RESUMEN

A un varón de 55 años con antecedentes de etilismo, hipertensión arterial y obesidad se le diagnosticó un carcinoma epidermoide de tercio medio de esófago. Recibió 2 ciclos de citostáticos con cisplatino y 5-fluorouracilo y debido a su mal estado general y a una disfagia completa para sólidos y líquidos estuvo durante 20 días con nutrición parenteral con una fórmula comercial que carecía de vitaminas y oligoelementos. Se le realizó una esofaguectomía distal; durante la intervención se objetivó una tendencia a la hipotensión y una acidosis metabólica muy intensa que no se justificaba por el cuadro hemodinámico y que continuó durante las primeras 24 horas del postoperatorio. Una vez corregidos estos trastornos se retiró la ventilación mecánica y se comprobaron las siguientes alteraciones neurológicas: desorientación temporoespacial, afasia, oftalmoplejia con estrabismo divergente y posteriormente una afasia de conducción, amnesia y fabulación. Asimismo presentó un estado circulatorio hiperdinámico que precisó inotropos y vasoconstrictores. Fue diagnosticado de síndrome de Korsakoff secundario a encefalopatía de Wernicke, instaurándose tratamiento con tiamina con buena respuesta. El beriberi puede verse en el medio hospitalario y el anestesiólogo puede estar involucrado en el cuidado perioperatorio de estos pacientes. Estos cuadros tienen una fácil solución con el aporte de vitamina B1, preferentemente junto a otras vitaminas hidrosolubles y no debe demorarse el tratamiento porque en caso contrario la morbimortalidad es mucho mayor (AU)

A 55-years-old man with a history of alcoholism, hypertension and obesity was diagnosed of epidermoid carcinoma of the middle third portion of the esophagus. He was treated with two cycles of cytostatics with cisplatin and 5-fluorouracil. Due to his poor general health an inability to swallow solids and liquids, he received parenteral nutrition for 20 days using a commercial formula lacking in vitamins and minerals. During distal esophagectomy we observed a tendency to hypotension and severe metabolic acidosis that was unexplained by the hemodynamic profile and that persisted throughout the first 24 hours after surgery. Once these complications were corrected, he was weaned from mechanical ventilation and the following neurological signs were observed: temporal and spacial disorientation, aphasia, ophthalmoplegia with divergent strabismus and later conduction aphasia, amnesia and confabulation. Circulation was hyperdynamic, requiring inotropics and vasoconstrictors. Korsakoff syndrome secondary to Wernicke's encephalopathy was diagnosed, and the response to thiamine treatment was favorable. Beriberi can be found in hospitalized patients and the anesthesiologist may be involved in their perioperative care. Symptoms resolve easily with vitamin B1 treatment, which is ideally provided along with other hydrosoluble vitamins. Treatment should be prompt because delay leads to greater morbiomortality (AU)

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RESUMEN

A 55-years-old man with a history of alcoholism, hypertension and obesity was diagnosed of epidermoid carcinoma of the middle third portion of the esophagus. He was treated with two cycles of cytostatics with cisplatin and 5-fluorouracil. Due to his poor general health an inability to swallow solids and liquids, he received parenteral nutrition for 20 days using a commercial formula lacking in vitamins and minerals. During distal esophagectomy we observed a tendency to hypotension and severe metabolic acidosis that was unexplained by the hemodynamic profile and that persisted throughout the first 24 hours after surgery. Once these complications were corrected, he was weaned from mechanical ventilation and the following neurological signs were observed: temporal and spacial disorientation, aphasia, ophthalmoplegia with divergent strabismus and later conduction aphasia, amnesia and confabulation. Circulation was hyperdynamic, requiring inotropics and vasoconstrictors. Korsakoff syndrome secondary to Wernicke's encephalopathy was diagnosed, and the response to thiamine treatment was favorable. Beriberi can be found in hospitalized patients and the anesthesiologist may be involved in their perioperative care. Symptoms resolve easily with vitamin B1 treatment, which is ideally provided along with other hydrosoluble vitamins. Treatment should be prompt because delay leads to greater morbiomortality.

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Un paciente de 72 años fue sometido a resección de aneurisma de aorta infrarrenal y en el postoperatorio presentó un cuadro de fallo multiorgánico secundario a microembolismos de colesterol en múltiples arterias. Inicialmente se manifestó por livideces en miembros inferiores con pulsos pedios conservados, orinas hematúricas y un shock hiperdinámico con gastos cardíacos elevados y resistencias vasculares disminuidas; posteriormente, evolucionó hacia una disfunción multiorgánica con edema de pulmón no cardiogénico, fallo renal oligúrico, coagulopatía, pancreatitis necrosante e isquemia cólica. Falleció 15 días después de la intervención quirúrgica. El embolismo múltiple de colesterol es una complicación poco frecuente tras cirugía aórtica, cateterización vascular o tratamientos anticoagulantes; es producido por cristales de colesterol de 100 a 200 µ de tamaño que embolizan y ocluyen arterias de pequeño tamaño. Su diagnóstico clínico es difícil porque los órganos afectados pueden ser múltiples y muy variados; no tiene un tratamiento específico, por lo que la morbimortalidad es elevada (AU)

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A 72-year-old man underwent resection of an infrarenal aortic aneurysm; during postoperative recovery, multiorgan failure developed secondary to cholesterol emboli in several arteries. The initial sign consisted of patches of livedo in the lower limbs with pedal pulses, hematuria and hyperdynamic shock with high cardiac output and reduced vascular resistance. The clinical picture progressed to multiple organ failure with non-cardiogenic pulmonary edema, oliguric kidney failure, coagulopathy, necrotizing pancreatitis and colic ischemia. The patient died 15 days after surgery. The formation of multiple cholesterol emboli is a rare complication after aortic surgery, vascular catheterization or anticoagulant treatment. It is caused by cholesterol crystals measuring 100 to 200 mu that embolize and block small arteries. Diagnosis is difficult because the organs involved can be many and various. No specific treatment is available and the rates of morbidity and mortality are high.

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The case of a patient who developed acute pancreatitis following resection of a ruptured aneurysm of the abdominal aorta is presented. During the first postoperative days the patient evolved satisfactorily except for specific abdominal symptoms. On the sixth day the patient suddenly presented tachycardia, hypotension, increase in abdominal distension and anemia for which emergency laparotomy was performed with signs of diffuse peritoneal steatonecrosis with an increase in the size and inflammation of the pancreas with necrotic and hemorrhagic zones being observed. The patient developed multiorganic failure and died at 18 days later. In this case, as in others described in the literature the beginning was uneventful. Only the determination of amylase and/or lipase, and the performance of abdominal CAT when these are increased, may be useful to obtain early diagnosis.

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A case of severe prolonged neurological deficit following inadvertent spinal anesthesia is presented. Intradural block occurred after a test dose of Bupivacaine and vasoconstrictor when inserting an epidural catheter for post-thoracotomy pain-relief treatment. The likely triggering and etiological factors responsible for the neurological damage after spinal anesthesia were studied and evaluated, mainly those toxic and traumatic. Special mention of the local anesthetics and sodium bisulfite used is made. Preventive measures for this sort of complication are suggested.

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