A novel regulatory role of TRAPPC9 in L-plastin-mediated osteoclast actin ring formation.

Trafficking protein particle complex 9 (TRAPPC9) is a major subunit of the TRAPPII complex. TRAPPC9 has been reported to bind nuclear factor κB kinase subunit ß (IKKß) and NF-kB-inducing kinase (NIK) where it plays a role in the canonical and noncanonical of nuclear factor-κB (NF-kB) signaling pathways, receptively. The role of TRAPPC9 in protein trafficking and cytoskeleton organization in osteoclast (OC) has not been studied yet. In this study, we examined the mRNA expression of TRAPPC9 during OC differentiation. Next, we examined the colocalization of TRAPPC9 with cathepsin-K, known to mediate OC resorption suggesting that TRAPPC9 mediates the trafficking pathway within OC. To identify TRAPPC9 protein partners important for OC-mediated cytoskeleton re-organization, we conducted immunoprecipitation of TRAPPC9 in mature OCs followed by mass spectrometry analysis. Our data showed that TRAPPC9 binds various protein partners. One protein with high recovery rate is L-plastin (LPL). LPL localizes at the podosomes and reported to play a crucial role in actin aggregation thereby actin ring formation and OC function. Although the role of LPL in OC-mediated bone resorption has not fully reported in detail. Here, first, we confirmed the binding of LPL to TRAPPC9 and, then, we investigated the potential regulatory role of TRAPPC9 in LPL-mediated OC cytoskeleton reorganization. We assessed the localization of TRAPPC9 and LPL in OC and found that TRAPPC9 is colocalized with LPL at the periphery of OC. Next, we determined the effect of TRAPPC9 overexpression on LPL recruitment to the actin ring using a viral system. Interestingly, our data showed that TRAPPC9 overexpression promotes the recruitment of LPL to the actin ring when compared with control cultures. In addition, we observed that TRAPPC9 overexpression reorganizes actin clusters/aggregates and regulates vinculin recruitment into the OC periphery to initiate podosome formation.

Autophagy plays an essential role in bone homeostasis.

Autophagy is very critical for multiple cellular processes. Autophagy plays a critical role in bone cell differentiation and function.

[Postoperative delirium among older people]. / Delirium postoperatorio: una consecuencia del envejecimiento poblacional.

Delirium (acute confusional state) is a common and disabling complication among surgical older people. It is often underdiagnosed and undertreated. Its incidence varies by type of intervention and it is associated with several complications such as functional impairment, cognitive dysfunction, prolonged hospitalization and institutionalization. These increase hospitalization costs and the risk of death. There are precipitating and predisposing risk factors, which increase the susceptibility for postoperative delirium. This condition should be considered as a syndrome of epidemiological importance, which needs to be prevented or treated in a timely manner through a multidisciplinary intervention. The perioperative care of elderly patients involves different medical specialties and is a subject of general knowledge.

[Microbiological and epidemiological analysis, and clinical outcome of patients with bloodstream infection from an Esquel hospital in the period 2007-200]. / Análisis microbiológico, epidemiológico y evolución clinica de los pacientes con bacteriemia en el Hospital Zonal de Esquel en el período 2007-2009.

In order to evaluate the bacteremic episodes, the blood cultures performed in 867 patients during a 29-month period were reviewed. The incidence of significant bloodstream infections was 10/1000 admissions/year. About 47% of bacteremias were community-acquired (CAB), 22% nosocomial (NB), and 31% health care-associated (HCAB). The five most common pathogens were: Streptococcus pneumoniae, Staphylococcus aureus, Escherichia coli, Enterococcus spp. and coagulase-negative staphylococci, whereas the main sources were: respiratory, intraabdominal and unknown. The major organism in CAB was S. pneumoniae, and S. aureus in NB and HCAB. The ineffective empirical-antimicrobial-therapy [IEAT (total 26.5%)] was much higher in NB and HCAB vs. CAB (p < 0.05). There was no significant difference in mortality and IEAT between known vs. unknown sources. Old age (> 70 yrs), previous antibiotic therapy, hospitalization in clinical medical services, Enterococcus spp. and methicillin-resistant Staphylococcus isolates were more associated with IEAT (p < 0.05). Previous antibiotic therapy and longer hospital stays were more common in NB vs. CAB and HCAB (p < 0.05). Overall and septicemia-associated mortality was 28.9% and 21.7%, respectively. Univariate associations with increased mortality (p < 0.05) included: hypothermia, WBC < 1499/mm3, hypotension, presentation with septic-shock, hospital-stay 10 days, and polymicrobial bacteremia. The early administration of effective empirical antimicrobial therapy according to our epidemiological characteristics and an aggressive hemodynamic treatment in presence of septic shock could reduce bacteremia-associated morbidity and mortality, costs and length of hospital stays.

TRAPPC9: Novel insights into its trafficking and signaling pathways in health and disease (Review).

