osteoarthritis level I-III on the Kellgren–Lawrence scale and knee pain intensity >5 on the Visual Analogue Scale (VAS). An ultrasound-guided intra-articular knee injection was performed, using the lateral suprapatellar approach. After aspiration of the existing joint effusion, 4 mL (60 mg) of HA (Hyalone®) was injected. Demographic characteristics, knee pain, functional improvement and complications were registered. Results The mean age was 74.86 years (SD 10.76). 16 women/6 men. 14 right knees/8 left. Knee pain decreased in the first month in almost all patients (81.8%) and remained until 6 months (72.7%). Baseline VAS mean 7.07 (SD 1.04) and 6-month VAS mean 4.00 (SD 2.02). The functional improvement 6 six-months was >50% in 72.7% of the patients and >75% in 36.3%. There were no recorded complications. Conclusions An intraarticular knee single-injection of hyaluronic acid (Hyalone®) improves the pain and function of patients with knee osteoarthritis in the short and long term. Reducing the number of injections reduces the risk of complications.

Background and aims Epidural injections of corticosteroids are commonly used as a nonsurgical treatment for radicular pain. Preprocedure ultrasound neuraxial has been associated with reduced risk of location failure of the epidural space. A handheld ultrasound device (Accuro, Rivanna Medical) recognizes lumbar spine bony landmarks and offering automated real-time identification of interspaces and epidural depth. The aim of this study was to evaluate the accuracy of epidural depth estimation of an ultrasound device. Methods 14 patients with lumbar radiculopathy, but without significant degenerative changes or anatomical abnormalities, were included in our prospective study. After the sonographic location, the device allowed to place a mark where the puncture was performed and provided an estimated distance to the epidural space. A transforaminal approach was performed through loss of resistance technique. Later, a mixture of LA and nonparticulated steroids was injected. Results The mean age was 64.21 years (SD 6.39) and BMI was 29.36 (SD 3.52). The mean needle distance was 5.32 ± 0.69 cm (4.0–6.8 cm), the mean estimated depth for divide was 4.07 ± 0.53 cm (3.0–5.2 cm), with a mean difference of -1.25 cm (SD 0.67 cm). All the epidural spaces were located at the point marked; only 5/14 patients needed a minimum redirection of the needle. Time was less than 5 minutes in all patients and the mean was 171.29 sec (SD 43.94). There were no complications. Conclusions The use of handheld ultrasound Accuro underestimates the distance skin-epidural space but helps the location of space, quickly and with few movements of the needle.

Introduction The management of an unanticipated difficult airway is a challenge for any anesthesiologist. Over the years, devices have been developed to improve intubation in cases of difficulty. Methods We present the case of a patient with an unanticipated difficult airway, who was intubated during the first attempt thanks to the use of a VivaSight tube. The consent for the publication of this case was obtained by the patient. He is a 57-year-old man, who underwent a programmed left upper lobectomy. Predictors of airway assessment performed in preanesthesia classified the patient as low risk. The initial plan included the use of a VivaSight SL tube and a bronchial blocker for left lung collapse under direct vision during surgery. Results The patient underwent general anesthesia. After 2 minutes of induction and verify that the ventilation could be carried out without problem, a direct laryngoscopy was performed. A spheroidal tumor adhered to the epiglottis was visualized (figure 1), turning the patient into a Cormack-Lehane III grade. Because we had prepared a VivaSight single lumen endotracheal tube for intubation, we chose to perform intubation guided by the video of the camera integrated in the VivaSight tube. The intubation sequence can be seen in the images of figure 1. The result was an intubation of less than a minute in duration and without incidents during the first attempt. Discussion VivaSight is a special tracheal tube, which has a built-in direct vision camera. It is used mostly in anesthesia for thoracic surgery. There are 2 models: double lumen and single lumen. The single lumen can usually be used together with bronchial blockers without requiring a fiber optic bronchoscope. The main advantages described with the use of these devices are the visualization of the correct position of the tube and the visualization of the correct position of the bronchial blocker2. Other authors have shown that the use of the VivaSight tube decreases intubation time and number of attempts with respect to video laryngoscopy in emergencies3. In the case that we have described, the camera of the tube allowed us to perform an intubation in a case of unanticipated difficult airway. Therefore, we think that the VivaSight tube should be an option to consider in the cases of patients with anticipated or known difficult airway in thoracic surgery. However, it is necessary to develop prospective studies that provide more evidence.

