Síndrome de abstinência de ropivacaína: relato de caso

Introduction and objectivesRopivacaine is a long‐acting local anesthetic that causes prolonged anesthesia and is beneficial for a wide variety of surgeries. Systemic toxicity has been reported after usage of high dose ropivacaine or inadvertent intravascular administration. We report a case of ropivacaine withdrawal, which to our knowledge has not been previously described in the literature.Case reportThe patient presented to our department with uncontrolled belt‐like upper‐abdominal pain, self‐rated as a 9/10 on the numeric rating scale. We decided to use continuous epidural analgesia with ropivacaine through a multi‐port epidural catheter. Pain was well controlled for one month without significant adverse effects. However, ropivacaine unexpectedly ran out and two hours later the patient developed agitation, generalized tremor, tachycardia, and tachypnea. These symptoms resolved 30 minutes after reinitiating epidural ropivacaine.DiscussionOur hypothesis of ropivacaine withdrawal was related to the timing of symptoms in relation to drug administration over two episodes. The possible mechanism of the observed withdrawal syndrome is upregulation of voltage‐gated sodium channels after prolonged inhibition, resulting in increase in sodium influx and genetic variation.     

Anestesia geral para Síndrome de Crisponi: relato de caso

Crisponi syndrome is a rare and severe heritable disorder characterised by muscle contractions, trismus, apnea, feeding troubles, and unexplained high fever spikes with multiple organ failure. Here we report perioperative care for endoscopic gastrostomy of a 17 month‐old female child with Crisponi syndrome. Temperature in the surgery room was strictly monitored and maintained at 19 °C. The patient was exposed to both inhaled and intravenous anesthetic agents. Surgical and perioperative periods were uneventful. Episodes of fever in Crisponi syndrome arise from CRLF1 mutation, which differs from the physiological pathway underlying malignant hyperthermia.     

Sialometria: Aspectos de interesse clínico

Whole saliva is a multiglandular secretion complex consisting of gingival fluid, desquamated epithelial cells, microorganisms, products of bacterial metabolism, food debris, leukocytes mu- cus from the nasal cavity and the pharynx. Saliva has many functions, including tissue repair, tamponage, protection, digestion, taste, antimicrobial action, maintaining tooth integrity and antioxidant defense system. A decrease in salivary flow (hyposalivation) is a common disorder and it is estimated that approximately 20% of the general population have this alteration.Hyposalivation may be due to diabetes mellitus, hypothyroidism, dehydration, impaired glan- dular parenchyma by infectious processes, granulomatous diseases or autoimmune and in- flammatory conditions (such as Sjögren's syndrome and rheumatoid arthritis), radiotherapy of head and/or neck region, or it may be associated with mood disorders, adverse effects caused by the use of some medications or even be idiopathic. Conventional therapies for the treatment of reduced saliva flow with the use of chemical and gustatory secretagogues are still limited. However, new alternatives have shown great perspective in the treatment of this disorder. To diagnose a patient as having chronic hyposalivation is a challenge in clinical practice and methods of salivary flow assessment are little known by rheumatologists. The serial evalua- tion of salivary flow is important for the diagnosis and prognosis of certain oral and systemic conditions. This review addresses some aspects related to the role of saliva, the consequenc- es of hyposalivation and methods of salivary flow rate measurement, useful concepts in the daily practice of rheumatology.     

Bloqueo BRILMA para extirpación de cartílago costal: caso clínico

The block of the lateral branches of the intercostal nerves in the middle axillary line (BRILMA) is an interfascial ultrasound-guided block for analgesia in thoracic wall and upper abdominal surgery, presenting as an adequate alternative to neuraxial techniques. We present the case of a 49-year-old female scheduled for idiopathic subglottic stenosis repair with a costal cartilage graft from the 10^th rib and tracheotomy. At the end of the surgery, unilateral ultrasound-guided BRILMA block with 20 ml of ropivacaine 0.2% was performed at the level of the 6^th rib, uneventfully. Postoperatively, the patient referred a maximum level of pain of 3/10. There was no opioid consumption after the 2^nd postoperative day, although a subcostal incision may produce considerable pain. BRILMA is a superficial block, easily reproducible in most patients. It diminishes the number of punctures needed in the thoracic wall, as well as the risk for pneumothorax and local anesthetic toxicity.     

