Arterial oxygen saturation in healthy Mexican full-term newborns at different altitudes above sea level.

BACKGROUND: Arterial oxygen saturation (SaO2) values are used to make clinical decisions that might change a patient's prognosis, and it has been proposed as the fifth vital sign. This study aimed to determine the variation of SaO2 at different altitudes above sea level (ASL) in healthy Mexican full-term newborns. METHODS: From July 2018 to June 2019, a cross-over study was conducted in six hospitals at different altitudes ASL in Mexico. SaO2 was measured in 4015 newborns after the first 24 h of birth and before leaving the hospital using pulse oximetry. We analyzed three groups: < 250 m ASL (group 1), 1500 m ASL (group 2), and 2250 m ASL (group 3). RESULTS: The mean SaO2 was 97.6 ± 1.8%. For group 1, mean oxygen saturation was 98.2 ± 1.9%; for group 2, 96.7 ± 1.9%, and for group 3, 96.0 ± 2.1%. A statistically significant difference was observed among the groups (p < 0.001), and this difference was higher between groups 1 and 2 (1.5%, p < 0.001). Linear regression analysis showed a decrease in oxygen saturation of 1.01% for every 1000 m ASL. CONCLUSIONS: We demonstrated a statistically significant reduction in SaO2 levels at higher altitudes. This observation can be relevant for clinical decision-making based on pulse oximetry such as critical congenital heart disease screening in Mexico, where more than half of the population lives above 1500 m ASL.

INTRODUCCIÓN: Los valores de SaO2 (saturación de oxígeno) se utilizan para la toma de decisiones clínicas que podrían cambiar el pronóstico del paciente. El objetivo de este estudio fue determinar la variación de la SaO2 en recién nacidos mexicanos a término sanos a diferentes altitudes en México. MÉTODOS: Se llevó a cabo un estudio transversal en seis hospitales situados a diferentes altitudes en México. Se determinó la SaO2 usando oximetría de pulso en 4015 recién nacidos después de las primeras 24 horas de vida, pero antes del egreso del hospital de nacimiento. Se formaron tres grupos para el análisis: grupo 1 con altitud < 250 m sobre el nivel del mar (SNM); grupo 2, altitud de 1500 m SNM y grupo 3, altitud de 2250 m SNM. RESULTADOS: El promedio de la SaO2 fue de 97.6 ± 1.8%. Para el grupo 1, la media fue 98.2 ± 1.9%, para el 2, 96.7 ± 1.9% y para el 3, 96.0 ± 2.1%. Se observó una diferencia estadísticamente significativa entre los grupos (p < 0.001), que fue mayor entre los grupos 1 y 2 (1.5%, p < 0.001). El análisis de regresión lineal mostró una reducción de 1.01% en la SaO2 por cada 1000 m SNM. CONCLUSIONES: Se demostró una disminución estadísticamente significativa de los valores de SaO2 conforme aumenta la altitud. Esto puede ser de particular relevancia en la toma de decisions clínicas basadas en la oximetría de pulso, como el tamiz neonatal cardiaco, sobre todo en México donde mas de la mitad de la población vive a una altitud superior a 1500 m SNM.

Arterial oxygen saturation in healthy Mexican full-term newborns at different altitudes above sea level / Saturación arterial de oxígeno en recien nacidos mexicanos a término sanos a diferentes altitudes sobre el nivel del mar

