Heterogeneity Among Countries in the Subspecialty of Cardiovascular Anesthesia in Latin America: Survey Results.

OBJECTIVES: To evaluate demographics, workload, training, facilities, and equipment in cardiovascular anesthesia (CVA) in Latin America (LA). DESIGN: A descriptive cross-sectional study with data collected through a survey. SETTING: A multicenter, international web-based questionnaire that included 37 multiple-choice questions. PARTICIPANTS: Physicians and specialists in anesthesiology who regularly participated in cardiovascular surgeries and were members of the scientific societies of the Latin American Confederation of Anesthesiology. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: A total of 484 completed questionnaires were collected. A total of 97.8% of the respondents had a university degree in anesthesiology. Most did not receive formal training in CVA, and only 41.5% received formal training. Moreover, most of them were trained in their own country, and a smaller percentage were trained abroad. Half of the respondents reported receiving <12 months of training. A third part of the respondents had received training in transesophageal echocardiography. Only 5.8% of the respondents worked exclusively in CVA, and a high percentage dedicated <60% of their weekly work hours to this subspecialty. A total of 80.6% of the centers had <3 cardiac surgery operating rooms. Only one-third of the centers performed heart/lung transplantation, venoarterial extracorporeal membrane oxygenation, venovenous extracorporeal membrane oxygenation, and ventricular assist device implantation. CONCLUSIONS: A significant lack of training programs in anesthesiology practice and complex procedures in medical centers in LA are evident. Thus, basic accredited programs should be developed in medical centers in LA.

Maternity After Orthotopic Liver Transplantation: Can the Use of Biological Fertility Indicators Help? Our Own Experience and Literature-based Recommendations.

Over the last 5 decades, the fulfillment of maternity wishes in solid organ transplanted women has become a reality. Despite pregnancy contraindication in transplanted women during the early post-transplant period, such a condition can be overcome after 12 months if patients show a good clinical evolution and do not present other general pre-conceptional findings. This article presents the case report of a young female liver transplanted patient that used symptothermal method as a reliable family planning method. After her gestational contraindication was lifted, observation of biological fertility indicators and fertility-guided sexual intercourse helped her fulfill her maternity wish and conceive and carry out a healthy offspring. Based on this case and on the available bibliographic evidence, this paper reviews the potential implications of the use of this kind of approach as a safe and effective alternative to assisted reproduction technology in the management of potential infertility problems in the young female transplanted population, a population which according to literature has higher rates of unsuccessful parenthood and might also be more vulnerable to iatrogenicity of ovarian hyperstimulation process and to multiple pregnancy.

Biomarkers as predictors of renal damage in neonates undergoing cardiac surgery.

BACKGROUND: Acute Kidney Injury is a complication in children with heart disease undergoing cardiac surgery with cardiopulmonary bypass. The aim of this study is to describe the behavior of KIM-1 (Kidney Injury Molecule) and NGAL (Neutrophil Gelatinase Associated Lipocalin) as early predictors of renal damage, comparing them with serum creatinine and creatinine clearance, in neonates undergoing cardiac surgery. METHODS: Twenty-one (21) neonates, under 4 kg, with complex congenital heart diseases, RACHS-1 > 3, without preoperative renal failure, were studied. Serum creatinine and creatinine clearance were measured preoperatively and at 24, 48, 72, 96 hours postoperatively. Urinary samples of KIM-1(pg/ml) and NGAL (ng/ml) were collected after induction of anesthesia at 24 and 48 hours post-operatively. RESULTS: nRIFLE criteria were used to divide cohorts in "NO AKI" (12 patients) and "AKI" (nine patients). In the AKI group, serum creatinine increased significantly and creatinine clearance decreased significantly at 24, 48, and 72 hours compared with their respective baseline values. There was no difference in KIM-1 and NGAL values between patients who developed AKI and those who did not at any measured time. CONCLUSIONS: The deterioration of renal function continues to be one of the most frequent complications in this population. In our study, biomarkers did not show any correlation with the appearance of AKI. It remains to be seen whether this behavior of the biomarkers is linked with the non-consistent release of these types of molecules in immature kidneys. It is likely that a larger panel of biomarkers together with other glomerular filtration rate assessment methods will provide more information about AKI diagnosis.

Acceso venoso difícil en pediatría / Difficult venous access in pediatrics

BACKGROUND: Cannulation of a peripheral venous access is a routine procedure in pediatric patients admitted to the hospital. 50% of the time cannulation on the first attempt is not feasible, so it is necessary to repeat the puncture, resulting in a complex and frustrating procedure. Half of the children admitted to the hospital have a difficult venous access (DIVA). OBJECTIVE: To carry out a review, which provides information about DIVA in pediatrics, how to evaluate and proceed in these patients. DESIGN: DIVA Score considers vein palpability, vein visibility, age and history of prematurity. The score ranges from 0 to 10 points. Values greater than 4 are associated with difficult venous access. There are associated risk factors: obesity, musculoskeletal malformations, chemotherapy treatment, diabetes mellitus, patients on dialysis, limb edema, moderate to severe dehydration, history of difficult venous access, anxiety of the patient and/or parents report that the child is less likely to cooperate. When making the decision to establish a venous access, it should be evaluated whether it is an emergency or not, the characteristics of the medications and infusions, the time of therapy and the anatomical sites for puncture. Ultrasound and transillumination techniques decrease the time to obtain a venous access and increase the success rate on the first attempt. CONCLUSION: The decision to obtain a venous access must take into account the criteria and risk factors for DIVA. The most recognized scale is the DIVA Score.

