Ultrasound monitoring to detect embolic phenomena in the inferior vena cava during hip arthroplasty.

INTRODUCTION AND OBJECTIVES: Embolic phenomena frequently occur during hip joint replacement surgery, and may lead to haemodynamic instability in frail patients. Transoesophageal ultrasound monitoring is rarely available in non-cardiac operating theatres, and cannot be performed in awake patients under spinal anaesthesia. The main objectives of this prospective exploratory study were to determine the feasibility of using an alternative ultrasound approach to monitor the inferior vena cava during hip replacement surgery, and to determine the intra and interobserver reliability of the ultrasound findings. METHOD: We conducted a prospective exploratory study in 20 patients undergoing cemented hip arthroplasty in the supine position under spinal anaesthesia and sedation. The inferior vena cava was assessed through a subcostal window at 10 intraoperative time points, and the findings were rated on a qualitative embolism severity scale. The ultrasound images were evaluated by 2 independent observers. RESULTS: An adequate subcostal window was obtained in 90% of cases. Intra- and inter-observer reliability was high (kappa index >0.80, p < 0.001). Nearly all (95%) patients presented some degree of embolism, which was severe in 50% of cases. CONCLUSIONS: Our study suggests that ultrasound assessment of embolic phenomena in the inferior vena cava through a subcostal window is feasible in 90% of cases. The qualitative embolic severity rating scale is highly reproducible and has high intra- and inter-observer reliability.

Posición semisentada en cirugía del ángulo pontocerebeloso: análisis de sus complicaciones y cómo evitarlas / Semisitting position for cerebello-pontine angle surgery: Analysis of complications and how to avoid it

Objetivo: Analizar las complicaciones asociadas a la posición semisentada en pacientes intervenidos de patología del ángulo pontocerebeloso (APC).MétodosEstudio retrospectivo, se analizaron los pacientes operados de patología tumoral del APC por un abordaje retrosigmoideo en posición semisentada. Se analizó la incidencia, gravedad, momento de aparición, forma de resolución, duración y repercusiones del embolismo aéreo venoso (EAV), neumoencéfalo, hipotensión postural y otras complicaciones. Se analizó el tiempo de estancia en unidad de críticos (TUCRI), tiempo de estancia hospitalaria (TEH) y puntuación en escala de Rankin a los seis meses.ResultadosSe intervinieron 50 pacientes, once (22%) presentaron EAV (8 ± 4,5 minutos duración media): cinco (10%) durante la resección tumoral, cuatro (8%) durante la apertura dural. Diez (20%) se resolvieron tapando el lecho quirúrgico, aspirando burbujas y aplicando compresión de yugulares, uno (2%) requirió cambio de posición. Uno (2%) tuvo repercusión hemodinámica intraoperatoria. La única variable asociada con desarrollar EAV fue una anatomía patológica de meningioma OR = 4,58, p = 0,001. El TUCRI fue superior en pacientes con EAV (5,5 ± 1,06 vs. 1,9 ± 0,20 días, p = 0,01). No hubo diferencias en la escala Rankin. Todos presentaron neumoencéfalo posquirúrgico con buen nivel de consciencia, salvo uno (2%) que requirió de evacuación. Siete pacientes (14%) presentaron una hipotensión arterial, tres (6%) tras la colocación y uno (2%) tras un EAV, todos revertieron con vasoactivos. No se registraron otras complicaciones asociadas a la posición ni mortalidad en esta serie. (AU)

Objective: To analyze the primary complications related to semisitting position in patients undergoing cerebelo-pontine angle surgery.MethodsRetrospective data analysis from patients undergoing elective tumoral cerebelo-pontine angle surgery in a semisitting position. The incidence, severity, occurrence moment, treatment, duration, and outcomes of venous air embolism (VAE), pneumocephalus, postural hypotension, and other complications were recorded. Neurointensive care unit (NICU), length of stay (LOS), hospital LOS, and modified Rankin scale scores were calculated six months after surgery.ResultsFifty patients were operated on. Eleven (22%) presented VAE (mean duration 8 ± 4.5 min): five (10%) during tumor resection, and four (8%) during dural opening. Ten (20%) were resolved by covering the surgical bed, air bubbles aspiration, jugular compression, and one (2%) tilted to a steep Trendelenburg position. One (2%) had intraoperative hemodynamic instability. The only variable associated with VAE was meningioma at histopathology OR = 4.58, P = 0.001. NICU was higher in patients with VAE (5.5 ± 1.06 vs. 1.9 ± 0.20 days, P = 0.01). There were no differences in the Rankin scale. All patients presented postoperative pneumocephalus with a good level of consciousness, except one (2%) who required evacuation. Seven patients (14%) showed postural hypotension, three (6%) after positioning, and one (2%) after developing a VAE; all were reversed with usual vasoactive drugs. No other position-related complications or mortality were registered in this series. (AU)

Semisitting position for cerebello-pontine angle surgery: Analysis of complications and how to avoid it.

