Effect of Intraoperative High Positive End-Expiratory Pressure (PEEP) With Recruitment Maneuvers vs Low PEEP on Postoperative Pulmonary Complications in Obese Patients: A Randomized Clinical Trial.

Importance: An intraoperative higher level of positive end-expiratory positive pressure (PEEP) with alveolar recruitment maneuvers improves respiratory function in obese patients undergoing surgery, but the effect on clinical outcomes is uncertain. Objective: To determine whether a higher level of PEEP with alveolar recruitment maneuvers decreases postoperative pulmonary complications in obese patients undergoing surgery compared with a lower level of PEEP. Design, Setting, and Participants: Randomized clinical trial of 2013 adults with body mass indices of 35 or greater and substantial risk for postoperative pulmonary complications who were undergoing noncardiac, nonneurological surgery under general anesthesia. The trial was conducted at 77 sites in 23 countries from July 2014-February 2018; final follow-up: May 2018. Interventions: Patients were randomized to the high level of PEEP group (n = 989), consisting of a PEEP level of 12 cm H2O with alveolar recruitment maneuvers (a stepwise increase of tidal volume and eventually PEEP) or to the low level of PEEP group (n = 987), consisting of a PEEP level of 4 cm H2O. All patients received volume-controlled ventilation with a tidal volume of 7 mL/kg of predicted body weight. Main Outcomes and Measures: The primary outcome was a composite of pulmonary complications within the first 5 postoperative days, including respiratory failure, acute respiratory distress syndrome, bronchospasm, new pulmonary infiltrates, pulmonary infection, aspiration pneumonitis, pleural effusion, atelectasis, cardiopulmonary edema, and pneumothorax. Among the 9 prespecified secondary outcomes, 3 were intraoperative complications, including hypoxemia (oxygen desaturation with Spo2 ≤92% for >1 minute). Results: Among 2013 adults who were randomized, 1976 (98.2%) completed the trial (mean age, 48.8 years; 1381 [69.9%] women; 1778 [90.1%] underwent abdominal operations). In the intention-to-treat analysis, the primary outcome occurred in 211 of 989 patients (21.3%) in the high level of PEEP group compared with 233 of 987 patients (23.6%) in the low level of PEEP group (difference, -2.3% [95% CI, -5.9% to 1.4%]; risk ratio, 0.93 [95% CI, 0.83 to 1.04]; P = .23). Among the 9 prespecified secondary outcomes, 6 were not significantly different between the high and low level of PEEP groups, and 3 were significantly different, including fewer patients with hypoxemia (5.0% in the high level of PEEP group vs 13.6% in the low level of PEEP group; difference, -8.6% [95% CI, -11.1% to 6.1%]; P < .001). Conclusions and Relevance: Among obese patients undergoing surgery under general anesthesia, an intraoperative mechanical ventilation strategy with a higher level of PEEP and alveolar recruitment maneuvers, compared with a strategy with a lower level of PEEP, did not reduce postoperative pulmonary complications. Trial Registration: ClinicalTrials.gov Identifier: NCT02148692.

Association between night-time surgery and occurrence of intraoperative adverse events and postoperative pulmonary complications.

BACKGROUND: The aim of this post hoc analysis of a large cohort study was to evaluate the association between night-time surgery and the occurrence of intraoperative adverse events (AEs) and postoperative pulmonary complications (PPCs). METHODS: LAS VEGAS (Local Assessment of Ventilatory Management During General Anesthesia for Surgery) was a prospective international 1-week study that enrolled adult patients undergoing surgical procedures with general anaesthesia and mechanical ventilation in 146 hospitals across 29 countries. Surgeries were defined as occurring during 'daytime' when induction of anaesthesia was between 8:00 AM and 7:59 PM, and as 'night-time' when induction was between 8:00 PM and 7:59 AM. RESULTS: Of 9861 included patients, 555 (5.6%) underwent surgery during night-time. The proportion of patients who developed intraoperative AEs was higher during night-time surgery in unmatched (43.6% vs 34.1%; P<0.001) and propensity-matched analyses (43.7% vs 36.8%; P=0.029). PPCs also occurred more often in patients who underwent night-time surgery (14% vs 10%; P=0.004) in an unmatched cohort analysis, although not in a propensity-matched analysis (13.8% vs 11.8%; P=0.39). In a multivariable regression model, including patient characteristics and types of surgery and anaesthesia, night-time surgery was independently associated with a higher incidence of intraoperative AEs (odds ratio: 1.44; 95% confidence interval: 1.09-1.90; P=0.01), but not with a higher incidence of PPCs (odds ratio: 1.32; 95% confidence interval: 0.89-1.90; P=0.15). CONCLUSIONS: Intraoperative adverse events and postoperative pulmonary complications occurred more often in patients undergoing night-time surgery. Imbalances in patients' clinical characteristics, types of surgery, and intraoperative management at night-time partially explained the higher incidence of postoperative pulmonary complications, but not the higher incidence of adverse events. CLINICAL TRIAL REGISTRATION: NCT01601223.

