Usefulness of resuscitative endovascular balloon occlusion of the aorta (REBOA) in controlling puerperal bleeding in patients with abnormal placental implantation.

BACKGROUND AND AIMS: Abnormalities of placental implantation, which make up the spectrum of placenta accreta, are associated with high maternal morbidity and mortality due to massive bleeding during delivery. Placing aortic occlusion balloons helps control the bleeding, facilitating surgical intervention. A new device, resuscitative endovascular balloon occlusion of the aorta (REBOA), minimizes the risks and complications associated with the placement of traditional aortic balloons and is also efficacious in controlling bleeding. The aim of this study is to evaluate the usefulness, efficacy, and safety of REBOA in puerperal bleeding due to abnormalities of placental implantation. MATERIAL AND METHODS: Between November 2019 and November 2021, our interventional radiology team placed six REBOA devices in six women scheduled for cesarean section due to placenta accrete. RESULTS: Mean blood loss during cesarean section after REBOA (3507.5 mL) was similar to the amounts reported for other aortic balloons. The mean number of units of packed red blood cells required for transfusion was 3.5. Using REBOA provided the surgical team with adequate conditions to perform the surgery. There were no complications derived from REBOA, and the mean ICU stay was <2 days. CONCLUSION: The technical characteristics of the REBOA device make it a safe and useful alternative for controlling massive bleeding in patients with placenta accreta.

Utilidad de la oclusión aórtica con balón REBOA para el control de las hemorragias puerperales en pacientes con anomalías de la implantación placentaria / Usefulness of resuscitative endovascular balloon occlusion of the aorta (REBOA) in controlling puerperal bleeding in patients with abnormal placental implantation

Antecedentes y objetivo: Las anomalías en la implantación placentaria, que conforman el espectro de la placenta acreta, son causa de alta morbimortalidad maternal por la hemorragia masiva que se produce en estas pacientes durante el parto. La colocación previa de balones de oclusión aórticos ayuda a controlar el sangrado, disminuyéndolo y facilitando la intervención quirúrgica. Existe un nuevo balón de oclusión aórtico denominado REBOA que minimiza los riesgos y las complicaciones asociadas a la colocación de los balones aórticos tradicionales además de lograr el control de las hemorragias. El objetivo del presente estudio es evaluar la utilidad, la eficacia y la seguridad del balón REBOA en las hemorragias puerperales por anomalías en la implantación placentaria. Material y métodos: Desde noviembre del 2019 hasta noviembre del 2021 se han colocado, por parte de radiología intervencionista, 6 balones REBOA en 6 mujeres que iban a ser tratadas mediante cesárea programada de acretismo placentario. Resultado: En el estudio realizado, las pérdidas de volumen sanguíneo durante la cesárea tras la colocación del balón REBOA son similares a las reportadas en la literatura con otros balones aórticos, con una media de 3.507,5ml. La media de requerimientos transfusionales fue de 3,5 concentrados de hematíes. El uso del balón REBOA proporcionó al equipo quirúrgico unas condiciones adecuadas para realizar la cirugía. No hubo complicaciones derivadas de su colocación y la estancia media en UCI de las pacientes fue inferior a 2 días. Conclusión: El balón REBOA, gracias a sus características técnicas, se plantea como una nueva alternativa segura y útil para el control de las hemorragias masivas en las pacientes con acretismo placentario.(AU)

Background and aims: Abnormalities of placental implantation, which make up the spectrum of placenta accreta, are associated with high maternal morbidity and mortality due to massive bleeding during delivery. Placing aortic occlusion balloons helps control the bleeding, facilitating surgical intervention. A new device, resuscitative endovascular balloon occlusion of the aorta (REBOA), minimizes the risks and complications associated with the placement of traditional aortic balloons and is also efficacious in controlling bleeding. The aim of this study is to evaluate the usefulness, efficacy, and safety of REBOA in puerperal bleeding due to abnormalities of placental implantation. Material and methods: Between November 2019 and November 2021, our interventional radiology team placed six REBOA devices in six women scheduled for cesarean section due to placenta accrete. Results Mean blood loss during cesarean section after REBOA (3507.5mL) was similar to the amounts reported for other aortic balloons. The mean number of units of packed red blood cells required for transfusion was 3.5. Using REBOA provided the surgical team with adequate conditions to perform the surgery. There were no complications derived from REBOA, and the mean ICU stay was < 2 days. Conclusion The technical characteristics of the REBOA device make it a safe and useful alternative for controlling massive bleeding in patients with placenta accreta.(AU)

Amnesia global transitoria: una entidad infrecuente pero presente en Pediatría / Transient global amnesia: an infrequent entity but present in Pediatrics