OBJECTIVE: To analyze the primary complications related to semisitting position in patients undergoing cerebelo-pontine angle surgery. METHODS: Retrospective data analysis from patients undergoing elective tumoral cerebelo-pontine angle surgery in a semisitting position. The incidence, severity, occurrence moment, treatment, duration, and outcomes of venous air embolism (VAE), pneumocephalus, postural hypotension, and other complications were recorded. Neurointensive care unit (NICU), length of stay (LOS), hospital LOS, and modified Rankin scale scores were calculated six months after surgery. RESULTS: Fifty patients were operated on. Eleven (22%) presented VAE (mean duration 8±4.5min): five (10%) during tumor resection, and four (8%) during dural opening. Ten (20%) were resolved by covering the surgical bed, air bubbles aspiration, jugular compression, and one (2%) tilted to a steep Trendelenburg position. One (2%) had intraoperative hemodynamic instability. The only variable associated with VAE was meningioma at histopathology OR=4.58, p=0.001. NICU was higher in patients with VAE (5.5±1.06 vs. 1.9±0.20 days, p=0.01). There were no differences in the Rankin scale. All patients presented postoperative pneumocephalus with a good level of consciousness, except one (2%) who required evacuation. Seven patients (14%) showed postural hypotension, three (6%) after positioning, and one (2%) after developing a VAE; all were reversed with usual vasoactive drugs. No other position-related complications or mortality were registered in this series. CONCLUSIONS: The semisitting position is a safe option with the knowledge, prevention, detection, and early solution of all the possible complications. The development of VAE rarely implies hemodynamic instability or greater disability after surgery. Postoperative pneumocephalus is very common and rarely requires evacuation. Excellent cooperation between anesthesia, nursing, neurophysiology, and neurosurgery teams is essential to manage complications.

Validación externa del algoritmo InShape II para la exclusión de la enfermedad tromboembólica crónica en los pacientes con tromboembolismo pulmonar / External validation of the InShape II study algorithm for exclusion of chronic thromboembolic pulmonary hypertension in patients with pulmonary thromboembolism

Antecedentes y objetivo La complicación a largo plazo más grave del embolismo pulmonar (EP) es la hipertensión pulmonar tromboembólica crónica (HPTEC), cuyo diagnóstico precoz implica la realización de un gran número pruebas. El estudio InShape II propone un algoritmo de cribado precoz que pretende disminuir el número de estudios ecocardiográficos. El objetivo de nuestro estudio es validar este algoritmo en nuestra cohorte de pacientes. Material y métodos Se analizaron retrospectivamente los pacientes ingresados con diagnóstico de EP por angio-TC, en el Hospital Rey Juan Carlos entre noviembre del 2017 y febrero del 2020, seguidos durante al menos un año. Se recogieron datos clínicos, analíticos, y pruebas complementarias a los 3 meses y al año. Se aplicó a estos pacientes el algoritmo del estudio InShape II para validar sus resultados. Resultados En el periodo de estudio fueron diagnosticados de EP 236 pacientes, de los cuales 137 fueron excluidos. Se validó el algoritmo en 99 pacientes. Aplicando el score del InShape II hubiéramos realizado 19 ecocardiogramas (3 de ellos con probabilidad intermedia/alta de HPTEC) y no se hubieran hecho en 80 (2 de ellos con probabilidad intermedia/alta), por lo que se estableció una sensibilidad del score de un 60%, con una especificidad de un 83%, y un área bajo la curva (AUC) de 0,715 (IC 95%: 0,472-0,958). Conclusiones Nuestros resultados apoyan que el algoritmo del estudio InShape II podría ser una herramienta útil en el cribado inicial del estudio de HPTEC en entornos de baja incidencia, ya que evitaría la realización de ecocardiogramas que no aportan valor (AU)

Background and aim The most severe long-term complication of pulmonary embolism (PE) is chronic thromboembolic pulmonary hypertension (CTEPH), and its early diagnosis often requires numerous diagnostic tests. The InShape II study proposes an early screening algorithm that aims to reduce the number of echocardiographic studies. The objective of our study is to validate this algorithm in our patient cohort. Materials and methods We retrospectively analyzed patients admitted to Hospital Rey Juan Carlos between November 2017 and February 2020, who were diagnosed with PE based on computed tomography angiography (CTA). Patients were followed for at least one year, and clinical, laboratory, and complementary test data were collected at three months and one year. The InShape II algorithm was applied to these patients to validate its results. Results During the study period, 236 patients were diagnosed with PE, of which 137 were excluded. The algorithm was validated in 99 patients. Applying the InShape II score, 19 echocardiograms would have been performed (three of them with intermediate-high probability of CTEPH), while 80 echocardiograms would have been avoided (two of them with intermediate-high probability). This yielded a sensitivity of 60% and a specificity of 83% for the score, with an area under the curve (AUC) of 0.715 (95% CI: 0.472-0.958). Conclusions Our results support the notion that the InShape II algorithm could be a useful tool for initial screening of CTEPH in low-incidence settings, as it would avoid unnecessary echocardiograms that do not provide additional value (AU)

External validation of the InShape II study algorithm for exclusion of chronic thromboembolic pulmonary hypertension in patients with pulmonary thromboembolism.