Intraoperative ventilation settings and their associations with postoperative pulmonary complications in obese patients.

BACKGROUND: There is limited information concerning the current practice of intraoperative mechanical ventilation in obese patients, and the optimal ventilator settings for these patients are debated. We investigated intraoperative ventilation parameters and their associations with the development of postoperative pulmonary complications (PPCs) in obese patients. METHODS: We performed a secondary analysis of the international multicentre Local ASsessment of VEntilatory management during General Anesthesia for Surgery' (LAS VEGAS) study, restricted to obese patients, with a predefined composite outcome of PPCs as primary end-point. RESULTS: We analysed 2012 obese patients from 135 hospitals across 29 countries in Europe, North America, North Africa, and the Middle East. Tidal volume was 8.8 [25th-75th percentiles: 7.8-9.9] ml kg-1 predicted body weight, PEEP was 4 [1-5] cm H2O, and recruitment manoeuvres were performed in 7.7% of patients. PPCs occurred in 11.7% of patients and were independently associated with age (P<0.001), body mass index ≥40 kg m-2 (P=0.033), obstructive sleep apnoea (P=0.002), duration of anaesthesia (P<0.001), peak airway pressure (P<0.001), use of rescue recruitment manoeuvres (P<0.05) and routine recruitment manoeuvres performed by bag squeezing (P=0.021). PPCs were associated with an increased length of hospital stay (P<0.001). CONCLUSIONS: Obese patients are frequently ventilated with high tidal volume and low PEEP, and seldom receive recruitment manoeuvres. PPCs increase hospital stay, and are associated with preoperative conditions, duration of anaesthesia and intraoperative ventilation settings. Randomised trials are warranted to clarify the role of different ventilatory parameters in obese patients. CLINICAL TRIAL REGISTRATION: NCT01601223.

A systematic review and consensus definitions for standardised end-points in perioperative medicine: pulmonary complications.

BACKGROUND: There is a need for robust, clearly defined, patient-relevant outcome measures for use in randomised trials in perioperative medicine. Our objective was to establish standard outcome measures for postoperative pulmonary complications research. METHODS: A systematic literature search was conducted using MEDLINE, Web of Science, SciELO, and the Korean Journal Database. Definitions were extracted from included manuscripts. We then conducted a three-stage Delphi consensus process to select the optimal outcome measures in terms of methodological quality and overall suitability for perioperative trials. RESULTS: From 2358 records, the full texts of 81 manuscripts were retrieved, of which 45 met the inclusion criteria. We identified three main categories of outcome measure specific to perioperative pulmonary outcomes: (i) composite outcome measures of multiple pulmonary outcomes (27 definitions); (ii) pneumonia (12 definitions); and (iii) respiratory failure (six definitions). These were rated by the group according to suitability for routine use. The majority of definitions were given a low score, and many were imprecise, difficult to apply consistently, or both, in large patient populations. A small number of highly rated definitions were identified as appropriate for widespread use. The group then recommended four outcome measures for future use, including one new definition. CONCLUSIONS: A large number of postoperative pulmonary outcome measures have been used, but most are poorly defined. Our four recommended outcome measures include a new definition of postoperative pulmonary complications, incorporating an assessment of severity. These definitions will meet the needs of most clinical effectiveness trials of treatments to improve postoperative pulmonary outcomes.

Protective intraoperative ventilation with higher versus lower levels of positive end-expiratory pressure in obese patients (PROBESE): study protocol for a randomized controlled trial.

