Perioperative hypertension

The effects of hypertension on perioperative outcomes are still unclear. No specific systolic or diastolic blood pressure measurement has been determined as the cutoff value to continue with a surgical plan or adjourn. This study is designed as a narrative review of the available scientific evidence on the perioperative management of hypertension. A search was conducted in Pubmed considering the title and abstract; 120 articles were pre-selected of which 55 papers were selected for full-text eligibility and 16 were excluded for a total of 39 articles including ACCF/AHA 2009 and ACC/AHA 2014 on perioperative cardiovascular care; 2013 ESH/ESC, 8 JNC, and the 2017 ACC/AHA/AAPA/ABC Guideline for the Prevention, detection, and management of hypertension in adults. Blood pressure values, target organ damage, and type of surgery should be considered for decision-making in the perioperative period. If surgery is elective, blood pressure fluctuations should be avoided and potential causes should be treated. A patient with mild hypertension with values below SBP 160 and DBP 110 mmHg may be managed in the ambulatory setting during the postoperative period, as long as the clinical conditions are favorable.

Los efectos de la hipertensión sobre los desenlaces durante el periodo perioperatorio aún no han quedado claramente establecidos. No se ha determinado una medición específica para la presión sistólica ni diastólica como punto de corte para continuar con el plan quirúrgico o suspenderlo. El presente estudio está diseñado a manera de revisión narrativa de la evidencia científica disponible sobre el manejo perioperatorio de la hipertensión. Se llevó a cabo una búsqueda en Pubmed, considerando el título y el resumen; se preseleccionaron 120 artículos, de los cuales se seleccionaron 55 para elegibilidad en texto completo y 16 se excluyeron, quedando un total de 39 artículos, incluyendo ACCF/AHA 2009 y ACC/AHA 2014 sobre el cuidado cardiovascular perioperatorio; 2013 ESH/ESC, 8 JNC, y la Guía del 2017 ACC/AHA/AAPA/ABC para la prevención, detección y manejo de la hipertensión en adultos. Se deben considerar los valores de la presión arterial, el daño a órgano diana y el tipo de cirugía para la toma de decisiones en el periodo perioperatorio. Si la cirugía es electiva, deben evitarse las fluctuaciones en la presión arterial y tratar activamente cualquiera de las causas potenciales. Un paciente con hipertensión leve, con valores por debajo de PAS 160 y PAD 110 mmHg puede manejarse de manera ambulatoria durante el período postoperatorio, siempre y cuando las condiciones clínicas sean favorables.

Capillary Refill Time and Serum Lactate as Predictors of Mortality and Postoperative Extracorporeal Membrane Oxygenation Requirement in Congenital Heart Surgery.

Multiple tissue perfusion markers are described to guide therapy in critically ill pediatric patients undergoing congenital heart surgery. Given the advantages of capillary refill time, our goal is to determine its predictive capacity for mortality and postoperative extracorporeal oxygenation requirements in congenital heart surgery and compare it to serum lactate. We conducted a prospective cohort observational study in a single high-complexity university hospital. Serum lactate and capillary refill time were measured at five predetermined time points: preoperative, immediate postoperative, 6, 12, and 24 h after the surgery. Prolonged immediate postoperative, 6 h, and 12 h capillary refill time measurements turned out to be independent risk factors for both outcomes. The capillary refill time area under the curve ranged between 0.70 and 0.80, while the serum lactate resulted between 0.79 and 0.92 for both outcomes. Both tissue perfusion markers resulted in mortality and extracorporeal oxygenation requirement predictors. Given the advantages of capillary refill time over serum lactate, a monitoring strategy including these two perfusion markers should be considered for congenital heart surgeries.

Successful Management of a Spontaneous Retrobulbar Hematoma After Heart Transplantation. A Case Report.

