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.

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.

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.

[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.

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.

[Survey of anesthetic techniques used in Catalonia: results of the analysis of 23,136 anesthesias (2003 ANESCAT study)]. / Encuesta sobre las técnicas anestésicas utilizadas en Cataluña: resultado del análisis de 23.136 anestesias (estudio ANESCAT 2003).

OBJECTIVE: To examine anesthesia practice in Catalonia in 2003 and to describe the specific characteristics and distribution of the anesthesia techniques used and the patient profiles. PATIENTS AND METHODS: We used the data from the ANESCAT epidemiological study that gathered information in questionnaire form on all anesthesias performed in Catalonia on 14 randomly selected days representative of practice in 2003. RESULTS: All 131 hospitals authorized to perform anesthesia participated in the study. We collected 23136 questionnaires, from which we extrapolated to estimate 603189 anesthesias for the year and a rate of 9.0 anesthesias per 100 inhabitants per year. Fifty-eight percent of the patients were women and the mean age was 52 years. The physical status of the patients was as follows: ASA 1 or 2, 73.3%; ASA 3, 213%; ASA 4 or 5, 5.4%. The mean duration of anesthesia was 60 minutes. The most common form of anesthesia was a regional block (41.4%) and spinal block was the one performed most often. General anesthesia was used in 33.5% of the cases, combined anesthesia in 3.5%, and sedation in 21.6%. In descending order, orthopedics/trauma, ophthalmology, general surgery, obstetrics, cataract surgery, vaginal delivery, inguinal hernia repair, and colonoscopy were the procedures for which anesthesia was most commonly administered. CONCLUSIONS: Almost 1 in 10 persons in Catalonia are given anesthesia each year and most of the procedures involve locoregional anesthesia or sedation. These data provide a picture of the current situation of anesthesiology and make it possible to forecast future anesthesia requirements.

[Specialized training in anesthesiology: the opinions of supervising tutors]. / La formación especializada en Anestesiología desde la perspectiva de los tutores.

OBJECTIVE: To evaluate the common curriculum for teaching theoretical knowledge in anesthesiology in Catalonia, Spain; to assess differences between hospital teaching programs, evaluation systems, and the situation for tutors. MATERIAL AND METHODS: A 35-item questionnaire was sent to 49 accredited tutors during the 2005-2006 academic year. The questionnaire covered 1) the curriculum and training rotations, 2) teaching and research, and 3) assessment and tutorial interventions. An additional question asked the respondent's view on how to improve instruction. RESULTS: Eighty-five percent of the tutors responded. Seventy-eight percent of the residents (168/216) follow some form of external rotation, most often in pediatric anesthesia (79%). The common courses are considered useful by 96% of the tutors. Ninety-two percent are satisfied with the current annual examination and 79% would extend the residency training period to 5 years. Eighty-two percent of the teaching centers have weekly instructional sessions. Eighty-one percent of the tutors consider the resident's logbook, filled in by 77% of residents, to be useful for assessment. Eighty-five percent take teacher training courses, 65% feel that their work is being recognized, and 92% do not allot a specific period of time for teaching. CONCLUSIONS: The survey has helped shed light on the current training situation in Catalonia. The common courses are of great help. The number of external rotations is high, overloading certain areas. Improvements could be made by unifying external rotations, updating the curriculum and extending the training period to 5 years, recognizing the role of the tutor, and establishing a specific time for teaching activity.

[Imprecise status allocation by users of the American Society of Anesthesiologists classification system: survey of Catalan anesthesiologists]. / Imprecisión en la aplicación de la escala de estado físico de la American Society of Anesthesiologists: encuesta realizada entre los anestesiólogos catalanes.

OBJECTIVES: To study precision in American Society of Anesthesiologists (ASA) physical status classification by Catalan anesthesiologists. METHODS: An anonymous survey carried out in Catalonia, Spain, asked medical residents, staff anesthesiologists, and chiefs of service to allocate ASA classifications in 10 hypothetical cases that were representative of usual clinicalpractice. Respondents were also asked to state how long they had been practicing. Frequency distributions, medians and interquartile ranges (IQR) were calculated for the scores for each hypothetical case. The differences between residents and staff specialists were assessed. RESULTS: Three hundred thirty-three responses were obtained: 30.4% from residents, 59.9% from staff anesthesiologists, and 9.7% from chiefs of service. The mean (SD) length of professional practice of the staff specialists was 15.13 (8) years. For 1 case the IQR was 0 points on the ASA scale; in another case it was 3, and in the remaining cases the IQR was 1. Over half of the respondents were unfamiliar with class 6 (organ donor). The responses of residents and staff specialists for 2 cases differed significantly. CONCLUSIONS: The use of the ASA physical status scale is somewhat imprecise. There are small differences between specialists and residents and the current version is not very well known.

