Unexpected obstetric haemorrhage. Krukenberg tumour. / Hemorragia obstétrica de causa inesperada. Tumor de Krukenberg.

Obstetric haemorrhage can endanger the lives of mother and foetus. It often occurs unexpectedly without clear predictors. A high degree of suspicion helps to avoid delaying resuscitation measures. We present the case of a ruptured ovarian metastasis that occurred during labour. It caused a massive bleed forcing a caesarean section due to non-reassuring foetal status. This was an unprecedented and undescribed onset of Krukenberg tumour formation. Malignant tumours in pregnancy are rare and difficult to diagnose due to their clinical manifestations which often overlap with those of pregnancy itself (dyspepsia, nausea and bloating). Despite the available therapeutic measures, a delay in diagnosis is a determining factor for long-term prognosis. We review the causes of obstetric bleeding, and underline how rare Krukenberg tumours concomitant to pregnancy are.

Implicaciones anestésicas en gestante con trombocitopenia extrema por síndrome de May-Hegglin: ¿anestesia regional o general? / Anaesthetic implications in a pregnant patient with an extreme thrombocytopenia due to a May-Hegglin anomaly: General o regional anaesthesia?

El síndrome de May-Hegglin es un trastorno hematológico, tan infrecuente que su incidencia es aún desconocida, caracterizado por macrotrombocitopenia con función plaquetaria normal e inclusiones citoplasmáticas en los granulocitos. Se presenta el caso de una primípara de 28 años, quien solicitó analgesia epidural y posteriormente requirió cesárea urgente por fracaso de la inducción. La paciente no tenía antecedente de hemorragias anormales. Se descartaron otras posibles causas asociadas de trombocitopenia o disfunción plaquetaria como la preeclampsia, el síndrome de HELLP o abruptio placentae. El recuento de plaquetas previo a la cesárea fue de 20.900/mm3, con una función plaquetaria normal. Se realizó una anestesia general. La hemorragia no fue mayor de lo habitual y no precisó transfusión plaquetaria (AU)

The May-Hegglin anomaly is an inherited disorder, so uncommon that the incidence is still unknown. It is characterized by macro-thrombocytopenia with normal platelet function and cytoplasmic inclusion bodies in granulocytes. The case is reported of a 28-year-old primiparous patient who had an urgent caesarean section due to failed induction of labour. The patient had no history of abnormal bleeding. Other causes of thrombocytopenia or platelet dysfunction, such as preeclampsia, HELLP syndrome, or placental abruption, were ruled out. The platelet count prior to surgery was 20,900/mm3 with normal platelet function. General anaesthesia was performed. No excessive bleeding occurred and a platelet transfusion was not needed (AU)

[Anaesthetic implications in a pregnant patient with an extreme thrombocytopenia due to a May-Hegglin anomaly: general o regional anaesthesia?]. / Implicaciones anestésicas en gestante con trombocitopenia extrema por síndrome de May-Hegglin: ¿anestesia regional o general?

The May-Hegglin anomaly is an inherited disorder, so uncommon that the incidence is still unknown. It is characterized by macro-thrombocytopenia with normal platelet function and cytoplasmic inclusion bodies in granulocytes. The case is reported of a 28-year-old primiparous patient who had an urgent caesarean section due to failed induction of labour. The patient had no history of abnormal bleeding. Other causes of thrombocytopenia or platelet dysfunction, such as preeclampsia, HELLP syndrome, or placental abruption, were ruled out. The platelet count prior to surgery was 20,900/mm(3) with normal platelet function. General anaesthesia was performed. No excessive bleeding occurred and a platelet transfusion was not needed.

[Labor pain worries future fathers more than the mothers]. / El dolor del parto preocupa más a los futuros padres que a las madres.