BACKGROUND AND AIM: The most severe long-term complication of pulmonary embolism (PE) is chronic thromboembolic pulmonary hypertension (CTEPH), and its early diagnosis often requires numerous diagnostic tests. The InShape II study proposes an early screening algorithm that aims to reduce the number of echocardiographic studies. The objective of our study is to validate this algorithm in our patient cohort. MATERIALS AND METHODS: We retrospectively analyzed patients admitted to Hospital Rey Juan Carlos between November 2017 and February 2020, who were diagnosed with PE based on computed tomography angiography (CTA). Patients were followed for at least one year, and clinical, laboratory, and complementary test data were collected at three months and one year. The InShape II algorithm was applied to these patients to validate its results. RESULTS: During the study period, 236 patients were diagnosed with PE, of which 137 were excluded. The algorithm was validated in 99 patients. Applying the InShape II score, 19 echocardiograms would have been performed (three of them with intermediate-high probability of CTEPH), while 80 echocardiograms would have been avoided (two of them with intermediate-high probability). This yielded a sensitivity of 60% and a specificity of 83% for the score, with an area under the curve (AUC) of 0.715 (95% CI: 0.472-0.958). CONCLUSIONS: Our results support the notion that the InShape II algorithm could be a useful tool for initial screening of CTEPH in low-incidence settings, as it would avoid unnecessary echocardiograms that do not provide additional value.

Cardiogenic shock due to pulmonary thromboembolism: the role of surgical thrombectomy / Shock cardiogénico debido a tromboembolismo pulmonar: el papel de trombectomía quirúrgica

Abstract A 53-year-old male patient with history of repaired hernia, who is admitted for 5 days of progressive dyspnea with diagnosis of abdominal sepsis, a computed tomography angiography was made, revealing pulmonary embolism in bilateral main pulmonary artery, and cardiac thrombectomy was performed.

Resumen Paciente masculino de 53 años de edad con historial de reparación de hernia, quien fue ingresado por presentar 5 días de disnea progresiva con diagnóstico de sepsis abdominal, se le realizó una angiografía por tomografía computada, revelando embolismo bilateral arteria pulmonar principal, se realizó una trombectomía cardíaca.

Lipoinjerto en gluteoplastia. ¿Es un procedimiento seguro? / Fat grafting in gluteoplasty. Is it a safe procedure?

Introducción y objetivo: La gluteoplastia de aumento con lipoinjertos es uno de los procedimientos estéticos más realizados en el mundo, sin embargo, dada su alta tasa de mortalidad frente a los demás procedimientos estéticos, durante la última década se han publicado varios estudios y artículos en busca de recomendaciones para reducir desenlaces fatales. Revisamos la literatura actual para identificar índices de mortalidad, consensuar las recomendaciones encontradas e identificar estudios cadavéricos que permitan cuestionar si este procedimiento es seguro y si las medidas tomadas hasta el momento son suficientes para la seguridad de los pacientes. Material y método: Revisión mediante búsqueda exhaustiva en bases de datos científicas de artículos en cuyo contenido hubiera datos sobre casos nuevos, fisiopatología de complicaciones mayores y menores y estrategias para prevenirlas. Resultados: Obtuvimos 11 documentos: boletines, artículos de revisión, reportes de caso, revisiones sistemáticas y estudios experimentales en cadáveres. Conclusiones: En la lipoinyección glútea, la inyección del lipoinjerto en planos submúsculares supone aumento del riesgo de presentación de complicaciones macroscópicas y microscópicas por la migración de grasa al torrente sanguíneo. A pesar de las múltiples recomendaciones ya establecidas, abogamos por el desarrollo de técnicas que permitan asegurar la lipoinyección en plano subcutáneo. (AU)

Background and objective: Augmentation gluteoplasty with fat grafting is one of the most performed aesthetic procedures in the world, however, given its high mortality rate compared to other aesthetic procedures, during the last decade several studies and articles have been published in search of recommendations for reduce their fatal outcomes. We conduct a literature review in order to identify mortality rates, reach a consensus on the recommendations found, and identify cadaveric studies that may question whether this procedure is safe and whether the measures taken to date will be sufficient for patient safety. Methods: A review article was carried out through an exhaustive search in scientific databases, which included data on new reported cases, pathophysiology of major and minor complications and presented strategies. prevention of these complications. Results: A total of 11 documents were obtained, among which we found bulletins, review articles, case reports, systematic reviews, and experimental studies in cadavers. Conclusions: In gluteal lipoinjection, the injection of the lipograft in submuscular planes implies an increased risk of macroscopic and microscopic complications of fat migration through the bloodstream. Despite the multiple recommendations already established, we advocate the development of techniques that allow graft injection to be ensured subcutaneously. (AU)

Cardiogenic shock due to pulmonary thromboembolism: the role of surgical thrombectomy.

A 53-year-old male patient with history of repaired hernia, who is admitted for 5 days of progressive dyspnea with diagnosis of abdominal sepsis, a computed tomography angiography was made, revealing pulmonary embolism in bilateral main pulmonary artery, and cardiac thrombectomy was performed.

Paciente masculino de 53 años de edad con historial de reparación de hernia, quien fue ingresado por presentar 5 días de disnea progresiva con diagnóstico de sepsis abdominal, se le realizó una angiografía por tomografía computada, revelando embolismo bilateral arteria pulmonar principal, se realizó una trombectomía cardíaca.