[Incidence in Catalonia of spinal cord compression due to spinal hematoma secondary to neuraxial anesthesia]. / Incidencia de hematomas espinales con compresión medular relacionados con anestesias neuroaxiales en Cataluña.

OBJECTIVE: To study the incidence in Catalonia of spinal cord compression due to spinal hematoma secondary to neuraxial anesthesia. METHODS: The incidence of hematoma was based on published cases (MEDLINE, the Spanish Medical Index [Indice Medico Español], and Google) or cases reported at medical meetings or conferences by anesthesiologists from Catalan hospitals from 1996 to 2005, inclusive. The annual number of neuraxial anesthesias (spinal, epidural, and combined) was estimated based on the ANESCAT 2003 survey and the total number of anesthesias was calculated using the ANESCAT 2003 survey in conjunction with the surgical reports of Catalan hospitals. RESULTS: A total of 11 cases of spinal hematoma after neuraxial anesthesia (7 after spinal anesthesia and 4 after epidural anesthesia) were reported or published from 1996 to 2005, inclusive. A total of 194 154 neuraxial anesthesias were performed in 2003 (126 560 spinal anesthesias and 5926 combined spinal-epidural anesthesias) and it was estimated that somewhat over 1 700 000 neuraxial anesthesias were performed over the 10 years reviewed. The incidence (95% confidence interval [CI]) of hematoma was 0.6 (95% CI, 0.3-1.2) per 100 000 neuraxial anesthesias, 0.6 (95% CI, 0.3-1.3) per 100 000 spinal anesthesias, and 0.7 (95% CI, 0.2-1.9) per 100 000 epidural anesthesias. CONCLUSIONS: The incidence of spinal hematoma after neuraxial anesthesia is slightly more than 1 per 150 000 anesthesias-a similar finding to that of other epidemiological studies. The incidence is slightly higher in epidural anesthesia. These data imply a risk of approximately 1 spinal hematoma per year in Catalonia.

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.

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.

[Survey of nursing roles in anesthesiology, postoperative recovery care and pain management in Catalonia, Spain: analysis of the current situation]. / Encuesta sobre las funciones de enfermería en Anestesiología, Reanimación y Tratamiento del Dolor en Cataluña. Análisis de la situación actual.

OBJECTIVE: To determine nursing functions in anesthesiology, postoperative recovery care, and pain management in Catalan hospitals and to analyze the roles of nurses in this specialty. METHODS: Development of a mail questionnaire sent to 70 public and private hospitals in Catalonia, to be filled in and returned separately by the nursing supervisor and by the anesthesiology department of each hospital. The survey included questions on whether tasks were or were not carried out by nurses. RESULTS: Responses were received from 31% of nursing supervisors and 45% of anesthesiology departments. Only 22% of the hospitals employed nursing staff with duties exclusively in the anesthesiology department. Nurses took on more responsibilities in major outpatient surgery services and postanesthetic recovery care units than in other areas. Significant discrepancies were found between answers given by nursing supervisors and those returned by anesthesiology departments regarding tasks of nurses in this specialty. Items with the greatest agreement were those related to maintenance of material. Those with the lowest agreement were related to drug management. CONCLUSIONS: Although responses came from only a third of the target population, the information obtained suggests a lack of definition in Spain of nursing tasks in the field of anesthesiology. This situation is different from that of most European countries and of the United States of America.

[Problem-based learning in an undergraduate medical school course on anesthesiology, recovery care, and pain management]. / El aprendizaje basado en problemas aplicado a la asignatura de pregrado de anestesiología, reanimación y terapéutica del dolor.