Vitrectomy surgery is a common procedure for the treatment of several types of ophthalmologic conditions. It can be performed under regional anaesthesia with peribulbar block (PB) or general anaesthesia (GA). There are no evidence-based recommendations on the optimal anaesthesia strategy for this procedure. The aim of this study was to compare the advantages of PB and GA for vitrectomy surgery.A prospective observational study was conducted on adults submitted for mechanical vitrectomy between January 2017 and December 2017. Demographic and perioperative data were collected, namely ASA physical status, median arterial pressure, heart rate, postoperative opioid consumption, postoperative nausea and vomiting, times of induction, surgery, recovery, and hospital stay and costs considering medication and material needed. Statistical analysis was performed using SPSS v.25, with chi-square, Fisher and Mann-Whitney U tests, according to the type of variables analysed.We included 179 patients submitted for mechanical vitrectomy: 91 (51 %) with PB and 88 (49 %) under GA. Patients submitted to PB were older (69.0 vs. 64.5 years, p = .006) and presented with higher ASA physical status (p = .001). For haemodynamic outcomes, patients submitted to PB presented with less variation of median arterial pressure (−3.0 vs. −13.5 mmHg, p = .000) and with no significant differences in heart rate (−2.0 vs. −3.0 bpm, p = .825). In the postoperative period, the PB group presented with decreased need of postoperative analgesia (0.0 vs. 5.0, p = .026) and a lower incidence of nausea and vomiting (1.0 vs. 12.0, p = .001). Times related to anaesthesia and surgery were better in PB group, with shorter induction time (10.0 vs. 11.0 min, p = .000), surgery time (56.5 vs. 62.0 min, p = .001), recovery time (10.0 vs. 75.5 min, p = .000), and hospital stay (2.0 vs. 3.0 days, p = .000). When analysing costs, PB was less expensive than GA (4.65 vs. 12.09 euros, p = .021).PB is a reliable and safe alternative to GA for patients undergoing mechanical vitrectomy, permitting good anaesthesia and akinesia conditions during surgery, better haemodynamic stability, and less postoperative complications, especially in older patients and those with more comorbidities.La cirugía de vitrectomía es un procedimiento común para el tratamiento devarios tipos de afecciones oftalmológicas, y se puede realizar bajo anestesia regional con blo-queo peribulbar (BP) o anestesia general (AG). No hay recomendaciones basadas en evidenciasobre el mejor tipo de anestesia para este procedimiento. En este contexto, nuestro objetivoes comparar AG y BP para la cirugía de vitrectomía.Estudio observacional prospectivo en adultos sometidos a vitrectomíamecánica entre enero de 2017 y diciembre de 2017. Se recogieron datos demográficos y perioperatorios, en particular: estado físico ASA, presión arterial media, frecuencia cardiaca, consumode opioides postoperatorio, náuseas y vómitos postoperatorios, tiempos de inducción, cirugía, recuperación y estadía en el hospital y costes considerando los fármacos y el material necesario. El análisis estadístico se realizó con SPSS v.25, con pruebas de chi cuadrado, Fisher y Mann–Whitney U, según el tipo de variables analizadas.Se incluyeron 179 pacientes, de los cuales 91 (51 %) estaban bajo BP y88 (49 %) bajo AG. Los pacientes sometidos a BP presentaban una edad más avanzada (69 vs.64,5 años, p = 0,006 y se presentaron con valores en la escala ASA más elevados p = 0,001.Para los resultados hemodinámicos, los pacientes sometidos a BP presentaron una menor variación de la presión arterial media −3 vs. −13,5 mmHg, p = 0,000 y sin diferencias significativasen la frecuencia cardiaca −2 vs. −3 ppm, p = 0,825. En el período postoperatorio, el grupo deBP presentó una menor necesidad de analgesia postoperatoria 0 vs. 5, p = 0,026 y una menorincidencia de náuseas y vómitos 1 vs. 12, p = 0,001. Los tiempos relacionados con la anestesia y la cirugía fueron mejores en el grupo BP, con un tiempo de inducción más corto 10vs. 11 min, p = 0,000, tiempo de cirugía 56,5 vs. 62 min, p = 0,001, tiempo de recuperación 10 vs. 75,5 min, p = 0,000, y estancia hospitalaria 2 vs. 3 días, p = 0,000. Al analizar los costes, el BP fue más económico que AG 4,65 frente a 12,09 euros, p = 0,021.El bloqueo peribulbar es una alternativa segura a la anestesia general para pacientes sometidos a vitrectomía, especialmente pacientes mayores y aquellos con más comor-bilidades.

