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Resumen: Introducción: la osteogénesis imperfecta es un trastorno sistémico del tejido conectivo, se caracteriza por una densidad ósea menor y variabilidad de la fragilidad ósea. Material y métodos: se realizó un estudio retrospectivo, observacional, descriptivo de casos consecutivos, cuyo objetivo principal fue determinar las complicaciones relacionadas al procedimiento anestésico en pacientes pediátricos con diagnóstico de osteogénesis imperfecta sometidos a procedimientos ortopédicos en el Hospital Infantil de México «Federico Gómez¼ mediante la revisión de expedientes clínicos. Se incluyeron pacientes con diagnóstico de osteogénesis imperfecta, menores de 18 años, sometidos a cirugía ortopédica electiva. Se utilizaron medidas de tendencia central y dispersión así como pruebas de hipótesis diversas. Resultados: se incluyeron 86 registros anestésicos. La mayoría del tipo III de osteogénesis imperfecta. La anestesia general balanceada fue la técnica más frecuente con intubación orotraqueal. De las complicaciones reportadas hubo intubación difícil en dos casos (2.3%). En seis casos (6.9%) se consideró ventilación difícil. Otra de las complicaciones reportadas fue el sangrado, encontrando un sangrado mayor al previsto en 33 casos (38.4%). Conclusiones: la anestesia requerida en los pacientes con osteogénesis imperfecta se llevó a cabo con un mínimo de complicaciones.

Abstract: Introduction: osteogenesis imperfecta is a systemic disorder of connective tissue, characterized by decreased bone density and variability of bone fragility. Material and methods: a retrospective, observational, descriptive study of consecutive cases was carried out, whose main objective was to determine the complications related to the anesthetic procedure in pediatric patients with a diagnosis of osteogenesis imperfecta undergoing orthopedic procedures at the «Federico Gómez¼ Children's Hospital of Mexico, through the review of clinical records. Patients diagnosed with osteogenesis imperfecta, under 18 years of age, undergoing elective orthopedic surgery, were included. Measures of central tendency and dispersion were used, as well as tests of various hypotheses. Results: 86 anesthetic records were included. Most of the type III of osteogenesis imperfecta. Balanced general anesthesia was the most frequent technique with orotracheal intubation. Of the reported complications, difficult intubation was found in two cases (2.3%). In six cases (6.9%) ventilation was considered difficult. Another of the complications reported was bleeding, finding bleeding greater than expected in 33 cases (38.4%). Conclusions: the anesthesia required in patients with osteogenesis imperfecta was carried out with a minimum of complications.

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Neurofibromatosis type 1 is a complex genetic disorder affecting multiple organ systems. Cardiovascular manifestations include hypertension, often associated with concomitant pheochromocytoma. We present a hypertensive crisis during induction of anesthesia in a patient with neurofibromatosis type 1, scheduled for abdominal myomectomy, which revealed an undiagnosed pheochromocytoma. The case highlights the importance of assessing all patients with neurofibromatosis type 1 for pheochromocytoma, because if it is left undiagnosed, it can be disastrous in the setting of anesthesia and surgery.

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Abstract Neurofibromatosis type 1 is a complex genetic disorder affecting multiple organ systems. Cardiovascular manifestations include hypertension, often associated with concomitant pheochromocytoma. We present a hypertensive crisis during induction of anesthesia in a patient with neurofibromatosis type 1, scheduled for abdominal myomectomy, which revealed an undiagnosed pheochromocytoma. The case highlights the importance of assessing all patients with neurofibromatosis type 1 for pheochromocytoma, because if it is left undiagnosed, it can be disastrous in the setting of anesthesia and surgery.

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Resumen: Se informa la conducta anestésica de un caso de pseudoaneurisma ventricular izquierdo crónico secundario a complicación de infarto de miocardio transmural, complicación rara y casi siempre mortal. En este informe se describe el caso de una mujer de 60 años con insuficiencia cardíaca aguda a consecuencia de un infarto cardíaco ocurrido cinco meses atrás, que generó la complicación de la cual damos referencia. El manejo anestésico perioperatorio se logró al enfocarse en mantener una presión arterial estable para garantizar la perfusión cerebral y reducir el riesgo de ruptura completa del aneurisma hacia el espacio mediastinal.