CASE DESCRIPTION: We present a case of a 65-year-old patient who underwent heart transplantation. After the surgery, left proptosis, conjunctival chemosis, and ipsilateral palpebral ecchymosis were found while he was still intubated. A retrobulbar hematoma was suspected, confirmed by a computed tomography scan. Initially, expectant management was considered, but with the appearance of an afferent pupillary defect, the patient underwent orbital decompression and posterior collection drainage, which prevented visual impairment. CONCLUSION AND IMPORTANCE: Spontaneous retrobulbar hematoma after heart transplantation is a rare condition that risks vision. We intend to discuss the importance of postoperative ophthalmologic examination after heart transplantation in intubated patients for early diagnosis and rapid treatment. Spontaneous retrobulbar hematoma (SRH) after heart transplantation is an exceptional condition that risks vision. Bleeding in the retrobulbar space provokes an anterior ocular displacement, extending the vessels and the optic nerve, which can generate ischemic neuropathy and, finally, a loss of vision [1]. A retrobulbar hematoma is usually associated with trauma or eye surgery. Though, in non-traumatic cases, the underlying cause is not evident. An adequate ophthalmologic examination is usually not performed in complex surgeries like heart transplantation. However, this simple measure can prevent permanent vision loss. Non-traumatic risk factors should also be considered, which include vascular malformations, bleeding disorders, use of anticoagulants, and increased central venous pressure usually triggered by a Valsalva maneuver [2]. The clinical presentation of SRH consists of ocular pain, decreased visual acuity, conjunctival chemosis, proptosis, abnormal extraocular movements, and elevated intraocular pressure (IOP). Its diagnosis is often clinical; however, it can be confirmed with computed tomography or magnetic resonance imaging. Treatment aims to reduce IOP with surgical decompression or pharmacologic measures [2]. In the reviewed literature, less than 5 spontaneous ocular hemorrhages related to cardiac surgery have been reported [3-6], of which only one is related to heart transplantation [3]. A clinical challenge of an SRH after heart transplantation is presented below. Surgical management was performed with a favorable result.

Disparities Influencing Functional Outcomes Between Rural and Urban Patients With Acute Stroke.

Introduction: There is scarce information in Latin America about factors related to stroke patient outcomes in rural areas compared to urban ones. Objective: To evaluate functional outcomes of stroke code patients from rural and urban areas and their relationship with socioeconomic disparity. Methods: Prospective cohort study included patients of urban, semi-urban, and rural origin with stroke code from a high complexity hospital in southwestern Colombia between 2018 and 2019. Demographic, clinical data modified Rankin at discharge, and 3-month follow-up were analyzed. The poverty index, barriers to health access and availability of ambulances by the municipality was assessed at an ecological level. Results: Five hundred and fifty five stroke patients were registered, 21.2% from rural areas, 432 (77.98%) had an ischemic stroke. There were no significant differences in sociodemographic factors and medical background. Urban patients had lower reperfusion therapies rates (23.25%). Favorable mRS at discharge (<3) was higher in urban areas (63.03%) and mortality was superior in rural patients (13.56%). The ambulance rate in semi-urban and rural areas was as low as 0.03 per 100.000 inhabitants, the poverty index was 11.9% in urban areas vs. 23.3% in semi urban and rural areas. Conclusions: Rural patients treated in our center were more likely to present with severe strokes and unfavorable mRS at hospital discharge and 3-month follow-up compared to urban, despite having similar risk factors. There is an inverse relationship, which is not related to the poverty rate or the percentage of people with barriers to access to health. There is a need for further studies that assess barriers inherent in rural patients and establish a regional stroke network.

Impacto del uso de analgesia peridural controlada por la paciente en la disminución del dolor durante el trabajo de parto en un hospital del suroccidente colombiano / Impact of the use of patient-controlled epidural analgesia on pain reduction during labor in a hospital in southwestern colombia

Introducción: La analgesia epidural controlada por la paciente (PCA) provee flexibilidad al permitir acomodar la analgesia de acuerdo con las necesidades crecientes del dolor a medida que progresa el trabajo de parto (TP). El propósito de este estudio es objetivar el impacto en el alivio del dolor y satisfacción materna en pacientes en TP con analgesia PCA.Pacientes y métodos: Estudio descriptivo prospectivo realizado en el segundo semestre del 2020. Se incluyeron gestantes con embarazo único con escala verbal numérica (EVN) mayor a 3 y se excluyeron a las pacientes con contraindicaciones para inserción de catéter. Posterior a la inserción, se valoró el dolor y se entregó un cuestionario para calificar el dolor a los 15 min y en el expulsivo.Resultados: La población estaba constituida por mujeres jóvenes, el 72 % con embarazo a término. El catéter peridural se insertó en la fase latente del trabajo de parto en el 53,4 % de los casos. Al momento de la inserción del catéter, la mediana de dolor fue de 8 (6-10), a los 15 minutos 2 (0-4) y en el expulsivo 5 (3-8). El 75 % de las maternas refirieron estar muy satisfechas y el 19 % satisfechas; un 3 % indicaron estar poco satisfechas y el 1 % restante, insatisfechas. La prevalencia náusea y vómito fue del 16 % y 15 %, respectivamente.Conclusiones: PCA como estrategia analgésica durante el trabajo de parto a través de bolos intermitentes a demanda logró un adecuado control del dolor en los primeros minutos posterior a la inserción sin un control óptimo durante el expulsivo, sin embargo, se obtuvo una satisfacción materna global alta.(AU)

