Manejo anestésico en un paciente con feocromocitoma y paragangliomas

Introduction: Pheochromocytoma and paraganglioma are neuroendocrine tumors of chromaffin cells with a low incidence, these tumors can be in the adrenal glands and between 25% are located extra-adrenal and are called paraganglioma. Material and methods: A 56-year-old patient with a diagnosis of pheochromocytoma, with symptoms of paroxysmal arterial hypertension, tachycardia, sweating, anxiety and with an abdominal tomography report that reports: mass of 4 x 1.8 x 3.5 centimeters located by behind the inferior vena cava compatible with a paraganglioma or pheochromocytoma. She underwent resection of the tumor with a high risk of tearing the inferior vena cava, invasive monitoring was performed, and anesthetic depth is important, administration of vasoactive drugs with the aim of reducing the peaks of arterial hypertension, arterial hypotension, arrhythmias, avoiding complications and providing patient safety. Discussion: Anesthetic management is a challenge due to intraoperative hemodynamic instability characterized by arrhythmias, abrupt variability of blood pressure. Among the drugs recommended for greater success:  doxazosin, magnesium sulfate, which prevent the release of catecholamines, dexmedetomidine, due to its sympatholytic effects, produce a decrease in plasma levels of norepinephrine. Conclusions: Thanks to multidisciplinary work, advances in technology, medications, it is possible that the risk of surgery and anesthesia are safer.Introducción: La feocromocitoma y paraganglioma son tumores neuroendocrinos de células cromafines de baja incidencia, la mayor parte se localiza en las glándulas suprarrenales y entre un 25% se de localización extra adrenal denominándose paraganglioma. Material y métodos: Paciente de 56 años con el diagnóstico de feocromocitoma, con sintomatología de hipertensión arterial paroxística, taquicardia, sudoración, ansiedad y con un informe de tomografía abdominal que reporta: masa de 4 x 1,8 x 3,5 centímetros localizada por detrás de la VCI compatible con un paraganglioma o feocromocitoma. Es sometida a resección del tumor con alto riesgo de desgarro de la vena cava inferior, se realizó monitorización invasiva, profundidad anestésica, administración de drogas vasoactivas para disminuir los picos de hipertensión arterial, hipotensión arterial, arritmias evitando las complicaciones y otorgando seguridad al paciente. Discusión: El manejo anestésico es un desafío por la inestabilidad hemodinámica durante el intraoperatorio. Entre los medicamentos recomendados para mayor éxito: doxazosina, sulfato de magnesio los cuales previenen la liberación de catecolaminas, la dexmedetomidina por sus efectos simpaticolíticos producen disminución de los niveles plasmáticos de norepinefrina. Conclusiones: Gracias al trabajo multidisciplinario, al avance de la tecnología y medicamentos es posible que el riesgo de la cirugía y anestesia sean más segura

Manejo anestésico en hepatectomia parcial por hemangioma

Introduction: A giant hepatic hemangioma is a benign vascular tumor more frequent in females, when the tumor measures more than 10 centimeters it is considered giant and can cause symptoms such as abdominal pain, anemia, thrombocytopenia, Kasabach-Merritt syndrome under these criteria they become candidates for surgery. Material and methods: A 33-year-old female patient who has an abdominal tomography report which informed giant hepatic hemangioma in segments II, III and IV of 21x10x13.8 centimeters, without portal hypertension criteria. It is scheduled for left hepatectomy (liver segments II and III). In the first and second phase of surgery, the objective was to maintain a central venous pressure of 1 mmHg and a mean arterial pressure pressure greater than 70 mmHg, starting continuous infusion of Nitroglycerin 5-15 µg/min, norepinephrine 0.05 µg/kg/min, remifentanil 0.5 µg/kg/hour, dexmedetomidine 0.6 µg/kg/hour these doses were modified according to blood pressure and central venous pressure throughout the surgery. Vascular hemi-pringle was performed with duration of 15 minutes; blood loss in the second phase was approximately 4000 milliliters, replacing with transfusion of blood products. Discussion: There are several strategies to minimize intraoperative complications such as maintaining low central venous pressure, normovolemic hemodilution, fluid restriction, administration of furosemide, nitroglycerin, phenylephrine and dexmedetomidine. Conclusion: The role of the anesthesiologist is a challenge because there must be extensive knowledge about the surgical technique, the risks and complications involved during hepatectomy, however, a balance must be made between an anesthetic technique that allows the protection of organs and provide hemodynamic stability.Introducción: Un hemangioma hepático gigante es un tumor benigno vascular, más frecuente en el sexo femenino, cuando el tumor mide más de 10 centímetros es considerado gigante y puede ocasionar sintomatología como dolor abdominal, anemia, trombocitopenia síndrome de Kasabach-Merritt bajo estos criterios se convierten en candidatos para cirugía. Material y métodos: Paciente femenina de 33 años quien cuenta con un informe de tomografía abdominal que reporto hemangioma hepático gigante en segmentos II, III y IV de 21x10x13.8 centímetros, sin criterios de hipertensión portal. Se programa para hepatectomia izquierda (segmentos hepáticos II y III). En la primera y segunda fase de la cirugía el objetivo fue mantener una presión venosa central de 1 mmHg y una presión arterial media mayor a 70 mmHg iniciando infusión continua de Nitroglicerina 5-15 µg/min, noradrenalina 0.05 µg/kg/min, remifentanil 0.5 µg/kg/hora, dexmedetomidina 0,6 µg /kg/hora modificando las dosis según presión arterial y presión venosa central durante toda la cirugía. Se realizó hemi-pringle vascular con una duración de 15 minutos, la perdida sanguínea en la segunda fase fue 4000 mililitros aproximadamente reponiendo con transfusión de hemoderivados. Discusión: Existen varias estrategias para minimizar las complicaciones intraoperatoria como mantener presión venosa central baja, hemodilución normovolémica, restricción de líquidos, administración de furosemida, nitroglicerina, fenilefrina y dexmedetomidina. Conclusión: El rol del anestesiólogo es un reto porque se debe tener un amplio conocimiento sobre la técnica quirúrgica, los riesgos y complicaciones que implica durante la hepatectomia, sin embargo, se debe realizar un equilibrio entre una técnica anestésica que permita la protección de órganos y brindar estabilidad hemodinámica

