Manejo anestésico y hallazgos radiológicos en siameses craneópagos durante resonancia magnética / Anesthetic management and radiological findings in craniopagus conjoined twins on nuclear magnetic resonante

Los siameses tienen una prevalencia demasiado baja, pero cuando se presenta un caso, es importante contar con un grupo humano multidisciplinario, conformado por anestesiólogo, radiólogo, pediatra y especialistas de las áreas quirúrgicas según el tipo de siameses. Así mismo, es fundamental estudiar todas las implicaciones fisiológicas, farmacodinámicas y anatómicas del caso; entre ellas, la circulación cruzada. Todo esto, con el fin de procurar una planificación adecuada que permita el mejor resultado posible. El presente es un reporte de caso de siamesas craneópagas de 3 días de vida programadas para resonancia magnética.

The prevalence of conjoined twins is extremely low, but whenever a case occurs, it is of the utmost importance to have a multidisciplinary team consisting of an anesthesiologist, a radiologist, a pediatrician, and specialists in various surgical areas, depending on the type of conjoined twins. Likewise, it is critical to consider all the physiological, pharmacodynamic and anatomical implications, including cross circulation. The goal is to plan appropriately in order to enable the best possible result. This report is intended to present a case of 3 day-old craniopagus conjoined female twins scheduled for nuclear magnetic resonance (MRI).

Padronização de modelo de coração isolado "working heart" com circulação parabiótica / Development of isolated swine "working heart model" with parabiotic circulation

OBJETIVO: Desenvolver modelo de coração isolado de suíno "working heart" sob suporte por circulação parabiótica e verificar se o mesmo é estável e se possibilitou de forma efetiva a mensuração dos dados propostos. MÉTODOS: O modelo foi padronizado durante preparação para estudo de associação de agente à solução cardioplégica. Foram realizados 18 experimentos com um animal suporte e um animal doador em cada. O coração do animal doador foi perfundido como coração isolado pelo animal suporte em modo de execução de trabalho ("coração ejetante"). O coração isolado foi submetido à isquemia regional por pinçamento da artéria interventricular anterior seguido de isquemia global. Durante reperfusão, com o coração ejetante (em modo "working heart"), aos 30, 60 e 90 minutos foram medidos parâmetros hemodinâmicos de contratilidade e metabólicos, obtendo-se assim a elastância máxima (Emáx), o trabalho sistólico pré-recrutável (PRSW), rigidez do ventrículo (EDPRV), fluxo coronariano, consumo de oxigênio e dosagens de lactato e glicose. RESULTADOS: Os animais suporte ficaram estáveis durante todo o experimento. O pH, a pressão parcial de oxigênio e o hematócrito foram mantidos estáveis e dentro da faixa fisiológica. O coração isolado foi perfundido de forma adequada durante todo o experimento. Os dados hemodinâmicos e metabólicos propostos puderam ser mensurados adequadamente e sempre com o coração ejetante, em modo de execução de trabalho ("working heart"). CONCLUSÃO: O modelo de coração isolado desenvolvido tipo "working heart" se manteve estável durante todo o experimento, sem a administração de drogas cardiotônicas e possibilitou a mensuração de todos os dados propostos de forma efetiva com o coração executando trabalho.

OBJECTIVE: To develop an isolated working heart model with parabiotic circulaton in swines and verify its stability and possibility to allow effective measurements of hemodinamic and metabolic data. METHODS: This model was developed during study of association of agents to cardiolegia. There were performed 18 experiments, each with a support animal and a donor animal. Donor animal heart was perfused as isolated working heart with parabiotic circulation from support animal. Isolated heart underwent regional ischemia by interventricular artery clamping, followed by global ischemia. During reperfusion in working heart state mode at 30, 60 and 90 minutes, contractility indices such as elastance, preload recruitable stroke work index and metabolic data were acquired. RESULTS: Support animals were kept stable throughout the procedures without use of blood transfusions or vasoactive drugs. pH, oxygen partial pressure and hematocrit were kept stable and within physiologic ranges. Isolated heart was perfused adequately throughout the experiment. All hemodinamic and metabolic data proposed were adequately measured in working heart state mode. CONCLUSION: This swine isolated "working heart" model was kept stable throughout the experiments with no administration of vasoactive drugs and it allowed adequate measurements of metabolic and hemodinamic data.

