[Pharmacologic treatment for 2 thrombocytopenic patients prior to neurosurgery]. / Tratamiento farmacológico preoperatorio de dos pacientes trombopénicos para intervención neuroquirúrgica.

Preoperative prophylaxis of hemorrhage for patients with thrombocytopenia or a platelet disorder is controversial. Platelet count correlates to a certain degree with risk of hemorrhage, and risk factors for hemorrhage should be assessed and treated before deciding on perioperative treatments. Thirteen percent of cirrhotic patients have a platelet count between 50,000 and 75,000/microL and thrombocytopenia is multifactorial in origin. Idiopathic thrombocytopenic purpura is an acquired disease; since it may be either primary or secondary to other conditions, treatment may vary considerably. No clinical method has been established for predicting risk of perioperative bleeding in patients with thrombocytopenia. We describe 2 thrombocytopenic patients scheduled for intracranial surgery who were treated with thrombopoietic growth factors; in both cases, platelet counts increased sufficiently for this type of surgery. Controlled clinical trials are needed to ascertain the safety and prophylactic utility of platelet transfusion and thrombopoietin analogs in certain situations of refractory thrombocytopenia.

[Respiratory failure from upper airway collapse following anterior cervical spine surgery]. / Insuficiencia respiratoria por obstrucción de la vía aérea superior en el postoperatorio de la cirugía de columna cervical por vía anterior.

OBJECTIVES: To determine the frequencies of variables that might predispose to upper airway collapse in a series of patients undergoing anterior cervical spine surgery. PATIENTS AND METHODS: Retrospective review of the medical records of 204 patients who underwent anterior cervical spine neurosurgery between 2003 and 2009. We gathered information on perioperative variables that might be related to upper airway collapse, on whether intensive care unit admission was planned or not, and on the moment when obstruction developed. RESULTS: Partial obstruction occurred in 7 cases (3.4%); 4 (1.9%) resolved with tracheal intubation and 3 (1.5%) required emergency tracheostomy. None of the variables were significantly associated with the development of postoperative upper airway obstruction in these patients. CONCLUSIONS: Upper airway obstruction after anterior cervical spine surgery is an unforeseen event and the emergency assessment of the airway may not coincide with the assessment of the anesthetist during the preanesthetic visit. This event may constitute an emergency for which preparation times and resources may differ from those available when this complication is foreseen. The problem for the anesthetist is not the impossibility of tracheal intubation but rather the difficulty of ventilating through a facial mask or supraglottic device, possibly with life-threatening consequences.

[Patient satisfaction with anesthetic care monitored during phacoemulsification]. / Satisfacción del paciente con el cuidado anestésico monitorizado durante la facoemulsificación.

OBJECTIVES: To assess satisfaction with anesthesia during cataract surgery, as a quality indicator for such surgery. MATERIAL AND METHODS: Patients undergoing cataract surgery with topical and intracameral anesthesia were studied prospectively. We analyzed patient characteristics, physical status, postoperative pain, duration of surgery, administration of an intraoperative sedative, systemic complications, and satisfaction on the Iowa Satisfaction with Anesthesia Scale (ISAS). For patients operated on both eyes, the ISAS score in the first (ISAS1) and second (ISAS2) interventions were compared. RESULTS: A total of 233 patients were included in the study; 36 of them (15.5%) had ISAS scores of less than 5.4. The median ISAS score was 6.0 (interquartile range [IQR], 5.6-6.0). In the 71 patients operated on both eyes, the ISAS1 score was significantly lower than the ISAS2 score. Ten patients (4.3%) had visual analog scores of 3 or more in the postoperative period. Complications developed in 2.9% of the procedures (9/304). The median duration of surgery was 9 minutes (IQR, 8-10 minutes). Postoperative pain was the only factor that predicted a lower level of satisfaction. CONCLUSIONS: Pain is common during phacoemulsification and is the main cause of patient dissatisfaction with anesthetic care.

[Outpatient external dacryocystorhinostomy under regional anesthesia and sedation]. / Dacriocistorrinostomía externa realizada en el consultorio bajo anestesia locorregional y sedación.

OBJECTIVE: To assess the rate of early complications of outpatient external dacryocystorhinostomy (DCR) and patient satisfaction with the anesthetic technique. MATERIAL AND METHODS: This prospective study enrolled 58 patients undergoing external DCR. We analyzed demographic variables, ASA physical status, level of sedation achieved, postoperative pain, systemic complications, intraoperative bleeding, duration of surgery, time until discharge home, and patient and surgeon satisfaction with the anesthetic technique. RESULTS: The mean (SD) level of satisfaction was 4.85 (0.80) points on the Iowa Satisfaction With Anesthesia Scale (ISAS). A positive association was found between postoperative pain and a lower ISAS score. There was also a positive association between use of rescue analgesia in the early postoperative period and a lower ISAS score. Mean blood loss per procedure was 178.9 (108.2) mL. The rate of minor systemic complications was 15.5%. The surgeon's rating of conditions in the surgical field was excellent or good in 89.6% of the cases. CONCLUSIONS: External DCR can be performed on an outpatient basis within a reasonable safety margin and with a low early postoperative complication rate. Patient satisfaction with anesthesia was high. Provision of preoperative information about the meaning of sedation, postoperative analgesia, and surgical bleeding are aspects to improve in this practice setting.

