Preoperative coagulation screening tests in pediatric patients: Clinical relevance and hemorrhagic outcomes of abnormal results.

PURPOSE: Coagulation screening tests in children are still frequently performed in many countries to evaluate bleeding risk. The aim of this study was to assess the management of unexpected prolongations of the activated partial thromboplastin time (APTT) and prothrombine time (PT) in children prior to elective surgery, and the perioperative hemorrhagic outcomes. METHODS: Children with prolonged APTT and/or PT who attended a preoperative anesthesia consultation from January 2013 to December 2018 were included. Patients were grouped according to whether they were referred to a Hematologist or were scheduled to undergo surgery without further investigation. The primary endpoint was to compare perioperative bleeding complications. RESULTS: 1835 children were screened for eligibility. 102 presented abnormal results (5.6%). Of them, 45% were referred to a Hematologist. Significant bleeding disorders were associated with a positive bleeding history, odds ratio of 51 (95% CI 4.8-538.5, P=.0011). No difference in perioperative hemorrhagic outcomes were found between the groups. An additional cost of 181 euros per patient and a preoperative median delay of 43 days was observed in patients referred to Hematology. CONCLUSIONS: Our results suggest that hematology referral has limited value in asymptomatic children with a prolonged APTT and/or PT. Hemorrhagic complications were similar among patients referred and not referred to Hematology. A positive personal or family bleeding history can help identify patients with a higher bleeding risk, thus it should guide the need for coagulation testing and hematology referral. Further efforts should be made to standardize preoperative bleeding assessments tools in children.

Validation of a novel respiratory rate monitor based on exhaled humidity.

BACKGROUND: Postoperative monitoring of ventilation is largely restricted to the measurement of haemoglobin-oxygen saturation and respiratory rate (RR) derived from the ECG. measurement is inadequate when used with supplemental oxygen and ECG-derived RR is subject to artifacts. A new monitor measures RR by quantifying the humidity of exhaled air (respiR8(®)). METHODS: The accuracy of the system was tested using a breathing simulator. In healthy volunteers, the respiR8(®) monitor was compared with two other methods of measuring RR: capnometry and counting of thoracic breathing movements. The ability of the monitor to track changes in RR resulting from the infusion of 2.5 µg kg(-1) fentanyl was assessed and compared with RR measured from a validated flow measurement system. The RR in 50 postoperative patients measured with the respiR8(®) was compared with that derived from the ECG. RR values were compared by population-based Bland-Altman analyses. RESULTS: The respiR8(®) monitor was accurate in the range required in clinical practice. There was a close agreement between RR from respiR8(®), capnometry, and manual counting of respiratory movements without bias (limits of agreement ±1 bpm). The respiR8(®) monitor was well able to accurately track RR changes from fentanyl. In postoperative patients, RR from respiR8(®) and ECG had a bias of 1.7 (5.7) bpm due to greater RR values observed from the ECG due to artifacts. CONCLUSIONS: The respiR8(®) gives an accurate measurement of RR and is useful in postoperative care.

[Serious complications after pulmonary radiofrequency ablation: report of 2 cases]. / Dos casos de complicaciones graves tras radiofrecuencia pulmonar.

Radiofrequency ablation can be used to treat primary or metastatic pulmonary tumors when surgery is not indicated or involves high risk. Although this technique is less invasive than surgical resection, it is not free of risk for complications and adverse events, especially when it is used in patients with serious respiratory disease in whom comorbidity is common. We report 2 cases of serious complications. One was an intractable air leak that led to death. The other was a large hemothorax that was brought under control in the radiology procedure room. We review the literature on this technique as well as recommendations that contribute to making it as safe as possible.

Causes for cancellation of elective surgical procedures in a Spanish general hospital.

Cancellation of scheduled surgery is undesirable for patients and an inefficient use of resources. We prospectively collected data for 52 consecutive months in a public general hospital to estimate the prevalence and causes. The overall cancellation rate was 6.5% (2559 of 39 115 scheduled operations). Cancellation by broad category was for 'medical reasons' in 50%, 'patient-related factors' in 23%, and due to 'administrative/logistic problems' in 25%. The commonest specific causes within these categories were respectively: infections/fever (18%), patient did not attend (20%) and lack of theatre time (23%). This data will help direct resources to target prevention of cancellations as a result of these main problems.

