Ammonia encephalopathy and awake craniotomy for brain language mapping: Cause of failed awake craniotomy / Encefalopatía por amonio y cirugía con el paciente despierto para mapeo del lenguaje; causa de fracaso de craneotomía despierta

We report the case of an aborted awake craniotomy for a left frontotemporoinsular glioma due to ammonia encephalopathy on a patient taking Levetiracetam, valproic acid and clobazam. This awake mapping surgery was scheduled as a second-stage procedure following partial resection eight days earlier under general anesthesia. We planned to perform the surgery with local anesthesia and sedation with remifentanil and propofol. After removal of the bone flap all sedation was stopped and we noticed slow mentation and excessive drowsiness prompting us to stop and control the airway and proceed with general anesthesia. There were no post-operative complications but the patient continued to exhibit bradypsychia and hand tremor. His ammonia level was found to be elevated and was treated with an infusion of l -carnitine after discontinuation of the valproic acid with vast improvement. Ammonia encephalopathy should be considered in patients treated with valproic acid and mental status changes who require an awake craniotomy with patient collaboration (AU)

Se presenta el caso de un paciente con un glioma insulofrontotemporal izquierdo, tratado con levetiracetam, valproato y clobazam. Se realizó una primera cirugía bajo anestesia general para la exéresis del lóbulo temporal tumoral, y 8 días después se sometió a una cirugía con el paciente despierto para mapeo del lenguaje, bajo sedación consciente con remifentanilo y anestesia local. A la llegada a quirófano, el paciente se encontraba cansado y con cierta bradipsiquia; tras parar la infusión de remifentanilo, y antes de abrir la duramadre, el paciente presentó una disminución del nivel de consciencia con privación respiratoria que requirió intubación endotraqueal y la finalización de la cirugía. En el periodo posoperatorio se apreció bradipsiquia moderada, cansancio y temblor de manos. Fueron detectados niveles altos de amonio en sangre, y la clínica mejoró tras la administración de L-carnitina y la suspensión del valproato. La encefalopatía por amonio, aunque con mínima sintomatología, debería ser considerada en pacientes tratados con valproato que van a ser sometidos a una cirugía bajo sedación, donde se requiere que el paciente colabore (AU)

Ammonia encephalopathy and awake craniotomy for brain language mapping: cause of failed awake craniotomy.

We report the case of an aborted awake craniotomy for a left frontotemporoinsular glioma due to ammonia encephalopathy on a patient taking Levetiracetam, valproic acid and clobazam. This awake mapping surgery was scheduled as a second-stage procedure following partial resection eight days earlier under general anesthesia. We planned to perform the surgery with local anesthesia and sedation with remifentanil and propofol. After removal of the bone flap all sedation was stopped and we noticed slow mentation and excessive drowsiness prompting us to stop and control the airway and proceed with general anesthesia. There were no post-operative complications but the patient continued to exhibit bradypsychia and hand tremor. His ammonia level was found to be elevated and was treated with an infusion of l-carnitine after discontinuation of the valproic acid with vast improvement. Ammonia encephalopathy should be considered in patients treated with valproic acid and mental status changes who require an awake craniotomy with patient collaboration.

Variación del índice biespectral durante la técnica de Jannetta / Variation in the bispectral index during the Jannetta technique

No disponible

[Update on the anesthetic management of patients with malignant carcinoid syndrome]. / Actualización del manejo anestésico de un paciente con síndrome carcinoide.

Carcinoid crisis during surgery can lead to severe hemodynamic alterations (hypo- and hypertension) and bronchospasm. Intravenous infusion of octreotide, preceded by preoperative subcutaneous administration, can allow such crises to be brought under control quickly. Given the high prevalence of carcinoid cardiopathy, which increases the risk of a crisis in these patients, a preoperative echocardiogram should be performed. General anesthesia combined with epidural blockade is effective in this context. Block onset should be gradual to avoid the development of hypotension, which is difficult to treat. The pharmacodynamic profile of remifentanil, its elevated potency, and low histamine releasing potential mean that this opioid offers novel advantages during general anesthesia.

Actualización del manejo anestésico de un paciente con síndrome carcinoide / Update on the anesthetic management of patients with malignant carcinoid syndrome

Las crisis carcinoides durante el intraoperatorio pueden dar lugar a severas alteraciones hemodinámicas (hipo e hipertensión)y broncospasmo. La administración de octeótrida endovenosa para el control de las crisis, precedido de su administración subcutánea preoperatoria, permite un rápido control. Dada la elevada frecuencia de cardiopatía carcinoide en estos pacientes, debe realizarse un ecocardiograma preoperatoriamente en todos. Su presencia supone un factor de riesgo para la presentación de las crisis. La anestesia general combinada con bloqueo epidural supone una alternativa eficaz en estos pacientes. Se debe instaurar el bloqueo progresivamente para evitar la aparición de hipotensión, de difícil tratamiento. El empleo del remifentanilo como opioide durante la anestesia general nos ofrece nuevas ventajas en este tipo de pacientes, gracias a su perfil farmacocinético, elevada potencia y bajo potencial histaminoliberador, dando buenos resultados

Carcinoid crisis during surgery can lead to severe hemodynamic alterations (hypo-and hypertension)and bronchospasm. Intravenous infusion of octreotide, pre- ceded by preoperative subcutaneous administration, can allow such crises to be brought under control quickly. Given the high prevalence of carcinoid cardiopathy, which increases the risk of a crisis in these patients, a preoperative echocardiogram should be performed. General anesthesia combined with epidural blockade is effective in this context. Block onset should be gradual to avoid the development of hypotension, which is difficult to treat. The pharmacodynamic profile of remifentanil, its elevated potency, and low histamine releasing potential mean that this opioid offers novel advantages during general anesthesia