OBJECTIVE: To evaluate the concerns of the future father about labor pain and another 9 items which could be important to the well-being of the mother during delivery. To investigate any possible differences in opinion between the future father and mother. PATIENTS AND METHODS: An anonymous and voluntary questionnaire was offered to the father and the pregnant patient during the last month of pregnancy. They had to answer the questionnaire separately, scoring 10 items in a 0-10 point ordinal scale, according to their concerns and the importance for the good development of the delivery (0= not concerned about/insignificant to 10=concerned about/great importance). The items included were: 1) esthetic aftermath, 2) embarassment, 3) continous information, 4) walking during labor, 5) drinking during labor, 6) companionship, 7) labor pain, 8) keeping composure, 9) kindness, 10) room comfortability. Data on age, education, parity and nationality were recorded. RESULTS: A total of 147 questionnaires were completed, 99 by mothers, and 48 by fathers. Pain was the most important concern for the future fathers scoring a mean (SD) of 8.15 (2), while continuous information 7.71 (2.5), kindness 7.9 (2.1), and companionship 8.21 (2.3) were more important than pain for mothers. A statistically significant difference was found between fathers and mothers regarding labor pain (P=.001), walking during labor (P=.003), and drinking during labor (P=.009). CONCLUSIONS: The result of our study suggests that increasing the presence of the father during the delivery process, and taking care of the emotional aspects and the quality of the information given could be very important for the perception of satisfaction.

Gestión de riesgos en anestesia obstétrica / Risk management in obstetric anestesia

El objetivo de este trabajo es analizar la epidemilogía de las complicaciones más graves que pueden presentarse durante la asistencia de pacientes obstétricas, valorando su incidencia, la demanda asistencia que generan y los principales factores de riesgo. Se analizan también los aspectos más generales de la planificación en anestesiología obstétrica, con ejemplos concretos para algunas situaciones

The aim of this piece of work is to analyse the epidemiology of the most serious complications which may appear during the anaesthesia of obstetric patients, assessing their incidence, the health care demand they develop and the main risk factors. The most general aspects in planning obstetric anaesthesia area analysed as well, with some particular examples of certain situations

[Dual atrioventricular nodal conduction and arrhythmia with severe hemodynamic alterations during liver retransplantation]. / Arritmia por doble via intranodal con descompensación hemodinámica grave en un retrasplante hepático.

We report the case of a man who developed tachycardia caused by atrioventricular reentry related to dual nodal conduction during liver retransplantation. The hemodynamic alterations were severe. Arrhythmia and altered cardiac conduction are potential complications of liver transplantation. The development of tachyarrhythmias--atrial fibrillation as well as episodes of supraventricular and ventricular tachycardia and bradycardia--have been described. Such arrhythmias tend to occur particularly during reperfusion of the graft. Risk factors implicated are the severe ion imbalances, acid-base imbalance, and hypothermia that accompany the reperfusion of a new organ. A review of the possible pathogenic and etiological mechanisms that lead to arrhythmia in patients with end-stage liver disease is provided.

Arritmia por doble vía intranodal con descompensación hemodinámica grave en un retrasplante hepático / Dual atrioventricular nodal conduction and arrythmia with severe hemodynamic alterations during liver retransplantation

Presentamos el caso de un paciente que presentó una taquicardia por reentrada auriculo-ventricular, en relación con la presencia de una doble vía intranodal con importante repercusión hemodinámica durante un retrasplante hepático. Las alteraciones del ritmo y de la conducción cardiaca representan unas de las complicaciones potenciales durante el trasplante hepático. Así están descritas la aparición de taquiarritmias del tipo de fibrilación auricular, taquicardias supraventriculares, ventriculares y bradiarritmias. Estas arritmias ocurren especialmente durante la reperfusión del injerto. Los factores implicados se relacionan con la presencia de alteraciones iónicas graves, del equilibrio ácido base y de la hipotermia que acompañan a la reperfusión del nuevo órgano. Se revisan los posibles mecanismos etiopatogénicos implicados en la aparición de las alteraciones del ritmo en los pacientes con enfermedad hepática terminal

We report the case of a man who developed tachycardia caused by atrioventricular reentry related to dual nodal conduction during liver retransplantation. The hemodynamic alterations were severe. Arrhythmia and altered cardiac conduction are potential complications of liver transplantation. The development of tachyarrhythmias —atrial fibrillation as well as episodes of supraventricular and ventricular tachycardia and bradycardia— have been described. Such arrhythmias tend to occur particularly during reperfusion of the graft. Risk factors implicated are the severe ion imbalances, acidbase imbalance, and hypothermia that accompany the reperfusion of a new organ. A review of the possible pathogenic and etiological mechanisms that lead to arrhythmia in patients with end-stage liver disease is provided

[Acute pain in "Don Quixote"]. / El dolor agudo en El Quijote.