Acute myocardial infarction in a young patient by coronary embolism / Infarto agudo de miocardio en un paciente joven causado por embolia coronaria

Abstract: Coronary artery disease continues to be the leading cause of death in modern society; the most frequent cause is atherosclerosis. There are other causes such as coronary embolism and coronary dissection, among others. This article presents the case of a young patient with acute myocardial infarction in whom a coronary embolism was documented as the cause of infarction.

Resumen: La enfermedad arterial coronaria continúa siendo una causa de mortalidad en nuestro medio; la causa más frecuente es la aterosclerosis. Existen otras causas como embolia coronaria, disección coronaria. En este artículo se describe el caso de un paciente joven, quien presentó un infarto agudo de miocardio y se documentó un embolia conoraria como causa.

Uso de escalas predictivas de tromboembolia pulmonar en un servicio de urgencias / Use of predictive scales for pulmonary thromboembolism in an emergency department

Antecedentes y objetivo: Diagnosticar la tromboembolia pulmonar (TEP) es difícil. Existen escalas de probabilidad clínica (EPC) que ayudan. Se quiere averiguar cuál es mejor.Pacientes y métodosSe realizó un estudio unicéntrico transversal retrospectivo que evaluó la validez de 4 EPC en 200 pacientes en los que se realizó una tomografía computarizada de arterias pulmonares: criterios Pulmonary Embolism Rule out Criteria (PERC), Wells, Ginebra y YEARS. Se estimó su grado de uso, y la posible correlación entre su puntuación y el dímero D (DD).ResultadosLas 4 EPC tienen una alta sensibilidad, cercana a uno y sin diferencias entre ellas. La escala YEARS resultó ser entre 2 y 4 veces más específica que las otras 3. El grado de uso de las escalas se estimó en un 14% (IC 95%: 9,19-18,81). Se halló una débil correlación positiva entre la puntuación de las escalas Wells y Ginebra y el DD.ConclusionesLa escala YEARS se muestra mejor que las demás por su potencial mayor número de pruebas de imagen evitadas y el grado de aplicación de las EPC es mejorable. (AU)

Background and objective: Diagnosing pulmonary thromboembolism (PTE) is difficult. Clinical probability scales (CPS) can help. The aim is to find out which one is the best.Patients and methodsA retrospective cross-sectional single-center study was conducted. It evaluated four CPS (Pulmonary Embolism Rule Out Criteria [PERC], Wells, Geneva, and YEARS criteria) validity in 200 patients who underwent computerized tomography angiography of the pulmonary arteries. Their degree of use was estimated, as well as the possible correlation between them and DD (D dimer).ResultsThe four CPS have a high sensitivity, close to 1 and without differences between them. The YEARS scale is between 2 and 4 times more specific than the others. The degree of use of the scales was estimated at 14% (95% CI: 9.19-18.81). A weak positive correlation was found between the scores on the Wells and Geneva scales and the DD.ConclusionsThe YEARS scale is shown to be better than the others due to its potential greater number of imaging tests avoided and the degree of application of the CPS could be improved. (AU)

Value of advanced interatrial block in the diagnosis of the ischemic stroke's aetiology: A cohort study

Introduction and objectives: Advanced interatrial block has been linked with atrial fibrillation (AF) (Bayes syndrome). On the other hand, the aetiology of the stroke remains unknown in approximately 20–25% of patients admitted due to ischaemic stroke. The aim of this study was to evaluate whether advanced interatrial block and CHADS2-VASC scale is linked to AF in patients admitted due to ischaemic stroke without previous AF history.MethodsA prospective analysis of consecutive in-hospital patients admitted with ischemic stroke between January/2018 and April/2019 in a stroke hospital was performed. Patients had to be in sinus rhythm at admission and without previous history of AF/atrial flutter. During follow up patients receive the usual care.ResultsA total of 236 patients were included. The median follow-up was 540 days (407–695). 19 patients (8.1%) had advanced interatrial block at admission. Advanced interatrial block was associated with the diagnosis of AF during follow up (5 (26.3%) Vs 21 (9.7%) p=0.027). A CHADS2-VASC score>4 at admission was also associated with AF diagnosis during follow up (23(14.6%) vs 3(3.9%) p=0.009).ConclusionThis study confirms the association of advanced interatrial block and CHADS2-VASC>4 at admission with the diagnosis of AF during follow up in patients with ischemic stroke. This association could have important implications in patients with ischemic stroke who present advanced interatrial block and without previous history of AF. (AU)

