Reporte de caso. Uso de toxina botulínica tipo A para la reparación de hernia ventral gigante planeada / Surgical treatment of diabetic foot based on Wagner classification, Case report

Introducción: La incidencia de eventración post quirúrgica es del 2-20%, se da mayormente en pacientes con factores de riesgo durante los primeros tres años posteriores a la cirugía inicial. La mayoría de las hernias de la pared abdominal pueden ser reparadas fácilmente, sin embargo, las hernias gigantes (>10cm de diámetro) o aquellas con pérdida de domicilio requieren métodos de expansión gradual de la pared abdominal pre y/o transoperatoriamente. Se ha descrito que posterior a la aplicación de toxina botulínica serotipo A (TBA) de forma bilateral en la pared abdominal, los defectos disminuyen clínica y tomográficamente hasta 5.25cm, por su efecto selectivo en terminaciones nerviosas periféricas colinérgicas, provocando atrofia muscular sin fibrosis. El efecto máximo ocurre al mes de la aplicación y dura 28 semanas. Esta técnica permite planear preoperatoriamente la magnitud de la cirugía. Nuestro caso, paciente masculino de 33 años. Quien ingresa por politrauma. Se realiza procedimiento quirúrgico abdominal y posteriormente se eviscera en múltiples ocasiones. Se cierra herida y posteriormente desarrolla hernia ventral gigante con la que egresa. Se realiza TC abdominal evidenciando defecto herniario de 15.9cm, con este resultado se aplica toxina botulínica serotipo A en la pared abdominal bilateral (50 unidades en cada lado) guiado por ultrasonido. 25 días después se realiza TC abdominal control que evidencia defecto herniario de 14.7cm y se decide ingreso para cirugía electiva. Se decide llevar a sala de operaciones donde se realiza hernioplastía con liberación de componentes anteriores mas colocación de malla de polietileno (cuatro semanas posteriores a la aplicación de la toxina), quedando defecto totalmente cerrado y sin tensión. Paciente con adecuada evolución posterior a intervención por lo que egresa. Actualmente sin defecto herniario recurrente. Conclusión: El uso de toxina botulínica serotipo A es un nuevo recurso prequirúrgico para la preparación de pacientes con hernias ventrales gigantes, ya que permite el cierre sin tensión en la mayoría de los casos. Además, ayuda a que transoperatoriamente la separación de componentes se realice de una mejor manera, ya que se da mejor manipulación al momento de desplazar las estructuras musculares. Idealmente se debe de realizar la intervención quirúrgica cuatro semanas posteriores a su aplicación. (AU)

ntroduction: The incidence of post-surgical eventration is 2-20%, it occurs mostly in patients with risk factors during the first three years after the initial surgery. Most abdominal wall hernias can be easily repaired, however, giant hernias (>10cm of diameter) or those with the loss of domain require methods of gradual expansion of the abdominal wall pre or intraoperatively. It has been described that after the application of botulinum toxin A bilaterally in the abdominal wall, the defect can decrease clinically and tomographically up to 5.25cm, due to its selective effect on cholinergic peripheral nerve endings, that cause muscle atrophy without fibrosis. The maximum effect occurs one month after the application and lasts 28 weeks. This technique allows to plan preoperatively the magnitude of the surgery. Description of case: A 33 year old male patient, who entered the emergency room due to polytrauma. Abdominal surgical procedure was performed and later he eviscerates on multiple occasions. The wound was closed and later he develops a giant ventral hernia with which it is discharged. An abdominal CT was performed, showing a hernia defect of 15.9cm. With this result botulinum toxin A was applied guided by ultrasound bilaterally in the abdominal wall (50 U on each side). A control abdominal CT was performed after 25 days, which it revealed a hernia defect of 14.7 cms, so admission was decided for elective surgery. The patient was taken to the operating room where a hernioplasty with anterior components separation plus the placement of a polyethylene mesh was performed (four weeks after the application of the botulinum toxin A), the hernia defect was completely close without tension. The patient had an adequate post-surgical evolution for which it was discharge. Currently without a recurrent hernia defect. Conclusion: The use of botulinum toxin A is a new pre-surgical resource for the preparation of patients with giant ventral hernias, since it allows the closure without tension in most cases. In addition, it helps transoperatively with the components separation, since there is a better manipulation at the time of displacing the muscular structures. Ideally, the surgical intervention should be performed four weeks after its application. (AU)

Effect of ultrasound-guided right stellate ganglion block on perioperative atrial fibrillation in patients undergoing lung lobectomy: a randomized controlled trial / Efeito do bloqueio do gânglio estrelado direito guiado por ultrassom na fibrilação atrial perioperatória em pacientes submetidos a lobectomia pulmonar: estudo controlado randomizado

Abstract Objective: To observe the effects of preoperative right stellate ganglion block on perioperative atrial fibrillation in patients undergoing lung lobectomy. Methods: Two hundred patients who underwent a scheduled lobectomy were randomly divided into the S and C groups. The S group was injected with 4 mL of 0.2% ropivacaine under ultrasound guidance, and the C group did not receive stellate ganglion block. The patients underwent continuous ECG monitoring, and the incidences of atrial fibrillation and other types of arrhythmias were recorded from the start of surgery to 24 hours after surgery. Results: The respective incidences of atrial fibrillation in the S group and the C group were 3% and 10% (p = 0.045); other atrial arrhythmias were 20% and 38% (p = 0.005); and ventricular arrhythmia were 28% and 39% (p = 0.09). Conclusions: The results of the study indicated that preoperative right stellate ganglion block can effectively reduce the incidence of intraoperative and postoperative atrial fibrillation.