BACKGROUND: Postoperative pulmonary complications (PPCs) increase the morbidity and mortality of surgery in obese patients. High levels of positive end-expiratory pressure (PEEP) with lung recruitment maneuvers may improve intraoperative respiratory function, but they can also compromise hemodynamics, and the effects on PPCs are uncertain. We hypothesized that intraoperative mechanical ventilation using high PEEP with periodic recruitment maneuvers, as compared with low PEEP without recruitment maneuvers, prevents PPCs in obese patients. METHODS/DESIGN: The PRotective Ventilation with Higher versus Lower PEEP during General Anesthesia for Surgery in OBESE Patients (PROBESE) study is a multicenter, two-arm, international randomized controlled trial. In total, 2013 obese patients with body mass index ≥35 kg/m2 scheduled for at least 2 h of surgery under general anesthesia and at intermediate to high risk for PPCs will be included. Patients are ventilated intraoperatively with a low tidal volume of 7 ml/kg (predicted body weight) and randomly assigned to PEEP of 12 cmH2O with lung recruitment maneuvers (high PEEP) or PEEP of 4 cmH2O without recruitment maneuvers (low PEEP). The occurrence of PPCs will be recorded as collapsed composite of single adverse pulmonary events and represents the primary endpoint. DISCUSSION: To our knowledge, the PROBESE trial is the first multicenter, international randomized controlled trial to compare the effects of two different levels of intraoperative PEEP during protective low tidal volume ventilation on PPCs in obese patients. The results of the PROBESE trial will support anesthesiologists in their decision to choose a certain PEEP level during general anesthesia for surgery in obese patients in an attempt to prevent PPCs. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02148692. Registered on 23 May 2014; last updated 7 June 2016.

Magnesium alloys and graphite wastes encapsulated in cementitious materials: Reduction of galvanic corrosion using alkali hydroxide activated blast furnace slag.

Magnesium alloys and graphite from spent nuclear fuel have been stored together in La Hague plant. The packaging of these wastes is under consideration. These wastes could be mixed in a grout composed of industrially available cement (Portland, calcium aluminate…). Within the alkaline pore solution of these matrixes, magnesium alloys are imperfectly protected by a layer of Brucite resulting in a slow corrosion releasing hydrogen. As the production of this gas must be considered for the storage safety, and the quality of wasteform, it is important to select a cement matrix capable of lowering the corrosion kinetics. Many types of calcium based cements have been tested and most of them have caused strong hydrogen production when magnesium alloys and graphite are conditioned together because of galvanic corrosion. Exceptions are binders based on alkali hydroxide activated ground granulated blast furnace slag (BFS) which are presented in this article.

[Court-ordered treatment: Analysing a complex practise through a literature review]. / Les soins pénalement ordonnés : analyse d'une pratique complexe à travers une revue de la littérature.

INTRODUCTION: In France, there are two main types of court-ordered treatment (COT) as far as mental health is concerned: obligations of treatment and injunctions of treatment. Obligations of treatment date back from 1958 whereas the law implementing injunctions of treatment is fairly recent as it was passed in 1998. Obligations and injunctions of treatment are two different types of COT that differ in terms of proceedings (obligations of treatment require no preliminary forensic psychiatric assessment; as for injunctions of treatment, they require the appointment of a coordinating medical doctor) and that are applied for different offences. However, both are psychiatric commitment procedures connecting the judicial, medical and social fields and their overall numbers have been on the rise. These common psychiatric practices have seldom been assessed and no review of the literature on the subject has ever been published. Better knowledge of such forensic practices is essential to their improvement and even to adjust the legal framework of these measures that are enjoying a boom. The purpose of this literature review is to define the prevalence of COT as well as the sociodemographic, criminal and psychiatric characteristics of those concerned by such measures. MATERIAL AND METHODS: A review of the French medical literature on COT was carried out using Science Direct up to December 2013. The results of seven studies were included and analysed. This was completed with a review of the articles listed in social sciences and law databases (Cairn and Dalloz). RESULTS: It has become increasingly frequent to rely on psychiatric teams to implement COT while at the same time public mental health services have to face a surge in activity with restricted financial means. Obligations of treatment are far more common (about 20,000 court orders a year) than injunctions of treatment (about 4000 measures are currently being enforced). However the latter have showed an increase of 506% over the 2000 decade. Both measures mainly concern men (83-99%) who are rather low on the social scale. In about half of these men, no mental disorder was found, however the prevalence of personality disorders ranged from 22 to 65% while that of psychotic disorders was low. Injunctions of treatment concerned sex offenders (90% of cases) whereas obligations of treatment concern non-sexual abusers (40-70%) rather than sex offenders (20-30%). DISCUSSION: Psychiatric research on COT is still thin on the ground and its methodology does not allow rigorous evaluation though the use of such measures is growing. When confronted with people who have not sought any care or treatment, healthcare professionals are at a loss. In France, training in forensic psychiatry is inadequate and specialised healthcare (particularly for sex offenders) need improving to reach the level of those found in many other European countries. The purpose of psychiatric treatment differs from that of lawmakers whose aim is to prevent recidivism. However, better treatment consistency requires setting up partnerships between justice, health and social services. To improve connections, there are various avenues of work such as, for instance, the creation of coordinating medical doctors for injunctions of treatment in France or European experiments using a multidisciplinary approach to prevent recidivism in sex offenders. The framework of such a partnership remains to be created as it is part and parcel of COT but has not been provided for in the law. Healthcare jurisdictions as defined in the 2009 French National Health Law might provide an appropriate framework for mental health and law professionals to collaborate.

