Efficacy and safety of three inflation methods of the laryngeal mask airway Ambu® Auraonce™: a randomized controlled study.

The laryngeal mask airway (LMA) is commonly used for airway management. Cuff hyperinflation has been associated with complications, poor ventilation and increased risk of gastric insufflation. This study was designed to determine the best cuff inflation method of AuraOnce™ LMA during bronchoscopy and EBUS (Endobronquial Ultrasound Bronchoscopy) procedure. We designed a Randomized controlled, doble-blind, clinical trial to compare the efficacy and safety of three cuff inflation methods of AuraOnce™ LMA. 210 consenting patients scheduled for EBUS procedure under general anesthesia, using AuraOnce™ LMA were randomized into three groups depending on cuff insufflation: residual volume (RV), half of the maximum volume (MV), unchanged volume (NV). Parameters regarding intracuff pressure (IP), airway leak pressure (OLP), leakage volume (LV) were assessed, as well as postoperative complications (PC). 201 (95.7%) patients completed the study. Mean IP differed between groups (MV: 59.4 ± 32.4 cm H2O; RV: 75.1 ± 21.1 cm H2O; NV: 83.1 ± 25.5 cmH20; P < 0.01). The incidence of IP > 60 cmH2O was lower in the MV group compared to the other two (MV: 20/65(30.8%); RV:47/69 (68.1%); NV 48/67 (71.6%); p < 0.01). The insertion success rate was 89,6% (180/201) at first attempt, with no difference between groups (p = 0.38). No difference between groups was found either for OLP (p = 0.53), LV (p = 0.26) and PC (p = 0.16). When a cuff manometer is not available, a partial inflation of AuraOnce™ LMA cuff using MV method allows to control intracuff pressure, with no significant changes of OLP and LV compared to RV and NV insufflation method.Registration clinical trial: NCT04769791.

COVID in obstetrics: labor analgesia and cesarean section.

PURPOSE OF REVIEW: This review is based on the latest evidence to provide a good standard of care for COVID-19 parturients and protection to healthcare givers. RECENT FINDINGS: COVID-19 by itself is not an indication for cesarean section. Different publications demonstrated the efficacy of neuraxial analgesia/anesthesia for delivery. Although SARS-CoV-2 was associated with a certain neurotropism, neuraxial block was not associated with neurological damage in COVID-19 parturients, and seems as safe and effective as in normal situations. It permits to avoid a general anesthesia in case of intrapartum cesarean section. Epidural failure is a concern: it may lead to a general anesthesia in case of emergency cesarean section. Local protocols and well-trained anesthesiologists will be helpful. COVID-19 patients require special circuits and every step (transfer to and from theatre, recovery, analgesia, and so on) should be planned in advance. For cesarean section under general anesthesia, personal protection equipment must be enhanced. Postoperative analgesia with neuraxial opioids, NSAIDs, or regional blocks are recommended. COVID-19 and pregnancy increase the risk of thrombosis, so thromboprophylaxis has to be considered and protocolized. SUMMARY: Anesthetic care for delivery in COVID-19 parturients should include neuraxial blocks. Special attention should be paid on the risk of thrombosis.

Combined spinal epidural for labour analgesia and caesarean section: indications and recommendations.

PURPOSE OF REVIEW: Even if its use is scarce in most countries, many articles concerning combined spinal epidural (CSE) were published. In this review, we present the latest advances concerning CSE in obstetrics. RECENT FINDINGS: During labour, CSE improves epidural analgesia quality. Epidural with intradural opioids can produce maternal hypotension and foetal heart rate abnormalities (FHR-Ab), without increasing the caesarean section rate. For caesarean section, CSE decreases the neuraxial block failure rate, with no significant increase of complications. Epidural volume extension (EVE) after CSE for caesarean section could be an interesting option even though more evidence is needed. SUMMARY: For labour analgesia, CSE has the fastest onset time of analgesia. Its side effects have no consequences on maternal, labour or foetal outcomes. It provides better analgesia than epidural analgesia and can be used for external cephalic version and high-risk patients. For caesarean section, CSE has become the reference neuraxial technique for low-dose spinal anaesthesia, with higher success rate compared with regular spinal anaesthesia. Recent systematic revisions did not confirm this superiority. CSE offers the advantage of EVE, intraoperative top-ups, postoperative administration of neuraxial opioids and local anaesthetics. The risk of complications is balanced by the benefits of the technique.