Abstract Background: Arterial oxygen saturation (SaO2) values are used to make clinical decisions that might change a patient's prognosis, and it has been proposed as the fifth vital sign. This study aimed to determine the variation of SaO2 at different altitudes above sea level (ASL) in healthy Mexican full-term newborns. Methods: From July 2018 to June 2019, a cross-over study was conducted in six hospitals at different altitudes ASL in Mexico. SaO2 was measured in 4015 newborns after the first 24 h of birth and before leaving the hospital using pulse oximetry. We analyzed three groups: < 250 m ASL (group 1), 1500 m ASL (group 2), and 2250 m ASL (group 3). Results: The mean SaO2 was 97.6 ± 1.8%. For group 1, mean oxygen saturation was 98.2 ± 1.9%; for group 2, 96.7 ± 1.9%, and for group 3, 96.0 ± 2.1%. A statistically significant difference was observed among the groups (p < 0.001), and this difference was higher between groups 1 and 2 (1.5%, p < 0.001). Linear regression analysis showed a decrease in oxygen saturation of 1.01% for every 1000 m ASL. Conclusions: We demonstrated a statistically significant reduction in SaO2 levels at higher altitudes. This observation can be relevant for clinical decision-making based on pulse oximetry such as critical congenital heart disease screening in Mexico, where more than half of the population lives above 1500 m ASL.

Resumen Introducción: Los valores de SaO2 (saturación de oxígeno) se utilizan para la toma de decisiones clínicas que podrían cambiar el pronóstico del paciente. El objetivo de este estudio fue determinar la variación de la SaO2 en recién nacidos mexicanos a término sanos a diferentes altitudes en México. Métodos: Se llevó a cabo un estudio transversal en seis hospitales situados a diferentes altitudes en México. Se determinó la SaO2 usando oximetría de pulso en 4015 recién nacidos después de las primeras 24 horas de vida, pero antes del egreso del hospital de nacimiento. Se formaron tres grupos para el análisis: grupo 1 con altitud < 250 m sobre el nivel del mar (SNM); grupo 2, altitud de 1500 m SNM y grupo 3, altitud de 2250 m SNM. Resultados: El promedio de la SaO2 fue de 97.6 ± 1.8%. Para el grupo 1, la media fue 98.2 ± 1.9%, para el 2, 96.7 ± 1.9% y para el 3, 96.0 ± 2.1%. Se observó una diferencia estadísticamente significativa entre los grupos (p < 0.001), que fue mayor entre los grupos 1 y 2 (1.5%, p < 0.001). El análisis de regresión lineal mostró una reducción de 1.01% en la SaO2 por cada 1000 m SNM. Conclusiones: Se demostró una disminución estadísticamente significativa de los valores de SaO2 conforme aumenta la altitud. Esto puede ser de particular relevancia en la toma de decisions clínicas basadas en la oximetría de pulso, como el tamiz neonatal cardiaco, sobre todo en México donde mas de la mitad de la población vive a una altitud superior a 1500 m SNM.

Early Extubation in a Pediatric Cardiac Surgery Program Located at High Altitude.

BACKGROUND: Early extubation is performed either in the operating room or in the cardiovascular intensive care unit during the first 24 postoperative hours; however, altitude might possibly affect the process. The aim of this study is the evaluation of early extubation feasibility of patients undergoing congenital heart surgery in a center located at 2,691 m (8,828 ft.) above sea level. MATERIAL AND METHODS: Patients undergoing congenital heart surgery, from August 2012 through December 2018, were considered for early extubation. The following variables were recorded: weight, serum lactate, presence or not of Down syndrome, optimal oxygenation and acid-base status according to individual physiological condition (biventricular or univentricular), age, bypass time, and ventricular function. Standardized anesthetic management with dexmedetomidine-fentanyl-rocuronium and sevoflurane was used. If extubation in the operating room was considered, 0.08 mL/kg of 0.5% ropivacaine was injected into the parasternal intercostal spaces bilaterally before closing the sternum. RESULTS: Four hundred seventy-eight patients were operated and 81% were early extubated. Mean pre- and postoperative SaO2 was 92% and 98%; postoperative SaO2 for Glenn and Fontan procedures patients was 82% and 91%, respectively. Seventy-three percent of patients who underwent Glenn procedure, 89% of those who underwent Fontan procedure (all nonfenestrated), and 85% with Down syndrome were extubated in the operating room. Reintubation rate in early extubated patients was 3.6%. CONCLUSION: Early extubation is feasible, with low reintubation rates, at 2,691 m (8,828 ft.) above sea level, even in patients with single ventricle physiology.

