Complicaciones relacionadas al manejo anestésico de pacientes pediátricos con osteogénesis imperfecta sometidos a procedimientos ortopédicos / Complications related to the anesthetic management of pediatric patients with osteogenesis imperfecta undergoing orthopedic procedures

Resumen: Introducción: la osteogénesis imperfecta es un trastorno sistémico del tejido conectivo, se caracteriza por una densidad ósea menor y variabilidad de la fragilidad ósea. Material y métodos: se realizó un estudio retrospectivo, observacional, descriptivo de casos consecutivos, cuyo objetivo principal fue determinar las complicaciones relacionadas al procedimiento anestésico en pacientes pediátricos con diagnóstico de osteogénesis imperfecta sometidos a procedimientos ortopédicos en el Hospital Infantil de México «Federico Gómez¼ mediante la revisión de expedientes clínicos. Se incluyeron pacientes con diagnóstico de osteogénesis imperfecta, menores de 18 años, sometidos a cirugía ortopédica electiva. Se utilizaron medidas de tendencia central y dispersión así como pruebas de hipótesis diversas. Resultados: se incluyeron 86 registros anestésicos. La mayoría del tipo III de osteogénesis imperfecta. La anestesia general balanceada fue la técnica más frecuente con intubación orotraqueal. De las complicaciones reportadas hubo intubación difícil en dos casos (2.3%). En seis casos (6.9%) se consideró ventilación difícil. Otra de las complicaciones reportadas fue el sangrado, encontrando un sangrado mayor al previsto en 33 casos (38.4%). Conclusiones: la anestesia requerida en los pacientes con osteogénesis imperfecta se llevó a cabo con un mínimo de complicaciones.

Abstract: Introduction: osteogenesis imperfecta is a systemic disorder of connective tissue, characterized by decreased bone density and variability of bone fragility. Material and methods: a retrospective, observational, descriptive study of consecutive cases was carried out, whose main objective was to determine the complications related to the anesthetic procedure in pediatric patients with a diagnosis of osteogenesis imperfecta undergoing orthopedic procedures at the «Federico Gómez¼ Children's Hospital of Mexico, through the review of clinical records. Patients diagnosed with osteogenesis imperfecta, under 18 years of age, undergoing elective orthopedic surgery, were included. Measures of central tendency and dispersion were used, as well as tests of various hypotheses. Results: 86 anesthetic records were included. Most of the type III of osteogenesis imperfecta. Balanced general anesthesia was the most frequent technique with orotracheal intubation. Of the reported complications, difficult intubation was found in two cases (2.3%). In six cases (6.9%) ventilation was considered difficult. Another of the complications reported was bleeding, finding bleeding greater than expected in 33 cases (38.4%). Conclusions: the anesthesia required in patients with osteogenesis imperfecta was carried out with a minimum of complications.

Manejo anestésico durante la cirugía para pseudoaneurisma ventricular izquierdo / Anesthetic management during surgery for left ventricular pseudoaneurysm

Resumen: Se informa la conducta anestésica de un caso de pseudoaneurisma ventricular izquierdo crónico secundario a complicación de infarto de miocardio transmural, complicación rara y casi siempre mortal. En este informe se describe el caso de una mujer de 60 años con insuficiencia cardíaca aguda a consecuencia de un infarto cardíaco ocurrido cinco meses atrás, que generó la complicación de la cual damos referencia. El manejo anestésico perioperatorio se logró al enfocarse en mantener una presión arterial estable para garantizar la perfusión cerebral y reducir el riesgo de ruptura completa del aneurisma hacia el espacio mediastinal.

Abstract: The anesthetic behavior of a case of chronic left ventricular pseudoaneurysm secondary to a complication of transmural myocardial infarction, a rare and almost always fatal complication, is reported. This report describes the case of a 60-year-old woman with acute heart failure, this is a consequence of a heart attack that occurred 5 months ago, which generated the complication of which we refer. Perioperative anesthetic management was achieved by focusing on maintaining a stable blood pressure to ensure cerebral perfusion and reduce the risk of complete rupture of the aneurysm into the mediastinal space.

