[Analgesia for childbirth in a patient with factor V Leiden mutation]. / Analgesia para trabajo de parto en paciente con mutación del factor V Leiden.

Factor V Leiden mutation is the most common congenital thrombophilic disorder, affecting between 5% and 8% of the Caucasian population. Pregnancy creates a state of hypercoagulability and all factors that increase the risk of thrombosis should be considered, as they may be cumulative. In recent years, the diagnosis of new allelic variants of thrombophilic states have increased the incidence of pregnant women receiving anticoagulant therapy, with the anesthetic considerations that implies. We report the case of a 33-year-old woman with heterozygous Leiden factor V mutation who was admitted with spontaneous amniorrhexis in the 38th week of gestation. She was taking low molecular weight heparin therapy. An epidural catheter was inserted to provide analgesia for labor, with all safety precautions to prevent an epidural hematoma. Epidural anesthesia is the technique of choice for obstetric labor in patients with hypercoagulability because of its effects of favoring blood flow and inhibiting clot formation.

Analgesia para trabajo de parto en paciente con mutación del factor V Leiden / Analgesia for childbirth in a patient with Factor V Leiden mutation

La mutación del factor V Leiden, es la forma más frecuente de trastorno trombofílico congénito, afectando al 5-8% de la población caucasiana. La gestación supone, en sí misma, un estado de hipercoagulabilidad que nos debe llevar a prestar especial atención a todos aquellos factores de riesgo trombótico que puedan sumarse. En los últimos años, el diagnóstico de las nuevas variantes alélicas de los estados trombofílicos, ha incrementado la incidencia de gestantes que reciben anticoagulación con las consideraciones anestésicas que ello conlleva. Presentamos el caso de una mujer de 33 años de edad, portadora heterocigoto de una mutación en el gen del factor V Leiden, en tratamiento con heparina de bajo peso molecular, que ingresa por amniorrexis espontánea a la semana 38 de gestación. La paciente requirió analgesia para el trabajo de parto, por lo que se le colocó un catéter epidural cumpliendo los protocolos de seguridad y prevención del hematoma epidural. La anestesia epidural es la técnica de elección para analgesia del trabajo de parto, en las pacientes con hipercoagulabilidad, por sus efectos sobre la reología vascular y su efecto antitrombótico

Factor V Leiden mutation is the most common congenital thrombophilic disorder, affecting between 5% and 8% of the Caucasian population. Pregnancy creates a state of hypercoagulability and all factors that increase the risk of thrombosis should be considered, as they may be cumulative. In recent years, the diagnosis of new allelic variants of thrombophilic states have increased the incidence of pregnant women receiving anticoagulant therapy, with the anesthetic considerations that implies. We report the case of a 33-year-old woman with heterozygous Leiden factor V mutation who was admitted with spontaneous amniorrhexis in the 38th week of gestation. She was taking low molecular weight heparin therapy. An epidural catheter was inserted to provide analgesia for labor, with all safety precautions to prevent an epidural hematoma. Epidural anesthesia is the technique of choice for obstetric labor in patients with hypercoagulability because of its effects of favoring blood flow and inhibiting clot formation

[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.

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

OBJETIVOS: Comparar el volumen gástrico postintubación entre pacientes con y sin síntomas de enfermedad por reflujo gastroesofágico (ERGE). MÉTODOS: Estudio prospectivo, aleatorio en 331 adultos, ASA I-II, cirugía programada. Los pacientes sintomáticos para ERGE (pirosis y regurgitación) se asignaron al Grupo A (n=83); los asintomáticos (n=248) a los grupos B (n=85), C (n=70) y D (n=93). El grupo A se subdividió en A1: tomaban tratamiento ambulatorio para la ERGE y A2: sin tratamiento. Los grupos A, B y C recibieron profilaxis con omeprazol 40 mg y metoclopramida 10 mg, el grupo D no recibió profilaxis. Se administró 1 mg·Kg-1 de succinilcolina en los grupos A y B y 0,2 mg.Kg-1 de cisatracurio en los grupos C y D. Se aspiró y cuantificó el contenido gástrico postintubación. Los resultados se analizaron con las pruebas de χ2 de Pearson, t de Student, ANOVA, Kruskal-Wallis y U de Mann-Whitney. RESULTADOS: Los volúmenes de contenido gástrico aspirados en cada grupo fueron: A: 36,6 ± 5 ml, B: 9,98 ± 4,9 mL, C: 10,8 ± 5,5 mL, D: 15,62 ± 6,3 mL; A1: 32,7 ± 5,1 mL y A2: 39,08 ± 3,6 ml; fueron significativamente mayores en el grupo A que en los grupos B, C y D (p<0,0001); y en el subgrupo A2 respecto al A1 (p<0,001). El porcentaje de volumen gástrico mayor de 25 mL en cada grupo fue: A: 98,8%, B: 1,2%, C: 2,8% y D: 8,6% (p<0,001). CONCLUSIÓN: Los pacientes sintomáticos (pirosis y regurgitación habituales) presentan un volumen gástrico postintubación mayor que los asintomáticos, atribuible al trastorno motor esofagogástrico característico de la ERGE que puede favorecer la aspiración. La anamnesis sobre la ERGE debe realizarse en la consulta preanestésica y tratar a los pacientes sintomáticos con un inhibidor de la bomba de protones ambulatorio