Resumo Objetivo: Observar os efeitos do bloqueio do gânglio estrelado na fibrilação atrial no período perioperatório em pacientes submetidos a lobectomia pulmonar. Método: Duzentos pacientes programados para lobectomia foram divididos aleatoriamente nos grupos S e C. O grupo S recebeu infusão de 4 mL de ropivacaína a 0,2% orientada por ultrassom e o grupo C não foi submetido a bloqueio do gânglio estrelado. Os pacientes foram submetidos à monitoração contínua de ECG, e as incidências de fibrilação atrial e outros tipos de arritmias foram registradas do início da cirurgia até 24 horas depois da cirurgia. Resultados: As incidências de fibrilação atrial no grupo S e no grupo C foram 3% e 10%, respectivamente (p = 0,045); as de outras arritmias atriais foram 20% e 38% (p = 0,005); e de arritmias ventriculares, 28% e 39% (p = 0,09). Conclusões: Os resultados do estudo indicaram que o bloqueio do gânglio estrelado no pré-operatório pode ser efetivo na redução da incidência de fibrilação atrial nos períodos intra- e pós-operatório.

Índice de colapsabilidad de la vena cava inferior como predictor de hipotensión intraoperatoria / Inferior vena cava collapsibility index of the as a predictor of intraoperative hypotension

OBJECTIVE: To evaluate the lower vena cava Collapse Index (CI) as a predictor parameter of hypotensive episodes after general anesthesia induction in ASA I and II patients who were scheduled for elective surgery. MATERIALS AND METHODS: A prospective, observational and simple blind study was designed. A sample of 80 patients was recruited. In the preoperative stage, they underwent protocolarized sedation and CI was obtained. Prior to induction, the baseline values ​​of heart rate, non-invasive mean arterial pressure and continuous electrocardiographic tracing in DII were noted. In the post-orotracheal intubation stage, the aforementioned hemodynamic monitoring variables were recorded manually for 10 minutes. RESULTS: The data of 78 individuals are presented. After anesthetic induction, 8 (10.3%) patients developed hypotension. The adjustment of the univariate logistic regression model for CI shows a good diagnostic capacity, with the area under the ROC curve equal to 0.76. The chance of presenting hypotension is increased by 62% by increasing the CI by 5 points (p = 0.003). Regarding the negative predictive value, we found that with values ​​corresponding to the cutoff points between 39% and 46%, a probability of at least 93.1% of not presenting hypotension was obtained. The optimal cutoff point of the CI to predict hypotension is estimated at 43%, with a sensitivity of 62.5% and a specificity of 92.9%. CONCLUSION: A lower IC was associated with a lower probability of developing intraoperative hypotension. The use of this tool could be useful to anticipate which patients will be prone to intra-surgical hypotension.

OBJETIVO: Evaluar el índice de colapsabilidad (IC) de la vena cava inferior (VCI) como predictor de episodios hipotensivos posinducción de anestesia general en cirugía electiva de pacientes ASA I y II. MATERIALES Y MÉTODOS: Se diseñó un estudio prospectivo, observacional y simple ciego. Se reclutó una muestra de 80 pacientes. En etapa preoperatoria fueron sometidos a una sedación protocolizada y se obtuvo el IC. Previo a la inducción, se anotaron los valores basales de la frecuencia cardíaca, la presión arterial media y el trazado electrocardiográfico continuo en DII. Posintubación orotraqueal, se registraron manualmente las variables hemodinámicas mencionadas durante 10 minutos. RESULTADOS: Se presentan datos de 78 individuos. Luego de la inducción, 8 (10,3%) pacientes desarrollaron hipotensión. El ajuste del modelo de regresión logística univariado para IC muestra una buena capacidad diagnóstica, siendo el área bajo la curva ROC igual a 0,76. La chance de presentar hipotensión se incrementa en un 62% al aumentar el IC en 5 puntos (p = 0,003). En cuanto al valor predictivo negativo, encontramos que con valores correspondientes a los puntos de corte entre 39% y 46%, se obtenía una probabilidad de 93,1% de no presentar hipotensión. El punto de corte óptimo del IC para predecir hipotensión se estima en 43%, con una sensibilidad del 62,5% y una especificidad del 92,9%. CONCLUSIÓN: Un menor IC se asoció con una menor probabilidad de desarrollar hipotensión intraoperatoria. El uso de esta herramienta podría ser de utilidad para anticipar qué pacientes serán propensos a hipotensión intraquirúrgica.

