Continuous thoracic paravertebral analgesia after minimally invasive atrial septal defect closure surgery in pediatric population: Effectiveness and safety analysis.

INTRODUCTION: Lateral thoracotomy is replacing traditional median sternotomy for atrial septal defect (ASD) closure in children in order to improve cosmetic outcomes. Continuous paravertebral block has been described as an effective and safe analgesic technique in children. The aim of this study is to assess pain management by continuous perfusion of local anesthetic through a thoracic paravertebral catheter (PVC) in a pediatric population after thoracotomy closure of ASD, and its effectiveness in a fast-track program. METHODS: Descriptive cross-sectional study. Analgesic effectiveness, perioperative and safety-related data were analyzed in 21 patients who underwent thoracotomy closure of ASD with PVC. In the postoperative period, patients received continuous perfusion of bupivacaine 0.125% and fentanyl (1 mcg.ml-1) at 0.2 ml.kg-1.h-1 through the PVC. RESULTS: The median of mean pain scale score for each patient was 1.5. All patients were extubated in the operating theatre. No patient with PVC required opioid rescue. The median length of stay in the Pediatric Intensive Care Unit was 48 hours. There were 3 adverse events related to PVC: 1 due to malposition and 2 due to accidental removal. No other complications or cases of local anesthetic toxicity were recorded. CONCLUSIONS: PVC provides effective, safe, opioid-saving analgesia in the postoperative period of ASD closure by thoracotomy in the context of a fast-track protocol.

[Diagnostic strategy for mitochondrial diseases]. / Estrategia diagnóstica de las enfermedades mitocondriales.

OBJECTIVE: The variability of both phenotypic and genotypic expression in mitochondrial diseases makes clinical diagnosis difficult, which is essential to establish therapy, aid in genetic counselling or for performing prenatal diagnosis. We have therefore proposed a strategy to help determine correct diagnosis of these alterations, in an attempt to rationalize the number of tests and, whenever possible, avoid tissue biopsy and minimize the size of the biopsy when indicated. DEVELOPMENT: Based on mitochondrial metabolism and molecular bases, as well as their alterations, a preliminary metabolic examination is carried out including at least one study of cytoplasmatic (lactate/pyruvate) and mitochondrial oxide reduction (hydroxibutirate/acetoacetate) in basal conditions or, if required, following glucose overload or an effort test. Metabolic study, in addition to clinical exploration, are the screening tests used to determine the need for tissue biopsy in which biochemical (pyruvate dehydrogenase, free and total carnitine, beta oxidation enzymes and respiratory chain complexes), genetic (mitochondrial DNA or nuclear alterations) and histologic tests are carried out to confirm diagnosis. CONCLUSIONS: a) Metabolic exploration may discard mitochondrial disease and many cases, avoid the use of an invasive procedure such as tissue biopsy. b) Biochemical study of tissue biopsy is the only useful key in the confirming of the diagnosis when no mitochondrial and/or nuclear DNA are observed.

[Glomus jugulare tumor: perioperative management]. / Tumor glómico yugular: manejo perioperatorio.

Surgical treatment of glomus jugulare tumors yields high rates of perioperative morbidity and mortality for several reasons, among them neuroendocrine secretory activity, a high degree of vascularization, intracranial extension, duration of surgery and cranial nerve lesion. Secretory activity (e.g. catecholamines and serotonin) should be investigated before surgery and treated appropriately. Carotid arteriography (and ball occlusion) are useful to assess vascularization of the tumor and determine the need to clamp the carotid artery during the procedure. Potential complications such as hemodynamic alterations (bleeding or endocrine response), pulmonary embolism (air or thrombotic), hypothermia, facial nerve lesion, should be monitored for during surgery. After surgery cranial nerve involvement, which can lead to dysphagia and bronchoaspiration, must be looked for; the risk of cerebro-spinal fluid fistula is also high. We report the case of a woman who underwent surgery for a non secreting glomus jugulare tumor with extradural intracranial invasion. The main complications during surgery were bleeding with hemodynamic repercussions, pulmonary embolism, lesions in the VII, VIII and X cranial nerves, and opening of the dura mater (which required insertion of an intradural drain to prevent formation of a fistula). After surgery oral intake was delayed until intestinal function was established and glottic sphincter competence was verified by fiberoptic laryngoscopy. The only complication presenting at this time was cephalea, which disappeared upon removal of the drain on day 4. The patient was released on day 10.

Effects of preweaning environmental stimulation on neuronal and behavioral impairment produced by undernutrition.

The present study investigates the effects of sensorimotor stimulation on the basal dendrogenesis of superficial cerebrocortical neurons and the accomplishment in the associated exploratory behavior in rats simultaneously exposed to nutritional deprivation. Sprague-Dawley albino rats were submitted to nutritional-environmental influences from birth to the 21st postnatal day. Exploratory behavior was assessed by the evaluation of locomotor activity in the open-field apparatus. In order to evaluate changes in neuronal morphology induced by nutritional-environmental variables, brains were stained according to the Golgi-Cox-Sholl procedure. Dendritic development was assessed under camera lucida by measuring basal dendritic branching of layer II and III pyramidal neurons, located in the dorsomedial region of the visual cortex of the rat. Morphometrical analysis revealed that both basal dendritic length and branching were significantly reduced by undernutrition. In contrast, environmental stimulation during the suckling period compensated for the neuronal impairment produced by protein-calorie deprivation. An improvement was also observed in exploratory behavior although to a lesser degree, as shown by the open field test data. In conclusion, the present results indicate that sensorimotor stimulation applied during the period of fastest rate of cortical cytodifferentiation compensates for neuronal and behavioral impairment produced by undernutrition.

Purkinje cell impairment induced by early movement restriction.

In the present work the effects of movement restriction imposed during the early postweaning period on both Purkinje cell dendritic development and exploratory behavior were analyzed. Male and female Sprague-Dawley albino rats were reared either in isolated-restricted or social-standard environments from postnatal day 18 to 30. On the 31st postnatal day, all rats were behaviorally evaluated by the open-field test and then sacrificed under deep ether anesthesia. Vermian cerebellar sections were later stained with the Golgi-Cox-Sholl method and the Purkinje cell dendritic morphology was quantified under light microscopy. The results indicate that early somatomotor restriction severely impairs both exploratory behavior and Purkinje cell dendritic growth.