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Case report
Epidural anesthesia for posterior spinal fusion and lumbar surgery in a patient with glanzmann's thrombasthenia – Case report and systematic review
Anestesia epidural para artrodesis e instrumentación de columna lumbar porvia posterior en paciente con tromboastenia de glanzmann – informe de caso y revisión sistematica
Sergio Hernando Cabarique-Serranoa,b,c,d, Víctor Hugo González-Cárdenasb,d,e,
Corresponding author
vhgonzalez@fucsalud.edu.co

Corresponding author at: Cra. 52 No. 67A-71, Oficina de Anestesiología, Hospital Infantil Universitario de San José, Bogotá, Colombia.
, Jean Pierre Dussán-Crosbyb, Rodolfo Enrique Páez-Gonzálezb,f, María Alejandra Ramírezb
a Anesthesiologist Intensivist, Department of Anesthesiology, Hospital Infantil Universitario de San José. Bogotá D. C., Colombia
b School of Medicine, Fundación Universitaria de Ciencias de la Salud (FUCS). Bogotá D. C., Colombia
c Intensive Care Unit, Clínica Universidad de La Sabana. Chía, Colombia
d School of Medicine, Universidad de La Sabana. Chía, Colombia
e Anesthesiologist, Clinical Epidemiologist and Master in Anesthesia and Regional Analgesia. Leading Coordinator Grupo Deorum Opus-Hospital Infantil Universitario de San José/ Hospital de San José / Fundación Universitaria de Ciencias de la Salud (FUCS). Bogotá D. C., Colombia
f Orthopedist, Subspecialist in Spinal Surgery. Hospital Infantil Universitario de San José. Bogotá D. C., Colombia
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and improved satisfaction&#59; these are all valid considerations for the anesthesia team when making a decision&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Though general anesthesia &#40;GA&#41; for the lumbar spine<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">1</span></a> has historically been the cornerstone for anesthesiology&#44; various studies have questioned this approach&#44; indicating that RA has a lower impact on hemodynamic stability during induction and maintenance of anesthesia and is associated with a considerable decrease in the use of pain killers as a result of lower immediate postoperative pain levels<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">2&#8211;6</span></a> and less intra and postoperative bleeding&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">RA has shown improved cost-effectiveness as compared to GA in lumbar spine surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">5</span></a> Furthermore&#44; there is evidence that RA is associated with lower mortality during the first 30 days after surgery&#44; which is particularly relevant in high cardiovascular risk patients&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">7</span></a> In contrast&#44; other trials have described similar surgical times&#44; satisfaction&#44; surgeon comfort and length of stay in the recovery room&#44; with no significant differences versus GA data&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">4&#44;5&#44;7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">One of the big challenges the anesthetist faces in RA is in patients with prophylactic or therapeutic anticoagulation&#44; dual anti-aggregation&#44; and coagulopathies who are more likely to develop spinal or epidural hematoma &#40;1 per 3000 to 150&#44;000 patients&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">8&#8211;10</span></a> Increased bleeding and the need for blood products transfusion defy the decision to stop the prescribed anticoagulant medications due to the high risk of thrombosis or perioperative embolism&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Despite the strategies agreed by the ASRA &#40;bridge therapy&#41;&#44; the implementation of such strategies is still controversial under extreme cases such as the patient herein discussed&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">11&#8211;13</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">This is a report of a case that exemplifies the above arguments&#44; followed by a discussion based on the information gathered from a systematic data search&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Case description</span><p id="par0040" class="elsevierStylePara elsevierViewall">64-year old male with intermittent lumbar pain after three months