[Subarachnoid hemorrhage: epidemiology, social impact and a multidisciplinary approach]. / Epidemiología de la hemorragia subaracnoidea: impacto social y abordaje multidisciplinario.

Cerebrovascular disease, whether ischemic or hemorrhagic, is a worldwide problem, representing personal tragedy, great social and economic consequences, and a heavy burden on the health care system. Estimated to be responsible for up to 10% of mortality in industrialized countries, cerebrovascular disease also affects individuals who are still in the workforce, with consequent loss of productive years. Subarachnoid hemorrhage (SAH) is a type of cerebrovascular accident that leads to around 5% of all strokes. SAH is most often due to trauma but may also be spontaneous, in which case the cause may be a ruptured intracranial aneurysm (80%) or arteriovenous malformation or any other abnormality of the blood or vessels (20%). Although both the diagnosis and treatment of aneurysmal SAH has improved in recent years, related morbidity and mortality remains high: 50% of patients die from the initial hemorrhage or later complications. If patients whose brain function is permanently damaged are added to the count, the percentage of cases leading to severe consequences rises to 70%. The burden of care of patients who are left incapacitated by SAH falls to the family or to private and public institutions. The economic cost is considerable and the loss of quality of life for both the patient and the family is great. Given the magnitude of this problem, the provision of adequate prophylaxis is essential; also needed are organizational models that aim to reduce mortality as well as related complications. Aneurysmal SAH is a condition which must be approached in a coordinated, multidisciplinary way both during the acute phase and throughout rehabilitation in order to lower the risk of unwanted outcomes.

[Neuroanesthetic management for surgical clipping of a ruptured cerebral aneurysm: clinical practice guidelines]. / Recomendaciones-guía de práctica clínica del manejo neuroanestesiológico para clipado quirúrgico del aneurisma cerebral roto.

Subarachnoid hemorrhage due to spontaneous rupture of a cerebral aneurysm is associated with high rates of morbidity and mortality and requires multidisciplinary treatment. The debate on surgical vs endovascular treatment continues, although short-term clinical outcomes and survival rates are better after endovascular treatment. In Spain, a strong trend toward reduced use of clipping has been noted, and neuroanesthetists are less often called on to provide anesthesia in this setting. Our intervention, however, can be decisive. The neuroscience working group of the Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor has developed guidelines for managing anesthesia in these procedures. Based on a national survey and a systematic review of the literature, the recommendations emphasize the importance of ensuring appropriate intracranial conditions, treating complications, and taking steps to protect against cerebral hemorrhage.

[Uterine leiomyoma with cardiac extension: anesthetic management]. / Leiomioma uterino con extensión cardíaca: manejo anestésico.

A 61-year-old woman complaining of dyspnea with moderate effort was diagnosed with intravenous leiomyomatosis arising in the inferior vena cava with right auricular extension. Surgery was performed in a one-stage procedure under extracorporeal circulation using atriotomy and venotomy of the inferior vena cava. Complete removal of the tumor was confirmed by transesophageal echocardiography during surgery. A femoral venous bypass graft to the root of the aorta allowed the effects of clamping the inferior vena cava to be attenuated and the use of blood products to be reduced. Intravenous leiomyomatosis is a rare benign tumor characterized by smooth muscle proliferation, sometimes involving the inferior vena cava and, very rarely, extending to the right heart chambers.

Leiomioma uterino con extensión cardíaca: manejo anestésico / Intravenous uterine leiomyoma with cardiac extension: anesthetic management

Una paciente de 61 años, tras comenzar con clínica de disnea a moderados esfuerzos, fue diagnosticada de una leiomiomatosis intravenosa procedente de vena cava inferior con extensión a aurícula derecha. Se procedió a su tratamiento quirúrgico en un solo tiempo bajo circulación extracorpórea mediante auriculotomía y venotomía de la cava inferior. El empleo del ecocardiograma transesofágico intraoperatoriamente confirmó la extracción completa de la cabeza tumoral y el uso de una derivación de vena femoral a raíz de aorta permitió minimizar los efectos del pinzamiento de la vena cava inferior y la reducción del uso de hemoderivados. La leiomiomatosis intravenosa es una entidad tumoral benigna muy poco frecuente, caracterizada por la proliferación del músculo liso del útero que en ocasiones puede presentar proliferaciones a la vena cava inferior, y muy ocasionalmente extenderse a cavidades cardíacas derechas (AU)