Abstract: The anesthetic behavior of a case of chronic left ventricular pseudoaneurysm secondary to a complication of transmural myocardial infarction, a rare and almost always fatal complication, is reported. This report describes the case of a 60-year-old woman with acute heart failure, this is a consequence of a heart attack that occurred 5 months ago, which generated the complication of which we refer. Perioperative anesthetic management was achieved by focusing on maintaining a stable blood pressure to ensure cerebral perfusion and reduce the risk of complete rupture of the aneurysm into the mediastinal space.

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Background: The Brazilian tapir (Tapirus terrestris), considered the largest land mammal in South America, is a vulnerable species in terms of its degree of conservation. In captivity, its health is evaluated through behavioral and physical observation and laboratory exams, and in some cases, chemical restraint, to reduce stress. Dissociative anesthetics and sedatives are used for the sedation of these animals, and few studies have reported the use of dexmedetomidine and its effects when associated with other drugs in chemical containment protocols; therefore, this work reports its use, in conjunction with ketamine and midazolam, in a young Brazilian tapir. Case: A male Brazilian tapir, male, weighing 89 kg, 1 and a half year old, housed at CETAS in Rio Branco, Acre, was chemically restrained with dexmedetomidine (7 µg/kg), ketamine (1.5 mg/kg), and midazolam (0.2 mg/kg) for venous blood collection, oral and rectal mucosal swabs, and microchipping. The protocol was administered intramuscularly to the right triceps brachii, after physical restraint. After 5 min of application, the animal assumed sternal recumbency and presented reflux. After 15 min, the patient was placed in the right lateral decubitus position. During collection, heart rate (48 ± 10 bpm), respiratory frequency (29 ± 1 mpm), rectal temperature (38.1 ± 0.18°C), oxyhemoglobin saturation (97 ± 1%), and electrocardiographic tracing were recorded. The tapir showed deep sedation, immobility, good muscle relaxation, discreet medial palpebral reflex, and bilateral rotation of the eyeball. After 40 min of protocol administration, sedative reversal was performed intramuscularly with 14 µg/kg atipamezole. Five min after administration, the tapir showed signs of mild sedation. After 10 min, he assumed the quadrupedal position, remained in this position for 8 min, and gently resumed the sternal decubitus. After only 20 min, he resumed the quadrupedal position, with mild ataxia and good muscular and conscious tone. After 50 min, the patient was discharged from anesthesia. Discussion: Domestic horses are phylogenetically close to tapirs, so the choice of drugs and doses of the protocol used was based on their use in horses, and on studies carried out with tapirs as well. Despite being docile and passive, the tapir was not conditioned and did not allow the manipulation and collection of samples collaboratively; therefore, it was chemically contained. The physical restraint performed did not generate satisfactory immobilization of the tapir, resulting in agitation and stress and causing the needle to break. The reflux presented by the tapir minutes after sedation and at recovery was induced by dexmedetomidine, and only the undigested banana pieces were offered to the animal. Reflux plus stress from extensive fasting and suboptimal physical restraint was responsible for the change in the tapir's eating behavior, with possible stress gastritis 24 h after chemical restraint. Only one study reported the use of dexmedetomidine in tapirs, associated with continuous infusions of ketamine, midazolam and guaiacol glyceryl ether for moderate to long-term field procedures. Sedative reversal of dexmedetomidine by atipamezole reduced the recovery time and the risk of death from cardiorespiratory depression. The anesthetic combination used was effective, promoting immobility, muscle relaxation, and stability of the physical parameters evaluated, with rapid and gentle induction and an adequate level of sedation for the objective, good sedative reversal, and anesthetic recovery.

