[Multidisciplinary consensus document on the management of massive haemorrhage (HEMOMAS document)]. / Documento multidisciplinar de consenso sobre elmanejo de la hemorragia masiva (document HEMOMAS)

Massive haemorrhage is common and often associated with high morbidity and mortality. We perform a systematic review of the literature, with extraction of the recommendations from the existing evidences because of the need for its improvement and the management standardization. From the results we found, we wrote a multidisciplinary consensus document. We begin with the agreement in the definitions of massive haemorrhage and massive transfusion, and we do structured recommendations on their general management (clinical assessment of bleeding, hypothermia management, fluid therapy, hypotensive resuscitation and damage control surgery), blood volume monitoring, blood products transfusion (red blood cells, fresh frozen plasma, platelets and their best transfusion ratio), and administration of hemostatic components (prothrombin complex, fibrinogen, factor VIIa, antifibrinolytic agents).

Multidisciplinary consensus document on the management of massive haemorrhage (HEMOMAS document).

Massive haemorrhage is common and often associated with high morbidity and mortality. We perform a systematic review of the literature, with extraction of the recommendations from the existing evidences because of the need for its improvement and the management standardization. From the results we found, we wrote a multidisciplinary consensus document. We begin with the agreement in the definitions of massive haemorrhage and massive transfusion, and we do structured recommendations on their general management (clinical assessment of bleeding, hypothermia management, fluid therapy, hypotensive resuscitation and damage control surgery), blood volume monitoring, blood products transfusion (red blood cells, fresh frozen plasma, platelets and their best transfusion ratio), and administration of hemostatic components (prothrombin complex, fibrinogen, factor VIIa, antifibrinolytic agents).

[The 2013 Seville Consensus Document on alternatives to allogenic blood transfusion. An update on the Seville Document]. / 2013. Documento Sevilla de Consenso sobre Alternativas a la Transfusión de Sangre Alogénica. Actualización del Documento Sevilla.

Since allogeneic blood transfusion (ABT) is not harmless, multiple alternatives to ABT (AABT) have emerged, though there is great variability in their indications and appropriate use. This variability results from the interaction of a number of factors, including the specialty of the physician, knowledge and preferences, the degree of anemia, transfusion policy, and AABT availability. Since AABTs are not harmless and may not meet cost-effectiveness criteria, such variability is unacceptable. The Spanish Societies of Anesthesiology (SEDAR), Hematology and Hemotherapy (SEHH), Hospital Pharmacy (SEFH), Critical Care Medicine (SEMICYUC), Thrombosis and Hemostasis (SETH) and Blood Transfusion (SETS) have developed a Consensus Document for the proper use of AABTs. A panel of experts convened by these 6 Societies have conducted a systematic review of the medical literature and have developed the 2013 Seville Consensus Document on Alternatives to Allogeneic Blood Transfusion, which only considers those AABT aimed at decreasing the transfusion of packed red cells. AABTs are defined as any pharmacological or non-pharmacological measure aimed at decreasing the transfusion of red blood cell concentrates, while preserving patient safety. For each AABT, the main question formulated, positively or negatively, is: « Does this particular AABT reduce the transfusion rate or not?¼ All the recommendations on the use of AABTs were formulated according to the Grades of Recommendation Assessment, Development and Evaluation (GRADE) methodology.

[The 2013 Seville Consensus Document on alternatives to allogenic blood transfusion. An update on the Seville Document]. / 2013. Documento Sevilla de Consenso sobre Alternativas a la Transfusión de Sangre Alogénica. Actualización del Documento Sevilla.

Since allogeneic blood transfusion (ABT) is not harmless, multiple alternatives to ABT (AABT) have emerged, though there is great variability in their indications and appropriate use. This variability results from the interaction of a number of factors, including the specialty of the physician, knowledge and preferences, the degree of anemia, transfusion policy, and AABT availability. Since AABTs are not harmless and may not meet cost-effectiveness criteria, such variability is unacceptable. The Spanish Societies of Anesthesiology (SEDAR), Hematology and Hemotherapy (SEHH), Hospital Pharmacy (SEFH), Critical Care Medicine (SEMICYUC), Thrombosis and Hemostasis (SETH) and Blood Transfusion (SETS) have developed a Consensus Document for the proper use of AABTs. A panel of experts convened by these 6 Societies have conducted a systematic review of the medical literature and have developed the 2013 Seville Consensus Document on Alternatives to Allogeneic Blood Transfusion, which only considers those AABT aimed at decreasing the transfusion of packed red cells. AABTs are defined as any pharmacological or non-pharmacological measure aimed at decreasing the transfusion of red blood cell concentrates, while preserving patient safety. For each AABT, the main question formulated, positively or negatively, is: "Does this particular AABT reduce the transfusion rate or not?" All the recommendations on the use of AABTs were formulated according to the Grades of Recommendation Assessment, Development and Evaluation (GRADE) methodology.