[Removal of an epidural catheter from a patient receiving anticoagulant and antiplatelet therapy]. / Retirada de catéter epidural en un paciente con doble antiagregación.

We describe the management of anticoagulant and antiplatelet therapy to reduce the risk of hematoma on removal of an epidural catheter. The situation arose following major vascular surgery complicated by an acute myocardial infarction that required anticoagulant and antiplatelet therapy following implantation of a coronary stent.

[Intravenous remifentanyl for labor analgesia]. / Remifentanilo intravenoso para analgesia del trabajo del parto.

BACKGROUND: Intravenous remifentanil may be the preferred analgesic when regional techniques are contraindicated. OBJECTIVE: To perform a systematic review on the use of remifentanil for analgesia in labor. METHODS: We searched MEDLINE (January 1995-August 2007) for studies on obstetric analgesia with remifentanil. RESULTS: We found 32 references representing the use of remifentanil in 257 women in labor. In most cases, patients reported relief of pain and a high level of satisfaction, with no severe side effects in mothers or neonates. When compared with meperidine and nitrous oxide in clinical trials, remifentanil provided better analgesia with fewer adverse effects. CONCLUSION: Analgesia with intravenous remifentanil is more effective and safer than other alternatives to regional analgesic techniques in obstetrics. Nevertheless, the optimum system for infusing the drug must b e established and further studies of maternal and fetal safety should be carried out.

Predictive value of six risk scores for outcome after surgical repair of hip fracture in elderly patients.

BACKGROUND: Hip fracture surgery is associated with high post-operative mortality and poor functional results: the excess mortality is 20% in the first year; of those patients who survive, only 50% recover their previous ability to walk. The purpose of this study was to assess the predictive value of six functional status and/or surgical risk scoring systems with regard to serious complications after hip fracture surgery in the elderly. METHODS: We performed a prospective study of a consecutive series of 232 patients (aged 65 years or older) undergoing hip fracture surgery. We pre-operatively applied: The American Society of Anesthesiologists classification, the Barthel index, the Goldman index, the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) scoring system, the Charlson index and the Visual Analogue Scale for Risk (RISK-VAS) scale. These scales were evaluated with respect to three variables: incidence of serious complications, the ability to walk after a 3-month period and 90-day survival. The predictive value of the different scales was assessed by the calculated area under a receiver operating characteristic curve. RESULTS: The RISK-VAS scale, the POSSUM scoring system and the Charlson index reached a sufficient predictive value with regard to serious post-operative complications. The Barthel index and the RISK-VAS scale were those most useful for predicting ambulation at 3 months. None of the scales proved to be capable of predicting 90-day mortality. CONCLUSIONS: A simple index such as the RISK-VAS scale was the best predictor of serious post-operative complications. The functional level before the fracture, measured with the Barthel index, had a major influence on the ambulation recovery.

[Pulsed radiofrequency treatment in idiopathic and secondary glossopharyngeal neuralgia: preliminary results in 2 cases]. / Tratamiento con radiofrecuencia pulsada en dos casos de neuralgia glosofaríngea idiopática y secundaria. Resultados preliminares.