Complicaciones durante la esofagoscopía con o sin dilatación con globo y con anestesia general en pacientes pediátricos: estudio prospectivo y observacional / Complications during esophageal endoscopy with or without baloon dilation under general anesthesia in pediatric patients: a prospective and observational study

Antecedentes. Durante una esofagoscopía en niños, pueden ocurrir complicaciones durante la dilatación. Identificamos alteraciones cardiorrespiratorias durante la esofagoscopía con o sin dilatación con globo y las complicaciones posoperatorias, en niños con anestesia. Métodos. Estudio prospectivo, observacional de procedimientos endoscópicos en niños de 0-16 años. Se dividieron en dos grupos: con endoscopía-dilatación (Grupo ED) y dilatación con globo por estenosis esofágica, y con endoscopía sin dilatación (Grupo E): endoscopía diagnóstica, esofagoscopía de control o escleroterapia. Registramos parámetros hemodinámicos y ventilatorios y las complicaciones durante la endoscopía, la dilatación y el seguimiento de dos horas en la sala de recuperación. Resultados. Incluimos 102 procedimientos en 60 pacientes. La presión inspiratoria máxima (PIM) aumentó significativamente en ambos grupos (p < 0,001) y aumentó significativamente durante el procedimiento en el grupo ED (p < 0,001). La diferencia en la PIM antes y después de la endoscopía se correlacionó negativamente en ambos grupos. Al subdividir los grupos según el punto de corte de 2 años para comparar la diferencia en la PIM antes y después de la endoscopía, la PIM aumentó de manera estadísticamente significativa en ambos grupos en los menores de 2 años. En el grupo ED, la frecuencia cardíaca aumentó estadísticamente significativa (p < 0,001). Conclusión. Durante la endoscopía, la PIM aumentó en niños con o sin dilatación con globo, especialmente en el grupo ED, y fue mayor en los niños más pequeños. Es necesario observar y tratar atentamente las complicaciones cardiorrespiratorias graves durante la dilatación con globo y con anestesia general.

Background. Complications can occur during esophagoscopy as a result of applied procedure in children, especially during dilation techic. Our aim was to identify cardio-respiratory alterations during esophagoscopy with or without baloon dilation under anesthesia in children, and to investigate the postoperative complications. Methods. Prospective, observational study of endoscopic procedures in patients 0-16 years. The patients were divided into two groups: the endoscopy-dilation group (Group ED: endoscopy and balloon dilation due to esophageal stricture) and endoscopy without dilation (Group E: endoscopy for diagnostic reasons, control esophagoscopy or sclerotherapy). Hemodynamic and ventilatory parameters alterations and complications during endoscopy, dilation and two-hours follow-up time in the postoperative recovery room were recorded. Results. 102 procedures in 60 patients were included. Peak inspiratory pressure (PIP) values significantly increased after endoscopy in both groups (p<0.001). There was a significant increase in mean PIP values in the dilation group during the procedure (p<0,001). The difference in PIP values before and after the endoscopy was negatively correlated with age in both groups. When the groups were subdivided taking two years of age as a cut-off point in comparing PIP difference before-after endoscopy, PIP increase was statistically significant in both groups under two-years old. In the dilation group, statistically significant increase of HR was detected during the procedure (p<0,001). Conclusion. During endoscopy PIP increased in patients with or without baloon dilation especially in the dilation group. PIP increase was higher in younger children. Severe respiratory and cardiovascular complications during balloon dilation under general anesthesia should be carefully observed and managed.

Specific questionnaire detects a high incidence of intra-operative hypersensitivity reactions

OBJECTIVE: To assess the incidence of intra-operative immediate hypersensitivity reactions and anaphylaxis. METHODS: A cross-sectional observational study was conducted at the Department of Anesthesiology, University of São Paulo School of Medicine, Hospital das Clínicas, São Paulo, Brazil, from January to December 2010. We developed a specific questionnaire to be completed by anesthesiologists. This tool included questions about hypersensitivity reactions during anesthesia and provided treatments. We included patients with clinical signs compatible with immediate hypersensitivity reactions. Hhypersensitivity reactions were categorized according to severity (grades I-V). American Society of Anesthesiologists physical status classification (ASA 1-6) was analyzed and associated with the severity of hypersensitivity reactions. RESULTS: In 2010, 21,464 surgeries were performed under general anesthesia. Anesthesiologists answered questionnaires on 5,414 procedures (25.2%). Sixty cases of intra-operative hypersensitivity reactions were reported. The majority patients (45, 75%) had hypersensitivity reactions grade I reactions (incidence of 27.9:10,000). Fifteen patients (25%) had grade II, III or IV reactions (intra-operative anaphylaxis) (incidence of 7:10,000). No patients had grade V reactions. Thirty patients (50%) were classified as ASA 1. The frequency of cardiovascular shock was higher in patients classified as ASA 3 than in patients classified as ASA 1 or ASA 2. Epinephrine was administered in 20% of patients with grade III hypersensitivity reactions and in 50% of patients with grade II hypersensitivity reactions. CONCLUSIONS: The majority of patients had hypersensitivity reactions grade I reactions; however, the incidence of intra-operative anaphylaxis was higher than that previously reported in the literature. Patients with ASA 3 had more severe anaphylaxis; however, the use of epinephrine was not prescribed in all of these cases. Allergists and anesthesiologists should implement preventive measures to reduce the occurrence of anaphylaxis.