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BACKGROUND: The role of type I thyroplasty (TIP) is well established as the treatment for glottal insufficiency due to vocal fold paralysis, but the ideal anesthetic management for this procedure is still largely debated. We present the case of a novel anesthetic approach for TIP using combined intermediate and superficial Cervical Plexus Block (CPB) and intermittent mild sedation analgesia. CASE REPORT: A 51-year-old presenting with left vocal fold paralysis and obstructive sleep apnea was scheduled for TIP. An ultrasound-guided intermediate CPB was performed using the posterior approach, and 15 mL of ropivacaine 0.5% were injected in the posterior cervical space between the sternocleidomastoid muscle and the prevertebral fascia. Then, for the superficial CPB, a total of 10 mL 0.5% ropivacaine was injected subcutaneously, adjacently to the posterior border of the sternocleidomastoid muscle, without penetrating the investing fascia. An intermittent sedation analgesia with a target-controlled infusion of remifentanyl (target 0.5 ng.mL-1) was used to facilitate prosthesis insertion and the fiberoptic laryngoscopy. This technique offered a safe anesthetic airway and good operating conditions for the surgeon, as well as feasible voice monitoring and optimal patient comfort. CONCLUSION: The use of regional technique is a promising method for the anesthetic management in TIP, especially in patients with compromised airway.

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Abstract Background: The role of type I thyroplasty (TIP) is well established as the treatment for glottal insufficiency due to vocal fold paralysis, but the ideal anesthetic management for this procedure is still largely debated. We present the case of a novel anesthetic approach for TIP using combined intermediate and superficial Cervical Plexus Block (CPB) and intermittent mild sedation analgesia. Case report: A 51-year-old presenting with left vocal fold paralysis and obstructive sleep apnea was scheduled for TIP. An ultrasound-guided intermediate CPB was performed using the posterior approach, and 15 mL of ropivacaine 0.5% were injected in the posterior cervical space between the sternocleidomastoid muscle and the prevertebral fascia. Then, for the superficial CPB, a total of 10 mL 0.5% ropivacaine was injected subcutaneously, adjacently to the posterior border of the sternocleidomastoid muscle, without penetrating the investing fascia An intermittent sedation analgesia with a target-controlled infusion of remifentanyl (target 0.5 ng.mL-1) was used to facilitate prosthesis insertion and the fiberoptic laryngoscopy. This technique offered a safe anesthetic airway and good operating conditions for the surgeon, as well as feasible voice monitoring and optimal patient comfort. Conclusion: The use of a regional technique is a promising method for the anesthetic management in TIP, especially in patients with compromised airway.

Resumo Introdução: O papel da tireoplastia tipo I (TPI) está bem estabelecido no tratamento de insuficiência glótica após a paralisia das pregas vocais, mas o manejo anestésico ideal para a TPI ainda é controverso. Descrevemos uma nova técnica anestésica para a TPI usando o Bloqueio do Plexo Cervical (BPC) superficial e o BPC intermediário associados, em presença de analgo-sedação leve e intermitente. Relato de caso: Paciente de 51 anos de idade com paralisia da prega vocal esquerda e apneia obstrutiva do sono foi agendada para TPI. BPC intermediário guiado por ultrassom foi realizado usando acesso posterior, e 15 mL de ropivacaína a 0,5% foram injetados no espaço cervical posterior entre o músculo esternocleidomastoideo e a fáscia prevertebral. A seguir, para o BPC superficial, 10 mL de ropivacaína a 0,5% foram injetados na região subcutânea adjacente à borda posterior do músculo esternocleidomastoideo, sem transfixar a fáscia de revestimento. Analgo-sedação intermitente com infusão alvo-controlada de remifentanil (alvo de 0,5 ng.mL-1) foi usada para facilitar a inserção da prótese e a laringoscopia com fibra ótica. A técnica ofereceu via aérea segura durante a anestesia, boa condição para o cirurgião, possibilidade de monitorar a voz, além de ótimo conforto à paciente. Conclusões: O uso de anestesia regional é uma técnica promissora para o cuidado anestésico durante a TPI, especialmente em pacientes com via aérea comprometida.

