Use of thoracic fluid content for prediction of fluid balance and postoperative pulmonary complications after major abdominal surgery: an observational study.

BACKGROUND AND OBJECTIVES: The harmful effects of excess fluids frequently manifest in the lungs. Thoracic fluid content (TFC) is a variable provided by the STARLINGTM bioreactance monitor, which represents the total volume of fluid in the chest. The objective is to analyse the association between the variation in TFC values (TFCd0%) at 24 h postoperatively, postoperative fluid balance, and postoperative pulmonary complications. MATERIAL AND METHODS: Prospective and analytical observational study. Patients scheduled for major abdominal surgery at a tertiary teaching hospital were included. They were monitored during the intervention and the first 24 postoperative hours with the monitor. STARLINGTM, measuring TFC and its variation in different stages of the perioperative period. Serial lung ultrasounds were performed and postoperative pulmonary complications were recorded. Logistic regression was performed to predict the occurrence of atelectasis and pulmonary congestion. The Pearson correlation coefficient was calculated to verify the association between TFC and fluid balance. RESULTS: 50 patients were analyzed. TFCd0% measured on the morning of the first postoperative day increased by a median of 27.1% [IQR: 20.3-37.5] and was correlated at r = 0.44 with the postoperative balance of 677 ml [IQR: 125.5-1,412]. Increased TFC was related to a higher risk of atelectasis (OR = 1.24) and pulmonary congestion (OR = 1.3). CONCLUSIONS: TFCd0% measured 24 h after surgery presents a moderate correlation with postoperative fluid balance. Its increase is a risk factor for the appearance of postoperative pulmonary complications.

Estimated metabolic equivalents of task do not correlate with the maximal oxygen consumption of patients undergoing lung resection surgery.

BACKGROUND AND OBJECTIVE: Metabolic equivalent of task (MET) is a physiological measure that represents the metabolic cost of an activity of daily living. One MET is equivalent to the resting metabolic rate. METs can be estimated by questionnaires or calculated by measuring maximal oxygen uptake (VO2max). The aim of this study is to determine whether METs estimated in the pre-consultation (METse) correlates with METs calculated from VO2max (METsVO2). PATIENTS AND METHODS: Retrospective observational study in patients scheduled for lung resection surgery. The estimation of METs was obtained in the pre-consultation according to the 2014 European and American guidelines for preoperative cardiovascular assessment in non-cardiac surgery. VO2max was calculated in the ergometry laboratory. RESULTS: A total of 104 patients were included in the study, of whom 25 (24%) were female. The mean age was 65.1 years (±9.8). In 26 patients (25%), the METse classification correlated with METsVO2 (κ = -0.107 P = .02). In the remaining patients, METse overestimated functional capacity measured by ergometry (METse > METsVO2). CONCLUSIONS: Subjective assessment overestimates functional capacity and should not replace objective testing in patients scheduled for lung resection surgery.

Preoperative nutritional status assessed using the CONUT tool and its relationship with the appearance of major postoperative complications.

INTRODUCTION: Malnutrition is a risk factor for the appearance of major postoperative complications; therefore, early identification and perioperative optimization of surgical patients may improve postoperative outcomes. The objective of our study was to determine the prevalence of moderate or high under nutrition alerts in patients undergoing major non-cardiac surgery, and their relationship with the appearance of major postoperative complications. Nutritional status was calculated using the CONUT tool. MATERIAL AND METHODS: A retrospective observational study in 190 patients who underwent major non-cardiac surgery over two consecutive years. Preoperative nutritional status was calculated using CONUT, and the patients' medical records were reviewed to determine their epidemiological characteristics and major complications. RESULTS: The under nutrition alert was moderate in 17% of patients, and high in 10%. A high under nutrition alert was an independent risk factor for treatment with vasoactive drugs (OR 3.58; 95% CI 1.18-10.89; p = 0.025), respiratory support (OR 7.63; 95% CI 1.25-46.43; p = 0.027), renal support (OR 23.29; 95% CI 2.0-271.08; p = 0.012), prolonged hospital stay (Coef 20.16; 95% CI 2.10-38.22; p = 0.029) and higher in-hospital mortality (OR 7.15; 95% CI 1.31-39.02; p = 0.023). CONCLUSIONS: In total, 10% of patients who underwent major non-cardiac surgery presented serious preoperative deterioration in their nutritional status. A high under nutrition alert was an independent risk factor for the appearance of major postoperative complications.