Randomized Pragmatic Pilot Trial Comparing Perpendicular Thin Electrode Versus Parallel Thick Electrode Approaches for Lumbar Medial Branch Neurotomy in Facetogenic Low Back Pain.

OBJECTIVES: Although there are different ways of performing medial branch neurotomy on facetogenic low back pain, few studies have compared clinical outcomes of a parallel technique over the medial branch vs. a perpendicular technique. We investigated differences in pain outcome with both techniques. DESIGN: This was a prospective, pilot, randomized, pragmatic trial (double blinded in the diagnostic phase). SETTING: A comparative pilot trial was conducted at an academic pain center. METHODS: Patients who did not respond to conservative medications and had severe lumbar pain for more than 3 months (VAS score ≥ 65) were included. A double diagnostic block with local anesthetic and placebo was performed, double blinded. Patients who had 80% relief from the local anesthetic and no substantial relief from placebo were randomized to undergo medial branch neurotomy under fluoroscopy, placing an electrode parallel or perpendicular to the medial branch. The primary outcome was differences in the VAS score at 1, 3, and 6 months. The secondary outcomes were Oswestry Disability Index score, Roland Morris Questionnaire score, and other functional Likert scale scores. RESULTS: Forty-three consecutive patients were randomized to parallel (n = 20) or perpendicular (n = 23) neurotomy. There were no significant differences in VAS, Oswestry Disability Index, or Roland Morris Questionnaire scores at 1, 3, or 6 months between groups. Statistically significant differences were found in the categorical analysis at 6 months in the evolution of pain, Oswestry Disability Index score, Roland Morris Questionnaire score, and some Likert scale scores in favor of the parallel group. CONCLUSIONS: There were differences at 6 months in the categorical analysis of the evolution of pain, Oswestry Disability Index score, Roland Morris Questionnaire score, and some functional Likert scale scores, all in favor of the parallel group.

Anesthesia and analgesia for transvaginal oocyte retrieval. Should we recommend or avoid any anesthetic drug or technique?

PURPOSE OF REVIEW: The objective of this review is to analyze and summarize the current anesthetic methods used to alleviate pain and discomfort during transvaginal oocyte retrieval procedures (TORP), to try to reach practical recommendations, based on the evidence, which will translate into daily practice, the knowledge on the anesthetic management of patients scheduled for TORP. RECENT FINDINGS: There is no strong evidence to recommend the avoidance of any technique or drug for TORP, including nitrous oxide or halogenated agents. Women should be offered any available technique. The evidence available up to date is not convincing enough to recommend avoiding any anesthetic technique in terms of pregnancy and birth rates. SUMMARY: TORP is painful for women and different techniques may be used for pain relief in day case surgery. The other important outcome to consider is the pregnancy rate, and any anesthetic technique or drug which would improve this pregnancy rate should be recommended. Conscious sedation and general anesthesia proved to be well tolerated for woman and the oocytes, despite the use of propofol, opioids, benzodiacepines, nitrous oxide, or other drugs. Spinal anesthesia and paracervical block are also acceptable options, and can be combined with conscious sedation. Nevertheless, more studies are needed to find out the ideal drug or technique combination for the woman and the oocyte.

Population pharmacokinetics/pharmacodynamics of micafungin against Candida species in obese, critically ill, and morbidly obese critically ill patients.

