E. Gredilla

Use of erythropoietin for bloodless surgery in a Jehovah's witness infant.

Summary We present a case of surgery in a 2‐month‐old infant of the Jehovahs Witness (JW) faith weighing 2.8 kg scheduled for left upper lobectomy because of congenital lobar emphysema. He presented with physiological anaemia (haematocrit 33.8%) in accordance with his age. Because of the relative emergency of surgery, a short erythropoietin course was instituted. Recombinant human erythropoietin (rHuEPO) at a dosage of 180 U·kg−1·day−1 was administered for 10 days preoperatively and for 4 days postoperatively. Iron was administered orally and intravenously over the entire perioperative period. No side‐effects from either erythropoietin or intravenously administered iron were observed. To our knowledge, this is the first case published of a short perioperative rHuEPO course in an infant.

Descripción de un caso de síndrome de cirugía fallida de espalda, estimulación medular y embarazo

Spinal cord stimulation is increasingly used to manage chronic pain syndromes, such as complex regional pain syndrome, chronic back pain, refractory angina pectoris or peripheral vascular diseases, which are unresponsive to other common less aggressive treatment methods. The early use of this technique in the aforementioned diseases makes it suitable in young women of childbearing age and who wish to become pregnant. We report the case of a 33-year-old woman who became pregnant 4 months after having undergone posterior cord stimulation, and we review the approach to this situation and the perioperative management during the perinatal period.

Cardiac Surgery Without Blood Products in a Jehovah's Witness Child With Factor VII Deficiency

In the case reported here, the situation was complicated by a congenital deficiency of factor VII (FVII), which increased the risk of surgical and postoperative bleeding. Perioperative rotational thromboelastometry coagulation monitoring avoided empiric prophylactic treatment with recombinant activated FVII (rFVIIa). CASE REPORT A 5-year-old girl weighing 37.8 lb of the JW faith without cardiologic symptoms or a history of bleeding episodes had been diagnosed with ostium secundum atrial septal defect (ASD) by echocardiogram and was scheduled for transcatheter device closure of the defect. The transesophageal echocardiographic study and cardiac catheterization confirmed a 16-mm diameter defect (Qp:Qs ratio of 2.4:1) and contraindicated transcatheter device closure due to insufficient rims and the extension of the defect into the inferior vena cava. The patient was scheduled for ASD closure with CPB. The patient’s parents, also JWs, did not authorize the use of whole blood or blood components (ie, packed red blood cells, fresh frozen plasma, platelets, and cryoprecipitate), but accepted the use of coagulation factor concentrates (ie, fibrinogen, factor VIIa, and prothrombin complex), erythropoietin, intravenous iron, and cell salvage. Preoperative routine tests showed a hemoglobin (Hb) concentration of 12.5 g/dL, hematocrit of 36.6%, a mild iron deficit (iron: 45 g/dL, transferrin: 253 mg/dL, transferrin saturation: 14%, ferritin: 40 ng/mL, and total iron-binding capacity: 321 g/dL), and an abnormal prothrombin time (PT) of 15 seconds (63% activity, international normalized ratio 1.3) with a normal activated partial thromboplastin time. After the confirmation of prolonged PT, further investigations revealed a mild FVII deficiency (43.3% activity), whereas all other coagulation factors were within the normal range. Surgery was scheduled 13 days later to allow adequate preparation of the patient and to avoid the administration of blood products during the procedure. Treatment was initiated with a short preoperative course of 7 doses of subcutaneous human recombinant erythropoietin (r-HuEPO) at a dosage of 600 U/kg every other day. At the start of erythropoietin treatment, the maximum single intravenous dose of ferric carboxymaltose (255 mg) was administered in a 15-minute infusion to prevent relative iron deficiency. The patient also received oral supplements of vitamin B12 and folic acid throughout the preoperative period. A complete blood count and coagulation panel were obtained the day before surgery, showing an increase in Hb of 2 g/dL. The PT remained prolonged because of the FVII deficiency. Laboratory findings from preoperative and postoperative tests are summarized in Table 1. Anesthesia management consisted of induction with sevoflurane in oxygen and air, followed by fentanyl and cisatracurium administration to facilitate endotracheal intubation, and maintenance with remifentanil, 0.25 g/kg/min, and 2% sevoflurane in an oxygen/air mixture. A radial arterial catheter and a right internal jugular central venous catheter were inserted for invasive pressure monitoring. Near-infrared spectroscopy and bispectral index were used for neurologic monitoring. After heparin administration and cannulation, a direct suturing of the edges of the ASD was performed under moderate hypothermic (32°C) CPB (36 minutes) with a cross-clamp time of 18 minutes. After rewarming, modified ultrafiltration, and protamine administration, weaning from CPB was achieved uneventfully using a continuous infusion of low-dose dopamine (3 g/kg/min). Preoperative erythropoietin treatment was combined with fibrinolytic prophylaxis intraoperatively (tranexamic acid given in a bolus dose of 15 mg/kg before surgical incision), a meticulous surgical technique, a crystalloid low-volume priming CPB circuit (500 mL), modified ultrafiltration (500 mL), and a reduction in the number and volume of blood samples for laboratory tests. During and immediately after surgery, coagulation was monitored with rotational thromboelastometry (ROTEM; TEM International, GmbH, Munich, Germany), which made the administration of coagulation factor concentrates unnecessary (Table 2). Bleeding was not heavier than normal. The chest drains were removed 48 hours after surgery with a total volume of 106 mL. The patient was discharged from the pediatric intensive care unit on day 2 after the surgery and was sent home on day 6. No transfusions of blood products were administered.