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 Awas 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·kg-1 of succinylcholine, and groups C and D received 0.2 mg·kg-1 of cisatracurium. After intubation, gastric content was aspirated and measured. The results were compared with Pearson’s χ2 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 and fibrobronchoscopy for the study of chronic stridor in a boy with Robinow syndrome]. / Anestesia y fibrobroncoscopia para el estudio de estridor crónico en un niño con síndrome de Robinow.

Robinow's syndrome involves fetal facial features, short stature, brachymelia, hypoplastic genitals and a normal karyotype. A 10-year-old boy with Robinow's syndrome was scheduled for study of chronic stridor by fiberoptic bronchoscopy. Airway exploration with the patient awake revealed hipertelorism, retromicrognathia, poor dental alignment, macroglossia and class IV Mallampati. After anesthetic induction in spontaneous ventilation with 5% sevoflurane, grade IV Cormack-Lehane conditions were observed. A laryngeal mask was placed without muscle relaxation after which the boy was ventilated manually for several minutes without stridor. Anesthetic maintenance was with 3% sevoflurane in 50% oxygen and air. After recovery of spontaneous ventilation, marked stridor presented along with a decrease in oxygen saturation and expired fractions of sevoflurane and CO2. Pulse oxymetry did not increase with increased FiO2. However, when continuous positive airway pressure (CPAP) was set al 10 cm H2O, pulse oxymetry did increase; likewise, expired and inspired sevoflurane concentrations became equal, and expired CO2 increased. Fiberoptic bronchoscopy revealed an area of intrathoracic tracheomalacia, which collapsed partially during spontaneous expiration and collapsed less when CPAP was started. We discuss the relation between the facial dysmorphia characteristic of this syndrome and the possibility of finding a difficult airway, as well as the diagnosis and treatment of intrathoracic tracheomalacia during anesthesia.

Anestesia y fibrobroncoscopia para el estudio de estridor crónicoen un niño con síndrome de Robinow / Anesthesia for the fiberoptic bronchoscopic study of chronic stridor in a child with Robinow's syndrome

El síndrome de Robinow reúne rasgos faciales fetales, talla baja, braquimelia, genitales hipoplásicos y un cariotipo normal1. Un niño de 10 años, con síndrome de Robinow, fue programado para fibrobroncoscopia diagnóstica por presentar un estridor crónico. La exploración de la vía aérea con el paciente despierto mostró: hipertelorismo, retromicrognatia, mala alineación dental, macroglosia y un Mallampatti clase IV. Tras realizar la inducción en ventilación espontánea con sevoflurano al 5 por ciento, presentó en la laringoscopia un test de Cormack-Lehane grado IV. Se introdujo una mascarilla laríngea sin relajación muscular, tras lo cual se le ventiló unos minutos manualmente sin que presentara estridor. El mantenimiento anestésico se realizó con sevoflurano al 3 por ciento y O2/aire al 50 por ciento. Tras dejarle recuperar la ventilación espontánea, presentó un estridor importante junto a disminución de la saturación de oxígeno y de las fracciones espiradas de sevoflurano y de CO2. El incremento de la FiO2 no mejoró la pulsioximetría. Con la instauración de una presión espiratoria continua de 10 cm de H2O, se elevó la pulsioximetría, las concentraciones de sevoflurano espirado e inspirado se igualaron, y el CO2 espirado se incrementó. La fibrobroncoscopia mostró una zona de traqueomalacia intratorácica que se colapsaba parcialmente durante la espiración en ventilación espontánea, y como disminuía el colapso cuando se instauraba la presión espiratoria positiva continua. Se discuten la relación entre la dismorfia facial característica de este síndrome y la posibilidad de presentar una vía aérea difícil y además el diagnóstico y tratamiento de la traqueomalacia intratorácica durante la anestesia. (AU)