Norwood Procedure in a Patient With Hypoplastic Left Heart Syndrome, Right Aortic Arch, and Right Descending Aorta.

We describe the surgical treatment of a patient with hypoplastic left heart syndrome and right aortic arch.

Definiciones operativas y protocolo anestésico durante la pandemia producida por SARS-CoV-2 en un programa de cirugía cardíaca pediátrica / Operative definitions and anesthetic protocol during the SARS-CoV-2 pandemic in a pediatric cardiac surgery program

The clinical characteristics of the pediatric population infected with the SARS-CoV-2 virus in general are not as severe as in the adult population, so they can be considered asymptomatic carriers. The pediatric patient with congenital heart disease are considered a high risk group of contagion in the SARS-CoV-2 pandemic, so healthcare personnel who interact with patients must have established guidelines to avoid transmission and spread of the disease. Each country is commanded by the central guidelines established by its health system considering operative definitions and protocols, but in certain places these guidelines do not fulfill international standards, as those proposed by the World Health Organization. In this communication we have done a current literature review and adaptation of the recommendations to face the infectious outbreak due to the SARS-CoV-2 virus in pediatric cardiovascular surgery programs, specifically in the ​​anesthesiology area. We also analyze the type of personal protective equipment that should be used in each area of ​​patient management, changes in the environment of work areas, shift times of health personnel, the protection of personnel performing transesophageal echocardiography, modification of the airway management algorithms, proper placement and withdrawal of personal protective equipment, patients transfer between wards or other services, and adequate disinfection of airway equipment used.

Las características clínicas de la población pediátrica contagiada del virus SARS-CoV-2 en general no son tan severas como en la población adulta, por lo que pueden ser considerados portadores asintomáticos. El paciente pediátrico con cardiopatía congénita pertenece a un grupo de alto riesgo de contagio dentro de la pandemia producida por el SARS-CoV-2, por lo que el personal sanitario que interactúe con los pacientes debe tener lineamientos establecidos para evitar la transmisión y propagación de la enfermedad. Cada país se rige por las guías centrales establecidas por su sistema de salud en cuanto a definiciones operativas y protocolos, pero en algunos lugares estas directrices no cumplen las metas internacionales, como las propuestas por la Organización Mundial de la Salud. En este comunicado hemos realizado una revisión de la literatura actual y adaptación de las recomendaciones para enfrentar el brote infeccioso por el virus SARS-CoV-2 en los programas de cirugía cardiovascular pediátrica, específicamente en el área de anestesiología. También analizamos el tipo de equipo de protección personal que debe ser utilizado en cada área del manejo de pacientes, cambios del ambiente de las áreas de trabajo, rotación de personal, la protección del personal que realiza ecocardiografía transesofágica, modificación de los algoritmos de manejo de la vía aérea, colocación y retiro correctos del equipo de protección personal, traslado de los pacientes entre servicios, y adecuada desinfección del equipo utilizado en el manejo de la vía aérea.

Outcomes of the Non-fenestrated Fontan Procedure at High Altitude.

BACKGROUND: Although high altitude has been considered a risk factor for the Fontan operation, and an indication for fenestration, there is a paucity of data to support its routine use. Fenestration, with its necessary right to left induced shunt, together with the lower partial pressure of oxygen found with progressive altitude, can significantly decrease hemoglobin oxygen saturation, and therefore, it would be desirable to avoid it. OBJECTIVE: To analyze immediate and medium-term results of the non-fenestrated, extracardiac, Fontan procedure at high altitude. METHODS: Retrospective analysis of data from consecutive patients who underwent non-fenestrated, extracardiac, Fontan procedure at two institutions located in Mexico City at 2,312 m (7,585 ft) and 2,691 m (8,828 ft) above sea level. High altitude was not considered a risk factor. RESULTS: Thirty-nine patients were included, with a mean age of 6.7 years. Mean preoperative indexed pulmonary vascular resistance was 1.7 Wood units. Seventy-nine percent of the patients extubated in the operating room. There was one in-hospital death (2.56%) and one at follow-up. Median chest tube drainage time was 6.5 and 6 days for the right and left pleural spaces. Median oxygen saturation at discharge was 90%. At a median follow-up of six months, all survivors, except one, had good tolerance to daily life activities. CONCLUSIONS: The present study shows good short- and medium-term results for the non-fenestrated, extracardiac, Fontan operation at altitudes between 2,300 and 2,700 m and might favor this strategy over fenestration to improve postoperative oxygen saturation. Further studies to examine the long-term outcomes of this approach need to be considered.