of evolution&#46; The level of pain is severe&#44; with frequent paresthesia irradiating to the hips and lower extremities&#44; with considerable difficulty to ambulate&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The relevant medical history included smoking&#44; high blood pressure&#44; and ischemic heart disease &#40;two vessels treated with two stents five years back&#41;&#59; the patient is under cardiology control due to persistent ischemic symptoms&#46; Additionally&#44; a femoral pseudo aneurysm developed in the right thigh which was managed with thrombin occlusion and Glanzmann coagulopathy&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The patient was evaluated by a spine orthopedist who diagnosed L4&#8211;L5 facet joint syndrome&#44; with root compression&#46; The initial therapies included&#58; combined oral therapy with no improvement of the condition and failed posteromedial branch neurolysis of the lumbar plexus&#46; The patient returned three months later and in view of the persistence of symptoms&#44; was scheduled for percutaneous interspinous spacers&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The pre-anesthesia evaluation classified the patient as ASA III&#44; non-assessable functional class and cardiac high risk &#40;based on AHA and Lee&#39;s revised cardiac index&#41;&#46; The patient was programmed for an intermediate bleeding risk procedure&#59; the ECG indicated a right branch blockade and the most recent echocardiogram revealed adequate biventricular function &#40;LVEF 65&#37;&#41;&#44; with diastolic dysfunction and non-dysfunctional aortic sclerosis&#46; In view of the patient&#39;s condition&#44; the decision was made to transfuse platelets prior to surgery and prepare ICU admission&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Medical intervention&#58; Following the transfusion of four units of platelets and in accordance with the patient&#39;s refusal to undergo general anesthesia&#44; we administered sedation and loco-regional anesthesia&#46; Basic monitoring was provided&#44; in addition to continuous invasive blood pressure monitoring&#59; &#40;40&#37;&#41; oxygen was administered via Venturi&#44; Remifentanil &#40;0&#46;5<span class="elsevierStyleHsp" style=""></span>mcg&#47;kg bolus and maintenance at 0&#46;02<span class="elsevierStyleHsp" style=""></span>mcg&#47;kg&#47;min&#41;&#59; Midazolam &#40;1<span class="elsevierStyleHsp" style=""></span>mg&#41; and Fentanyl &#40;50 mcg&#41;&#44; for achieving the sedation target &#40;RASS-2&#41;&#46; During surgery there was a need to convert to open surgery &#40;Lumbar Arthrodesis&#41;&#44; so in addition to sedation&#44; epidural anesthesia was administered &#40;point of insertion at L1&#8211;L2 with the tip of the catheter at T8&#41;&#46; Intravascular or spinal &#8211; conventional test &#8211; placement was ruled out&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">14</span></a> and 50<span class="elsevierStyleHsp" style=""></span>mg of Bupivacaine plus 100<span class="elsevierStyleHsp" style=""></span>mcg of Fentanyl were administered&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Continuous range of hemodynamic stability was achieved in the course of the procedure&#44; with the support of intermittent doses of phenylephrine for optimal cerebral and myocardial perfusion&#46; Surgery was completed maintaining an adequate RASS throughout the procedure that lasted 95<span class="elsevierStyleHsp" style=""></span>min&#44; with approximately 40<span class="elsevierStyleHsp" style=""></span>cc of blood loss&#46; The patient was transferred to the ICU for hemodynamic monitoring and after obtaining a reasonable Aldrete score and satisfactory resolution of the lumbar pain with no need for additional care&#44; we removed the epidural catheter early in order to restart anticoagulation therapy&#46; The patient was then transferred to the inpatients unit and two days later was discharged&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Materials and methods</span><p id="par0070" class="elsevierStylePara elsevierViewall">Our study designed the case description and openly discussed the most recent information on the topic&#44; in an attempt to answer the following questions&#58; Is epidural anesthesia the right choice for patients undergoing lumbar spine