[Pulmonary oedema due to re-expansion after resection of a giant thymoma]. / Edema pulmonar por reexpansión tras resección de timoma gigante.

A 36 year-old woman was subjected to resection of a giant thymoma that occupied a large area of the left hemithorax. After resection of the tumour and insufflation of the left lung there was pulmonary oedema due to early re-expansion. She was treated with diuretics and corticoids and was kept on mechanical ventilation. The patient progressed favourably. Although pulmonary oedema due to re-expansion is an uncommon complication it has a high mortality. It is essential to be aware of the factors involved in its aetiopathogenesis. It should be diagnosed and treated immediately.

[Cardiovascular and respiratory complications after pneumonectomy]. / Complicaciones cardiovasculares y respiratorias postneumonectomía.

Thoracic surgery has made important progress thanks to parallel advances in anesthetic techniques, which have lowered mortality and complication rates. Pneumonectomy, however, continues to carry a high risk of perioperative death and morbidity, with complications involving the heart and lung being the most common. Pneumonectomy requires careful preoperative assessment to identify patients at high risk of cardiac complications. However, there is no evidence available on the best approach to take in determining risk of impaired lung function after pneumonectomy. Postoperative arrhythmias increase mortality, although evidence does not suggest a need for systematic prophylactic treatment of patients who will undergo lung resection. The incidence of acute myocardial infarction ranges from 1.5% to 5% and diagnosis is difficult because most episodes are silent. The incidence of post-pneumonectomy pulmonary edema is between 4% and 7% and evidence indicates that prevention is the most important therapeutic measure. Patients tend to have greater risk of pneumonia after thoracotomy, but few studies have provided a high level of evidence for the usefulness of antibiotic prophylaxis in chest surgery. The aim of the present study was to review the literature on the most common complications of surgery on the lung in order to support decision making based on the integration of knowledge and clinical judgment acquired with experience. A MEDLINE search was carried out to locate studies published from 1980 through January 2005.

[Comparison of gastric aspirate volume after intubation in patients with and without symptoms of gastroesophageal reflux disease]. / Comparación del volumen gástrico tras intubación entre pacientes con y sin síntomas de enfermedad por reflujo gastroesofágico.

OBJECTIVES: To compare the postintubation gastric aspirate volume of patients with and without symptoms of gastroesophageal reflux disease (GERD). METHODS: Prospective randomized study of 331 physical status ASA I-II adults scheduled for surgery. Patients with GERD symptoms (heartburn and regurgitation) were assigned to group A (n=83); asymptomatic patients (n=248) were assigned to groups B (n=85), C (n=70), and D (n=93). Group A was subdivided: group A1 received outpatients treatment for GERD and group A2 did not. Groups A, B, and C received prophylaxis with omeprazole 40 mg and metoclopramide 10 mg, respectively. Group D received no prophylaxis. Groups A and B patients received 1 mg x kg(-1) of succinylcholine, and groups C and D received 0.2 mg x kg(-1) of cisatracurium. After intubation, gastric content was aspirated and measured. The results were compared with Pearson's chi2 and Student t tests, analysis of variance, and Kruskal-Wallis and Mann-Whitney U tests. RESULTS: The gastric aspirate volumes in each group were as follows: 36.6 (SD 5) mL in group A; 9.98 (4.9) mL in group B; 10.8 (5.5) mL in group C; 15.62 (6.3) mL in group D; 32.7 (5.1) mL in group A1; and 39.08 (3.6) mL in group A2. Volumes were significantly greater in group A than in groups B, C, and D (P<0.0001), and in subgroup A2 than in subgroup A1 (P<0.001). The percentages of patients from whom a volume greater than 25 mL was aspirated in each group were as follows: 98.9% of group A, 1.2% of group B, 2.8% of group C, and 8.6% of group D (P<0.001). CONCLUSION: Patients with chronic heartburn and regurgitation have greater postintubation gastric aspirate volumes than do asymptomatic patients, attributable to the gastroesophageal motility dysfunction characteristic of GERD that can favor aspiration. GERD questions should be included in preanesthetic medical history taking, and symptomatic patients should be prescribed outpatient proton pump inhibitor therapy.

[Anesthesia for carbon dioxide laser surgery to correct Zenker's diverticulum]. / Anestesia para la cirugía del divertículo de Zenker con láser CO2.

Two 48- and 62-year-old men, the latter with a history of ischemic heart disease, underwent endoscopic carbon dioxide laser surgery to correct Zenker's diverticulum. We provided total intravenous anesthesia, taking into consideration the special requirements of laser surgery. The pathogenesis of Zenker's diverticulum, the most common type of esophageal diverticulum, is poorly understood and the treatment approach depends on size and overall patient status. Patients with Zenker's diverticulum need a thorough preoperative assessment with special attention to airway permeability and the degree of difficulty of intubation. Anesthesia should be maintained in a manner that provides the safest, most effective surgical conditions.