BACKGROUND: Dosing in obese critically ill patients is challenging due to pathophysiological changes derived from obesity and/or critical illness, and it remains fully unexplored. This study estimated the micafungin probability of reaching adequate 24-h area under the curve (AUC0-24h)/minimum inhibitory concentration (MIC) values against Candida spp. for an obese/nonobese, critically ill/noncritically ill, large population. METHODS: Blood samples for pharmacokinetic analyses were collected from 10 critically ill nonobese patients, 10 noncritically ill obese patients, and 11 critically ill morbidly obese patients under empirical/directed micafungin treatment. Patients received once daily 100-150 mg micafungin at the discretion of the treating physician following the prescribing information and hospital guidelines. Total micafungin concentrations were determined by high-performance liquid chromatography (HPLC). Monte-Carlo simulations were performed and the probability of target attainment (PTA) was calculated using the AUC0-24/MIC cut-offs 285 (C. parapsilosis), 3000 (all Candida spp.), and 5000 (nonparapsilosis Candida spp.). Intravenous once-daily 100-mg, 150-mg, and 200-mg doses were simulated at different body weights (45, 80, 115, 150, and 185 kg) and age (30, 50, 70 and 90 years old). PTAs ≥ 90% were considered optimal. Fractional target attainment (FTA) was calculated using published MIC distributions. A dosing regimen was considered successful if the FTA was ≥ 90%. RESULTS: Overall, 100 mg of micafungin was once-daily administered for nonobese and obese patients with body mass index (BMI) ≤ 45 kg/m2 and 150 mg for morbidly obese patients with BMI > 45 kg/m2 (except two noncritically ill obese patients with BMI ~ 35 kg/m2 receiving 150 mg, and one critically ill patient with BMI > 45 kg/m2 receiving 100 mg). Micafungin concentrations in plasma were best described using a two-compartment model. Weight and age (but not severity score) were significant covariates and improved the model. FTAs > 90% were obtained against C. albicans with the 200 mg/24 h dose for all body weights (up to 185 kg), and with the 150 mg/24 h for body weights < 115 kg, and against C. glabrata with the 200 mg/24 h dose for body weights < 115 kg. CONCLUSION: The lack of adequacy for the 100 mg/24 h dose suggested the need to increase the dose to 150 mg/24 h for C. albicans infections. Further pharmacokinetic/pharmacodynamic studies should address optimization of micafungin dosing for nonalbicans Candida infections.

Epidural Space Identification With Loss of Resistance Technique for Epidural Analgesia During Labor: A Randomized Controlled Study Using Air or Saline-New Arguments for an Old Controversy.

BACKGROUND: The best technique to identify the epidural space for labor analgesia is still unclear despite the publication of various randomized controlled studies and meta-analyses. Our aim was to assess the superiority of the saline loss of resistance (SLOR) technique over the air loss of resistance (ALOR) technique with respect to the quality of the block. METHODS: Consenting parturients admitted to our obstetric suite for spontaneous or induced labor were randomized to receive epidural analgesia using either the ALOR or SLOR technique. Our primary outcome was to compare the impact of the SLOR and ALOR technique on pain score improvement measured 30 minutes after administration of epidural block. Our secondary outcomes included the density of motor blockade and analgesic efficacy measured at 30 minutes. Primary and secondary outcomes were compared using the Student t test and Mann-Whitney U test. Statistical significance was set at P < .017 for primary and secondary outcomes, considering Bonferroni correction for multiple comparisons. Other comparisons were considered exploratory. RESULTS: Four hundred parturients were included; 24 were excluded from the final analysis. After 30 minutes, pain score reduction (ALOR, 4.7 ± 2.9/10; SLOR, 4.9 ± 3.0/10; P = .49), motor block (ALOR, 1.4 ± 0.8; SLOR, 1.3 ± 0.8; P = .27), and efficacy of the block (ALOR, 1.0 ± 0.7; SLOR, 1.0 ± 0.6; P = .87) did not differ significantly between groups. CONCLUSIONS: Pain score reduction after 30 minutes and onset of the block were not affected by the technique used to locate the epidural space.

Risk factors for colonization by carbapenemase-producing enterobacteria at admission to a Surgical ICU: A retrospective study.

INTRODUCTION: In 2011, a hospital-wide outbreak of OXA-48 producing Klebsiella pneumoniae occurred in our hospital, an epidemiological setting of high ESBL-producing K. pneumoniae rates. This study identifies risk factors for colonization with carbapenemase-producing enterobacteria (CPE) at Surgical Intensive Care Unit (SICU) admission. METHODS: A 2-year retrospective study was performed in all patients admitted to the SICU that following routine had a rectal swab collected upon admission. RESULTS: Of 254 patients admitted, 41 (16.1%) harbored CPE (five showing two carbapenemase-producing isolates). Most frequent carbapenemase-producing isolates and carbapenemases were K. pneumoniae (39/46, 84.8%) and OXA-48 (31/46; 76.1%), respectively. Carriers significantly had higher rates of chronic renal disease, previous digestive/biliary endoscopy, hospitalization, ICU/SICU admission, intraabdominal surgery, and antibiotic intake, as well as higher median values of clinical scores (SOFA, SAPS II and APACHE II). In the multivariate analysis (R2=0.309, p<0.001), CPE carriage was associated with prior administration of 3rd-4th generation cephalosporins (OR=27.96, 95%CI=6.88, 113.58, p<0.001), ß-lactam/ß-lactamase inhibitor (OR=11.71, 95%CI=4.51, 30.43, p<0.001), abdominal surgery (OR=6.33, 95%CI=2.12, 18.89, p=0.001), and prior digestive/biliary endoscopy (OR=3.88, 95%CI=1.56, 9.67, p=0.004). CONCLUSIONS: A strong association between production of ESBLs and carriage of CPE (mainly OXA-48 producing K. pneumoniae) was found. According to the model, the co-selection of ß-lactamases by previous exposure to broad-spectrum cephalosporins and ß-lactam/ß-lactamase inhibitors (with lower relative risk), abdominal surgery and prior digestive/biliary endoscopy were factors associated with CPE carriage.