Trafficking protein particle complex 9 (TRAPPC9) is a protein subunit of the transport protein particle II (TRAPPII), which has been reported to be important in the trafficking of cargo from the endoplasmic reticulum (ER) to the Golgi, and in intra­Golgi and endosome­to­Golgi transport in yeast cells. In mammalian cells, TRAPPII has been shown to be important in Golgi vesicle tethering and intra­Golgi transport. TRAPPC9 is considered to be a novel molecule capable of modulating the activation of nuclear factor­κB (NF­κB). Mutations in TRAPPC9 have been linked to a rare consanguineous hereditary form of mental retardation, as part of the NF­κB pathways. In addition, TRAPPC9 has been reported to be involved in breast and colon cancer and liver diseases. The present review highlights the most recent publications on the structure, expression and function of TRAPPC9, and its association with various human diseases.

Primitive neuroectodermal tumor of the lung.

Primitive neuroectodermal tumors occur most frequently in bone and soft tissue but have been reported in other locations. Primary lung primitive neuroectodermal tumors without pleural or chest wall involvement are extremely rare. We present a case with immunohistochemical and ultrastructural studies and follow-up of the patient. An 18-year-old man presented with hemoptysis. Chest radiographs revealed a right middle lobe mass, and bronchoscopy showed an endobronchial tumor. The lesion was resected by middle lobectomy. After 2 years, a local recurrence was treated by pneumonectomy. The patient died after surgery. Histologically, the tumor was composed of uniform cells with round nuclei and scanty cytoplasm arranged in cohesive lobules with occasional rosette formation. Immunohistochemically, the tumor was positive for vimentin, CD99, neuron-specific enolase, and neurofilaments. Ultrastructural study revealed neurosecretory granules and cytoplasmic processes. Our case shows the value of immunohistochemistry and electron microscopy in the diagnosis of primitive neuroectodermal tumors in unusual locations.

[Clostridium difficile diarrhea: frequency of detection in a medical center in Buenos Aires, Argentina]. / Diarrea asociada a Clostridium difficile: frecuencia de detección en un centro médico de Buenos Aires, Argentina.

Clostridium difficile has been recognized as the most important enteric pathogen of nosocomial antibiotic-associated diarrhea (CDAD) in adults from industrialized countries. The importance of C. difficile as a cause of diarrhea in ambulatory patients appears underestimated or under-recognized. Since the 1980's, outbreaks of CDAD have been increasingly reported, but there are few data available in Argentina. We developed a retrospective study to provide some information about CDAD in our country. From July 1998 to November 1999, a total of 245 fecal specimens from hospitalized and some ambulatory patients were tested in order to confirm the diagnosis of CDAD. C. difficile cytotoxin (toxin B) was identified by detecting its cytopathic effect on monolayers of McCoy culture cells. For culture and isolation of C. difficile, stool samples were prepared by ethanol shock prior to plating onto a selective medium which contained blood, cefoxitin and fructose. Of the 245 samples, 14 (5.8%) were identified as positive by the cell cytotoxicity assay. Using the criteria of isolation of cytotoxigenic C. difficile positivity increased to 6.5% (16 samples). Thirteen of the positive results were from hospitalized patients (81.3%) and 3 (18.7%) from outpatients. The mean age of inpatients was 72.9 years (ranging from 47 to 88). All patients had received 2 or more antimicrobial agents (most of them beta-lactams) 2 months before the appearance of diarrhea. There was one patient who had received only chemotherapy. The prevalence of CDAD in this study was less than in others previously reported. This difference may be due to the fact that not all general practitioners include testing for C. difficile when the patient with diarrhea had previously received antibiotics. More educational programs should be directed to all physicians, concerning the role of C. difficile as an important enteric pathogen in patients who have undergone treatment with antimicrobial or chemotherapeutic agents.

Nuevos anticoagulantes orales y antiagregantes plaquetarios, en el período perioperatorio de cirugía no cardíaca. Parte 2: Nuevos antiagregantes plaquetarios / Novel oral anticoagulants and new platelet antiaggregants, in the perioperative period of non cardiac surgery. Part 2: New platelet antiaggregants

Coronary disease and the cerebro-vascular accidents represent the first causes of mortality worldwide. Platelet antiaggregants are fundamental for the management and prevention of these diseases. Aspirin is still the most used drug in this group, but new antagonists of the ADP receptor and glycoprotein IIb/IIIa antagonists have been added with increasing frequency, so its management in the perioperative period deserves special attention. There are clinical guidelines that help us decide on the maintenance or suspension of these drugs in the perioperative period, all of which are based mainly on expert recommendations and state that the decision should be taken jointly by the entire treatment team. If their antiplatelet effects are not desired, Clopidogrel and Ticagrelor should be discontinued at least 5 days before surgery, and at least 7 days with Prasugrel. Cangrelor should be discontinued at least 60 minutes prior to the procedure. After the suspension of glycoprotein IIb/IIIa inhibitors, platelet activity returns to normal at 8 hours with Tirofiban and Eptifibatide, and up to 24 to 48 hours with Abciximab. There are also recommendations regarding the use of neuroaxial anesthesia in patients who use this type of drug.

