Implicaciones anestésicas en una paciente con Síndrome de Donohue / Managing anesthesia for a woman with Donohue syndrome

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Non-surgical management of intracranial subdural hematoma complicating spinal anesthesia.

We report the case of a 29 year-old woman who presented a symptomatic intracranial subdural hematoma developing shortly after spinal anesthesia. The patient was fully conscious at clinical onset, and thus we treated her conservatively with an epidural autologous blood patch and close neurological observation. Given the clinical improvement the possibility of surgery was discauded in agreement with the neurosurgical team. Most cases of subdural hematoma appearing after spinal anesthesia are treated with surgery. In the present case the subdural hemorrhage was detected at our hospital 20 days after the anesthetic procedure, and given the excellent state of consciousness, we choosed a conservative management.

[Infant boy with propionic acidemia: anesthetic implications]. / Implicaciones anestésicas en un niño afecto de acidemia propiónica.

A 12-month-old boy diagnosed with propionic acidemia underwent gastrostomy. The patient's general state was good and he was alert, but with reduced muscular tone (unstable when seated with support, floppy head) and with dystonic movements in all extremities. An electroencephalogram showed slightly slowed brain activity. The patient was being treated with a low protein diet, phenobarbital, L-carnitine, L-isoleucine, and biotin. Surgery was carried out in satisfactory conditions with general anesthesia without opioids combined with infiltration of the surgical wound with local anesthetic. Recovery from anesthesia was rapid and free of complications. Propionic acidemia is caused by mitochondrial propionyl coenzyme carboxylase deficiency. Most patients have episodes of severe metabolic ketoacidosis as a result of excessive protein intake, delayed development, vomiting, gastroesophageal reflux, lethargy, hypotonia, and convulsions. The anesthetic approach involves avoiding triggers of metabolic acidosis (such as fasting, dehydration, hypoxemia, and hypotension) and preventing airway complications. Agents that metabolize propionic acid (such as succinylcholine, benzylisoquinoline neuromuscular blocking agents, and propofol) are not used, as they can exacerbate acidemia. We also believe that using local or regional anesthesia in combination with general anesthesia without opiates is safe and effective for controlling pain during surgery and postoperative recovery, as that combination avoids respiratory depression in these patients, who are highly sensitive to opiates.

Implicaciones anestésicas en un niño afecto de acidemia propiónica / Infant boy with propionic acidemia: anesthetic implications

Un niño de 12 meses de edad con diagnóstico de acidemia propiónica fue intervenido para gastrostomía. El paciente presentaba buen estado general y sensorio despejado, tono muscular disminuido, sedestación inestable con apoyo, sostén cefálico incompetente y movimientos distónicos de las cuatro extremidades. El EEG mostraba una actividad bioeléctrica cerebral discretamente enlentecida. El paciente estaba siendo tratado con dieta hipoproteica, fenobarbital, L-carnitina, L-isoleucina y biotina. La cirugía fue realizada bajo anestesia general sin opioides combinada con infiltración de la herida quirúrgica con anestésico local, que proporcionó condiciones quirúrgicas satisfactorias y una recuperación de la anestesia rápida y sin complicaciones. La acidemia propiónica se produce como consecuencia de la actividad deficiente de la enzima mitocondrial propionilCo-A carboxilasa. La mayoría de los pacientes presentan episodios de cetoacidosis metabólica severa secundaria a la excesiva ingesta proteica, retraso del desarrollo, vómitos, reflujo gastroesofágico, letargia, hipotonía y crisis convulsivas. La conducta anestésica se dirige a evitar los precipitantes de acidosis metabólica (ayuno, deshidratación, hipoxemia e hipotensión arterial) y las complicaciones de la vía aérea, así como no utilizar agentes anestésicos que se metabolizan a ácido propiónico como la succinilcolina, bloqueantes neuromusculares bencilisoquinoleínicos y el propofol, ya que pueden contribuir a la acidemia. Además, consideramos que el empleo de anestesia locorregional combinada con anestesia general sin opioides es segura y efectiva para el control del dolor durante la intervención y en el postoperatorio, ya que evitaría la depresión respiratoria en estos pacientes con elevada sensibilidad a los opioides