Introducción y objetivos: El bloqueo interauricular (BIA) completo se relaciona con el desarrollo de arritmias supraventriculares, especialmente de fibrilación auricular (FA) (síndrome de Bayés). En este trabajo evaluamos la utilidad de este fenómeno para discernir la etiología cardioembólica en los pacientes ingresados por ictus isquémico. También se estudió la relación entre la puntuación en la escala CHADS 2-VA 2 Sc y el desarrollo de FA durante el seguimiento.MétodosAnálisis prospectivo de pacientes consecutivos ingresados por ictus isquémico entre enero del 2018 y abril del 2019 en un hospital terciario centro de referencia de ictus. Los pacientes incluidos debían de estar en ritmo sinusal en el momento del ingreso y no tener historia previa de FA/flutter auricular. Se realizó el seguimiento mediante las consultas y estudios de rutina, sin intervenir en su manejo habitual.ResultadosSe incluyó a 236 pacientes. La mediana de seguimiento fue de 540 días (407-695); 19 pacientes (8,1%) presentaron BIA en el electrocardiograma al ingreso. El BIA completo al ingreso se relacionó con el desarrollo posterior de FA (5 [26,3%) vs. 21 [9,7%]; p=0,027). También se observó que un CHADS 2-VA 2 Sc>4 al ingreso se relacionaba con presentar FA durante el seguimiento (23 [14,6%] vs. 3 [3,9%]; p=0,009).ConclusiónCon este estudio se demuestra por primera vez en pacientes con ictus isquémico que tanto el BIA completo como un CHADS 2-VA 2 Sc>4 se asocian con el desarrollo de FA en el seguimiento. Esta asociación puede tener importantes implicaciones prácticas en el manejo de pacientes ingresados por ictus que presenten BIA completo. (AU)

Caracterización clínica, diagnóstica y pronóstica de los pacientes con sospecha de tromboembolismo pulmonar antes y durante la COVID-19 / Clinical, Diagnostic and Prognostic Characterization of Patients with Suspected Pulmonary Embolism Before and During COVID-19

RESUMEN Introducción: El tromboembolismo pulmonar (TEP) es una patología frecuente, que genera repercusiones hemodinámicas importantes y alta tasa de mortalidad, con alta incidencia en la enfermedad por coronavirus 2019 (COVID-19). Objetivo: Caracterizar el comportamiento clínico, de diagnóstico y pronóstico de los pacientes con sospecha de TEP antes y durante la pandemia de SARS-CoV-2. Metodología: Estudio de cohorte prospectiva de pacientes adultos llevados a angiotomografía de tórax por sospecha de TEP durante dos periodos de tiempo: a) pre-COVID-19: junio de 2018 a diciembre de 2019, y b) COVID-19: junio a diciembre de 2020. Se condujeron análisis bivariados y se construyeron curvas ROC calculando las áreas bajo la curva para el diagnóstico de TEP del dímero D y las reglas de predicción clínica. Resultados: Se incluyeron 302 pacientes pre COVID-19 y 55 pacientes con COVID-19. El dímero D muestra un desempeño moderado para diagnóstico del TEP con AUC: 0,73 (IC 95% 0,62-0,84) en fase pre-COVID-19 vs. 0,75 (IC95% 0,58-0,92) en fase COVID-19. Las áreas bajo la curva de cada una de las reglas de predicción clínica tuvieron un desempeño moderado a bajo en la fase pre-COVID-19 (AUC: 0,623 a 0,697), frente a una no discriminatoria en la fase COVID-19 (0,355 a 0,450). Conclusiones: Los factores de riesgo tradicional fueron poco prevalentes en pacientes con COVID-19 y TEP. Aunque el dímero D fue más alto en aquellos con TEP, la diferencia no fue estadísticamente significativa. Las reglas de predicción clínicas para el diagnóstico de TEP mostraron un bajo poder discriminativo en pacientes con COVID-19.

ABSTRACT Background: Pulmonary embolism (PE) is a frequent disease generating important hemodynamic effects and high mortality rate, with great incidence in coronavirus disease (COVID-19). Objective: The aim of this study was to characterize the clinical, diagnostic, and prognostic behavior of patients with suspected PE before and during the SARS-CoV-2 pandemic. Methods: A prospective cohort study of adult patients with suspected PE undergoing computed tomography pulmonary angiography was carried out during two periods: a) the pre-COVID-19 phase: June 2018 to December 2019, and b) during the COVID-19 phase: June to December 2020. Bivariate analyses were conducted and ROC curves were built calculating the areas under the curve (AUC) for D-dimer PE diagnosis and clinical prediction rules. Results: Three-hundred and two pre-COVID-19 patients and 55 patients with COVID-19 were included in the study. D-dimer showed a moderate performance for the diagnosis of PE, with AUC 0.73 (95% CI 0.62-0.84) in pre-COVID-19 phase vs. 0.75 (95% CI 0.58-0.92) in COVID-19 phase. The AUC of each of the clinical prediction rules had moderate to low performance in the pre-COVID-19 phase (AUC 0.623 to 0.697), with a non-discriminatory AUC in the COVID-19 phase (0.355 to 0.450). Conclusions: Traditional risk factors were poorly prevalent in patients with COVID-19 and PE. Although D-dimer was higher in those with PE, the difference was not statistically significant. Clinical prediction rules for PE diagnosis showed low discriminative power in COVID-19 patients.

