[Massive intravascular hemolysis secondary to sepsis due to Clostridium perfringens]. / Hemólisis masiva intravascular secundaria a sepsis por Clostridium perfringens.

Massive hemolysis secondary to sepsis caused by Clostridium perfringens is a rare entity but appears fairly often in the literature. In nearly all published reports, the clinical course is rapid and fatal. We describe the case of a 75-year-old woman with diabetes who was admitted with symptoms consistent with acute cholecystitis. Deteriorating hemodynamics and laboratory findings were consistent with intravascular hemolysis, coagulation disorder, and renal failure. Gram-positive bacilli of the Clostridium species were detected in blood along with worsening indicators of hemolysis. In spite of antibiotic and surgical treatment, hemodynamic support and infusion of blood products, the patient continued to decline and died in the postoperative recovery unit 14 hours after admission. Mortality ranges from 70% to 100% in sepsis due to Clostridium perfringens, and risk of death is greater if massive hemolysis is present, as in the case we report. Only a high degree of clinical suspicion leading to early diagnosis and treatment can improve the prognosis. This bacterium should therefore be considered whenever severe sepsis and hemolysis coincide.

Hemólisis masiva intravascular secundaria a sepsis por Clostridium perfringens / Massive intravascular hemolysis secondary to sepsis due to Clostridium perfringens

La hemólisis masiva asociada a la sepsis por Clostridiumperfringens, aunque infrecuente, ha sido descritaen un número significativo de casos clínicos. En casitodos ellos la evolución del cuadro ha sido rápidamentefatal. Presentamos el caso de una mujer de 75 años diabéticaingresada por un cuadro compatible con colecistitisaguda que sufrió un deterioro hemodinámico y datosanalíticos compatibles con hemólisis intravascular, coagulopatíae insuficiencia renal. Se detectaron bacilosgram positivo tipo clostridio en sangre y un marcadoempeoramiento de los datos de hemólisis. A pesar deltratamiento antibiótico y quirúrgico y del soporte hemodinámicoy hemoterápico, la paciente evolucionó negativamente,falleciendo a las 14 horas de su ingreso en reanimación.La mortalidad de la sepsis por Clostridiumperfringens llega a ser del 70-100%, sobre todo si se asociaa una hemólisis masiva como ocurrió en nuestrocaso. Sólo un alto grado de sospecha clínica que determineun diagnóstico y tratamiento precoz puede evitar elpronóstico tan infausto. Por ello deberíamos pensar enesta bacteria ante toda sepsis grave asociada a hemólisis(AU)

Massive hemolysis secondary to sepsis caused by Clostridium perfringens is a rare entity but appears fairlyoften in the literature. In nearly all published reports, theclinical course is rapid and fatal. We describe the case of a75-year-old woman with diabetes who was admitted withsymptoms consistent with acute cholecystitis. Deterioratinghemodynamics and laboratory findings were consistentwith intravascular hemolysis, coagulation disorder, andrenal failure. Gram-positive bacilli of the Clostridiumspecies were detected in blood along with worseningindicators of hemolysis. In spite of antibiotic and surgicaltreatment, hemodynamic support and infusion of bloodproducts, the patient continued to decline and died in thepostoperative recovery unit 14 hours after admission.Mortality ranges from 70% to 100% in sepsis due toClostridium perfringens, and risk of death is greater ifmassive hemolysis is present, as in the case we report. Onlya high degree of clinical suspicion leading to early diagnosisand treatment can improve the prognosis. This bacteriumshould therefore be considered whenever severe sepsis andhemolysis coincide(AU)

Síndrome de dificultad respiratoria del recién nacido. Descripción de unacomplicación grave intraoperatoria no diagnosticada previamente / No disponible

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[Recombinant activated factor VII in the postanesthetic recovery unit: review of 16 cases]. / Utilización del rFVIIa en una unidad de reanimación. Revisión de 16 casos.