Globally, oxygen is the most used drug in perioperative medicine; it is used in any surgery, patient or condition. Its perioperative use is so widespread that in many cases we forget that it is a drug and we use oxygen indiscriminately. Like any drug we use, we must know its effects on the organism, its indications and contraindications.1 the current target for perioperative use of oxygen is not uniformly standardised. Many anesthetists titrate inspiratory oxygen fraction (FiO2) to achieve a normal peripheral blood oxygen saturation (SpO2), whereas others give higher FiO2 to increase the arterial partial pressure of oxygen (PaO2) to supranormal levels (hyperoxia) in an attempt to protect vulnerable organs in high-risk patients or during high-risk procedures.2 One of the major sources of variability in the established use of Oxygen concentration in anaesthesia practice is related to the dual nature of this gas, with its beneficial profile in treating hypoxaemia and its deleterious effects producing reactive oxygen metabolites (ROMs) with hyperoxemia. the oxidative stress resulting from these ROMs is a primary cause of DNA damage, impairment of mitochondrial function and organ injuries affecting the brain and lung parenchyma primarily.2–4 In the last times, several systematic reviews and meta-analyses provide evidence of the risks/benefits of oxygen at different concentrations, but there are not clear-cut conclusions. This discrepancy in the scientific literature is mainly attributable to the multiple factors affecting perioperative care.3 Perioperative medicine is generally a very safe period with few serious complications in the immediate postoperative hours, so it therefore requires a much larger sample size to detect relevant differences in harm due to hyperoxia compared with critically ill patients.4 Research groups in emergency medicine and critical care have published several studies and meta-analyses showing significantly increased mortality attributed to liberal oxygen therapy,5 and they have even moved forward to establishing specific SpO2 targets for stopping and restarting oxygen if needed. Perioperatively, pre-oxygenation is standard practice during induction of anesthesia. It produces hyperoxemia to increase time to obtain tracheal intubation.1 Delivering 100% oxygen substantially extends the time to arterial desaturation in the event of loss of airway patency following induction. If airway obstruction occurs in a patient breathing air, desaturation occurs in 1 min.6 With pre-oxygenation, this time is increased to 6 minutes.7 the use of high concentrations of oxygen further enhances ventilation defects by inducing airway closure and alveolar collapse. the kinetics of such oxygen-absorption atelectasis development is primarily determined by the alveolar concentration of oxygen and time of administration. Some previous studies involving the use of lung imaging techniques have established the existence of a threshold FiO2, provided at the induction of anaesthesia until no clinically significant areas of alveolar derecruitment remain. Exceeding the critical threshold of FIO2 of 80% leads to the rapid development of alveolar collapse.8 9 Also, Lung imaging studies have revealed that alveolar collapse persists despite the application of recruitment manoeuvres when a high concentration of oxygen is maintained during anaesthesia.9 An interesting confirmatory study summarizes these ideas,10 this study showed that during pre-oxygenation with 100% oxygen time to desaturation (SpO2<90%) extends to 6.5 min but it produces 5.6% of atelectasis. When 80% oxygen was used during pre-oxygenation time to desaturation extends to 5 min, but the production of atelectasis was almost four times lower 1.3%. These data provide compelling evidence that allowing patients to breathe air on induction of anesthesia is a high-risk strategy, but using 100% oxygen is also potentially harmful. Probably, pre-oxygenate with a FiO2 of 80% will be the best option to reduce atelectasis extending time to arterial desaturation during apnoea. 