Trombose de seios durais após analgesia peridural para parto: caso clínico

Background and objectives

Neurological complications of spinal anesthesia are rare conditions. Headache caused by low pressure of the cerebrospinal fluid is one of the most frequent, which occurs after post‐dural puncture. A comprehensive history and physical exam must be carried out before making the diagnosis of Post‐Dural Puncture Headache (PDPH) and additional tests are necessary to exclude the possibility of developing serious neurological complications such as Dural Sinus Thrombosis (DST). According to the Case Report a differential diagnosis between Dural Sinus Thrombosis with PDPH is discussed.

Quemadura por clorhexidina alcohólica. Exposición de caso clínico

Surgical wound infection is one of the main sources of postoperative morbidity/mortality. Skin preparation with an antiseptic agent such as chlorhexidine alcohol solution is an effective method to reduce the incidence of surgical wound infections. Nevertheless, the use of alcohol solutions is associated with some risk as they are inflammable products. We report a case of a 51-year-old male who suffered an extensive burn associated with concurrent use of electrocautery and clorhexidine alcohol solution.     

Hematoma subdural intracraneal tras punción dural accidental: caso clínico

Intracranial subdural hematoma is a rare, but potentially lethal complication of neuraxial procedures. Considering the high frequency of neuraxial techniques in the obstetric population, parturients are more susceptible to this fearful complication. The diagnosis is often masked and delayed because it shares similar clinical characteristics with posdural puncture headache, with headache being the most common symptom. This case report describes a timely diagnosis and successful management of an intracranial subdural hematoma, after unintentional dural puncture during labour epidural analgesia. Postpartum headache following epidural analgesia, remains a clinical challenge for the caring team, requiring a close follow-up and awareness for non-benign causes that require prompt management, avoiding devastating consequences.     

Hernia vesical inguinoescrotal gigante. caso clínico y revisión de la literatura

Bladder hernia is an uncommon condition with a frequency between 0,5 and 3%, reaching the 10% between patients older than 50 years. It´s more predominant in males aged between 50 and 70. The diagnosis usually happens in the course of surgical repair of inguinal hernias, because the bladder hernia has no specific clinical findings. Management includes the resection or reduction of the bladder hernia, with de-obstruction of the lower urinary tract, if present, and repairmen of inguinal path. We report a new case and review the literature     

Vía aérea difícil en paciente con linfoma. Descripción de un caso clínico

A 86-year-old male patient, diagnosed with lymphoma, was scheduled for a submaxillectomy to choose his best chemotherapy treatment. He referred recent voice changes and laterocervical adenopathies without respiratory symptoms. There were no additional risk predictors in preoperative airway assessment. Following anaesthesic induction, an upper airway obstruction occurred. After that, an unexpected difficult airway was encountered. Both clinical situations resulted in unpredicted difficult airway management. Image tests seen after the procedure revealed a severe narrowing of parapharyngeal space due to Waldeyer's ring hypertrophy. This medical condition had remained unnoticed in preoperative assessment.Advanced lymphoproliferative syndromes cause disseminated adenopathies whose parapharyngeal involvement can lead to a difficult airway even in the absence of preoperative risk predictors.     

Mastectomía libre de opioides bajo anestesia-analgesia epidural torácica en un paciente con estenosis traqueal crítica: caso clínico

Mastectomy is traditionally performed under general anaesthesia and invasive ventilation, and is often complemented with regional techniques. In this setting, tracheal stenosis can pose a challenge to airway management. The aim of this report is to describe the successful management of a 68-year-old woman with severe subglottic tracheal stenosis undergoing mastectomy due to breast cancer. Surgery was performed without airway instrumentation under an opioid-free regimen consisting of thoracic epidural, propofol and dexmedetomidine perfusion, and non-opioid analgesics. Spontaneous ventilation and adequate perioperative analgesia were achieved. Opioid-free anaesthesia without airway instrumentation, consisting of thoracic epidural anaesthesia and sedation, is a good alternative in patients undergoing mastectomy in whom airway manipulation is best avoided.     

Tamponamento cardíaco: uma complicação rara da cateterização venosa central – relato de um caso clínico

The extensive use of central venous catheters (CVC) in a hospital environment leads to increased iatrogenic complications, as more catheters are used enclosed and its maintenance is prolonged. Several complications are known to be related to central venous catheter, of which the uncommon cardiac tamponade (CT), hardly recognized and associated with high mortality.We present a clinical case, with favorable outcome, of a patient who developed a CT 17 days after CVC placement, and try to reflect on the measures that can be taken to reduce its incidence, as well as the therapeutic approaches to practice in the presence of a suspected CT.     