Preoperative estimated glomerular filtration rate and the risk of major adverse cardiovascular and cerebrovascular events in non-cardiac surgery.

BACKGROUND: Chronic kidney disease is an independent predictor of perioperative cardiovascular morbidity and mortality. We analysed the preoperative estimated glomerular filtration rate (eGFR) as a risk factor for perioperative major adverse cardiovascular and cerebrovascular events (MACCE) in non-cardiac surgery. METHODS: In a post hoc analysis of the ANESCARDIOCAT database, patients were classified into six stages of eGFR calculated with the abbreviated Modification of Diet in Renal Disease Study and the Chronic Kidney Disease Epidemiology Collaboration equations: >90 (1), 60-89.9 (2), 45-59.9 (3a), 30-44.9 (3b), 15-29.9 (4), and <15 (5) ml min(-1) 1.73 m(-2). We analysed differences in MACCE, length of hospital stay, and all-cause mortality between eGFR stages. RESULTS: The eGFR was available in 2323 patients. Perioperative MACCE occurred in 4.5% of patients and cardiac-related mortality was 0.5%. Five hundred and forty-three (23.4%) patients had an eGFR of <60 ml min(-1) 1.73 m(-2) and 127 (5.4%) had an eGFR below 45 ml min(-1) 1.73 m(-2). Logistic regression analysis showed that MACCE increased with eGFR impairment (P<0.001), with a marked increase from stage 3b onwards (odds ratio 1.8 vs 3.9 in 3a and 3b, respectively, P=0.047). All-cause mortality was not related to eGFR (P=0.071), but increased substantially between stages 3b and 4. The length of stay correlated with eGFR (P<0.001). CONCLUSIONS: Perioperative MACCE increase with declining eGFR, primarily when <45 ml min(-1) 1.73 m(-2). We recommend the use of preoperative eGFR for cardiovascular risk assessment.

Effects of intraoperative colloid administration on outcome in a population-based general surgical cohort: a propensity score analysis.

BACKGROUND: Many studies on colloids have recently been retracted, leaving us with uncertain evidence of their safety. We aimed to analyze whether intraoperative colloid administration is associated with postoperative complications. METHODS: The prospectively compiled database of the ARISCAT study of a large, representative cohort of general surgical patients was reanalyzed to compare outcomes according to whether intraoperative colloids were administered or not; a propensity score was used to adjust for potential confounders. The primary outcomes were major postoperative complications. Secondary outcomes were postoperative hospital-free days within 90 days and mortality at 30 and 90 days. In a retrospective survey we asked each center's data collectors to estimate the proportions of the different colloids administered during the study period. RESULTS: Of 2462 patients analyzed, 556 (22.6%) received some type of colloid intraoperatively. The median (25th-75th percentile) of total fluids administered was significantly higher in patients receiving colloids (10.0 [6.9-14.1] mL·kg-1·h-1 vs. 8.8 [6.0-12.8] mL·kg-1·h-1 for patients not receiving colloids; P<0.01). The median volume of colloids administered was 7.5 (6.3-10.4) mL·kg-1. An estimated 75.7% of the patients received third-generation hydroxyethyl starches (130/0.4). Significantly associated complications, after propensity score adjustment, were atelectasis, respiratory infection, bronchospasm, arrhythmia, sepsis, paralytic ileum, and hyperglycemia. Patients receiving colloids had 1.9 fewer postoperative hospital-free days (P<0.006). There were no significant differences in 30- and 90-day mortality. CONCLUSION: Our study suggests an association of intraoperative colloid administration, mainly of 130/0.4 hydroxyethyl starches, with diverse major postoperative complications and longer hospital stay. Controlled studies are urgently needed to assess the safety profile of colloid use in surgical patients.