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Hereditary angioedema is an autosomal dominant disorder, presenting as sudden and recurring episodes of variable severity of subcutaneous and mucosa edema that may occur spontaneously or in response to triggers. There are three knwon types of hereditary angioedema. The disorder is caused by decrease in the plasma level or change in the functional capacity of C1 inhibitor, with increase in bradykinin and in vascular permeability, and consequent edema. Several measures are required in the perioperative period in order to avoid an acute attack. Prophylaxis should be carried out throughout pregnancy before any surgical procedure, before dental procedures, upon airway handling, on patients with previous episodes of angioedema, and when there are significant changes in volemia. The literature is scarce in regard to the association between hereditary angioedema and pregnancy. We describe a successful case of a pregnant patient with type I hereditary angioedema submitted to a C-section.

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Abstract Hereditary angioedema is an autosomal dominant disorder, presenting as sudden and recurring episodes of variable severity of subcutaneous and mucosa edema that may occur spontaneously or in response to triggers. There are three knwon types of hereditary angioedema. The disorder is caused by decrease in the plasma level or change in the functional capacity of C1 inhibitor, with increase in bradykinin and in vascular permeability, and consequent edema. Several measures are required in the perioperative period in order to avoid an acute attack. Prophylaxis should be carried out throughout pregnancy before any surgical procedure, before dental procedures, upon airway handling, on patients with previous episodes of angioedema, and when there are significant changes in volemia. The literature is scarce in regard to the association between hereditary angioedema and pregnancy. We describe a successful case of a pregnant patient with type I hereditary angioedema submitted to a C-section.

Resumo O angioedema hereditário é uma doença autossômica dominante, que se manifesta por crises súbitas, recorrentes e de gravidade variável de edema subcutâneo e submucoso, que podem ocorrer espontaneamente ou em resposta a gatilhos. São conhecidos três tipos de angioedema hereditário. A doença é condicionada por diminuição do nível plasmático ou alteração da capacidade funcional do inibidor de C1, com aumento da bradicinina e da permeabilidade vascular, com consequente edema. Várias medidas devem ser tomadas no período perioperatório de forma a evitar uma crise aguda. A profilaxia deverá ser realizada durante a gravidez antes de qualquer procedimento cirúrgico, antes de procedimentos dentários, quando existe manuseamento da via aérea, nos doentes com episódios prévios de angioedema e quando há alterações significativas da volemia. A literatura é escassa no que que diz respeito à associação de angioedema hereditário e gravidez. Descrevemos um caso de sucesso de uma grávida com angioedema hereditário tipo I submetida a cesariana.

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BACKGROUND AND OBJECTIVES: Dilated cardiomyopathy is a state of progressive enlargement of cardiac chambers mainly left ventricle which leads to decreased cardiac output and ultimately cardiac failure. Although it has multifactorial etiology, it is quite common in patients with end stage renal disease who require renal transplant surgery for their cure. Both conditions go side by side and anesthetic management of such cases poses real challenge to anesthesiologist. Strict monitoring and control of cardiac physiology is of utmost importance besides meticulous fluid management, thus preserving renal blood flow on one hand and preventing cardiac failure on other hand. This is the basis of achieving good outcome of the renal transplant surgery. METHODS: This is a retrospective observational study done by analysing electronic database of 31 patients with dilated cardiomyopathy who underwent renal transplant surgery. Data was studied in terms of demographics, duration of renal disease, comorbidities mainly hypertension, cardiac echo graphic findings including ejection fraction, medications and post-operative outcome. RESULTS: Most common perioperative complication in this patient population was hypotension (51.61%) followed by pulmonary complications postoperative mechanical ventilation (12.9%) and pulmonary edema (6.45%). High incidence of hypotension may be a causative factor to increased rate of delayed graft functioning (12.9%) and acute tubular necrosis (2.23%) in these patients. CONCLUSION: Strict monitoring and control of hemodynamic parameters as well as meticulous fluid therapy is the cornerstone in improving outcome in patients with dilated cardiomyopathy undergoing renal transplant surgery.