[Even more critical medicine: a retrospective analysis of casualties admitted to the intensive care unit in the Spanish Military Hospital in Herat (Afghanistan)]. / Medicina aún más crítica: análisis retrospectivo de las bajas atendidas en la UCI del Hospital Militar español de Herat (Afganistán).

OBJECTIVE: To analyze casualties from firearm and explosives injuries who were admitted to the Intensive Care Unit in the Spanish ROLE-2E from December 2005 to December 2008 and to evaluate which damaging agent had produced the highest morbidity-mortality in our series using score indices with anatomical base (ISS and NISS). DESIGN: Observational and retrospective study performed between 2005 and 2008. SETTING: Polyvalent Intensive Care Unit in the Spanish Military Hospital of those deployed in Afghanistan. PATIENTS OR PARTICIPANTS: The inclusion criteria were all patients who had been wounded by firearm or by explosive devices and who had been admitted in ICU in Spanish Military Hospital in Herat (Afghanistan). INTERVENTION: The anatomic scores Injury Severity Score and the New Injury Severity Score (NISS) were applied to all the selected patients to estimate the grade of severity of their injuries. VARIABLES OF INTEREST: Independent: damaging agent, injured anatomical area, protection measures and dependent: mortality, surgical procedure applied, score severity and socio-demographics and control variables. RESULTS: Eighty-six casualties, 30 by firearm and 56 by explosive devices. Applying the NISS, 38% of the casualties had suffered severe injuries. Mean stay in the ICU was 2.8 days and mortality was 10%. Significant differences in admission to the ICU for the damaging agent were not observed (P=.142). CONCLUSIONS: No significant differences were observed in the need for admission and stay in the ICU according to the damaging agent. The importance of the strategy, care and logistics of the intensive care military physician in Intensive Medicine in the Operating Room in Afghanistan is stressed.

Incidence of electrocardiographic alterations in the preoperative period of non-cardiac surgery.

BACKGROUND: The electrocardiogram is the most widely used test to assess cardiovascular risk during the preoperative period. The objective of the present study is to evaluate the incidence of electrocardiographic alterations in the general population scheduled for non-cardiac surgery and to determine if the age greater than or equal to 65 years or the revised cardiac risk index ≥1 represent a risk factor for presenting these alterations. MATERIAL AND METHODS: Over a period of one month, all preoperative electrocardiograms (ECG) from the anesthesia clinic were analyzed. Various epidemiological data were collected and the revised cardiac risk index was calculated. Major alterations were defined as those requiring Cardiology follow-up. RESULTS: 476 patients were recruited, of whom 40.8% were ≥65 years, 32.6% had HTN, 14.4% DM and 27.9% dyslipidemia. 16.16% of the patients had a Lee Index ≥1. Of the entire sample, 80.5% had a normal ECG, 6.5% minor alterations and 13.0% major alterations. In the multivariate analysis, age ≥65 years and the presence of HTN were shown as independent risk factors for presenting alterations in the total and major ECG. The Lee index ≥1 was not associated with an increased risk of electrocardiographic abnormalities. CONCLUSIONS: Patients ≥65 years old and those with HTN are at greater risk of presenting major electrocardiographic abnormalities, so we recommend including the ECG as a routine diagnostic test in the preoperative period of non-cardiac surgery.

Preoperative nutritional status assessed using the CONUT tool and its relationship with the appearance of major postoperative complications. / Estado nutricional preoperatorio valorado mediante la herramienta CONUT y su relación con la aparición de complicaciones mayores postoperatorias.