[Evaluation of the efficiency of pharmacological antiemetic prophylaxis in different risk groups after general anaesthesia in the surgical population of Catalonia]. / Valoración de la eficiencia de la profilaxis antiemética farmacológica en diferentes grupos de riesgo tras anestesia general en la población quirúrgica de Cataluña.

OBJECTIVE: To assess the efficiency of pharmacological antiemetic prophylaxis in patients subjected to surgery under general anaesthetic in different postoperative nausea and vomiting (NVPO) risk groups. MATERIAL AND METHODS: A randomised, observational, prospective and multicentre cohort study was conducted. The study included 1239 patients from 26 hospitals who were subjected to elective surgery under general anaesthesia. The data collected included, demographic characteristics, the NVPO risk factors, anaesthetic technique, type of surgery, the duration, fluid therapy, antiemetic prophylaxis administered, and the incidence of NVPO in the first 24h after surgery. A stratified analysis (low, moderate and high risk) was performed with the intention of evaluating the relationship between prophylaxis and NVPO using a logistic regression model adjusted for propensity score. The number of patients needed to treat (NNT) to prevent an NVPO episode was then calculated for each of the strata. RESULTS: The incidence of NVPO in the low risk stratum was 21.6% without prophylaxis and 8.6% with prophylaxis, 31.3% compared to 17.7% in the moderate risk, and 46.5% compared to 32.7% in the high risk group. There was a significant protective effect in the three strata (odds ratio between treated and untreated patients) and in the NNT (95% CI) was 7 (5-11) in the low risk stratum, 7 (5-13) in that of the moderate risk, and 6 (4-16) in the high risk. CONCLUSIONS: The efficiency of pharmacological antiemetic prophylaxis in patients subjected to surgery under general anaesthesia was similar in all risk groups. Not providing antiemetic prophylaxis in low risk patients may not be justified due to the cost-effectiveness criteria. Future clinical guidelines to improve the quality of health care of patients operated on under general anaesthesia should consider the advantages of a universal NVPO prophylaxis.

Incidence and predictors of major perioperative adverse cardiac and cerebrovascular events in non-cardiac surgery.

BACKGROUND: Major adverse cardiac and cerebrovascular events (MACCE) represent the most common cause of serious perioperative morbidity and mortality. Our aim was to identify risk factors for MACCE in a broad surgical population with intermediate-to-high surgery-specific risk and to build and validate a model to predict the risk of MACCE. METHODS: A prospective, multicentre study of patients undergoing surgical procedures under general or regional anaesthesia in 23 hospitals. The main outcome was the occurrence of at least one perioperative MACCE, defined as any of the following complications from admittance to discharge: cardiac death, cerebrovascular death, non-fatal cardiac arrest, acute myocardial infarction, congestive heart failure, new cardiac arrhythmia, angina, or stroke. The MACCE predictive index was based on ß-coefficients and validated in an external data set. RESULTS: Of 3387 patients recruited, 146 (4.3%) developed at least one MACCE. The regression model identified seven independent risk factors for MACCE: history of coronary artery disease, history of chronic congestive heart failure, chronic kidney disease, history of cerebrovascular disease, preoperative abnormal ECG, intraoperative hypotension, and blood transfusion. The area under the receiver-operating characteristic curve was 75.9% (95% confidence interval, 71.2-80.6%). CONCLUSIONS: The risk score based on seven objective and easily assessed factors can accurately predict MACCE occurrence after non-cardiac surgery in a population at intermediate-to-high surgery-specific risk.

[Risk factors for postoperative acute kidney injury in a cohort of 2378 patients from 59 hospitals]. / Factores de riesgo de insuficiencia renal aguda postoperatoria. Análisis en una cohorte de 2.378 pacientes de 59 hospitales.