La enfermedad coronaria y el accidente cerobrovascular representan las primeras causas de mortalidad a nivel mundial. Los antiagregantes plaquetarios, son fundamentales para el manejo y prevención de estas enfermedades. La Aspirina sigue siendo el fármaco más utilizado de este grupo, pero se han ido agregando nuevos antagonistas del receptor de ADP y antagonistas de la Glicoproteína IIb/IIIa con cada vez mayor frecuencia, por lo que su manejo en el perioperatorio merece atención especial. Existen guías clínicas que nos ayudan a decidir la mantención o suspensión de estos fármacos en el perioperatorio, todas ellas son basadas principalmente en recomendaciones de expertos y recomiendan que la decisión sea tomada en conjunto por todo el equipo tratante. Si se quiere suspender estos fármacos y evitar sus efectos antiplaquetarios, clopidogrel y ticagrelor se deben suspender al menos 5 días previo a la cirugía, y al menos 7 días en el caso de prasugrel. Cangrelor se debe suspender al menos 60 minutos previo al procedimiento. Luego de la suspensión de los inhibidores de glicoproteína IIb/IIIa, la actividad plaquetaria vuelve a la normalidad a las 8 horas en el caso de tirofiban y eptifibatide, y hasta 24 a 48 horas en el caso de abciximab. Existen también recomendaciones con respecto al uso de anestesia neuroaxial en los pacientes usuarios de este tipo de fármacos.

Manejo perioperatorio de pacientes usuarios de antiagregantes plaquetarios / Perioperative management of patients using antiplatelet agents

Resumen El uso de fármacos antiagregantes plaquetarios para prevención primaria y secundaria de eventos cardiovasculares es una práctica común en clínica. La terapia antiagregante plaquetaria disminuye significativamente la incidencia de eventos cardiovasculares, incluyendo infarto agudo al miocardio y accidente cerebro-vascular. Cada vez es más frecuente enfrentarse a pacientes en terapia antiagregante plaquetaria que serán sometidos a algún procedimiento quirúrgico, por tanto es fundamental conocer el manejo perioperatorio de estos fármacos, para disminuir los riesgos y complicaciones asociados a la suspensión o mantención de estas drogas en el período perioperatorio. Los antiagregantes plaquetarios de mayor uso en Chile son la aspirina y las tienopiridinas, siendo el clopidogrel el fármaco más utilizado en este grupo. El enfrentamiento perioperatorio de estos fármacos está supeditado al riesgo trombótico individual de cada paciente y al riesgo hemorrágico de cada cirugía. En cirugías no cardiacas, se sugiere mantener la aspirina, excepto en pacientes con bajo-moderado riesgo trombótico que serán sometidos a cirugías con alto riesgo de sangrado, en los cuales se recomienda suspenderla 5-7 días previo a la intervención quirúrgica. El clopidogrel se sugiere suspenderlo 5 días antes de la cirugía, excepto en pacientes con alto riesgo trombótico que se someterán a procedimientos quirúrgicos con riesgo hemorrágico bajo-moderado. En cirugías de revascularización miocárdica, se recomienda mantener aspirina y suspender clopidogrel 5 días antes del procedimiento. En relación al reinicio postquirúrgico de estos fármacos, se sugiere reanudar aspirina 6 h posterior a la cirugía y clopidogrel durante las primeras 24 h postoperatorias, asegurando previamente una adecuada hemostasia quirúrgica.

The use of antiplatelet drugs for primary and secondary prevention of cardiovascular disease events is a common clinical practice. Antiplatelet therapy significantly decreases the incidence of cardiovascular disease events, including acute myocardial infarction and cerebrovascular accident. It is increasingly common to face patients on antiplatelet therapy who will undergo some surgical procedure, so it is essential to know the perioperative management of these drugs, to reduce the risks and complications associated with the suspension or maintenance of these therapies in the perioperative period. The most common antiplatelet agents used in Chile are acetylsalicylic acid and thienopyridines, of which clopidogrel is the most frequent one. The perioperative management of these drugs has to be based on the individual thrombotic risk of each patient and the risk of hemorrhage of each surgery. In noncardiac surgeries, it is suggested to maintain acetylsalicylic acid, except in patients with low to moderate thrombotic risk who will undergo surgeries with a high risk of bleeding, in which case it is recommended to suspend it 5 to 7 days before surgery. Clopidogrel is suggested to be discontinued 5 days before surgery, except in patients with high thrombotic risk who will undergo surgical procedures with low to moderate risk of hemorrhage. In myocardial revascularization surgeries, it is recommended to maintain acetylsalicylic acid and to suspend clopidogrel 5 days before the procedure. Once assuring adequate surgical hemostasis, it is suggested to reinitiate acetylsalicylic acid 6 hours after surgery and to reinitiate clopidogrel during the first 24 postoperative hours.