OBJECTIVES: To describe the use of pulsed radiofrequency (PRF) to treat 2 cases of glossopharyngeal neuralgia, 1 idiopathic and 1 secondary. PATIENTS: The first case involved a man diagnosed with Hodgkin's lymphoma involving the tonsils and manifesting as glossopharyngeal neuralgia that was refractory to all treatment approaches tried, including opioids and neuromodulation. The second case involved a patient diagnosed with essential glossopharyngeal neuralgia that was also resistant to drug treatment. The PRF procedure was performed in the operating room on an outpatient basis, under fluoroscopic guidance and with conventional monitoring. No perioperative events were reported. RESULTS: The treatment was effective for both patients, leading to decreases in visual analog scale pain reports between 5 and 7 points that were maintained over 6 months, although improvement for the patient with essential neuralgia was less intense and of shorter duration. Overall self-reported improvement assessed subjectively 6 months after PRF was 75% for the patient with Hodgkin's lymphoma and 50% for the patient with essential neuralgia, for whom a second PRF procedure was scheduled. Neither patient suffered complications or side effects that were potentially attributable to the procedure. CONCLUSIONS: PRF seems to be a safe, effective approach to treating neuralgia of the glossopharyngeal nerve, whether the condition is essential or secondary to another process. It is possible that if the condition is secondary, the clinical response may be greater in intensity and last longer.

[Epidural obstetric analgesia, maternal fever and neonatal wellness parameters]. / Analgesia epidural obstétrica, fiebre materna y parámetros de bienestar neonatal.

OBJECTIVE: To study the relation between epidural analgesia and the development of maternal fever during labor and childbirth, and to determine the possible relation between that association and neonatal welfare and in the performance of tests to rule out sepsis in newborns. PATIENTS AND METHODS: Prospective study of all women who gave birth at Fundación Hospital Alcorcón over a period of 3 years. All the women were offered epidural analgesia based on infusion of 0.0625% bupivacaine and 2 microg x mL(-1). Data collected were age, nulliparity, epidural analgesia infusion, induction of labor, uterine stimulation with oxytocin, type of birth, fetal weight, duration of dilation and expulsion, Apgar score (at 1 and 5 minutes), umbilical artery pH, and maternal temperature. RESULTS: Data for 4364 women were analyzed. Fever developed during labor in 5.7%; 93.7% of the fevers occurred in women receiving epidural analgesia (P<0.05). Logistic regression analysis revealed that independent risk factors for the development of fever were epidural analgesia (odds ratio [OR], 1.78; 95% confidence interval [CI], 1.05-3.04), nulliparity (OR, 2,929; 95% CI, 2.005-4.279), fetal weight (OR, 1.484; 95% CI, 1.102-2.001), and duration of labor (OR, 1.003; 95% CI, 1.003-1.004). No significant differences in Apgar score at 5 minutes or umbilical artery pH were found between the women with and without fever. Tests to rule out sepsis were ordered for 85.1% of the infants of mothers with fever after epidural analgesia. CONCLUSIONS: Epidural analgesia was associated with greater risk of developing fever in mothers giving birth, but that association had no repercussion on the neonatal wellness parameters studied.

Effects of droperidol and ondansetron on dispersion of ventricular repolarization: A randomized double-blind clinical study in anesthetized adult patients.

BACKGROUND AND OBJECTIVE: Droperidol and ondansetron prolong QT interval, a circumstance that has raised some concerns regarding the possibility of inducing torsades de pointes (TdP). However drug-induced spatial dispersion of ventricular repolarization has been shown to be the principal arrhythmogenic substrate for TdP. The aim of this study is to explore the effects of droperidol and ondansetron on the dispersion of repolarization, measured using the T peak-to-end interval (Tp-e) and Tp-e/QT and Tp-e/RR(1/2) ratios in surgical anesthetized patients. METHODS: A randomized, double-blind study carried out on sixty-three adult patients without cardiac disease or factors favoring QT prolongation and undergoing non-cardiac surgery were randomly assigned to the droperidol or ondansetron group. Under propofol anesthesia, a 12-lead EKG was obtained, and 1.25mg droperidol or 4mg ondansetron was injected. Five minutes later, a new 12-lead EKG was recorded. EKG analyses were independently performed by two cardiologists blinded to the state of the traces or group allocation. QT, RR and Tp-e intervals were measured by averaging five successive beats in leadII (QT) or V5 (Tp-e). The mean value for each measurement was calculated for statistical analysis. RESULTS: Thirty-two patients (19 women) received droperidol, and 31 (22 women) ondansetron. Droperidol and ondansetron prolonged the QTcF interval (Fridericia formula) by 6.8 and 7.2ms (mean values) respectively, but neither droperidol nor ondansetron increased the Tp-e interval or Tp-e/QT and Tp-e/RR(1/2) ratios. CONCLUSION: At antiemetic doses, neither ondansetron (4mg) nor droperidol (1.25mg) increases the dispersion of ventricular repolarization in healthy adult patients anesthetized with propofol.

