Lumbar fusion with collagen type I and polyvinylpyrrolidone in combination with autograft. An experimental study in New Zealand rabbits / Colágena tipo I y polivinilpirrolidona en combinación con autoinjerto para artrodesis lumbar. Estudio experimental en conejos de Nueva Zelanda

Abstract: Introduction: Multiple strategies have been developed looking for upgrading the consolidation rate of spine arthrodesis with autolog bone graft, but no evidence exists that adhesion with Collagen type 1 and polyvinylpyrrolidone (FibroquelMR) have application on this field. Objective: Determine if collagen type 1 + Polyvinylpyrrolidone are effective as bone enhancer in posterolateral arthrodesis on rabbits. Method: Posterolateral arthrodesis in 15 New Zealand rabbits on level L5-L6 using autolog bone graft in left side (control group) and autolog bone graft + 1 ml FibroquelMR (study group) in right side of arthrodesis. Euthanasia and block resection of lumbar segment eight weeks post surgery. Radiographic analysis, manual exploration and light microscopy of fussed segments. Results: Radiographic consolidation was observed in 80% in control group and 95% in study group, interleaved trabecular pattern with bone continuity and normal characteristics in 12 left sides and 14 right sides. Conclusion: Collagen type 1 and polyvinylpyrrolidone use is likely to have positive effect in bone consolidation process, therefore it can be recommended to use it as a bone enhancer.

Resumen: Introducción: Existen diversas estrategias para aumentar la tasa de consolidación de la artrodesis de columna en presencia de injerto óseo autólogo, sin aún comprobar si la adhesión de Colágena tipo I y polivinilpirrolidona (FibroquelMR) tienen aplicaciones en este campo. Objetivo: Determinar la efectividad de la colágena tipo I con polivinilpirrolidona como potenciador óseo en artrodesis posterolateral de conejos. Métodos: Artrodesis posterolateral en 15 conejos de Nueva Zelanda L5-L6 colocando injerto autólogo del lado izquierdo (Control) e injerto autólogo + 1 ml FibroquelMR (Estudio) en el lado derecho de la artrodesis. Eutanasia con resección en bloque del segmento lumbar a las ocho semanas del postoperatorio. Análisis radiográfico, palpación manual y por microscopia de luz de los segmentos fusionados. Resultados: Se observó consolidación radiográfica en 80% en grupo control y 93% en el estudio, continuidad ósea con patrón trabecular intercalado y hueso de características normales en 12 del lado izquierdo y 14 en el lado derecho. Conclusiones: La utilización de Colágena tipo I y polivinilpirrolidona puede tener efectos positivos en el proceso de consolidación ósea por lo que se puede recomendar su utilización como reforzador óseo.

Conservative treatment of Angle Class III malocclusion with anterior crossbite

Angle Class III malocclusion is characterized by anteroposterior dental discrepancy which might be associated or not with skeletal changes. Class III molar relationship is associated with vertical or lingually tipped mandibular incisors and a usually concave profile. These characteristics seriously affect facial esthetics and most frequently are the reason why patients seek orthodontic treatment. This case was presented to the committee of the Brazilian Board of Orthodontics and Facial Orthopedics (BBO) as part of the requisites to become a BBO Diplomate.

A má oclusão de Classe III de Angle é caracterizada por uma discrepância dentária anteroposterior, que pode ou não estar acompanhada por alterações esqueléticas. Observa-se uma relação molar de Classe III associada ao posicionamento vertical ou retroinclinado dos incisivos inferiores e, geralmente, perfil facial côncavo. Esse aspecto gera grande comprometimento estético na face, sendo justamente esse o fator que, na maioria das vezes, motiva o paciente a procurar pelo tratamento ortodôntico. O presente caso clínico foi apresentado à Diretoria do Board Brasileiro de Ortodontia e Ortopedia Facial (BBO) como parte dos requisitos para a obtenção do título de Diplomado pelo BBO.