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Abstract Background and objectives: Dilated cardiomyopathy is a state of progressive enlargement of cardiac chambers mainly left ventricle which leads to decreased cardiac output and ultimately cardiac failure. Although it has multifactorial etiology, it is quite common in patients with end stage renal disease who require renal transplant surgery for their cure. Both conditions go side by side and anesthetic management of such cases poses real challenge to anesthesiologist. Strict monitoring and control of cardiac physiology is of utmost importance besides meticulous fluid management, thus preserving renal blood flow on one hand and preventing cardiac failure on other hand. This is the basis of achieving good outcome of the renal transplant surgery. Methods: This is a retrospective observational study done by analysing electronic database of 31 patients with dilated cardiomyopathy who underwent renal transplant surgery. Data was studied in terms of demographics, duration of renal disease, comorbidities mainly hypertension, cardiac echo graphic findings including ejection fraction, medications and post-operative outcome. Results: Most common perioperative complication in this patient population was hypotension (51.61%) followed by pulmonary complications postoperative mechanical ventilation (12.9%) and pulmonary edema (6.45%). High incidence of hypotension may be a causative factor to increased rate of delayed graft functioning (12.9%) and acute tubular necrosis (2.23%) in these patients. Conclusion: Strict monitoring and control of hemodynamic parameters as well as meticulous fluid therapy is the cornerstone in improving outcome in patients with dilated cardiomyopathy undergoing renal transplant surgery.

Resumo Justificativa e objetivos A cardiomiopatia dilatada é um estado de aumento progressivo das câmaras cardíacas, principalmente do ventrículo esquerdo, que leva à diminuição do débito cardíaco e, por fim, à insuficiência cardíaca. Embora tenha etiologia multifatorial, é bastante comum em pacientes com doença renal terminal que precisam de transplante renal para sua cura. Ambas as condições andam lado a lado e o manejo anestésico de tais casos é um verdadeiro desafio para o anestesiologista. A monitoração e o controle rigoroso da fisiologia cardíaca são de extrema importância, além de um meticuloso manejo dos líquidos, o que por um lado preserva o fluxo sanguíneo renal, por outro previne a insuficiência cardíaca. Essa é a base para alcançar o bom resultado da cirurgia de transplante renal. Métodos Este estudo observacional retrospectivo foi feito mediante a análise de prontuários eletrônicos de 31 pacientes com cardiomiopatia dilatada submetidos à cirurgia de transplante renal. Os dados foram avaliados em termos demográficos, duração da doença renal, comorbidades (principalmente hipertensão), achados ecocardiográficos (inclusive fração de ejeção), medicamentos e resultados no pós-operatório. Resultados A complicação perioperatória mais comum nessa população de pacientes foi hipotensão (51,61%), seguida de complicações pulmonares, como ventilação mecânica pós-operatória (12,9%) e edema pulmonar (6,45%). A alta incidência de hipotensão pode ser um fator causador do aumento da incidência de atraso no funcionamento do enxerto (12,9%) e necrose tubular aguda (2,23%) nesses pacientes. Conclusão A monitoração rigorosa e o controle dos parâmetros hemodinâmicos, bem como a fluidoterapia criteriosa, são a pedra angular na melhoria dos resultados em pacientes com cardiomiopatia dilatada submetidos à cirurgia de transplante renal.

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Introducción: Los tumores primitivos de la tráquea son infrecuentes. Objetivo: Presentar la evolución de un paciente para resección de un tumor traqueal que ocluía el 95 por ciento de su luz. Caso Clínico: Disnea con tiraje supraesternal. No tolera el decúbito supino, presencia de tos y expectoración. Se le administró anestesia general endotraqueal convencional. Intubación con tubo No. 8. Se colocó en decúbito lateral izquierdo. Se procedió a realizar toracotomía. Con la tráquea abierta, el cirujano intubó el bronquio izquierdo con tubo No. 7. Se aspiraron secreciones, descendió la saturación de oxígeno. Se colocó sonda de levine en el pulmón derecho para oxigenación apneica con lo cual mejoró la saturación. En el pulmón ventilado se aplicó presión positiva al final de la espiración de 3 cm de agua con una fracción inspirada de oxígeno de 1. Luego de cerrada la pared posterior de la tráquea, se pasó una sonda nasogástrica a través del tubo colocado por vía orotraqueal. El cirujano fijó el extremo distal con una pinza. Se retiró el tubo orotraqueal inicial y se colocó un tubo 5.5 para intubar selectivamente el bronquio izquierdo por la boca y terminar la sutura de la tráquea y ambos bronquios. Terminado el procedimiento, se retiró el tubo y se ventilaron ambos pulmones. Conclusiones: La cirugía de tráquea impone un gran reto al anestesiólogo y al cirujano actuante, por lo que resultan imprescindibles las buenas relaciones del equipo de trabajo(AU)

