Respuesta al artículo de réplica "Tromboprofilaxis en cirugía cardíaca" / No disponible

No disponible

Utilización intraoperatoria de factor FVII activado recombinante (RFVIIA) en el paciente neurooncológico / No disponible

No disponible

Sustitución valvular en un paciente con enfermedad de Chagas. Consideraciones anestésicas / No disponible

No disponible

Complicaciones perianestésicas en una paciente con osteomalacia no conocida secundaria a cirugía bariátrica previa / Perianesthetic complications in a woman with undiagnosed osteomalacia secondary to earlier gastric bypass surgery

No disponible

No disponible

[Cardiovascular and respiratory complications after pneumonectomy]. / Complicaciones cardiovasculares y respiratorias postneumonectomía.

Thoracic surgery has made important progress thanks to parallel advances in anesthetic techniques, which have lowered mortality and complication rates. Pneumonectomy, however, continues to carry a high risk of perioperative death and morbidity, with complications involving the heart and lung being the most common. Pneumonectomy requires careful preoperative assessment to identify patients at high risk of cardiac complications. However, there is no evidence available on the best approach to take in determining risk of impaired lung function after pneumonectomy. Postoperative arrhythmias increase mortality, although evidence does not suggest a need for systematic prophylactic treatment of patients who will undergo lung resection. The incidence of acute myocardial infarction ranges from 1.5% to 5% and diagnosis is difficult because most episodes are silent. The incidence of post-pneumonectomy pulmonary edema is between 4% and 7% and evidence indicates that prevention is the most important therapeutic measure. Patients tend to have greater risk of pneumonia after thoracotomy, but few studies have provided a high level of evidence for the usefulness of antibiotic prophylaxis in chest surgery. The aim of the present study was to review the literature on the most common complications of surgery on the lung in order to support decision making based on the integration of knowledge and clinical judgment acquired with experience. A MEDLINE search was carried out to locate studies published from 1980 through January 2005.

Complicaciones cardiovasculares y respiratorias postneumonectomía / Cardiovascular and respiratory complications after pneumonectomy

La cirugía torácica ha experimentado un importante desarrollo, gracias a la evolución paralela de las técnicas anestésicas, que han permitido disminuir la morbimortalidad; sin embargo, las neumonectomías continúan asociadas con elevado riesgo de morbimortalidad perioperatoria, siendo las complicaciones de origen pulmonar y cardíaco las principales responsables. La neumonectomía requiere una evaluación preoperatoria minuciosa, que nos permita identificar a los pacientes con alto riesgo de sufrir complicaciones cardíacas; sin embargo no existe evidencia sobre cuál es la mejor medida para determinar el riesgo de la función pulmonar postneumonectomía. Las arritmias postoperatorias incrementan la mortalidad, aunque la evidencia no indica la necesidad de realizar tratamiento profiláctico sistemático de los pacientes que vayan a someterse a resección pulmonar. La incidencia de infarto agudo de miocardio postneumonectomía varía entre 1,5-5% y su diagnóstico es muy difícil porque la mayoría de los episodios son silentes. La incidencia de edema de pulmón postneumonectomía es de 4-7% y la evidencia nos indica que lo más importante del tratamiento del edema pulmonar postneumonectomía es la prevención. Los pacientes post-toracotomía tienen mayor tendencia a la infección pulmonar; sin embargo existen pocos estudios con alto grado de evidencia acerca de la utilidad de la profilaxis antibiótica en cirugía torácica. El objetivo de este trabajo es realizar una revisión de la literatura médica existente sobre las complicaciones, más frecuentes, postneumonectomía, que nos permita tomar decisiones fundamentadas en la interacción del conocimiento y juicio clínico individual adquirido a través de la experiencia clínica diaria. Para ello se realizó una búsqueda bibliográfica en MEDLINE buscando las evidencias disponibles en el periodo de tiempo desde 1980 hasta enero de 2005

Thoracic surgery has made important progress thanks to parallel advances in anesthetic techniques, which have lowered mortality and complication rates. Pneumonectomy, however, continues to carry a high risk of perioperative death and morbidity, with complications involving the heart and lung being the most common. Pneumonectomy requires careful preoperative assessment to identify patients at high risk of cardiac complications. However, there is no evidence available on the best approach to take in determining risk of impaired lung function after pneumonectomy. Postoperative arrhythmias increase mortality, although evidence does not suggest a need for systematic prophylactic treatment of patients who will undergo lung resection. The incidence of acute myocardial infarction ranges from 1.5% to 5% and diagnosis is difficult because most episodes are silent. The incidence of postpneumonectomy pulmonary edema is between 4% and 7% and evidence indicates that prevention is the most important therapeutic measure. Patients tend to have greater risk of pneumonia after thoracotomy, but few studies have provided a high level of evidence for the usefulness of antibiotic prophylaxis in chest surgery. The aim of the present study was to review the literature on the most common complications of surgery on the lung in order to support decision making based on the integration of knowledge and clinical judgment acquired with experience. A MEDLINE search was carried out to locate studies published from 1980 through January 2005