Effect of protective solutions and hydroxyethyl starch in the attenuation of the injuries of ischemia and reperfusion of splanchnic organs

PURPOSE: Vogt´s antioxidant solution (red blood cells, Ringer's solution, sodium bicarbonate, mannitol, allopurinol and 50% glucose) or its modification including hydroxyethyl starch (HES) were tested for the prevention of splanchnic artery occlusion shock. METHODS: Seventy rats were distributed in treatment (3), control (1), and sham (3) groups. Ischemia and reperfusion were induced by celiac, superior mesenteric and inferior mesenteric arteries occlusion for 40 min, followed by 60 min reperfusion or sham procedures. Controls received saline, both treatment and sham groups received the Vogt's solution, modified Vogt's solution (replacing Ringer's solution by HES), or HES. Mean arterial blood pressure (MABP), ileal malondialdehyde (MDA) and plasmatic MDA were determined, and a histologic grading system was used. RESULTS: At reperfusion, MABP dropped in all I/R groups. Only HES treatment was able to restore final MABP to the levels of sham groups. Plasmatic MDA did not show differences between groups. Ileum MDA was significantly higher in the control and treatment groups as compared to the sham group. Histology ranking was higher in the only in control group. CONCLUSIONS: Hydroxyethyl starch was able to prevent hemodynamic shock but not intestinal lesions. Both treatments with Vogt's solutions did not show any improvement. .

Dehydration, hemodynamics and fluid volume optimization after induction of general anesthesia

OBJECTIVES: Fluid volume optimization guided by stroke volume measurements reduces complications of colorectal and high-risk surgeries. We studied whether dehydration or a strong hemodynamic response to general anesthesia increases the probability of fluid responsiveness before surgery begins. METHODS: Cardiac output, stroke volume, central venous pressure and arterial pressures were measured in 111 patients before general anesthesia (baseline), after induction and stepwise after three bolus infusions of 3 ml/kg of 6% hydroxyethyl starch 130/0.4 (n = 86) or Ringer's lactate (n = 25). A subgroup of 30 patients who received starch were preloaded with 500 ml of Ringer's lactate. Blood volume changes were estimated from the hemoglobin concentration and dehydration was estimated from evidence of renal water conservation in urine samples. RESULTS: Induction of anesthesia decreased the stroke volume to 62% of baseline (mean); administration of fluids restored this value to 84% (starch) and 68% (Ringer's). The optimized stroke volume index was clustered around 35-40 ml/m2/beat. Additional fluid boluses increased the stroke volume by ≥10% (a sign of fluid responsiveness) in patients with dehydration, as suggested by a low cardiac index and central venous pressure at baseline and by high urinary osmolality, creatinine concentration and ...

Injúria Renal Aguda no paciente politraumatizado / Acute Renal Injury in polytrauma patients

A Injúria Renal Aguda (IRA) no contexto do paciente politraumatizado ocorre, na maioria das vezes, por uma conjuntura de fatores que passam por eventos correlacionados à ressuscitação volêmica inicial, ao grau de resposta inflamatória sistêmica associada ao trauma, ao uso de contraste iodado para procedimentos diagnósticos, à rabdomiólise e à síndrome compartimental abdominal. Atualmente, passamos por uma fase de uniformização dos critérios diagnósticos da IRA com o Acute Kidney Injury Network (AKIN), sendo a referência mais aceita. Consequentemente, o estudo da IRA no politraumatismo também passa por uma fase de reformulação. Esta revisão da literatura médica visa trazer dados epidemiológicos, fisiológicos e de implicação clínica para o manuseio destes pacientes, bem como expor os riscos do uso indiscriminado de expansores volêmicos e particularidades sobre a instituição de terapia renal substitutiva em indivíduos sob risco de hipertensão intracraniana.