Cincuenta años de circulación extracorpórea: la historia de la máquina corazón-pulmón / Fifty years of extracorporeal circulation: the history of the heart-lung machine

Si bien 1953 fue el año del descubrimiento del ADN y de la conquista del Monte Everest, también lo fue de un gran invento tecnológico: la máquina corazón-pulmón, la que ofreció un tratamiento, y en muchos casos cura, a la mayoría de las enfermedades cardiovasculares. En efecto, el 6 de mayo de 1953 John Gibbon logró coronar con el éxito el trabajo de toda su vida al cerrar por primera vez una comunicación interauricular en una joven mujer utilizando una máquina corazón-pulmón de su invención. Sin embargo, previamente la cirugía exploró otros caminos para operar el corazón, como la hipotermia, la que consistía en bajar la temperatura del paciente introduciéndolo en una tina de agua fría para luego efectuar la corrección quirúrgica de una malformación del corazón, en el menor tiempo posible. Por otra parte, luego de su primer éxito, los 4 pacientes siguientes de Gibbon fallecieron, por lo que este abandonó todo intento ulterior, lo que fue seguido por un pesimismo generalizado sobre la circulación extracorpórea. Este fue revertido un año más tarde por Walton Lillehei con la introducción de la "circulación cruzada controlada" en la que un paciente, habitualmente un niño, era conectado a un "donante", habitualmente el padre o la madre, cuyo corazón y pulmón servían como un oxigenador para así efectuar la cirugía a corazón abierto del paciente. Finalmente, es el mismo Lillehei, quien un año más tarde introduce el oxigenador de burbujas, simple y de bajo costo, que abrió las puertas de la cirugía a corazón abierto a todos los cirujanos del mundo. Por esto, para muchos, Walton Lillehei es considerado el "Padre de la Cirugía a Corazón Abierto". Lillehei visitó Chile en 1963 y luego de operar en los pabellones del Hospital Clínico de la Universidad Católica fue nombrado Miembro Honorario de la Facultad de Medicina de dicha Universidad. Previamente, en 1957, Helmuth Jaeger había efectuado el primer cierre quirúrgico exitoso de una comunicación interauricular con circul...

Cincuentenario de la máquina corazón-pulmón Un relato acerca de los pioneros y héroes y de las circunstancias que llevaron al gran invento que permitió el tratamiento y la cura de las enfermedades del corazón / Fifty years of the heart-lung machine. The report about the pioneers and heroes and about the circumstances that elevated the great invention, which allowed the treatment, and in many cases, the cure of heart illnesses

In 1953 DNA was discovered and the Everest was conquered but also a great invention was developed: the heart-lung machine, which allowed the treatment, and in many cases, the cure of most cardiovascular illnesses. In fact, on May 6, 1953 John Gibbon crowned with success the work of his entire life closing for the first time an atrial septal defect in a young woman using a heart-lung machine of his own invention. Before that, surgeons had explored other roads like hypothermia, cooling the patient in a cold water tub and then rapidly performing the surgical correction of a heart malformation. After his first success, the following 4 patients of Gibbon died, which led him to abandon heart surgery and produced a generalized pessimism about extracorporeal circulation. However, a year later Walton Lillehei reverted this situation with the introduction of controlled cross-circulation in which a patient, usually a child, was connected to a "donor", usually his father or mother, whose heart and lung served as a pump and oxigenator, allowing the performance of open heart surgery. Finally, it was Lillehei again who a year later introduced the bubble oxigenator, simple and inexpensive, opening the doors of open heart surgery to all surgeons around the world. For this, and many other reasons, Walton Lillehei is considered by most surgeons as the "Father of Open Heart Surgery". Lillehei visited Chile in 1963 and operated on a patient in the surgical theaters of the Hospital Clínico de la Universidad Católica and was named an Honorary Member of the School of Medicine of this University. Before that, in 1957 Helmut Jaeger at the Hospital Luis Calvo Mackenna performed the first successful surgical closure of an atrial septal defect with extracorporeal circulation in Chile using a De Wall-Lillehei bubble oxigenator (Rev Méd Chile 2003; 131: 1337-44).