[Anesthesia in Sebastian syndrome: a new hereditary macrothrombocytopenia]. / Anestesia en el síndrome de Sebastian: una nueva macrotrombocitopenia hereditaria.

The macrothrombocytopenias make up a heterogeneous group of disease involving thrombocytopenia and giant platelets; other clinical or laboratory findings, such as hereditary nephritis, sensorineural hearing loss, leukocyte inclusions, and cataracts, may also be present. The tendency to bleeding is highly variable and is due to decreased expression of the GP1b-V-IX complex on the surface of platelets, leading to altered platelet-vessel wall and platelet-platelet interactions. The 5 autosomal dominant giant-platelet disorders that are associated with macrothrombocytopenia are May-Hegglin anormaly, Epstein, Fechtner, and Sebastian syndromes, and Alport-like syndrome with macrothrombocytopenia. The mutation responsible is in gene 9 (MYH9) coding for the nonmuscle myosin heavy chain IIA that has been identified in the long arm of chromosome 22 (22q12.3-q13.2). The most recently described macrothrombocytopenia is Sebastian syndrome, consisting of thrombocytopenia with giant platelets and leukocyte inclusions. We report the case of a woman with Sebastian syndrome scheduled for abdominoperineal resection for rectal carcinoma. Preoperative studies revealed isolated thrombocytopenia (35,000 platelets/microL) and a mean platelet volumen of 13 fL. Preoperative prophylactic platelet transfusion was carried out with no adverse events. After a postoperative transfusion of packed red cells, needed because of abundant bleeding, clinical course continued to be satisfactory. The anesthetic implications of this syndrome are not well known because few cases have been reported in the literature, and none was found that describes anesthetic management. Nevertheless, thrombocytopenia and the tendency to bleeding present challenges to the anesthesiologist.

[Severe perioperative hypotension after nephrectomy with adrenalectomy]. / Hipotensión perioperatoria grave tras nefrectomía con suprarrenalectomía.

A 70-year-old obese, hypertensive woman taking angiotensin converting enzyme (ACE) inhibitors and chlorthalidone but with no history of corticosteroid treatment or hypothalamus-hypophyseal-adrenal disease, underwent nephrectomy and adrenalectomy under combined general and epidural anesthesia. Severe hypotension with oliguria developed during surgery and persisted during postoperative recovery, with anuria, metabolic acidosis, hyponatremia and hyperpotassemia. Although the symptoms were initially attributed to prior treatment with ACE inhibitors and diuretics together with combined anesthesia, the patient's lack of response to crystalloid, colloid and inotropic catecholamine therapy in the context of anuria, metabolic acidosis, hyponatremia and hyperpotassemia led us to consider a diagnosis of Addisonian crisis. Blood samples were taken to determine adrenocorticotropic hormone levels, and hydrocortisone treatment was started. The patient responded to treatment and cortisol levels fell, confirming the diagnosis of adrenal insufficiency. Compensatory endrocrine secretion of cortisol by the contralateral adrenal gland has been observed in patients undergoing nephrectomy and adrenalectomy for excision of a hypernephroma, and replacement therapy is therefore not recommended. Perioperative Addisonian crises have also been described in patients suffering great surgical stress, and severe hypotension has been observed in patients on long-term treatment with ACE inhibitors after induction of general anesthesia and after epidural anesthesia with local anesthetics. The combination of these factors made rapid diagnosis and start of appropriate therapy difficult.

[Acute myocardial infarction in the postoperative period following pneumonectomy]. / Infarto agudo de miocardio en el perioperatorio de una neumonectomía.

A 72-year-old man, smoker, with insuline-dependent diabetes and dislipemia underwent left pneumonectomy. Several episodes of intraoperative hemodynamic instability associated with electrocardiographic ST segment alterations were attributed to surgical manipulation; ischemia was not suspected. Cardiorespiratory failure, related to extensive anterior infarction, developed a few minutes after admission to the postoperative intensive care unit (PICU). Cardiopulmonary resuscitation and mechanical ventilation were required. The patient responded to treatment with beta blockers, platelet antiaggregants and statins. Tube was removed a few hours later and the patient was discharged from the PICU on the fifth day. Pneumonectomy has a high rate of morbidity and mortality, with complications mainly arising in the lung and heart. Risk from anesthesia is considered to be great in this procedure, and for that reason it is essential to identify intraoperative myocardial ischemia so that it can be treated aggressively. In patients at high cardiovascular risk who undergo lung resection, intraoperative episodes of myocardial ischemia are associated with a high incidence of postoperative miocardial infarction. Therefore, careful postoperative monitoring is needed and measures should be taken to prevent angina. Early extubation should be avoided.