Consideraciones perioperatorias en el paciente obeso / Perioperative considerations in the obese patient

La obesidad es una condición de acumulación excesiva de grasa corporal a un nivel que resulta dañino para la salud. La prevalencia de obesidad está aumentando en todo el mundo a un ritmo alarmante, por lo tanto, es fundamental conocer el manejo perioperatorio y consideraciones específicas en esta población. La mayoría de los pacientes obesos que se someten a procedimientos quirúrgicos tienen pocas patologías agregadas, por lo que su riesgo perioperatorio es similar a pacientes normopesos. El Obesity Surgery Mortality Risk Stratification Score OS-MRS es una escala validada para evaluar el riesgo de mortalidad perioperatoria en estos pacientes. Es esencial buscar la presencia de trastornos respiratorios del sueño en estos pacientes, y para ello el cuestionario STOP-BANG es el de mayor validez en la actualidad. Durante la inducción anestésica se recomienda colocar al paciente en posición "de rampa" ya que mejora significativamente la visualización de la glotis durante la laringoscopia. Además, esta posición optimiza la oxigenación y mecánica ventilatoria de estos pacientes, aumentando el tiempo de apnea seguro. Respecto al manejo de vía aérea, la intubación orotraqueal con ventilación controlada es la técnica de elección en esta población. Las dosis de drogas anestésicas deben calcularse en base al peso ajustado o magro, dependiendo del tipo de fármaco elegido. Finalmente, se recomienda una monitorización posoperatoria completa y frecuente en la unidad de recuperación, trasladando a estos pacientes a su pieza sólo cuando cumplan los criterios incluidos en la escala de White y Song.

Obesity is a condition of excessive accumulation of body fat to a level that is harmful to health. The prevalence of obesity is increasing worldwide at an alarming rate. Therefore it is essential to know the perioperative management and specific considerations in this population. The majority of obese patients who undergo surgical procedures have few additional pathology, so their perioperative risk is similar to eutrophic patients. Obesity Surgery Mortality Risk Stratification Score OS-MRS is a validated scale for assessing the risk of perioperative mortality in these patients. It is essential to look for the presence of respiratory sleep disorders in these patients, and for this purpose, the STOP-BANG questionnaire is the most valid today. During anesthetic induction it is recommended to place the patient in the "ramp" position as it significantly improves the visualization of the glottis during laryngoscopy. Also, this position optimizes the oxygenation and ventilatory mechanics of these patients, increasing the time of safe apnea. Regarding airway management, orotracheal intubation with controlled ventilation is the technique of choice in this population. Anesthetic drug doses should be calculated based on adjusted weight or lean weight, depending on the type of drug chosen. Finally, complete and frequent postoperative monitoring is recommended in the recovery unit, transferring these patients to their room only when they meet the criteria included in the White and Song scale.

Manejo perioperatorio de pacientes con tratamiento anticoagulante crónico / Perioperative management of patients with chronic anticoagulant therapy

Resumen La terapia anticoagulante es ampliamente utilizada en la práctica clínica, como profilaxis en pacientes con riesgo de presentar fenómenos tromboembólicos o como tratamiento en aquellos que han presentado algún evento trombótico. Cada vez es más frecuente enfrentarse a pacientes en tratamiento anticoagulante crónico que serán intervenidos mediante procedimientos quirúrgicos, por lo que es importante y necesario conocer el manejo perioperatorio de los diferentes fármacos anticoagulantes, para disminuir los riesgos y complicaciones asociados a la suspensión o mantención de estos en el período perioperatorio. Para lograr este objetivo se debe evaluar y balancear el riesgo de sangrado versus el riesgo de eventos tromboembólicos, considerando la condición médica de cada paciente y el tipo de procedimiento quirúrgico que recibirá. La recomendación para fármacos anticoagulantes orales antagonistas de vitamina K es mantenerlos en cirugías con bajo riesgo de sangrado y suspenderlos 5 días antes de procedimientos quirúrgicos con riesgo hemorrágico moderado y alto, controlando el international normalized ratio el día previo a la cirugía. Los nuevos anticoagulantes orales no requieren monitorización de rutina, recomendándose suspenderlos a las 24-96 h previas al procedimiento quirúrgico, dependiendo del riesgo hemorrágico de cada cirugía y de la función renal. En relación con los anticoagulantes parenterales, la heparina no fraccionada en infusión intravenosa se recomienda suspenderla 4-5 h antes de la cirugía, mientras que la utilizada vía subcutánea, 12 h previas a la intervención quirúrgica. Las heparinas de bajo peso molecular en dosis de tratamiento se sugiere descontinuarlas 24 h previas a la cirugía, mientras que las usadas en dosis profilácticas, solo 12 h antes.