Is the introduction of another variable to the strength-duration curve necessary in neurostimulation?

INTRODUCTION: Neurostimulation is the process and technology derived from the application of electricity with different parameters to activate or inhibit nerve pathways. Pulse width (Pw) is the duration of each electrical impulse and, along with amplitude (I), determines the total energy charge of the stimulation. OBJECTIVES: The aim of the study was to test Pw values to find the most adequate pulse widths in rechargeable systems to obtain the largest coverage of the painful area, the most comfortable paresthesia, and the greatest patient satisfaction. MATERIAL AND METHODS: A study of the parameters was performed, varying Pw while maintaining a fixed frequency at 50 Hz. Data on perception threshold (Tp ), discomfort threshold (Td ), and therapeutic threshold (Tt ) were recorded, applying 14 increasing Pw values ranging from 50 µsec to 1000 µsec. Lastly, the behavior of the therapeutic range (TR), the coverage of the painful area, the subjective patient perception of paresthesia, and the degree of patient satisfaction were assessed. RESULTS: The findings after analyzing the different thresholds were as follows: When varying the Pw, the differences obtained at each threshold (Tp , Tt , and Td ) were statistically significant (p < 0.05). The differences among the resulting Tp values and among the resulting Tt values were statistically significant when varying Pw from 50 up to 600 µsec (p < 0.05). For Pw levels 600 µsec and up, no differences were observed in these thresholds. In the case of Td , significant differences existed as Pw increased from 50 to 700 µsec (p ≤ 0.05). The coverage increased in a statistically significant way (p < 0.05) from Pw values of 50 µsec to 300 µsec. Good or very good subjective perception was shown at about Pw 300 µsec. CONCLUSIONS: The patient paresthesia coverage was introduced as an extra variable in the chronaxie-rheobase curve, allowing the adjustment of Pw values for optimal programming. The coverage of the patient against the current chronaxie-rheobase formula will be represented on three axes; an extra axis (z) will appear, multiplying each combination of Pw value and amplitude by the percentage of coverage corresponding to those values. Using this new comparison of chronaxie-rheobase curve vs. coverage, maximum Pw values will be obtained different from those obtained by classic methods.

Micafungin pharmacokinetic/pharmacodynamic adequacy for the treatment of invasive candidiasis in critically ill patients on continuous venovenous haemofiltration.

OBJECTIVES: To explore the pharmacokinetics (PK) and pharmacodynamics (PD) of micafungin in patients undergoing continuous venovenous haemofiltration (CVVH). PATIENTS AND METHODS: Ten patients receiving CVVH treated with 100 mg/day micafungin were included (April-December 2012). CVVH was performed using polyethersulphone or polysulphone haemofilters. Dialysis membranes were not changed on sampling days. On Days 1 and 2, blood samples from arterial pre-filter and venous post-filter ports and ultrafiltrate samples were collected at the start and end of the infusion and at 3, 5, 8, 18 and 24 h. Concentrations were determined using HPLC. Values for the area under the concentration-time curve (AUC0-24) were calculated. Monte Carlo simulations were performed using pre-filter and post-filter AUC0-24/MIC ratios on Days 1 and 2. The probability of target attainment (PTA) was calculated using AUC0-24/MIC cut-offs: 285 (C. parapsilosis), 3000 (all Candida spp.) and 5000 (non-parapsilosis Candida spp.). Cumulative fraction responses (CFRs) were calculated using EUCAST MIC distributions. RESULTS: Mean post-filter AUC0-24 (mg·h/L) values were higher than pre-filter values on Day 1 (83.31 ±â€Š15.87 versus 71.31 ±â€Š14.24; P = 0.008) and Day 2 (119.01 ±â€Š27.20 versus 104.54 ±â€Š21.23; P = 0.005). PTAs were ≥90% for MICs of 0.125 mg/L (cut-off = 285), 0.016 mg/L (cut-off = 3000) and 0.008 mg/L (cut-off = 5000) on Day 1, and for MICs of 0.25 mg/L (cut-off = 285) and 0.016 mg/L (cut-off = 3000 and 5000) on Day 2, without differences between pre- and post-filter values. On Day 2, CFRs >90% were obtained for C. albicans (cut-off = 3000 and 5000) and C. glabrata (cut-off = 3000), but not for C. parapsilosis. CONCLUSIONS: There was no removal of micafungin by CVVH or need for dose adjustment, and there was optimal PK/PD coverage for non-parapsilosis Candida and equivalence of pre- and post-filter PD.

