COVID-19 thromboprophylaxis. New evidence.

Recent publications have questioned the efficacy of using therapeutic or intermediate doses of low molecular weight heparin (LMWH) in COVID-19 patients, especially in the most severe patients. In order to update these recommendations, a non-systematic review has been carried out in the main medical databases. A total of 14 randomized clinical trials, 14 meta-analyses and the recommendations of 12 scientific societies were selected, stratified according to the type of patient (outpatient, hospitalized, admitted to critical care or post-discharge). The efficacy of LMWH and other therapeutic approaches (rivaroxaban, apixaban, sulodexide, acetylsalicylic acid and P2Y12 inhibitors) has been analyzed. The findings recommend using standard doses of LMWH as thromboprophylaxis in critically hospitalized COVID-19 patients and therapeutic doses in non-critically hospitalized patients if the risk of bleeding is low. In outpatients and those discharged from the hospital, LMWH could be used at a prophylactic dose if there are thrombotic risk factors, and the bleeding risk is low. It is not recommended to associate antiplatelet agents with LMWH unless previously indicated.

SEDAR-SEMICYUC consensus recommendations on the management of haemostasis disorders in severely ill patients with COVID-19 infection. / Recomendaciones de consenso SEDAR-SEMICYUC sobre el manejo de las alteraciones de la hemostasia en los pacientes graves con infección por COVID-19.

The infection by the coronavirus SARS-CoV-2, which causes the disease called COVID-19, mainly causes alterations in the respiratory system. In severely ill patients, the disease often evolves into an acute respiratory distress syndrome that can predispose patients to a state of hypercoagulability, with thrombosis at both venous and arterial levels. This predisposition presents a multifactorial physiopathology, related to hypoxia as well as to the severe inflammatory process linked to this pathology, including the additional thrombotic factors present in many of the patients. In view of the need to optimise the management of hypercoagulability, the working groups of the Scientific Societies of Anaesthesiology-Resuscitation and Pain Therapy (SEDAR) and of Intensive, Critical Care Medicine and Coronary Units (SEMICYUC) have developed a consensus to establish guidelines for actions to be taken against alterations in haemostasis observed in severely ill patients with COVID-19. These recommendations include prophylaxis of venous thromboembolic disease in these patients, and in the peripartum, management of patients on long-term antiplatelet or anticoagulant treatment, bleeding complications in the course of the disease, and the interpretation of general alterations in haemostasis.

Preservation of renal function in cardiac surgery patients with low cardiac output syndrome: levosimendan vs beta agonists.

BACKGROUND: Some studies have been performed to assess the effects of levosimendan on cardiac function when administered to cardiac surgery patients with low cardiac output syndrome (LCOS) in the immediate postoperative period. Levosimendan is an inotropic agent for the treatment of low cardiac output syndrome that seems to have a protective effect on renal function. METHODS: It is a quasi-experimental study. A total of 100 patients with LCOS received either beta-agonists or levosimendan. We assessed the incidence of postoperative kidney failure in cardiac surgery patients. In patients who had kidney failure at diagnosis of LCOS, we examined whether differences existed in the evolution of kidney failure based on the treatment administered for LCOS. The parameters measured included haemodynamics, oxygen supply, and renal function as assessed by the AKI scale. ANOVA, Student's t-test and Wilcoxon or Friedman tests were used. RESULTS: Up to 30% of cardiac surgery patients had kidney failure at diagnosis of LCOS. Kidney failure at discharge from the ICU was more frequent in patients who received beta-agonist drugs as compared to those who received levosimendan (p < 0.05). CONCLUSION: The incidence of kidney failure decreased with the postoperative administration of levosimendan to cardiac surgery patients with LCOS, as compared to beta-agonists. TRIAL REGISTRATION: Current Controlled Trials ISRCTN 46058317. Date of registration: 7/10/2019. Retrospectively registered.