A Novel Private-Public Hybrid Model for Treatment of Congenital Heart Disease in Mexico.

Mortality after surgery for congenital heart disease (CHD) in Mexico is significantly higher than in high-income countries due to structural, medical, and financial factors. In Mexico, public hospitals have a large volume of patients but inadequate quality control systems, whereas private hospitals, although having higher quality control systems, have an insufficient number of patients to build programs of excellence. We describe the creation of a novel hybrid private-public program in Mexico that leverages the advantages of both sectors while establishing an integrated multidisciplinary unit that has allowed us to improve the quality of care for patients with CHD.

Seguridad de la re-esternotomía media en el tratamiento paliativo de pacientes con corazón univentricular / Safety of repeat median sternotomy in the palliative treatment of patients with a univentricular heart

Resumen: Objetivo: Describir la morbimortalidad operatoria relacionada a re-esternotomía media en pacientes con corazón univentricular en el Instituto Nacional de Pediatría. Método: Estudio de serie de casos retrospectiva, descriptiva y analítica del año 2001 al 2016. Resultados: Se encontraron 65 pacientes que requirieron 76 procedimientos. Hubo 59 primeras re-esternotomías, con promedio de edad de 36 meses (4-176 meses) y peso 12.2 kg (3.2-21.5 kg); se realizaron 40 procedimientos de Glenn y 19 procedimientos de Fontan. Se practicaron 17 segundas re-esternotomías, con promedio de edad de 89 meses (48-156 meses) y 22.7 kg de peso (14.4-41 kg), en quienes se realizaron 17 procedimientos de Fontan. Hubo dos lesiones en primeras re-esternotomías, una lesión a la coronaria derecha con cambios electrocardiográficos, y una apertura incidental de la aurícula derecha que causó hipotensión. Reportamos una muerte secundaria a lesión de la aorta con sangrado masivo durante una segunda re-esternotomía, lo que representa una morbimortalidad del 3.9%. Conclusiones: Concluimos que la re-esternotomía es un procedimiento seguro en nuestro centro.

Abstract: Objective: To establish the morbidity and mortality of patients with univentricular hearts who underwent a repeat median sternotomy at the Instituto Nacional de Pediatría. Method: A retrospective review was performed on the clinical charts of all patients who under-went a repeat median sternotomy from 2001 to 2016. Results: Sixty-five patients underwent 76 surgeries by repeat median sternotomy. Fifty-nine patients had a first repeat median sternotomy, with a mean age of 36 months (range: 4-176 months) and a mean weight of 12.2 kg (range: 3.2-21.5 kg). Forty patients had a Glenn procedure, and 19 patients had a Fontan procedure. There were 17 patients with a second repeat median sternotomy, with a mean age of 89 months (range 48-156 months), and a mean weight of 22.7 kg (14.4-41 kg). A Fontan procedure was performed on all these 17 patients. A section of the right coronary artery with electrocardiographic changes and a right atrium tear that caused hypotension occurred during first repeat sternotomy. An aortic tear occurred during a second repeat sternotomy with massive bleeding and subsequent death. This represents 3.9% of re-entry injuries. Conclusion: It is concluded that repeat median sternotomy is a safe procedure.