[Survival of rats subjected to different levels of pulmonary injury]. / Supervivencia de ratas sometidas a diferentes grados de agresión pulmonar.

OBJECTIVE: To determine a pulmonary injury model in rats that is associated with moderate mortality after extubation. DESIGN AND SETTING: An experimental study in an animal model of ventilator-induced lung injury in the animal research laboratory in Virgen de las Nieves University Hospital. SUBJECTS AND METHOD: A total of 45 male Wistar-Kyoto rats weighing 250-300g received food and water ad libitum. The rats were anesthetized and a tracheotomy was performed by insertion of endotracheal tube by tracheotomy. INTERVENTIONS: Pulmonary injury due to mechanical ventilation was maintained for 60 min with high tidal volume (25 ml/kg) combined with intratracheal instillation of different doses of 0,9% saline solution. Rats were randomly distributed into 3 groups (15 animals in each group) with different amounts of instilled saline solution: group I, 0.5 ml/250 g body weight; group II, 1 ml/250 g body weight, and group III, 1.5 ml/250 g body weight. MAIN MEASUREMENTS: Survival of animals after extubation was recorded every 5 min for the first 40 min and then at 3 h, 24 h, 72 h, and 7 days. RESULTS: Survival in rats that received 0.5, 1 and 1.5 ml/250 g of intratracheal saline solution was 60%, 43% and 0% respectively, with statistically significant differences between groups receiving 0.5 and 1.5 ml/250 g (p = 0.003). CONCLUSIONS: Survival in rats mechanically ventilated with high moderate volume is influenced by increased doses of intratracheal saline solution and this is important to design studies that analyze the effect the interventions on mortality.

[Current concepts of pathophysiology, monitoring and resolution of pulmonary edema]. / Conceptos actuales en la fisiopatología, monitorización y resolución del edema pulmonar*

Pulmonary edema, both in its lesional as well as hydrostatic version, is a frequent cause of acute respiratory failure. From the pathophysiological point of view, the most important advance is undoubtedly the knowledge that the reabsorption process of pulmonary edema is an active process with energy consumption. This concept has revolutionized this field due to the possibility of finding substances or factors that stimulate or inhibit this reabsorption. Furthermore, in the monitoring field, significant advances have also been experimented due to the possibility of quantifying the edema in a simple and reliable way with transpulmonary thermodilution.

Acute respiratory distress syndrome: resource use and outcomes in 1985 and 1995, trends in mortality and comorbidities.

PURPOSE: The purpose of this study was to compare resource consumption and mortality between (ARDS) patients with adult respiratory distress syndrome treated at our center in 1985 (45 patients) and those treated in 1995. MATERIALS AND METHODS: This was a retrospective observational study, considering trauma and nontrauma ARDS separately. We recorded severity index scores (APACHE III), infectious complications and multiorgan failure, intensive care unit (ICU) resource consumption (TISS 28), length of stay, time on mechanical ventilation, and ICU mortality. RESULTS: We found no variation in overall ARDS mortality and no reduction in mortality in the ARDS trauma group (43.5% in 1985 vs. 38.5% in 1995, not significant) but a significant increase in mortality among nontrauma septic ARDS patients (68.2% vs. 82.9%, P < .001), largely attributable to the new comorbidities of human immunodeficiency virus (HIV) infection and hematologic malignancy. TISS-28 showed an overall reduction over this time period (49.7 +/- 6.6 vs. 38.3 +/- 9.7, P < .001), due to fewer monitoring measures, particularly a lower use of pulmonary artery catheter. There were no overall changes in length of stay or days on mechanical ventilation between 1985 and 1995, but these variables did increase among the trauma subgroup. CONCLUSION: In our setting, mortality remained constant from 1985 to 1995 among ARDS trauma patients but not among nontrauma ARDS patients because of the new case-mix of the latter population, which now includes HIV and other immunodepressed patients.