Síndrome neuroléptico maligno en paciente postoperada: a propósito de un caso

Neuroleptic malignant syndrome is a rare medical emergency associated with the use of antipsychotics and other antidopaminergic drugs. There is no specific test, and diagnosis is based on high clinical suspicion and good differential diagnosis.A clinical picture consistent with hyperthermia, muscle rigidity, altered level of consciousness, together with signs of rhabdomyolysis in analytical studies and a history of taking neuroleptic drugs are the key elements in the detection of this entity.Due to its low incidence and potential mortality, it is essential to publish case reports of neuroleptic malignant syndrome in order to raise awareness of this entity and facilitate diagnostic suspicion when encountering a patient with compatible symptoms.The following is the case of a 79 year old patient with chronic alcohol consumption as the only history of interest, who was given a single dose of haloperidol after an episode of delirium in the postoperative period of conventional trauma surgery. She subsequently developed a picture of progressive deterioration of the level of consciousness, diaphoresis, generalized muscle rigidity, hyperthermia, together with severe metabolic acidosis, hyperlacticaemia, rhabdomyolysis, hypertransaminasemia and hypocalcemia. After ruling out other entities compatible with the clinical picture, neuroleptic malignant syndrome was given as the main diagnostic hypothesis. Diagnosis was confirmed after clinical and analytical improvement following treatment with dantrolene. The patient was discharged from hospital with no sequelae a few days after onset of the condition.     

Manejo anestésico en neurocirugía de paciente con síndrome de Eisenmenger y síndrome de Down. Reporte de un caso

Adults patients with congenital heart disease increasingly present for non cardiac surgery. The anesthetic management this type of patients in neurosurgery requires a meticulous surgical anesthetic planning. The need for urgent intervention, with the presence of a congenital heart disease evolved to Eisenmenger Syndrome, associated to a difficult airway, is a challenge for the anesthesiologist. The use of dexmedetomidine may be a valid alternative. We present the case of a patient with Down syndrome, and Eisenmenger syndrome who underwent drainage of brain abscess from the emergency department and was subsequently scheduled for reintervention. We compare the different anesthetic techniques used in both procedures, analyzing the implications they had on the main physiopathological alterations presented by the patient.     

Infusión accidental de cloruro de potasio a través de un catéter epidural para analgesia postoperatoria: reporte de caso clínico

An infusion of 100 cc of 0,2% potassium chloride was accidental performed through a thoracic epidural catheter, inserted to perioperative analgesia, to a 66 years old man who was scheduled for right hemicolectomy, 48 hours after surgery. Paresis of upper limbs, flaccid paralysis of lower limbs and a sensitive level at T8 was observed. An epidural lavage with an initial dose of 20 cc of saline was slowly injected, followed for a saline infusion of 20 cc per hour. Neurologic signs were totally reverted some hours later and 24 hours after the incident the physical exam was normal. We reviewed the clinical presentation of the complication and its mechanisms, the more frequent clinical evolution, as well as treatment measures and strategies to prevent the incident.     

Anestesia para cesárea em gestante com síndrome de Cockayne: relato de caso

Cockayne syndrome is an autosomal recessive multi‐systemic disorder due to DNA repair failure. It was originally described in 1936 in children of small stature, retinal atrophy and deafness, characterized by dwarfism, cachexia, photosensitivity, premature aging and neurologic deficits. The most typical feature is described as birdlike facies: protruding maxilla, facial lipoatrophy, sunken eyes, large ears and thin nose. Difficult airway management with subglottic stenosis and risk of gastric content aspiration has been described. Although the clinical characteristics of Cockayne syndrome have been well described in pediatric publications, there is only one report in the literature on anesthesia for an obstetric patient. We report the case of a pregnant patient diagnosed with Cockayne syndrome, submitted successfully to spinal anesthesia for a cesarean section due to cephalopelvic disproportion. In view of the difficult decision between inducing general anesthesia in a patient with a likely difficult airway, or neuraxial anesthesia in a patient with cardiovascular, respiratory and neurocognitive limitations, we suggest tailored management to reach the best results for the mother and newborn.