Introduction: Patient-controlled analgesia (PCA) allows patients to accommodate analgesia according to increasing pain needs as labor progresses. This study aims to objectify the impact on pain relief and maternal satisfaction in labor patients with PCA analgesia.Patients and methods: A prospective descriptive study was carried out in the second semester of 2020. Pregnant women with a singleton pregnancy with a numerical rating scale (NRS) greater than three were included, and patients with contraindications for catheter insertion were excluded. After insertion, pain was assessed, and a questionnaire was given to rate pain at 15 min and during expulsion.Results: The population consisted of young women, 72 % of whom were pregnant at term. The epidural catheter was inserted in the latent phase of labor in 53.4 % of cases. At the time of catheter insertion, the median pain was 8 (6-10), at 15 minutes 2 (0-4), and expulsion 5 (3-8). Seventy-five percent of the mothers reported being very satisfied and 19 % satisfied; 3 % reported being slightly satisfied, and the remaining 1 % dissatisfied. The prevalence of nausea and vomiting was 16 % and 15 %, respectively.Conclusions: PCA as an analgesic strategy during labor through intermittent boluses on-demand achieved adequate pain control in the first minutes after insertion without optimal control during expulsion. However, high overall maternal satisfaction was obtained.(AU)

Neurozika, de las ciencias básicas a la práctica clínica. Revisión de la literatura / Neurozika, from the basic science to the clinical practice. Literature review

RESUMEN El virus del zika (VZ) hace parte de la familia Flaviviridae y de los Spondweni serocomplejo; es transmitido principalmente por la familia de vectores Aedes. El primer reporte de una enfermedad exantemática desconocida fue llevado a cabo en Brasil en el año 2014 y posteriormente se reconoció como la infección por VZ en mayo del 2014. Para mayo del 2015, dicha infección se había extendido por Brasil y en noviembre de aquel año se confirmó la asociación de microcefalia y anormalidades congénitas durante el embarazo. Con posterioridad se han reportado múltiples alteraciones neurológicas en la población pediátrica, como microcefalia; alteraciones corticoespinales; síntomas neuromusculares; disquinesias; atrofia coriorretininana con coloboma macular; nistagmus; glaucoma congénito e hipoacusia neurosensorial asociada con atrofia o displasia cortical; ventriculomegalia; calcificaciones; hipoplasia de tallo y del cerebelo con compromiso del vermix; pérdida del volumen de la sustancia blanca; disgenesia del cuerpo calloso e hidrocefalia; malformación de Dandy Walker y adelgazamiento de la porción torácica y de la médula espinal hacia el aspecto ventral; alteraciones todas que explican los signos clínicos del síndrome del VZ congénito. En los adultos se ha documentado el síndrome de Guillain-Barré con una incidencia de dos a tres casos por cada 10 000 infecciones y, en menor medida, se han reportado casos de mielitis y encefalitis por la infección con el VZ. Adicionalmente, se han descrito alteraciones del comportamiento, disminución del nivel de conciencia, convulsiones y meningismo. Por último, las menos frecuentemente reportadas hasta el momento son la encefalomielitis aguda diseminada, la parálisis facial periférica y la mielorradiculopatía.

SUMMARY Zika virus (ZV) is a member of the Flaviviridae family and part of the Spondweni serocomplex, mainly transmitted by the Aedes vector family. The first case report of an unknown exanthematous disease was identified in Brazil and subsequently, it was recognized as ZV infection in December 2014. By May 2015, ZV spread throughout Brazil and in November 2015 the association with microcephaly and congenital abnormalities during pregnancy, was confirmed. Subsequently, multiple neurological alterations have been reported among the pediatric population such as microcephaly, corticospinal alterations, neuromuscular symptoms, dyskinesia, chorioretinal atrophy with macular coloboma, nystagmus, congenital glaucoma, sensorineural hearing loss and cortical dysplasia, ventriculomegaly, calcifications, hypoplasia of the brain stem and cerebellum with afection of the vermis, white matter alteration, dysgenesis of the corpus callosum and hydrocephalus, Dandy Walker malformation, thinning of the thoracic portion and spinal cord may explain the clinical signs of congenital ZV syndrome. Also, Guillain-Barre syndrome has been documented in adults with an incidence of 2 to 3 cases per 10,000 infections and, less frecuently, myelitis and encephalitis have been reported. Additionally, behaviour impairments have been described as well as decreased level of consciousness, seizures and meningism. Finally, the least frequent manifestations reported so far are acute disseminated encephalomyelitis, peripheral facial palsy and myeloradiculopathy.