Traqueostomía percutánea por dilatación sin broncoscopía: Experiencia en la Unidad de Terapia Intensiva del Insttuto Guatemalteco de Seguridad Social / Percutaneos dilatatonal tracheostomy without fber optc bronchoscopy. Experience at Intensive Care Unit

Introducción: La traqueostomía percutánea es un procedimiento frecuente en la Unidad de Terapia Intensiva indicado en el manejo del paciente críticamente enfermo que requiere ventilación mecánica prolongada. El objetivo del estudio es describir la experiencia de traqueostomía percutánea sin broncoscopía, utilizando la técnica Ciaglia Blue Rhino en la unidad de terapia intensiva del IGSS. Métodos: Estudio descriptvo, observacional, longitudinal y analítco, incluyendo a 42 pacientes críticos ingresados a UTIA del Instituto Guatemalteco de Seguridad Social, a los que se realizó traqueostomía percutánea durante un periodo de 12 meses (Febrero 2016 a Febrero 2017). Se registraron variables demográficas, de severidad, días de ventilación mecánica antes del procedimiento y las complicaciones. Resultados: Se reclutaron 42 pacientes con una edad media de 68 años, con predominio del sexo masculino (28 pacientes). La media de puntuación del Sofa Score fue de 9.3 puntos. Los pacientes requirieron en promedio 13.4 días de ventilación mecánica antes del procedimiento. El 9.53% de pacientes presentaron complicaciones transoperatorias siendo estas: punción inadvertida del tubo orotraqueal (2 casos) y sangrado autolimitado del sito de la traqueostomía (2 casos). Mientras que el 4.76% presentaron complicaciones post-operatorias. Conclusiones: La traqueostomía percutánea por dilatación sin broncoscopía mediante la técnica Ciaglia Blue Rhino es un procedimiento seguro, que se puede realizar al pie de la cama del paciente, con un bajo índice de complicaciones.

Background: Percutaneos dilatatonal tracheostomy techniques have facilitated the procedure in the Intensive Care Unit. The purpose of the study is to describe our experience using this technique, in the ICU. Methods: We collected data from forty two patents during a year. The demographic variables were recorded, also we reviewed the severity of illness, number of days of mechanical ventlaton prior to the procedure, intraoperatve and postoperatve complicatons as well. Results: Forty two patents were included, mean age was 68 years old, most of them were men (28 patents). The mean Sofa Score was 9.3 points. In average, the patents requiered 13.4 days of mechanical ventlaton prior to the perutaneos dilatatonal tracheostomy. In two patents the endotracheal tube was accidentally punctured and two patents had self-limited bleeding at the surgical site. None of the complications were life-threatng to the patents. Conclusions: Percutaneos dilatatonal tracheostomy techniques using the Ciaglia Blue Rhino technique without fber optc bronchoscope is an easy procedure with a low incidence of complications.

Lesiones iatrogénicas de las vías biliares / Iatrogenic lesions of the biliary tract

Las lesiones iatrogénicas de las vías biliares (LIVB) representan una complicación quirúrgica grave de la colecistectomía laparoscópica (CL). Ocurre frecuentemente cuando se confunde el conducto biliar con el conducto cístico; y han sido clasificados por Strasberg y Bismuth, según el grado y nivel de la lesión. Alrededor del tercio de las LIVB se reconocen durante la CL, al detectar fuga biliar. No es recomendable su reparación inmediata, especialmente cuando la lesión está próxima a la confluencia o existe inflamación asociada. El drenaje debe establecerse para controlar la fuga de bilis y prevenir la peritonitis biliar, antes de transferir al paciente a un establecimiento especializado en cirugía hepatobiliar compleja. En pacientes que no son reconocidos intraoperatoriamente, las LIVB manifiestan tardíamente fiebre postoperatoria, dolor abdominal, peritonitis o ictericia obstructiva. Si existe fuga biliar, debe hacerse una colangiografía percutánea para definir la anatomía biliar y controlar la fuga mediante stent biliar percutáneo. La reparación se realiza seis a ocho semanas después de estabilizar al paciente. Si hay obstrucción biliar, la colangiografía y drenaje biliar están indicados para controlar la sepsis antes de la reparación. El objetivo es restablecer el flujo de bilis al tracto gastrointestinal para impedir la formación de litos, estenosis, colangitis y cirrosis biliar. La hepáticoyeyunostomía con anastomosis en Y de Roux termino-lateral sin stents biliares a largo plazo, es la mejor opción para la reparación de la mayoría de las lesiones del conducto biliar común.