Acute Kidney Injury (AKI) in trauma is, in most cases, multifactorial. Factors related to the initial ressuscitation protocol, degree of the systemic inflamatory response to trauma, contrast nephropathy in diagnostic procedures, rhabdomyolysis and abdominal compartment syndrome are some of those factors. Nowadays a uniformization in diagnostic criteria for AKI has been proposed by the Acute Kidney Injury Network (AKIN) and as a result the incidence of AKI and its impact in outcomes in trauma patients also needs to be reconsider. In this review we aim to approach epidemiologic, physiologic and clinical relevant data in the critical care of patients victims of trauma and also to expose the risks of indiscriminate use of volume expanders and the interaction between renal replacement theraphy and intracranial hypertension.

The effect of 6% Hydroxyethyl starch vs. Ringer's lactate on acute kidney injury after renal ischemia in rats

PURPOSE: To compare fluid replacement therapy with Hydroxyethyl starch 6% (HES) versus Ringer's lactate (RL) in a rodent model of non-septic renal ischemia. METHODS: Forty male Wistar rats were randomized to receive HES 2 ml.kg-1.hr-1or RL 5 ml. kg-1.hr-1 that underwent 30 minutes of renal ischemia followed by reperfusion. Twelve hours after kidney ischemia, the kidneys were evaluated for histological changes. Serum NGAL levels were obtained at different times of the experimental protocol. RESULTS: Rodents in the HES group had a median (IQR) grade of renal injury 3 (3 to 5) compared to 2 (2 to 4) in the RL group (p=0.03). NGAL levels were not associated with the severity of kidney injury. CONCLUSION: Hydroxyethyl starch administration caused more kidney injury than Ringer's lactate in a non-infectious model of renal hypoperfusion.

Protective perioperative strategy using a third generation hydroxyethyl starch during surgery in a murine model of liver reperfusion injury / Estratégia protetora perioperatória usando um hidroxietilamido de terceira geração para expansão volêmica durante a cirurgia em modelo murino de lesão de reperfusão hepática

PURPOSE: To investigate whether a third generation colloid, hydroxyethyl starch (HES 130/0.4), used for perioperative fluid therapy, protects the rat liver against the late-phase response of ischemia/reperfusion injury (IRI) and if inhibition of neutrophil hepatic infiltration plays a part in this mechanism. METHODS: Wistar rats were used (8 in each group). Three groups had IRI induced by lobar vascular occlusion (60 minutes) and reperfusion (24 hours) and received HES (13 mL/kg iv), 7.5 percent saline (HS) (13 mL/kg iv) or no fluid. Three other groups were sham-operated and received the same fluid as the test groups. After 24 hours of reperfusion, blood was drawn for alanine aminotransferase (ALT) quantification and ischemic liver samples were taken for histological study (hematoxylin and eosin and chloroacetate staining of neutrophils). RESULTS: HES treatment attenuated the elevation in serum ALT (P=0.001) and reduced the extent of hepatocellular necrosis (P<0.01) compared with the IRI controls. HES-mediated cytoprotection was associated with a decrease of infiltration of neutrophils in the necrotic areas (P<0.05) compared with the untreated IRI rats, but not with the volume control IRI rats (P>0.05). CONCLUSION: Hydroxyethyl starch suppresses inflammatory response and ameliorates the late-phase response of hepatic ischemia/reperfusion injury.

OBJETIVO: Investigar se um colóide de terceira geração (HES 130/0.4), utilizado para fluidoterapia perioperatória, protege o fígado de rato contra a resposta da fase tardia de isquemia/reperfusão e se a inibição da infiltração hepática de neutrófilos desempenha um papel neste mecanismo. MÉTODOS: Foram utilizados ratos Wistar (8 em cada grupo). Três grupos tiveram lesão de isquemia/reperfusão (IRI) induzida por oclusão vascular lobar (60 minutos) e reperfusão (24 horas) e receberam HES (13 ml / kg iv), soro fisiológico a 7,5 por cento (HS) (13 ml / kg iv) ou nenhum fluido. Três outros grupos foram sham-operados e receberam o mesmo tipo de fluido dos grupos de teste. Após 24 horas de reperfusão, o sangue foi retirado para quantificação da alanina aminotransferase (ALT) e amostras de fígado isquêmico foram retiradas para estudo histológico (hematoxilina e eosina e coloração cloroacetato para neutrófilos). RESULTADOS: O tratamento com HES atenuou a elevação da ALT sérica (P = 0,001) e reduziu a extensão da necrose hepatocelular (P<0,01) em comparação com os controles da IRI. A citoproteção mediada por HES foi associada a uma diminuição da infiltração de neutrófilos nas áreas de necrose (P<0,05) em comparação com os ratos não tratados IRI, mas não com os ratos controlo IRI (P> 0,05). CONCLUSÃO: HES suprime a resposta inflamatória e melhora a resposta na fase tardia da isquemia/reperfusão hepática.

