Joint Recommendations From The Latin American Association of Cardiac and Endovascular Surgery (LACES) and The Cardiovascular Anesthesia Committee of The Latin American Confederation of Anesthesia Societies (CLASA) on the Timing for Cardiac Surgery After COVID-19 Infection

ABSTRACT Introduction: Since the coronavirus disease 2019 (COVID-19) pandemic, cardiac surgeries in patients with previous infection by COVID-19 were suspended or postponed, which led to surgeries performed in patients with an advanced stage of their disease and an increase in the waiting list. There is a heterogeneous attitude in Latin America on the optimal timing to cardiac surgery in patients with previous COVID-19 infection due to scarce data on its outcome. Two Latin American associations joined to establish common suggestions on the optimal timing of surgery in patients with previous COVID-19 infection. Methods: Data collection was performed using a pre-established form, which included year of publication, objective, type of study (prospective/retrospective, descriptive/analytical), number of patients, year of study, waiting time between infection and surgery, type of surgery, morbidity, mortality, and conclusions regarding the association between mortality and morbidity. Final recommendations were approved by the board of directors of Latin American Association of Cardiac and Endovascular Surgery (LACES) and Latin American Confederation of Anesthesia Societies (CLASA). Results: Of the initial 1,016 articles, 11 comprised the final selection. Only six of them included patients who underwent cardiac surgery. According to the analyzed literature, optimal timing for cardiac surgery needs to consider the following aspects: deferable surgery, symptomatic COVID-19 infection, completeness of COVID-19 vaccination. Conclusion: These recommendations derive from the analysis of the scarce literature published at present on outcomes after cardiac surgery in patients with previous COVID-19 infection. These are to be taken as a dynamic recommendation in which Latin American reality was taken into consideration.

Paraplegia após revascularização cirúrgica do miocárdio: relato de caso / Paraplegia after myocardial revascularization: case report / Paraplejia después de la revascularización quirúrgica del miocardio: relato de caso

JUSTIFICATIVA E OBJETIVOS: Os avanços ocorridos na Anestesiologia permitiram melhores índices de segurança. Várias técnicas e agentes são utilizados visando controlar a resposta hemodinâmica e minimizar os efeitos adversos do estimulo cirúrgico em pacientes submetidos a procedimentos cardíacos. RELATO DO CASO: Paciente de 70 anos, masculino, 1,74 m, 75 kg, ASA III, e NYHA II. Portador de dislipidemia, diabetes mellitus tipo II e hipertensão arterial controladas; tabagismo, enfermidade vascular periférica e história de infarto agudo do miocárdio há 20 anos. O paciente foi submetido a revascularização com artéria mamária interna esquerda e enxertos de safena com pinçamento intermitente da aorta em circulação extracorpórea. Durante as primeiras 24 horas na UTI apresentou eventos de instabilidade hemodinâmica, hipotensão súbita e fibrilação atrial. Após 26 horas do final do procedimento cirúrgico, o paciente estava acordado, hemodinamicamente estável e com boa dinâmica respiratória quando foi extubado. O paciente estava comunicativo, orientado, porém com imobilidade e reflexos abolidos nos membros inferiores. Na avaliação neurológica: pares de nervos cranianos sem alteração, ausência de queixa de dor de qualquer tipo da cintura pélvica para baixo, preservação da sensibilidade superficial e profunda, perfusão distal adequada sem edemas, e paraplegia flácida na região abaixo de T8. Exame de ecocardiografia sem alterações. A tomografia computadorizada da coluna lombo-sacra, não mostrou massa compressiva no espaço epidural ou adjacente. CONCLUSÃO: A síndrome da artéria espinhal anterior, deve ser sempre considerada nos procedimentos de manipulação da aorta. A prevenção, particularmente nos pacientes de risco é necessária. A tomografia computadorizada é importante para o diagnóstico diferencial e a ressonância magnética para a localização da lesão.

BACKGROUND AND OBJECTIVES: Developments in anesthesiology have improved safety indices. Several techniques and agents are used to control the hemodynamic response and minimize adverse effects triggered by surgical stimuli in patients undergoing cardiac procedures. CASE REPORT: This is a 70 years old male patient, 1.74 m, 75 kg, ASA III, and NYHA II. The patient had controlled dyslipedemia, type II diabetes mellitus, and hypertension; history of smoking, peripheral vascular disease, and myocardial infarction 20 years ago. The patient underwent revascularization with the left internal mammary artery and saphenous grafts with extracorporeal circulation with intermittent clamping of the aorta. During the first 24 hours in the ICU, the patient developed hemodynamic instability, sudden hypotension, and atrial fibrillation. Twenty-six hours after the end of the surgery, the patient was awake, hemodynamically stable, and with good respiratory dynamics, being extubated. The patient was talkative and oriented, but immobile and negative reflexes in the lower limbs. Neurological evaluation showed: cranial nerves without changes, no complaints of pain below the hips, preserved superficial and deep sensitivity, adequate distal perfusion without edema, and flaccid paraplegia below T8. The echocardiogram did not show any changes. CT scan of the lumbosacral spine was negative for compressive mass in the epidural space or adjacent to it. CONCLUSION: Anterior spinal artery syndrome should be considered in procedures with manipulation of the aorta. Prevention, especially in patients at risk, is necessary. Computed tomography, for the differential diagnosis, and MRI, to localize the lesion, are important.

JUSTIFICATIVA Y OBJETIVOS: En las últimas décadas, los avances que se han dado en anestesiología resultaron en una reducción de los indicadores de morbilidad y mortalidad. En ese contexto, varias técnicas y agentes anestésicos han sido utilizados para controlar la respuesta hemodinámica y minimizar los efectos perjudiciales provenientes del estimulo quirúrgico en pacientes sometidos a procedimientos cardíacos. En cirugía cardíaca, la asociación de la anestesia regional a la anestesia general, ha sido motivo de muchas controversias entre los anestesistas, además de haber promovido muchos estudios en los últimos años. El surgimiento de las complicaciones neurológicas, es una situación devastadora que puede ocurrir después de una cirugía cardiovascular. En este artículo, relatamos un caso de paraplejia ocurrida en un paciente de 70 años, del sexo masculino, y después de una cirugía de revascularización del miocardio añadiéndosele opioide subaracnoideo a la anestesia general.