Disfunción cognitiva postoperatoria / Postoperative cognitive dysfunction

Cognitive function may decline after surgical procedures. Cognitive postoperative dysfunction (CPOD) is subtle and requires neuropsychological test for diagnosis. Multifactorial in origin, its cause is unknown but associated with different risk factors, which especially affects origin people submitted to extense surgery. CPOD is transient, but in some cases is prolonged and is associated with an increase in mortality and permanente disability. The aging population and the increase of elderly patients requiring surgery a cause of concern. Clinical studies are required to recognize preventive and therapeutic measures to reduce CPOD in the future. (AU)

Déficit de vitamina D. Revisión epidemiológica actual / Vitamin D deficiency. Current epidemiological review

Vitamin D is a liposoluble hormone that exists in two molecular forms. Ergocalciferol (vitamin D-2) and colecalciferol (vitamin D-3). Vitamin D-3 is produced in the skin by the action of UV-B radiation. Both forms are metabolized by the liver to 25-hydroxy-Vit D (25OHD) and later in the kidney to the active form 1,25-dihydroxy-Vit D. This form promotes bone mineralization by intestinal absorption of calcium and phosphate. Normal levels of 25OHD are associated with less fracture, normal neuromuscular and immune function and possibly have a preventive effect on certain types of cancer. The Endocrine Society's Clinical Practice Guidelines recommends that optimal plasma levels of 25OHD are above 30 ng/ml, insufficiency between 21 and 29 ng/ml and deficiency below 20 ng/ml. The prevalence rate of 25OHD deficit is about 2 to 90% in different populations. Risk factors of Vitamin D deficit like year season, skin pigmentation, sunlight exposition, use of sunblock and inadecuate Vitamin D ingestion, together with different measurement techniques explain the variability of results between epidemiological studies. An important risk group is the health professionals that are not exposed to sunlight. There are no studies that describe the prevalence in this population in Chile. (AU)

Anestesia local vs anestesia espinal en hernioplastia inguinal: comparación de efecto anestésico postoperatorio / Local anestesia vs spinal anestesia in inguinal hernioplasty: comparison of the postsurgical anesthetic effect

La literatura sugiere que la anestesia local preinjuria tisular bloquería algunas aferencias del dolor y modularía la intensidad de éste, favoreciendo una evolución postoperatoria con un menor requerimiento de analgesia. Se evaluó y comparó el efecto analgésico postoperatorio y el grado de aceptabilidad de la técnica anestésica por parte del paciente en hernioplastia inguinal, utilizando anestesia local v/s anestesia espinal. La técnica quirúrgica fue la reparación anatómica del piso inguinal y colocación de prótesis sin nidos de hernia inguinal primaria unilateral. La técnica anestésica empleada se definió por sorteo: local por infiltración o espina. Grupo A: anestesia local por infiltración, la que fue realizad por el cirujano operador, con bupivacaína (hasta 2 m/kg) y lidocaína (hasta 4 mg/kg). Grupo B. anestesia espinal, en L2-L3 con intensidad del dolor, pasivo (en reposo) y activo (al toser o sentarse) con una escala verbal análoga (EVA), la que se expresara en valores de 1 a 10. Se efectuaron mediciones a las 4,8,12 y 24 horas de realizadas la anestesia. En términos de evacuación del dolor, éste es menor en el grupo que recibió anestesia local, comparado con el grupo que recibió anestesia espinal, a las 8, 12 y 24 horas. Esta diferencia alcanzó significación estadística, especialmente en el dolor activo

[Implantable defibrillators in the management of malignant ventricular tachyarrhythmias. Experience at the Arrhythmia National Center]. / Desfibrilador implantable en el manejo de taquiarritmias ventriculares malignas. Experiencia del Centro Nacional de Arritmias.