Low bispectral index values in hydranencephaly.

Editor, We read with great interest the article by Prabhakar et al. [1] regarding the use of bispectral index (BIS) monitoring for an elective frontal craniotomy and fenestration in a 2-year-old boy with bilateral frontal lobe porencephalic cysts. During the procedure, the patient presented low preanaesthetic BIS values (39) that showed no significant change (between 30 and 40), despite a reduction in the inspired concentration of sevoflurane from 1 to 0.2%. No burst suppression pattern was observed, and BIS values remained low after anaesthetic recovery. In the discussion, the authors suggest that intracranial pressure increments could be responsible for the low BIS values.

Inserción de balones intraarteriales ilíacos previa a la realización de cesárea ante la sospecha de acretismo placentario

Massive obstetric hemorrhage still remains a major cause of maternal mortality and morbidity. The risk factors associated with this pathology must be identified in order to schedule the appropriate delivery with the necessary resources. A case is presented of an iliac artery occlusion with intravascular balloons for suspected placenta accreta during cesarean section. The perioperative treatment, as well as an analysis of the treatment options is described, along with their advantages and disadvantages, from the use of postpartum hemorrhage protocols, blood transfusion and procoagulant factors, and other maneuvers to control bleeding, until the hysterectomy.

Imagen del mesColocación de filtro de cava por trombosis venosa profunda durante el embarazoInsertion of a vena cava filter for deep venous thrombosis during pregnancy

Mujer de 27 anos en tratamiento con 12.500 UI de dalteparina sodica desde la semana 28 de gestacion (embarazo gemelar), por trombosis venosa profunda (TVP) en vena femoral e iliaca izquierda. En la semana 36 se indico la colocacion de un filtro de cava (fig. 1) al objetivarse la obstruccion de la vena femoral comun izquierda por un trombo de 18 mm de diametro, tras lo cual se realizo cesarea con anestesia general sin incidencias. En el postoperatorio inmediato se reinicio el tratamiento con heparina de bajo peso molecular y 5 dias despues se retiro el filtro de cava. En este caso, la decision de terminar la gestacion por cesarea se baso en la existencia de un embarazo gemelar casi a termino y en la persistencia de la TVP a pesar del tratamiento. Dado que la terapia anticoagulante con heparina durante 8 semanas no fue suficiente, y para reducir la posibilidad de desprendimiento del trombo durante la cesarea, se inserto el filtro de cava previo a la realizacion de la cesarea como prevencion del tromboembolismo pulmonar.

Colocación de filtro de cava por trombosis venosa profunda durante el embarazo

Mujer de 27 anos en tratamiento con 12.500 UI de dalteparina sodica desde la semana 28 de gestacion (embarazo gemelar), por trombosis venosa profunda (TVP) en vena femoral e iliaca izquierda. En la semana 36 se indico la colocacion de un filtro de cava (fig. 1) al objetivarse la obstruccion de la vena femoral comun izquierda por un trombo de 18 mm de diametro, tras lo cual se realizo cesarea con anestesia general sin incidencias. En el postoperatorio inmediato se reinicio el tratamiento con heparina de bajo peso molecular y 5 dias despues se retiro el filtro de cava. En este caso, la decision de terminar la gestacion por cesarea se baso en la existencia de un embarazo gemelar casi a termino y en la persistencia de la TVP a pesar del tratamiento. Dado que la terapia anticoagulante con heparina durante 8 semanas no fue suficiente, y para reducir la posibilidad de desprendimiento del trombo durante la cesarea, se inserto el filtro de cava previo a la realizacion de la cesarea como prevencion del tromboembolismo pulmonar.