Eficacia de la hialuronidasa retrobulbar en el tratamiento de la ceguera provocada por rellenos cosméticos. Revisión sistemática / Effectiveness of retrobulbar hyaluronidase in the treatment of visual loss caused by periocular hyaluronic acid injection. A systematic review

Introducción La pérdida visual relacionada con la inyección periocular de rellenos con fines cosméticos es infrecuente pero muy grave. Como recomendaciones protocolizadas ante la pérdida visual por inyección intravascular inadvertida de ácido hialurónico se encuentran, entre otras, la inyección de hialorunidasa en el espacio retroocular. Es de esperar que, dada la creciente demanda de tratamientos de rellenos estéticos y la gran heterogeneidad de profesionales que pueden administrarlos, el número de casos y complicaciones relacionadas con estos procedimientos se incremente de manera sustancial. Objetivo Evaluar si existe evidencia científica para recomendar la inyección retroocular de hialuronidasa en el tratamiento de pérdidas visuales relacionadas con la inyección periocular de ácido hialurónico cosmético. Material y métodos Hemos realizado una búsqueda de artículos publicados en inglés y español siguiendo la declaración PRISMA sobre el uso de hialuronidasa retrobulbar para revertir la pérdida de visión producida por los rellenos de ácido hialurónico. Los artículos revisados incluyeron los casos clínicos y las investigaciones experimentales. Identificamos a un total de 13 pacientes en esta revisión siguiendo unos criterios de inclusión y exclusión definidos. Finalmente, incluimos 15 artículos en el estudio, 13 de ellos fueron casos/series de casos. Los 2artículos restantes son estudios experimentales en animales con grupo control, en los que, tras provocar una oclusión selectiva de la arteria oftálmica, se administran inyecciones seriadas de hialuronidasa retroocular con control de la función visual. Resultados De los 15 artículos incluidos en el estudio, recogimos los datos de un total de 17 pacientes que, tras inyección de ácido hialurónico facial por motivos estéticos, presentaron una disminución brusca de la visión y en los que se inyectaron dosis variables de hialuronidasa retroocular (AU)

Introduction Blindness after periocular cosmetic filler injection is a rare but devastating complication. Complication management protocols recommend injecting retrobulbar hyaluronidase if visual loss related to accidental intravascular injection of hyaluronic acid occurs. Given the dramatic increase in cosmetic filler injections and the variety of professionals that can deliver them, it is reasonable to assume that the incidence of complications will rise significantly. Objective To evaluate if there is evidence-based efficacy of retrobulbar hyaluronidase injection in visual loss secondary to periocular cosmetic filler injection. Material and methods The authors performed a search of English and Spanish language articles following the PRISMA statement published on the use of retrobulbar hyaluronidase to reverse vision loss precipitated by hyaluronic acid gel fillers. Articles reviewed included case reports/series and experimental investigations. We identified a total of 13 patients in this review following defined inclusion and exclusion criteria. Finally, we included 15 articles in the study, 12 of them were cases / case series. The 2remaining articles are experimental studies in animals with a control group, in which after causing selective occlusion of the ophthalmic artery, serial injections of retroocular hyaluronidase are administered with control of visual function. Results Of the 15 articles included in the study, we studied 17 patients treated with retrobulbar hyaluronidase for hyaluronic acid-induced blindness. Improvement was demonstrated in 3 cases. Animal studies demonstrate variable data are provided regarding the recovery of visual acuity. Conclusions There is no confirmed evidence of retrobulbar hyaluronidase injection effectiveness in treating visual loss due to accidental intravascular injection of hyaluronic acid. More studies are needed to show the efficacy of hyaluronidase as a treatment for blindness caused by hyaluronic acid (AU)

Effectiveness of retrobulbar hyaluronidase in the treatment of visual loss caused by periocular hyaluronic acid injection. A systematic review.

INTRODUCTION: Blindness after periocular cosmetic filler injection is a rare but devastating complication. Complication management protocols recommend injecting retrobulbar hyaluronidase if visual loss related to accidental intravascular injection of hyaluronic acid occurs. Given the dramatic increase in cosmetic filler injections and the variety of professionals that can deliver them, it is reasonable to assume that the incidence of complications will rise significantly. OBJECTIVE: To evaluate if there is evidence-based efficacy of retrobulbar hyaluronidase injection in visual loss secondary to periocular cosmetic filler injection. MATERIAL AND METHODS: The authors performed a search of English and Spanish language articles following the PRISMA statement published on the use of retrobulbar hyaluronidase to reverse vision loss precipitated by hyaluronic acid gel fillers. Articles reviewed included case reports/series and experimental investigations. We identified a total of 13 patients in this review following defined inclusion and exclusion criteria. Finally, we included 15 articles in the study, 12 of them were cases / case series. The 2 remaining articles are experimental studies in animals with a control group, in which after causing selective occlusion of the ophthalmic artery, serial injections of retroocular hyaluronidase are administered with control of visual function. RESULTS: Of the 15 articles included in the study, we studied 17 patients treated with retrobulbar hyaluronidase for hyaluronic acid-induced blindness. Improvement was demonstrated in 3 cases. Animal studies demonstrate variable data are provided regarding the recovery of visual acuity. CONCLUSIONS: There is no confirmed evidence of retrobulbar hyaluronidase injection effectiveness in treating visual loss due to accidental intravascular injection of hyaluronic acid. More studies are needed to show the efficacy of hyaluronidase as a treatment for blindness caused by hyaluronic acid.