100% oxygen should be reserved for patients at particularly high risk. In these cases to apply CPAP during pre-oxygenation and after intubation, FiO2 reduction, recruitment manoeuvre and optimal PEEP should follow as soon as feasible. In addition to these adverse pulmonary effects, anaesthetic management of age and COPD patients demands special attention; hyperoxia compromises the contractile function of the diaphragm in aged subjects.11 This disorder is related to hyperoxia-induced exacerbation of the generalized skeletal muscle destruction with age. Furthermore, in COPD patients even a modest increase in FiO2 (30%) for a short period (1h) leads to oxidative stress and airway inflammation. Both related to the pathogenesis of COPD.12 High FiO2 intraoperatively is related to a greater propensity to alveolar collapse (as described above), and High FiO2 after surgery suppresses hypoxic drive, which is crucial in maintaining alveolar ventilation in the presence of COPD. Thus, in the patients at high risk of hypercapnia, Oxygen should be carefully titrated in order to target Oxygen saturation between 88 and 92%.13 There is a general misbelief among clinicians that elevation of FiO2 results in increased oxygen transport capacity, thereby improving oxygenation at the level of the microcirculation. Blood oxygen content equation determines that when haemoglobin is fully saturated under physiological conditions, an increase in the arterial partial pressure of oxygen (PaO2) increases blood oxygen content only marginally.14 In contrast, High PaO2 concentration increases systemic vascular resistance; this leads to a decrease in cardiac output via both increased afterload and decreased preload.15 Due to these cardiovascular alterations, hyperoxygenation can reduce tissue perfusion and compromise oxygen transport. This effect is confirmed in studies where FiO2 of 100% compared with 30% reduces cardiac index by 4–6% in health ASA physical status I-II patients.16 In this line, a recent Cochrane review17 suggests that high concentration oxygen therapy may be harmful to patients with myocardial injury through mechanisms like reduced coronary arterial flow, reactive oxygen species, increased coronary and systemic vascular resistance, and reperfusion injury with oxidative stress and DNA damage. the adverse cardiovascular effects of giving high oxygen concentration have led to a change in resuscitation guidelines. the European Resuscitation Council Guidelines now recommend18 that patients should only be ventilated with 100% oxygen during cardiopulmonary resuscitation, but after return of spontaneous circulation, the inspired oxygen concentration should be titrated to achieve arterial oxygen saturation (SpO2) between 94 and 98%, or 88–92% if the patient is at risk of hypercapnic respiratory failure. About the brain physiology, supplementing oxygen preoperatively leads to an increase in cerebral vascular resistance, with a subsequent decrease in cerebral blood flow, independently of the effect of CO2 on cerebral vasoreactivity.19 These effects on the cerebral vasculature have to be taken into account in routine clinical practice, where perioperative ventilation with high concentrations of oxygen is often performed arbitrarily in the context of traumatic brain injury or post-resuscitation. the frequently associated hypocapnia attributable to mechanical ventilation linked to the administration of high concentrations of oxygen can intensify cerebral vascular ischaemia. Finally, since 2000 some articles reported that high perioperative FiO2 has a beneficial effect on surgical site infection (SSI) because adequate oxygen delivery to the wound facilitates bacterial killing by neutrophils and reduce SSI. the World Health Organization (WHO) published a comprehensive systematic review of SSI prevention in 2016 recommending 80% oxygen perioperatively.20 This meta-analysis of perioperative oxygen showed no overall significant benefit with hyperoxia on SSI. Only a subgroup analysis of trials where patients had oxygen therapy given through a tracheal tube resulted in significant benefit. Recently, WHO reviews perioperative hyperoxia comparing 80% vs 30% FiO2. In these meta-analyses21 22 they found no differences in the rates of atelectasis, cardiovascular events, ICU admission, and mortality. Although previous data suggest increased long-term mortality with perioperative 80% oxygen.23 the WHO founds small benefits on SSI with 80% FiO2 in intubated patients. a relative risk reduction (RRR) of 5%. Despite no overall benefit when including studies with oxygen therapy given through