fusion&#63; Is there any scientific support for the use of epidural anesthesia in cardiac patients and&#47;or patients with a predisposition to bleed or taking anticoagulants&#63;</p><p id="par0075" class="elsevierStylePara elsevierViewall">With a view to analyze and discuss the case&#44; in February 2015 a systematic data search was undertaken&#44; complemented with a snowball strategy&#44; in PubMed&#44; Lilacs&#44; Cochrane&#44; and Ebsco as the <span class="elsevierStyleItalic">Primary</span> sources and ACP Journal Club&#44; and National Library of Medicine Health Service Research as <span class="elsevierStyleItalic">secondary</span> sources&#59; <span class="elsevierStyleItalic">Graduate Dissertation and grey literature&#58;</span> OPENSIGLE&#44; New York Academy of Sciences Grey Sources&#44; Clinical Medicine Netprints&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The acronym &#8220;PICOS&#8221; was used to refer to the studies &#40;PRISMA Declaration&#41;&#58; &#8220;<span class="elsevierStyleBold">P&#8221;</span>&#58; cardiac <span class="elsevierStyleBold">P</span>atients and&#47;or with predisposition to bleed&#44; using anticoagulants&#44; undergoing lumbar spine fusion&#59; &#8220;<span class="elsevierStyleBold">I&#8221;</span> &#40;<span class="elsevierStyleBold">Intervention</span>&#41;&#58; regional anesthesia &#40;epidural&#41;&#59; &#8220;<span class="elsevierStyleBold">C&#8221;</span>&#58; &#40;<span class="elsevierStyleBold">C</span>omparison&#41; general anesthesia&#44; and &#8220;<span class="elsevierStyleBold">O&#8221;</span>&#58; &#40;<span class="elsevierStyleItalic"><span class="elsevierStyleBold">O</span>utcomes</span>&#41; 1&#58; Changes in hemodynamic stability during induction and maintenance of regional versus general anesthesia&#46; 2&#58; Potential adverse outcomes in patients with prophylactic or therapeutic anticoagulation&#44; dual aggregation and&#47;or coagulopathies&#44; associated with regional anesthesia for lumbar spine fusion&#46; &#8220;<span class="elsevierStyleBold">S&#8221;</span>&#58; &#40;<span class="elsevierStyleItalic"><span class="elsevierStyleBold">S</span>tudies</span>&#41; Experimental trials in human subjects&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Similar search strategies were used for each one of the above databases&#46; The Medline-PubMed &#8211; based approach was as follows&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0160" class="elsevierStylePara elsevierViewall">For oral anticoagulation and regional anesthesia&#58; <span class="elsevierStyleItalic">&#40;&#40;&#8220;mouth&#8221;&#91;MeSH Terms&#93; OR &#8220;mouth&#8221;&#91;All Fields&#93; OR &#8220;oral&#8221;&#91;All Fields&#93;&#41; AND &#40;&#8220;anticoagulants&#8221;&#91;Pharmacological Action&#93; OR &#8220;anticoagulants&#8221;&#91;MeSH Terms&#93; OR &#8220;anticoagulants&#8221;&#91;All Fields&#93;&#41; AND &#40;&#8220;regional anaesthesia&#8221;&#91;All Fields&#93; OR &#8220;anesthesia&#44; conduction&#8221;&#91;MeSH Terms&#93; OR &#40;&#8220;anesthesia&#8221;&#91;All Fields&#93; AND &#8220;conduction&#8221;&#91;All Fields&#93;&#41; OR conduction &#8220;anesthesia&#8221;&#91;All Fields&#93; OR &#40;&#8220;regional&#8221;&#91;All Fields&#93; AND &#8220;anesthesia&#8221;&#91;All Fields&#93;&#41; OR&#8220;regional anesthesia&#8221;&#91;All Fields&#93;&#41;&#41; AND &#40;&#8220;2005&#47;02&#47;06&#8221;&#91;PDat&#93;&#58; &#8220;2015&#47;02&#47;03&#8221;&#91;PDat&#93;&#41;</span>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0165" class="elsevierStylePara elsevierViewall">For lumbar surgery and anesthesia&#58; <span class="elsevierStyleItalic">&#40;&#40;&#8220;lumbar vertebrae&#8221;&#91;MeSH Terms&#93; OR &#40;&#8220;lumbar&#8221;&#91;All Fields&#93; AND &#8220;vertebrae&#8221;&#91;All Fields&#93;&#41; OR &#8220;lumbar vertebrae&#8221;&#91;All Fields&#93; OR &#40;&#8220;lumbar&#8221;&#91;All Fields&#93; AND &#8220;spine&#8221;&#91;All Fields&#93;&#41; OR &#8220;lumbar spine&#8221;&#91;All Fields&#93;&#41; AND &#40;&#8220;surgery&#8221;&#91;Subheading&#93; OR &#8220;surgery&#8221;&#91;All Fields&#93; OR &#8220;surgical procedures&#44; operative&#8221;&#91;MeSH Terms&#93; OR &#40;&#8220;surgical&#8221;&#91;All Fields&#93; AND &#8220;procedures&#8221;&#91;All Fields&#93; AND &#8220;operative&#8221;&#91;All Fields&#93;&#41; OR &#8220;operative surgical procedures&#8221;&#91;All Fields&#93; OR &#8220;surgery&#8221;&#91;All Fields&#93; OR &#8220;general surgery&#8221;&#91;MeSH Terms&#93; OR &#40;&#8220;general&#8221;&#91;All Fields&#93; AND &#8220;surgery&#8221;&#91;All Fields&#93;&#41; OR &#8220;general surgery&#8221;&#91;All Fields&#93;&#41; AND &#40;&#8220;anaesthesia&#8221;&#91;All Fields&#93; OR &#8220;anesthesia&#8221;&#91;MeSH Terms&#93; OR &#8220;anesthesia&#8221;&#91;All Fields&#93;&#41;&#41; AND &#40;&#8220;loattrfull text&#8221;&#91;sb&#93; AND &#8220;2005&#47;02&#47;06&#8221;&#91;PDat&#93;&#58; &#8220;2015&#47;02&#47;03&#8221;&#91;PDat&#93; AND &#8220;humans&#8221;&#91;MeSH Terms&#93;&#41;</span>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0170" class="elsevierStylePara elsevierViewall">For lumbar fusion and anesthesia&#58; <span class="elsevierStyleItalic">&#40;&#8220;lumbosacral region&#8221;&#91;MeSH Terms&#93; OR &#40;&#8220;lumbosacral&#8221;&#91;All Fields&#93; AND &#8220;region&#8221;&#91;All Fields&#93;&#41; OR &#8220;lumbosacral region&#8221;&#91;All Fields&#93; OR &#8220;lumbar&#8221;&#91;All Fields&#93;&#41; AND interbody&#91;All Fields&#93; AND &#40;&#8220;Nucl Eng Des&#47;Fusion&#8221;&#91;Journal&#93; OR &#8220;fusion&#8221;&#91;All Fields&#93; OR &#8220;FUSION&#8221;&#91;Journal&#93; OR &#8220;fusion&#8221;&#91;All Fields&#93;&#41; AND &#40;&#8220;anaesthesia&#8221;&#91;All Fields&#93; OR &#8220;anesthesia&#8221;&#91;MeSH Terms&#93; OR &#8220;anesthesia&#8221;&#91;All Fields&#93;&#41;</span>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0175" class="elsevierStylePara elsevierViewall">For Glanzmann thromboasthenia and surgery&#58; <span class="elsevierStyleItalic">&#40;&#40;&#8220;thrombasthenia&#8221;&#91;MeSH Terms&#93; OR &#8220;thrombasthenia&#8221;&#91;All Fields&#93; OR &#40;&#8220;glanzmann&#8221;&#91;All Fields&#93; AND &#8220;thrombasthenia&#8221;&#91;All Fields&#93;&#41; OR &#8220;glanzmann thrombasthenia&#8221;&#91;All Fields&#93;&#41; AND &#40;&#8220;surgery&#8221;&#91;Subheading&#93; OR &#8220;surgery&#8221;&#91;All Fields&#93; OR &#8220;surgical procedures&#44; operative&#8221;&#91;MeSH Terms&#93; OR &#40;&#8220;surgical&#8221;&#91;All Fields&#93; AND &#8220;procedures&#8221;&#91;All Fields&#93; AND &#8220;operative&#8221;&#91;All Fields&#93;&#41; OR &#8220;operative surgical procedures&#8221;&#91;All Fields&#93; OR &#8220;surgery&#8221;&#91;All Fields&#93; OR &#8220;general surgery&#8221;&#91;MeSH Terms&#93; OR &#40;&#8220;general&#8221;&#91;All Fields&#93; AND &#8220;surgery&#8221;&#91;All Fields&#93;&#41; OR &#8220;general surgery&#8221;&#91;All Fields&#93;&#41;&#41; AND systematic&#91;sb&#93;</span>&#46;</p></li></ul></p><p id="par0110" class="elsevierStylePara elsevierViewall">We considered article published between 2005 and 2015&#44; in English and&#47;or Spanish&#44; and on experimental methodology applied to human subjects&#46; The sessions to discuss the research articles and questions submitted before the experts panel at the Service of Anesthesiology of the San Jos&#233; Children&#39;s University Hospital required an analysis of the bibliography corresponding to each of the 19 articles considered relevant &#40;for this study&#58; included&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0115" class="elsevierStylePara elsevierViewall">Based on the selection strategies to undertake the literature search in the various databases suggested&#44; 27 articles were collected&#58; 21 in Pubmed&#44; three in LILACS and three more in sciencedirect&#46; Eight articles were excluded based on title and abstract&#44; leaving 19 full text articles for evaluation&#46; These were submitted for expert panel discussions and in the end were included in the discussion&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0120" class="elsevierStylePara elsevierViewall">Both Glanzmann&#39;s Thromboasthenia &#8211; a hereditary autosomal recessive predisposition with low incidence rates among the general population &#8211; &#40;1&#58;1000&#46;000&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">15&#8211;17</span></a> and the presence of severe&#44; difficult to manage&#44; ischemic heart disease&#44; further complicated our anesthetic and surgical approaches in a patient undergoing lumbar spine fusion&#44; and required significant changes in the usual