Curso de Atualização em Emergências Médicas: aula 19: reposição volêmica / Course of Updating in Medical Emergencies: class 19: volemic replacement

Hipovolemia em pacientes agudamente enfermos é um evento relativamente comum, e com importância clínica para o paciente, sendo a rápida e vigorosa reposição volêmica capaz de diminuir o risco de morte inicialmente e de evolução para falência renal na sequência. Neste artigo revisaremos os diferentes tipos de expansores, suas propriedades, vantagens e desvantagens. Os cristaloides se mantêm como preferência pela segurança, eficácia e baixo custo, com a desvantagem da importante formação de edema. As soluções hipertônicas têm indicação no atendimento pré-hospitalar por ser eficaz, porém com estabilização hemodinâmica de caráter efêmero, e pela possibilidade de distúrbios eletrolíticos. Estudos clínicos randomizados não demonstraram superioridade da albumina aos cristalóides e assim como são de custo alto ficam como segunda alternativa ou casos selecionados.

Hypovolemia in critically ill patients is a common event in intensive care patients, and it is clinically relevant for the patient. The fluid replacement is used to try to reduce risk of death and evolution to renal failure. In this article we review different types of expansors, their properties, advantages and disadvantages. Crystalloids are indicated for the safety, efficacy and low cost, the only disadvantage is oedema formation. Hypertonic crystalloid are indicated only in prehospitalar fluid resuscitation, because of your efficacy, but for a short period of time, and the possibility of hydroeletrolitic derangements. There is no evidence that colloids are more effective than crystalloids in reducing mortality in people who are critically ill or injured, and the high cost, turn them the second choice.

Experiencia clínica de monitorización hemodinámica del shock mediante el sistema PiCCO® / Preliminary clinical experience with PiCCO® system in children with shock

Objetivo: Evaluar la utilidad clínica del empleo del sistema de monitorización PiCCO® (pulse induced contour cardiac output ‘gasto cardíaco por análisis del contorno de la onda de pulso’) en pacientes pediátricos en situación de shock. Pacientes y métodos: Estudio analítico prospectivo y multicéntrico en niños de un mes a 18 años en situación de shock ingresados en 5 unidades de cuidados intensivos pediátricos. Se realizaron mediciones antes y después de 3 tipos de intervenciones: a) expansión volumétrica; b) aumento de dosis en fármacos vasoactivos, y c) cambio de dosis en fármacos que pudieran disminuir las resistencias periféricas. Los parámetros que se recogieron incluyeron los datos obtenidos de las termodiluciones junto con los parámetros hemodinámicos habituales. Resultados: Se realizaron 120 mediciones en 35 pacientes de edad de 36 (2,6 a 156) meses y peso de 15 (5,8 a 72) kg. La etiología del shock fue séptica (37%), cardiogénica (26%), hipovolémica (20%) y neurogénica (17%). No se registraron complicaciones en relación con el procedimiento. Se registraron 22 expansiones volumétricas en 17 pacientes, que produjeron una elevación significativa del ITBI (intrathoracic blood volume index ‘índice de volumen de sangre intratorácico’) de 501(235 a 763) a 584 ml/m2 (418 a 810), del CI (cardiac index ‘índice cardíaco’) de 4,04 (2,58 a 6,25) a 4,48 l/min/m2 (2,86 a 8,71) y de la presión arterial media de 74 (53 a 99) a 87 mmHg (59 a 112). Los cambios en el CI se correlacionaron con el incremento del ITBI (coeficiente de correlación = 0,678; p = 0,001). Las 13 intervenciones destinadas a incrementar el tono vasomotor se asociaron a un incremento del índice de resistencia vascular sistémica del 18%. Conclusiones: La monitorización hemodinámica mediante el sistema PiCCO® es factible y parece segura en pacientes pediátricos en shock. Los datos de monitorización obtenidos podrían añadir información relevante sobre el estado de precarga y la respuesta hemodinámica a sus modificaciones (AU)