[Evaluation of quality of life, social stigma and treatment adherence in patients with epilepsy in the Caceres Healthcare Area: a cross-sectional study]. / Valoracion de la calidad de vida, estigma social y adhesion al tratamiento en pacientes con epilepsia del Area de Salud de Caceres: estudio transversal.

INTRODUCTION: Epilepsy is a chronic disease with high prevalence. Its impact in the quality of life is influenced by factors like disease characteristics, comorbidities, stigma perception and treatment adherence. AIM: To assess the quality of life, the social stigma and the treatment adherence of patients with epilepsy in our area. PATIENTS AND METHODS: Descriptive, observational and cross-sectional study. Sociodemographic and clinical data were collected. We analyzed data on quality of life (QUOLIE-10), social stigma and treatment adherence through different questionnaires. RESULTS: 40 patients were studied. The mean age was 42.43 ± 17.20 years, and the onset of epilepsy was 25.88 ± 16.81 years. 55% were women. The score in the quality of life questionnaire was 19.28 ± 8.03 points in men and 17.00 ± 7.69 for women, this difference being not significant. There were also no significant differences for social stigma, with a mean of 11.50 ± 13.47 points in men and 6.00 ± 10.36 points for women (p = 0.152). According to the treatment adherence questionnaire (Morisky-Green), 70% of the patients studied were compliant with the treatment. CONCLUSIONS: Patients with epilepsy in our environment have a good quality of life, probably related to good treatment adherence and compliance. There is low perceived social stigma but people with epilepsy still trend to hide their condition.

TITLE: Valoracion de la calidad de vida, estigma social y adhesion al tratamiento en pacientes con epilepsia del Area de Salud de Caceres: estudio transversal.Introduccion. La epilepsia es una enfermedad cronica, con elevada prevalencia. La repercusion de la epilepsia en la calidad de vida de las personas que la padecen se ve influida por factores como las caracteristicas de la enfermedad, la presencia de comorbilidad, la percepcion de estigma social y la adhesion al tratamiento. Objetivo. Valorar la calidad de vida, el estigma social y la adhesion al tratamiento de pacientes con epilepsia de nuestra area. Pacientes y metodos. Estudio descriptivo, observacional y transversal. Se recogieron datos sociodemograficos y clinicos. Analizamos datos sobre la calidad de vida (Quality of Life in Epilepsy-10), el estigma social y la adhesion al tratamiento a traves de diferentes cuestionarios. Resultados. Se estudio a 40 pacientes, con una media de edad de 42,43 ± 17,2 años y una media de edad de inicio de la epilepsia de 25,88 ± 16,81 años. El 55% fueron mujeres. La puntuacion en el cuestionario sobre calidad de vida fue de 19,28 ± 8,03 puntos para los hombres y 17,00 ± 7,69 para las mujeres, y esta diferencia no fue significativa. Tampoco se observaron diferencias significativas para el estigma social: media de 11,50 ± 13,47 puntos para los hombres y 6,00 ± 10,36 para las mujeres (p = 0,152). Segun el cuestionario de adhesion terapeutica (Morisky-Green), el 70% de los pacientes fue cumplidor del tratamiento. Conclusiones. Los pacientes con epilepsia tienen una buena calidad de vida, que creemos atribuible a la buena adhesion y el cumplimiento del tratamiento. Se detecta una baja percepcion de estigma social, pero los pacientes tienden a ocultar el diagnostico.

Forum for debate: Safety of allogeneic blood transfusion alternatives in the surgical/critically ill patient.