Tromboembolismo pulmonar durante la pandemia por SARS-CoV-2: características clínicas y radiológicas / Pulmonary embolism during SARS-CoV-2 pandemic: clinical and radiological features

Antecedentes Se ha descrito una elevada incidencia de tromboembolismo pulmonar (TEP) durante la pandemia por coronavirus. Métodos Estudio retrospectivo unicéntrico, con revisión de las angiografías pulmonares por tomografía computarizada solicitadas por sospecha de tromboembolismo pulmonar durante dos períodos, del 01 de marzo del 2020 al 31de mayo del 2020 (pandemia), e igual intervalo en 2019 (control). Resultados Se diagnosticaron 22 tromboembolismos pulmonares durante el período control y 99 en el pandémico, 74 asociados con COVID-19. El 5,3% de los pacientes hospitalizados con COVID-19 sufrió un tromboembolismo pulmonar, con un retraso entre ambos diagnósticos de 9,1 ± 8,4 días. Durante la pandemia, los pacientes con tromboembolismo pulmonar tenían menos condiciones predisponentes (tromboembolismo pulmonar previo 5,1 vs. 18,2%, p = 0,05, cirugía previa 2 vs. 35,4%, p = 0,0001, trombosis venosa profunda 11,1 vs. 45,5%, p = 0,0001), y los tromboembolismos pulmonares periféricos eran más frecuentes (73,5 vs. 50%, p = 0,029). Conclusiones Existe un riesgo incrementado de sufrir un TEP durante la pandemia por SARS-CoV-2, que afecta a pacientes con perfil clínico diferente y causa más frecuentemente TEP distales (AU)

Background A high incidence of pulmonary embolism has been described during the coronavirus pandemic. Methods This work is a single-center retrospective study which reviewed computed tomography pulmonary angiograms ordered due to suspected pulmonary embolism during two periods: from March 1, 2020 to May 31, 2020 (pandemic) and during the same interval in 2019 (control). Results Twenty-two pulmonary embolism were diagnosed during the control period and 99 in the pandemic, 74 of which were associated with COVID-19. Of all patients hospitalized with COVID-19, 5.3% had a pulmonary embolism, with a delay between the two diagnoses of 9.1 ± 8.4 days. During the pandemic, patients with pulmonary embolism had fewer predisposing conditions (previous pulmonary embolism 5.1 vs. 18.2%, p = .05; previous surgery 2 vs. 35.4%, p = .0001; deep vein thrombosis 11.1 vs. 45.5%, p = .0001); peripheral pulmonary embolisms were the most frequent (73.5 vs. 50%, p = . 029). Conclusions There is an increased risk of having a pulmonary embolism during the SARS-CoV-2 pandemic, which affects patients with a different clinical profile and more often causes distal pulmonary embolisms (AU)

Use of predictive scales for pulmonary thromboembolism in an emergency department. / Uso de escalas predictivas de tromboembolia pulmonar en un servicio de urgencias.

BACKGROUND AND OBJECTIVE: Diagnosing pulmonary thromboembolism (PTE) is difficult. Clinical probability scales (CPS) can help. The aim is to find out which one is the best. PATIENTS AND METHODS: A retrospective cross-sectional single-center study was conducted. It evaluated four CPS (Pulmonary Embolism Rule Out Criteria [PERC], Wells, Geneva, and YEARS criteria) validity in 200 patients who underwent computerized tomography angiography of the pulmonary arteries. Their degree of use was estimated, as well as the possible correlation between them and DD (D dimer). RESULTS: The four CPS have a high sensitivity, close to 1 and without differences between them. The YEARS scale is between 2 and 4 times more specific than the others. The degree of use of the scales was estimated at 14% (95% CI: 9.19-18.81). A weak positive correlation was found between the scores on the Wells and Geneva scales and the DD. CONCLUSIONS: The YEARS scale is shown to be better than the others due to its potential greater number of imaging tests avoided and the degree of application of the CPS could be improved.

Desenlace fatal en embarazadas contagiadas con la COVID-19 / Fatal outcome wiht pregnant and COVID-19

Introducción: Múltiples han sido las muertes y contagios por el nuevo coronavirus. En medio de este contexto el contagio de la enfermedad en pacientes embarazadas ha sido bien documentado. Objetivo: Presentar los eventos ocurridos en embarazadas para transmitir la experiencia a quienes tratan estas pacientes. Presentación del caso: Se expone el caso de una gestante de 24 años, obesa, con embarazo de 25 semanas. Fue ingresada con neumonía por COVID-19 y evolución hacia la insuficiencia respiratoria grave que fallece durante la cesárea. Se recibió en el quirófano con hipoxemia e hipercapnia, taquicardia, cianosis, oliguria y ventilada a presión positiva con oxígeno al 100 %. Se conduce con ketamina, fentanilo y rocuronio. A los 35 min, y posterior a la histerotomía, presentó bradicardia progresiva, por lo que se inicia compresiones torácicas externas y tratamiento farmacológico. Se recuperó el ritmo sinusal a los 12 min, pero recidiva la parada en asistolia a los 20 min, con cianosis en esclavina. Se implementó compresiones y administración de epinefrina hasta fallecer 30 min después por no recuperación de ritmo y signos ciertos de la muerte. Conclusiones: La atención multidisciplinaria mejora las condiciones de tratamiento en todas las etapas. El manejo anestésico individualizado ofrece una estrategia invaluable en casos como estos, independientemente del resultado. El tromboembolismo pulmonar en la gestante es un riesgo latente y asociado a la COVID-19, incrementa, exponencialmente, su letalidad.