A 61-year-old woman complaining of dyspnea with moderate effort was diagnosed with intravenous leiomyomatosis arising in the inferior vena cava with right auricular extension. Surgery was performed in a one-stage procedure under extracorporeal circulation using atriotomy and venotomy of the inferior vena cava. Complete removal of the tumor was confirmed by transeso-phageal echocardiography during surgery. A femoral venous bypass graft to the root of the aorta allowed the effects of clamping the inferior vena cava to be attenuated and the use of blood products to be reduced. Intravenous leiomyomatosis is a rare benign tumor characterized by smooth muscle proliferation, sometimes involving the inferior vena cava and, very rarely, extending to the right heart chambers (AU)

Levosimendán como soporte inotrópico tras cirugía coronaria con circulación extracorpórea a un paciente con la función ventricular gravemente deprimida / Inotropic support with levosimendan after coronary surgery and extracorporeal circulation in a patient with severely depressed ventricular function

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[Autotransfusion after cardiac surgery. Hematological, biochemical and immunological properties of shed mediastinal blood]. / Autotransfusión postoperatoria en cirugía cardíaca. Características hematológicas, bioquímicas e inmunológicas de la sangre recuperada del drenaje mediastínico.

OBJECTIVE: Although it is well documented that the reinfusion of unwashed shed blood reduces postoperative homologous blood requirements after cardiac surgery, the efficacy and safety of the technique has been questioned on the basis of several possible adverse effects. We therefore aimed to evaluate the extent of mediastinal shed blood damage by cardiopulmonary bypass (CPB) and extravasation. PATIENTS AND METHOD: Five perioperative blood samples were obtained from each of the 20 patients undergoing cardiac surgery: by venipuncture, during the induction of anesthesia (sample 1), at the end of CPB (sample 2), and one hour after mediastinal shed blood reinfusion (sample 5), and from the cardiotomy reservoir at the first and sixth postoperative hours (samples 3 and 4). Hematological, biochemical and immunological parameters, and the metabolic and functional status of shed erythrocytes were studied in each sample. RESULTS: Hematological and biochemical values were lower at the end of CPB and in shed blood, but not after reinfusion. Inversely, plasma free hemoglobin levels and echinocyte formation were elevated after CPB and in shed blood, the latter correlating with the decrease in serum albumin levels due to hemodilution. No alterations were detected in erythrocyte median corpuscular fragility, D-glucose, L-phenylalanine and L-serine uptakes or 2,3-bisphosphoglycerate content. Plasma IL-10 levels were elevated at the end of CPB, whereas shed blood showed increased levels of IL-1beta, IL-6 and IL-10. Shed blood retrieval did not modify the pattern of circulating cytokines found at the end of CPB. CONCLUSIONS: Shed mediastinal blood salvaged after cardiac surgery seems to be an excellent source of red cells, which conserve functional and metabolic status; once reinfused, shed blood does not modify the inflammatory response of the patient to CPB.

