Fallo hepático agudo tras anestesia con sevoflurano en un paciente pediátrico / Acute liver failure after sevoflurane anesthesia in a pediatric patient

El sevoflurano es un anestésico volátil que se caracteriza por su baja toxicidad siendo el más utilizado en edad pediátrica. A diferencia de otros anestésicos inhalados halogenados, el sevoflurano no se metaboliza a productos intermedios que conducen a la formación de proteínas hepatotóxicas; sin embargo, algunos casos de hepatotoxicidad han sido atribuidos a su uso. Describimos el caso de un niño de 11 años que presentó fallo hepático agudo tras la intervención neuroquirúrgica de un tumor de fosa posterior, realizada bajo anestesia con sevoflurano asociado a otros fármacos. Durante el postoperatorio manifestó dolor abdominal y en la analítica sanguínea se observó marcada elevación de enzimas hepáticas, coagulopatía y trombocitopenia. Permaneció afebril, sin presentar hipoglucemia ni signos de encefalopatía. Su evolución fue favorable, con normalización de los parámetros analíticos al séptimo día de postoperatorio. Se evaluaron todas las posibles causas de fallo hepático agudo y se expone el diagnóstico diferencial realizado

Sevoflurane is a volatile anesthetic characterized by low toxicity and is the most used in pediatric age. Unlike other halogenated anesthetic, sevoflurane is not metabolized to reactive intermediates that lead to the formation of hepatotoxic proteins. However, a few cases of hepatotoxicity have been associated with its use. We report a case of an 11-year-old boy who developed acute liver failure after neurosurgical intervention, resection of a posterior fossa mass, under sevoflurane anesthesia and other drugs. Postoperatively, he presented abdominal pain and the laboratory tests showed markedly elevated aminotransferase levels, coagulopathy and thrombocytopenia. He had no fever, hypoglycemia or evidence of encephalopathy. The clinical evolution was favorable and after 7 days, laboratory values were completely normalized. All the possible causes of acute liver failure were evaluated and the differential diagnosis is exposed

Acute liver failure after sevoflurane anesthesia in a pediatric patient. / Fallo hepático agudo tras anestesia con sevoflurano en un paciente pediátrico.

Sevoflurane is a volatile anesthetic characterized by low toxicity and is the most used in pediatric age. Unlike other halogenated anesthetic, sevoflurane is not metabolized to reactive intermediates that lead to the formation of hepatotoxic proteins. However, a few cases of hepatotoxicity have been associated with its use. We report a case of an 11-year-old boy who developed acute liver failure after neurosurgical intervention, resection of a posterior fossa mass, under sevoflurane anesthesia and other drugs. Postoperatively, he presented abdominal pain and the laboratory tests showed markedly elevated aminotransferase levels, coagulopathy and thrombocytopenia. He had no fever, hypoglycemia or evidence of encephalopathy. The clinical evolution was favorable and after 7 days, laboratory values were completely normalized. All the possible causes of acute liver failure were evaluated and the differential diagnosis is exposed.

Impact of empirical treatment with antifungal agents on survival of patients with candidemia.