In recent years, several safety alerts have questioned or restricted the use of some pharmacological alternatives to allogeneic blood transfusion in established indications. In contrast, there seems to be a promotion of other alternatives, based on blood products and/or antifibrinolytic drugs, which lack a solid scientific basis. The Multidisciplinary Autotransfusion Study Group and the Anemia Working Group España convened a multidisciplinary panel of 23 experts belonging to different healthcare areas in a forum for debate to: 1) analyze the different safety alerts referred to certain transfusion alternatives; 2) study the background leading to such alternatives, the evidence supporting them, and their consequences for everyday clinical practice, and 3) issue a weighted statement on the safety of each questioned transfusion alternative, according to its clinical use. The members of the forum maintained telematics contact for the exchange of information and the distribution of tasks, and a joint meeting was held where the conclusions on each of the items examined were presented and discussed. A first version of the document was drafted, and subjected to 4 rounds of review and updating until consensus was reached (unanimously in most cases). We present the final version of the document, approved by all panel members, and hope it will be useful for our colleagues.

[Perioperative management of direct oral anticoagulant in emergency surgery and bleeding. Haemostasis monitoring and treatment]. / Manejo perioperatorio de los anticoagulantes orales directos en cirugía urgente y sangrado. Monitorización y tratamiento hemostático.

There is an almost unanimous consensus on the management of the direct new oral anticoagulants, dabigatran, rivaroxaban, and apixaban in elective surgery. However, this general consensus does not exist in relation with the direct new oral anticoagulants use in emergency surgery, especially in the bleeding patient. For this reason, a literature review was performed using the MEDLINE-PubMed. An analysis was made of the journal articles, reviews, systematic reviews, and practices guidelines published between 2000 and 2014 using the terms "monitoring" and "reversal". From this review, it was shown that the routine tests of blood coagulation, such as the prothrombin time and activated partial thromboplastin time, have a limited efficacy in the perioperative control of blood coagulation in these patients. There is currently no antidote to reverse the effects of these drugs, although the possibility of using concentrated prothrombin complex and recombinant activated factor vii has been suggested for the urgent reversal of the anticoagulant effect.

The perioperative management of new direct oral anticoagulants: a question without answers.

New direct oral anticoagulant agents (DOAC) are currently licensed for thromboprophylaxis after hip and knee arthroplasty and for long-term prevention of thromboembolic events in non-valvular atrial fibrillation as well as treatment and secondary prophylaxis of venous thromboembolism. Some other medical indications are emerging. Thus, anaesthesiologists are increasingly likely to encounter patients on these drugs who need elective or emergency surgery. Due to the lack of experience and data, the management of DOAC in the perioperative period is controversial. In this article, we review available information and recommendations regarding the periprocedural management of the currently most clinically developed DOAC, apixaban, dabigatran, and rivaroxaban. We discuss two trends of managing patients on DOAC for elective surgery. The first is stopping the DOAC 1-5 days before surgery (depending on the drug, patient and bleeding risk) without bridging. The second is stopping the DOAC 5 days preoperatively and bridging with low-molecular-weight heparin. The management of patients on DOAC needing emergency surgery is also reviewed. As no data exist for the use of haemostatic products for the reversal of the anticoagulant effect in these cases, rescue treatment recommendations are proposed.

[The 2013 Seville Consensus Document on alternatives to allogenic blood transfusion. An update on the Seville Document]. / 2013. Documento Sevilla de Consenso sobre Alternativas a la Transfusión de Sangre Alogénica. Actualización del Documento Sevilla.

Since allogeneic blood transfusion (ABT) is not harmless, multiple alternatives to ABT (AABT) have emerged, though there is great variability in their indications and appropriate use. This variability results from the interaction of a number of factors, including the specialty of the physician, knowledge and preferences, the degree of anemia, transfusion policy, and AABT availability. Since AABTs are not harmless and may not meet cost-effectiveness criteria, such variability is unacceptable. The Spanish Societies of Anesthesiology (SEDAR), Hematology and Hemotherapy (SEHH), Hospital Pharmacy (SEFH), Critical Care Medicine (SEMICYUC), Thrombosis and Hemostasis (SETH) and Blood Transfusion (SETS) have developed a Consensus Document for the proper use of AABTs. A panel of experts convened by these 6 Societies have conducted a systematic review of the medical literature and have developed the 2013 Seville Consensus Document on Alternatives to Allogeneic Blood Transfusion, which only considers those AABT aimed at decreasing the transfusion of packed red cells. AABTs are defined as any pharmacological or non-pharmacological measure aimed at decreasing the transfusion of red blood cell concentrates, while preserving patient safety. For each AABT, the main question formulated, positively or negatively, is: « Does this particular AABT reduce the transfusion rate or not?¼ All the recommendations on the use of AABTs were formulated according to the Grades of Recommendation Assessment, Development and Evaluation (GRADE) methodology.

