RESUMO
Spinal cord ischaemia leading to paraplegia or paraparesis is one of the most devastating complications of aortic surgery. The risk of ischaemia is particularly high in repairs involving both the thoracic and abdominal segments, because in these cases blood flow to the spinal arteries can be interrupted. Multimodal protocols have now been developed to reduce the incidence of this complication, and include measures such as cerebrospinal fluid (CSF) drainage, avoidance of hypotension and anaemia, systemic hypothermia, neuromonitoring, maintaining distal perfusion during proximal clamping of the aorta, and reimplantation of intercostal or lumbar arteries, whenever feasible. We describe a case in which, due to the special characteristics of the surgery, veno-arterial extracorporeal membrane oxygenation (VA ECMO) was used to maintain distal blood flow in the lumbar, inferior mesenteric, and hypogastric arteries during aortic clamping. This approach reduced the risk of spinal cord and visceral ischaemia, and also eliminated the need for thoracotomy because partial left bypass was not required.
RESUMO
Eisenmenger syndrome (ES) is a complex combination of cardiovascular abnormalities defined as pulmonary hypertension with investment or bidirectional flow through an intracardiac or aortopulmonary communication, usually secondary to a congenital heart disease not resolved promptly. It carries a significant risk of perioperative mortality, with an incidence close to 30% for non-cardiac surgery. We report the anaesthetic management in a ES patient undergoing breast surgery, which was successfully performed under general anaesthesia combined with thoracic analgesic blocks. The main pathophysiological implications of this syndrome are discussed, emphasizing the importance of appropriate preoperative evaluation with thorough assessment of associated risks, careful intraoperative management, and postoperative care, which should be initially performed in a critical care unit. The need to individualize and tailor the choice of drugs and anesthetic technique to the hemodynamic condition of the patient and the surgical procedure is highlighted.
Assuntos
Anestesia Geral/métodos , Complexo de Eisenmenger/fisiopatologia , Mastectomia , Bloqueio Nervoso/métodos , Antibioticoprofilaxia , Neoplasias da Mama/complicações , Neoplasias da Mama/cirurgia , Complexo de Eisenmenger/complicações , Complexo de Eisenmenger/diagnóstico por imagem , Endocardite/prevenção & controle , Feminino , Comunicação Interatrial/complicações , Humanos , Pessoa de Meia-Idade , Monitorização Intraoperatória , Complicações Pós-Operatórias/prevenção & controle , Artéria Pulmonar/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Ultrassonografia de Intervenção , Resistência VascularAssuntos
Anestesia por Inalação/métodos , Insuficiência da Valva Aórtica/cirurgia , Eletroencefalografia/métodos , Circulação Extracorpórea , Parada Cardíaca Induzida , Implante de Prótese de Valva Cardíaca/métodos , Monitorização Intraoperatória/métodos , Adulto , Período de Recuperação da Anestesia , Insuficiência da Valva Aórtica/complicações , Circulação Cerebrovascular/efeitos dos fármacos , Humanos , Hipertensão/complicações , Hipotermia Induzida , Hipóxia Encefálica/prevenção & controle , Complicações Intraoperatórias/prevenção & controle , Masculino , Éteres Metílicos , Propofol , Sevoflurano , TiopentalRESUMO
Delayed onset of paraplegia secondary to spinal cord ischemia is a rare but serious complication that can appear after endovascular repair of an aneurysm in the descending thoracic aorta, although this complication is significantly less frequent after stent grafting than after conventional surgical repair. We report the case of a man who developed paraplegia 36 hours after insertion of 4 stents in the descending thoracic aorta. The paraplegia reversed after a spinal catheter was placed to monitor cerebrospinal fluid pressure and to provide drainage.
Assuntos
Angioplastia com Balão , Aneurisma da Aorta Torácica/terapia , Líquido Cefalorraquidiano , Drenagem , Isquemia/etiologia , Paraplegia/cirurgia , Medula Espinal/irrigação sanguínea , Stents , Idoso , Humanos , Masculino , Paraplegia/etiologiaRESUMO
The case of a patient who developed acute pancreatitis following resection of a ruptured aneurysm of the abdominal aorta is presented. During the first postoperative days the patient evolved satisfactorily except for specific abdominal symptoms. On the sixth day the patient suddenly presented tachycardia, hypotension, increase in abdominal distension and anemia for which emergency laparotomy was performed with signs of diffuse peritoneal steatonecrosis with an increase in the size and inflammation of the pancreas with necrotic and hemorrhagic zones being observed. The patient developed multiorganic failure and died at 18 days later. In this case, as in others described in the literature the beginning was uneventful. Only the determination of amylase and/or lipase, and the performance of abdominal CAT when these are increased, may be useful to obtain early diagnosis.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Dissecção Aórtica/cirurgia , Pancreatite/etiologia , Complicações Pós-Operatórias/etiologia , Doença Aguda , Humanos , Masculino , Pessoa de Meia-Idade , Pancreatite/diagnóstico , Complicações Pós-Operatórias/diagnósticoRESUMO
A 55-years-old man with a history of alcoholism, hypertension and obesity was diagnosed of epidermoid carcinoma of the middle third portion of the esophagus. He was treated with two cycles of cytostatics with cisplatin and 5-fluorouracil. Due to his poor general health an inability to swallow solids and liquids, he received parenteral nutrition for 20 days using a commercial formula lacking in vitamins and minerals. During distal esophagectomy we observed a tendency to hypotension and severe metabolic acidosis that was unexplained by the hemodynamic profile and that persisted throughout the first 24 hours after surgery. Once these complications were corrected, he was weaned from mechanical ventilation and the following neurological signs were observed: temporal and spacial disorientation, aphasia, ophthalmoplegia with divergent strabismus and later conduction aphasia, amnesia and confabulation. Circulation was hyperdynamic, requiring inotropics and vasoconstrictors. Korsakoff syndrome secondary to Wernicke's encephalopathy was diagnosed, and the response to thiamine treatment was favorable. Beriberi can be found in hospitalized patients and the anesthesiologist may be involved in their perioperative care. Symptoms resolve easily with vitamin B1 treatment, which is ideally provided along with other hydrosoluble vitamins. Treatment should be prompt because delay leads to greater morbiomortality.