A 12-month-old boy diagnosed with propionic acidemia underwent gastrostomy. The patient's general state was good and he was alert, but with reduced muscular tone (unstable when seated with support, floppy head) and with dystonic movements in all extremities. An electroencephalogram showed slightly slowed brain activity. The patient was being treated with a low protein diet, phenobarbital, L-carnitine, L-isoleucine, and biotin. Surgery was carried out in satisfactory conditions with general anesthesia without opioids combined with infiltration of the surgical wound with local anesthetic. Recovery from anesthesia was rapid and free of complications. Propionic acidemia is caused by mitochondrial propionyl coenzyme carboxylase deficiency. Most patients have episodes of severe metabolic ketoacidosis as a result of excessive protein intake, delayed development, vomiting, gastroesophageal reflux, lethargy, hypotonia, and convulsions. The anesthetic approach involves avoiding triggers of metabolic acidosis (such as fasting, dehydration, hypoxemia, and hypotension) and preventing airway complications. Agents that metabolize propionic acid (such as succinylcholine, benzylisoquinoline neuromuscular blocking agents, and propofol) are not used, as they can exacerbate acidemia. We also believe that using local or regional anesthesia in combination with general anesthesia without opiates is safe and effective for controlling pain during surgery and postoperative recovery, as that combination avoids respiratory depression in these patients, who are highly sensitive to opiates

[Intraoperative anaphylaxis in a patient with undiagnosed latex sensitivity]. / Anafilaxia intraoperatoria en un paciente con sensibilización al látex desconocida.

Latex allergy is a cause of anaphylactic reactions during general anesthesia. It is currently the second most common cause of anaphylaxis during anesthesia and should be considered in all cases in which signs develop during surgery. Clinical manifestations are highly variable and depend on the type and amount of exposure to the allergen as well as on individual sensitivity. Cardiovascular collapse is the most common presentation in anesthetized patients, and the second most common manifestations are skin rash and bronchospasm. Latex gloves are implicated in most allergic reactions triggered by latex. Individuals allergic to latex are also sensitive to certain fruits (latex-fruit syndrome) because the presence of specific proteins common in both causes a phenomenon known as cross reactivity. A 34-year-old man with acute abdomen underwent emergency exploratory laparoscopy, which was converted to laparotomy based on findings in the surgical field. Coinciding with surgical manipulation, the patient developed severe hypotension, tachycardia, bronchospasm, and arterial desaturation, which responded favorably to intravenous fluids and medication. After all other possible causes of the events were ruled out, intraoperative anaphylactic reaction was suspected and later confirmed by tests, including allergy tests. When the patient was stable and the surgical environment was latex-free, the procedure was carried out with no complications and the postoperative course was uneventful.

Anafilaxia intraoperatoria en un paciente con sensibilización al látex desconocida / Intraoperative anaphylaxis in a patient with undiagnosed latex sensitivity

La alergia al látex es causa de reacciones anafilácticas durante la anestesia general. Debe tenerse en cuenta en todo paciente que sufre un cuadro de anafilaxia intrao- peratoria, ya que el látex representa actualmente la segunda causa más importante de anafilaxia durante la anestesia. Las manifestaciones clínicas son muy variables, dependiendo de la vía de exposición, la cantidad del alergeno contactado y la susceptibilidad personal. En los pacientes anestesiados el colapso cardiovascular es la forma más frecuente de presentación clínica seguida por el rash cutáneo y broncoespasmo, estando implicados, en la mayoría de las reacciones alérgicas mediadas por el látex, los guantes del látex. Las personas alérgicas al látex lo son también a determinadas frutas (síndrome látex-frutas),debido a la existencia de proteínas comunes, fenómeno conocido como reactividad cruzada. Un varón de 34 años de edad se somete a laparoscopia exploradora de urgencias por un cuadro de abdomen agudo. Debido a los hallazgos en el campo quirúrgico, se decide la reconversión en laparotomía. Coincidiendo con la manipulación quirúrgica, el paciente desarrolló un cuadro de hipotensión severa, taquicardia,broncoespasmo y desaturación arterial, el cual respondió favorable- mente a la administración intravenosa de fluidos y agentes farmacológicos. Tras excluir otras posibles causas etiológicas que pudiesen justificar el cuadro clínico se sospechó una reacción anafiláctica intraoperatoria al látex, que posteriormente fue confirmada mediante pruebas de laboratorio y estudio alergológico. Después de estabilizar al paciente y disponer un ambiente quirúrgico exento de látex, el procedimiento quirúrgico, así como la evolución del paciente transcurrió sin incidencias