[The 2013 Seville Consensus Document on alternatives to allogenic blood transfusion. An update on the Seville Document]. / 2013. Documento Sevilla de Consenso sobre Alternativas a la Transfusión de Sangre Alogénica. Actualización del Documento Sevilla.

Since allogeneic blood transfusion (ABT) is not harmless, multiple alternatives to ABT (AABT) have emerged, though there is great variability in their indications and appropriate use. This variability results from the interaction of a number of factors, including the specialty of the physician, knowledge and preferences, the degree of anemia, transfusion policy, and AABT availability. Since AABTs are not harmless and may not meet cost-effectiveness criteria, such variability is unacceptable. The Spanish Societies of Anesthesiology (SEDAR), Hematology and Hemotherapy (SEHH), Hospital Pharmacy (SEFH), Critical Care Medicine (SEMICYUC), Thrombosis and Hemostasis (SETH) and Blood Transfusion (SETS) have developed a Consensus Document for the proper use of AABTs. A panel of experts convened by these 6 Societies have conducted a systematic review of the medical literature and have developed the 2013 Seville Consensus Document on Alternatives to Allogeneic Blood Transfusion, which only considers those AABT aimed at decreasing the transfusion of packed red cells. AABTs are defined as any pharmacological or non-pharmacological measure aimed at decreasing the transfusion of red blood cell concentrates, while preserving patient safety. For each AABT, the main question formulated, positively or negatively, is: "Does this particular AABT reduce the transfusion rate or not?" All the recommendations on the use of AABTs were formulated according to the Grades of Recommendation Assessment, Development and Evaluation (GRADE) methodology.

[Management of direct action oral anticoagulants in the peri-operative period and invasive techniques]. / Manejo de los anticoagulantes orales de acción directa en el período perioperatorio y técnicas invasivas.

The new direct-acting oral anticoagulants (ACOD) in patients on prolonged treatment require the need to balance the risk of haemorrhage by administering them against the risk of thrombosis on withdrawing them. Recommendations for their management are proposed in the present article: A) Thromboprophylaxis and general anaesthesia: the performing of regional anaesthesia if administered with an ACOD as thromboprophylaxis requires some safety intervals based on their pharmacokinetic parameters; B) Management of ACOD in elective surgery: in patients with normal renal function and a low haemorrhage/thrombosis risk, stop the ACOD two days before the surgery; it the haemorrhage/thrombosis risk is high and/or renal function is impaired, therapy with a low molecular weight heparin is proposed from 5 days prior to the surgery, and C) Management of ACOD in urgent surgery and associated haemorrhage: the systematic prophylactic administration of haemostatics is recommended. In the event of acute bleeding that may place the life of the patient at risk (due to volume or location), the administration of concentrated prothrombin complex, fresh plasma, or factor VIIa, must be assessed, together with general control measures of acute haemorrhage. These recommendations should be considered in the context of the use drugs that do have a specific antidote, where their monitoring by the usual coagulation tests is not routine, and with those in which there is limited experience. We believe they need to be reviewed in the future, depending on further studies and clinical experience obtained.

Perioperative use of prothrombin complex concentrates.

