Riesgo anafiláctico por mastocitosis sistémica: manejo perioperatorio en cirugía cardíaca / Anaphylactic risk due to systemic mastocytosis: perioperative management in cardiac surgery

La mastocitosis es una enfermedad caracterizada por una proliferación anormal de los mastocitos. La degranulación de los mastocitos puede desencadenarse por factores químicos, físicos y psíquicos, y en casos graves puede cursar con alteraciones cardiovasculares y shock. Concentraciones de triptasa superiores a 20mcg/l se podrían correlacionar con mayor riesgo de degranulación mastocitaria. Presentamos el caso de un varón de 71 años sometido a cirugía de sustitución valvular aórtica y derivación aortocoronaria con mastocitosis sistémica indolente, con antecedentes de crisis histaminérgicas y con valores basales previos a la cirugía de tripatasa de 58,1mcg/l

Mastocytosis is a disease characterised by an abnormal proliferation of mast cells. The degranulation of mast cells can be triggered by chemical, physical, and psychological factors, and in severe cases may be accompanied by cardiovascular alterations and shock. Tryptase concentrations greater than 20ug/L may be associated with an increased risk of mastocyte degranulation. The case is presented on a 71 year-old man that underwent an aortic valve replacement and aortic-coronary bypass surgery. He had an indolent systemic mastocytosis and a history of histaminergic crises, with a baseline value of tryptase prior to surgery of 58.1ug/L

Anaphylactic risk due to systemic mastocytosis: Perioperative management in cardiac surgery. / Riesgo anafiláctico por mastocitosis sistémica: manejo perioperatorio en cirugía cardíaca.

Mastocytosis is a disease characterised by an abnormal proliferation of mast cells. The degranulation of mast cells can be triggered by chemical, physical, and psychological factors, and in severe cases may be accompanied by cardiovascular alterations and shock. Tryptase concentrations greater than 20ug/L may be associated with an increased risk of mastocyte degranulation. The case is presented on a 71 year-old man that underwent an aortic valve replacement and aortic-coronary bypass surgery. He had an indolent systemic mastocytosis and a history of histaminergic crises, with a baseline value of tryptase prior to surgery of 58.1ug/L.

[Cerebral oximetry monitoring during bypass surgery: can the approach be changed?]. / Monitorización de la oximetría cerebral durante cirugía extracorpórea: puede modificar la actitud quirúrgica.

We describe the detection of postoperative neurologic complications by means of monitoring cerebral oximetry during cardiac surgery. A 54-year-old man underwent emergency surgery for aortic dissection, type A. Cerebral oximetry was monitored by near-infrared spectroscopy. At the start of total cardiopulmonary bypass through the axillary artery, cerebral oxygen saturation fell more than 50% from baseline in both hemispheres. Saturation did not improve on optimizing factors that influence cerebral blood flow. Improvement came only when the recently inserted arterial cannula was switched to the ascending aortic prosthetic graft. After surgery, the patient was diagnosed with anoxic brain injury. We believe that the detected fall in cerebral oxygen saturation during axillary artery cannulization probably coincided with the occurrence of anoxic brain injury.

Monitorización de la oximetría cerebral durante cirugía extracorpórea ¿puede modificar la actitud quirúrgica / Cerebral oximetry monitoring during bypass surgery: can the approach be changed?

OBJETIVO: Describir la detección de complicacionesneurológicas postoperatorias en cirugía cardiaca pormedio de la monitorización intraoperatoria de la oximetríacerebral.CASO CLÍNICO: Presentamos el caso de un varón de 54años intervenido de urgencia con el diagnóstico de disecciónaórtica tipo A. Durante la cirugía se monitorizó laoximetría cerebral mediante la tecnología NIRS (NearInfrared Spectroscopy: espectroscopía óptica con unabanda cercana al infrarrojo).RESULTADOS Y CONCLUSIONES: Al iniciarse la derivacióncardiopulmonar total a través de la arteria axilar, seapreció un descenso superior al 50% respecto a la líneabasal de los valores de saturación regional cerebral deoxígeno en ambos hemisferios cerebrales. Estos valoresno mejoraron al optimizar los factores que influyen en laregulación del flujo sanguíneo cerebral, y sólo se modificaronal cambiar la canulación arterial a la prótesis deaorta ascendente recién colocada. En el postoperatorio elpaciente fue diagnosticado de encefalopatía anóxica. Ennuestra opinión, el descenso mantenido de los valores desaturación regional cerebral de oxígeno observadodurante la canulación axilar, podría corresponder con elepisodio de anoxia cerebral(AU)

We describe the detection of postoperative neurologiccomplications by means of monitoring cerebral oximetryduring cardiac surgery. A 54-year-old man underwentemergency surgery for aortic dissection, type A.Cerebral oximetry was monitored by near-infraredspectroscopy. At the start of total cardiopulmonarybypass through the axillary artery, cerebral oxygensaturation fell more than 50% from baseline in bothhemispheres. Saturation did not improve on optimizingfactors that influence cerebral blood flow. Improvementcame only when the recently inserted arterial cannulawas switched to the ascending aortic prosthetic graft.After surgery, the patient was diagnosed with anoxicbrain injury. We believe that the detected fall in cerebraloxygen saturation during axillary artery cannulizationprobably coincided with the occurrence of anoxic braininjury(AU)

[Efficacy of the EMLA cream in the reduction of pain caused by venipuncture in children premedicated with oral midazolam]. / Eficacia de la crema EMLA en la disminución del dolor a la venopunción en niños premedicados con midazolam oral.

OBJECTIVE: EMLA cream, a lidocaine-prilocaine mixture, penetrates skin easily. Our aim was to compare EMLA and placebo to assess the efficacy of EMLA in decreasing the pain of venipuncture in children premedicated with oral midazolam 0.5 mg/kg. PATIENTS AND METHODS: This was a prospective study enrolling 100 children 3 to 9 years of age (5.6 +/- 2) randomly distributed in 2 groups of 50. EMLA cream was applied in group 1 while placebo was applied in group 2 (control group). All were premedicated with oral midazolam. Either EMLA or placebo was applied at least 30 minutes before transfer to the operating theater and the area was covered with a transparent dressing. Parameters recorded upon arrival in the operating room and upon hand puncture with a 22-G needle were systolic and diastolic arterial pressures (SAP and DAP) and heart rate (HR). Pain was assessed on a behavior scale, a visual analog scale evaluated by the anesthesiologist (VAS-anesthesiologist) and a VAS evaluated by a nurse (VAS-nurse). Adverse events were also recorded. A Student t-test and a Mann-Whitney U-test were used for statistical analysis; the level of significance was p < 0.05. RESULTS: There were no significant differences in mean age or weight between the 2 groups. In the area EMLA was applied, 2 children presented erythema and 2 pruritus. Mean scores on the pain scales were lower in the EMLA group (p < 0.05) than in the control group: behavior scale 1.8 +/- 1.3 versus 3.2 +/- 1.7; VAS-anesthesiologist 2.8 +/- 2.3 versus 5.1 +/- 2.7; VAS-nurse 2.7 +/- 2.1 versus 5.9 +/- 1.9. HR increased in both groups (with placebo from 105 +/- 16 to 118 +/- 19, and with EMLA from 99 +/- 19 to 109 +/- 21), but the increase in SAP was statistically significant only in the placebo group, in which it rose from 113 +/- 11 to 125 +/- 16. CONCLUSION: EMLA cream decreases the pain of hand venipuncture in children premedicated with oral midazolam.