ABSTRACT
Background: The present article describes three cases of patients in cardiogenic shock (CS) with previous cardiac surgery that made them initially inoperable. Perioperative support with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) improved haemodynamic status and results in these high-risk patients. Case summary: Case 1 is a 57-year-old male morbidly obese with previous aortic valve replacement (AVR) who presented with chest pain and developed cardiac arrest. Cardiopulmonary resuscitation and femoral VA-ECMO were initiated. Three days later, a redo AVR was performed. Veno-arterial extracorporeal membrane oxygenation was maintained for 12 days, followed by 7 days of veno-venous ECMO for complete recovery. Case 2 features a 39-year-old male with two previous mitral valve replacements (MVRs). The first is due to papillary muscle rupture, and the second is due to endocarditis of the mitral prosthesis. He presented with CS and pulmonary oedema. Emergency surgery was performed and the patient was then placed in VA-ECMO. Weaning off was achieved 3 days after surgery. Case 3 is a 21-year-old female with a previous MVR due to rheumatic disease. She presented with CS, severe mitral prosthesis stenosis, and a pulmonary embolism. Femoral VA-ECMO was initiated, and one day later, she underwent a redo MVR operation. Extracorporeal membrane oxygenation was discontinued 4 days later. Discussion: Dysfunctional prosthetic valves leading to CS may benefit from a redo cardiac operation supported by a perioperative VA-ECMO to optimize haemodynamic status. Despite the results from risk prediction scores, this approach has the potential to reduce operative mortality in initial inoperable patients and allow a definitive redo cardiac surgery.
ABSTRACT
El síndrome de hipotensión endocraneana (SHE) es una patología causada por el descenso del cerebro debido a fuga de líquido cefalorraquídeo a partir de lesiones durales diagnósticas, terapéuticas o espontáneas. Tanto la fisiopatología como el enfoque clínico y terapéutico son similares a la cefalea pospunción dural, siendo esta ultima considerada como una forma leve del SHE. Se describen 2 pacientes con cefalea ortostática y alteraciones neurológicas severas luego de anestesia epidural y espinal que fueron diagnosticados y tratados como cefalea pospunción dural, pero que por su evolución anormal debieron recibir atención adicional. El SHE constituye una complicación seria que puede llevar al deterioro clínico y a la muerte, motivo por el cual requiere de un abordaje integral sobre sus factores desencadenantes, cuadro clínico, métodos diagnósticos, fisiopatología y manejo.
The intracranial hypotension syndrome (IHS) is a disorder caused by brain descent due to a CSF leak resulting from diagnostic, therapeutic or spontaneous lesions. The pathophysiology, the clinical and the therapeutic approach are similar as in post dural puncture headache, the latter being considered a mild form of IHS. This paper describes two patients with orthostatic headache and severe neurological involvement after epidural and spinal anesthesia, diagnosed and treated as post dural puncture headache, but who required additional care because of their abnormal course. IHS is a serious complication that may result in clinical decline and death; consequently, it requires a comprehensive approach to the various triggering factors, the clinical picture, diagnostic methods, pathophysiology and management.
Subject(s)
HumansABSTRACT
Introducción: La cirugía plástica estética implica usualmente la realización de dos o más eventos quirúrgicos, siendo las técnicas anestésicas más usadas la general o epidural; una alternativa muy interesante es la utilización de anestesia combinada epidural general ligera, tratando de obtener los beneficios de cada técnica y de disminuir los inconvenientes inherentes a cada una de ellas. Objetivo: Describir el uso de la técnica anestésica combinada epidural-general ligera en pacientes de cirugía estética. Métodos: Estudio descriptivo tipo serie de casos en el cual se recolectaron datos de 67 pacientes de cirugía plástica realizados en la Clínica Corpus y Rostrum de la ciudad de Cali, a quienes se les administró anestesia combinada epidural-general ligera en el periodo comprendido entre enero y junio de 2008. Fueron incluidos pacientes con dos o más eventos anatomo-quirúrgicos durante el mismo procedimiento anestésico, o cirugías con requerimiento anestésico en dermatomas superiores a T4 y lumbares o sacros al mismo tiempo. Resultados: Los volúmenes y concentraciones de anestésico local fueron bajos, igualmente los requerimientos de anestésicos generales. El efecto secundario más frecuente fue la hipotensión, fácilmente manejado con vasopresores. No se presentaron casos de recuerdo intraoperatorio. Conclusiones: La anestesia general-epidural constituye una alternativa atractiva para la realización de cirugías estéticas.
Introduction: Aesthetic plastic surgery usually involves two or more surgical events taking place during the same anaesthetic procedure; the most widely used anaesthetic techniques are general and epidural anaesthesia. A very interesting alternative is the use of combined epidural and light general anaesthesia, attempting to obtain the benefits of each technique and reduce the disadvantages inherent in each one. Objective: Describing the use of the combined epidural-light general anaesthesia technique in aesthetic surgery patients. Methods: This was a descriptive case series in which data were collected from 67 patients having plastic surgery performed at the Corpus and Rostrum Clinic in Cali, who received combined epidural-light general anaesthesia between January and June 2008. Patients undergoing two or more anatomo-surgical events during the same anaesthetic procedure were included, as were those undergoing surgery with an anaesthetic requirement involving dermatomes over T4 and lumbar or sacral dermatomes at the same time. Results: Local anaesthetic volume and concentration were low, as were general anaesthetic requirements. The most common side-effect was hypotension which was easily managed with vasopressors. There were no cases of intraoperative recall. Conclusions: The light general-epidural anaesthesia technique is an attractive option for cosmetic surgery.