OBJECTIVE: A descriptive analysis of references to pain symptoms in Don Quixote based on linguistic, literary, clinical, and mannerist features. METHODS AND MATERIAL: Don Quixote was read and an entry was created for each description of an injury or illness (group I/I). A second group of entries was created for each medical commentary (group C). This information was complemented using a computer search for the roots of words referring to pain symptoms, with an asterisk placed after each root to locate all word forms used. Data entries with pain references were analyzed in group I/I by examining patient, location, characteristics, causes, associated disorders, remedies, caregivers, and recovery times and in group C by examining the full text. RESULTS: Ninety-one entries were made (64 in group I/I, 27 in group c). References to pain were found in 37 entries (29 in group I/I, 8 in group C). The most commonly used words came from the roots dol (the Spanish root for dolor, or pain, among other related words) (52) and moli (for forms related to Spanish idiomatic uses of molido, suggesting severe injury) (19). All pains were due to injuries. Forty-two occasions of injury (Don Quixote 14, Sancho 9, others 19) and 51 lesions (ribs 5, back 5, other 15, unspecified 26) were mentioned. Known remedies and caregivers of the period were described, but other invented ones were also present. Associated disorders were insomnia, anxiety, rage, melancholy, functional impotence and other sexual dysfunctions. Recovery times ranged from 0 to 8 days. CONCLUSION: Pain references are subject to literary considerations. The style is simple and the descriptions are credible for the period depicted but do not meet clinical standards. Issues of current interest are treated: pain threshold and sensitivity, social influences, the placebo effect, and affective disorders.

El dolor agudo en El Quijote / Acute pain in Don Quixote

JUSTIFICACIÓN Y OBJETIVOS: Análisis descriptivo de las referencias al síntoma dolor en El Quijote desde el punto de vista lingüístico, literario, clínico y costumbrista. MATERIAL Y MÉTODOS: Lectura del texto haciendo una ficha de cada traumatismo o enfermedad descrito (grupo T) y de los comentarios relativos a la medicina (grupo C). Se completó la información con una búsqueda informática, utilizando la raíz de las palabras que designaban el síntoma dolor seguida de asterisco para incluir todas las variaciones gramaticales. Se analizaron las fichas que incluían alusiones al dolor; en el grupo T se recogió en cada caso: pacientes, localización, características, causas, trastornos asociados, remedios, sanadores y tiempos de recuperación, en el grupo C el texto completo. RESULTADOS: Total 91 fichas (64 T, 27 C). Referencias al dolor en 37 (29 T, 8 C). Las palabras más utilizadas provienen de las raíces: dol (52) y moli (19). Todos los dolores son de causa traumática. Lesionados 42 (Don Quijote: 14, Sancho: 9, otros: 19). Lesiones 51 (costillas: 5, espalda: 5, varios: 15, no precisado: 26). Se citan remedios y sanadores de la época y otros fantásticos. Trastornos asociados: insomnio, ansiedad, furor, hipoventilación, melancolía, impotencia funcional y sexual. Tiempos de recuperación: 0 a 8 días. CONCLUSIONES: Las referencias al dolor se supeditan a consideraciones literarias, el lenguaje es sencillo y son verosímiles para la época, pero no se ajustan a criterios clínicos. Se tratan aspectos de interés científico actual: umbral y sensibilidad, sociología, efecto placebo, trastornos afectivos (AU)

[Comparative study of recovery times and psychomotor function after anesthesia with desflurane or isoflurane]. / Estudio comparativo de los tiempos de recuperación y función psicomotriz tras anestesia con desflurano o isoflurano.

OBJECTIVE: To compare recovery from anesthesia with desflurane and isoflurane by analyzing awakening and psychomotor function. PATIENTS AND METHODS: In this prospective study of 30 ASA I-II patients undergoing general or urologic surgery the following variables were assessed before surgery: confusion, fatigue, drowsiness, torpor and pain. The Steward and Trieger tests of psychomotor function were also applied. After induction and intubation, maintenance was with isoflurane (0.6 +/- 0.3%) or desflurane (3 +/- 1.5%) and 60% nitrous oxide with fresh gas at a rate of 1 l/min. After withdrawing the halogen and switching to an open circuit (10 l/min), we counted time until appearance of the first sign of awakening. Clinical variables and psychomotor function were assessed 5, 30, 60 and 90 min later. RESULTS: The two groups were similar anthropometrically. Duration of anesthesia and surgery were also similar. Times until awakening, eye opening, extubation and orientation were shorter in the desflurane group. Scores for fatigue (5 min), confusion (5 and 30 min), motor incoordination (5 min) and drowsiness (5 and 30 min) were also more favorable in the desflurane group. Patients receiving desflurane also scored significantly better on the Trieger test at 30 and 60 min. CONCLUSIONS: Recovery times are shorter with desflurane than with isoflurane. Clinical variables are also more favorable with desflurane and psychomotor function returns more quickly during the first hour after anesthesia.