Introducción: La amnesia global transitoria es una entidad caracterizada por la aparición súbita de amnesia anterógrada con amnesia retrógrada variable, conservando intacta la memoria inmediata. No asocia otros déficits neurológicos. La recuperación es progresiva en pocas horas, habitualmente menos de 12, aunque suele persistir amnesia del episodio y presentar posteriormente cefalea leve. Caso clínico. Niño de 10 años, sin antecedentes de interés, que consulta en Urgencias por aparición brusca de amnesia retrógrada de las últimas 48 horas, así como incapacidad para la fijación de nueva información. Se mostraba ansioso y desorientado, y repetía la misma pregunta varias veces. La exploración neurológica por lo demás era estrictamente normal y negaba cefalea u otra sintomatología asociada. No antecedente de traumatismo craneoencefálico. Se realiza analítica sanguínea y gasometría venosa, sin alteraciones significativas; tóxicos en orina, negativos; TAC cerebral que descarta patología intracraneal aguda y punción lumbar, que es normal. Ingresa en planta de hospitalización con evolución favorable, con cese espontáneo de la clínica a las 8 horas, permaneciendo amnesia del episodio, con resto de la memoria conservada. Comentarios. La fisiopatología de la amnesia global transitoria no está del todo aclarada, aunque hay trabajos que sugieren un origen vascular de la misma, produciéndose durante estos episodios una hipoperfusión del lóbulo temporal medial. Es una entidad típica de adultos de mediana edad y ancianos siendo excepcional en pediatría. Sin embargo, debemos considerar este diagnóstico ante niños con clínica típica, normalidad de la neuroimagen y resolución espontánea de los síntomas.(AU)

Introduction: Transient global amnesia is an entity characterized by the sudden onset of anterograde amnesia with variable retrograde amnesia, preserving immediate memory intact. It is not associated with other neurological deficits. Recovery is progressive in a few hours, usually less than 12 hours, although amnesia of the episode usually persists and later presents mild headache. Case report. A 10-year-old boy, with no previous history of interest, consulted the emergency department for sudden onset of retrograde amnesia of the last 48 hours, as well as inability to fix new information. He was anxious and disoriented and repeated the same question several times. The neurological examination was otherwise strictly normal, and he denied headache or other associated symptoms. There was no history of cranioencephalic trauma. Blood analysis and venous blood gas analysis were performed, with no significant alterations; urine toxins were negative; brain CAT scan ruled out acute intracranial pathology and lumbar puncture was normal. She was admitted to the hospital ward with favorable evolution, with spontaneous cessation of the clinical symptoms after 8 hours, remaining amnesia of the episode, with the rest of the memory preserved. Comments. The pathophysiology of transient global amnesia has not been fully clarified, although some studies suggest a vascular origin, with hypoperfusion of the medial temporal lobe occurring during these episodes. It is a typical entity of middle-aged and elderly adults, being exceptional in pediatrics. However, we should consider this diagnosis in children with typical clinical symptoms, normal neuroimaging and spontaneous resolution of symptoms.(AU)

¿Es necesario realizar una angiografía por tomografía computarizada urgente en la hemorragia digestiva baja aguda? Proyecto MAPAC-IMAGEN / Is urgent CT angiography necessary in cases of acute lower gastrointestinal bleeding?

La hemorragia digestiva baja aguda se presenta en forma de hematoquecia, rectorragia o melenas, y constituye el 1-2% de los motivos de consulta en los servicios de urgencia. La mortalidad alcanza el 30-40%, en relación con la gravedad y la comorbilidad. La mayoría de las guías de práctica clínica incluyen la colonoscopia en algún momento del proceso diagnóstico-terapéutico (precoz en las graves y programada en las leves), y buscan factores predictores de gravedad. En los últimos años se han publicado numerosos estudios en los que queda patente la relevancia y la complementariedad diagnóstica de las técnicas de imagen avanzadas, incorporadas paulatinamente como alternativa o de segundo escalón en los casos graves. Por ello, hemos realizado una revisión de la evidencia científica actual que permita establecer una regla de predicción clínica para la óptima indicación de la angiografía por tomografía computarizada en estos pacientes. Son necesarios, no obstante, futuros estudios que aporten mayor robustez y nivel de evidencia (AU)

Acute lower gastrointestinal bleeding usually presents as hematochezia, rectal bleeding or melena and represents 1-2% of the medical appointments in the Emergency Services. Mortality reaches the 30-40% and it is highly related with the severity and associated comorbidity. Most clinical practice guidelines include colonoscopy at some point in the diagnostic and therapeutic process (urgent for severe cases and ambulatory for mild ones) and look for predictors of severity. In the last years, there have been numerous studies where is clear the relevance and complementarity of advanced diagnostic imaging techniques, gradually incorporated as an alternative or second step in severe cases. Therefore, we have made a review of current scientific evidence to establish a clinical prediction rule for optimal indication of CT angiography in these patients. However, future studies providing greater robustness and level of evidence are necessary (AU)

Multimodal analgesia and regional anaesthesia. / Analgesia multimodal y anestesia regional.

Multimodal analgesia provides quality analgesia, with fewer side effects due to the use of combined analgesics or analgesic techniques. Regional anaesthesia plays a fundamental role in achieving this goal. The different techniques of regional anaesthesia that include both peripheral and central blocks in either a single dose or in continuous infusion help to modulate the nociceptive stimuli that access the central level. The emergence of the ultrasound as an effective system to perform regional anaesthesia techniques has allowed the development of new regional anaesthesia techniques that formerly could not be carried out since only neurostimulation or skin references were used. It is essential to take into account that even with effective blocking it is advisable to associate other drugs by other routes, in this way we will be able to reduce the required doses individually and attempt to achieve a synergistic, not purely additive, effect.