techniques to ensure better results&#44; avoiding the most likely adverse outcomes in this type of interventions&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">For decades&#44; GA has been the gold standard for lumbar spine procedures<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">1</span></a>&#59; however&#44; several studies have shown that epidural RA results in optimization of analgesics&#44; lower postoperative acute pain intensity&#44; adequate hemodynamic stability&#44; improved cost-effectiveness&#44; and reduced mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">2&#44;7</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Notwithstanding the lack of explicit literature on the management of anesthesia in patients with special characteristics &#40;such as our patient&#41;&#44; undergoing lumbar spine fusion&#44; we argue that such predisposition to bleed should be approached similarly to the group of patients receiving anticoagulation or platelet anti aggregation&#46; In other words&#44; we must prepare ideal pro-coagulation conditions to prevent bleeding complications &#40;similar to those recommended by ASRA&#41;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">11&#8211;13</span></a> allowing for the manipulation of the neuraxis&#46; The significance of having reliable&#44; affordable&#44; and quick methods available during the coagulation study for the right use of therapies that maximize the coagulation ability should be emphasized&#46; This is the case with conventional or rotational thromboelastography&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">18&#44;19</span></a> In our case&#44; these interventions were secured with pre-surgical platelet concentrate transfusion and availability of recombinant Factor VIIa&#44;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">15&#44;20</span></a> &#40;specifically recommended by the FDA in Glanzmann&#39;s Thromboasthenia&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">21</span></a> However&#44; we lack the relevant diagnostic devices to provide qualitative platelet recommendations beyond the conventional thrombus formation times which in the end are poorly effective to approach the intervention&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Whilst hemodynamic stability during surgery is an individual&#44; multidimensional analysis&#44; research has shown that this type of epidural anesthesia has the least impact on changing the vital signs and target organ perfusion pressures&#46; Consequently&#44; in selected cases and under selective and ultraselective techniques&#44; may yield significant benefits&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">2&#44;7</span></a> According to Popescu&#44;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">22</span></a> epidural anesthesia in patients with ischemic heart disease&#44; not only reduces the level of postoperative pain&#44; but also the sympathetic load decreasing the cardiac oxygen demand and preventing cardiac decompensation&#46; In our patient&#44; these factors were probably the key toward achieving such encouraging results&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conclusions</span><p id="par0140" class="elsevierStylePara elsevierViewall">The use of epidural RA in lumbar arthrodesis procedures &#40;particularly in patients with Glanzmann&#39;s Thromboasthenia and severe ischemic heart disease&#41; needs further specific supportive research&#46; Consequently&#44; the successful anesthetic intervention in this particular case highlights the importance of researching alternative approaches to widely used general balanced anesthesia or total intravenous anesthesia &#40;TIVA&#41;&#46; The unbeatable outcomes achieved make us believe that RA could be the technique of choice in patients with the characteristics described above&#46; Lastly&#44; we recommend embarking on in-depth studies about the characteristics of RA in patients at high anesthetic risk undergoing similar procedures&#44; including studies of stronger epidemiological impact and the potential to make general recommendations&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Ethical disclosures</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Protection of human and animal subjects</span><p id="par0240" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Confidentiality