Iatrogenic bile duct injuries (IBDI) represent a serious surgical complication of laparoscopic cholecystectomy (LC). Often it occurs when the bile duct merges with the cystic duct; and they have been ranked by Strasberg and Bismuth, depending on the degree and level of injury. About third of IBDI recognized during LC, to detect bile leakage. No immediate repair is recommended, especially when the lesion is near the confluence or inflammation is associated. The drain should be established to control leakage of bile and prevent biliary peritonitis, before transferring the patient to a specialist in complex hepatobiliary surgery facility. In patients who are not recognized intraoperatively, the IBDI manifest late postoperative fever, abdominal pain, peritonitis or obstructive jaundice. If there is bile leak, percutaneous cholangiography should be done to define the biliary anatomy, and control leakage through percutaneous biliary stent. The repair is performed six to eight weeks after patient stabilization. If there is biliary obstruction, cholangiography and biliary drainage are indicated to control sepsis before repair. The ultimate aim is to restore the flow of bile into the gastrointestinal tract to prevent the formation of calculi, stenosis, cholangitis and biliary cirrhosis. Hepatojejunostomy with Roux-Y anastomosis termino-lateral without biliary stents long term, is the best choice for the repair of most common bile duct injury.

Técnica con indocianina verde (ICG) como predictor de la falla de sutura: inicio de la experiencia en nuestro medio / Technical indocyanine green (ICG) as a predictor of suture failure

Objetivo: Valorar en el intraoperatorio en tiempo real, el flujo sanguíneo de los cabos anastomóticos y la anastomosis. El objetivo final de este trabajo busca que este sea el inicio de un estudio prospectivo, con el fin de auditar las anastomosis colónicas de forma intraoperatoria buscando así disminuir el número de fallas de suturas. Material y método: Se realizó un estudio prospectivo, observacional y descriptivo, desarrollado en el Hospital de Clínicas en el período comprendido entre enero de 2014 y julio 2015. Se incluyeron en el mismo pacientes sometidos a resección de colon y reconstrucción primaria del tránsito intestinal de coordinación. El indocianina verde (ICG) se empleó como colorante vital fluorescente para la valoración in situ de la anastomosis colónica. La presencia de falla de sutura en el postoperatorio en relación con la perfusión anastomótica objetivada con ICG constituye un parámetro de importancia en nuestro estudio. Resultados: En lo referente a la perfusión de la anastomosis, destacamos que en el primer caso la misma fue sensiblemente inferior en el cabo colónico, en tanto que en los 2 casos restantes la vascularización de los cabos fue óptima. Conclusiones: La técnica con ICG constituye una herramienta apropiada para poder auditar la calidad de las anastomosis intestinales realizadas de coordinación. Se trata de una técnica segura, aplicable en nuestro medio. Siendo un predictor de falla de sutura, permite un descenso de la morbimortalidad postoperatoria por esta causa.

Aim: Rate intraoperatively in real time, blood flow and ends anastomotic and anastomosis. The ultimate goal of this work seeks to make this the beginning of a prospective study in order to audit the colonic anastomosis intraoperatively and seeking to reduce the number of sutures failure. Material and method: A prospective, observational and descriptive study, to be held in the Clinics Hospital in the period between January 2014 and July 2015. They were included in the same patients undergoing resection of colon and intestinal transit reconstruction on primary coordination. Indocyanine green (ICG) was used as a fluorescent vital dye for in situ evaluation of colonic anastomosis. The presence of failure postoperative suture relative to the anastomotic objectified perfusion with ICG, is an important parameter in our study.Results:Regarding the perfusion of the anastomosis, in the first case it was significantly lower than in the colonic out. While in the remaining two cases the vascularization of the ends was optimal. Conclusions: The technique with indocyanine green is an appropriate tool to audit the quality of intestinal anastomoses performed coordination.

ST-segment elevation during general anesthesia for non-cardiac surgery: a case of takotsubo / Supradesnivelamento do segmento ST durante anestesia geral para cirurgia não cardíaca: um caso de takotsubo

ABSTRACTBACKGROUND AND OBJECTIVES: Takotsubo cardiomyopathy, also known as broken heart syndrome is a stress-induced cardiomyopathy, which can be interpreted as an acute coronary syndrome as it progresses with suggestive electrocardiographic changes. The purpose of this article is to show the importance of proper monitoring during surgery, as well as the presence of an interdisciplinary team to diagnose the syndrome.CASE REPORT: Male patient, 66 years old, with diagnosis of gastric carcinoma, scheduled for diagnostic laparoscopy and possible gastrectomy. In the intraoperative period during laparoscopy, the patient always remained hemodynamically stable, but after conversion to open surgery he presented with ST segment elevation in DII. ECG during surgery was performed and confirmed ST-segment elevation in the inferior wall. The cardiology team was contacted and indicated the emergency catheterization. As the surgery had not yet begun irreversible steps, we opted for the laparotomy closure, and the patient was immediately taken to the hemodynamic room where catheterization was performed showing no coronary injury. The patient was taken to the hospital room where an echocardiogram was performed and showed slight to moderate systolic dysfunction, with akinesia of the mid-apical segments, suggestive of apical ballooning of the left ventricle. Faced with such echocardiographic finding and in the absence of coronary injury, the patient was diagnosed with intraoperative Takotsubo syndrome.CONCLUSION: Because the patient was properly monitored, the early detection of ST-segment elevation was possible. The presence of an interdisciplinary team favored the syndrome early diagnosis, so the patient was again submitted to safely intervention, with the necessary security measures taken for an uneventful new surgical intervention.