Identificación de un patrón tromboelastográfico en niños sometidos a cirugía cardiaca con exposición prolongada a circulación extracorpórea / Identification of a thromboelastographic pattern in children undergoing cardiac surgery with prolonged exposure to cardiopulmonary bypass

Background: Point-of-care thromboelastography is used for guiding peri-operative haemostatic therapy. Objective: To identify a thromboelastographic pattern in children with prolonged cardiopulmonary bypass exposure. Material and methods: A cohort study of 62 patients undergoing prolonged cardiopulmonary bypass was performed. Patients with preexisting coagulopathy, use of drugs known to interfere with clotting, hematocrit > 60%, weight < 3 kg, or hepatic disease were excluded. The thromboelastography study was conducted at the point of care. Results: Baseline and rewarming reaction time values were 8.24 ± 6.35 and 7.66 ± 2.15min, respectively (p = 0.102). Baseline and rewarming angle values were 64.88 ± 13.08 and 54.67 ± 8.98 degrees, respectively (p < 0.001). Baseline and rewarming maximum amplitude values were 64.54 ± 12.31 and 43.14 ± 12.47 mm, respectively (p = 0.001). The same trend was observed when the cohort was divided into patients under and over 3 years of age, and patients under and over 10 kg of body weight. Discussion: This study suggests the existence of a thromboelastographic pattern independent of age or weight in patients undergoing paediatric cardiac surgery with prolonged cardiopulmonary bypass exposure, characterised by a reduction of angle and maximum amplitude values, with no change in reaction time.

Introducción: La tromboelastografía se emplea para la orientación en el manejo de la coagulación perioperatoria en el sitio de atención. Objetívo: Identificar un patrón de coagulación en niños sometidos a tiempos prolongados en circulación extracorpórea así como su asociación con edad y peso. Material y Métodos: Realizamos un estudio de cohorte en 62 pacientes sometidos a circulación extracorpórea prolongada. Excluimos pacientes con coagulopatía pre - existente, empleo de medicamentos interfiriendo con la coagulación, hematocrito > 60%, peso < 3 Kg o con enfermedad hepática. El estudio de tromboelastografía fue realizado en el sitio de atención. Resultados: Los valores para el tiempo de Reacción basales y durante recalentamiento fueron: 8,24 +/- 6,35 y 7,66 +/- 2,15 minutos respectivamente (p= 0,102). Los valores para el Ángulo basales y durante recalentamiento fueron: 64,89 +/- 13,08 y 54,67 +/- 8,98 grados (p< 0,001). Los valores para Amplitud Máxima basales y durante recalentamiento fueron: 64,54 +/-12,31 y 43,14 +/- 12,47 mm respectivamente (p = 0,001). Dividiendo la cohorte en pacientes menores o mayores a 3 años o bien en menores o mayores a 10 Kg se observó el mismo comportamiento. Discusión: Este estudio sugiere la existencia de un patrón tromboelastográfico independiente de la edad o peso en pacientes sometidos cirugía cardiaca pediátrica con permanencia prolongada en circulación extracorpórea caracterizado por reducción en los valores de ángulo y amplitud máxima, sin modificación en el tiempo de reacción.

Postoperative Infection in Developing World Congenital Heart Surgery Programs: Data From the International Quality Improvement Collaborative.