Standardization of an isolated pig heart preparation with parabiotic circulation: methodological considerations

In the present study we standardized an experimental model of parabiotic circulation of isolated pig heart. The isolated heart was perfused with arterial blood from a second animal as support and submitted to regional ischemia for 30 min, followed by total ischemia for 90 min and reperfusion for 90 min. Parameters for measurement of ventricular performance using different indices measured directly or indirectly from intraventricular pressure were defined as: maximum peak pressure, final diastolic pressure, pressure developed, first derivative of maximum pressure (dP/dt max), first derivative of minimum pressure (dP/dt min), systolic stress of the left ventricle (sigmas), and maximum elastance of the left ventricle. Isolated hearts subjected to regional and global ischemia presented significant worsening of all measured parameters. Less discriminative parameters were dP/dt max and dP/dt min. Elastance was the most sensitive parameter during the reperfusion period, demonstrating an early loss of ventricular function during reperfusion. The model proved to be stable and reproducible and permitted the study of several variables in the isolated heart, such as ischemia and reperfusion phenomena, the effects of different drugs, surgical interventions, etc. The model introduces an advantage over the classical models which use crystalloid solutions as perfusate, because parabiotic circulation mimics heart surgery with extracorporeal circulation

Sistema extracorpóreo para soporte de la falla hepática fulminante como puente al trasplante de hígado (xenohemodiafiltración): informe del primer caso clínico con un procedimiento desarrollado en el Hospital Italiano de Buenos Aires / Extracorporeal system for fulminant hepatic failure support as a bridge to liver transplantation (xenohemodiafiltration): case report of a procedure developed at Hospital Italiano in Buenos Aires

Antecedentes: La falla hepática es una causa importante de morbilidad y mortalidad en Unidades de Terapia Intensiva. Las terapias convencionales no son lo suficientemente efectivas. El trasplante hepático es el tratamiento definitivo para esta entidad, pero debido a la falta de donantes se hacía necesario desarrollar una "terapia puente" o de sostén de la vida hasta que aquél se realizara. La xenohemodiafiltración hepática extracorpórea pretende ser el soporte transitorio de un paciente con falla hepática fulminante. Objetivo: Presentamos el primer caso de xenohemodiafiltración hepática extracorpórea. Lugar de aplicación: Hospital Italiano de Buenos Aires. Diseño: Descripción del primer caso clínico de xenohemodialfiltración. Población: Mujer de 42 años portadora de falla hepática fulminante, con grave alteración de la coagulación, déficit de factor V y severa hipertensión intracraneana. Método: El sistema consiste en una circulación cruzada entre un hígado porcino y un paciente con falla hepática fulminante a través de una membrana de poliacrilonitril. Resultados: El procedimiento duró 5 horas y alcanzó mejoras hemodinámicas, bioquímicas y metabólicas. La presión intracraneana disminuyó de 34 a 5 cm H2O, el amoníaco sérico cayó de 673 a 370 ng/dl, ácido láctico de 11 a 5.3 mmol/L y la bilirrubina de 7.4 a 2.5 mg/dl. Los valores hemodinámicos se mantuvieron estables durante el procedimiento. La paciente pudo recibir el trasplante y continúa viva 11 meses después. Conclusiones: La xenohemodiafiltración hepática extracorpórea es un método clínico experimental que puede constituir una terapia clínica alternativa para soporte de pacientes con falla hepática fulminante hasta que se obtenga un órgano apto para trasplante.

femoro-femoral cross-over by-pass an alternative treatment of unilateral iliac artery obstruction

From 10/82 until 10/89, 13 femoro-femoral cross over by-pass procedures were performed in Assiut University Hospital. The low mortality rate 7% and the high patency rates 77% in poor risk patients suggest that procedure can be used in other patients with symptomatic occlusive disease of one iliac artery if a femoral pulse of good quality exists in the opposite groin

Centrally mediated hypocholesterolaemic response of insulin in dogs.

Insulin on intravenous administration in dogs caused a rise in blood cholesterol level. This may be due to its direct action on liver or other peripheral structures. On the other hand, insulin administered into the lateral cerebral ventricles in normal as well as in spinal and vagotomized dogs resulted in a lowering of blood cholesterol. In cross circulation studies insulin administered into lateral cerebral ventricles of donor dogs produced a hypocholesterolaemia in the recepient dogs without significant changes in blood cholesterol of donor dogs. It is suggested that some substance may be liberated from some parts of central nervous system due to an action of centrally administered insulin. This substance in turn causes hypocholesterolaemia by acting on liver or some other peripheral structures in dogs.