INTRODUCTION: We describe our experience with problem-based learning (PBL) in an undergraduate course in anesthesiology and recovery care. MATERIAL AND METHODS: The study was carried out over 5 consecutive academic years from 2000 through 2005. In total, 168 students took part. PBL was started in seminars in the first 3 years the course was given. In the last 2 years, PBL was used throughout the entire course, which consisted of 12 seminars. At the end, each student evaluated the activities overall, the tutor's intervention, the student's own participation, and the time invested in searching for information and preparing for discussions. RESULTS: In the first 3 years, most students considered they had better assimilated the knowledge presented and that they had participated more. In the last 2 years, assessment of the course overall reached a score of 8.47 (SD, 1.24); of the instructor, 8.84 (0.98); and of student participation, 7.38 (1.29). The students used 2.11 (1.43) hours to search for information and 1.74 (1.14) hours to prepare for discussion. CONCLUSIONS: The medical students' level of satisfaction with and acceptance of PBL in this anesthesiology course were high. The instructor's intervention and student participation were assessed highly. A large amount of time was used for study.

[Comparison of the bispectral index and spectral entropy in gynecological surgery]. / Estudio comparativo del indice biespectral y la entropía espectral en cirugía ginecológica.

OBJECTIVES: Spectral entropy quantifies variations in cortical electrical activity measured by electroencephalography and frontal activity measured by electromyography. The aim of this study, in the context of general anesthesia, was to compare bispectral index values with the two components of spectral entropy: state entropy and response entropy. MATERIAL AND METHODS: Sixteen women (ASA I-II) undergoing gynecological surgery were enrolled. The bispectral index was maintained between 40 and 50 for all patients. Both sensors, for monitoring the bispectral index and spectral entropy, were placed on each patient. Simultaneous readings were recorded at the following moments: operating room arrival, induction, relaxation, intubation, switching on the vaporizer, start of surgery, traction of the intestinal mesenteries and maneuvering of the electric scalpel, switching off the vaporizer, end of surgery, during cough, extubation, and eye opening. The data sets were subjected to analysis of variance, and the intraclass correlation coefficient (ICC) was used to analyze agreement. RESULTS: Differences between mean values of the bispectral index, state entropy and response entropy were observed at operating room arrival, intubation, and induction. Differences when the patient awakened from anesthesia were observed only between the bispectral index and response entropy, on the one hand, and state entropy on the other. There was no agreement (ICC<0.7) upon operating room arrival, maneuvering the electric scalpel, or awakening from anesthesia. CONCLUSION: The bispectral index, state entropy, and response entropy show good agreement during recordings that reflect the effects of anesthesia. The differences observed at baseline and upon awakening can be attributed to frontal electromyographic activity. Distinguishing cortical electrical activity from frontal electromyographic activity may provide additional information in these situations.

Respiratory input impedance in anesthetized paralyzed patients.

Respiratory impedance (Zrs) was measured between 0.25 and 32 Hz in seven anesthetized and paralyzed patients by applying forced oscillation of low amplitude at the inlet of the endotracheal tube. Effective respiratory resistance (Rrs; in cmH2O.l-1.s) fell sharply from 6.2 +/- 2.1 (SD) at 0.25 Hz to 2.3 +/- 0.6 at 2 Hz. From then on, Rrs decreased slightly with frequency down to 1.5 +/- 0.5 at 32 Hz. Respiratory reactance (Xrs; in cmH2O.l-1.s) was -22.2 +/- 5.9 at 0.25 Hz and reached zero at approximately 14 Hz and 2.3 +/- 0.8 at 32 Hz. Effective respiratory elastance (Ers = -2pi x frequency x Xrs; in cmH2O/1) was 34.8 +/- 9.2 at 0.25 Hz and increased markedly with frequency up to 44.2 +/- 8.6 at 2 Hz. We interpreted Zrs data in terms of a T network mechanical model. We represented the proximal branch by central airway resistance and inertance. The shunt pathway accounted for bronchial distensibility and alveolar gas compressibility. The distal branch included a Newtonian resistance component for tissues and peripheral airways and a viscoelastic component for tissues. When the viscoelastic component was represented by a Kelvin body as in the model of Bates et al. (J. Appl. Physiol. 61: 873-880, 1986), a good fit was obtained over the entire frequency range, and reasonable values of parameters were estimated. The strong frequency dependence of Rrs and Ers observed below 2 Hz in our anesthetized paralyzed patients could be mainly interpreted in terms of tissue viscoelasticity. Nevertheless, the high Ers we found with low volume excursions suggests that tissues also exhibit plasticlike properties.