A critical review of the perioperative fluid therapy and hemodynamic monitoring recommendations of the Enhanced Recovery of the Adult Pathway (RICA): A position statement of the fluid therapy and hemodynamic monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section (SHTF) of the Spanish Society of Anesthesiology and Critical Care (SEDAR).

In an effort to standardize perioperative management and improve postoperative outcomes of adult patients undergoing surgery, the Ministry of Health, through the Spanish Multimodal Rehabilitation Group (GERM), and the Aragonese Institute of Health Sciences, in collaboration with multiple Spanish scientific societies and based on the available evidence, published in 2021 the Spanish Intensified Adult Recovery (RICA) guideline. This document includes 12 perioperative measures related to fluid therapy and hemodynamic monitoring. Fluid administration and hemodynamic monitoring are not straightforward but are directly related to postoperative patient outcomes. The Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section (SHTF) of the Spanish Society of Anesthesiology and Critical Care (SEDAR) has reviewed these recommendations and concluded that they should be revised as they do not follow an adequate methodology.

Fluid challenges in operating room: A planned sub study of the Fluid Day observational study.

BACKGROUND: Intraoperative fluid administration is a ubiquitous intervention in surgical patients. But inadequate fluid administration may lead to poor postoperative outcomes. Fluid challenges (FCs), in or outside the so-called goal-directed fluid therapy, allows testing the cardiovascular system and the need for further fluid administration. Our primary aim was to evaluate how anesthesiologists conduct FCs in the operating room in terms of type, volume, variables used to trigger a FC and to compare the proportion of patients receiving further fluid administration based on the response to the FC. METHODS: This was a planned substudy of an observational study conducted in 131 centres in Spain in patients undergoing surgery. RESULTS: A total of 396 patients were enrolled and analysed in the study. The median [interquartile range] amount of fluid given during a FC was 250ml (200-400). The main indication for FC was a decrease in systolic arterial pressure in 246 cases (62.2%). The second was a decrease in mean arterial pressure (54.4%). Cardiac output was used in 30 patients (7.58%), while stroke volume variation in 29 of 385 cases (7.32%). The response to the initial FC did not have an impact when prescribing further fluid administration. CONCLUSIONS: The current indication and evaluation of FC in surgical patients is highly variable. Prediction of fluid responsiveness is not routinely used, and inappropriate variables are frequently evaluated for assessing the hemodynamic response to FC, which may result in deleterious effects.

Research priorities in perioperative fluid therapy and hemodynamic monitoring: A Delphi Consensus Survey from the Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section (SHTF) of the Spanish Society of Anesthesiology and Critical Care (SEDAR).

BACKGROUND: Research in fluid therapy and perioperative hemodynamic monitoring is difficult and expensive. The objectives of this study were to summarize these topics and to prioritize these topics in order of research importance. METHODS: Electronic structured Delphi questionnaire over three rounds among 30 experts in fluid therapy and hemodynamic monitoring identified through the Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section of the Spanish Society of Anesthesiology and Critical Care. RESULTS: 77 topics were identified and ranked in order of prioritization. Topics were categorized into themes of crystalloids, colloids, hemodynamic monitoring and others. 31 topics were ranked as essential research priority. To determine whether intraoperative hemodynamic optimization algorithms based on the invasive or noninvasive Hypotension Prediction Index versus other management strategies could decrease the incidence of postoperative complications. As well as whether the use of renal stress biomarkers together with a goal-directed fluid therapy protocol could reduce hospital stay and the incidence of acute kidney injury in adult patients undergoing non-cardiac surgery, reached the highest consensus. CONCLUSIONS: The Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section of the Spanish Society of Anesthesiology and Critical Care will use these results to carry out the research.

Use of viscoelastic tests in the principle bleeding scenarios in Spanish hospitals.

Viscoelastic tests are designed to study the dynamics of clot formation, identify coagulopathies in real time, arrive at a diagnosis, and guide patient-specific administration of haemostatics. They are mainly used to treat clinically significant bleeding in any setting, and are also used in other situations involving clinically relevant alterations in haemostasis, such as coagulopathy in critically ill patients. These tests are administered following evidence-based algorithms that vary depending on the clinical context. This review summarises the results of a survey conducted in several hospitals to determine the prevalence and standardisation of viscoelastic tests in cardiac surgery, liver transplantation, and multiple trauma patients in Spain. The results reveal divergent opinions on key aspects, ranging from the diagnostic capacity of these tests to the interpretation of the basic parameters. On the basis of these findings, we propose a number of potential areas in which further research will improve the performance of these tests.