INTRODUCCIÓN: La canulación de un acceso venoso periférico es un procedimiento rutinario en los pacientes pediátricos que ingresan al hospital. 50% de las veces la canulación al primer intento es frustra, por lo que es necesario repetir la punción resultando el procedimiento complejo y frustrante. La mitad de los niños que ingresa al hospital presentan un acceso venoso difícil (DIVA, sigla derivada de "difficult intravenous access"). OBJETIVO: Realizar una revisión, que entrega información acerca de DIVA en pediatría, cómo evaluar y proceder en estos pacientes. DESARROLLO: DIVA Score considera palpabilidad y visibilidad venosa, edad y antecedente de prematurez. El puntaje va desde 0 a 10 puntos. Valores mayores a 4 se asocian a acceso venoso difícil. Existen factores de riesgo asociados: obesidad, malformaciones osteomusculares, tratamiento con quimioterapia, diabetes mellitus, pacientes en diálisis, edema de extremidades, deshidratación moderada a severa, historia de acceso venoso difícil, ansiedad del paciente y/o padres que refieren que el niño es poco probable que coopere. Al tomar la decisión de establecer un acceso venoso se debe evaluar si es urgencia o no, las características de los medicamentos e infusiones, tiempo de terapia y los sitios anatómicos para punción. La ultrasonografía y las técnicas de transiluminación disminuyen el tiempo de obtención del acceso venoso e incrementan la tasa de éxito en el primer intento. CONCLUSIÓN: En la decisión de obtener un acceso venoso se deben tener en cuenta los criterios y factores de riesgo de acceso venoso difícil. La escala más reconocida es el DIVA Score.

Anestesia cardiovascular en cirugía no cardiaca / Cardiovascular anesthesia in noncardiac surgery

Clinical evaluation remains one of the main issues while considering anesthetic and surgical risk. Different scores for cardiac evaluation in non-cardiac surgery are traditionally based on the exclusion of active cardiac conditions, the risk of surgery, the functional capacity of the patient and the presence of specific cardiac risk factors. In recent decades, new guidelines incorporate an association between cardiac biomarkers and adverse cardiac events. For the management of coronary patients receiving double antiplatelet therapy, derived for non-cardiac surgery, the risk of stent thrombosis, the consequences of delaying the surgical procedure and the risk of bleeding must be considered. At this moment, there is no evidence regarding which is the best anesthetic management that decreased peri-operative cardiovascular complications in this group of patients. This article refers to the differences in preoperative assessment for non-cardiac surgery incorporated in the guidelines of the American College of Cardiology, the American Heart Association, the European Society of Cardiology and the Canadian Cardiovascular Society. Consideration are also given to the management of coronary patients on double antiplatelet therapy and its main complications as well as intraoperative management maneuvers that may decrease cardiovascular complications.

La valoración clínica sigue siendo uno de los pilares fundamentales en la evaluación del riesgo anestésico-quirúrgico. Los scores de riesgo para la evaluación cardiovascular y cirugía no cardíaca se basan tradicionalmente en la exclusión de condiciones cardíacas activas, la determinación del riesgo de cirugía, la capacidad funcional del paciente y la presencia de factores de riesgo cardíaco. En las últimas décadas, nuevas guías incorporan una asociación entre los biomarcadores cardiacos y los eventos cardiacos adversos. Para el manejo de pacientes coronarios en tratamiento antiagregante doble, derivados a cirugía no cardiaca, hay que considerar el riesgo de trombosis del stent, las consecuencias de retrasar el procedimiento quirúrgico y el aumento del riesgo de hemorragia. Hasta la fecha no existe evidencia acerca de cuál es el mejor manejo anestésico que disminuya las complicaciones cardiovasculares perioperatorias en este grupo de pacientes. Este artículo, hace referencia a las diferencias de la valoración preoperatoria para cirugía no cardiaca incorporados en las guías del American College of Cardiology, la American Heart Association, la European Society of Cardiology y la Canadian Cardiovascular Society. Algunas consideraciones acerca del manejo de pacientes coronarios, terapia antiplaquetaria dual y eventuales complicaciones. Se incluyen algunas estrategias farmacológicas, así como consideraciones específicas para el perioperatorio, con el fin de reducir morbilidad de origen cardiovascular.

Implante percutáneo de válvula aórtica con apoyo de circulación extracorpórea en paciente con insuficiencia aórtica severa / Trans catheter aortic valve implantation with extra corporeal circulation support in a patient with severe aortic insufficiency

An 84-year man with prior coronary artery bypass surgery and endovascular repair of an abdominal aortic aneurysm developed congestive heart failu-re. He had calcific aortic valve disease with severe regurgitation. A #29 Edwards-Sapien aortic valve via trans-apical approach was implanted with the patient connected to extra corporeal circulation. The patient recovered successfully and remained in functional class II 8 months after hospital dis-charge.