Bezold-Jarisch reflex in a patient undergoing endoscopic sympathectomy for management of refractory angina pectoris: a case report / Reflexo de Bezold-Jarisch em paciente submetida à simpatectomia endoscópica para tratamento de angina pectoris refratária: relato de caso

Abstract Background and objectives Ischemic cardiomyopathy is characterized by imbalance between supply and demand of myocardial oxygen. Endoscopic transthoracic sympathectomy is a therapeutic option indicated in refractory cases. However, the patient's position on the operating table may favor ischemic coronary events triggering the Bezold-Jarisch reflex. Case report A female patient, 47 years old, with refractory ischemic cardiomyopathy, admitted to the operating room for endoscopic transthoracic sympathectomy, developed the Bezold- Jarisch reflex with severe bradycardia and hypotension after placement in semi-sitting position to the procedure. Conclusion Bradyarrhythmia, hypotension, and asystole are complications potentially associated with patient placement in a semi-sitting position, particularly in cases with previous ischemic heart disease.

Resumo Justificativa e objetivos A cardiomiopatia isquêmica caracteriza-se pelo desbalanço entre a oferta e o consumo de oxigênio pelo miocárdio. A simpatectomia transtorácica endoscópica é uma opção terapêutica indicada nos casos refratários. Contudo, a posição do paciente na mesa cirúrgica pode favorecer eventos coronarianos isquêmicos e deflagrar o reflexo de Bezold-Jarisch. Relato de caso Paciente do sexo feminino, 47 anos, portadora de cardiomiopatia isquêmica refratária, admitida na sala de cirurgia para simpatectomia transtorácica endoscópica, deflagrou o reflexo de Bezold-Jarisch e desenvolveu bradicardia e hipotensão graves logo após colocação em posição semissentada para o procedimento. Conclusão Bradiarritmia, hipotensão e assistolia são complicações potencialmente associadas à colocação do paciente em posição semissentada, especialmente nos casos em que há prévio comprometimento isquêmico do coração.

[Bezold-Jarisch reflex in a patient undergoing endoscopic sympathectomy for management of refractory angina pectoris: a case report]. / Reflexo de Bezold­Jarisch em paciente submetida à simpatectomia endoscópica para tratamento de angina pectoris refratária: relato de caso.

BACKGROUND AND OBJECTIVES: Ischemic cardiomyopathy is characterized by imbalance between supply and demand of myocardial oxygen. Endoscopic transthoracic sympathectomy is a therapeutic option indicated in refractory cases. However, the patient's position on the operating table may favor ischemic coronary events triggering the Bezold-Jarisch reflex. CASE REPORT: A female patient, 47 years old, with refractory ischemic cardiomyopathy, admitted to the operating room for endoscopic transthoracic sympathectomy, developed the Bezold-Jarisch reflex with severe bradycardia and hypotension after placement in semi-sitting position to the procedure. CONCLUSION: Bradyarrhythmia, hypotension, and asystole are complications potentially associated with patient placement in a semi-sitting position, particularly in cases with previous ischemic heart disease.

Pseudoplaquetopenia em paciente submetida à esplenectomia de baço acessório: relato de caso / Pseudoplaquetopenia en paciente sometida a la esplenectomía de bazo accesorio: relato de caso / Pseudothrombocytopenia in a patient undergoing splenectomy of an accessory spleen: case report

JUSTIFICATIVA E OBJETIVOS: Os testes de coagulação (hemograma e tempo de protrombina) foram inicialmente concebidos como uma forma de rastrear e acompanhar coagulopatias congênitas raras e o hemograma é o que fornece o número de plaquetas por milímetro cúbico. O objetivo deste relato foi apresentar o caso de uma paciente que apresentava um número de plaquetas extremamente baixo quando sua amostra de sangue era analisada em tubo com EDTA e um número normal quando analisada com citrato, alertando para o risco de administração errônea de hemoderivados. RELATO DO CASO: Paciente do sexo feminino, 40 anos, ASA II. Em 2001, apresentou plaquetopenia no hemograma e foi encaminhada para o hematologista em Manaus, AM, sendo realizada esplenectomia nesse mesmo ano, com diagnóstico de púrpura trombocitopênica idiopática. Com a persistência da plaquetopenia nos hemogramas foi verificado na ecografia de abdômen: imagem hipoecóica de ecotextura semelhante à esplênica, medindo 2,0 × 1,7 cm, forma esférica, conteúdo bem definido (baço acessório) e indicada esplenectomia de baço acessório. Após uma hora de operação, foram colhidas amostras para hemograma e bioquímica: Hb = 11,3 g.dL-1; Ht = 33,4 por cento; Plaquetas = 35.000.µL-1; TAP = 15,2 (86,0 por cento Atividade) (RNI = 1,09). Em virtude do sangramento mínimo no campo cirúrgico, foi solicitado novo exame com citrato para dosagem de plaquetas (resultado: 138.000 plaquetas). CONCLUSÕES: O resultado anômalo em um exame isolado sem correspondência com a clínica do paciente não deve guiar a terapêutica. Todos os exames têm uma porcentagem definida de erros, e a busca desses erros técnicos impede que uma terapêutica errônea seja usada.