Subdural hygroma accompanied by parenchymal and subarachnoid haemorrhage after epidural analgesia in an obstetric patient.

BACKGROUND: Anaesthetists need to know the different causes of persistent headache or a change in level of consciousness following epidural analgesia for labour. Failure to recognise these neurological complications can lead to delayed diagnoses, with subsequent serious implications. METHODS: We present a patient who was re-admitted for postural headache resulting from an unrecognised dural puncture during an epidural for pain relief while in labour. During the interview, the patient confirmed drug use (cocaine), so she was evaluated by a psychiatrist with possible post-partum psychosis or drug withdrawal syndrome. Afterwards, the patient deteriorated neurologically, showing impaired consciousness and seizures. RESULTS: The cranial computed tomography showed bilateral frontoparietal subdural collections with intraparenchymal and subarachnoid haemorrhaging. She improved by burr hole drainage of subdural hygroma and a blood patch. CONCLUSIONS: Neurological signs should alert the clinician to the possibility of subdural collection and other possible complications such as sinking of the brain in order not to delay the request for imaging tests for diagnoses and effective treatments.

[Disseminated cryptococosis in renal transplant recipient]. / Criptococosis diseminada en una paciente portadora de trasplante renal.

The incidence of cryptococosis ranges from 0.4-5.8% in renal transplant. Meningitis is the principal clinical manifestation, frequently with a subacute curse. In renal transplantation recipients, disseminated cryptococcosis appears as the more frequent presentation. We report a case of a 32 years old woman renal transplant recipient who presents altered mental status, headache and tremor during the month before her assessment to our hospital. Microbiological study was performed in cerebrospinal fluid and cryptococcus was isolated. She was treated with amphotericin B and 5 flucytosine. She developed refractory increased intracranial pressure and a lumboperitoneal derivation was necessary. Cryptococcosis must be considered as cause of meningitis in patients with renal transplant. The early diagnosis and treatment are fundamental due to high mortality of this pathology.

Criptococosis diseminada en una paciente portadora de trasplante renal / Disseminated cryptococosis in renal transplant recipient

La incidencia de criptococosis en el trasplante renal oscila entre 0,4-5,8% según lasdistintas series y conlleva una alta mortalidad. La meningoencefalitis constituye suprincipal manifestación clínica, generalmente en forma subaguda. En pacientes portadoresde trasplante renal, la criptococosis diseminada aparece como la forma de presentaciónmás frecuente en las diferentes series publicadas.Presentamos el caso de una paciente mujer portadora de trasplante renal que ingresaen nuestro servicio por un cuadro de alteración del nivel de conciencia, cefalea ytemblor de 1 mes de evolución. Mediante el estudio microbiológico del líquido cefalorraquídeofue diagnosticada de meningoencefalitis por criptococo, por lo que se iniciótratamiento con anfotericina B liposomal y 5-flucitosina.Durante su evolución desarrolló hipertensión intracraneal refractaria a tratamientoque precisó realización de derivación lumboperitoneal.La infección por criptococo debe valorarse como causa de meningoencefalitis enpacientes portadores de trasplante renal. El diagnóstico y tratamiento precoz en estoscasos son prioritarios debido a la elevada mortalidad de esta patología

The incidence of cryptococosis ranges from 0.4-5.8% in renal transplant. Meningitisis the principal clinical manifestation, frequently with a subacute curse. In renaltransplantation recipients, disseminated cryptococcosis appears as the more frequentpresentation.We report a case of a 32 years old woman renal transplant recipient who presentsaltederd mental status, headache and tremor during the month before her assessmentto our hospital. Microbiological study was performed in cerebrospinal fluid and cryptococcuswas isolated. She was treated with amphotericin B and 5 flucytosine.She developed refractory increased intracranial pressure and a lumboperitonealderivation was necessary. Cryptococcosis must be considered as cause of meningitis in patients with renaltransplant. The early diagnosis and treatment are fundamental due to high mortality ofthis pathology

[Scrotal oedema in a kidney graft recipient]. / Edema escrotal en un paciente portador de trasplante renal reciente.

A 54-year old man received a cadaveric renal allograf for end-stage renal disease due to membranous nephropathy. The patient developed scrotal oedema, 14 days after renal transplantation. The biochemical analysis of scrotal fluid after surgical drainage demostrated urine. Helical computed tomography was performed and it showed contrast leaks in medial, distal ureter and bladder. The urinary fistula was treated with surgical repairment and catheter endoluminal of ureter which was retired in four weeks. The incidence of urinary fistula ranged from 3 to 9%. The scrotal or perineal oedema is unusual clinical presentation of urinary leaks. The diagnosis of urinary fistula may be difficult and depends on a high degree of clinical suspicion. The helical computed tomography is a technique which allows a high resolution three-dimensional reconstruction and it can be used to make the diagnosis of urinary fistula.