face masks. Against this, the World Federation of Societies of Anaesthesiologists (WFSA) recommends FiO230%–40% for general anaesthesia in intubated patients intraoperatively, and suggests using FiO2 to maintain a normal peripheral oxygen saturation, above 93%, postoperatively.24 Also, the latest Cochrane review to conclude that there is ‘insufficient evidence to support the routine use of high fraction of inspired oxygen beyond what is needed to maintain normal arterial oxygen saturation.25 As a conclusion, oxygen is a safe drug and using it to prevent hypoxemia is mandatory. All the problems described with oxygen, come from an overdose of oxygen, hyperoxia. the anesthesiologist must know the physiological effects produced by oxygen and the risks and benefits of hyperoxia. the objective is to use the most beneficial and safe oxygen concentration in each patient and each situation. References Ferrando C, Belda J, Soro M.. Perioperative hyperoxia: Myths and realities. Rev Esp Anestesiol Reanim 2018 Apr;65(4):183–187. Meyhoff, Christian S. Perioperative hyperoxia: why guidelines, research and clinical practice collide. Br J Anaesth 2019 Mar;122(3):289–291. Habre W, Peták F. Perioperative use of oxygen: variabilities across age. Br J Anaesth 2014 Dec;113Suppl 2:ii26–36. Lumb A, Walton L. Perioperative Oxygen Toxicity. Anesthesiology Clin 2012;30(2012):591–605. Chu DK, Kim LH, Young PJ, et al. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. Lancet 2018;391:1693–705. Farmery AD, Roe PG. A model to describe the rate of oxyhaemoglobin desaturation during apnoea. Anaesthesia 1996;76:284–91. Jense HG, Dubin SA, Silverstein PI, et al. Effect of obesity on safe duration of apnoea in anesthetized humans. Anesth Analg 1991;72:89–93. Magnusson L, Spahn DR. New concepts of atelectasis during general anaesthesia. Br J Anaesth 2003;91:61–72. Rothen HU, Sporre B, Engberg G, Wegenius G, Hogman M, Hedenstierna G. Influence of gas composition on recurrence of atelectasis after a reexpansion maneuver during general anesthesia. Anesthesiology 1995;82:832–42. Edmark L, Kostova-Aherdan K, Enlund M, et al. Optimal oxygen concentration during induction of general anesthesia. Anesthesiology 2003;98:28–33. Andrade PV, dos Santos JM, et al. Influence of hyperoxia and mechanical ventilation in lung inflammation and diaphragm function in aged versus adult rats. Inflammation 2014;37:486–94. Carpagnano GE, Kharitonov SA, et al. Supplementary oxygen in healthy subjects and those with COPD increases oxidative stress and airway inflammation. Thorax 2004;59:1016–1019. Decalmer S, O’Driscoll BR. Oxygen: friend or foe in peri-operative care? Anaesthesia 2013;68:8–12. Lumb AB. Nunn’s Applied Respiratory Physiology. New York: Churchill Livingstone, 2010. Park JH, Balmain S, Berry C, et al. Potentially detrimental cardiovascular effects of oxygen in patients with chronic left ventricular systolic dysfunction. Heart 2010; 96:533–8. Anderson KJ, Harten JM, Booth MG, Kinsella J. the cardiovascular effects of inspired oxygen fraction in anaesthetized patients. Eur J Anaesthesiol 2005;22:420–5. Cabello JB, Burls A, Emparanza JI, et al. Oxygen therapy for acute myocardial infarction. Cochrane Database Syst Rev 2010:CD007160. Nolan JP, Soar J, Zideman DA, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 1: executive summary. Resuscitation 2010; 81:1219–1276. Floyd TF, Clark JM, Gelfand R, et al. Independent cerebral vasoconstrictive effects of hyperoxia and accompanying arterial hypocapnia at 1 ATA. J Appl Physiol (1985) 2003;95:2453–61. Allegranzi B, Zayed B, Bischoff P, et al. New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis 2016;16:e288–303. de Jonge S, Egger M, Latif A, et al. Effectiveness of 80% vs 30–35% fraction of inspired oxygen in patients undergoing surgery: an updated systematic review and metaanalysis. Br J Anaesth 2019 Mar;122(3):325–334. Mattishent K, Thavarajah M, Sinha A, et al. Safety of 80% vs 30–35% fraction of inspired oxygen in patients undergoing surgery: a systematic review and meta-analysis. Br J Anaesth 2019 Mar;122(3):311–324. Meyhoff CS, Jorgensen LN, Wetterslev J, Christensen KB, Rasmussen LS. Increased long-term mortality after a high perioperative inspiratory oxygen fraction during abdominal surgery: follow-up of a randomized clinical trial. Anesth Analg 2012;115:849–54.