INTRODUCTION: Malnutrition is a risk factor for the appearance of major postoperative complications; therefore, early identification and perioperative optimization of surgical patients may improve postoperative outcomes. The objective of our study was to determine the prevalence of moderate or high under nutrition alerts in patients undergoing major non-cardiac surgery, and their relationship with the appearance of major postoperative complications. Nutritional status was calculated using the CONUT tool. MATERIAL AND METHODS: A retrospective observational study in 190 patients who underwent major non-cardiac surgery over two consecutive years. Preoperative nutritional status was calculated using CONUT, and the patients' medical records were reviewed to determine their epidemiological characteristics and major complications. RESULTS: The under nutrition alert was moderate in 17% of patients, and high in 10%. A high under nutrition alert was an independent risk factor for treatment with vasoactive drugs (OR 3.58; 95% CI 1.18-10.89; p=.025), respiratory support (OR 7.63; 95% CI 1.25-46.43; p=.027), renal support (OR 23.29; 95% CI 2.0-271.08; p=.012), prolonged hospital stay (coef. 20.16; 95% CI 2.10-38.22; p=.029) and higher in-hospital mortality (OR 7.15; 95% CI 1.31-39.02; p=.023). CONCLUSIONS: In total, 10% of patients who underwent major non-cardiac surgery presented serious preoperative deterioration in their nutritional status. A high under nutrition alert was an independent risk factor for the appearance of major postoperative complications.

Incidence of electrocardiographic alterations in the preoperative period of non-cardiac surgery. / Incidencia de alteraciones electrocardiográficas en el preoperatorio de cirugía no cardiaca.

BACKGROUND: The electrocardiogram is the most widely used test to assess cardiovascular risk during the preoperative period. The objective of the present study is to evaluate the incidence of electrocardiographic alterations in the general population scheduled for non-cardiac surgery and to determine if the age greater than or equal to 65 years or the revised cardiac risk index ≥ 1 represent a risk factor for presenting these alterations. MATERIAL AND METHODS: Over a period of one month, all preoperative electrocardiograms (ECG) from the anesthesia clinic were analyzed. Various epidemiological data were collected and the revised cardiac risk index was calculated. Major alterations were defined as those requiring Cardiology follow-up. RESULTS: 476 patients were recruited, of whom 40.8% were ≥ 65 years, 32.6% had HTN, 14.4% DM and 27.9% dyslipidemia. 16.16% of the patients had a Lee Index ≥ 1. Of the entire sample, 80.5% had a normal ECG, 6.5% minor alterations and 13.0% major alterations. In the multivariate analysis, age ≥ 65 years and the presence of HTN were shown as independent risk factors for presenting alterations in the total and major ECG. The Lee index ≥ 1 was not associated with an increased risk of electrocardiographic abnormalities. CONCLUSIONS: Patients ≥ 65 years old and those with HTN are at greater risk of presenting major electrocardiographic abnormalities, so we recommend including the ECG as a routine diagnostic test in the preoperative period of non-cardiac surgery.

[Cerebral oximetry monitoring during bypass surgery: can the approach be changed?]. / Monitorización de la oximetría cerebral durante cirugía extracorpórea: puede modificar la actitud quirúrgica.

We describe the detection of postoperative neurologic complications by means of monitoring cerebral oximetry during cardiac surgery. A 54-year-old man underwent emergency surgery for aortic dissection, type A. Cerebral oximetry was monitored by near-infrared spectroscopy. At the start of total cardiopulmonary bypass through the axillary artery, cerebral oxygen saturation fell more than 50% from baseline in both hemispheres. Saturation did not improve on optimizing factors that influence cerebral blood flow. Improvement came only when the recently inserted arterial cannula was switched to the ascending aortic prosthetic graft. After surgery, the patient was diagnosed with anoxic brain injury. We believe that the detected fall in cerebral oxygen saturation during axillary artery cannulization probably coincided with the occurrence of anoxic brain injury.

Extracorporeal CO2 removal in a case of respiratory distress syndrome by sepsis. / Eliminación extracorpórea de CO2 en un caso de síndrome de distrés respiratorio por sepsis.

Multiorgan dysfunction syndrome is the most common cause of mortality in intensive care units. The lungs and kidneys are frequently affected, so up to 60% of patients require simultaneous respiratory support and renal replacement therapy. Extracorporeal CO2 elimination systems have now been developed with the aim of reducing the incidence of acute lung injury. These systems can be combined with renal support therapies in patients with dysfunction of both organs. We present a case of respiratory septic shock with renal failure and respiratory distress syndrome, in which extracorporeal elimination of CO2 therapy facilitated the use of protective ventilation, with a low tidal volume of 4ml/kg, plateau pressure below 30cmH2O, and PaCO2 values of less than 60mmHg.

Lung pulse visualized through pleural effusion as a diagnostic sign of complete obstructive atelectasis of the left lung in a critical patient with respiratory failure. / Pulso pulmonar visualizado a través de derrame pleural como signo diagnóstico de atelectasia obstructiva completa del pulmón izquierdo en paciente crítico con insuficiencia respiratoria.