Invasive techniques for pain management in palliative care: a single center experience.

UNLABELLED: To achieve a successful pain control, interventional techniques are required in approximately 15% of the patients admitted to the Palliative Care Service (PCS). OBJECTIVES: To evaluate the frequency and effectiveness of the invasive procedures performed in the PCS of our health area. Other matters studied included complications associated with these procedures, the effects on morphine consumption, and functional status, survival rate, as well as the type and location of pain. METHODS: A descriptive, observational, retrospective study was performed between January 2009 and December 2011. Patients included were considered difficult to manage and required the assistance of the PCS of the University Hospital La Paz (Madrid). RESULTS: Patients were divided into 3 groups according to the technique used: sympathetic blocks (group S), epidural catheters (group C), and series of plexus, peripheral nerve, or epidural infiltrations (group I). Ninety-four procedures in 45 patients were performed (3.6% of patients admitted by the PCS). The average mean value of pain intensity before and after procedures decreased significantly (8.6 vs. 3.1, respectively, P < 0.01). The need for strong opioids was reduced (275.5 mg/day previously and 212.8 mg/day after the technique, P < 0.01). The overall complication rate was 16%. CONCLUSION: The analgesic efficacy of these techniques has been adequate in all groups. Patients who required epidural catheters had a higher rate of complications.

Management of patients with chronic pelvic pain associated with endometriosis refractory to conventional treatment.

The literature contains numerous studies on the diagnosis, pathogenesis, atypical locations, and clinical (hormonal) and surgical management of the disorder. However, no information is available on the management of endometriosis involving pain refractory to the usual treatment from the perspective of a pain unit. Our hospital has a pain unit specifically dedicated to pain in gynecology and obstetrics. The unit has been functioning since December 2005, and 52% of the attended patients have CPP of different origins. Endometriosis is present in 48% of all patients with CPP and is the most prevalent pathology in our practice. It moreover poses an important challenge in view of its enormous complexity. A descriptive study was made of the management of 44 patients with endometriosis refractory to therapy, evaluated and treated over a period of 3 years in the Pain Unit of the Maternity Center of La Paz University Hospital (Madrid, Spain).

Teaching and Learning Obstetric Anaesthesia in Low- and Middle-Income Countries: Current Situation and Perspectives.

Purpose of Review: Our goal in this review is to describe the current context and peculiarities of obstetric anaesthesia in low- and middle-income countries (LMIC) and the ongoing actions and perspectives in terms of teaching and learning, focusing on improving maternal outcomes. Recent Findings: Correct identification of barriers and lack of infrastructures and anaesthesia providers are still major problems despite efforts of different stakeholders. International consensus and commitment for 2030 goals are trying to be achieved. Summary: Structured training courses look a good option as short- and long-term evaluations show a positive impact. Future efforts will have to be also focused on indicators that may help to decrease the high mortality and morbidity ratios in LMIC.

Helmet noninvasive mechanical ventilation in patients with acute postoperative respiratory failure.

BACKGROUND: The physiological and clinical effects of noninvasive ventilation (NIV) on acute postoperative respiratory failure are relatively unknown. The aim of this study was to determine the prediction factors for failure in the use of NIV with a helmet in this context. METHODS: This was a prospective observational study. The use of NIV was assessed for a period of 2 years in a postoperative ICU. Demographic data were collected, as well as acute respiratory failure (ARF) and arterial gas readings. Hemodynamic changes were assessed using pulse contour cardiac output technology, and the clinical development of subjects was recorded. All subjects who developed ARF were treated using NIV as their primary care, depending on whether the technique was successful or the subject required intubation. The risk factors that determined failure in the application of NIV were subsequently determined. RESULTS: Of the 99 subjects presenting with postoperative ARF treated with NIV using a helmet, 74 did not require intubation (74.7%). Following a multivariate analysis using logistic regression, we determined that there are 3 independent risk factors for the failure of NIV. Three factors were associated with respiratory failure: ARDS, pneumonia, and lack of improvement with NIV in 1 hour (increase in the P(aO(2))/F(IO(2))). CONCLUSIONS: NIV using a helmet could provide an effective alternative to conventional ventilation in selected patients with postoperative ARF.