OBJECTIVES: To assess risk factors for postoperative acute kidney injury (AKI) in adults with normal renal function hospitalized for major surgery. To analyze mortality and length of hospital stay in patients who develop postoperative AKI. PATIENTS AND METHODS: Data for analysis were drawn from the 2006 ARISCAT study. The dependent variable was postoperative AKI defined as a decline in renal function demonstrated by a rise in plasma creatinine level to twice the baseline measurement or a 50% reduction in the glomerular filtration rate. Bivariate and multivariate analyses were used to identify preoperative and intraoperative risk factors. RESULTS: We analyzed 2378 of the ARISCAT cases, which had been enrolled from 59 participating hospitals; 25 patients (1.1%) developed AKI. Analysis identified 5 risk factors: age, peripheral arterial disease, type of surgical incision, blood loss, and infusion of colloids. The area under the receiver operating characteristic curve was 0.88% (95% confidence interval, 0.79%-0.69%). Duration of hospital stay was longer for patients with postoperative AKI (21.8 days, vs 5.5 days for other patients; P=.007). Mortality was higher in patients with AKI at 30 days (36% vs 0.9%) and at 3 months (48% vs 1.7%). CONCLUSIONS: The incidence of postoperative AKI was slightly over 1%. Knowledge of postoperative AKI risk factors can facilitate the planning of surgical interventions and anesthesia to reduce subsequent morbidity and mortality and length of hospital stay.

[Neuromuscular block management during general anesthesia in a cohort of 1545 patients: a multicenter study]. / Estudio multicéntrico sobre el manejo del bloqueo neuromuscular durante la anestesia general en una cohorte de 1.545 pacientes.

BACKGROUND AND OBJECTIVE: Neuromuscular blockers (NMBs) have traditionally been thought to increase the risk of respiratory complications, although drawing conclusions in this respect would require complex studies in large patient samples. The aim of this study was to analyze data from the ARISCAT study to obtain an overall picture of how NMBs are being used and blocks are reversed in Catalonia, Spain. MATERIAL AND METHODS: NMB use as reflected in data from the ARISCAT study was analyzed. Case information from the database was organized into 4 groups: for patients not receiving a NMB (No-NMB), patients whose NMB block was performed with succinylcholine alone (SC), patients who received a single dose of a nondepolarizing NMB (SD-NMB), and patients who received additional doses of a nondepolarizing NMB or a continuous perfusion (AD-NMB). We analyzed patient characteristics, clinical and surgical characteristics, and complications during and after surgery in each of the groups. Variables were also analyzed according to whether the NMB effect had to be reversed. RESULTS: Of the 2991 patients included in the ARISCAT study, 1545 received general or combined anesthesia. Of the 1545 patients, 1267 (89%) received a NMB and the block was reversed with an anticholinesterase agent in 54%. The group distribution was as follows: No-NMB, 103 patients; SC, 31; SD-NMB, 527; and AD-NMB, 709. The highest rate of comorbidity, longest duration of surgery, highest rate of complications during and after surgery, and the longest hospital stays were observed in the last of the 4 groups (AD-NMB). Reversion was required significantly more often after cardiothoracic and upper abdominal surgical procedures; the complication rates after those 2 types of surgery were statistically similar. CONCLUSIONS: Nondepolarizing NMBs are used in combination with general anesthesia often in Catalonia; their use is associated with duration and type of surgery. A reversal drug is administered relatively more often in Catalonia than in other geographic areas.

[Health-care workload and instructional capacity of Spanish hospitals accredited to train residents in anesthesiology]. / Actividad asistencial y capacidad docente de los hospitales españoles acreditados para la formación de residentes de anestesiología.

OBJECTIVES: To describe the health-care workload and instructional capacity of Spanish hospitals accredited to train anesthesiology residents. METHODS: Survey of supervisors of anesthesiology residents in 2008 to determine caseloads in surgery and obstetrics as well as in pain clinics and critical care units. The results are presented for different Spanish autonomous communities. The maximum theoretical capacity for instruction in accordance with European guidelines is calculated. RESULTS: The 100 hospitals surveyed train 325 residents per year and could theoretically increase the training opportunities they offer, within certain limits. Given optimal distribution of resources, the system could train 397 residents per year in pediatric surgery in 3-month rotations, 442 residents in neurosurgery in 2-month rotations, and 479 residents in thoracic surgery in 1-month rotations. Some Spanish communities presently have problems giving training in the settings of pediatric, thoracic, and major outpatient surgery. Furthermore, even though anesthesiologists are presently responsible for 41.6% of available critical care beds, 46 hospitals do not have a sufficient number of beds to give training in this setting. This shortage may have negative repercussions on the accreditation of training programs. CONCLUSIONS: Although certain limitations were found, the survey showed that the training capacity of the system is greater than accreditation suggests. It would therefore be possible to increase the number of residents.