BACKGROUND: Postoperative infections contribute substantially to morbidity and mortality after congenital heart disease surgery and are often preventable. We sought to identify risk factors for postoperative infection and the impact on outcomes after congenital heart surgery, using data from the International Quality Improvement Collaborative for Congenital Heart Surgery in Developing World Countries. METHODS AND RESULTS: Pediatric cardiac surgical cases performed between 2010 and 2012 at 27 participating sites in 16 developing countries were included. Key variables were audited during site visits. Demographics, preoperative, procedural, surgical complexity, and outcome data were analyzed. Univariate and multivariable logistic regression were used to identify risk factors for infection, including bacterial sepsis and surgical site infection, and other clinical outcomes. Standardized infection ratios were computed to track progress over time. Of 14 545 cases, 793 (5.5%) had bacterial sepsis and 306 (2.1%) had surgical site infection. In-hospital mortality was significantly higher among cases with infection than among those without infection (16.7% versus 5.3%; P<0.001), as were postoperative ventilation duration (80 versus 14 hours; P<0.001) and intensive care unit stay (216 versus 68 hours; P<0.001). Younger age at surgery, higher surgical complexity, lower oxygen saturation, and major medical illness were independent risk factors for infection. The overall standardized infection ratio was 0.65 (95% confidence interval, 0.58-0.73) in 2011 and 0.59 (95% confidence interval, 0.54-0.64) in 2012, compared with that in 2010. CONCLUSIONS: Postoperative infections contribute to mortality and morbidity after congenital heart surgery. Younger, more complex patients are at particular risk. Quality improvement targeted at infection risk may reduce morbidity and mortality in the developing world.

[Safety of repeat median sternotomy in the palliative treatment of patients with a univentricular heart]. / Seguridad de la re-esternotomía media en el tratamiento paliativo de pacientes con corazón univentricular.

OBJECTIVE: To establish the morbidity and mortality of patients with univentricular hearts who underwent a repeat median sternotomy at the Instituto Nacional de Pediatría. METHOD: A retrospective review was performed on the clinical charts of all patients who underwent a repeat median sternotomy from 2001 to 2016. RESULTS: Sixty-five patients underwent 76 surgeries by repeat median sternotomy. Fifty-nine patients had a first repeat median sternotomy, with a mean age of 36 months (range: 4-176 months) and a mean weight of 12.2 kg (range: 3.2-21.5 kg). Forty patients had a Glenn procedure, and 19 patients had a Fontan procedure. There were 17 patients with a second repeat median sternotomy, with a mean age of 89 months (range 48-156 months), and a mean weight of 22.7 kg (14.4-41 kg). A Fontan procedure was performed on all these 17 patients. A section of the right coronary artery with electrocardiographic changes and a right atrium tear that caused hypotension occurred during first repeat sternotomy. An aortic tear occurred during a second repeat sternotomy with massive bleeding and subsequent death. This represents 3.9% of re-entry injuries. CONCLUSION: It is concluded that repeat median sternotomy is a safe procedure.

Tromboelastografía como guía para terapia transfusional en paciente con síndrome de Turner, hipoplasia de arco aórtico y coartación aórtica sometido a aortoplastia con «técnica de deslizamiento¼: reporte de un caso / Thromboelastography as a guide for transfusion therapy in a patient with Turner's syndrome, hypoplasia of the aortic arch and aortic coarctation, undergoing aortoplasty with sliding technique: Case report

Una de las lesiones más comunes en el grupo de cardiopatías congénitas es la hipoplasia del arco aórtico y la coexistencia de coartación aórtica en niños mayores, lo cual es de muy difícil manejo. Recientemente se describió una técnica para tratar esta patología que requiere extensas líneas de sutura y un preciso manejo de las alteraciones de coagulación asociadas con el empleo de circulación extracorpórea. Presentamos el caso de una niña de 8 años y 9 meses de edad con síndrome de Turner, coartación aórtica e hipoplasia de arco aórtico, que ingresó para plastia del arco por deslizamiento y que recibió terapia transfusional guiada mediante tromboelastografía.

One of the most frequent lesions in congenital heart disease is hypoplasia of the aortic arch and the co-existence of aortic coarctation in older children, which is very difficult to treat. A new technique for treating this condition was recently described and it requires extensive suture lines and an accurate management of coagulation disorders associated with the use of extracorporeal circulation. We present a case of an 8 years and 9 months old girl with Turner’s syndrome, aortic coarctation and aortic arch hypoplasia that was admitted for sliding arch aortoplasty and received thromboelastography guided transfusion therapy.