Prothrombin complex concentrates (PCCs) are purified drug products with hemostatic activity derived from a plasma pool. Today, PCCs contain a given and proportional amount of four non-activated vitamin K-dependent coagulation factors (II, VII, IX, and X), a variable amount of anticoagulant proteins (proteins C and S, and in some antithrombin) and low-dose heparin. In some countries PCC products contained only three clotting factors, II, IX, and X. Dosage recommendations are based on IU of F-IX, so that one IU of F-IX represents the activity of F-IX in 1 mL of plasma. Reversion of the anticoagulant effect of vitamin K antagonists (VKAs) in cases of symptomatic overdose, active bleeding episodes, or need for emergency surgery is the most important indication for PCCs and this effect of PCCs appears to be more complete and rapid than that caused by administration of fresh frozen plasma. They may be considered as safe preparations if they are used for their approved indications at the recommended dosage with adequate precautions for administration, and have been shown to be effective for reversing the effect of VKAs. Their adequate use based on decision algorithms in the perioperative setting allows a rapid normalization of International Normalized Ratio (INR) for performing emergency surgery, minimizing bleeding risk. This review aims to propose two algorithms for the use of PCCs in the perioperative setting, one to calculate the PCCs dose to be administered in a bleeding patient and/or immediately before urgent surgery, based on patient's clinical status, prior INR and INR target and another for reversing the action of oral anticoagulants depending on urgency of surgery.

[Pain and anxiety in pediatric surgery]. / Dolor y ansiedad en cirugía pediátrica.

INTRODUCTION: Postsurgery pain is a common complaint in children and significant postoperative pain may last for weeks. Severe perisurgery pain may aggravate long-lasting negative effects. In order to prevent harmful effects, children should be provided with effective-secure analgesia. The aim of this work was to determine current practice of postsurgery pain management in children. MATERIAL AND METHODS: An observational prospective study in pediatric patients undergoing surgery in our hospital was performed. Children's (< 14 years old) having elective major surgery and outpatient surgery were collected prospectively. Clinical stage, surgery and anaesthesia procedures, postsurgery analgesia and perioperative complications were recorded. Pain control was measured by an analogic visual scale (AVS) before surgery, in post-anaesthesia recovery unit (PARU), in one-day unit (ODU) and 24 h after surgery (24hU). STATISTICAL ANALYSIS: mean values +/- sem or SD, frequency and percentage of incidence of N cases, t-test, ANOVA of one and several ways, chi-square, correlations of two variables, linear and logistic regressions depending of variables' types. RESULTS: 77 patients with mean age of 5 years old and mean weight of 22 kg were studied. The most frequently employed anesthetic technique was the general one. Forty per cent of the patients were pre-medicated with midazolam. Little pain before surgery is observed and after surgery it is moderate. Anxiety is higher after surgery and immediately after it in the recovery room or the Post Anesthesia Care Unit (PACU), subsequently it diminishes, especially patients with same-day admission surgery. Positive correlations between pain and anxiety intensities were found in each determination done. CONCLUSIONS: Is observed that pain and anxiety round surgery in children had insufficient treatment, reason why we think we should make treatment protocols, adapted at this population, its necessities and the different types of procedures they can be subjected.

Anticlotting drugs and regional anaesthetic and analgesic techniques: comparative update of the safety recommendations.

The wide use of anticlotting drugs by patients scheduled for surgery is a challenge for the anaesthesiologist when considering a regional anaesthesia technique. This practice seems safe if there is an appropriate management based on safety intervals established according to the pharmacology of the drug and the regional technique. Some anaesthesiology societies have published recommendations for the safe practice of regional anaesthesia with the simultaneous use of anticoagulants (heparin, low molecular weight heparins, oral anticoagulants (OA), fondaparinux and others) and antiplatelet agents (aspirin, clopidogrel, ticlopidine, argatroban and others). One of the most recent guidelines has been published by the Spanish Society of Anaesthesia and Critical Care. This article reviews these recommendations and compares them with others published in the last years. The recommendations are similar, but some interesting differences can be observed and need to be considered. A European consensus in this setting would probably be necessary.