Anticoagulant therapy is widely used in clinical practice, as prophylaxis in patients at risk of presenting thromboembolic phenomena or as treatment in those who have presented a thrombotic event. It is increasingly the number of patients on chronic anticoagulant therapy to undergo surgical procedures, so it is important and necessary to know the perioperative management of the different anticoagulant drugs to reduce the risks and complications associated with suspension or maintenance of these in the perioperative period. To achieve this goal, the risk of bleeding should be evaluated and balanced against the risk of thromboembolic events, considering the medical condition of each patient and the type of surgical procedure to which they have undergone. The recommendation for vitamin K antagonist oral anticoagulant drugs is to maintain them for surgeries at low risk of bleeding and to suspend them 5 days before surgical procedures with moderate and high bleeding risk, controlling 'International Normalized Ratio' the day before surgery. The new oral anticoagulants do not require routine monitoring, recommending suspending them 24-96 h prior to the surgical procedure, depending on the hemorrhagic risk of each surgery and renal function of patient. In relation to parenteral anticoagulants, unfractionated heparin in intravenous infusion is recommended to be discontinued 4-5 h prior to surgery, while the subcutaneous route, 12 h prior to surgery. Low-molecular-weight heparins in treatment doses should be suspended 24 h prior to surgery, while in prophylactic doses, only 12 h earlier.

Toxicidad sistémica por anestésicos locales: consideraciones generales, prevención y manejo / Systemic toxicity by local anesthetics: general considerations, prevention and management

La administración de anestésicos locales se lleva a cabo en distintos escenarios clínicos y por diferentes profesionales de la salud, principalmente, médicos y odontólogos. Su uso está asociado a complicaciones de baja frecuencia como edema, urticaria y dermatitis, pero la intoxicación por anestésicos locales puede ser fatal. La presentación clínica de esta complicación es muy variable y abarca un gran espectro de síntomas relacionados principalmente con la toxicidad neurológica y cardiovascular, incluyendo presentaciones atípicas. La prevención de la toxicidad sistémica se basa en considerar los factores de riesgo para su presentación, elegir cuidadosamente el anestésico local y la dosis a administrar, aspirar antes de inyectar, fraccionar la dosis y el uso de marcadores de inyección intravascular. El manejo de la intoxicación por anestésicos locales incluye un manejo de la vía aérea, control de las convulsiones, mantención de la circulación sistémica y el uso de terapia intravenosa con emulsión lipídica.(AU)

The administration of local anesthetics is carried out in different clinical settings and by different health professionals, mainly physicians and dentists. Its use is associated with low frequency complications such as edema, urticaria and dermatitis, but poisoning by local anesthetics can be fatal. The clinical presentation of this complication is highly variable and encompasses a large spectrum of symptoms mainly related to neurological and cardiovascular toxicity, including atypical presentations. The prevention of systemic toxicity is based on considering the risk factors for its presentation, carefully choosing the local anesthetic and the dose to be administered, aspirating before injecting, fractionating the dose and the use of intravascular injection markers. Management of local anesthetic poisoning includes airway management, seizure control, systemic circulation maintenance, and intravenous lipid emulsion therapy.(AU)

Prevención y tratamiento de pacientes con náuseas y vómitos postoperatorios / Prevention and treatment of patients with postoperative nausea and vomiting

Resumen Las náuseas y vómitos postoperatorios (NVPO) son un problema frecuente en los pacientes quirúrgicos. Cuando no son prevenidos adecuadamente pueden provocar mayor morbilidad, estadía prolongada en la unidad de recuperación postoperatoria y hospitalización no planificada. El objetivo del equipo quirúrgico debe ser la profilaxis de las NVPO más que su tratamiento, con el fin de disminuir significativamente su incidencia y complicaciones asociadas. Los principales factores de riesgo para NVPO son: sexo femenino, historia de NVPO en cirugías previas y/o cinetosis, no fumar, uso de opioides sistémicos en el postoperatorio, someterse a ciertos tipos de cirugía (como colecistectomía, cirugía laparoscópica y cirugía ginecológica), utilizar anestésicos volátiles y/u óxido nitroso intraoperatorios, y duración de la cirugía. Sugerimos objetivar el riesgo de NVPO utilizando las escalas de riesgo de NVPO de Apfel o Koivuranta. Los principales fármacos antieméticos usados como profilaxis y tratamiento en el período perioperatorio son dexametasona, ondansetrón y droperidol. Existen estrategias generales que se pueden utilizar para reducir el riesgo quirúrgico basal de NVPO como evitar la anestesia general, privilegiando la anestesia regional, utilizar propofol para la inducción y mantención de la anestesia, evitar el uso de óxido nitroso y/o anestésicos inhalatorios, minimizar el uso postoperatorio de opioides sistémicos y recibir una hidratación intravenosa abundante durante la cirugía. La etiología de las NVPO es multifactorial, por lo que la prevención y tratamiento deben incluir diferentes clases de antieméticos, que actúen sobre los diferentes receptores de náuseas y/o vómitos hasta el momento conocidos, junto con las estrategias generales antes mencionadas.

