[Peridural anesthesia for subcostal cholecystectomy in patients with dilated cardiomyopathy. Apropos of 2 cases]. / Anestesia peridural para colecistectomía subcostal en pacientes con miocardiopatía dilatada. A propósito de dos casos.

Two patients with dilated cardiomyopathy (DCM) were considered to be at high risk for anesthesia and surgery due to possible complications during and after surgery. The anesthetic technique used in such cases must be selected based on the type of surgery and the severity of heart disease. We describe the cases of 2 patients with histories of DCM, arising in a context of alcohol use in one case and of ischemia in the other. The patients were scheduled for uncomplicated cholecystectomy by subcostal approach under epidural anesthesia. The patients remained hemodynamically stable during surgery and there were no complications. They were released 26 and 13 days after surgery, respectively. We conclude that epidural anesthesia is a valid alternative to general anesthesia in DCM patients undergoing subcostal cholecystectomy.

[Study of presurgical anxiety in urologic, gynecologic, and ophthalmologic surgery as a function of the administration or non-administration of anxiolytic premedication]. / Estudio de la ansiedad prequirúrgica en cirugía urológica, ginecológica y oftálmica en relación con la administración o no de premedicación ansiolítica.

OBJECTIVE: Anxiety commonly appears before surgery, triggering a set of events that can be described as a general stress response. We measured changes in preoperative stress in relation to premedication or not with diazepam in patients undergoing urologic, gynecologic and ophthalmologic surgery. PATIENTS AND METHOD: We enrolled 87 patients undergoing elective surgery in urology (n = 30), gynecology (n = 30) and ophthalmology (n = 27). Randomly, the patients were premedicated with diazepam, placebo or nothing. During the preoperative visit the patient was administered a test to determine the level of anxiety and blood pressure, heart rate and potassium plasma concentration (K+) the night before surgery and moments before entering the operating theater. RESULTS: No significant differences in anxiety between patients undergoing different types of surgery were detected in the operating theater; however, at that time, anxiety was found to be significantly less among patients premedicated with diazepam than among those given placebo. Preoperative anxiety was significantly less in ophthalmology patients and in those premedicated with diazepam. Both systolic and diastolic blood pressure increased significantly among urologic and ophthalmologic surgery patients and in those who were not premedicated with diazepam regardless of type of surgery. Heart rate did not change significantly. Potassemia decreased significantly in all patients. CONCLUSION: The discrepancy between the psychological and somatic response to the stress conditions studied may be the result of the calming effect of the preoperative visit by the anesthesiologist and to premedication with a tranquilizer. However, neither the preoperative visit nor premedication seem to completely block the stress response.

[Laparoscopic resection of hepatic hydatid cyst under general anesthesia with remifentanil infusion]. / Resección de quiste hidatídico hepático por laparoscopia bajo anestesia general con perfusión de remifentanilo.

We report the case of a 52-year-old woman who underwent scheduled laparoscopic resection of a hydatid liver cyst under general anesthesia by infusion of remifentanil and sevoflurane. Surgery was uneventful, although invasive monitoring was required, just as it would have been in major open abdominal surgery, given the risk of bleeding secondary to organ manipulation, the risk of anaphylactic shock related to the etiology of the cyst and the possibility of gas embolism related to laparoscopy. The concept of "minimally invasive" surgery has developed thanks to continued progress in laparoscopy. The considerable advantages of such procedures in comparison with "open" or "conventional" surgery has led to their use with organs such as the liver, which in principle require caution. In such cases, the anesthesiologist must take an approach that is not as simple or minimalist as the term "minimally invasive" might lead us to expect.

[Learning cardiopulmonary resuscitation using conventional external cardiac massage or active compression-decompression in simulated cardiopulmonary resuscitation]. / Aprendizaje de la reanimación cardíaca mediante masaje cardíaco externo convencional o compresión-descompresión activa en reanimación cardiopulmonar simulada.