Cervical plexus block as an alternative anesthetic approach for type I thyroplasty: a case report / Bloqueio do plexo cervical como técnica anestésica alternativa para tireoplastia tipo I: relato de caso

Abstract Background: The role of type I thyroplasty (TIP) is well established as the treatment for glottal insufficiency due to vocal fold paralysis, but the ideal anesthetic management for this procedure is still largely debated. We present the case of a novel anesthetic approach for TIP using combined intermediate and superficial Cervical Plexus Block (CPB) and intermittent mild sedation analgesia. Case report: A 51-year-old presenting with left vocal fold paralysis and obstructive sleep apnea was scheduled for TIP. An ultrasound-guided intermediate CPB was performed using the posterior approach, and 15 mL of ropivacaine 0.5% were injected in the posterior cervical space between the sternocleidomastoid muscle and the prevertebral fascia. Then, for the superficial CPB, a total of 10 mL 0.5% ropivacaine was injected subcutaneously, adjacently to the posterior border of the sternocleidomastoid muscle, without penetrating the investing fascia An intermittent sedation analgesia with a target-controlled infusion of remifentanyl (target 0.5 ng.mL-1) was used to facilitate prosthesis insertion and the fiberoptic laryngoscopy. This technique offered a safe anesthetic airway and good operating conditions for the surgeon, as well as feasible voice monitoring and optimal patient comfort. Conclusion: The use of a regional technique is a promising method for the anesthetic management in TIP, especially in patients with compromised airway.

Resumo Introdução: O papel da tireoplastia tipo I (TPI) está bem estabelecido no tratamento de insuficiência glótica após a paralisia das pregas vocais, mas o manejo anestésico ideal para a TPI ainda é controverso. Descrevemos uma nova técnica anestésica para a TPI usando o Bloqueio do Plexo Cervical (BPC) superficial e o BPC intermediário associados, em presença de analgo-sedação leve e intermitente. Relato de caso: Paciente de 51 anos de idade com paralisia da prega vocal esquerda e apneia obstrutiva do sono foi agendada para TPI. BPC intermediário guiado por ultrassom foi realizado usando acesso posterior, e 15 mL de ropivacaína a 0,5% foram injetados no espaço cervical posterior entre o músculo esternocleidomastoideo e a fáscia prevertebral. A seguir, para o BPC superficial, 10 mL de ropivacaína a 0,5% foram injetados na região subcutânea adjacente à borda posterior do músculo esternocleidomastoideo, sem transfixar a fáscia de revestimento. Analgo-sedação intermitente com infusão alvo-controlada de remifentanil (alvo de 0,5 ng.mL-1) foi usada para facilitar a inserção da prótese e a laringoscopia com fibra ótica. A técnica ofereceu via aérea segura durante a anestesia, boa condição para o cirurgião, possibilidade de monitorar a voz, além de ótimo conforto à paciente. Conclusões: O uso de anestesia regional é uma técnica promissora para o cuidado anestésico durante a TPI, especialmente em pacientes com via aérea comprometida.

Coronavirus y anestesia / Coronavirus and anesthesia

Resumen: La pandemia del nuevo coronavirus COVID-19 ha infectado a más de 800,000 casos en todo el mundo y aún no hay vacuna ni tratamiento específico. Como especialistas en el manejo de la vía aérea, los anestesiólogos estamos expuestos a las secreciones y con un alto riesgo de contraer la infección por COVID-19. En esta revisión se muestran las recomendaciones para disminuir el riesgo a través de técnicas de control de infecciones.

Abstract: The pandemic of the new coronavirus disease, COVID-19 has been involved in more than 800,000 cases worldwide. There isn't vaccine or specific treatment. As specialists in airway management, anesthesiologist are routinely exposed to patients' respiratory secretions and are at high risk of contracting COVID-19 from infected patients. This review provides suggestions on how to minimize this risk by improved infection control.