RESUMOJUSTIFICATIVA E OBJETIVOS: A cardiomiopatia de takotsubo, também conhecida como síndrome do coração partido, é uma cardiomiopatia induzida por estresse que pode ser interpretada como uma síndrome coronária aguda, pois cursa com alterações eletrocardiográficas sugestivas. O objetivo do presente artigo é mostrar a importância de uma monitoração adequada no intraoperatório, assim como a presença de uma equipe interdisciplinar para o diagnóstico da síndrome.RELATO DE CASO: Doente masculino, 66 anos, com o diagnóstico de carcinoma gástrico, proposto para laparoscopia diagnóstica e possível gastrectomia. No intraoperatório durante a laparoscopia manteve sempre estabilidade hemodinâmica, porém após a conversão para cirurgia aberta apresentou elevação do segmento ST em DII e foi feito um ECG no intraoperatório que confirmou supradesnivelamento do segmento ST em parede inferior. Foi contactada a equipe de cardiologia, que indicou cateterismo de urgência. Como a cirurgia ainda não havia iniciado passos irreversíveis, optou-se pelo encerramento da laparotomia e o doente foi levado imediatamente para a sala de hemodinâmica. Foi feito cateterismo que não evidenciou lesão nas coronárias. O doente foi levado para o internamento, onde foi feito um ecocardiograma que mostrava disfunção sistólica ligeira a moderada, com acinésia dos segmentos médio-apicais, imagem sugestiva de balonamento apical do ventrículo esquerdo. Diante de tal achado ecocardiográfico e na ausência de lesões coronárias, foi diagnosticada síndrome de takotsubo intraoperatória.CONCLUSÃO: Devido ao fato de o doente estar monitorado de uma forma adequada foi possível a detecção precoce do supradesnivelamento do segmento ST. A presença de uma equipe interdisciplinar favoreceu o diagnóstico precoce da síndrome. Dessa forma o doente foi novamente intervencionado de forma segura e foram tomadas as devidas medidas de segurança, para que a nova intervenção cirúrgica transcorresse sem intercorrências.

Perioperative anaphylaxis / Anafilaxia perioperatória / Anafilaxia perioperatoria

Anaphylaxis remains one of the potential causes of perioperative death, being generally unanticipated and quickly progress to a life threatening situation. A narrative review of perioperative anaphylaxis is performed.

A anafilaxia continua sendo uma das causas potenciais de morte perioperatória, pois geralmente não é prevista e evolui rapidamente para uma situação ameaçadora da vida. Uma revisão da anafilaxia perioperatória é feita.

La anafilaxia sigue siendo una de las causas potenciales de muerte perioperatoria por ser generalmente no anticipada, y progresar rápidamente a una situación amenazante de la vida. Se realiza una revisión de la anafilaxia perioperatoria.

Perioperative latex hypersensitivity reactions: an integrative literature review / Hipersensibilidade ao látex no período perioperatório: revisão integrativa da literatura / Hipersensibilidad al latex en el peri-operatório: una revisión integradora de la literatura

This article characterizes hypersensitivity reactions during anesthetic-surgical procedures. This integrative literature review was conducted in the LILACS, CINAHL, COCHRANE and MEDLINE databases including papers published from 1966 to September 2011. A total of 17 case reports, two prevalence studies and one cohort study were identified. Latex reactions were mainly type III and the primary source of intraoperative reaction was latex gloves. The average time for clinical manifestation was 59.8 minutes after anesthetic induction; 44.4% of patients reported a reaction to latex at the pre-anesthetic evaluation. It was determined that the history of allergic reactions to latex obtained in the pre-anesthetic evaluation does not ensure the safety of patients if the staff is inattentive to the severity of the issue. There is also a tendency to initially attribute the anaphylactic event to the anesthetic drugs.

Este estudo teve por objetivo caracterizar as reações de hipersensibilidade ao látex em procedimentos anestésico-cirúrgicos. Foi realizada revisão integrativa da literatura nas bases LILACS, CINAHL, COCHRANE e MEDLINE, com seleção de artigos publicados em periódicos indexados de 1966 a setembro de 2011. Foram identificados 17 relatos de caso, dois estudos de prevalência e um de coorte. As reações ao látex foram majoritariamente do tipo III, e a principal fonte desencadeadora de reações no intraoperatório foram as luvas de látex; o tempo médio para manifestação da reação foi de 59,8 minutos após a indução anestésica; 44,4% dos pacientes relataram episódio de reação ao látex na avaliação pré-anestésica. Identificou-se que a história de episódios de reações a materiais de borracha, ou alimentos, na avaliação pré-anestésica não garante a segurança dos pacientes, se o profissional não estiver alerta à gravidade do problema; no caso de ocorrência de um evento anafilactoide, os profissionais tendem a suspeitar inicialmente dos medicamentos anestésicos.