OBJECTIVE: To compare medical students' simulated learning of two different techniques of cardiopulmonary resuscitation (CPR). One was conventional external cardiac massage (ECM) and the other was active compression-decompression (ACD-CPR). MATERIAL AND METHODS: The study group (group S) comprised 111 students enrolled in their fourth year of medical studies who had no prior experience of CPR. Group R, the control group, was made up of 32 medical residents in anesthesiology and post-anesthetic intensive care. Before the study, group S received 5 hours of theoretical classes on CPR and both groups saw a video explaining each technique just before performing the test. All subjects applied each method to an adult dummy for one minute. The variables evaluated were frequency of complete and effective thoracic compressions and the body weight of the resuscitator. RESULTS: Each group performed similarly using the two techniques in terms of frequency of total compressions achieved. For each technique, the number of effective compressions achieved by group S (49.4 +/- 22.9 with ECM and 42.5 +/- 20.7 with ACD-CPR) was significantly lower (p < 0.05) than the number attained by group R (71.2 +/- 18.6 with ECM and 58.8 +/- 12 with ACD-CPR). Group R's frequency of effective compressions was significantly higher (p < 0.05) with CPR than with ACD-CPR. Body weight had no influence on the number of total compressions or efficacy in group R, whereas lower body weight in group S was significantly related to lower frequency of effective compressions with ECM p < 0.05). Neither group achieved a frequency of 80 total compressions in one minute. CONCLUSIONS: With the present teaching method, the medical students' performance was poor for both types of CPR and was affected by body weight. The residents' performance was less effective with ACD-CPR, a technique that was new to them, than with conventional ECM, with which they were expert and on which body weight had no impact.

[Abdominal aortic injury as a complication of laparoscopic cholecystectomy]. / Lesión de la aorta abdominal como complicación de la colecistectomía laparoscópica.

A 58-year-old woman with a history of high blood pressure and cesarean section by median laparotomy underwent elective laparoscopic cholecystectomy under general anesthesia. After initiation of pneumoperitoneum, hemodynamic instability developed (blood pressure 75/40 mm Hg, heart rate 47 beats/min) and resolved after volume replacement and administration of vasoactive drugs. The rest of the procedure was completed without further adverse events. After extubation, the patient was transferred to the anesthetic recovery ward, where she tended to hypotension that was unresponsive to volume replacement, with a hematocrit of 18% and hemoglobin concentration of 6.9 g/dL. Hemoperitoneum was suspected, and an emergency median laparotomy revealed 300 cc of blood in the peritoneal cavity, a large hematoma putting pressure on retroperitoneal structures, and 2 infrarenal aortic lesions (anterior and posterolateral). During the reoperation the patient required multiple transfusions and vasoactive drugs to maintain hemodynamic stability. Recovery in the postanesthetic care unit was uneventful. After transfer to the ward, on the 20th day after surgery she developed septic shock with intraabdominal fluid requiring surgical drainage and admission to the intensive care unit. Abdominal aortic injury during laparoscopic surgery usually occurs upon introduction of trocars for initiating pneumoperitoneum. The technique must be performed correctly and monitored properly to assure early detection of adverse events associated with high mortality.

[Epidural hematoma after catheter removal in a patient without coagulation disorders]. / Hematoma epidural tras la retirada de un catéter a un paciente sin transtornos de la coagulación.

A 69-year-old man with rectal adenocarcinoma and no relevant medical history was scheduled for anterior resection of the tumor under combined anesthesia. The epidural catheter was removed 48 h after surgery. A clinical picture consistent with a diagnosis of epidural hematoma developed gradually and was confirmed by magnetic resonance imaging. The last dose of low molecular weight heparin had been administered 8 h before catheter removal and blood analyses were normal. Recovery was complete following laminectomy and evacuation of the hematoma 31 h after the onset of symptoms. Our analysis of the literature on conditions leading to epidural hematoma after catheter insertion revealed that complications may appear for unknown reasons even when catheter management and thrombolytic prophylaxis are appropriate. Nevertheless, the maneuver for removing an epidural catheter is clearly not risk-free and can cause complications. Monitoring after removal is therefore important if complications are to be detected early.

[Spontaneous closure of a intracraneal dural arteriovenous fistula by controlled hypotension during a general anesthesia procedure. A case report]. / Cierre espontáneo de fístula arteriovenosa dural intracraneal tras hipotensión controlada bajo anestesia general. A propósito de un caso.

Intracranial dural arteriovenous fistulas (DAVF) are arteriovenous communications within the duramater, which seem to be pathophysiologically related to a venous sinus thrombosis. DAVF may require invasive treatment, although rarely spontaneous occlusion has been reported. The present case is a 48-year-old male with a diagnosed type III DAVF of the right lateral sinus. Complete endovascular embolization was not possible to perform, so he was considered a candidate for surgical treatment. During perioperative management, under general anesthesia, the intraoperative arteriographyc monitoritation showed a spontaneous closure of the DAVF after induced controlled hypotension, resulting in complete cure. We conclude that controlled hypotension could become an alternative for treatment of DAVF in high risk patients or when there is no chance for embolization.patients or when there is no chance for embolization. Neurología 2003;18(10):746-749