Anesthesia for renal transplantation in patients with dilated cardiomyopathy: a retrospective study of 31 cases / Anestesia para transplante renal em pacientes com cardiomiopatia dilatada: estudo retrospectivo de 31 casos

Abstract Background and objectives: Dilated cardiomyopathy is a state of progressive enlargement of cardiac chambers mainly left ventricle which leads to decreased cardiac output and ultimately cardiac failure. Although it has multifactorial etiology, it is quite common in patients with end stage renal disease who require renal transplant surgery for their cure. Both conditions go side by side and anesthetic management of such cases poses real challenge to anesthesiologist. Strict monitoring and control of cardiac physiology is of utmost importance besides meticulous fluid management, thus preserving renal blood flow on one hand and preventing cardiac failure on other hand. This is the basis of achieving good outcome of the renal transplant surgery. Methods: This is a retrospective observational study done by analysing electronic database of 31 patients with dilated cardiomyopathy who underwent renal transplant surgery. Data was studied in terms of demographics, duration of renal disease, comorbidities mainly hypertension, cardiac echo graphic findings including ejection fraction, medications and post-operative outcome. Results: Most common perioperative complication in this patient population was hypotension (51.61%) followed by pulmonary complications postoperative mechanical ventilation (12.9%) and pulmonary edema (6.45%). High incidence of hypotension may be a causative factor to increased rate of delayed graft functioning (12.9%) and acute tubular necrosis (2.23%) in these patients. Conclusion: Strict monitoring and control of hemodynamic parameters as well as meticulous fluid therapy is the cornerstone in improving outcome in patients with dilated cardiomyopathy undergoing renal transplant surgery.

Resumo Justificativa e objetivos A cardiomiopatia dilatada é um estado de aumento progressivo das câmaras cardíacas, principalmente do ventrículo esquerdo, que leva à diminuição do débito cardíaco e, por fim, à insuficiência cardíaca. Embora tenha etiologia multifatorial, é bastante comum em pacientes com doença renal terminal que precisam de transplante renal para sua cura. Ambas as condições andam lado a lado e o manejo anestésico de tais casos é um verdadeiro desafio para o anestesiologista. A monitoração e o controle rigoroso da fisiologia cardíaca são de extrema importância, além de um meticuloso manejo dos líquidos, o que por um lado preserva o fluxo sanguíneo renal, por outro previne a insuficiência cardíaca. Essa é a base para alcançar o bom resultado da cirurgia de transplante renal. Métodos Este estudo observacional retrospectivo foi feito mediante a análise de prontuários eletrônicos de 31 pacientes com cardiomiopatia dilatada submetidos à cirurgia de transplante renal. Os dados foram avaliados em termos demográficos, duração da doença renal, comorbidades (principalmente hipertensão), achados ecocardiográficos (inclusive fração de ejeção), medicamentos e resultados no pós-operatório. Resultados A complicação perioperatória mais comum nessa população de pacientes foi hipotensão (51,61%), seguida de complicações pulmonares, como ventilação mecânica pós-operatória (12,9%) e edema pulmonar (6,45%). A alta incidência de hipotensão pode ser um fator causador do aumento da incidência de atraso no funcionamento do enxerto (12,9%) e necrose tubular aguda (2,23%) nesses pacientes. Conclusão A monitoração rigorosa e o controle dos parâmetros hemodinâmicos, bem como a fluidoterapia criteriosa, são a pedra angular na melhoria dos resultados em pacientes com cardiomiopatia dilatada submetidos à cirurgia de transplante renal.

Anesthetic management of carcinoid syndrome: is octreotide enough? A case report / Manejo anestésico del síndrome carcinoide: es el octreótido suficiente? Presentación de un caso

Abstract: Carcinoid tumors are rare slow-growing neuroendocrine tissue neoplasms. Their ability to secrete bioactive substances to the systemic circulation is accountable for a clinical presentation known as carcinoid syndrome. Main symptoms include bronchoconstriction, flushing, diarrhea and hemodynamic instability. Octreotide, a somatostatin analogue, is the current mainstay for carcinoid syndrome treatment and perioperative management. However, no regimen has proven to be completely effective in preventing systemic manifestations and recent literature suggests that it might be an insufficient measure. We report a case of a 51-year-old male with a functioning small bowel neuroendocrine tumor and carcinoid syndrome presenting for a primary tumor resection, discussing possible pitfalls and key points in the care of these patients.