Purpose: To evaluate the PiCCO® hemodynamics monitor in terms of clinical usefulness in children with shock. Methods: Prospective multicenter analytical study in children aged from one month to 18 years with shock admitted to five pediatric intensive care units. Measurements were made before and after three interventions: a) volume load; b) increases in vasoactive drugs; c) dosage changes of drugs that could lessen vascular resistance. Recorded parameters included thermodilution data, along with the usual hemodynamic parameters. Results: A total of 120 measurements were performed on 35 patients: mean age 36 (2.6–156) months, mean weight 15 (5.8–72)kg. Shock etiology was septic in 37% of cases, cardiogenic in 26%, hypovolemic in 20% and neurogenic in 17%. No procedure related complication was noticed. Twenty-two volume challenges in 17 patients were registered. Volume load induced a significant intrathoracic blood volume index (ITBI) increase from 501(235–763) to 584 (418–810)ml/m2, cardiac index (CI) 4.04 (2.58–6.25) to 4.48 (2.86–8.71)lmin-1m2, and mean blood pressure from 74 (53–99) to 87 (59–112)mmHg. CI changes correlated with ITBI increase (r=0.678, p=0.001). 13 interventions to increase vasomotor tone were associated with an increase in contractility of 18% in systemic vascular resistance index (SVRI). Conclusions: Hemodynamic monitoring with the PiCCO® system is feasible and seems safe in children with shock. PiCCO® derived parameters could add clinically important information to assess preload state and its modifications with therapy (AU)

Hemodynamic effects of volume replacement with saline solution and hypertonic hydroxyethyl starch in dogs / Efeitos hemodinâmicos da reposição volêmica com solução salina e hidroxi-etil amido hipertônico em cães

PURPOSE: To investigate hemodynamic response to volume replacement with saline solution and hypertonic hydroxyethyl starch in hypovolemic dogs. METHODS: Forty dogs under general anesthesia and hemodynamic monitoring, following measurements at baseline, were bled 20 ml.Kg-1 and parameters were measured again after 10 minutes. The animals were randomly divided in two groups and volume replacement was performed with saline solution twice the volume removed or 4 ml.Kg-1 of hypertonic hydroxyethyl starch. Hemodynamic data were again measured after 5, 15, 30, 45 and 60 minutes. RESULTS: With both solutions values returned to satisfactory hemodynamic levels. With saline solution, there was a greater amplitude in variations that tended to decrease progressively. With hypertonic hydroxyethyl starch, the parameters studied returned more rapidly to levels similar to those at baseline and varied less. CONCLUSION: Both solutions proved to be efficient at replacing volume in the short period studied, although hypertonic hydroxyethyl starch produced more stable results.