BACKGROUND: Implantable defibrillators are the most effective means to prevent sudden death in patients with malignant ventricular tachyarrhythmias. The availability of this type of devices is limited in Chile, due to their high price. AIM: To report the first patients treated with implantable defibrillators in our hospital. PATIENTS AND METHODS: Nine males and one female aged 13 to 65 years old are reported. Three presented with ventricular fibrillation (presenting out of the hospital in three) and the rest had ventricular tachycardia resistant to drugs or radiofrequency ablation. RESULTS: All implants were performed using intracardiac electrodes. The generator was implanted in the pectoral region in nine and in the abdomen in one. A successful defibrillation was obtained with less than 15 J in four patients, with 20 J in three and with 24 J in three. There were no complications during the procedure. After a 12 months follow up, four patients have been treated by the implantable device. One of these subjects had a ventricular fibrillation in two occasions. One patient died of a bronchopneumonia two years after the implant. CONCLUSIONS: Implantable defibrillators are an effective therapy for the treatment of malignant ventricular arrhythmias with a high risk of sudden death.

[Extracorporeal membrane oxygenation in adult respiratory distress syndrome. Experience in 2 patients]. / Oxigenación extracorpórea de membrana en sindrome de distrés respiratorio del adulto. Experiencia en 2 pacientes.

We report two female patients with adult respiratory distress syndrome and severe respiratory failure in whom extracorporeal membrane oxygenation was used. Its indication was due to a bad response to conventional treatment with mechanical ventilation and high levels of positive end expiratory pressure. A 2.0 or 2.2 m2 membrane oxygenator in a veno-venous circuit with systemic anticoagulation was used, maintaining mechanical ventilation. In the first patient, the procedure was done early and was successful, increasing hemoglobin saturation from 39 to 87%. The patient was withdrawn from the procedure 48 hours later and died one week later due to a septic shock. The second patient was connected to the procedure after three weeks of respiratory distress syndrome and no increase in arterial oxygenation was achieved. The patient died due to an intracranial hemorrhage, probably hastened by systemic anticoagulation. The real benefits of extracorporeal membrane oxygenation are not defined yet.

Revascularización miocárdica en un paciente con calcificación de la aorta ascendente y arco aórtico: aorta de porcelana / Myocardial revascularization in a patient with calcification of ascending aorta and aortic arch: porcelain aorta

El hallazgo de una aorta ascendente intensamente calcificada (aorta de porcelana) durante la cirugía de revascularización miocárdica ofrece dificultades tanto en la decisión de llevar a cabo la cirugía como en la elevada frecuencia de complicación neurológica que esta condición acarrea. Se presenta el caso de un paciente de 59 años operado de urgencia por una angina posinfarto miocárdico grave y en quien se encontró una aorta ascendente y arco aórtico totalmente calcificados. Enfrentados a esta situación se decidió efectuar una revascularización miocárdica utilizando perfusión arterial por vía femoral, cánula única cavoatrial y uso de un drenaje aurículo ventricular. Así, enfriando a 25º C y durante fibrilación ventricular espontánea se construyeron anastomosis distales con vena safena a la arteria circunfleja y arteria mamaria interna (AMI) a la arteria descendente anterior. Luego de defibrilar el corazón se efectuó la anastomosis venosa terminolateral a la AMI. El paciente fue retirado de bomba con bajo apoyo y completó un postopertorio sin incidentes. Una ecocardiografía transesofágica postoperatoria reveló la extensión y magnitud de la aterosclerosis en la aorta

Oxigenación extracorpórea de membrana en síndrome de distrés respiratorio del adulto: experiencia en 2 pacientes / Extracorporeal oxygenation of membrane in adult distress respiratory syndrome: experience in 2 patients

We report 2 female patients with adult respiratory distress syndrome and severe respiratory failure in whom extracorporeal membrane oxygenation was used. Its indication was due to a bad response to conventional tretament with mechanical ventilation and high levels of positive end expiratory pressure. A 2.0 or 2.2 m2 membrane oxygenator in a veno-venous circuit with systemic anticoagulation was used, maintaining mechanical ventilation. In the first patient, the procedure was done early and was succesful, increasing hemoglobin saturation from 39 to 87 percent. The patient was withdrawn from the procedure 48 hours later and died one week later due to a septic shock. The second patient was connected to the procedure after three weeks of respiratory distress syndrome and no increase in arterial oxygenation was achieved. The patient died due to an intracraneal hemorrhage, probably hastened by systemic anticoagulation. The real benefits of extracorporeal membrane oxygenation are not defined yet