Dynamics of lung collapse and recruitment during prolonged breathing in porcine lung injury.

Oleic acid (OA) injection, lung lavage, and endotoxin infusion are three commonly used methods to induce experimental lung injury. The dynamics of lung collapse and recruitment in these models have not been studied, although knowledge of this is desirable to establish ventilatory techniques that keep the lungs open. We measured lung density by computed tomography during breath-holding procedures. Lung injury was induced with OA, lung lavage, or endotoxin in groups of six mechanically ventilated pigs. After a stabilization period, repetitive computed tomography scans of the same slice were obtained during prolonged expirations with and without positive end-expiratory pressure and during prolonged inspirations after 5 and 30 s of expiration. Lung collapse and recruitment occurred mainly within the first 4 s of breath-holding procedures in all three lung injury models, and some collapse and recruitment occurred even within 0.6 s. OA-injured lungs were significantly more unstable than lungs injured by bronchoalveolar lavage or endotoxin infusion. In this experimental setting, expiration times <0.6 s are required to avoid cyclic alveolar collapse during mechanical ventilation without extrinsic positive end-expiratory pressure.

Differential effects of IL-1 beta and ibuprofen after endotoxic challenge in mice.

Interleukin-1 (IL-1) and ibuprofen modulate the host response in different models after endotoxic challenge. A comparative study was made between the two drugs, as they were jointly administered, to explore a potentiation of their therapeutic effects. Endotoxic challenge was provoked in CBA/H mice with lipopolysaccharide (LPS) from Escherichia coli (125 mg/kg), with administration of recombinant murine IL-1 beta (80 ng/mouse) 24 hr pre-LPS. Two doses of ibuprofen (1 mg/kg) were administered 1 hr before and 30 min after the septic challenge. Serum levels of IL-1 alpha, tumor necrosis factor-alpha (TNF alpha), and interleukin-6 (IL-6) were determined 1,2, and 4 hr, post-LPS, and prostaglandin E2 (PGE2) urine levels 4,8, and 12 hr post-LPS, and a comparative mortality study was performed. IL-1 beta treatment provoked a reduction of IL-1 alpha, TNF alpha, and IL-6 without affecting PGE2, while ibuprofen provoked a later increase of IL-1 alpha, TNF alpha, and IL-6, with a decrease of PGE2. Both drugs caused a notable enhancement of survival, with no difference between them, but their combined administration caused no improvement. We conclude that both drugs exert a similar therapeutic effect in endotoxic shock by different mechanisms.

Thrombolytic treatment for massive thrombosis of prosthetic cardiac valves.

OBJECTIVE: To present the efficacy of thrombolytic treatment in place of emergency surgery in massive thrombosis of prosthetic cardiac valves (TPCV), and to set out the diagnostic criteria and the patients' evolution. DESIGN: Retrospective study. SETTING: Coronary Care Unit of a Spanish reference hospital. PATIENTS: 7 patients admitted into the ICU with 10 episodes of TPCV and with advanced functional class. INTERVENTIONS: The diagnosis of TPCV was arrived at through clinical data and was confirmed by Doppler-echocardiography before treatment. Thrombolytic treatment (streptokinase, urokinase or rt-PA) was used. The analysis of paired samples between the data before and after treatment was used. MEASUREMENTS AND RESULTS: All the patients underwent an improvement in their clinical condition. A reduction of sPAP and in the mean transprosthetic gradient and an increase in the effective valvular area was achieved. Four patients needed surgical intervention during their follow-up. No case required emergency surgery. One patient died after surgery and the other 6 patients are alive after follow-up of 6-33 months. With the fibrinolytic treatment hemorrhagic complications were always controlled. None of the treated patients presented embolic complications. CONCLUSIONS: Fibrinolytic treatment is the recommended initial treatment in cases of massive TPCV. When fibrinolysis is only partially successful, reoperation can be performed at lower risk. Doppler echocardiography is fundamental in the diagnosis of TPCV and in monitoring the response to fibrinolytic treatment.