La infección por SARS-CoV-2 ha evolucionado hasta convertirse progresivamente en una pandemia declarada por la Organización Mundial de la Salud (OMS) que ha obligado a las organizaciones de salud a nivel mundial, regional y local a adoptar una serie de medidas para hacer frente al COVID-19 e intentar disminuir su impacto, no sólo en el ámbito social sino también en el ámbito sanitario, modificándose las pautas de actuación en los servicios de salud. Dentro de estas recomendaciones que incluyen las Unidades de Tratamiento del Dolor, los pacientes con sospecha o infección confirmada por SARS-CoV-2 pueden encontrase en situación de espera para intervención no demorable para implante o revisión de dispositivos electrónicos para manejo de dolor crónico refractario a otras terapias. Se recogen en este manuscrito una serie de pautas encaminadas a disminuir el riesgo de infección del personal de salud, otros pacientes y la comunidad.SARS-CoV-2 infection has evolved into a pandemic declares by the World Health Organization (WHO) that has forced health organizations at the global, regional and local levels to adopt a series of measures to address to COVID-19 and try to reduce its impact, not only in the social sphere but also in the health sphere, modifying the guidelines for action in the health services. Within these recommendations that include the Pain Treatment Units, patients with suspected or confirmed SARS-CoV-2 infection may be waiting for intervention for implantation or revision of electronic devices for the management of chronic pain refractory to other therapies. Sugerences aimed at reducing the risk of infection of health personnel, other patients and the community are included in this manuscript.

Introduction The first thoracic lobectomies and robotic transsegmental resections date from 2003, since then robotic-assisted thoracic surgeries have been increasing (1). Extensive benefits of robotic-assisted thoracic surgery (RATS) versus video-assisted thoracic surgery (VATS) have been demonstrated, among which we find improvement in surgical field vision, reduction in bleeding and decreased postoperative morphine consumption (2). Therefore, and due to its boom, it's necessary to know the surgical technique and the anesthetic implications involved in the implementation of robotic surgery in our daily clinical practice (3). Methods This is a retrospective descriptive study that includes patients undergoing thoracic surgery using a robotic technique from January 2018 to May 2018 in our hospital. It includes a total of 10 patients, 70% undergoing transsegmental lobar resections and 30% with exeresis of mediastinal cysts. Subsequently, we describe both the anesthetic technique used, as well as the stay in the ICU, the hospital stay and the incidence of postoperative complications. Results Surgical positioning was lateral decubitus in all patients. The anesthetic induction was performed with intravenous midazolam, propofol, fentanyl and rocuronium. Pulmonary separation was performed by double lumen tube with embedded camera (VivaSight DL) for continuous airway monitoring and to facilitate repositioning of the device, invasive blood pressure monitoring, and central venous catheterization. The anesthetic maintenance included inhaled sevoflourane and continuous infusion of remifentanil and rocuronium; after surgery muscle relaxation was reverted with sugammadex. The average length of stay in the ICU and hospital stay was 1.6 days and 6.3 days, respectively. Only 2 patients presented postoperative complications as nosocomial pneumonia, bilateral pleural effusion and presence of atelectasis. One of these was death after 18 days of hospital admission. The 6-month survival was 90%. Discussion Robotic surgery allows performing thoracic interventions in a less invasive way. We must take into account the difficulty in accessing both the airway and peripheral intravenous catheters and we need using of advanced monitoring devices. More studies comparing postsurgical events of interventions performed by robotic surgery versus thoracoscopic surgery are necessary.