[Late ischemia and carpal tunnel syndrome secondary to catheterization of the radial artery]. / Isquemia tardía y síndrome del túnel del carpo secundarios a cateterización de la arteria radial.

Invasive measurement of blood pressure has many advantages. Although arterial canalization is a low-risk technique of great benefit to the patient, complications must be looked for. We report the case of a man who underwent triple coronary bypass with arterial canalization requiring several punctures to achieve. Two weeks after the procedure the patient showed signs of hand ischemia and acute carpal tunnel syndrome, which evolved favorably after treatment with heparin sodium and prostaglandin E1. We emphasize the importance of an earlier wrist fracture as the predisposing factor for both conditions and the need to examine collateral circulation in the hand and look for carpal tunnel syndrome before canalization.

[Glomus jugulare tumor: perioperative management]. / Tumor glómico yugular: manejo perioperatorio.

Surgical treatment of glomus jugulare tumors yields high rates of perioperative morbidity and mortality for several reasons, among them neuroendocrine secretory activity, a high degree of vascularization, intracranial extension, duration of surgery and cranial nerve lesion. Secretory activity (e.g. catecholamines and serotonin) should be investigated before surgery and treated appropriately. Carotid arteriography (and ball occlusion) are useful to assess vascularization of the tumor and determine the need to clamp the carotid artery during the procedure. Potential complications such as hemodynamic alterations (bleeding or endocrine response), pulmonary embolism (air or thrombotic), hypothermia, facial nerve lesion, should be monitored for during surgery. After surgery cranial nerve involvement, which can lead to dysphagia and bronchoaspiration, must be looked for; the risk of cerebro-spinal fluid fistula is also high. We report the case of a woman who underwent surgery for a non secreting glomus jugulare tumor with extradural intracranial invasion. The main complications during surgery were bleeding with hemodynamic repercussions, pulmonary embolism, lesions in the VII, VIII and X cranial nerves, and opening of the dura mater (which required insertion of an intradural drain to prevent formation of a fistula). After surgery oral intake was delayed until intestinal function was established and glottic sphincter competence was verified by fiberoptic laryngoscopy. The only complication presenting at this time was cephalea, which disappeared upon removal of the drain on day 4. The patient was released on day 10.

[Electromyographic response to precurarization with vecuronium bromide]. / Respuesta electromiográfica de la precurarización con bromuro de vecuronio.

OBJECTIVE: To analyze electromyographic response and clinical effects after precurarization with vecuronium bromide (0.01 mg/Kg), also noting intubation conditions and the presence or not of fasciculations after administration of succinylcholine (1.5 mg/Kg). PATIENTS AND METHODS: A single precurarization dose of vecuronium was administered to 20 patients 5 minutes before anesthetic induction for general surgery. During this period we monitored neuromuscular transmission of the cubital nerve in the wrist by electromyography with a series of 4 stimuli, expressing each as the percentage of the first response and of the ratio T4/T1. We also recorded clinical repercussions. General anesthesia was then induced; after administration of succinylcholine, the presence or not of fasciculations was noted and intubation conditions were evaluated. RESULTS: The electromyographic response after precurarization was highly variable, as 4 different responses were recorded. We found potentiation phenomena in 20% of our patients, diminished response in 60%, fatigue phenomena in 15% and no change in 5%. Clinical signs noted were blurred vision and heavy eyelids. Fasciculations disappeared in 95% of the patients and intubation conditions were excellent. CONCLUSIONS: Vecuronium at a precurarization dose produces highly varied but well-tolerated electromyographic responses. The drug is effective in eliminating fasciculations produced by succinylcholine and does not affect intubation conditions.