Edema pulmonar por reexpansión tras resección de timoma gigante / Pulmonary oedema due to re-expansion after resection of a giant thymoma

Mujer de 36 años que fue sometida a una resección de timoma gigante que ocupaba gran parte del hemitórax izquierdo. Tras la resección del tumor y la insuflación del pulmón izquierdo apareció un edema pulmonar por reexpansión precoz. Se trató con diuréticos, corticoides y se mantuvo la ventilación mecánica. La paciente evolucionó favorablemente. El edema pulmonar por reexpansión es una complicación poco frecuente, pero con una alta mortalidad. Es fundamental conocer los factores implicados en su etiopatogenia. El diagnóstico y tratamiento se deben realizar de forma inmediata(AU)

A 36 year-old woman who was subjected to resection of a giant thymoma that occupied a large area of the left hemithorax. After resection of the tumour and insufflation of the left lung there was pulmonary oedema due to early re-expansion. She was treated with diuretics and corticoids and was kept on mechanical ventilation. The patient progressed favourably. Although pulmonary oedema due to re-expansion is an uncommon complication it has a high mortality. It is essential to be aware of the factors involved in its aetiopathogenesis. It should be diagnosed and treated immediately(AU)

[Pulmonary oedema due to re-expansion after resection of a giant thymoma]. / Edema pulmonar por reexpansión tras resección de timoma gigante.

A 36 year-old woman was subjected to resection of a giant thymoma that occupied a large area of the left hemithorax. After resection of the tumour and insufflation of the left lung there was pulmonary oedema due to early re-expansion. She was treated with diuretics and corticoids and was kept on mechanical ventilation. The patient progressed favourably. Although pulmonary oedema due to re-expansion is an uncommon complication it has a high mortality. It is essential to be aware of the factors involved in its aetiopathogenesis. It should be diagnosed and treated immediately.

Nuevas aportaciones de la mascarilla laríngea en cirugía ambulatoria. Contribución de la mascarilla laríngea Supreme / No disponible

Desde la introducción de la mascarilla laríngea, su uso se ha expandido especialmente en el contexto de la cirugía ambulatoria. La mascarilla laríngea representa el “patrón oro” de los dispositivos supraglóticos, y es la referencia con la que los nuevos dispositivos deben ser comparados. La presente revisión es una actualización de las principales indicaciones de la mascarilla laríngea en usos avanzados, incluyendo el abordaje de la vía aérea difícil en el paciente intervenido de forma ambulatoria. Así mismo se incluye una revisión de las indicaciones, aportaciones, y ventajas de la mascarilla laríngea Supreme aplicadas al contexto de la cirugía sin ingreso (AU)

Since the introduction of the original laryngeal mask airway(LMA) in the nineties in our country, its use has expanded especially in the context of outpatient surgery. The LMA remains the “gold standard” of the supraglotic devices and the standard by which all other devices should be compared. This review is an update of the main indications of the LMA in advanced applications, including addressing the difficult airway in the patient operated on an outpatient basis. Also includes a review of the information, contributions, and advantages of the LMA supreme applied to the context of day surgery (AU)

Sustitución valvular en un paciente con enfermedad de Chagas. Consideraciones anestésicas / No disponible

No disponible

[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

[Cardiovascular and respiratory complications after pneumonectomy]. / Complicaciones cardiovasculares y respiratorias postneumonectomía.

Thoracic surgery has made important progress thanks to parallel advances in anesthetic techniques, which have lowered mortality and complication rates. Pneumonectomy, however, continues to carry a high risk of perioperative death and morbidity, with complications involving the heart and lung being the most common. Pneumonectomy requires careful preoperative assessment to identify patients at high risk of cardiac complications. However, there is no evidence available on the best approach to take in determining risk of impaired lung function after pneumonectomy. Postoperative arrhythmias increase mortality, although evidence does not suggest a need for systematic prophylactic treatment of patients who will undergo lung resection. The incidence of acute myocardial infarction ranges from 1.5% to 5% and diagnosis is difficult because most episodes are silent. The incidence of post-pneumonectomy pulmonary edema is between 4% and 7% and evidence indicates that prevention is the most important therapeutic measure. Patients tend to have greater risk of pneumonia after thoracotomy, but few studies have provided a high level of evidence for the usefulness of antibiotic prophylaxis in chest surgery. The aim of the present study was to review the literature on the most common complications of surgery on the lung in order to support decision making based on the integration of knowledge and clinical judgment acquired with experience. A MEDLINE search was carried out to locate studies published from 1980 through January 2005.

