Pregnancy and partum in the woman with a spinal cord lesion in chronic phase

A 34-year-old pregnant paraplegic woman with a T12 medullary lesion in chronic phase underwent cesarean delivery in the thirty-seventh week due to pelvic-cephalic disproportion. After failure of epidural anesthesia related to technical difficulties, general anesthesia was provided. A hypertensive crisis developed during surgery but was resolved within minutes after administration of hydralazine. No further complications arose. Pregnancy in a patient with medullary lesion in chronic phase is considered high risk, requiring special care due to extraordinary changes in pathophysiology caused by the lesion in addition to changes directly related to gestation. The main complications that arise are decreased respiratory volume and arterial pressure, increased incidence of thromboembolic events, anemia, urinary tract infections, premature birth, unusual progression of delivery and autonomic hyperreflexia, which is the most serious. When a hypertensive peak develops in such patients, the anesthesiologist must first rule out autonomic hyperreflexia, which has an incidence of 85% in lesions over T7 and has also been described in patients with lower lesions.     

Fastrach laryngeal mask, sevoflurane and remifentanil: an anesthetic alternative for the myasthenic patient

A 46-year-old myasthenic man diagnosed two months earlier and experiencing nocturnal dyspnea was scheduled for transsternal thymectomy. The patient was premedicated with midazolam in the operating room. Anesthetic induction and maintenance were with inhaled sevoflurane and an intravenous infusion of remifentanil, with no need for neuromuscular relaxants. Airway management was achieved by inserting a Fastrach laryngeal mask (LM-Fastrach), through which an endotracheal tube could be inserted easily. The tube was withdrawn through the mask at the end of surgery and the mask was removed in the operating room 6 minutes later. Anesthesia in patients with myasthenia gravis is one of the greatest challenges in clinical anesthesiology. The interest of this case lies mainly in that the anesthetic technique chosen allows neuromuscular relaxants to be avoided. Moreover, airway access through the Fastrach laryngeal mask is highly useful for transsternal thymectomy of the patient with myasthenia gravis, providing immobility and adequate hemodynamic stability during sternotomy as well as facilitating safe and rapid postanesthetic recovery.     

Cerebrospinal fluid drainage and deep systemic hypothermia with total absence of circulation for spinal cord protection during surgery on the thoracic aorta

A 53-yearold man with a dissecting aneurysm of Stanford's type-B or Crawford's type I measuring 8.5 cm in diameter underwent replacement of the distal descending aorta and the thoracic aorta using techniques for spinal cord protection involving deep hypothermia at 17 degrees C and lasting 38 minutes with total absence of circulation. A subarachnoid catheter was inserted at the lumbar level to monitor spinal fluid pressure as well as to provide drainage if pressure exceeded 10 mm Hg. During surgery 60 ml was drained, followed by 95 ml after surgery on the same day and 325, 262 and 169 ml on the following three days.No signs of neurological deficit were observed during the postoperative period. Clinical course was good until hypovolemic shock developed 27 days after the operation due to upper digestive tract bleeding caused by two duodenal ulcers that perforated the gastroduodenal artery. Emergency antrectomy and vagotomy were performed. The patient died from multiple organ failure.Spinal cord injury continues to be one of the most feared complications after excision of thoracic and thoracoabdominal aorta aneurysm. Currently, various ways of protecting the spinal cord are practiced, including drainage of cerebrospinal fluid, partial bypass of the femoral artery, intercostal artery reimplantation, drug therapy and local spinal and/or systemic hypothermia. These methods, together with shorter clamping time have achieved a reduction in the incidence of spinal cord injuries.     

Preoperative testing routines for healthy, asymptomatic patients in the Canary Islands (Spain)

OBJECTIVES: To analyze patterns of routine testing before elective/scheduled surgery in healthy/asymptomatic patients classified as ASA I or II according to the American Society of Anesthesiologists. MATERIAL AND METHOD: A questionnaire on the organization of preoperative testing was completed by anesthesiologists at five public hospitals in the Canary Islands. The questionnaire emphasized the most commonly ordered screening procedures, such as chest X-rays, electrocardiograms, laboratory tests and spirometry. RESULTS: Red cell counts were most frequently requested (for 86% of the patients), followed by platelet counts (80%) and blood chemistry (75%) and coagulation studies (72%). Least requested were urine tests and spirometry. The frequencies of electrocardiogram and chest X-ray requests fell between the two extremes, with patient age and the presence of certain indications seeming to affect whether those tests would be ordered or not. The need for such screening was perceived to increase for patients over 40 years of age. The ordering of preoperative tests varied from hospital to hospital and among anesthesiologists at a single site in spite of established protocols. CONCLUSIONS: Hospitals and individual anesthesiologists differ considerably in how they request preoperative tests. The variations can not be explained solely by differing patient needs given that respondents were contemplating only healthy/asymptomatic individuals undergoing relatively simple procedures.     

External progressive ophthalmoplegia secondary to mitochondrial myopathy. Report of a case and review of the literature

Progressive limitation of occular motility, accompanied by ptosis but usually without diplopia, occurs in many pathologic states, including mitochondrial diseases. A case with chronic progressive external ophthalmoplegia with onset during childhood, associated with proximal myopathy and dysphasia is presented. The muscle biopsy showed a myopathic pattern and abnormal subsarcolemmal mitochondrial deposits. Muscle biopsy for important in the correct diagnosis of this entity.