OBJETIVO: Avaliar em cães hipovolêmicos as respostas hemodinâmicas da reposição volêmica com solução salina e hidroxi-etil amido hipertônico. MÉTODOS: Quarenta cães sob anestesia geral e monitorização hemodinâmica, após medidas em repouso foram sangrados 20 ml.Kg-1 e tiveram os parâmetros novamente medidos após 10 minutos. Os animais foram aleatoriamente divididos em dois grupos nos quais foi realizada reposição volêmica com solução fisiológica duas vezes o volume retirado ou 4 ml.Kg-1 de hidroxi-etil amido hipertônico e os dados hemodinâmicos medidos novamente após 5, 15, 30, 45 e 60 minutos. RESULTADOS: A reposição volêmica com as duas soluções fez os valores retornarem a níveis hemodinâmicos satisfatórios, a amplitude das variações com solução fisiológica foi maior, mas tendeu a diminuir progressivamente, com o hidroxi-etil amido hipertônico os parâmetros estudados retornaram a semelhantes ao repouso mais rapidamente e variaram menos. CONCLUSÃO: Ambas soluções se mostraram eficientes na reposição volêmica, o hidroxi-etil amido hipertônico proporcionou resultados mais estáveis.

Utilización perioperatoria de coloides por los anestesiólogos españoles: encuesta de opinión / Perioperative colloid administration: a survey of Spanish anesthesiologists' attitudes

OBJETIVOS: Determinar la disponibilidad de sueros enlos centros hospitalarios españoles, conocer la utilizaciónde los coloides por los anestesiólogos, los posibles efectosadversos que evitan la utilización de cada uno de ellos yla disponibilidad de información sobre el tema.MATERIAL Y MÉTODOS: Encuesta realizada “on-line”durante 6 meses (Julio 2004-Enero 2005) en la dirección:www.encuestacoloides.com difundida por vía e-mail y enla Revista Española de Anestesiología y Reanimacióndirigida a anestesiólogos de todas las ComunidadesAutónomas españolas.RESULTADOS: Contestada por 142 anestesiólogos. Seencontró una amplia disponibilidad de cristaloides-coloidesen la mayoría de hospitales. Los hidroxietilalmidones(HEA) son los coloides más utilizados (73%), seguidosde las gelatinas (28%), mientras que los dextranosestán en desuso. Los motivos de esta utilización por losencuestados vienen determinados por el tiempo de permanenciaen el espacio intravascular, la mayor expansiónvolémica y la preservación de la hemostasia. El efectosecundario más temido es el riesgo de reacciónanafiláctica de las gelatinas, el límite de volumen ainfundir de los almidones y la alteración de la hemostasiapor los dextranos. El 54% opina que en las reunionescientíficas se aborda escasamente la información relacionadacon coloides y reposición volémica.CONCLUSIONES: Existe un amplio uso de coloides asociadosa cristaloides en la reposición volémica, a excepciónde los dextranos. Los anestesiólogos españoles tienenclaros algunos conceptos importantes del uso de loscoloides, sin embargo un alto porcentaje tiene dudassobre determinados aspectos básicos. Sería deseableincrementar la formación continuada en fluidoterapia

OBJECTIVES: To determine the availability ofintravascular fluid volume replacement solutions inSpanish hospitals, to survey the extent of use ofcolloids by anesthesiologists, to ascertain the possibleadverse effects they seek to prevent when using eachsolution, and to assess their level of knowledge aboutthe subject.MATERIAL AND METHODS: A questionnaire wasadministered over a period of 6 months (July 2004-January 2005). The questionnaire was available onlineat www.encuestacoloides.com. The address wasdistributed by e-mail to anesthesiologists of all theSpanish autonomous communities and published in theRevista Española de Anestesiología y Reanimación.RESULTS: One hundred forty-two anesthesiologistsresponded. Crystalloids and colloids were widely availablein most hospitals. Hydroxyethyl starch (HES) solutionswere the colloids most often used (73%), followed bygelatins (28%). Dextran solutions, on the other hand, wereno longer being used. The reasons the respondents gave forusing these solutions were related to the time theyremained in the vascular system, their greater effect ofvolume expansion, and the preservation of hemostasis. Themost-feared complication was anaphylactic reaction togelatins and there were concerns about the dose limit forinfusion of HES solutions and about hemodynamicinstability caused by dextran solutions. Fifty-four percentfelt that scientific meetings provide little informationabout colloids and volume replacement.CONCLUSIONS: There is widespread use of colloidsother than dextran along with crystalloids for plasmavolume replacement. Spanish anesthesiologists are clearabout important concepts related to colloid use.However, a high percentage have doubts about certainfundamental issues. Continuing professionaldevelopment opportunities related to intravascular fluidreplacement therapy should be increased