Autotransfusión postoperatoria en cirugía cardíaca. Características hematológicas, bioquímicas e inmunológicas de la sangre recuperada del drenaje mediastínico / Autotransfusion after cardiac surgery. Hematological, biochemical and immunological properties of shed mediastinal blood

OBJETIVOS. Aunque está bien documentado que la reinfusión de sangre no lavada del drenaje mediastínico disminuye los requerimientos postoperatorios de sangre homóloga tras cirugía cardíaca, se cuestiona su seguridad y eficacia sobre la base de sus posibles efectos adversos. El objetivo del presente trabajo ha sido evaluar el grado de alteración de la sangre de dicho drenaje en cirugía cardíaca con circulación extracorpórea.PACIENTES Y MÉTODO. En 20 pacientes sometidos a cirugía cardíaca bajo circulación extracorpórea se han obtenido 5 muestras perioperatorias de sangre: por venopunción, durante la inducción anestésica (muestra 1), al final de la circulación extracorpórea (muestra 2) y una hora después de la reinfusión de la sangre del drenaje mediastínico (muestra 5); y del reservorio de cardiotomía, en la primera y sexta horas del postoperatorio (muestras 3 y 4). En cada muestra se han evaluado parámetros hematológicos, bioquímicos e inmunológicos, así como el estado metabólico y funcional de los eritrocitos.RESULTADOS. Las concentraciones de hemoglobina libre en el plasma y el porcentaje de equinocitos estaban más elevados al final de la circulación extracorpórea y en el drenaje, correlacionándose este último con el descenso de la albúmina debido a la hemodilución. El resto de valores hematológicos y bioquímicos eran más bajos al final de la circulación extracorpórea y en el drenaje, pero no tras la reinfusión. No se detectaron alteraciones en la fragilidad osmótica eritrocitaria media, la captación de glucosa y aminoácidos o la concentración de 2,3bisfosfoglicerato (2,3-BPG). Las concentraciones plasmáticas de interleucina (IL) 10 se elevaron al final de la circulación extracorpórea, mientras que en sangre de drenaje se observó un aumento de IL-1 , IL-6 e IL-10.La reinfusión de sangre del drenaje no modificó significativamente el patrón de citocinas circulantes con respecto al observado al final de la CEC.CONCLUSIONES. La sangre recuperada del drenaje mediastínico tras cirugía cardíaca supone una excelente fuente de eritrocitos que conservan una funcionalidad y un estado metabólico normales y su reinfusión no modifica la respuesta inflamatoria del paciente a la circulación extracorpórea (AU)

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[Platelet changes during heart surgery with extracorporeal circulation]. / Variación plaquetaria durante la cirugía cardíaca con circulación extracorpórea.

The changes in the number of platelets during anesthesia and operation were evaluated in 24 patients (8 females and 16 males) scheduled for cardiac surgery with cardiopulmonary bypass. There was a significant (p less than 0.05) thrombopenia at the beginning of perfusion, which persisted 60 minutes after the end of cardiopulmonary bypass. There were no significant differences when these changes were evaluated depending on the type of oxygenator, the need for transfusion or the duration of cardiopulmonary bypass. There was a reduction in the platelet count at the beginning of the bypass (207 to 124 x 10(9).1(-1), when blood contacts with the synthetic surfaces of the circuits and the oxygenator, al though-the most marked reduction was found at the end of bypass (95.9 x 10(9).1-1), coinciding with protamine administration. The function and number of platelets tended to become normal in the first hours of the postoperative period.

[Changes in total and differential leukocyte counts during heart surgery with extracorporeal circulation]. / Variación en el recuento y fórmula leucocitarios durante la cirugía cardíaca con circulación extracorpórea.

The changes in leukocyte overall and differential counts during anesthesia and surgery were evaluated in 24 patients scheduled for cardiac surgery with cardiopulmonary bypass. All the end of cardiopulmonary bypass a marked and sustained leukocytosis was found (10.2 and 11.1 x 10(9).l-1), which was significantly different from baseline values (6.7 x 10(9).l-1), the values previous to cardiopulmonary bypass (6.2 and 6.4 x 10(9).l-1, and the values 30 minutes after it (5.3 x 10(9).l-1). In the differential count there were significant increases in neutrophils, associated with band and immature forms, corresponding with significant reductions in lymphocytes. There was no significant association of leukocyte variability during and after cardiopulmonary bypass and the perfusion time, the type of oxygenator or the need for intraoperative transfusion. All the reported changes tended to become normal during the first postoperative days.