"Experimental Studies on Cross Circulation between Normal Dogs with Disturbed Kidney Function: Part III. Influence of Cross Circulation on Non-protein Nitrogen, Urea Nitrogen and Creatinine Blood Levels of Dogs with Renal Arteries Clamped Bilaterally / 대한비뇨기과학회지

In Part II, the authors have reported that cross circulation between normal dogs and bilaterally nephrectomized dogs resulted in decreased blood concentrations of non-protein nitrogen, urea nitrogen and creatinine in the bilaterally nephrectomized dogs and improvement of the dogs' general condition for a short time. In this study the renal arteries of normal dogs were occluded by clamping for varied periods of time to cause reversible renal insufficiency. After renal insufficiency developed cross criculation with untreated normal dogs was instituted to investigate the effects of cross circulation on blood concentrations of NPN, urea nitrogen and creatinine, urinary out-put and in the general condition of the dogs.As a control experiment, renal arteries of dogs were clamped bilaterally for 1, 2, 3, 4, 5 and 6 hours and blood concentrations of NPN, urea nitrogen and creatinine, general condition and urinary out-put of these dogs were studied.In the oliguric phase caused by bilateral clamping of the renal arteries of dogs for 3, 4, 5, and 6 hours, cross circulation between these dogs and normal dogs was performed. One to three cross circulations were done on each dog and one cross circulation lasted for 2 to 4 hours. Changes in the blood concentration of NPN, urea nitrogen and creatinine, the general condition of the dogs and urinary out-put were studied.In the control and cross circulation studies 5 dogs were studied in each of the groups designated by the time interval of clamping renal arteries except one dog was used for the 1 and 2 hour groups. Using normal Korea mongrels weighing 12kg. or more, the kidneys were exposed through a flank incision under pentothal anesthesia. Perirenal fat tissue was freed and vessels supplying the renal capsule were severed and ligated. The upper ureters were freed of abarrent vessels. The right kidney was first exposed and then the left. Clamping of both renal arteries was instituted at the same time. The renal arteries were lightly clamped using a rubber shod clamp to interrrupt the blood stream but bot to damage the arterial wall. Clamping of both renal arteries were released simultaneously and the operative wounds were closed. Direct cross circulation as described previously was used in this study and all procedures were done under aseptic technic. Prophylactic penicillin and streptomycin were also given pre- and postoperatively. All observation and determination of experimental items were done before clamping the arteries and at 12 hours after clamping. Daily determinaton for 5 days followed thereafter. Hourly determinatons were performed during the cross circulation. The results of the experiment are summarized as follows: When bilateral renal arteries of normal dogs were clamped for 1, 2, 3, 4, 5 and 6 hours, oliuria or anuria was observed immediately after clamping. Blood levels of NPN, urea nitrogen and creatinine were increased at 12 hours after clamping. A poor general condition was observed in most dogs one to two days post-experimentally in these and there was gradual exacerbation in the induced kidney insufficiency during oliguric phase. Most experimental animals died except a few did recover after regaining enough renal unction to produce diuresis. During cross circulation, urinary out-put was not altered and the general condition of the dogs was remarkedly improved. A decrease in the blood concentrations of NPN, urea nitrogen and creatinine was observed in all the dogs. For one to seven days after the circulation the condition of these dogs became slightly worse but a diuretic phase soon developed and most dogs in these experimental groups survived except for the few which died during or after the cross circulaton.In each of the six control groups in which the renal arteries were clamped for 1 to 6 hours as described above, 1, 1, 2, 2, 0 and 0 dogs survived. With cross circulation, experimental groups in which the renal arteries were clamped for 3, 4, 5 and 6 hours, had a survival of 4, 3, 3 and 2 dogs, respectively. Of 20 dogs, 12 survived and 8 died.Cross circulation increased the survival rate of dogs with induced renal insufficieney, but it is unlikely that pathological changes and function in these kidneys were changed during the curculation. It, however, is clear that the toxic state of renal insufficiency was relieved markedly during the cross circulation, although temporarily, but long enough to provide better survival condition. Most dogs were supported adequately to overcome the oliguric crisis and return to the diuretic phase.In normal dogs used in the cross circulation the development of an apathetic state, and elevation in blood concentrations of NPN, urea nitrogen and creatinine were observed. These dogs urinated several times during the experiment and experienced frequent pulse and respiratory rates. Arrhythmias of a temporary nature were observed. These dogs returned to normal in one to three days after the cross circulation.