[Aortic arch advancement surgery as treatment for aortic coarctation with hypoplastic aortic arch in children]. / Avance de arco aórtico en el manejo de la coartación de aorta con hipoplasia del arco aórtico en niños.

INTRODUCTION: Treatment of aortic coarctation with hypoplastic aortic arch is still a surgical challenge. The aortic arch advancement surgery has shown less re-coarctation frequency. OBJECTIVE: To determine the re-coarctation frequency in patients who underwent aortic arch advancement technique for aortic coarctation with hypoplastic aortic arch and analyze the results. MATERIAL AND METHODS: Retrospective and observational study of 38 patients who underwent aortic arch advancement in a third level Institution from 2002 to 2010. RESULTS: Twenty four males and 14 females all with aortic arch Z index diameter of < or = -2 were found. The median age was 2.6 months and the median weight was 3.8 kg. Twelve patients (31.5%) did not show post operative complications. Eighteen (47%) had only one complication; one patient (2.6%) had 2 complications and 2 (5.2%) had 3 complications. After a follow up of 3.7 years the frequency of re-coarctation was O%. DISCUSSION: With the previously mentioned technique the recoarctation frequency on medium and long term basis was 0%. From the anatomical and functional point of view, we believe this technique offers the best possible results.

[Hepatic fasciolasis diagnosed in state phase]. / Fasciolosis hepática diagnosticada en fase de estado.

INTRODUCTION: Hepatic fasciolosis is a zoonosis that accidentally can invade the human. REPORT OF A CASE: 62 years old male, farmer, lives in a rural community in Tehuacan, Puebla, Mexico. His living space is not provided with running water nor drainage. He has contact with sheep and bovines. Started presenting symptoms two years before. Suffered from myalgia, joint pain, fever of 38 degrees C and epigastric pain that radiated the hypocondrium and the right shoulder. He had diarrhea five times in 24 hours as well as lack of appetite that lead to a weight loss of 20 kilograms in two years. He was hospitalized and the physical examination revealed diminished muscular mass, right hypocondrium pain and hepatomegaly of 3 cm below costal margin. He said he ate watercress (Nasturium officinalis) two or three times a week. Blood test revealed erythrocytes of 3.6 x 105 mm3; hemoglobin of 11.9 g/dL; hematocrit of 30%; leukocytes 8950 mm3; neutrophils 65%; lymphocytes of 30%; eosinophils of 3%; monocytes of 1% and basophiles of 1%. Globular sedimentation was 83 mm and hemoglobin concentration was 33. Liver test results were normal and mycobacterium in fecal samples was negative, but stool detection tests revealed eggs of Fasciola hepatica. The diagnosis was hepatic fasciolosis in its biliar stage. Dehidrohemetine (1.5 mg/kg) was administered during 10 days. Symptoms disappeared within 48 hours. CONCLUSION: The lack of knowledge about fasciolosis makes it hard to diagnose it. The publication of case reports must help to facilitate its diagnosis.

Miasis de nasofaringe, completando ciclo biológico in vitro / Myasis of nasopharynx, biologic cycle completed in vitro

Introducción. Miasis es la destrucción de tejidos de animales, incluido el hombre, por larvas de moscas. Caso clínico. Paciente femenino de 13 años de edad con antecedente de convivencia con aves de corral, que presentó, 5 días previos a su ingreso, temperatura de 38° C, dolor y prurito nasofaríngeo. En el servicio de urgencias se diagnosticó como rinofaringitis bacteriana, prescribiéndole penicilina procaínica y clorfeniramina. A los 3 días refirió salida de gusanos por boca y nariz en número de 10. A la exploración física se apreció faringe con hiperemia, saliendo por nariz y boca gusanos activamente móviles de color blancoamarillento, de 10 mm de longitud y 3 mm de ancho, en número de 20. Enviados a la Facultad de Medicina de Puebla, donde completaron ciclo biológico. La mosca obtenida fue Dermatobia hominis, familia Enterebridae. En el hospital se le practicó extracción de 85 larvas utilizando anestesia general e irrigación continua. Fue dada de alta 10 días después, asintomática. Conclusiones. La miasis es poco frecuente y puede ocasionar grandes destrucciones de tejido.