Assuntos
Beriberi/etiologia , Esofagectomia/efeitos adversos , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
A 72-year-old man underwent resection of an infrarenal aortic aneurysm; during postoperative recovery, multiorgan failure developed secondary to cholesterol emboli in several arteries. The initial sign consisted of patches of livedo in the lower limbs with pedal pulses, hematuria and hyperdynamic shock with high cardiac output and reduced vascular resistance. The clinical picture progressed to multiple organ failure with non-cardiogenic pulmonary edema, oliguric kidney failure, coagulopathy, necrotizing pancreatitis and colic ischemia. The patient died 15 days after surgery. The formation of multiple cholesterol emboli is a rare complication after aortic surgery, vascular catheterization or anticoagulant treatment. It is caused by cholesterol crystals measuring 100 to 200 mu that embolize and block small arteries. Diagnosis is difficult because the organs involved can be many and various. No specific treatment is available and the rates of morbidity and mortality are high.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Estenose da Valva Aórtica/complicações , Arteriosclerose/complicações , Implante de Prótese Vascular/efeitos adversos , Embolia de Colesterol/etiologia , Adenocarcinoma/complicações , Idoso , Aneurisma da Aorta Abdominal/complicações , Colelitíase/complicações , Colite/etiologia , Colo/irrigação sanguínea , Terapia Combinada , Embolia de Colesterol/terapia , Evolução Fatal , Humanos , Hipertensão/complicações , Hipertensão/tratamento farmacológico , Isquemia/etiologia , Pneumopatias Obstrutivas/complicações , Masculino , Insuficiência de Múltiplos Órgãos/etiologia , Insuficiência de Múltiplos Órgãos/terapia , Neoplasias da Próstata/complicações , Estresse MecânicoAssuntos
Anestésicos Locais/efeitos adversos , Síndrome de Brugada/complicações , Proteínas Musculares/antagonistas & inibidores , Complicações Pós-Operatórias/etiologia , Fibrilação Ventricular/etiologia , Anestésicos Locais/farmacologia , Síndrome de Brugada/genética , Suscetibilidade a Doenças , Humanos , Hipopotassemia/complicações , Masculino , Proteínas Musculares/genética , Canal de Sódio Disparado por Voltagem NAV1.5 , Complicações Pós-Operatórias/induzido quimicamente , Canais de Sódio/genética , Fibrilação Ventricular/induzido quimicamenteRESUMO
OBJECTIVE: To analyze the experience and anesthetic management in the transcatheter implantation of the CoreValve(®) self-expanding aortic valve, in a university tertiary hospital. MATERIAL AND METHODS: Observational analytical review of data incorporated into a prospectively maintained database of 142 patients diagnosed with severe aortic stenosis who underwent implantation of a CoreValve(®) aortic self-expanding aortic valve between December 2007 and December 2012. RESULTS: The mean age of patients was 82.5±6.1 years and the logistic EuroSCORE was 14.9±11.2. General anesthesia was used in 107 patients (75.3%), with local anesthesia with sedation in 35 (24.6%). Local anesthesia and sedation was associated with a lower requirement of vasoactive drugs (P=.003) during implantation. No statistically significant differences were found between the 2 anesthetic techniques in the duration of the procedure, hospital stay, or morbimortality. The success rate was 97.1%. The most common complication was conduction disorders that required implantation of a permanent pacemaker in 46 patients (32.3%). There was no intraoperative mortality, and all-cause mortality at 30 days was 6.3%, with a one-year survival estimated by the Kaplan-Meier of 83.1%. CONCLUSIONS: This study confirms that in patients with severe aortic stenosis and high surgical risk, transcatheter implantation of aortic valve is a safe and effective alternative. Both, general anesthesia and local anesthesia with sedation are valid options, depending on the experience of the team.