[Hypertonic saline 7.5% in the treatment of severe hypochloremic metabolic alkalosis]. / Suero salino hipertónico 7,5% en el tratamiento de la alcalosis metabólica hipoclorémica grave.

A 63 year-old man with a history of anal carcinoma treated by surgery, chemotherapy and radiotherapy was admitted to our hospital two years later with small bowel obstruction requiring emergency surgery. Fifteen days later, he had to be operated on once again. During the procedure, severe metabolic alkalosis developed: pH 7.58, CO3H- 47.7 mmol/L and a base excess of 24.3 mmol/L. The patient had the following preoperative risk factors for hypochloremic metabolic alkalosis: low levels of Cl and K, prolonged aspiration of gastric contents, low plasma volume and parenteral nutrition. Metabolic alkalosis was managed with 250 mL of 7.5% hypertonic saline, 40 mEq of KCl, readjustment of the ventilatory pattern, perfusion of lactated Ringer's solution instead of 0.9% saline and administration of omeprazole. Response to treatment was good as elevated values fell to acceptable levels within two hours. Metabolic alkalosis is a common acid-base balance disorder which arises for a variety of reasons and which has significant anesthetic implications. Hypertonic saline may be useful for treating severe, acute hypochloremic metabolic alkalosis.

[Bilateral ossification of the earlobes. Addisonian crisis in the postoperative period]. / Osificación bilateral de los pabellones auriculares. Crisis addisoniana en el postoperatorio.

Case report. A 53 year-old male patient was scheduled for surgical resection of biliary lithiasis and correction of anal fistula. He had previous history of repetitive biliary colics and appendicectomy at the age of 34 with undetermined anesthetic complications. Under epidural anesthesia with 270 mg of mepivacaine at the L1-L2 level cholecystectomy and fistulectomy was performed with any immediate surgical or postoperative complication. Eighteen hours after surgery the patient presented clinical signs of shock with systolic arterial pressure between 40 and 50 mmHg. This clinical situation associated with the finding of hard ear auricles with radiologic signs of calcification allowed to suspect the presence of an addisonian crisis. Clinical recovery was obtained with corticosteroid therapy: a bolus of 500 mg of methylprednisolone followed by 40 mg every 8 hours. The postoperative period was therefore uneventful. Examination of suprarenal function demonstrated the presence of Addison disease. Calcification of ear auricles is an uncommon clinical sign which is associated to local traumatisms, gout, and several endocrine diseases. The presence of ear auricle calcification in postoperative patients with shock should lead to consider the possibility of addisonian crisis.