Consensus document for multimodal intraoperatory neurophisiological monitoring in neurosurgical procedures. Basic fundamentals. / Documento de consenso para la monitorización neurofisiológica intraoperatoria multimodal en procedimientos neuroquirúrgicos. Fundamentos básicos.

The present work aims to establish a guide to action, agreed by anaesthesiologists and neurophysiologists alike, to perform effective intraoperative neurophysiological monitoring for procedures presenting a risk of functional neurological injury, and neurosurgical procedures. The first section discusses the main techniques currently used for intraoperative neurophysiological monitoring. The second exposes the anaesthetic and non-anaesthetic factors that are likely to affect the electrical records of the nervous system structures. This section is followed by an analysis detailing the adverse effects associated with the most common techniques and their use. Finally, the last section describes a series of guidelines to be followed upon the various intraoperative clinical events.

Development of concomitant diseases in COVID-19 critically ill patients. / Desarrollo de enfermedades concomitantes en pacientes críticos con COVID-19.

It may be necessary a consideration about the best approach to the acute concomitant problems that critical COVID-19 patients can develop. They require a rapid diagnosis and an early treatment by a multidisciplinary team. As a result, we would like to describe two clinical cases a patient with diagnosis of COVID-19 pneumonia with good respiratory evolution that, after extubation suffered an acalculous cholecystitis and a patient with COVID-19 pneumonia that suffered an overinfection with necrotising pneumonia that presented with haemoptysis and was finally treated with arterial embolisation by the interventional radiologist's team.

[Health policy strategies for Patient Blood Management implementation throughout the Spanish health systems]. / Estrategias de gestión y política sanitaria para el desarrollo del Patient Blood Management en los sistemas de salud en España.

Patient Blood Management (PBM) programs have proven to be successful in reducing overuse and improving patient safety, clinical outcomes and efficiency. Despite its benefits, PBM is still scarcely used in real clinical practice with a high variability among hospitals in Spain. Recent guidelines from the European Union on how to implement PBM, as well as recommendations from experts in the field, suggest that further development in PBM implementation requires not only the participation of healthcare professionals but also the commitment and support of Health Authorities and senior hospital management. This article provides some thoughts on health care management and policy strategies to help implement PBM throughout the Spanish autonomous healthcare systems.

Assessment of the knowledge level of the professional as regards Patient Blood Management in their organisation. Results of the MAPBM project survey. / Valoración del grado de conocimiento de los profesionales sobre el Patient Blood Management en su organización. Modelo y resultados de la encuesta del proyecto MAPBM.

INTRODUCTION: The Maturity Assessment Model in Patient Blood Management project involves the use of a matrix that evaluates the maturity of the centre as regards blood transfusion practice. This tool includes a questionnaire to be completed by physicians to determine their level of knowledge of patient blood management strategies in their centre. MATERIAL AND METHODS: Forty one hospitals took part in the Maturity Assessment Model in Patient Blood Management project in 2016. The questionnaire included 10 questions, 3 about the centre, specialty, and years of experience, and 7 about patient blood management protocols in the respondent's centre. The minimum responses required per centre was calculated according to the number of beds. Responses from at least 3 different specialties were required in order to be evaluated. RESULTS: A total of 1403 questionnaires were completed. The specialty with the highest completion rate was anaesthesiology (40.9%). The distribution as regards professional experience was homogeneous: <10 years, 33.4%, 10-20 years, 33%, and> 20 years 33.6%. Nearly three-quarters (74.2%) knew the patient blood management protocol used in their centre, and 60.7% knew the protocol for the treatment of pre-operative anaemia. Slightly fewer (72%) reported knowing the blood transfusion protocol (transfusion threshold) used in their centre, and 90% considered other factors besides haemoglobin in the decision to transfuse. Only 30.7% of professionals reported receiving periodic information on transfusion practices. CONCLUSIONS: There is a significant lack of knowledge about preoperative anaemia and perioperative transfusion protocols used in the centres polled. Few centres provide their physicians with information on transfusion practices.

Intraoperative tranexamic acid use in major spine surgery in adults: a multicentre, randomized, placebo-controlled trial†.