Challenges in the Diagnosis and Management of Acquired Nontraumatic Urethral Strictures in Boys in Yaoundé, Cameroon

Introduction. Urethral strictures in boys denote narrowing of the urethra which can be congenital or acquired. In case of acquired strictures, the etiology is iatrogenic or traumatic and rarely infectious or inflammatory. The aim of this study was to highlight the diagnostic and therapeutic difficulties of acquired nontraumatic urethral strictures in boys in Yaoundé, Cameroon. Methodology. The authors report five cases of nontraumatic urethral strictures managed at the Pediatric Surgery Department of the YGOPH over a two-year period (November 2012–November 2014). In order to confirm the diagnosis of urethral stricture, all patients were assessed with both cystourethrography and urethrocystoscopy. Results. In all the cases the urethra was inflammatory with either a single or multiple strictures. The surgical management included internal urethrotomy (n=1), urethral dilatation (n=1), vesicostomy (n=2), and urethral catheterization (n=3). With a median follow-up of 8.2 months (4–16 months) all patients remained symptoms-free. Conclusion. The authors report the difficulties encountered in the diagnosis and management of nontraumatic urethral strictures in boys at a tertiary hospital in Yaoundé, Cameroon. The existence of an inflammatory etiology of urethral strictures in boys deserves to be considered

A bronchogenic cyst, presenting as a retroperitoneal cystic mass

Bronchogenic cysts are mostly benign, congenital abnormalities originating from the remnants of the primitive foregut. A retroperitoneal location is rare. Due to the mostly asymptomatic behavior and the historical confusion regarding histology, an exact prevalence is not known. We present here a case report of a retroperitoneal bronchogenic cyst. A literature review was performed for cases of retroperitoneal bronchogenic cysts written in English. Anatomopathological criteria for inclusion were pseudo stratified, ciliated, columnar epithelium together with the presence of at least one of the following: cartilage, smooth muscle or seromucous glands. In addition, the embryology, pathogenesis, radiological, clinical and suggested treatment modalities are reviewed. We report the surgical excision of a retroperitoneal bronchogenic cyst that presented as a non-functioning left adrenal mass. Our review of literature revealed only 62 potential cases of retroperitoneal bronchogenic cysts. After applying the strict anatomopathological criteria, only 30 cases of true retroperitoneal bronchogenic cysts could be identified. Retroperitoneal location of a bronchogenic cyst is rare. Despite the rarity of this pathologic entity, bronchogenic cysts should be considered in the differential diagnosis of retroperitoneal cystic lesions. Only histology can confirm definitive diagnosis. Surgery remains the recommended treatment of choice

Using a mHealth tutorial application to change knowledge and attitude of frontline health workers to Ebola virus disease in Nigeria: a before-and-after study

Background: The Ebola epidemic exposed the weak state of health systems in West Africa and their devastating effect on frontline health workers and the health of populations. Fortunately, recent reviews of mobile technology demonstrate that mHealth innovations can help alleviate some health system constraints such as balancing multiple priorities, lack of appropriate tools to provide services and collect data, and limited access to training in health fields such as mother and child health, HIV/AIDS and sexual and reproductive health. However, there is little empirical evidence of mHealth improving health system functions during the Ebola epidemic in West Africa. Methods: We conducted quantitative cross-sectional surveys in 14 health facilities in Ondo State, Nigeria, to assess the effect of using a tablet computer tutorial application for changing the knowledge and attitude of health workers regarding Ebola virus disease. Results: Of 203 participants who completed pre- and post-intervention surveys, 185 people (or 91%) were female, 94 participants (or 46.3%) were community health officers, 26 people (13 %) were nurses/midwives, 8 people (or 4%) were laboratory scientists and 75 people (37%) belonged to a group called others. Regarding knowledge of Ebola: 178 participants (or 87.7%) had foreknowledge of Ebola before the study. Further analysis showed an 11% improvement in average knowledge levels between pre- and post-intervention scores with statistically significant differences (P < 0.05) recorded for questions concerning the transmission of the Ebola virus among humans, common symptoms of Ebola fever and whether Ebola fever was preventable. Additionally, there was reinforcement of positive attitudes of avoiding the following: contact with Ebola patients, eating bush meat and risky burial practices as indicated by increases between pre- and post-intervention scores from 83 to 92%, 57 to 64% and 67 to 79%, respectively. Moreover, more participants (from 95 to 97%) reported a willingness to practice frequent hand washing and disinfecting surfaces and equipment following the intervention, and more health workers were willing (from 94 to 97%) to use personal protective equipment to prevent the transmission of Ebola. Conclusions: The modest improvements in knowledge and reported attitudinal change toward Ebola virus disease suggests mHealth tutorial applications could hold promise for training health workers and building resilient health systems to respond to epidemics in West Africa