BACKGROUND AND OBJECTIVES: Coagulation tests (CBC and prothrombin time) were initially conceived as a mean of screening and following rare congenital coagulopathies; the CBC provides the number of platelets per cubic milliliter. The objective of this report was to present the case of a patient who presented with an extremely low number of platelets when her blood was analyzed in an EDTA-containing tube and its numbers were normal when the blood was analyzed with citrate, alerting for the risk of erroneously administering blood products. CASE REPORT: This is the case of a 40-year old female patient, ASA II. In 2001 she presented with thrombocytopenia and was referred to a hematologist in Manaus, in the state of Amazonas, Brazil and underwent splenectomy that same year with a diagnosis of idiopathic thrombocytopenic purpura. Since her CBCs continued to show thrombocytopenia, an abdominal ultrasound was done and showed a spherical hypoechoic image, with an echotexture similar to the spleen, measuring 2.0 × 1.7 cm, with well-defined contents (accessory spleen), and a splenectomy was indicated. One hour into the surgery, blood samples were drawn for CBC and chemistry: Hb = 11.3 g.dL-1; Ht = 33.4 percent; Platelets = 35,000.µL-1; PT = 15.2 (86.0 percent Activity) (INR = 1.09). Due to the minimal blood loss in the surgical field, a new test with citrate was requested to determine the platelet count (results: 138,000 platelets). CONCLUSIONS: The anomalous result of an isolated exam without corresponding clinical signs should not guide the treatment. All exams have a defined percentage of errors and the search for those technical errors can avoid the use of the wrong treatment.

JUSTIFICATIVA Y OBJETIVOS: Las pruebas de coagulación (hemograma y tiempo de protrombina) fueron inicialmente concebidas como una forma de rastrear y acompañar las coagulopatías congénitas raras, siendo el hemograma el que suministra el número de plaquetas por milímetro cúbico. El objetivo de este relato fue presentar el caso de una paciente que presentaba un número de plaquetas extremadamente bajo cuando su muestra de sangre era analizada en un tubo con EDTA y un número normal cuando se analizaba con citrato, avisando sobre el riesgo de la administración equivocada de hemoderivados. RELATO DEL CASO: Paciente del sexo femenino, 40 años, ASA II. En 2001, presentó plaquetopenia en el hemograma y fue llevada al hematólogo en Manaus, estado brasileño de Amazonas, siendo realizada la esplenectomía en ese mismo año, con diagnóstico de púrpura trombocitopénica idiopática. Al continuar la plaquetopenía en los hemogramas se verificó en la ecografía de abdomen: imagen hipoecoica de ecotextura similar a la esplénica, midiendo 2,0 × 1,7 cm, forma esférica, contenido bien definido (bazo accesorio) e indicada esplenectomía de bazo accesorio. Después de una hora de operación, se recogieron muestras para hemograma y bioquímica: Hb = 11,3 g.dL-1; Ht = 33,4 por ciento; Plaquetas = 35.000.µL-1; TAP = 15,2 (86,0 por ciento Actividad) (RNI = 1,09). Debido al sangramiento mínimo en el campo quirúrgico, fue solicitado un nuevo examen con citrato para la dosificación de plaquetas (resultado: 138.000 plaquetas). CONCLUSIONES: El resultado anómalo en un examen aislado en correspondencia con la clínica del paciente, no debe ser el leitmotiv de la terapéutica. Todos los exámenes poseen un porcentaje definido de errores, y la búsqueda de esos errores técnicos impide que una terapéutica equivocada sea usada.

Pseudothrombocytopenia in a patient undergoing splenectomy of an accessory spleen. Case report.

BACKGROUND AND OBJECTIVES: Coagulation tests (CBC and prothrombin time) were initially conceived as a mean of screening and following rare congenital coagulopathies; the CBC provides the number of platelets per cubic milliliter. The objective of this report was to present the case of a patient who presented with an extremely low number of platelets when her blood was analyzed in an EDTA-containing tube and its numbers were normal when the blood was analyzed with citrate, alerting for the risk of erroneously administering blood products. CASE REPORT: This is the case of a 40-year-old female patient, ASA II. In 2001 she presented with thrombocytopenia and was referred to a hematologist in Manaus, in the state of Amazonas, Brazil and underwent splenectomy that same year with a diagnosis of idiopathic thrombocytopenic purpura. Since her CBCs continued to show thrombocytopenia, an abdominal ultrasound was done and showed a spherical hypoechoic image, with an echotexture similar to the spleen, measuring 2.0 x 1.7 cm, with well-defined contents (accessory spleen), and a splenectomy was indicated. One hour into the surgery, blood samples were drawn for CBC and chemistry: Hb = 11.3 g x dL(-1); Ht = 33.4%; Platelets = 35,000 microL(-1); PT = 15.2 (86.0% Activity) (INR = 1.09). Due to the minimal blood loss in the surgical field, a new test with citrate was requested to determine the platelet count (results: 138,000 platelets). CONCLUSIONS: The anomalous result of an isolated exam without corresponding clinical signs should not guide the treatment. All exams have a defined percentage of errors and the search for those technical errors can avoid the use of the wrong treatment.