[Posterior reversible encephalopathy syndrome after neurosurgery: A literature review]. / Síndrome de encefalopatía posterior reversible en el postoperatorio de neurocirugía. Revisión de la literatura.

Posterior reversible encephalopathy syndrome is a clinical-radiological characterized by decreased level of consciousness, seizures, and visual disturbances, as well as radiologically ras brain edema, predominantly in parieto-occipital white matter regions. There are many situations that can trigger the disorder, including the administration of immunosuppressants, chemotherapy agents, hypertensive disorders, and sepsis. The case is described of a patient diagnosed with stage IV prostate adenocarcinoma, receiving chemotherapy, andundergoing a posterior reversible encephalopathy syndrome after surgery for resection of brain metastasis.

[Near infrared spectroscopy (NIRS) in a neurocritical patient with an air embolisism and pneumocephalus]. / Monitorización NIRS en paciente neurocrítico con embolismo aéreo y neumoencéfalo.

The pneumocephalus is commonly encountered after neurosurgical procedures. The collections are usually small with benign behavior, and they respond to a conservative therapy. However, there is a high percentage of cases that may behave like a space-occupying lesion. A high index of suspicion is necessary to make the diagnosis and prompt treatment of these cases. Monitoring Near infra-red spectrometry (NIRS) monitoring could help to complete the diagnosis and treatment in these cases. A venous air embolism is a common complication in neurosurgical procedures that are performed in a sitting position, where this monitoring has also been shown to be useful. In the case presented, NIRS monitoring, along with clinical and analytical data, was used for the diagnosis of the two complications.

[Phacoemulsification without mydriasis before surgery: benefits to the patient]. / Facoemulsificación sin midriasis preoperatoria: beneficios para el paciente.

PURPOSE: The aim of our study was to evaluate the frequency of side effects (ataxia, dizziness and dry mouth) due to systemic absorption of parasympatholytic eye-drops, before phacoemulsification. METHODS: This single surgeon, prospective, randomized and controlled study included 303 consecutive patients selected to undergo phacoemulsification with topical and intracameral anesthesia. Patients were distributed in two groups; those receiving no mydriatics before surgery (n=151) as control group and those dilated with cyclopentolate 1% and tropicamide 1% eye-drops (n=152) as the study group. Ataxia, dizziness and dry mouth were recorded in both groups by the same observer. Surgery time and changes in systolic and diastolic blood pressures were noted. Note was also taken of the cases where pupil widening maneuvers and a second intracameral instillation of lidocaine 1% plus epinephrine 1/200,000 were needed. RESULTS: Fifteen patients (9.9%) suffered ataxia in the study group vs. three patients (2%) in the control group. Twenty-three patients (15.1%) suffered dizziness in the study group vs. two patients (1.3%) in the control group. Thirty patients (19.7%) experienced dry mouth in the study group vs. ten patients (6.6%) in the control group. No significant changes in blood pressures, surgery time and pupil dilating maneuvers were noted between groups. The odds ratio for a second intracameral instillation was 2.0 in the control group vs. the study group. CONCLUSIONS: Lidocaine 1% plus epinephrine 1/200,000 as an adjunct to topical anesthesia during phacoemulsification showed to be an effective and safe alternative to abolish side effects caused by systemic absorption of mydriatics eye-drops before surgery.

[Locoregional anesthesia in ophthalmology: update]. / Anestesia locorregional en oftalmología: una puesta al día.

Regional anesthesia for ophthalmic procedures has changed significantly in the past ten years. Phacoemulsification for cataract surgery through corneal microincisions, soft foldable lenses and topical anesthesia simplify surgery such that most operations can be performed on an outpatient basis. Some anesthetic blocks are performed by either anesthesiologists or ophthalmologists, who should understand the advantages and disadvantages for each patient. This review discusses anatomical aspects of interest to the anesthesiologist, the main techniques used and anesthetic innovations, complications and certain controversies such as management of the patient who is taking medications that alter hemostasis, the withdrawal of hyaluronidase in some countries and the systematic ordering of tests before the procedure.

[Conjunctival phenylephrine and acute edema of the lung]. / Fenilefrina por vía conjuntival y edema agudo de pulmón.