OBJECTIVE: The objective of this study was to evaluate the impact of echinocandins and fluconazole) on mortality 7 and 30 days after candidemia onset and overall in-hospital mortality), in patients with candidemia at a Spanish tertiary hospital. METHODS: A retrospective study was conducted that enrolled all non-neutropenic adult patients diagnosed with candidemia at Hospital Clínico Universitario de Valladolid between 2007 and 2016. A total of 179 patients were evaluated, they were divided into two sub-groups: surviving patients (n = 92) and non-surviving patients (n = 87). RESULTS: The 7-day mortality was 25,1% (45), 30-day mortality was 46,9% (84), and overall in-hospital mortality was 48,6% (87). 40.8% of patients received no antifungal treatment (43.8% of surviving patients and 37.8% of non-surviving patients; p=0.15). A total of 106 (59.2%) patients were treated, of which 90 patients (50.3%) received empiric treatment. 19.6% and 47.8% of surviving patients were treated with echinocandins and fluconazole, respectively. By contrast, of non-surviving patients, 31.0% were treated with echinocandins and 47.1% received fluconazole. Survival for the first 7 days was significantly higher in treated with antifungal agents (log-rank = 0.029), however, there were not significant differences in 30-day survival. Factors linked to a significant increase in overall in-hospital mortality were age (OR 1.040), septic shock (OR 2.694) and need for mechanical ventilation > 48 h (OR 2.812). CONCLUSIONS: Patients who received antifungal treatment, regardless of whether they received fluconazole or echinocandins, had a significantly lower mortality rate after 7 days than untreated patients, although no significant differences in 30-day mortality were seen.

Hb Palencia: a novel δßδ-type two-way fusion variant with ß-globin-like expression levels.

AIMS: Fusion proteins of unequal recombination events at the ß-globin locus have pathological effect. The haemoglobin (Hb) variants of type Lepore are fusion proteins characterised by ß-like globin chains with a δ-globin (HBD) N-terminus and a ß-globin (HBB) C-terminus, whereas reciprocal products of underlying crossover events hold a HBB N-terminus and HBD C-terminus instead. Finally, Hb Parchman contains a ß-like globin chain with a central HBB fragment and HBD-derived N-termini and C-termini, whereas reciprocal hybrid proteins are as yet unknown. METHODS: The propositus was an 80-year-old Caucasian man, whose HbA1c quantification by HPLC (Variant II turbo) for exclusion of type-2 diabetes revealed an abnormal peak. Haemoglobins were analysed by ion-exchange HPLC (Variant II) and capillary electrophoresis (Sebia Capillarys Flex) and DNA by automatic Sanger sequencing of δ-globin and ß-globin genes. RESULTS: Sequencing showed an HBB-HBD-HBB hybrid gene, with HBD-derived central codons 9-31, and HBB-derived UTRs and complementary coding regions. The corresponding new hybrid haemoglobin (Hb Palencia) is represented at ≈40%, similar to HbA. CONCLUSION: Hb Palencia contains the first globin variant with internal HBD sequences and HBB-derived N-terminal and C-terminal and regulatory sequences. Relative quantity of the new ßδß-type variant suggests transcriptional control by HBB elements and a half-life similar to normal HBB.

Antifungal treatment with echinocandins: a 10-year clinical experience.

OBJECTIVE: The number of studies evaluating the use of echinocandins, whether or not its indication meets international guidelines, in clinical practice is limited. The objective of the present study was to determine the use of echinocandins in a tertiary Spanish hospital in 10 years of clinical practice, and to evaluate its impact on prognosis. METHODS: This retrospective study involved adult nonneutropenic ill patients with suspicion of fungal invasion who started treatment with echinocandins between 2006 and 2015. RESULTS: The number of patients treated with echinocandins was 153, and candidemia was detected thereafter in 25.5%. Factors associated with in-hospital mortality in patients receiving echinocandins were: sex male, septic shock, Charlson comorbidity index, and total stay at the hospital. In-hospital mortality after 7, 30 and 90 days was 13.7%, 24.8%, and 56.8%, respectively. From patients receiving echinocandins, 98 did no show multifocal colonization, 50 had Candida score <2.5, and 49 did not meet Ostrosky-Zeichner prediction rule. A total of 19 patients did not show any of these 3 potential risk factors for candidemia. CONCLUSIONS: The use of echinocandins in 10 years of clinical practice in our tertiary hospital has been performed according to international guidelines; however, candidemia was only diagnosed thereafter in only 25.5% of cases. Furthermore, according to our results, the adequate use of echinocandins seems not to be associated with reduced mortality rates. Further studies, involving a large cohort of patients and more hospitals, are required to corroborate these results.