Introduction: Primitive tumors of the trachea are rare. Objective: To present the evolution of a patient for removal of a tracheal tumor that occluded 95 percent of its light. Clinical case: Dyspnea with suprasternal retractions. No tolerance of supine decubitus, presence of cough and expectoration. The patient was administered conventional endotracheal general anesthesia. Intubation with tube number 8. The patient was placed in the left lateral decubitus position. A thoracotomy was performed. With the trachea open, the surgeon intubated the left bronchus with tube number 7. Secretions were aspirated, oxygen saturation decreased. A Levine tube was placed in the right lung for apneic oxygenation, which improved the saturation. In the ventilated lung, positive pressure was applied at the end of the expiration of 3 cm of water with an inspired fraction of oxygen of 1. After closing the posterior wall of the trachea, a nasogastric tube was passed through the tube placed via the orotracheal approach. The surgeon fixed the distal end with a clamp. The initial orotracheal tube was removed and a 5.5 tube was placed to intubate the left bronchus selectively through the mouth and complete the suture of the trachea and both bronchi. After the procedure, the tube was removed and both lungs were ventilated. Conclusions: The trachea surgery represents a great challenge for the anesthesiologist and the surgeon, a reason why good team working relations are essential(AU)

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Introducción: la endocarditis infecciosa es una enfermedad que involucra con másfrecuencia las válvulas cardíacas, pero también puede ocurrir sobre cuerdas tendinosas, o el endocardio mural. La lesión característica − vegetación − consiste en una masa de plaquetas, fibrina, microcolonias de microorganismos y escasas células inflamatorias. Objetivo: describir la conducta perioperatoria, así como la evolución clínico-anestesiológica de un paciente que presentó paro cardiaco secundario a insuficiencia mitral aguda por endocarditis bacteriana. Caso clínico: hombre joven con diagnóstico de endocarditis infecciosa e insuficiencia valvular mitral con ruptura de las cuerdas tendinosas, presentó paro cardiorrespiratorio que requirió reanimación cerebrocardiopulmonar con recuperación de la circulación espontánea. Fue llevado al quirófano de emergencia para sustitución valvular mitral y conservación de las cuerdas tendinosas. Se obtuvieron resultados satisfactorios, sin secuelas pulmonares ni neurológicas. Conclusiones: la rápida identificación y tratamiento de la endocarditis bacteriana mejora el pronóstico y evita nefastas complicaciones. La ecocardiografía transesofágica brinda adecuada resolución espacial y precisión en su evaluación y posibilita la mejoría terapéutica(AU)

Introduction: Infectious endocarditis is a disease that involves the heart valves more frequently, but it can also occur on chordae tendineae, or the mural endocardium. The characteristic lesion, vegetation, consists of a mass of platelets, fibrin, microorganisms microcolonies, and few inflammatory cells. Objective: To describe the perioperative behavior, as well as the clinical anesthesiological evolution of a patient who presented cardiac arrest secondary to acute mitral regurgitation due to bacterial endocarditis. Clinical case: A young man with a diagnosis of infective endocarditis and mitral valve insufficiency with ruptured tendinous cords presented cardiorespiratory arrest requiring brain and cardiopulmonary resuscitation with spontaneous circulation recovery. He was taken to the emergency operating room for mitral valve replacement and chordae tendineae conservation. Satisfactory results were obtained, without pulmonary or neurological sequelae. Conclusions: The quick identification and treatment of bacterial endocarditis improves prognosis and prevents nefarious complications. Transesophageal echocardiography provides adequate spatial resolution and accuracy in its evaluation and gives the possibility for therapeutic improvement(AU)