of data</span><p id="par0245" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Right to privacy and informed consent</span><p id="par0250" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Funding</span><p id="par0145" class="elsevierStylePara elsevierViewall">This study was funded by the authors&#8217; resources&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflict of interest</span><p id="par0150" class="elsevierStylePara elsevierViewall">The researchers have no conflict of interests to disclose with regards to the data reported and the systematic literature review&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Lumbar spine arthrodesis under regional epidural anesthesia provides adequate hemodynamic stability and timely treatment of acute postoperative pain to patients undergoing the procedure&#46; However&#44; the presence of intimidating comorbidities limits its widespread practice&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objetives</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To describe the use of epidural anesthesia for spinal fusion in a patient with Glanzmann&#39;s Thrombasthenia and high anesthetic risk of cardiovascular complications&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methodology</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Case reports and clinical discussion based on a systematic search of the medical literature&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Upon selecting the strategies for a literature search on various databases&#44; some articles were selected from Pubmed&#44; LILACS&#44; and sciencedirect&#46; The articles were screened based on title and abstract and 19 full text articles were analyzed and submitted for discussion of an appointed panel of experts &#40;Anesthesiology Group&#41; for inclusion herein&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusion</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The use of epidural anesthesia in spinal surgery of a patient with significant hematological and cardiovascular complications was a successful approach and represents one further step forward in the implementation of protocols and robust clinical trials for the management of complex patients like the one herein described&#46;</p></span>"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La artrodesis de columna lumbar&#44; bajo anestesia regional epidural&#44; permite a los pacientes programados para &#233;ste tipo de procedimiento mantener una adecuada estabilidad hemodin&#225;mica y ser tratados oportunamente de su dolor postoperatorio agudo&#46; Sin embargo&#44; la presencia de intimidantes comorbilidades limita su pr&#225;ctica de forma generalizada&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Describir la utilizaci&#243;n de anestesia epidural para artrodesis lumbar en un paciente con Tromboastenia de Glanzmann y alto riesgo anest&#233;sico de complicaciones de predominio cardiovascular&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Metodologia</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Reporte de Casos y discusi&#243;n cl&#237;nica basada en b&#250;squeda sistem&#225;tica de la literatura m&#233;dica&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Tras la selecci&#243;n de estrategias para la b&#250;squeda de la literatura en diferentes bases de datos&#44; se obtuvieron art&#237;culos de Pubmed&#44; LILACS y sciencedirect&#46; Posterior a exclusi&#243;n por titulo y resumen&#44; analizamos 19 art&#237;culos en texto completo&#44; los cuales fueron sometidos a sesiones de discusi&#243;n por parte de un panel de expertos designado &#40;Grupo de Anestesiolog&#237;a&#41;&#44; y fueron incluidos en esta revisi&#243;n&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusi&#243;n</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Para este caso&#44; el uso de la anestesia epidural en cirug&#237;a de columna&#44; en un paciente con importantes comorbilidades hematol&#243;gicas y cardiovasculares&#44; fue una medida exitosa&#44; y representa un paso m&#225;s en la implementaci&#243;n de protocolos y estudios cl&#237;nicos robustos para su uso en pacientes complejos como el descrito&#46;</p></span>"
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

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