Introduction. Myasis is the parasitism of organs and tissues of warm-blooded vertebrates by the larvae of flies of different species. Case report. Thirteen year old female. Her house is provided with running water and sewer she had contact with farm house poultry. She began presenting symptoms 5 days prior to admission she presented with nasal discharge and pharyngitis. Her temperature was 38° C. At emergency services the patient was diagnosed with bacterial pharyngytis. Penicillin and clorfeniramine were administered. Three days later, larvae started coming out of her nose and mouth. In total 10 larvae were documented. In emergency services at a hospital, physical examination revealed pharyngeal erythema and rinorrhea. The larvae were described as yellowish, 10 mm long and 3 mm wide. The worms were sent to the Department of Parasitology of the School of Medicine of Puebla, Mexico, where they completed the in vitro cycle and were identified as Dermatobia hominis (fly), belonging to the Enterebridae family. In the hospital, 85 larvae were extracted from the patient. She discharged after 10 days of asymptomatic hospitalization. Conclusion. Myasis is not frequent and it can cause great tissue destruction. Antibiotic administration is generally not warranted unless there is evidence of concomitant superinfection.

Efecto de la infusión temporal de pentoxifilina sobre la relación aporte/consumo de oxígeno en el perioperatorio del paciente de alto riesgo / Effect of a temporary infusion of pentoxifylline on the oxygen delivery/consumption relationships in the high risk surgical patient

Introducción. Se han descrito algunos métodos para tratar de detectar a los portadores de deuda crónica de oxígeno, especialmente en pacientes críticamente enfermos. Con el objeto de encontrar pacientes con sufrimiento tisular crónico en el pre operatorio, se diseño una prueba de estimulación utilizando una metilxantina con efecto sobre determinantes de oxigenación tisular. Material y Métodos. Se estudiaron 10 pacientes sometidos a cirugía de alto riesgo o portadores de patología múltiple. Los pacientes se monitorizaron en forma avanzada y recibieron una infusión de 300 mg de pentoxifilina después de la inducción. Se determinaron parámetros hemodinámicos, respiratorios y de oxigenación tisular. La prueba se consideró positiva cuando se obtenía un incremento superior al 10 por ciento del nivel de exceso de base (EB) con respecto a su basal. Resultados. Se encontró un descenso significativo en los valores de pH (basal: 7.44 ñ 0.02; post infusión: 7.40 ñ0.03; p=0.05) y EB (basal: -2.1 ñ 3; post infusión: -6.0 ñ2; p=0.02). El aporte y consumo de oxígeno incrementaron sus valores en forma no significativa. Discusión. Estos resultados, sugieren que la pentoxifilina condiciona una mejor perfusión de tejidos crónicamente comprometidos, lo cual es evidenciado por el hallazgo de incremento en los niveles de exceso de base

Un caso de Leishmaniasis viscel / A case of visceral leishmaniasis

Se presenta el caso de leishmaniasis en una niña de cinco años de edad, residente de Acatlán, estado de Puebla. El cuadro se caracterizó por la presencia de fiebre intermitente de hasta 39ºC, mialgias, artralgia generalizadas sin sinovitis o flogosis, hiporexia y pérdida de siete kilogramos de peso. Asimismo se observó palidez de tegumentos e incremento en el perímetro abdominal secundario a esplenomegalia. En el laboratorio destacó la presencia de pancitopenia; un estudio de médula ósea mostró amastigotes de Leishmania denovani. Se confirmó el diagnóstico mediante cultivo en medio NNN (Novy - Nicolle - MacNeal). La paciente recibió tratamiento de N-metilglucamina con remisión total de la sintomatología. Se presenta también una revisión de la literatura nacional con relación a leishmaniasis visceral