Resumen: Los tumores carcinoides son neoplasias de tejido neuroendocrino poco comunes y de crecimiento lento. Su capacidad para secretar sustancias bioactivas a la circulación sistémica es responsable por una presentación clínica conocida como síndrome carcinoide. Los principales síntomas incluyen broncoconstricción, enrojecimiento, diarrea e inestabilidad hemodinámica. Octreótido, un análogo de la somatostatina, es el pilar actual para el tratamiento del síndrome carcinoide y su manejo perioperatorio. Sin embargo, ningún tratamiento ha demostrado ser completamente eficaz para prevenir las manifestaciones sistémicas y estudios recientes indican que puede ser una medida insuficiente. Presentamos un caso de un varón de 51 años con un tumor neuroendocrino funcionante en el intestino delgado y un síndrome carcinoide, sometido a una resección del tumor primario, discutiendo posibles dificultades y puntos clave en la atención de estos pacientes.

Paro cardiaco en paciente con insuficiencia mitral aguda por endocarditis bacteriana / Cardiac arrest in a patient with acute mitral insufficiency for bacterial endocarditis

Introducción: la endocarditis infecciosa es una enfermedad que involucra con másfrecuencia las válvulas cardíacas, pero también puede ocurrir sobre cuerdas tendinosas, o el endocardio mural. La lesión característica − vegetación − consiste en una masa de plaquetas, fibrina, microcolonias de microorganismos y escasas células inflamatorias. Objetivo: describir la conducta perioperatoria, así como la evolución clínico-anestesiológica de un paciente que presentó paro cardiaco secundario a insuficiencia mitral aguda por endocarditis bacteriana. Caso clínico: hombre joven con diagnóstico de endocarditis infecciosa e insuficiencia valvular mitral con ruptura de las cuerdas tendinosas, presentó paro cardiorrespiratorio que requirió reanimación cerebrocardiopulmonar con recuperación de la circulación espontánea. Fue llevado al quirófano de emergencia para sustitución valvular mitral y conservación de las cuerdas tendinosas. Se obtuvieron resultados satisfactorios, sin secuelas pulmonares ni neurológicas. Conclusiones: la rápida identificación y tratamiento de la endocarditis bacteriana mejora el pronóstico y evita nefastas complicaciones. La ecocardiografía transesofágica brinda adecuada resolución espacial y precisión en su evaluación y posibilita la mejoría terapéutica(AU)

Introduction: Infectious endocarditis is a disease that involves the heart valves more frequently, but it can also occur on chordae tendineae, or the mural endocardium. The characteristic lesion, vegetation, consists of a mass of platelets, fibrin, microorganisms microcolonies, and few inflammatory cells. Objective: To describe the perioperative behavior, as well as the clinical anesthesiological evolution of a patient who presented cardiac arrest secondary to acute mitral regurgitation due to bacterial endocarditis. Clinical case: A young man with a diagnosis of infective endocarditis and mitral valve insufficiency with ruptured tendinous cords presented cardiorespiratory arrest requiring brain and cardiopulmonary resuscitation with spontaneous circulation recovery. He was taken to the emergency operating room for mitral valve replacement and chordae tendineae conservation. Satisfactory results were obtained, without pulmonary or neurological sequelae. Conclusions: The quick identification and treatment of bacterial endocarditis improves prognosis and prevents nefarious complications. Transesophageal echocardiography provides adequate spatial resolution and accuracy in its evaluation and gives the possibility for therapeutic improvement(AU)

Manejo anestésico de emergencia hipertensiva perioperatoria secundaria a tumores neuroendocrinos A propósito de un caso / Anesthetic management of hypertensive emergency perioperative secondary neuroendocrine tumors. Report of a case

Resumen Introducción: Los tumores neuroendocrinos son neoplasias secretoras de hormonas, principalmente catecolaminas, que pueden presentarse en cualquier parte del cuerpo. La incidencia del feocromocitoma es de 2 a 8 por millón de personas por año, y el 10% de ellos son tumores extra adrenales. El manejo anestésico se considera un reto para el anestesiólogo, ya que deben tomar en cuenta varios puntos para el control hemodinámico del paciente, así como el manejo multidisciplinario en el periodo pre, trans y posquirúrgico. Caso clínico: Presentamos el caso de un paciente masculino portador de para-ganglioma vesical sometido a resección quirúrgica bajo anestesia general e infusión de isosorbide para control de la emergencia hipertensiva. Conclusiones: Se consideró, en este caso en particular, que el uso de vasodilatadores periféricos fue benéfico para el tratamiento de la emergencia hipertensiva durante el transanestésico. Discusión: El tratamiento de la emergencia hipertensiva reportado en la bibliografía muestra que el uso de fármacos intravenosos como nitroprusiato de sodio, nitroglicerina, labetalol, esmolol, entre otros, son los más indicados. El uso de nitritos es una alternativa viable con descontrol hipertensivo severo.