Abstract Postoperative nausea and vomiting (PONV) are a common problem in surgical patients. When not properly prevented, they can lead to increased morbidity, prolonged stay in the postoperative recovery unit and unplanned hospitalization. The objective of the surgical team should be the prophylaxis of PONV rather than its treatment, in order to significantly reduce its incidence and associated complications. The main risk factors for PONV are: female sex, history of PONV in prior surgeries and/or motion sickness, non-smoking, use of systemic opioids postoperatively, undergo certain types of surgery (such as cholecystectomy, laparoscopic surgery and gynecological surgery), use volatile anesthetics and/or intraoperative nitrous oxide, and duration of surgery. We suggest to objectify the risk of PONV using the Apfel or Koivuranta PONV risk scales. The main anti-emetic drugs used as prophylaxis and treatment in the perioperative period are dexamethasone, ondansetron and droperidol. There are general strategies that can be used to reduce the baseline surgical risk of PONV such as avoiding general anesthesia, favoring regional anesthesia, using propofol for induction and maintenance of general anesthesia, avoiding the use of nitrous oxide and/or inhalational anesthetics, minimizing the postoperative use of systemic opioids and to receive an abundant intravenous hydration during surgery. The etiology of PONV is multifactorial, so prevention and treatment should include different classes of antiemetics, acting on the different receptors of nausea and/or vomiting so far known, together with the general strategies mentioned above.

Manejo perioperatorio de pacientes usuarios de antidepresivos / Perioperative management of patients using antidepressants

El uso de antidepresivos en el perioperatorio es muy frecuente, y la práctica clínica indica que los pacientes usuarios de antidepresivos que son sometidos a cirugía tienen un riesgo perioperatorio aumentado. No existen en la actualidad guías clínicas basadas en la evidencia que orienten el manejo de este tipo de pacientes, por lo que las recomendaciones se basan en las escasas revisiones sistemáticas y metaanálisis disponibles, reportes de casos y opinión de expertos, que en muchos casos resultan controversiales. La decisión de mantener o suspender la medicación antidepresiva implica considerar los riesgos tanto desde el punto de vista fisiológico (características generales del paciente, riesgos asociados al antidepresivo utilizado, la cirugía propiamente como tal, la interacción con fármacos frecuentemente utilizados en el perioperatorio, entre otros) como desde el punto de vista psiquiátrico (riesgo de síndrome de retirada, recaída de la enfermedad psiquiátrica, intentos suicidas), por lo que la decisión debe ser tomada idealmente de forma multidisciplinaria entre cirujanos, anestesiólogos y psiquiatras, con la idea de confeccionar un plan quirúrgico, anestésico y de manejo perioperatorio seguro para el paciente.

Antidepressant use in the perioperative is a common practice, and clinical evidence shows that surgical patients using antidepressants have an increased perioperative risk. There are not evidence-based guidelines for the perioperative management of these patients, and recommendations are based on few systematic reviews and meta-analysis, case reports and expert opinion, which in many cases are controversial. The decision to continue or discontinue the medication involves considering general patient characteristics, risks associated with the antidepressant used, type of surgery, interaction with drugs commonly used in the perioperative, risk of withdrawal symptoms, relapse of psychiatric disease and suicide risk, so decision should be made between surgeons, anesthesiologists and psychiatrists, in order to design a safe management plan for the patient who undergo surgery.

Manejo perioperatorio de pacientes con patología tiroidea y tratamiento crónico con corticoides / Perioperative management in patients with thyroid disorders and chronic glucocorticoid therapy

Abstract Thyroid disorders and chronic use of corticosteroids are common in the surgical population, so is necessary an appropriate perioperative management of these patients. There is no contraindication for elective surgery in patients with asymptomatic hypothyroidism and good control, it is not necessary to maintain thelevothyroxine dose the day of surgery, due to the pharmacokinetic properties of the drug. If hypothyroidpatients are symptomatic and/or have not reached the euthyroid phase, should be treated and compensatedprior to the elective surgical procedure. Patients with hyperthyroidism should keep their antithyroid treatmentincluding the day of surgery. The symptomatic and/or decompensated hyperthyroidism have an increasedrisk of developing a thyroid storm, so no elective surgery is recommended in these patients, which should beconducted once achieved an euthyroid state. A strict monitoring in the postoperative period is key to preventcomplications. Chronic glucocorticoid use is common. In these patients there is risk of developing acute adrenal insufficiency by surgical stress, so before surgery (elective or emergency) it is necessary to supplementwith exogenous corticosteroid dose dependent on the type of surgical procedure performed.