Complete obstructive atelectasis occurs when mucous or a foreign body obstruct one of the main bronchi. Several lung ultrasound signs have been associated with this entity. We describe the case of a patient admitted to the surgical critical care unit in whom lung ultrasound led to a diagnosis of complete obstructive atelectasis, and the presence of pleural effusion provided direct visualization of lung pulse, a sign that has only previously been described by interpreting ultrasound artifacts.

Pre-Operative pro-adrenomedullin as a predictor of postoperative requirement of organ support in patients scheduled for major abdominal surgery. A prospective observational pilot study. / Pro-adrenomedulina preoperatoria como predictor de la necesidad de soporte orgánico postoperatorio en pacientes programados para cirugía abdominal mayor.

BACKGROUND: Mid-Regional-Pro-Adrenomedullin (MR-Pro-ADM) is a marker of severity in a wide spectrum of pathological conditions such as sepsis, and cardiovascular dysfunction. Its usefulness as a predictor of morbidity and mortality in surgical patients has yet to be elucidated. We examined the ability of preoperative MR-Pro-ADM in predicting Postoperative Requirement of Organ Support (PROS). METHODS: One centre, pilot, prospective observational cohort study, enrolling adult patients scheduled for major abdominal surgery. The accuracy of the MR-Pro-ADM to predict PROS was determined by area under the receiver operating characteristic curve (AUROC) analysis. An univariate analysis was performed to identify the association of PROS and the MR-Pro-ADM value with the best combination of sensitivity and specificity. A multivariate analysis was performed to identify preoperative MR-Pro-ADM as independent risk factor for PROS. RESULTS: A total of 59 patients scheduled for major abdominal surgery were enrolled. The incidence of PROS was 13.6%. The association of MR-Pro-ADM levels with the incidence of PROS, was determined by an area under the ROC curve of 0.85 (95% CI: 0.74-0.96, p=0.002). The preoperative value of MR-Pro-ADM with the best combination of sensitivity and specificity to predict PROS was 0.87 nmol/l. Patients with preoperative serum levels of MR-Pro-ADM≥0.87 nmol/l had a significantly higher incidence of PROS (33.3% vs 4.9%, p=0.007). MR-Pro-ADM≥0.87 nmol/l was shown to be an independent risk factor for PROS (p=0.001; OR 9.758; IC 1.73-54.78) in the multivariate analysis. CONCLUSION: The preoperative serum level of MR-Pro-ADM may be a useful biomarker of perioperative risk and to predict postoperative requirement of organic support (PROS) in adult patients scheduled for major abdominal surgery.

Consensus Document of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC), the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) and the Spanish Society of Anesthesiology and Resuscitation (SEDAR) on Tracheotomy in Patients with COVID-19 Infection. / Documento de consenso de la Sociedad Española de Medicina Intensiva, Crítica, y Unidades Coronarias (SEMICYUC), la Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello (SEORL-CCC) y la Sociedad Española de Anestesiología y Reanimación (SEDAR) sobre la traqueotomía en pacientes con COVID-19.

The current COVID-19 pandemic has rendered up to 15% of patients under mechanical ventilation. Because the subsequent tracheotomy is a frequent procedure, the three societies mostly involved (SEMICYUC, SEDAR and SEORL-CCC) have setup a consensus paper that offers an overview about indications and contraindications of tracheotomy, be it by puncture or open, clarifying its respective advantages and enumerating the ideal conditions under which they should be performed, as well as the necessary steps. Regular and emergency situations are displayed together with the postoperative measures.

[Consensus document of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC), the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) and the Spanish Society of Anesthesiology and Resuscitation (SEDAR) on tracheotomy in patients with COVID-19 infection]. / Documento de consenso de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC), la Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello (SEORL-CCC) y la Sociedad Española de Anestesiología y Reanimación (SEDAR) sobre la traqueotomía en pacientes con COVID-19.

The current COVID-19 pandemic has rendered up to 15% of patients under mechanical ventilation. Because the subsequent tracheotomy is a frequent procedure, the three societies mostly involved (SEMICYUC, SEDAR and SEORL-CCC) have setup a consensus paper that offers an overview about indications and contraindications of tracheotomy, be it by puncture or open, clarifying its respective advantages and enumerating the ideal conditions under which they should be performed, as well as the necessary steps. Regular and emergency situations are displayed together with the postoperative measures.

