[Complex regional pain syndrome type 2 after radial artery catheterization: a case report]. / Síndrome de dolor regional complejo tipo II tras cateterización de arteria radial. A propósito de un caso.

Complex regional pain syndrome has multiple causes. The clinical picture includes pain that can be debilitating, along with vascular and motor abnormalities, changes in sweating, delayed recovery, eating disorders, and occasionally psychological changes. Treatment is complex and should be started early if symptoms are to be reversed. We report the case of a man who developed complex regional pain syndrome type 2 in his left arm after surgery with extracorporeal circulation to repair an interatrial septal defect. The clinical picture was believed to have been triggered by catheterization of the radial artery.

[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.

[Update on transfusion practice among anesthesiologists and its impact on the surgical patient]. / Actualización de la práctica transfusional entre los anestesiólogos y su impacto en el paciente quirúrgico.

OBJECTIVE: To determine the effectiveness of a new educational program on transfusion practice, directed to the staff of an anesthesia and postoperative recovery service, by evaluating its impact on intraoperative transfusion (IOT). MATERIAL AND METHODS: We reviewed the incidence of IOT during the first semesters of 1996 and 2001 for general, urologic, otolaryngologic, maxillofacial, thoracic, and vascular surgery. Other factors such as sex, age, type of intervention, emergency status, duration of operation, and use of blood products were also taken into consideration. RESULTS: A statistically significant overall reduction in IOT occurred between 1996 (4.9%) and 2001 (3.6%). The decrease in transfusions (a reduction of 18.8% in transfused patients) was even greater in general surgery and urology, particularly in scheduled surgery (4.1% in 1996 vs 2.6% in 2001). However, the total use of packed red blood cells did not change inasmuch as the number of units per patient was higher in 2001 (2.8 units/patient) than in 1996 (2.4 units/patient). In emergency surgery, the IOT rate increased from 7.6% in 1996 to 8.1% in 2001. We also noticed a higher rate of multiple transfusions (defined as the use of 5 or more units of packed red blood cells during surgery) in 2001. CONCLUSION: The introduction of an educational program directed to anesthesiologists has been useful for reducing IOT, although the overall use of blood products has not decreased.

[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.

[Hypertonic saline 7.5% in the treatment of severe hypochloremic metabolic alkalosis]. / Suero salino hipertónico 7,5% en el tratamiento de la alcalosis metabólica hipoclorémica grave.

A 63 year-old man with a history of anal carcinoma treated by surgery, chemotherapy and radiotherapy was admitted to our hospital two years later with small bowel obstruction requiring emergency surgery. Fifteen days later, he had to be operated on once again. During the procedure, severe metabolic alkalosis developed: pH 7.58, CO3H- 47.7 mmol/L and a base excess of 24.3 mmol/L. The patient had the following preoperative risk factors for hypochloremic metabolic alkalosis: low levels of Cl and K, prolonged aspiration of gastric contents, low plasma volume and parenteral nutrition. Metabolic alkalosis was managed with 250 mL of 7.5% hypertonic saline, 40 mEq of KCl, readjustment of the ventilatory pattern, perfusion of lactated Ringer's solution instead of 0.9% saline and administration of omeprazole. Response to treatment was good as elevated values fell to acceptable levels within two hours. Metabolic alkalosis is a common acid-base balance disorder which arises for a variety of reasons and which has significant anesthetic implications. Hypertonic saline may be useful for treating severe, acute hypochloremic metabolic alkalosis.

[Constraints on the use of a nerve stimulator in peripheral conduction blocks when there is disturbance in the neuromuscular junction]. / Limitación del uso del neuroestimulador en la realización de bloqueos de conducción periféricos en alteraciones de la unidad neuromuscular.

An 81-year-old woman with right lower limb ischemia was scheduled for revascularization of a femoropopliteal bypass grafted 10 years earlier. A popliteal blockade, attempted as part of regional anesthesia with the aid of a nerve stimulator, was not achieved because the posterior tibial nerve could not be located. After surgery, the patient mentioned symptoms in the region of the right knee consistent with complex regional pain syndrome (Ducke's stage 3); the symptoms appeared after the first operation and would explain the absence of response to the nerve stimulator. Using a nerve stimulator to facilitate location of the various nerve trunks for anesthesia involves obtaining a motor response to electrical stimulation. The procedure is becoming more and more frequent because of its many advantages over other more traditional methods. However, it may be impossible to locate a nerve for a variety of reasons.

[Brugada syndrome and anesthesia. Apropos of a case]. / Síndrome de Brugada y anestesia. A propósito de un caso.

We describe a patient with a tentative diagnosis of Brugada syndrome who was given general anesthesia without complications. We review the main characteristics of Brugada syndrome.