Este estudio tuvo como objetivo caracterizar las reacciones de hipersensibilidad al látex en la anestesia. Ha sido realizada una revisión integradora de la literatura en LILACS, CINAHL, COCHRANE y MEDLINE, con una selección de artículos publicados en periódicos indexados de 1966 hasta septiembre 2011. Fueron identificados 17 casos clínicos, 2 estudios de prevalencia y 1 de la cohorte. Las reacciones al látex fueron en su mayoría del tipo III y la principal fuente de reacción intra-operatoria fue el contacto con los guantes de látex. El tiempo medio hasta la aparición de respuesta fue de 59.8 minutos después de la inducción, 44,4% de los pacientes informaron una reacción al látex en el periodo pre-anestésico. La historia de reacciones alérgicas al látex en el periodo pre-anestésico no garantiza la seguridad de los pacientes si el profesional no está atento a la gravedad del problema. Al principio, se tiende a atribuir que el efecto de la anafilaxia se debe a los medicamentos anestésicos.

Lesões de pele no intra-operatório de cirurgia cardíaca: incidência e caracterização / Skin lesions in the intraoperative period of cardiac surgery: incidence and characterization / Lesiones de piel en el intraoperatorio de cirugía cardíaca: incidencia y caracterización

Neste estudo exploratório, descritivo e de coorte o objetivo principal foi verificar a incidência de pacientes submetidos à cirurgia cardíaca que desenvolveram lesões de pele no período intra-operatório, caracterizar as lesões. A coleta de dados foi realizada no Centro Cirúrgico (CC) de um hospital público de ensino, de atenção terciária à saúde, predominantemente cirúrgico, especializado em cardiologia no Município de São Paulo. A amostra do estudo foi de 182 pacientes. O estudo foi feito com um p significativo (<0,05) frente aos testes estatísticos não-paramétricos. Quanto à incidência de pacientes submetidos à cirurgia cardíaca, que desenvolveram lesões de pele em decorrência do período intra-operatório, obteve-se incidência de 20,9 por cento. Tivemos que 19,2 por cento das lesões apresentaram-se como Úlceras por Pressão (UP) no estágio I; 1,1 por cento das lesões caracterizaram-se como abrasão; 1,1 por cento feridas incisas; 0,5 por cento laceração; 0,5 por cento queimadura elétrica superficial e 0,5 por cento UP no estágio II.

The main objective of this exploratory, descriptive cohort study was to verify the incidence of patients submitted to cardiac surgery who developed skin lesions during the intraoperative period, and characterize the lesions. Data collection was performed at the Surgery Department of a public teaching hospital, of tertiary health care, mostly surgical, specialized in cardiology, and located in São Paulo. The study sample consisted of 182 patients. The study was performed with a significant p (<0.05) in nonparametric statistical tests. The incidence found for patients submitted to cardiac surgery who developed skin lesions due to the preoperative period was 20.9 percent. It was observed that 19.2 percent of lesions were Pressure Ulcers (PU) in stage I; 1.1 percent of lesions were abrasive; 1.1 percent incisive; 0.5 percent lacerative; 0.5 percent superficial electrical burns; and 0.5 percent PU in stage II.

Estudio exploratorio, descriptivo y de corte, que objetivó principalmente verificar la incidencia de pacientes sometidos a cirugía cardíaca que desarrollaron lesiones de piel en período intraoperatorio, y caracterizar tales lesiones. Recolección de datos realizada en Centro Quirúrgico (CC) de hospital público de enseñanza, de atención terciaria de salud, predominantemente quirúrgico, especializado en cardiología, del municipio de San Pablo. La muestra se constituyó con 182 pacientes. El estudio se realizó con un p significativo (<0,05) frente a tests estadísticos no paramétricos. Respecto a incidencia de pacientes sometidos a cirugía cardíaca que desarrollaron lesiones de piel derivadas del período intraoperatorio, se obtuvo incidencia de 20,9 por ciento. El 19,2 por ciento de las lesiones se presentaron como Úlcera por Presión (UP) en estadío I; 1,1 por ciento de las lesiones correspondieron a abrasión; 1,1 por ciento a heridas por incisión; 0,5 por ciento laceraciones; 0,5 por ciento quemadura eléctrica superficial y 0,5 por ciento UP en estadío II.

C-Reactive protein predicts acute myocardial infarction during high-risk noncardiac and vascular surgery

BACKGROUND: High-sensitivity C-reactive protein predicts cardiovascular events in a wide range of clinical contexts. However, the role of high-sensitivity C-reactive protein as a predictive marker for perioperative acute myocardial infarction during noncardiac surgery is not yet clear. The present study investigated high-sensitivity C-reactive protein levels as predictors of acute myocardial infarction risk in patients undergoing high-risk noncardiac surgery. METHODS: This concurrent cohort study included patients aged >50 years referred for high-risk noncardiac surgery according to American Heart Association/ACC 2002 criteria. Patients with infections were excluded. Electrocardiograms were performed, and biomarkers (Troponin I or T) and/or total creatine phosphokinase and the MB fraction (CPK-T/MB) were evaluated on the first and fourth days after surgery. Patients were followed until discharge. Baseline high-sensitivity C-reactive protein levels were compared between patients with and without acute myocardial infarction. RESULTS: A total of 101 patients undergoing noncardiac surgery, including 33 vascular procedures (17 aortic and 16 peripheral artery revascularizations), were studied. Sixty of the patients were men, and their mean age was 66 years. Baseline levels of high-sensitivity C-reactive protein were higher in the group with perioperative acute myocardial infarction than in the group with non-acute myocardial infarction patients (mean 48.02 vs. 4.50, p = 0.005). All five acute myocardial infarction cases occurred in vascular surgery patients with high CRP levels. CONCLUSIONS: Patients undergoing high-risk noncardiac surgery, especially vascular surgery, and presenting elevated baseline high-sensitivity C-reactive protein levels are at increased risk for perioperative acute myocardial infarction.