Experimental Studies on Cross Circulation between Normal Dogs and Dogs with Disturbed Kidney Function: Part I. Cross Circulation in Normal Dog / 대한비뇨기과학회지

Normal adult Korean dogs (Mongrel) were used for these experiments. Operations and cross circulations were performed under sterile conditions and anesthesia with intravenous sodium pentothal injection. Heparin was used as the anticoagulant before and during cross circulation. Two dogs were placed on operating tables so that their legs were together. The femoral arteries and veins in adjacent legs were isolated and cannulated with tubes of 1.0mm inside diameter. The arterial cannule of each animal was connected to the venous cannule of the other dog, and cross circulation was started and continued for 2 to 13 hours. This method is referred as direct cross circulation. A second method, indirect cross circulation, was devised to connect the arterial cannule of each dog to the venous cannule of the other dog through a glass bottle containing 20cc of ACD solution elevated one meter above the animals. With the venous tubing clamped, arterial blood flowed into the bottles. When 100cc of arterial blood had been collected, blood flow was reversed by clamping the arterial tubings and removing the venous clamps. The procedures were repeated for 5 hours. General condition, pulse, respiration, NPN. BUN and creatinine of blood content were observed and determined before, during and after cross circulation. The experiments were done in 7 pairs of animals by the direct method, and in 2 pairs by the indirect method. During the experiment, pulse and respiration became frequent and irregular. They showed sign of weakness. But dogs returned to normal in 1 to 3 days after the experiment. No significant differences were noted in the amount of blood NPN, BUN and creatinine content during and after cross circulation by both animals. However, the indirect method appears safer for the animals but less blood volume can be exchanged than in using the direct method.

Experimental Studies on Cross Circulation between Normal Dogs and Dogs with Disturbed Kidney Function: Part II. Influence of Cross Circulation on Non-Protein Nitrogen, Urea Nitrogen and Creatinine Blood Levels of Nephrectomized Dogs / 대한비뇨기과학회지

In the first paper of this experiment, the author reported no significant changes in NPN, urea nitrogen and creatinine blood levels resulting from cross circulation between normal dogs. In this experiment cross circulations between Nephrectemized dogs and normal ones were performed and the rate of removal of waste products from the blood of bilaterally nephrectomized dogs through the kidneys of normal dogs as well as the state of improvement of a general condition were observed. Blood levels of NPN, urea nitrogen and creatinine were determined. Sixty to seventy-two hours after both kidneys were removed, the dogs developed anorexia, nausea, vomiting and apathy. Cross circulation as previously described was instituted when blood concentration of NPN varied from 139.2 to 193 mg%; urea nitrogen, from 86.7 to 137.8 mg; and creatinine, from 4.8 to 6.8 mg%. All procedures were carried out under an aseptic technique and penicillin or streptomycin were given to prevent infection. Using the indirect cross circulation in two pairs of dogs, 2080 cc and 3520 cc of blood was cross transfused for periods of 100 minutes and 5 hours respectively. Blood was exchanged by the direct cross circulation in four pairs of dogs for periods ranging from four hours 35 minutes to eight hours. The results obtained are as follows: During cross circulation between the nephrectomized dogs and the normal ones, the former exhibited improvement in their vitality, ceased nausea and vomiting and began to eat. During the indirect cross circulation the NPN of the nephrectomized dogs was lowered 13.8 mg% and 27.2 mg; whereas when using the direct cross circulation a decrease of 57.6 mg% to 84.6mg% and obtained. Decreases in urea nitrogen and creatinine blood concentrations were observed to be 10.2 mg% to 22.6 mg% and O.6 mg% respectively by the indirect cross circulation. whereas 32.7mg% to 65.1 mg% and 2.2 mg% to 3.O mg% respectively by the direct method. The lowered blood concentrations of the waste products, however, rose again and the general condition of the nephrectomized dogs became worse one or two days after the completion of the experiment. The normal dogs receiving blood from the nephrectomized dogs developed a rapid pulse, frequent and irregular respirations, a weakened general condition and elevation of blood concentrations of NPN. urea nitrogen and creatinine. The general condition and the blood concentrations, however, returned to normal one to four days after the completion of the experiments. The direct method of cross circulation between bilaterally nephrectomized dogs and healthy ones is superior to the indirect method in respect to the animals general condition and to the removal of waste products from the blood of the nephrectomized animal.