We report two cases of acute pulmonary edema occurring in healthy patients during vitreoretinal surgery. The adverse systemic effects of conjunctival phenylephrine are discussed, along with constraints on its clinical use and the concentration that should be used.

[Subarachnoid hemorrhage in a patient with corrected cyanotic congenital cardiopathy]. / Hemorragia subaracnoidea en un paciente con una cardiopatía congénita cianótica corregida.

A 19-year-old man with congenital cyanotic heart disease experienced subarachnoid bleeding from a ruptured cerebral aneurysm. Immediate rebleeding with disordered hemostasis caused by prophylactic anticoagulation treatment was the cause of death. Medical progress in repairing congenital heart disease or attenuating its effects has increased the life expectancy of such patients. Anesthesiologists who are not specialized in this area may find themselves assuming responsibility for these patients during non-cardiac surgery of greater or lesser extension.

[Malignant neuroleptic syndrome associated with myocardial infarction, acute renal insufficiency and rhabdomyolysis]. / Síndrome neuroléptico maligno asociado a infarto de miocardio, insuficiencia renal aguda y rabdomiólisis.

We present a case of malignant neuroleptic syndrome in a 55 years old male diagnosed 3 years ago of alcoholic paranoid psychosis who was chronically treated with haloperidol, clothiapine, and phenobarbital. Twenty one days after neuroleptic drug withdrawal the patient was admitted to the recovery room because of hyperthermia (40.2 degrees C), left basal pneumonia, acute respiratory insufficiency, extrapyramidal rigidity, mutism, dysarthria, deep coma, hypotension, and tachycardia. Two days after he presented massive rhabdomyolysis, atrial flutter with hemodynamic deterioration which reverted to sinus rhythm and acute anterolateral and inferior myocardial infarction documented by enzyme rise and electrocardiographic alterations. Rhabdomyolysis and myocardial infarction were the precipitating factors of the renal insufficiency. A malignant neuroleptic syndrome was suspected and intravenous treatment with dantrolene sodium 1.5 mg/kg every 24 hours was initiated. Bromocriptine was not administered. The patient died 14 days after in the course of a sepsis and cardiogenic shock.

[Usefulness of the Cameron tracheostomy scoring system after oral tumor surgery]. / Utilidad del score predictivo de Cameron para la realización de traqueostomía electiva después de cirugía tumoral oral.

OBJECTIVES: The aim of this study was to analyze the results of applying the predictive score (PS) of Cameron to perform elective tracheostomy (ET) in oral tumor surgery. MATERIAL AND METHODS: A retrospective and descriptive study was conducted on consecutive patients undergoing oral tumor surgery between January 2010 and December 2012. Items of the PS were collected: reconstruction and type of graft, mandibulectomy, bilateral neck dissection, and tumor location. Patients were grouped according to the management of the airway at the end of surgery into 4 groups: extubated, intubated, ET, and urgent tracheostomy. A cutoff of≥5 points PS was considered for conducting ET. RESULTS: A total of 90 patients were included. Group distribution was: extubated=27.8%, intubated=17.8%, ET=53.3%, and one case (1.1%) of urgent tracheostomy. Using the cutoff value of PS≥5 points yielded a diagnostic sensitivity value of 0.7 for a 95% confidence interval (CI) (0.57 to 0.82), and a diagnostic specificity value of 0.9 (95% CI 0.79 to 0.99). The PPV was 0.9 (95% CI 0.81 to 0.99) and the NPV was 0.67 (95% CI 0.54 to 0.8). The AUC gave a value of 0.87 (standard error 0.36). The likelihood ratio was 6.48. CONCLUSION: The decision to perform an ET for oral tumor surgery can be enhanced using the PS of Cameron based on objective data.

[Anesthesia for craniotomy in the conscious patient]. / Anestesia para la craneotomía en el paciente consciente.

Craniotomy in the conscious patient (CPC) enables the neurological changes to be assessed during the mapping in epilepsy surgery, the location of the electrodes during deep brain stimulation surgery, and tumor resection in eloquent areas of the brain. CPC is a useful technique for radical surgery in order to minimize the damage to the functional areas of the brain. The anesthesiologist must ensure, adequate patient comfort, analgesia and ensure optimal collaboration. The appropriate selection of potential candidates for CPC should be made jointly with all professionals involved in the case. Knowledge of the different phases of CPC, coordination and communication among specialists, the right management of the pharmacology, and anesthetic techniques specific to CPC, along with the ability of psycho-emotional communication with the patient, determine the success of the procedure to be performed in the culture of patient safety. The aim of this review was to describe the anesthetic management, comprehensive considerations, and intraoperative neurophysiological tests for CPC.