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Resumen Introducción: Los tumores neuroendocrinos son neoplasias secretoras de hormonas, principalmente catecolaminas, que pueden presentarse en cualquier parte del cuerpo. La incidencia del feocromocitoma es de 2 a 8 por millón de personas por año, y el 10% de ellos son tumores extra adrenales. El manejo anestésico se considera un reto para el anestesiólogo, ya que deben tomar en cuenta varios puntos para el control hemodinámico del paciente, así como el manejo multidisciplinario en el periodo pre, trans y posquirúrgico. Caso clínico: Presentamos el caso de un paciente masculino portador de para-ganglioma vesical sometido a resección quirúrgica bajo anestesia general e infusión de isosorbide para control de la emergencia hipertensiva. Conclusiones: Se consideró, en este caso en particular, que el uso de vasodilatadores periféricos fue benéfico para el tratamiento de la emergencia hipertensiva durante el transanestésico. Discusión: El tratamiento de la emergencia hipertensiva reportado en la bibliografía muestra que el uso de fármacos intravenosos como nitroprusiato de sodio, nitroglicerina, labetalol, esmolol, entre otros, son los más indicados. El uso de nitritos es una alternativa viable con descontrol hipertensivo severo.

Abstract Introduction: Neuroendocrine tumors, can be found anywhere on the body. The incidence of pheochromocytoma is 2-8 per million people per year and 10% of these are extra-adrenal tumors. Anesthetic management is considered a challenge for the anesthesiologist, since they are primarily catecholamine secreting tumors, and they must take into account several points for a hemodynamic monitoring of the patient and the multidisciplinary management in the pre, trans and postsurgical period. Case report: We report the case of a male patient carrier of a bladder para-ganglioma who underwent a surgical resection under general anesthesia and an infusion of isosorbide to control a hypertensive emergency. Conclusions: We considered, in this particular case, that the use of peripheral vasodilators was beneficial for the treatment of hypertensive emergency during trans- anesthetic. Discussion: The treatment of hypertensive emergencies reported in the literature shows that the use of intravenous drugs such as sodium nitroprusside, nitroglycerin, labetalol, esmolol, among others, are the most recommended. The use of nitrite is a viable alternative with severe uncontrolled hypertension.

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ABSTRACT The anesthetic management of patients with large mediastinal masses can be complicated due to the pressure effects of the mass on the airway or major vessels. We present the successful anesthetic management of a 64-year-old female with a large mediastinal mass that encroached on the great vessels and compressed the trachea. A tracheal stent was placed to relieve the tracheal compression under general anesthesia. Spontaneous ventilation was maintained during the perioperative period with the use of a classic laryngeal mask airway. We discuss the utility of laryngeal mask airway for anesthetic management of tracheal stenting in patients with mediastinal masses.

RESUMO O manejo anestésico de pacientes com grandes massas situadas no mediastino pode ser complicado por causa dos efeitos da pressão da massa sobre as vias aéreas ou grandes vasos. Relatamos o manejo anestésico bem-sucedido de uma paciente de 64 anos com uma grande massa mediastinal que invadiu os grandes vasos e comprimiu a traqueia. Um stent traqueal foi colocado para aliviar a compressão da traqueia, sob anestesia geral. A ventilação espontânea foi mantida durante o período perioperatório com o uso de uma máscara laríngea clássica. Discutimos a utilidade da máscara laríngea para o manejo da colocação de stent traqueal em pacientes com massas situadas no mediastino.

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The anesthetic management of patients with large mediastinal masses can be complicated due to the pressure effects of the mass on the airway or major vessels. We present the successful anesthetic management of a 64-year-old female with a large mediastinal mass that encroached on the great vessels and compressed the trachea. A tracheal stent was placed to relieve the tracheal compression under general anesthesia. Spontaneous ventilation was maintained during the perioperative period with the use of a classic laryngeal mask airway. We discuss the utility of laryngeal mask airway for anesthetic management of tracheal stenting in patients with mediastinal masses.