Resumen Los trastornos tiroideos y el uso crónico de corticoides son frecuentes en la población quirúrgica, por lo que es necesario un manejo perioperatorio adecuado en este tipo de pacientes. No existe contraindicación para una cirugía electiva en pacientes con hipotiroidismo asintomáticos y buen control, no siendo necesario mantener la dosis habitual de levotiroxina el día de la cirugía, debido a las características farmacocinéticas del medicamento. Si los pacientes hipotiroideos se encuentran sintomáticos y/o no han alcanzado la fase eutiroidea, deben ser tratados y compensados previo al procedimiento quirúrgico electivo. Los pacientes hipertiroideos deben mantener su tratamiento antitiroideo incluso el día de la cirugía. En el hipertiroidismo sintomático y/o descompensado existe mayor riesgo de desarrollar una tormenta tiroidea, por lo que no se recomiendacirugía electiva en este tipo de pacientes, la cual debe realizarse una vez logrado un estado eutiroideo. Una estricta monitorización en el período postoperatorio es clave para prevenir complicaciones. El uso crónico degluco corticoides es frecuente. En estos pacientes existe riesgo de desarrollar insuficiencia suprarrenal aguda ante el estrés quirúrgico, por lo que antes de una cirugía (electiva o de urgencia) es necesario suplementar concorticoides exógenos, en dosis dependientes del tipo de procedimiento quirúrgico a realizarse.

Cirugía ambulatoria: selección de pacientes y procedimientos quirúrgicos / Ambulatory surgery: patients and surgeries selection

Outpatient surgery is being performed with increasing frequency due to its significant benefits, including lower costs in health care, and lower incidence of complications and mortality, requiring an appropriate selection of patients and surgeries to be performed in this setting. To select patients and surgeries to be operated on an ambulatory basis, it is relevant an adequate preoperative evaluation. Regarding the risks of patient, it is important the comorbidities and the American Society of Anesthesiologists classification. Risks associated with the type of surgery are divided according to their cardiovascular risk and duration of the procedure. Both will define those suitable for outpatient surgery. Serious complications and associated mortality are infrequents nowadays, therefore it is necessary to take into account other indicators, such as unanticipated hospital admission, hospital readmission and prolonged postoperative stay. There are some patients that require more specific preoperative evaluation, such as the elderly, obese, among others.

La cirugía ambulatoria se realiza cada vez con mayor frecuencia debido a sus importantes beneficios, como menores costos y menor morbimortalidad, y requiere una cuidadosa selección de pacientes y procedimientos quirúrgicos a realizar. Para seleccionar qué pacientes se pueden operar en forma ambulatoria es necesaria una adecuada evaluación preoperatoria quirúrgica y anestésica. Respecto a los riesgos asociados al paciente, destacan sus comorbilidades y clasificación American Society of Anesthesiologists. Los riesgos asociados a la cirugía se dividen según su riesgo cardiovascular y duración del procedimiento. Entre los riesgos del paciente y la cirugía se pueden definir cuáles son aptos para una cirugía ambulatoria. Las complicaciones graves y mortalidad asociadas son muy infrecuentes hoy en día, por lo que se hace necesario tener en cuenta otro tipo de indicadores, como la hospitalización no programada, hospitalización post alta y retardo del alta hospitalaria. Existen ciertos pacientes que requieren una evaluación más específica de la indicación de cirugía ambulatoria, como los ancianos y obesos, entre otros.

Alergia al látex en el período perioperatorio / Latex allergy in the perioperative period

Latex or natural rubber latex is a processed plant-based product, extracted from the tropical tree Hevea Brasiliensis. This raw material is widely used in about 40.000 medical and daily-used products. Latex allergy is a relevant pathology in surgical environments that arose after the establishment of universal precautions during the nineties. Risk groups include health-care workers and children with spine bifida who have a prevalence ranging between 2.9-17 percent and 30-70 percent, respectively. Latex allergy occurs in a variety of ways in health facilities including hypersensitivity reaction type IV or type I. In the former, chemical substances added to latex trigger the allergic reactions; where allergic dermatitis is the most-frequently found case. In the latter, the reactions are triggered by the contact with latex proteins causing from urticarial to anaphylactic shock and death. Diagnosis of latex allergy is based on a clinical history and/or physical examination associated with a confirmatory test as prick test (latex allergy type I) or cutaneous patches (latex allergy type IV). Nowadays, there is no definitive cure for the latex allergy and its treatment is based on allergen avoidance.

El látex o caucho natural es un producto vegetal procesado que se obtiene a partir del árbol tropical Hevea Brasiliensis. Esta materia prima es ampliamente usada, estando presente en hasta 40.000 productos médicos y de uso diario. La alergia al látex es una patología relevante en el ámbito quirúrgico, que surgió posterior a la instauración de las precauciones universales en la década del 90. Dentro de los grupos de riesgo se encuentran trabajadores de la salud y pacientes con espina bífida con una prevalencia que oscila entre 2,9 a 17 por ciento y 30 a 70 por ciento, respectivamente. La presentación clínica de alergia al látex tiene un espectro amplio, pudiendo presentarse como reacciones por hipersensibilidad tipo IV o tipo I. En el primer grupo, las reacciones son gatilladas por los químicos adicionados al látex, siendo la dermatitis alérgica de contacto su presentación más frecuente. En el segundo grupo, las reacciones son secundarias al contacto con proteínas del látex, pudiéndose manifestar desde urticaria hasta shock anafiláctico y muerte. El diagnóstico de alergia al látex se basa en una historia clínica y/o examen físico compatible asociado a un examen confirmatorio, como el prick test (alergia al látex tipo I) y el parche cutáneo (alergia al látex tipo IV). Actualmente no existe una cura definitiva para la alergia al látex y su tratamiento se basa en evitar la exposición al alérgeno.