Two Cases of Systemic Capillary Leak Syndrome that were Treated with Pentastarch

Systemic capillary leak syndrome (SCLS) is a condition that's caused by the shift of fluid and protein from the intravascular space to the interstitial space as a result of repetitive episodes of capillary hyperpermeability. The pathogenesis of SCLS is still unclear, but there's recently been a report showing this syndrome in association with monoclonal gammopathy. This syndrome can be a fatal disease because cardiovascular collapse can occur in the initial capillary leak phase. Although theophylline, diuretics, terbutaline, steroids, calcium antagonist, Ginkgo biloba extracts and plasmapheresis have been suggested as medication, none of them have been proven to be effective. Considering that this disease is self-limiting, conservative treatment in the acute phase is believed to be very important. Because hypoalbuminemia is very a common manifestation of SCLS, Pentastarch, which has a higher molecular weight than albumin, could be efficient to prevent cardiovascular collapse. We used 10% Pentastarch during the acute SCLS attacks of 2 patients and the patients both showed a dramatic response. Pentastarch may be helpful to treat SCLS in its initial capillary leak phase by the elevating blood pressure, and this might contribute to somewhat decreasing the acute mortality of SCLS.

Arritmia por doble vía intranodal con descompensación hemodinámica grave en un retrasplante hepático / Dual atrioventricular nodal conduction and arrythmia with severe hemodynamic alterations during liver retransplantation

Presentamos el caso de un paciente que presentó una taquicardia por reentrada auriculo-ventricular, en relación con la presencia de una doble vía intranodal con importante repercusión hemodinámica durante un retrasplante hepático. Las alteraciones del ritmo y de la conducción cardiaca representan unas de las complicaciones potenciales durante el trasplante hepático. Así están descritas la aparición de taquiarritmias del tipo de fibrilación auricular, taquicardias supraventriculares, ventriculares y bradiarritmias. Estas arritmias ocurren especialmente durante la reperfusión del injerto. Los factores implicados se relacionan con la presencia de alteraciones iónicas graves, del equilibrio ácido base y de la hipotermia que acompañan a la reperfusión del nuevo órgano. Se revisan los posibles mecanismos etiopatogénicos implicados en la aparición de las alteraciones del ritmo en los pacientes con enfermedad hepática terminal

We report the case of a man who developed tachycardia caused by atrioventricular reentry related to dual nodal conduction during liver retransplantation. The hemodynamic alterations were severe. Arrhythmia and altered cardiac conduction are potential complications of liver transplantation. The development of tachyarrhythmias —atrial fibrillation as well as episodes of supraventricular and ventricular tachycardia and bradycardia— have been described. Such arrhythmias tend to occur particularly during reperfusion of the graft. Risk factors implicated are the severe ion imbalances, acidbase imbalance, and hypothermia that accompany the reperfusion of a new organ. A review of the possible pathogenic and etiological mechanisms that lead to arrhythmia in patients with end-stage liver disease is provided

Fisiopatología de la ascitis refractaria y el síndrome hepatorrenal / Pathophisiology of refractary ascites and hepatorenal síndrome

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Empleo del pentalmidón al 100 por ciento como agente expandente del plasma en cirugía mayor electiva y de urgencia / The use of pentastarch as an expanding plasma agent in major either elective or emergency surgery

A 25 pacientes de ambos sexos, tratados bajo anestesia general balanceada o de conducción se les sometió a procedimientos quirúrgicos que presuponían sangrado abundante, fue posible restaurar a la normalidad los signos vitales tras la aplicación de 500 a 1,000 mL. del coloide pentalmidón al 10 por ciento. Se concluye que hay abatimiento en los requerimientos de transfusión sanguínea en virtud de que hay solamente 10 pacientes la ameritaron