Complicaciones cardiovasculares y respiratorias postneumonectomía / Cardiovascular and respiratory complications after pneumonectomy

La cirugía torácica ha experimentado un importante desarrollo, gracias a la evolución paralela de las técnicas anestésicas, que han permitido disminuir la morbimortalidad; sin embargo, las neumonectomías continúan asociadas con elevado riesgo de morbimortalidad perioperatoria, siendo las complicaciones de origen pulmonar y cardíaco las principales responsables. La neumonectomía requiere una evaluación preoperatoria minuciosa, que nos permita identificar a los pacientes con alto riesgo de sufrir complicaciones cardíacas; sin embargo no existe evidencia sobre cuál es la mejor medida para determinar el riesgo de la función pulmonar postneumonectomía. Las arritmias postoperatorias incrementan la mortalidad, aunque la evidencia no indica la necesidad de realizar tratamiento profiláctico sistemático de los pacientes que vayan a someterse a resección pulmonar. La incidencia de infarto agudo de miocardio postneumonectomía varía entre 1,5-5% y su diagnóstico es muy difícil porque la mayoría de los episodios son silentes. La incidencia de edema de pulmón postneumonectomía es de 4-7% y la evidencia nos indica que lo más importante del tratamiento del edema pulmonar postneumonectomía es la prevención. Los pacientes post-toracotomía tienen mayor tendencia a la infección pulmonar; sin embargo existen pocos estudios con alto grado de evidencia acerca de la utilidad de la profilaxis antibiótica en cirugía torácica. El objetivo de este trabajo es realizar una revisión de la literatura médica existente sobre las complicaciones, más frecuentes, postneumonectomía, que nos permita tomar decisiones fundamentadas en la interacción del conocimiento y juicio clínico individual adquirido a través de la experiencia clínica diaria. Para ello se realizó una búsqueda bibliográfica en MEDLINE buscando las evidencias disponibles en el periodo de tiempo desde 1980 hasta enero de 2005

Thoracic surgery has made important progress thanks to parallel advances in anesthetic techniques, which have lowered mortality and complication rates. Pneumonectomy, however, continues to carry a high risk of perioperative death and morbidity, with complications involving the heart and lung being the most common. Pneumonectomy requires careful preoperative assessment to identify patients at high risk of cardiac complications. However, there is no evidence available on the best approach to take in determining risk of impaired lung function after pneumonectomy. Postoperative arrhythmias increase mortality, although evidence does not suggest a need for systematic prophylactic treatment of patients who will undergo lung resection. The incidence of acute myocardial infarction ranges from 1.5% to 5% and diagnosis is difficult because most episodes are silent. The incidence of postpneumonectomy pulmonary edema is between 4% and 7% and evidence indicates that prevention is the most important therapeutic measure. Patients tend to have greater risk of pneumonia after thoracotomy, but few studies have provided a high level of evidence for the usefulness of antibiotic prophylaxis in chest surgery. The aim of the present study was to review the literature on the most common complications of surgery on the lung in order to support decision making based on the integration of knowledge and clinical judgment acquired with experience. A MEDLINE search was carried out to locate studies published from 1980 through January 2005

[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 for carbon dioxide laser surgery to correct Zenker's diverticulum]. / Anestesia para la cirugía del divertículo de Zenker con láser CO2.

Two 48- and 62-year-old men, the latter with a history of ischemic heart disease, underwent endoscopic carbon dioxide laser surgery to correct Zenker's diverticulum. We provided total intravenous anesthesia, taking into consideration the special requirements of laser surgery. The pathogenesis of Zenker's diverticulum, the most common type of esophageal diverticulum, is poorly understood and the treatment approach depends on size and overall patient status. Patients with Zenker's diverticulum need a thorough preoperative assessment with special attention to airway permeability and the degree of difficulty of intubation. Anesthesia should be maintained in a manner that provides the safest, most effective surgical conditions.

[Anesthesia in Sebastian syndrome: a new hereditary macrothrombocytopenia]. / Anestesia en el síndrome de Sebastian: una nueva macrotrombocitopenia hereditaria.

The macrothrombocytopenias make up a heterogeneous group of disease involving thrombocytopenia and giant platelets; other clinical or laboratory findings, such as hereditary nephritis, sensorineural hearing loss, leukocyte inclusions, and cataracts, may also be present. The tendency to bleeding is highly variable and is due to decreased expression of the GP1b-V-IX complex on the surface of platelets, leading to altered platelet-vessel wall and platelet-platelet interactions. The 5 autosomal dominant giant-platelet disorders that are associated with macrothrombocytopenia are May-Hegglin anormaly, Epstein, Fechtner, and Sebastian syndromes, and Alport-like syndrome with macrothrombocytopenia. The mutation responsible is in gene 9 (MYH9) coding for the nonmuscle myosin heavy chain IIA that has been identified in the long arm of chromosome 22 (22q12.3-q13.2). The most recently described macrothrombocytopenia is Sebastian syndrome, consisting of thrombocytopenia with giant platelets and leukocyte inclusions. We report the case of a woman with Sebastian syndrome scheduled for abdominoperineal resection for rectal carcinoma. Preoperative studies revealed isolated thrombocytopenia (35,000 platelets/microL) and a mean platelet volumen of 13 fL. Preoperative prophylactic platelet transfusion was carried out with no adverse events. After a postoperative transfusion of packed red cells, needed because of abundant bleeding, clinical course continued to be satisfactory. The anesthetic implications of this syndrome are not well known because few cases have been reported in the literature, and none was found that describes anesthetic management. Nevertheless, thrombocytopenia and the tendency to bleeding present challenges to the anesthesiologist.