Pseudoaneurysm of the femoral artery following percutaneous puncture and cannulation for invasive monitoring.

The risk of damage to the femoral artery after its cannulation is low; it coincides with a series of risk factors that include the use of relatively large-diameter introductor sheaths. We present a case in which pseudoaneurysm of the femoral artery developed after the introduction of a 16-gauge catheter (Abbocath, Abbott Laboratories, Chicago, Illinois, USA) into this vessel for the invasive monitoring of the arterial pressure in a patient who was admitted to the Postsurgical Intensive Care Unit during the postoperative course because of hemodynamic instability secondary to septic shock. We also discuss the prophylactic and therapeutic measures that can prevent or alleviate, respectively, that complication.

Cardiovascular and respiratory complications after elective supratentorial craniotomy.

The cardiovascular and respiratory complications and their treatment during the immediate postoperative period in the intensive care unit (ICU) are analyzed in 145 consecutive cases of supratentorial craniotomy. In this series, 87.5% of the patients remained in the unit less than 48 hours. In all, 67 cardiovascular disorders were observed in 49 subjects (33.7%). Supraventricular tachycardia, arterial hypotension and hypertension were, in order of frequency, the most common hemodynamic alterations. Fifty percent of the arterial hypertensions were treated with vasodilators. The etiological cause of hypotension was hypovolemia in 66.6% of the cases. Extubation was not performed in the operating room in 17.93% of the subjects, and seven patients in which it was had to be reintubated. The stay in the ICU was longer for those intubated (3.03 +/- 0.77 days). Mortality was 2.06%.

[Intraoperative arrhythmias in a patient with mitral valve prolapse]. / Arritmias intraoperatorias en una paciente con un prolapso valvular mitral.

We report a case of mitral valve prolapse in which the first manifestation was the occurrence of arrhythmias during anesthesia. A 28 years old female patient, ASA I, without previous medical or surgical history was programmed for surgical repair of an anal fistula. Preoperative physical and laboratory examination were normal. During anesthetic induction with propofol and droperidol and coinciding with orotracheal intubation the patient developed ventricular premature beats, bigeminy, and runs of ventricular tachycardia which were controlled with intravenous lidocaine. Anesthesia was maintained with 66% of O2/N2O, 0.5 to 1% of isoflurane, alfentanil, and atracurium. At the beginning of the intervention the patient presented an episode of supraventricular tachycardia at a rate of 140 to 160 beats/min which did not respond to a deeper anesthetic level nor to the administration of 5 mg of verapamil. This arrhythmia was finally interrupted with 3 mg of propranolol and it did not relapse during the surgical procedure. We discuss the physiopathology of the lesion, the possible arrhythmic effect of the anesthetic agents used in this case, and the effects of several pathologic situations (anemia, pain, anxiety, hypovolemia, etc) documented in patient with this abnormality.

[Combined subarachnoid-epidural technique for obstetric analgesia]. / Técnica combinada subaracnoidea-epidural para la analgesia obstétrica.

Combined spinal-epidural blockade for labor pain has enjoyed increasing popularity in obstetric anesthesia. The usual procedure is to use a single space and a single needle for dural puncture, inserting a spinal needle through an epidural needle followed by insertion of a catheter. A small dose of one or several substances (usually a lipophilic opioid and a local anesthetic) is first injected in the intrathecal space to provide rapid, effective analgesia with minimal muscle blockade. The epidural catheter is used if labor lasts longer than the spinal block, if the spinal block is insufficient, or in case of cesarean section. Combined spinal-epidural blockade is a safe, valid alternative to conventional epidural analgesia and has become the main technique for providing obstetric analgesia in many hospitals. The most widely-recognized advantage of the technique is high maternal satisfaction with rapid and effective analgesia. Mobility of the lower extremities is preserved and the mother is often able to walk. Because opioids are injected into the intrathecal space and because the technique is more invasive than standard epidural analgesia, the potential risk to mother and fetus increases.