Introduction: Multiple deaths and infections due to the new coronavirus have occurred. In the midst of this context, the spread of the disease in pregnant patients has been well documented. Objective: Present the events that occurred in pregnant women, in order to share the experience with those who treat these patients. Presentation of the case: The case of a 24-year-old pregnant woman, obese, with a pregnancy of 25 weeks is presented. She was admitted with COVID-19 pneumonia and evolution towards severe respiratory failure led to her death during cesarean section. She was received in the operating room with hypoxemia and hypercapnia, tachycardia, cyanosis, oliguria and ventilated at positive pressure with 100% oxygen. She was treated with ketamine, fentanyl and rocuronium. At 35 min, and after hysterotomy, she presented progressive bradycardia, so external chest compressions and pharmacological treatment were initiated. The sinus rhythm was recovered at 12 min, but the asystole stop relapsed at 20 min, with cyanosis. Compressions and administration of epinephrine were implemented until death 30 minutes later due to non-recovery of rhythm and certain signs of death. Conclusions: Multidisciplinary care improves treatment conditions at all stages. Individualized anesthetic management offers an invaluable strategy in cases like these, regardless of the outcome. Pulmonary thromboembolism in pregnant women is a latent risk associated with COVID-19, exponentially increasing its lethality.

Trombolisis sistémica complicada en embolia cerebral múltiple por trombo intraventricular / Systemic thrombolysis following multiple embolic cerebral lesions in a patient with myocardial infarction and intraventricular thrombus

RESUMEN Se presenta un caso de trombólisis sistémica complicada con transformación hemorrágica en paciente con evento isquémico cerebral sintomático por embolia múltiple a partir de trombo intraventricular en contexto de infarto agudo de miocardio por oclusión total de arteria descendente anterior con deterioro severo de función sistólica de ventrículo izquierdo.

ABSTRACT: We describe a case of complicated systemic thrombolysis with hemorrhagic transformation in a patient with a cerebral ischemic event due to multiple embolisms from intraventricular thrombus in the context of acute myocardial infarction due to total occlusion of the anterior descending artery and severe deterioration of left ventricular systolic function.

Value of advanced interatrial block in the diagnosis of the ischemic stroke's aetiology: A cohort study.

INTRODUCTION AND OBJECTIVES: Advanced interatrial block has been linked with atrial fibrillation (AF) (Bayes syndrome). On the other hand, the aetiology of the stroke remains unknown in approximately 20-25% of patients admitted due to ischaemic stroke. The aim of this study was to evaluate whether advanced interatrial block and CHADS2-VASC scale is linked to AF in patients admitted due to ischaemic stroke without previous AF history. METHODS: A prospective analysis of consecutive in-hospital patients admitted with ischemic stroke between January/2018 and April/2019 in a stroke hospital was performed. Patients had to be in sinus rhythm at admission and without previous history of AF/atrial flutter. During follow up patients receive the usual care. RESULTS: A total of 236 patients were included. The median follow-up was 540 days (407-695). 19 patients (8.1%) had advanced interatrial block at admission. Advanced interatrial block was associated with the diagnosis of AF during follow up (5 (26.3%) Vs 21 (9.7%) p=0.027). A CHADS2-VASC score>4 at admission was also associated with AF diagnosis during follow up (23(14.6%) vs 3(3.9%) p=0.009). CONCLUSION: This study confirms the association of advanced interatrial block and CHADS2-VASC>4 at admission with the diagnosis of AF during follow up in patients with ischemic stroke. This association could have important implications in patients with ischemic stroke who present advanced interatrial block and without previous history of AF.

Pulmonary embolism during SARS-CoV-2 pandemic: Clinical and radiological features.

BACKGROUND: A high incidence of pulmonary embolism has been described during the coronavirus pandemic. METHODS: This work is a single-center retrospective study which reviewed computed tomography pulmonary angiograms ordered due to suspected pulmonary embolism during two periods: from March 1, 2020 to May 31, 2020 (pandemic) and during the same interval in 2019 (control). RESULTS: Twenty-two pulmonary embolisms were diagnosed during the control period and 99 in the pandemic, 74 of which were associated with COVID-19. Of all patients hospitalized with COVID-19, 5.3% had a pulmonary embolism, with a delay between the two diagnoses of 9.1 ± 8.4 days. During the pandemic, patients with pulmonary embolism had fewer predisposing conditions (previous pulmonary embolism 5.1 vs. 18.2%, p = .05; previous surgery 2 vs. 35.4%, p = .0001; deep vein thrombosis 11.1 vs. 45.5%, p = .0001); peripheral pulmonary embolisms were the most frequent (73.5 vs. 50%, p = . 029). CONCLUSIONS: There is an increased risk of having a pulmonary embolism during the SARS-CoV-2 pandemic, which affects patients with a different clinical profile and more often causes distal pulmonary embolisms.