[Comparison of gastric aspirate volume after intubation in patients with and without symptoms of gastroesophageal reflux disease]. / Comparación del volumen gástrico tras intubación entre pacientes con y sin síntomas de enfermedad por reflujo gastroesofágico.

OBJECTIVES: To compare the postintubation gastric aspirate volume of patients with and without symptoms of gastroesophageal reflux disease (GERD). METHODS: Prospective randomized study of 331 physical status ASA I-II adults scheduled for surgery. Patients with GERD symptoms (heartburn and regurgitation) were assigned to group A (n=83); asymptomatic patients (n=248) were assigned to groups B (n=85), C (n=70), and D (n=93). Group A was subdivided: group A1 received outpatients treatment for GERD and group A2 did not. Groups A, B, and C received prophylaxis with omeprazole 40 mg and metoclopramide 10 mg, respectively. Group D received no prophylaxis. Groups A and B patients received 1 mg x kg(-1) of succinylcholine, and groups C and D received 0.2 mg x kg(-1) of cisatracurium. After intubation, gastric content was aspirated and measured. The results were compared with Pearson's chi2 and Student t tests, analysis of variance, and Kruskal-Wallis and Mann-Whitney U tests. RESULTS: The gastric aspirate volumes in each group were as follows: 36.6 (SD 5) mL in group A; 9.98 (4.9) mL in group B; 10.8 (5.5) mL in group C; 15.62 (6.3) mL in group D; 32.7 (5.1) mL in group A1; and 39.08 (3.6) mL in group A2. Volumes were significantly greater in group A than in groups B, C, and D (P<0.0001), and in subgroup A2 than in subgroup A1 (P<0.001). The percentages of patients from whom a volume greater than 25 mL was aspirated in each group were as follows: 98.9% of group A, 1.2% of group B, 2.8% of group C, and 8.6% of group D (P<0.001). CONCLUSION: Patients with chronic heartburn and regurgitation have greater postintubation gastric aspirate volumes than do asymptomatic patients, attributable to the gastroesophageal motility dysfunction characteristic of GERD that can favor aspiration. GERD questions should be included in preanesthetic medical history taking, and symptomatic patients should be prescribed outpatient proton pump inhibitor therapy.

Comparación del volumen gástrico tras intubación entre pacientes con y sin síntomas de enfermedad por reflujo gastroesofágico / Comparison of gastric aspirate volume after intubation in patients with and without symptoms of gastroesophageal reflux disease

OBJETIVOS: Comparar el volumen gástrico postintubación entre pacientes con y sin síntomas de enfermedad por reflujo gastroesofágico (ERGE). MÉTODOS: Estudio prospectivo, aleatorio en 331 adultos, ASA I-II, cirugía programada. Los pacientes sintomáticos para ERGE (pirosis y regurgitación) se asignaron al Grupo A (n=83); los asintomáticos (n=248) a los grupos B (n=85), C (n=70) y D (n=93). El grupo A se subdividió en A1: tomaban tratamiento ambulatorio para la ERGE y A2: sin tratamiento. Los grupos A, B y C recibieron profilaxis con omeprazol 40 mg y metoclopramida 10 mg, el grupo D no recibió profilaxis. Se administró 1 mg·Kg-1 de succinilcolina en los grupos A y B y 0,2 mg.Kg-1 de cisatracurio en los grupos C y D. Se aspiró y cuantificó el contenido gástrico postintubación. Los resultados se analizaron con las pruebas de χ2 de Pearson, t de Student, ANOVA, Kruskal-Wallis y U de Mann-Whitney. RESULTADOS: Los volúmenes de contenido gástrico aspirados en cada grupo fueron: A: 36,6 ± 5 ml, B: 9,98 ± 4,9 mL, C: 10,8 ± 5,5 mL, D: 15,62 ± 6,3 mL; A1: 32,7 ± 5,1 mL y A2: 39,08 ± 3,6 ml; fueron significativamente mayores en el grupo A que en los grupos B, C y D (p<0,0001); y en el subgrupo A2 respecto al A1 (p<0,001). El porcentaje de volumen gástrico mayor de 25 mL en cada grupo fue: A: 98,8%, B: 1,2%, C: 2,8% y D: 8,6% (p<0,001). CONCLUSIÓN: Los pacientes sintomáticos (pirosis y regurgitación habituales) presentan un volumen gástrico postintubación mayor que los asintomáticos, atribuible al trastorno motor esofagogástrico característico de la ERGE que puede favorecer la aspiración. La anamnesis sobre la ERGE debe realizarse en la consulta preanestésica y tratar a los pacientes sintomáticos con un inhibidor de la bomba de protones ambulatorio