Background: Perioperative tranexamic acid (TXA) use can reduce bleeding and transfusion requirements in several types of surgery, but level I evidence proving its effectiveness in major spine surgery is lacking. This study was designed to investigate the hypothesis that TXA reduces perioperative blood loss and transfusion requirements in patients undergoing major spine procedures. Methods: We conducted a multicentre, prospective, randomized double-blind clinical trial, comparing TXA with placebo in posterior instrumented spine surgery. Efficacy was determined based on the total number of blood units transfused and the perioperative blood loss. Other variables such as the characteristics of surgery, length of hospital stay, and complications were also analysed. Results: Ninety-five patients undergoing posterior instrumented spine surgery (fusion of >3 segments) were enrolled and randomized: 44 received TXA (TXA group) and 51 received placebo (controls). The groups were comparable for duration of surgery, number of levels fused, and length of hospitalization. Transfusion was not required in 48% of subjects receiving TXA compared with 33% of controls (P = 0.05). Mean number of blood units transfused was 0.85 in the TXA group and 1.42 with placebo (P = 0.06). TXA resulted in a significant decrease in intraoperative bleeding (P = 0.01) and total bleeding (P = 0.01) relative to placebo. The incidence of adverse events was similar in the two groups. Conclusions: TXA did not significantly reduce transfusion requirements, but significantly reduced perioperative blood loss in adults undergoing major spinal surgery. Clinical trial registration: NCT01136590.

Fluid resuscitation management in patients with burns: update.

Since 1968, when Baxter and Shires developed the Parkland formula, little progress has been made in the field of fluid therapy for burn resuscitation, despite advances in haemodynamic monitoring, establishment of the 'goal-directed therapy' concept, and the development of new colloid and crystalloid solutions. Burn patients receive a larger amount of fluids in the first hours than any other trauma patients. Initial resuscitation is based on crystalloids because of the increased capillary permeability occurring during the first 24 h. After that time, some colloids, but not all, are accepted. Since the emergence of the Pharmacovigilance Risk Assessment Committee alert from the European Medicines Agency concerning hydroxyethyl starches, solutions containing this component are not recommended for burns. But the question is: what do we really know about fluid resuscitation in burns? To provide an answer, we carried out a non-systematic review to clarify how to quantify the amount of fluids needed, what the current evidence says about the available solutions, and which solution is the most appropriate for burn patients based on the available knowledge.

Clinical practice guide for the choice of perioperative volume-restoring fluid in adult patients undergoing non-cardiac surgery.

The present Clinical practice guide responds to the clinical questions about security in the choice of fluid (crystalloid, colloid or hydroxyethyl starch 130) in patients who require volume replacement during perioperative period of non-cardiac surgeries. From the evidence summary, recommendations were made following the GRADE methodology. In this population fluid therapy based on crystalloids is suggested (weak recommendation, low quality evidence). In the events where volume replacement is not reached with crystalloids, the use of synthetic colloids (hydroxyethyl starch 130 or modified fluid gelatin) is suggested instead of 5% albumin (weak recommendation, low quality evidence). The choice and dosage of the colloid should be based in the product characteristics, patient comorbidity and anesthesiologist's experience.

[Implementation of blood sparing programs in Spain: results of a survey of departments of anesthesiology and resuscitation]. / Implementación de los programas de ahorro de sangre en España: resultados de la encuesta a los servicios de anestesiología y reanimación.

The objective of this article is to determine the availability of a perioperative transfusion management program (Patient Blood Management [PBM]) in various hospitals through a survey that included a description of the preanesthesia visit, the availability and use of the various blood-sparing techniques and the factors limiting their implementation in elective surgery. The survey included 42 questions, directed at the representative departments of anesthesiology of hospitals in Spain (n=91). The survey was conducted from September to November 2012. We analyzed the 82 surveys in which all the questions were answered (90%). Preoperative consultations are routinely performed (>70%) in 87% of the hospitals. The time from the consultation to surgery varied between 1 week and 2 months for 74% of the patients scheduled for orthopedic or trauma surgery, 78% of those scheduled for oncologic surgery and 77% of those scheduled for cardiac surgery. Almost all hospitals (77, 94%) had a transfusion committee, and 90% of them had an anesthesiologist on the committee. Seventy-nine percent of the hospitals had a blood-sparing program, and the most widely used technique was the use of antifibrinolytic agents (75% of hospitals), followed by intraoperative and postoperative blood recovery in equal proportions (67%). Optimization of preoperative hemoglobin was routinely performed with intravenous iron in 39% of the hospitals and with recombinant erythropoietin in 28% of the hospitals. The absence of a well-established circuit and the lack of involvement and collaboration with the surgical team were the main limiting factors in implementing PBM. Currently, the implementation of PBM in Spain could be considered acceptable, but it could also be improved, especially in the treatment of preoperative anemia. The implementation of PBM requires multidisciplinary collaboration among all personnel responsible for perioperative care, including the health authorities.