We describe a series of 16 cases in which recombinant activated factor VII (rFVIIa) was used in our postanesthetic recovery unit. The mean age of the patients was 53.5 years (range, 30-84 years). Eleven were men and 5 women. The mean dose of rFVIIa used was 75 microg x kg(-1) (range, 60-90 microg x kg(-1)) and 25% of the patients needed a second dose. All the patients had postoperative bleeding, 62.5% after general surgery, 25% after a liver transplant, and 12.5% after a lung transplant. rFVIIa therapy was effective in 66% of the patients and no adverse thrombotic events related to treatment were observed. rFVIIa can be an efficacious therapeutic option for bleeding and coagulation disorders that are refractory to conventional replacement therapy. Approval to use rFVIIa in this setting and the establishment of indications should be based on further research.

Utilización del rFVIIa en una Unidad de Reanimación. Revisión de 16 casos / Recombinant activated factor VII in the postanesthetic recovery unit: review of 16 cases

Describimos una serie de 16 pacientes en los que seutilizó el factor VII recombinante activado (rFVIIa) ennuestro Servicio de Reanimación.La media de edad fue de 53,5 años (30-84), 11 varonesy 5 mujeres. La dosis media de rFVIIa utilizada fue de75 µg kg-1 (60-90 µg kg-1) precisando repetir la dosis en el25% de los casos. Todos los pacientes padecían complicacioneshemorrágicas postoperatorias, el 62,5% trascirugía general, el 25% tras trasplante hepático y el12,5% tras trasplante pulmonar.En el 66% de los enfermos, el factor fue efectivo y nohubo episodios trombóticos clínicos secundarios al tratamiento.El rFVIIa puede ser un arma terapéutica efectiva enhemorragias con coagulopatía refractarias al tratamientosustitutivo habitual. La aprobación para su uso eneste contexto así como la determinación de sus indicacionesprecisa de más estudios de investigación

We describe a series of 16 cases in which recombinantactivated factor VII (rFVIIa) was used in our postanestheticrecovery unit.The mean age of the patients was 53.5 years (range, 30-84 years). Eleven were men and 5 women. The mean doseof rFVIIa used was 75 µg·kg-1 (range, 60-90 µg·kg-1) and25% of the patients needed a second dose. All the patientshad postoperative bleeding, 62.5% after general surgery,25% after a liver transplant, and 12.5% after a lung transplant.rFVIIa therapy was effective in 66% of the patients andno adverse thrombotic events related to treatment wereobserved.rFVIIa can be an efficacious therapeutic option for bleedingand coagulation disorders that are refractory to conventionalreplacement therapy. Approval to use rFVIIa inthis setting and the establishment of indications should bebased on further research

[Anaphylactic reaction versus carcinoid crisis: the role of octreotide as a vasoconstrictor]. / Reaccin anafiláctica o crisis carcinoide? papel del octreótido como vasopresor.

A 35-year-old woman was scheduled for laparoscopic removal of an ovarian tumor. Intravenous metamizol was administered and when pneumoperitoneum was performed she developed severe hypotension and bronchospasm. Anaphylactic reaction was suspected, all drugs were suspended, and 2 doses of intravenous adrenalin (0.2 and 1 mg) were injected followed by continuous perfusion. Because response was slow and given the unknown origin of the tumor, the possibility of a carcinoid crisis was considered. When an intravenous bolus dose of octreotide was administered, pressure recovered, patient was extubated and could be transferred asymptomatic to the recovery ward. Tests later ruled out carcinoid syndrome, whereas tryptase levels in blood extracted during surgery and allergy tests confirmed an anaphylactic reaction to metamizol. Carcinoid crisis can be difficult to distinguish from anaphylactic reaction because the clinical pictures are similar. Anesthetic management of carcinoid crisis has been facilitated by administration of octreotide. Less is known about the use of octreotide to treat hypotension in patients with autonomic neuropathy based mainly on the drug's ability to produce splanchnic vasoconstriction. This is probably the reason why octreotide resolved our patient's shock in a context of systemic vasodilation caused by the anaphylactic reaction.