OBJECTIVES: To compare the postintubation gastric aspirate volume of patients with and without symptoms of gastroesophageal reflux disease (GERD). METHODS: Prospective randomized study of 331 physical status ASA I-II adults scheduled for surgery. Patients with GERD symptoms (heartburn and regurgitation) were assigned to group A(n=83); asymptomatic patients (n=248) were assigned to groups B (n=85), C (n=70), and D (n=93). Group Awas subdivided: group A1 received outpatients treatment for GERD and group A2 did not. Groups A, B, and C received prophylaxis with omeprazole 40 mg and metoclopramide 10 mg, respectively. Group D received no prophylaxis. Groups A and B patients received 1 mg·kg-1 of succinylcholine, and groups C and D received 0.2 mg·kg-1 of cisatracurium. After intubation, gastric content was aspirated and measured. The results were compared with Pearson’s χ2 and Student t tests, analysis of variance, and Kruskal-Wallis and Mann-Whitney U tests. RESULTS: The gastric aspirate volumes in each group were as follows: 36.6 (SD 5) mL in group A; 9.98 (4.9) mL in group B; 10.8 (5.5) mL in group C; 15.62 (6.3) mL in group D; 32.7 (5.1) mL in group A1; and 39.08 (3.6) mL in group A2. Volumes were significantly greater in group A than in groups B, C, and D (P<0.0001), and in subgroup A2 than in subgroup A1 (P<0.001). The percentages of patients from whom a volume greater than 25 mL was aspirated in each group were as follows: 98.9% of group A, 1.2% of group B, 2.8% of group C, and 8.6% of group D (P<0.001). CONCLUSION: Patients with chronic heartburn and regurgitation have greater postintubation gastric aspirate volumes than do asymptomatic patients, attributable to the gastroesophageal motility dysfunction characteristic of GERD that can favor aspiration. GERD questions should be included in preanesthetic medical history taking, and symptomatic patients should be prescribed outpatient proton pump inhibitor therapy

[Anesthesia in Sebastian syndrome: a new hereditary macrothrombocytopenia]. / Anestesia en el síndrome de Sebastian: una nueva macrotrombocitopenia hereditaria.

The macrothrombocytopenias make up a heterogeneous group of disease involving thrombocytopenia and giant platelets; other clinical or laboratory findings, such as hereditary nephritis, sensorineural hearing loss, leukocyte inclusions, and cataracts, may also be present. The tendency to bleeding is highly variable and is due to decreased expression of the GP1b-V-IX complex on the surface of platelets, leading to altered platelet-vessel wall and platelet-platelet interactions. The 5 autosomal dominant giant-platelet disorders that are associated with macrothrombocytopenia are May-Hegglin anormaly, Epstein, Fechtner, and Sebastian syndromes, and Alport-like syndrome with macrothrombocytopenia. The mutation responsible is in gene 9 (MYH9) coding for the nonmuscle myosin heavy chain IIA that has been identified in the long arm of chromosome 22 (22q12.3-q13.2). The most recently described macrothrombocytopenia is Sebastian syndrome, consisting of thrombocytopenia with giant platelets and leukocyte inclusions. We report the case of a woman with Sebastian syndrome scheduled for abdominoperineal resection for rectal carcinoma. Preoperative studies revealed isolated thrombocytopenia (35,000 platelets/microL) and a mean platelet volumen of 13 fL. Preoperative prophylactic platelet transfusion was carried out with no adverse events. After a postoperative transfusion of packed red cells, needed because of abundant bleeding, clinical course continued to be satisfactory. The anesthetic implications of this syndrome are not well known because few cases have been reported in the literature, and none was found that describes anesthetic management. Nevertheless, thrombocytopenia and the tendency to bleeding present challenges to the anesthesiologist.