Anestesia en el síndrome de Sebastian: una nueva macrotrombocitopenia hereditaria / Anesthesia in Sebastian syndrome, a new hereditary macrothrombocytopenia

Las macrotrombocitopenias son un grupo heterogéneo de enfermedades con trombocitopenia y plaquetas gigantes que pueden incluir otros hallazgos como nefritis hereditaria, sordera neurosensorial, inclusiones leucocitarias y cataratas. Su tendencia al sangrado es muy variable, por una disminución de los niveles de la expresión del complejo GPIb-V-IX en la superficie de las plaquetas que implica una alteración de la adhesión y de la agregación plaquetaria. Los cinco desórdenes plaquetarios, autosómicos dominantes que asocian macrotrombocitopenia son los síndromes de May-Hegglin, Epstein, Alport-like con macrotrombocitopenia, Fechtner y Sebastian. La mutación genética causante se localiza en el gen 9 (MYH9) para la cadena pesada de la miosina no muscular IIA, NMMHC-IIA, que se ha identificado en el brazo largo del cromosoma 22 (22q12.3-q13.2). La macrotrombocitopenia más recientemente descrita es el síndrome de Sebastian, que consiste en una trombocitopenia con plaquetas gigantes e inclusiones leucocitarias. Describimos el caso de una paciente con síndrome de Sebastian programada para amputación abdominoperineal por neoplasia de recto. En el preoperatorio se objetivó una trombocitopenia aislada (35.000 plaquetas/µl) con volumen plaquetario medio de 13 fl. Se realizó transfusión profiláctica de plaquetas antes de la intervención que transcurrió sin incidencias. En el postoperatorio requirió la transfusión de concentrados de hematíes por sangrado abundante y la evolución fue favorable. Las implicaciones anestésicas son poco conocidas, por el escaso número de casos descritos y no se ha encontrado bibliografía sobre su manejo anestésico, pero la trombocitopenia y la tendencia al sangrado son un reto para el anestesiólogo (AU)

Anestesia a pacientes con herniasdiafragmáticas traumáticas / Anesthesia for patients with diaphragmatic hernies due to trauma

No disponible

Infarto agudo de miocardio en el perioperatorio de una neumonectomía / Perioperative acute myocardial infarction during a pneumonectomy

A un varón de 71 años con diabetes insulino-dependiente, hábito tabáquico y dislipemia se le realizó una neumonectomía izquierda. Durante el período intraoperatorio se produjeron varios episodios de inestabilidad hemodinámica asociados a cambios en el segmento ST del ECG que se justificaron por la manipulación quirúrgica no sospechándose la posibilidad de un origen isquémico. A los pocos minutos de su ingreso en la Unidad de Reanimación se produjo una parada cardiorrespiratoria, por infarto anterior extenso, que precisó ventilación mecánica y maniobras de reanimación cardiopulmonar. El paciente evolucionó favorablemente y respondió al tratamiento con betabloqueantes, antiagregantes plaquetarios y estatinas. A las pocas horas se extubó y pudo ser dado de alta de la Unidad de Reanimación a los 5 días. La neumonectomía es una cirugía con elevado índice de morbimortalidad, siendo las complicaciones de origen pulmonar y cardíaco las principales responsables. Se considera un procedimiento de elevado riesgo anestésico, razón por la cual la identificación de isquemia miocárdica durante el período intraoperatorio es fundamental para tratarla agresivamente. En pacientes de elevado riesgo cardiovascular, que se someten a cirugía de resección pulmonar, la presencia de episodios de isquemia miocárdica intraoperatoria se asocian con una incidencia elevada de eventos isquémicos postoperatorios y, por tanto, debería condicionar una monitorización agresiva postoperatoria, medidas antianginosas y evitar la extubación precoz (AU)

Hipotensión perioperatoria grave tras nefrectomía con suprarrenalectomía / Severe perioperative hypotension after nephrectomy with adrenalectomy