Latex allergy is a cause of anaphylactic reactions during general anesthesia.It is currently the second most common cause of anaphylaxis during anesthesia and should be considered in all cases in which signs develop during surgery. Clinical manifestations are highly variable and depend on the type and amount of exposure to the allergen as well as on individual sensitivity. Cardiovascular collapse is the most common presentation in anesthetized patients, and the second most common manifestations are skin rash and bronchospasm. Latex gloves are implicated in most allergic reactions triggered by latex. Individuals allergic to latex are also sensitive to certain fruits (latex-fruit syndrome)because the presence of specific proteins common in both causes a phenomenon known as cross reactivity. A 34-year-old man with acute abdomen underwent emergency exploratory laparoscopy, which was converted to laparotomy based on findings in the surgical field. Coinciding with surgical manipulation, the patient developed severe hypotension, tachycardia, bronchospasm, and arterial desaturation, which responded favorably to intravenous fluids and medication. After all other possible causes of the events were ruled out, intraoperative anaphylactic reaction was suspected and later confirmed by tests, including allergy tests. When the patient was stable and the surgical environment was latex-free, the procedure was carried out with no complications and the postoperative course was uneventful

[Postoperative analgesia with epidural methadone in patients operated for hernia of the lumbar disc]. / Analgesia postoperatoria con metadona epidural en pacientes intervenidos de hernia de disco lumbar.

OBJECTIVES: To determine whether the direct application of a single dose of methadone on the dura mater at the end of surgery to repair a lumbar disk hernia provides effective analgesia over the next 24 hours. PATIENTS AND METHODS: We conducted a randomized double blind study in 40 ASA I patients undergoing elective herniated disk repair under general anesthesia. The sample was divided into two groups (A and B). Group A patients received a solution of methadone in saline solution (5 mg methadone/5 ml saline) applied to the dura before the end of surgery. Group B patients (controls) received only 5 ml of saline. Pain intensity was assessed on a visual analog scale (VAS) during the postoperative period. Also recorded were the observer's impression and the amount of analgesia (ketorolac) consumed through a system providing patient controlled analgesia. RESULTS: Each group contained 20 patients. Group A patients needed significantly less postoperative analgesia (64.2 +/- 14.3 mg) than group B patients (109.6 +/- 16.5 mg). The VAS scores were significantly lower in group A during the first two hours after surgery and were correlated with the observer's impression. No patients suffered serious complications during the study. CONCLUSIONS: Topical administration of 5 mg of methadone on the dura mater at the end of herniated lumbar disk repair is an easy, safe and effective technique for providing postoperative analgesia.

[Effects of precurarization on oxygen arterial saturation measure with pulse oximetry and neuromuscular function]. / Efectos de la precurarización sobre la saturación arterial de oxígeno medida por pulsioximetría y la función neuromuscular.

OBJECTIVE: To study changes in arterial oxygen saturation (SpO2) measured by pulse oximetry, and the effect of neuromuscular function after precurarization with different nondepolarizing muscle relaxants. PATIENTS AND METHOD: One hundred twenty-four patients scheduled for elective surgery were randomly assigned to four groups according to the NDPMR received: d-tubocurarine 0.05 mg/kg, atracurium 0.05 mg/kg, vecuronium 0.01 mg/kg or pancuronium 0.015 mg/kg. We recorded SpO2 before precurarization and 4 minutes after administering the dose. We also recorded signs and symptoms of muscle weakness after the 4-minute period of precurarization. RESULTS: We observed a statistically significant decrease in SpO2 4 minutes after starting precurarization in the groups receiving pancuronium, vecuronium and atracurium. These three groups were also significantly different from the d-tubocurarine group with regard to signs and symptoms of muscle weakness; the incidences of such symptoms were similar among the three groups, the only exception being the greater difficulty patients in the pancuronium group had in maintaining the Valsalva maneuver for 10 seconds. The lowest incidence of clinical signs of muscle weakness were in the d-tubocurarine group. We found a significant relation between decreased SpO2 caused by precurarization and the variables of inability to maintain the Valsalva maneuver for 10 seconds and to raise the head for more than 4 seconds. CONCLUSIONS: SpO2 measured by pulse oximetry is an effective method for monitoring breathing function in the precurarized patient, as it detects early changes in arterial oxygen saturation related to respiratory muscle weakness. The agent d-tubocurarine is recommended for precurarization, because of its scarce effect on neuromuscular function at the dose used in this study.