Manejo preoperatorio de pacientes con enfermedades respiratorias crónicas / Preoperative care of patients with chronic respiratory disorders

Chronic respiratory disease is the 3rd leading cause of death in Chile and its prevalence is increasing significantly in the world, so it is very common that we find patients with these pathologies undergoing elective surgical procedures. Perioperative complications are more frequent in these patients than in the general population, so it is essential adequate preoperative evaluation and management in them. Chronic obstructive pulmonary disease (COPD) is a major predictor of postoperative complications; therefore preoperative bronchodilators and inhaled corticosteroids are indicated in patients with this disease who will undergo elective surgery, particularly related to lung cancer. Likewise, COPD patients who will undergo coronary artery bypass graft surgery (CABG) should receive oral or intramuscular corticosteroids preoperatively. Smoking is an independent risk factor for developing postoperative respiratory complications in thoracic surgery, so patients should stop this habit at least 4 weeks before elective surgery in order to significantly reduce such complications. A poorly controlled asthma is a specific risk factor for developing postoperative pulmonary complications, therefore these patients should be treated preoperatively with inhaled bronchodilators exclusive if they have mild asthma, bronchodilators associated with inhaled corticosteroids in the case of a moderate asthma, and inhaled bronchodilators associated to inhaled and oral corticosteroids, if they have severe asthma.

Las enfermedades respiratorias crónicas son la tercera causa de muerte en Chile y su prevalencia está aumentando significativamente en el mundo, por lo cual es muy frecuente que nos encontremos con pacientes con estas patologías sometiéndose a procedimientos quirúrgicos electivos. En estos casos las complicaciones perioperatorias son más frecuentes que en la población general, por lo cual es indispensable una adecuada evaluación y manejo preoperatorio. La presencia de enfermedad pulmonar obstructiva crónica (EPOC) es un predictor mayor de complicaciones postoperatorias y deben indicarse broncodilatadores y corticoides inhalatorios preoperatorios en pacientes con esta patología que serán sometidos a cirugía electiva, especialmente en la relacionada a cáncer pulmonar. Así mismo, los pacientes con EPOC que se someterán a cirugía de revascularización miocárdica deben recibir además corticoides vía sistémica en el período preoperatorio. El tabaquismo es otro factor de riesgo independiente para desarrollar complicaciones respiratorias postoperatorias en cirugía torácica, por lo que los pacientes deberían suspender el consumo de tabaco por lo menos 4 semanas antes de la cirugía programada con el fin de disminuir significativamente dichas complicaciones. El asma bronquial mal controlada también es un factor de riesgo específico para desarrollar complicaciones pulmonares postoperatorias, por lo cual estos pacientes deben tratarse preoperatoriamente con broncodilatadores inhalatorios, asociados a corticoides inhalatorios u orales según la gravedad del asma.

Obesidad y embarazo: implicancias anestésicas / Obesity and pregnancy: anesthetic implications

La obesidad es una epidemia a nivel mundial, con más de 2.000 millones de adultos con sobrepeso u obesidad, por lo que cada vez es más probable enfrentarse a una embarazada obesa en la práctica clínica del equipo obstétrico. La obesidad incrementa los cambios fisiológicos del embarazo a nivel cardiovascular, respiratorio, metabólico y gastrointestinal, lo que tiene implicancias clínicas que aumentan los costos en salud y la morbimortalidad materna y fetal. Las embarazadas obesas son un constante desafío para el equipo obstétrico, anestesiológico y de salud, debiendo ser enfrentadas de forma multidisciplinaria para la obtención de mejores resultados obstétricos y perinatales. El anestesiólogo debe tener especial cuidado en el manejo analgésico del trabajo de parto y en la técnica anestésica para la operación cesárea. El objetivo central de la siguiente revisión es explicar, analizar y desarrollar las principales implicancias anestésicas a las cuales se ve enfrentado el especialista en una embarazada obesa.

Obesity is a global epidemic, with more than 2,000 million overweight or obese adults, so it is very likely to have an obese pregnant in the clinical practice of the anesthesiologist. Obesity increases the physiological changes of pregnancy in the cardiovascular, respiratory, metabolic and gastrointestinal system, which has clinical implications that increase health care costs and maternal and fetal morbidity and mortality. Obese pregnant are a constant challenge for the obstetric, anesthesiology and health team, and must be considerate in a multidisciplinary way to obtain better maternal and perinatal outcomes. The anesthesiologist should take special care in the labor analgesia and anesthetic technique for caesarean section. The focus of the following review is to present and develop the main anesthetic implications to which the anesthesiologist is confronted in obese pregnant patient.