Anestesia en el síndrome de Sebastian: una nueva macrotrombocitopenia hereditaria / Anesthesia in Sebastian syndrome, a new hereditary macrothrombocytopenia

Las macrotrombocitopenias son un grupo heterogéneo de enfermedades con trombocitopenia y plaquetas gigantes que pueden incluir otros hallazgos como nefritis hereditaria, sordera neurosensorial, inclusiones leucocitarias y cataratas. Su tendencia al sangrado es muy variable, por una disminución de los niveles de la expresión del complejo GPIb-V-IX en la superficie de las plaquetas que implica una alteración de la adhesión y de la agregación plaquetaria. Los cinco desórdenes plaquetarios, autosómicos dominantes que asocian macrotrombocitopenia son los síndromes de May-Hegglin, Epstein, Alport-like con macrotrombocitopenia, Fechtner y Sebastian. La mutación genética causante se localiza en el gen 9 (MYH9) para la cadena pesada de la miosina no muscular IIA, NMMHC-IIA, que se ha identificado en el brazo largo del cromosoma 22 (22q12.3-q13.2). La macrotrombocitopenia más recientemente descrita es el síndrome de Sebastian, que consiste en una trombocitopenia con plaquetas gigantes e inclusiones leucocitarias. Describimos el caso de una paciente con síndrome de Sebastian programada para amputación abdominoperineal por neoplasia de recto. En el preoperatorio se objetivó una trombocitopenia aislada (35.000 plaquetas/µl) con volumen plaquetario medio de 13 fl. Se realizó transfusión profiláctica de plaquetas antes de la intervención que transcurrió sin incidencias. En el postoperatorio requirió la transfusión de concentrados de hematíes por sangrado abundante y la evolución fue favorable. Las implicaciones anestésicas son poco conocidas, por el escaso número de casos descritos y no se ha encontrado bibliografía sobre su manejo anestésico, pero la trombocitopenia y la tendencia al sangrado son un reto para el anestesiólogo (AU)

[Anesthesia and fibrobronchoscopy for the study of chronic stridor in a boy with Robinow syndrome]. / Anestesia y fibrobroncoscopia para el estudio de estridor crónico en un niño con síndrome de Robinow.

Robinow's syndrome involves fetal facial features, short stature, brachymelia, hypoplastic genitals and a normal karyotype. A 10-year-old boy with Robinow's syndrome was scheduled for study of chronic stridor by fiberoptic bronchoscopy. Airway exploration with the patient awake revealed hipertelorism, retromicrognathia, poor dental alignment, macroglossia and class IV Mallampati. After anesthetic induction in spontaneous ventilation with 5% sevoflurane, grade IV Cormack-Lehane conditions were observed. A laryngeal mask was placed without muscle relaxation after which the boy was ventilated manually for several minutes without stridor. Anesthetic maintenance was with 3% sevoflurane in 50% oxygen and air. After recovery of spontaneous ventilation, marked stridor presented along with a decrease in oxygen saturation and expired fractions of sevoflurane and CO2. Pulse oxymetry did not increase with increased FiO2. However, when continuous positive airway pressure (CPAP) was set al 10 cm H2O, pulse oxymetry did increase; likewise, expired and inspired sevoflurane concentrations became equal, and expired CO2 increased. Fiberoptic bronchoscopy revealed an area of intrathoracic tracheomalacia, which collapsed partially during spontaneous expiration and collapsed less when CPAP was started. We discuss the relation between the facial dysmorphia characteristic of this syndrome and the possibility of finding a difficult airway, as well as the diagnosis and treatment of intrathoracic tracheomalacia during anesthesia.

Anestesia y fibrobroncoscopia para el estudio de estridor crónicoen un niño con síndrome de Robinow / Anesthesia for the fiberoptic bronchoscopic study of chronic stridor in a child with Robinow's syndrome