A una mujer de 70 años, obesa e hipertensa en tratamiento con inhibidores de la enzima convertidora de angiotensina (IECA) y clortalidona, pero sin antecedentes de tratamiento corticoideo ni enfermedad del eje hipotálamohipófiso-suprarrenal, se le realizó una nefrectomía más suprarrenalectomía bajo anestesia combinada: general y peridural. Presentó una hipotensión arterial grave con oliguria intraoperatoria, que continuó en el postoperatorio junto al desarrollo de anuria, acidosis metabólica, hiponatremia e hiperpotasemia. Aunque inicialmente el cuadro se atribuyó al tratamiento previo con IECA más diuréticos junto a la anestesia combinada, la refractariedad a la administración de cristaloides, coloides e inotrópicos catecolamínicos, con respuesta parcial a la efedrina y el desarrollo de anuria, acidosis metabólica, hiponatremia e hiperpotasemia, nos hizo pensar en la concurrencia de una crisis addisoniana. Tras extraer muestras para determinar cortisol y ACTH, se inició el tratamiento con hidrocortisona. La respuesta al tratamiento junto al cortisol descendido confirmaron el diagnóstico de insuficiencia suprarrenal. En los pacientes sometidos a una nefrectomía más suprarrenalectomía por hipernefroma, se ha observado que la suprarrenal contralateral compensa la secreción endógena del cortisol, por esto no se recomienda tratamiento sustitutivo. Por otra parte, se han descrito crisis addisonianas perioperatorias en pacientes sometidos a cirugías con estrés quirúrgico importante. También se han visto hipotensiones graves en los pacientes tratados crónicamente con IECA tras la inducción de la anestesia general y tras la anestesia epidural con anestésicos locales. En este caso la conjunción de todos estos factores dificultó el diagnóstico y la rápida instauración del tratamiento adecuado (AU)

[Severe perioperative hypotension after nephrectomy with adrenalectomy]. / Hipotensión perioperatoria grave tras nefrectomía con suprarrenalectomía.

A 70-year-old obese, hypertensive woman taking angiotensin converting enzyme (ACE) inhibitors and chlorthalidone but with no history of corticosteroid treatment or hypothalamus-hypophyseal-adrenal disease, underwent nephrectomy and adrenalectomy under combined general and epidural anesthesia. Severe hypotension with oliguria developed during surgery and persisted during postoperative recovery, with anuria, metabolic acidosis, hyponatremia and hyperpotassemia. Although the symptoms were initially attributed to prior treatment with ACE inhibitors and diuretics together with combined anesthesia, the patient's lack of response to crystalloid, colloid and inotropic catecholamine therapy in the context of anuria, metabolic acidosis, hyponatremia and hyperpotassemia led us to consider a diagnosis of Addisonian crisis. Blood samples were taken to determine adrenocorticotropic hormone levels, and hydrocortisone treatment was started. The patient responded to treatment and cortisol levels fell, confirming the diagnosis of adrenal insufficiency. Compensatory endrocrine secretion of cortisol by the contralateral adrenal gland has been observed in patients undergoing nephrectomy and adrenalectomy for excision of a hypernephroma, and replacement therapy is therefore not recommended. Perioperative Addisonian crises have also been described in patients suffering great surgical stress, and severe hypotension has been observed in patients on long-term treatment with ACE inhibitors after induction of general anesthesia and after epidural anesthesia with local anesthetics. The combination of these factors made rapid diagnosis and start of appropriate therapy difficult.

[Acute myocardial infarction in the postoperative period following pneumonectomy]. / Infarto agudo de miocardio en el perioperatorio de una neumonectomía.

A 72-year-old man, smoker, with insuline-dependent diabetes and dislipemia underwent left pneumonectomy. Several episodes of intraoperative hemodynamic instability associated with electrocardiographic ST segment alterations were attributed to surgical manipulation; ischemia was not suspected. Cardiorespiratory failure, related to extensive anterior infarction, developed a few minutes after admission to the postoperative intensive care unit (PICU). Cardiopulmonary resuscitation and mechanical ventilation were required. The patient responded to treatment with beta blockers, platelet antiaggregants and statins. Tube was removed a few hours later and the patient was discharged from the PICU on the fifth day. Pneumonectomy has a high rate of morbidity and mortality, with complications mainly arising in the lung and heart. Risk from anesthesia is considered to be great in this procedure, and for that reason it is essential to identify intraoperative myocardial ischemia so that it can be treated aggressively. In patients at high cardiovascular risk who undergo lung resection, intraoperative episodes of myocardial ischemia are associated with a high incidence of postoperative miocardial infarction. Therefore, careful postoperative monitoring is needed and measures should be taken to prevent angina. Early extubation should be avoided.