[Comparison of 2 systems for continuous intraoperative monitoring of oxygen saturation in the jugular bulb]. / Comparación de dos sistemas de medida para la monitorización continua intraoperatoria de la saturación de oxígeno en el bulbo de la yugular.

OBJECTIVE: To compare accuracy, precision and stability of two jugular venous blood catheters for continuous monitoring of oxygen saturation during surgery, in a nonrandom, prospective sample. PATIENTS AND METHODS: We studied 47 patients requiring continuous monitoring of SjvO2 during a variety of neurosurgical procedures. Swan-Ganz pediatric 5.5F catheters (Opticath P575-EH) were used in 27 patients; neonatal umbilical artery 4F catheters (Opticath U425C) were used in 20. Both catheters were equipped with a fiberoptic system for continuous monitoring of hemoglobin oxygen saturation. After checking correct placement, readings transmitted were compared with co-oximetry readings for a sample taken from the distal end of the catheter. We also compared time spent placing the catheters and stability of SjvO2 reading during surgery. RESULTS: Insertion time (+/- SD) was 10.3 +/- 2.5 minutes for the 4F catheter and 15.9 +/- 5.5 minutes for the 5.5F model (p < 0.01). Although both systems tended to overestimate, the 5.5F catheters were more accurate: the mean differences were -6.8% for the 4F catheter and -1.2% for the 5.5F. These results made it necessary to calibrate the 4F catheters after placement and before use, a procedure not needed if the 5.5F catheters are used. Stability of SjvO2 readings during surgery was significantly greater (p < 0.01) for the 5.5F catheters, such that only 25.9% were considered clinically useful based on this parameter. However, 70% of the 5.5F catheters provided acceptable SjvO2 readings. Intracranial pressure during insertion and removal of the SjvO2 catheters was measured in only 5 patients; there were no changes greater than 1 mmHg. CONCLUSIONS: Although the 5.5F pediatric catheters take longer to put into position, their greater accuracy, precision and stability makes them preferable to the 4F catheters for continuous monitoring of SjvO2. Long-term vascular effects must be studied further.

[Anesthesia in a patient with latex allergy]. / Anestesia en una paciente con alergia al látex.

Anaphylactic reactions triggered by latex-based products are increasingly frequent, particularly in the hospital environment. We describe a patient with a prior history of atopic allergy and documented allergy to latex who was scheduled for abdominal surgery. A great deal of anesthetic and surgical equipment contains latex and substitutes for such material must be used in order to prevent severe hypersensitivity reactions.

[ 2 cases of tension pneumopericardium after unilateral lung transplantation]. / Dos casos de neumopericardio a tensión tras trasplante pulmonar unilateral.

We present 2 patients who developed tension pneumopericardium after undergoing unilateral lung transplantation, describing their clinical evolution after surgery until the diagnosis of tension pneumopericardium. In both cases aspiration of air from the pericardium resulted in improved hemodynamic status. Tension pneumopericardium is rare in adults. Our patients were at high risk due to the difficulty of ventilating native and implanted lungs with different compliances. Moreover, the passage of air from the mediastinum to the pericardium is facilitated by the large opening made in order to dissect the pulmonary veins.

[Pharmacological properties of aprotinin and its therapeutic use in heart surgery]. / Propiedades farmacológicas de la aprotinina y empleo terapéutico en cirugía cardíaca.

Aprotinin (Trasylol) is a protease-specific inhibitor that has been used for over 5 years in extracorporeal circulation (ECC) during cardiac surgery. Patients treated with this inhibitor have considerably less postoperative bleeding, along with correspondingly lower consumption of blood products. This article reviews the history of the drug, its pharmacokinetics and pharmacodynamics, its usefulness in biological sciences and its clinical application in cardiac surgery, as well as drug interactions and side effects.