Thoracic surgery in patients with lung infections is an absolute indication to isolate healthy lung or lobes. Different methods have been described, including the double-lumen endotracheal tube (DLT) or a variety of bronchial blockers (BBs) (1). However, when an abscess is present in only one lobe and lobectomy is planned, the insertion of a DLT alone or a single tube plus a BB may not be sufficient to prevent the spread of infection to an ipsilateral lobe. We present three cases with lung infection in which the isolation was made by combining DLT with a BB.

A collapsed lung may require lung manipulation during the course of thoracic surgery. In some cases selective lobar isolation may be required such as in patients who have had a previous pulmonary resection and therefore they present with reduced pulmonary functional reserve. Selective lobar blockade (SLB) can be achieved by using the bronchial blocker (BB) through a conventional tube1 or a double-lumen tube (DLT). We present two cases in which SLB was performed with different techniques on patients with previous pulmonary resections. A 75-year-old-woman (ASA III) underwent a lobectomy of the right middle lobe. She had a history of a left upper lobectomy. Her preoperative function test showed FVC 80%, FEV 1 65% and DLCO 68%. After a standard anaesthetic induction a 37Fr DLT was inserted. This patient suffered a serious hypoxemia. After checking DLT was in the correct place, a 7Fr Arndt BB was introduced into the right intermediate bronchus through the tracheal lumen of DLT guided by a fiberoptic bronchoscope. A 62-year-old male (ASA IV) was scheduled for a right middle and lower lobectomy by thoracotomy. He had previously undergone a left upper lobectomy. His preoperative pulmonary function tests showed CVF 70,6%, FEV1 59,3% and DLCO 42,3%. In this case, because the tests showed a reduced pulmonary functional reserve, we decided to insert a 9Fr Cohen BB into the right intermediate bronchus guided by fibreoptic bronchoscopy. In both cases the correct lobar collapse and optimal SpO2 was achieved without incident. The one lung ventilation of patients undergoing thoracic surgery who have undergone previous surgery in this lung can be very difficult due to the rapid onset of hypoxemia due to low pulmonary reserve. In this context, SLB by BB becomes important, allowing the collapse of the lobe undergoing surgery by blocking the entrance of a specific bronchial branch while the remaining lobes of the lung being operated could be normally ventilated2. This is only possible by using BB and a fiberoptic bronchoscope to guide and verify the BB’s correct placement. Choosing between a DLT or a conventional tube is based on each particular patient’s condition, with both options generally being acceptable. Knowing the bronchial anatomy is essential to ensure the success of the technique. 1. Campos JH. Lung isolation techniques. Anesthesiol Clin North America. 2001 Sep; 19(3):455-74. 2. Orgaz OV, Navacerrada MIR, Guerrero MC, Gutierrez AFG, Fernández CM, Silvestre FP. Aislamiento pulmonar en pacientes con resecciones pulmonares previas : bloqueo lobular selectivo secuencial con bloqueador bronquial Fuji Uniblocker ®. Rev Esp Anestesiol Reanim 2016.

After a steady growth in global offshoring activities, it appears now a marked flow in the opposite direction with both a partial and full reversal of offshoring decisions. Research on reshoring put less stresses on the operation of dispersed facilities of an intra-firm network manufacturing. The purpose of this paper is to address the relevance of strategic capabilities for the operation of international manufacturing to the reshoring decision. The paper reports on retrospective studies of three European based companies, which have had recent reshoring experience. We adopt qualitative research using a case-based methodology that includes multiple in-depth interviews based on three companies. The study demonstrates that managerial challenges in the operation of dispersed facilities have played an important role in the reshoring decision. The findings allow understanding how the capability dimensions, ‘thriftiness’ and ‘learning’ being the most important, connect with the phenomenon of reshoring.