Impact of Goal Directed Therapy in Head and Neck Oncological Surgery with Microsurgical Reconstruction: Free Flap Viability and Complications.

(1) Background: Surgical outcomes in free flap reconstruction of head and neck defects in cancer patients have improved steadily in recent years; however, correct anaesthesia management is also important. The aim of this study has been to show whether goal directed therapy can improve flap viability and morbidity and mortality in surgical patients. (2) Methods: we performed an observational case control study to analyse the impact of introducing a semi invasive device (Flo Trac®) during anaesthesia management to optimize fluid management. Patients were divided into two groups: one received goal directed therapy (GDT group) and the other conventional fluid management (CFM group). Our objective was to compare surgical outcomes, complications, fluid management, and length of stay between groups. (3) Results: We recruited 140 patients. There were no differences between groups in terms of demographic data. Statistically significant differences were observed in colloid infusion (GDT 53.1% vs. CFM 74.1%, p = 0.023) and also in intraoperative and postoperative infusion of crystalloids (CFM 5.72 (4.2, 6.98) vs. GDT 3.04 (2.29, 4.11), p < 0.001), which reached statistical significance. Vasopressor infusion in the operating room (CFM 25.5% vs. GDT 74.5%, p < 0.001) and during the first postoperative 24h (CFM 40.6% vs. GDT 75%, p > 0.001) also differed. Differences were also found in length of stay in the intensive care unit (hours: CFM 58.5 (40, 110) vs. GDT 40.5 (36, 64.5), p = 0.005) and in the hospital (days: CFM 15.5 (12, 26) vs. GDT 12 (10, 19), p = 0.009). We found differences in free flap necrosis rate (CMF 37.1% vs. GDT 13.6%, p = 0.003). One-year survival did not differ between groups (CFM 95.6% vs. GDT 86.8%, p = 0.08). (4) Conclusions: Goal directed therapy in oncological head and neck surgery improves outcomes in free flap reconstruction and also reduces length of stay in the hospital and intensive care unit, with their corresponding costs. It also appears to reduce morbidity, although these differences were not significant. Our results have shown that optimizing intraoperative fluid therapy improves postoperative morbidity and mortality.

[Duration of antibiotic therapy in intraabdominal infections]. / Duración del tratamiento antibiótico en la infección intraabdominal.

The duration of antibiotic treatment in patients with an infectious process is based on empirical considerations and those with intraabdominal infections are no exception. Therefore, the recommended duration of antibiotic therapy in intraabdominal infection is controversial and no consensus has been reached due to the lack of controlled studies that would provide sufficient scientific evidence. Excessive duration of antibiotic therapy can increase the risk of developing bacterial resistance as well as treatment-associated costs. These considerations have led to the exploration of "short-term treatment" strategies, lasting 3-5 days, with encouraging results. However, the development of biomarkers such as procalcitonin opens the door to individualized treatment that might allow the duration of antibiotic treatment in intraabdominal and other infections to be individually tailed to patient response.

New techniques and recommendations in the management of free flap surgery for head and neck defects in cancer patients.

Free flap surgery is the gold standard surgical treatment for head and neck defects in cancer patients. Outcomes have improved considerably, probably due to recent advances in surgical techniques. In this article, we review improvements in the parameters traditionally used to optimize hematocrit levels and body temperature and to prevent vasoconstriction, and describe the use of cardiac output-guided fluid management, a technique that has proved useful in other procedures. Finally, we review other parameters used in free flap surgery, such as clotting/platelet management and nutritional optimization.

Quality and safety guidelines of postanaesthesia care: Working Party on Post Anaesthesia Care (approved by the European Board and Section of Anaesthesiology, Union Européenne des Médecins Spécialistes).

Postanaesthesia care units are standard parts of hospital care in most European Union countries. Their main purpose is to identify and immediately treat early complications of surgery or anaesthesia, before they develop into deleterious problems. This review, prepared by the Working Party on Post Anaesthesia Care of the European Board of Anaesthesiology. European Union of Medical Specialists (Union Européenne des Médecins Spécialistes) and approved by the European Board and Section of Anaesthesiology, gives recommendations on relevant aspects of organization, responsibilities, methods, safety and quality control of postanaesthesia care.