El síndrome de Robinow reúne rasgos faciales fetales, talla baja, braquimelia, genitales hipoplásicos y un cariotipo normal1. Un niño de 10 años, con síndrome de Robinow, fue programado para fibrobroncoscopia diagnóstica por presentar un estridor crónico. La exploración de la vía aérea con el paciente despierto mostró: hipertelorismo, retromicrognatia, mala alineación dental, macroglosia y un Mallampatti clase IV. Tras realizar la inducción en ventilación espontánea con sevoflurano al 5 por ciento, presentó en la laringoscopia un test de Cormack-Lehane grado IV. Se introdujo una mascarilla laríngea sin relajación muscular, tras lo cual se le ventiló unos minutos manualmente sin que presentara estridor. El mantenimiento anestésico se realizó con sevoflurano al 3 por ciento y O2/aire al 50 por ciento. Tras dejarle recuperar la ventilación espontánea, presentó un estridor importante junto a disminución de la saturación de oxígeno y de las fracciones espiradas de sevoflurano y de CO2. El incremento de la FiO2 no mejoró la pulsioximetría. Con la instauración de una presión espiratoria continua de 10 cm de H2O, se elevó la pulsioximetría, las concentraciones de sevoflurano espirado e inspirado se igualaron, y el CO2 espirado se incrementó. La fibrobroncoscopia mostró una zona de traqueomalacia intratorácica que se colapsaba parcialmente durante la espiración en ventilación espontánea, y como disminuía el colapso cuando se instauraba la presión espiratoria positiva continua. Se discuten la relación entre la dismorfia facial característica de este síndrome y la posibilidad de presentar una vía aérea difícil y además el diagnóstico y tratamiento de la traqueomalacia intratorácica durante la anestesia. (AU)

Hipotensión perioperatoria grave tras nefrectomía con suprarrenalectomía / Severe perioperative hypotension after nephrectomy with adrenalectomy

A una mujer de 70 años, obesa e hipertensa en tratamiento con inhibidores de la enzima convertidora de angiotensina (IECA) y clortalidona, pero sin antecedentes de tratamiento corticoideo ni enfermedad del eje hipotálamohipófiso-suprarrenal, se le realizó una nefrectomía más suprarrenalectomía bajo anestesia combinada: general y peridural. Presentó una hipotensión arterial grave con oliguria intraoperatoria, que continuó en el postoperatorio junto al desarrollo de anuria, acidosis metabólica, hiponatremia e hiperpotasemia. Aunque inicialmente el cuadro se atribuyó al tratamiento previo con IECA más diuréticos junto a la anestesia combinada, la refractariedad a la administración de cristaloides, coloides e inotrópicos catecolamínicos, con respuesta parcial a la efedrina y el desarrollo de anuria, acidosis metabólica, hiponatremia e hiperpotasemia, nos hizo pensar en la concurrencia de una crisis addisoniana. Tras extraer muestras para determinar cortisol y ACTH, se inició el tratamiento con hidrocortisona. La respuesta al tratamiento junto al cortisol descendido confirmaron el diagnóstico de insuficiencia suprarrenal. En los pacientes sometidos a una nefrectomía más suprarrenalectomía por hipernefroma, se ha observado que la suprarrenal contralateral compensa la secreción endógena del cortisol, por esto no se recomienda tratamiento sustitutivo. Por otra parte, se han descrito crisis addisonianas perioperatorias en pacientes sometidos a cirugías con estrés quirúrgico importante. También se han visto hipotensiones graves en los pacientes tratados crónicamente con IECA tras la inducción de la anestesia general y tras la anestesia epidural con anestésicos locales. En este caso la conjunción de todos estos factores dificultó el diagnóstico y la rápida instauración del tratamiento adecuado (AU)

[Severe perioperative hypotension after nephrectomy with adrenalectomy]. / Hipotensión perioperatoria grave tras nefrectomía con suprarrenalectomía.

A 70-year-old obese, hypertensive woman taking angiotensin converting enzyme (ACE) inhibitors and chlorthalidone but with no history of corticosteroid treatment or hypothalamus-hypophyseal-adrenal disease, underwent nephrectomy and adrenalectomy under combined general and epidural anesthesia. Severe hypotension with oliguria developed during surgery and persisted during postoperative recovery, with anuria, metabolic acidosis, hyponatremia and hyperpotassemia. Although the symptoms were initially attributed to prior treatment with ACE inhibitors and diuretics together with combined anesthesia, the patient's lack of response to crystalloid, colloid and inotropic catecholamine therapy in the context of anuria, metabolic acidosis, hyponatremia and hyperpotassemia led us to consider a diagnosis of Addisonian crisis. Blood samples were taken to determine adrenocorticotropic hormone levels, and hydrocortisone treatment was started. The patient responded to treatment and cortisol levels fell, confirming the diagnosis of adrenal insufficiency. Compensatory endrocrine secretion of cortisol by the contralateral adrenal gland has been observed in patients undergoing nephrectomy and adrenalectomy for excision of a hypernephroma, and replacement therapy is therefore not recommended. Perioperative Addisonian crises have also been described in patients suffering great surgical stress, and severe hypotension has been observed in patients on long-term treatment with ACE inhibitors after induction of general anesthesia and after epidural anesthesia with local anesthetics. The combination of these factors made rapid diagnosis and start of appropriate therapy difficult.