Abstract Introduction: Neuroendocrine tumors, can be found anywhere on the body. The incidence of pheochromocytoma is 2-8 per million people per year and 10% of these are extra-adrenal tumors. Anesthetic management is considered a challenge for the anesthesiologist, since they are primarily catecholamine secreting tumors, and they must take into account several points for a hemodynamic monitoring of the patient and the multidisciplinary management in the pre, trans and postsurgical period. Case report: We report the case of a male patient carrier of a bladder para-ganglioma who underwent a surgical resection under general anesthesia and an infusion of isosorbide to control a hypertensive emergency. Conclusions: We considered, in this particular case, that the use of peripheral vasodilators was beneficial for the treatment of hypertensive emergency during trans- anesthetic. Discussion: The treatment of hypertensive emergencies reported in the literature shows that the use of intravenous drugs such as sodium nitroprusside, nitroglycerin, labetalol, esmolol, among others, are the most recommended. The use of nitrite is a viable alternative with severe uncontrolled hypertension.

Anestesia para pacientes con trauma cráneo encefálico / Anesthesia for patients with traumatic brain injury

Traumatic Brain Injury (TBI) is a complex disease with a high social burden because of its high mortality and high rate of sequelae. Outcome after TBI is related to early management, including anesthetic management. In this article we review up to date concepts for anesthetic management of TBI patients; from pre-anesthetic evaluation to different aspects of surgical management: induction of anesthesia, airway control, mechanical ventilation, intravenous fluid management, maintenance of anesthesia during neurological and nonneurological surgery, and the treatment of brain edema, coagulopathy, electrolyte balance and temperature. We think the treatment must be directed to goals in order to offer the patient the best conditions for recovery and to avoid secondary brain injury.

El Trauma Cráneo Encefálico (TCE) es una enfermedad compleja, con gran repercusión social por su alta mortalidad y alta tasa de secuelas. El desenlace que tenga nuestro enfermo está relacionado con el manejo temprano que reciba, incluido el manejo anestésico. En este escrito se revisan los conceptos actuales de manejo anestésico de enfermos con TCE, desde su evaluación preanestésica hasta los diferentes aspectos del manejo quirúrgico: inducción de anestesia, control de la vía aérea, ventilación mecánica, manejo de líquidos intravenosos, mantenimiento anestésico en cirugía neurológica y no neurológica, manejo del edema cerebral, de la coagulopatía, de los electrolitos y de la temperatura. Nuestro enfoque se basa en el manejo orientado a metas de manera que ofrezcamos al paciente las mejores condiciones de recuperación y evitemos la lesión secundaria.

Manejo anestésico en una mujer con malformación de Arnold-Chiari tipo II residual / Anesthetic management in a woman with residual Arnold-Chiari malformation Type II

Background: The Arnold-Chiari malformation (ACM) is a group of congenital abnormalities of the hindbrain and the spinal cord and is characterized by herniation of the cerebellum, kinking of the medulla oblongata and hydrocephalus, the anesthetic management Is complicated due to the anatomic and physiologic alterations. Case description: A 23 years old woman with Arnold-Chiari type II malformation, and perforated appendicitis. Conclusions: The present case demonstrates that patients with partially corrected ACM type II, restrictive lung disease due to scoliosis and perforated appendicitis delivery require an interdisciplinary team approach, diligent preparation, and skilled physicians.