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BACKGROUND: Current recommendations for the anesthetic management of placenta accreta support a conservative approach with neuraxial anesthesia and uterine artery embolization. These are based on case series from experienced centers in developed countries. The aim of this study was to describe the anesthetic management of placenta accreta in a low-resource setting. METHODS: A retrospective case note review was performed. From 1 August 2006 to 31 July 2011 placentas from cases of suspected placenta accreta were reassessed histologically to confirm the diagnosis. Patient charts were reviewed and information on anesthetic technique, monitoring, blood transfusion, maternal and fetal outcomes was extracted. RESULTS: Thirty-nine cases were identified. Mean (± SD) maternal age was 33 ± 5.4 years. Hysterectomy was performed at the time of cesarean section in all cases. Thirty-four patients received neuraxial anesthesia, of whom 15 required conversion to general anesthesia. Invasive blood pressure monitoring was used in all patients and a central venous catheter was inserted in 33 cases. Complications associated with monitoring occurred in five patients. Median [IQR] blood loss was 2000 [1100-2700] mL and the median [IQR] number of units of red blood cell transfused was 2 [0-6]. Vasoactive medication was used in 14 patients and 15 patients were transferred to the intensive care unit postoperatively. No maternal or newborn deaths occurred. CONCLUSION: A multidisciplinary approach can prove valuable when placenta accreta is suspected before delivery. In low-resource settings, lack of interventional radiology services and prenatal diagnostic capability may have an impact on anesthetic management in patients with placenta accreta. However, other than greater blood loss, our study demonstrated that good maternal and neonatal outcomes are possible in spite of limited resources.

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Introducción: la Osteogénesis Imperfecta (OI) es una rara enfermedad congénita autosómica dominante del tejido conectivo con una incidencia aproximada de 1:21 000 a 1:60 000 nacimientos, con mayor incidencia en mujeres.1 Aunque también se han descrito casos de herencia recesiva o mutación espontánea.2 La Osteogénesis Imperfecta puede ser causada por la mutación en los cromosomas 7 o 17, en uno de los dos genes que codifcan el colágeno tipo 1A1 o 1A2. 3 Sus manifestaciones clínicas incluyen la susceptibilidad a las fracturas óseas y retraso del crecimiento, así como compromiso del tejido conectivo de otros órganos. Bajo este contexto existen múltiples implicaciones anestésicas que determinan un buen desenlace en el posoperatorio. Caso: es una revisión de caso clínico y revisión bibliográfca. Resultados: el presente caso muestra el manejo anestésico en un niño de 12 años con Osteogénesis Imperfecta, sometido a osteosíntesis por fractura de miembro superior. Patología poco frecuente en nuestro medio. Conclusiones: se puede concluir que el manejo anestésico de un paciente con Osteogénesis Imperfecta implica varios ámbitos desde su fragilidad ósea, vía aérea difícil, control de temperatura entre otros. Además que se requiere un abordaje multidisciplinario en el perioperatorio.

Introduction: Osteogenesis Imperfecta (OI) is a rare autosomal dominant congenital connective tissue disorder with an incidence of 1:21 000 to 1:60 000 births, with higher incidence in women. 1 Also we can fnd cases of recessive heritage or spontaneous 1 mutation. 2 Osteogenesis Imperfecta (OI), can be caused by mutations in chromosomes 7 or 17, in one of two genes encoding collagen type 1A1 or 1A2. 3 Its clinical manifestations include susceptibility to bone fractures and delayed growth and commitment of the connective tissue of other organs. In this context there are multiple anesthetic implications that determine a good postoperative outcome. Case: this is a clinical case review and a literature review. Results: this case shows de anesthetic management in a 12 years old boy with Osteogénesis Imperfecta, who underwent an osteosinthesis of an upper limb fracture. A rare pathology in our environment. Conclusions: we can conclude that the anesthetic management of a patient with Osteogénesis Imperfecta, involves several scopes from bone fragility, diffcult airway, core temperature control, etc. Besides that a multidisciplinary approach is required in the perioperative.

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