Monitoring pulse pressure variation during lung resection surgery. / Monitorización de la variación de la presión de pulso durante la cirugía de resección pulmonar.

BACKGROUND AND OBJECTIVE: Although pulse pressure variation (PPV) is an effective dynamic parameter widely used to predict the increase in cardiac output after the administration of fluids in abdominal surgery, its use in thoracic surgery is controversial. A study was designed to describe the behaviour of PPV during lung resection surgery. PATIENTS AND METHODS: A prospective observational study was conducted on adult patients scheduled for lung resection surgery. Patients with bleeding greater than 200cc, or those who required vasopressors during data collection, were excluded. The PPV values were collected during different phases: in bipulmonary ventilation (T1), after the start of single lung ventilation, and the opening of the thorax (T2), at the end of the procedure prior to the restoration of the bipulmonary ventilation (T3), and after the closure of the thorax in bipulmonary ventilation (T4). The correlation coefficient of the PPV values at the different times was calculated. RESULTS: The study included 50 consecutive patients. The mean values and standard deviations of PPV in the different phases were: T1, 11.14% (6.67); T2 6.24% (3.21, T3 5.68% (3.19), and T4 7.84% (4.61). The repeated ANOVA measurements found significant differences between the mean values of PPV in the different phases (P<.001). The correlation between the PPV values during T1 and T2 (PPVT1 and PPVT2) was r=0.868 ([P<.001], r2=0.753), while between T3 and T4 (PPVT3 and PPVT4) the correlation was r=0.616 ([P<.001], r2=0.379) between the PPV values in T3 and T4. CONCLUSIONS: PPV presents a predictable behaviour in the course of lung resection surgery, characterised by a decrease of almost half at the beginning of the unipulmonary ventilation and opening of the thorax. It then remains stable throughout the surgery when there are no changes in the intravascular blood volume.

Anaphylactic risk due to systemic mastocytosis: Perioperative management in cardiac surgery. / Riesgo anafiláctico por mastocitosis sistémica: manejo perioperatorio en cirugía cardíaca.

Mastocytosis is a disease characterised by an abnormal proliferation of mast cells. The degranulation of mast cells can be triggered by chemical, physical, and psychological factors, and in severe cases may be accompanied by cardiovascular alterations and shock. Tryptase concentrations greater than 20ug/L may be associated with an increased risk of mastocyte degranulation. The case is presented on a 71 year-old man that underwent an aortic valve replacement and aortic-coronary bypass surgery. He had an indolent systemic mastocytosis and a history of histaminergic crises, with a baseline value of tryptase prior to surgery of 58.1ug/L.

[Anesthetic induction with nitrous-oxide-free sevoflurane in pediatric patients]. / Inducción anestésica con sevoflurano libre de óxido nitroso en pediatría.

OBJECTIVE: To evaluate the pediatric use of inhaled nitrous oxide (N2O)-free induction with sevoflurane for the purpose of protecting staff from exposure to workplace air pollution. PATIENTS AND METHODS: Prospective, randomized trial in ASA class 1-2 children in whom a tidal breathing technique was used for anesthetic induction in a variety of surgical procedures. Patients were allocated to 2 groups. The sevo-N2O group inhaled 8% sevoflurane in a 60/40% mixture of oxygen and N2O. The sevo-air group received 8% sevoflurane in a mixture of oxygen and air (inspired oxygen fraction, 40%). We recorded mean arterial pressure (MAP), heart rate, oxygen saturation by pulse oximetry (SpO2), limb response to venous puncture, alveolar concentration of sevoflurane, and incidence of adverse events. RESULTS: Twenty-two patients were assigned to each group. The vein was catheterized in all patients without a pain reflex in the limb, and there were no statistically significant differences in MAP, heart rate, SpO2, or incidence of adverse events. Mean (SD) alveolar concentration of sevoflurane, however, differed between the 2 groups: 53% (0.51%) in the sevo-N2O group and 4.91% (0.41%) in the sevo-air group (P = .028). CONCLUSIONS: N2O-free anesthetic induction by tidal breathing of 8% sevoflurane provides similar anesthetic conditions (efficacy, safety, and rapid onset) without a higher incidence of adverse events. The use of N2O can therefore be avoided.