Antecedentes: La malformación de Arnold-Chiari (ACM) es un grupo de anomalías congénitas del cerebro posterior y la médula espinal que se caracteriza por la herniación del cerebelo, retorcimiento del bulbo raquídeo e hidrocefalia, el manejo anestésico se complica debido a la anatomía y alteraciones fisiológicas. Descripción del caso: Una mujer de 23 años con Arnold-Chiari tipo II malformación y apendicitis perforada. Conclusiones: El presente caso demuestra que los pacientes con corregido parcialmente ACM tipo II, enfermedad pulmonar restrictiva debido a la escoliosis y la entrega apendicitis perforada requieren un enfoque multidisciplinario en equipo, preparación diligente, y los médicos cualificados.

Oclusión intestinal en una paciente portadora de un Feocromocitoma no diagnosticado. Manejo anestésico / Intestinal occlusion in a patient with an undiagnosed pheochromocytoma. Anesthetic management

El feocromocitoma es un tumor productor de catecolaminas que procede de las células cromafines del sistema nervioso simpático que puede causar hipertensión severa entre otros trastornos sistémicos. Pueden ser esporádicos o encontrarse asociados a varias enfermedades genéticas: neoplasia endocrina múltiple tipo 2, enfermedad de von Hippel-Lindau, neurofibromatosis de tipo 1 y paraganglioma familiar. Cuando un paciente en el que se sospecha la presencia de un feocromocitoma se presenta con una ugencia quirúrgica representa un gran desafío para el anestesiólogo, ya que en esta situación la mortalidad aumenta notablemente. Presentamos el caso de una paciente que resultó ser portadora de un feocromocitoma, integrando un síndrome MEN 2b con masas suprarrenales bilaterales que se presentó en la urgencia con una oclusión intestinal con una crisis hipertensiva severa con edema agudo de pulmón.

Pheochromocytoma is a tumor catecholamine-producing derived from chromaffin cells of the sympathetic nervous system that can cause severe hypertension among other systemic disorders. They may be sporadic or be associated with several genetic diseases: multiple endocrine neoplasia type 2, von Hippel-Lindau, neurofibromatosis type 1 and familial paraganglioma disease. When a patient who is suspected the presence of a pheochromocytoma presents with a surgical urgency represents a great challenge for the anesthesiologist, since in this situation the mortality increases significantly. We report the case of a patient who was found to be carrying a pheochromocytoma, integrating a MEN 2b syndrome with bilateral adrenal masses showed the urgency with bowel obstruction with severe hypertensive crisis with acute pulmonary edema.

Feocromocitoma é um tumor produtor de catecolamina derivada de células cromafins do sistema nervoso simpático que pode causar hipertensão grave entre outros distúrbios sistémicos. Eles podem ser esporádica ou estar associada a várias doenças genéticas: neoplasia endócrina múltipla tipo 2, von Hippel-Lindau, a neurofibromatose tipo 1 e doença paraganglioma familiar. Quando um paciente no qual a presença de um feocromocitoma suspeito apresenta-se com um ugencia cirúrgica representa um grande desafio para o anestesiologista, uma vez que nesta situação os mortalidade aumenta significativamente. Relatamos o caso de um paciente que foi encontrado carregando um feocromocitoma, integrando MEN 2b síndrome com massas adrenais bilaterais mostrou a urgência com obstrução intestinal com crise hipertensiva grave com edema pulmonar agudo.

Consideraciones anestésicas en un paciente con enfermedad de von Willebrand y Síndrome

La enfermedad de von Willebrand y el Síndrome de Bernard Soulier son entidades que presenten alteraciones de la coagulación de herencia autosómica dominante y recesiva respectivamente. Se presenta el caso de una paciente con diagnóstico de ambas entidades la cual fue sometida a una amigdalectomía, haciéndose énfasis en su manejo perioperatorio, así como la revisión de la literatura sobe su tratamiento.

summary The von Willebrand disease and the Bernard Soulier syndrome are diseases that present coagulation alterations with dominat and recesive hereditar character respectively. We present a case of a patient with both entites, who was operated of a adenotonsillectomy, making emphasis in the transoperatory management, and including a literature review.

resumo A doença de von Willebrand e a Síndrome de Bernard Soulier são entidades que apresentam alterações da coagulação de herança autossômica dominante e recessiva respectivamente. Se apresenta o caso de uma paciente com diagnóstico de ambas entidades a qual foi submetida a uma amigdalectomia, dando-se ênfase ao seu manejo peri-operatório, assim como a revisão da literatura sobre seu tratamento.