Intraoperative myocardial ischemia during renal transplantation caused by anomalous origin of the right coronary artery.

Anomalous origin of the right coronary artery (AORCA) is a rare congenital anomaly with an incidence of 0.92% during routine cardiac catheterization. Its presence raises an important concern to the anaesthesiologist because it can lead on to myocardial ischaemia manifesting as either angina pectoris or myocardial infarction, or sudden death in young patients with minimal exertion, even in the absence of atherosclerosis. Patients with AORCA may be intolerant to stress and the high cardiac output condition owing to volume loading. Such a therapeutic manoeuvre may be desirable during renal transplantation to enable better perfusion of the renal graft immediately after grafting the kidney, in order to improve its function. Hence, haemodynamic goals in renal transplant recipient with AORCA can be contradictory during surgery, thereby rendering anaesthetic management challenging. We report a case of acute myocardial ischemia precipitated by fluid loading conditions in a patient with AORCA during renal transplant that was successfully treated with emergent intra-aortic balloon pump therapy intraoperatively. Judicious intraoperative fluid replacement is recommended, and volume overload must be avoided in AORCA patients undergoing surgery.

Factores de riesgo asociados a lesión de vias urinarias en pacientes sometidas a histerectomía en el servicio de ginecologia del Hospital Bertha Calderon Roque en el periodo comprendido entre enero 2003 a diciembre 2007 / Risk factors associated with urinary tract injury in patients undergoing hysterectomy in the service ginecologia Hospital Bertha Calderon Roque in the period January 2003 to December 2007

Dado la frecuencia de lesión de vías urinarias posterior a histerectomía en el Hospital Bertha Calderón Roque, decido realizaer el presente estudio, teniendo como objetivo general conocer cuales son los factores de riesgo asociados a Lesión de vías urinarias en pacientes sometidas a histerectomía en el servicio de ginecología de este centro hospitalario. Se realizó un estudio, retrospectivo, caso - control, en el Hospital Bertha Calderón en el período de tiempo comprendido entre enero 2003 a diciembre 2007. Un total de 62 pacientes fueron estudiadas, 31 fueron aquellas que su cirugía se complicó con una lesión del tracto urinario y las 31 restantes pacientes del grupo control sin lesión de vías urinarias. Y se estudiaron todos aquellos factores de riesgo descritos en la literatura internacional para este tipo de lesiones...

Evaluación del riesgo cardiovascular en cirugía no cardíaca / Assessment of cardiovascular risk in non-cardiac surgery

Antes de someter al paciente a una cirugía no cardiaca es necesario establecer el riesgo cardiovascular, ya que gran parte de las complicaciones como angina inestable, infarto, insuficiencia cardiaca y muertes ocurridas en el perioperatorio, pueden ser evitadas mediante la adecuada valoración del riesgo cardiológico del paciente, en función de la intervención a la que será sometido. La frecuencia creciente de la cirugía en pacientes mayores, quienes suelen tener una importante prevalencia de patología cardiovascular, plantea el desafío de evaluar cada vez en mejor forma su reserva funcional previo a soportar el estrés quirúrgico y anestésico.

Vitreous loss during phacoemulsification learning curve performed by third-year residents.

OBJECTIVES: To assess the resident's phacoemulsification learning curve as a risk factor for vitreous loss and to determine the incidence of vitreous loss among the residents performing phacoemulsification. DESIGN: Retrospective matched case-control study MATERIAL AND METHOD: A case-control study comparing all consecutive cases of attempted phacoemulsification with intraocular lens (IOL) implantation from January 1st, 1998 to December 31st, 1999. The surgeon variable will be categorized into two groups, the third year ophthalmology residents, representing resident's phacoemulsification learning curve, and faculty staffs. The study group consisted of eyes that had had intraoperative complication of vitreous loss. The control group consisted of eyes that had not had vitreous loss. Continuous variables were compared with the 2-sided unpaired t-test. Categorical variables were compared between groups using analytical matched case-control study with relative risk or odd ratio, Mc Nemar's (Marginal) o 2 test and 95% confident interval of relative risk. RESULTS: The odds that the eyes in the resident group would have an intraoperative complication of vitreous loss were 4 times the odds that the eyes in the faculty staff group would have such complication (P = 0.0052, 95% confidential interval (CI) of relative risk (RR) = 1.516-10.556). The incidence of vitreous loss among residents was 6.93% (28/404) and 2.06% (28/1358) among the faculty staffs. The overall incidence of vitreous loss was 3.18% (56/1762). CONCLUSION: The incidence of intraoperative complication of vitreous loss, the relative risk of such complication performed by the learning curve surgeon in the present study serve as benchmarks for residents-in-training, beginning and surgeon-in-practice converting to phacoemulsification.