Telomerase Reverse Transcriptase-Promoter Mutation in Young Patients with Bladder Tumors.

The TERT (Telomerase Reverse Transcriptase) gene promoter mutation is one of the most prevalent mutations in urothelial bladder tumors and this mutation is related to bladder tumor progression. Our purpose was to evaluate the presence of this mutation in a population of patients who were first diagnosed at age ≤ 40 years and to examine its relationship with tumor characteristics and progression. A molecular study was performed to detect the two most prevalent mutations in the TERT promoter (C228T and C250T). The study included 29 patients, with a mean follow-up of 152 months. There were no statistically significant differences in the clinical or tumor characteristics according to the presence or absence of the mutation. Although the mutation group showed poorer recurrence-free survival (RFS), there was no statistically significant difference and there was no difference in progression-free survival by group (p > 0.05). The pTERT mutations in bladder tumor cells occurred less frequently in younger patients than in older patients, a finding that could indicate different mechanisms of carcinogenesis. The trend towards lower RFS in patients with mutated pTERT needs to be confirmed by further studies, given the small number of patients included in these studies due to the low incidence of bladder tumors in this age group.

Wound Infusion of 0.35% Levobupivacaine Reduces Mechanical Secondary Hyperalgesia and Opioid Consumption After Cesarean Delivery: A Prospective, Randomized, Triple-Blind, Placebo-Controlled Trial.

BACKGROUND: Some patients still report moderate-to-severe postoperative pain after cesarean delivery. Local anesthetic wound infusion improves acute pain and might act on peripheral and central sensitization mechanisms; however, no studies have proved this hypothesis. We evaluated the potential benefits of continuous wound infusion of levobupivacaine after cesarean delivery on secondary hyperalgesia (primary end point) and primary hyperalgesia, pain relief, persistent pain, and inflammatory and metabolic stress response. METHODS: Healthy women scheduled for elective cesarean delivery participated in this prospective, randomized, triple-blind, placebo-controlled trial (NCT01458431). All patients received spinal anesthesia with 0.5% hyperbaric bupivacaine with fentanyl and a multiholed wound catheter placed under the fascia. Women were randomized to receive continuous wound infusion (0.35% levobupivacaine 7 mL/h for 48 hours; group L) or an equal volume of saline (group S). Secondary hyperalgesia to punctate mechanical stimuli was evaluated using dynamic tests, and primary hyperalgesia was evaluated using an electronic von Frey anesthesiometer; both were assessed at 24, 48, and 72 hours. The following variables were collected: intensity of postoperative parietal and visceral pain at rest and on movement rated on a visual analog scale >72 hours, time to first bolus of patient-controlled analgesia (PCA), cumulative dose of rescue morphine (PCA) and acetaminophen, ability to sleep and sleep quality, and patient satisfaction. Persistent postoperative pain was evaluated during a telephone interview at 1, 3, 6, and 12 months after surgery. C-reactive protein, acid glycoprotein, preprandial glucose, insulin, cortisol, prolactin, growth hormone, and interleukin-6 were measured before cesarean delivery and at 8, 24, and 48 hours. Adverse events and patient outcomes were recorded. RESULTS: Seventy women were included. In group L, the area of secondary hyperalgesia was significantly reduced (43.4 [18.5-80] vs 68.4 [39.0-136] cm2 and 45.1 [0.9-89.8] vs 67.3 [31.3-175] cm2 at 24 and 48 hours, respectively; group:time interaction P value < .001), the mechanical pain threshold was significantly higher at 24 hours (633 [441-802] vs 417 [300-572] g.mm-2; P = .001), and morphine consumption was significantly lower at 24 hours (4 [2-11] vs 11[6-23]; P = .003) compared with group S. Levobupivacaine had no effect on persistent postoperative pain at 1, 3, 6, and 12 months. Plasma insulin levels in the immediate postoperative period and at 8, 24, and 48 hours were significantly lower in group L (P < .001). There were no significant differences in other biochemical parameters of inflammatory and endocrine-metabolic response. CONCLUSIONS: Levobupivacaine wound infusion provides adequate analgesia and might be an effective antihyperalgesic adjunct.

Dynamic versus standard bougies for tracheal intubation with direct or indirect laryngoscopy in simulated or real scenarios: a systematic review and meta-analysis.

INTRODUCTION: This systematic review and meta-analysis aimed to compare the efficacy of dynamic versus standard bougies to achieve tracheal intubation. METHODS: We searched MEDLINE, Embase, CENTRAL, Web of Science, Scopus and Google Scholar on 10 October 2023. We included clinical trials comparing both devices. The primary outcome was the first-attempt intubation success rate. The secondary outcome was the time required for tracheal intubation. RESULTS: Eighteen studies were included. Dynamic bougies do not increase first-attempt success rate (RR 1.11; p = 0.06) or shorten tracheal intubation time (MD -0.30 sec; p = 0.84) in clinical trials in humans. In difficult airways, first-attempt success intubation rate was greater for dynamic bougies (RR 1.17; p = 0.002); Additionally, they reduced the time required for intubation (MD -4.80 sec; p = 0.001). First-attempt intubation success rate was higher (RR 1.15; p = 0.01) and time to achieve intubation was shorter when using Macintosh blades combined with dynamic bougies (MD -5.38 sec; p < 0.00001). Heterogeneity was high. CONCLUSION: Dynamic bougies do not increase the overall first-pass success rate or shorten tracheal intubation time. However, dynamic bougies seem to improve first-attempt tracheal intubation rate in patients with difficult airways and in those intubated with a Macintosh blade. Further research is needed for definitive conclusions. REGISTRATION OF PROSPERO: CRD42023472122.

Clinical, Pathological Characteristics and Progression of Urothelial Bladder Cancer in Young Adult Patients. Our Experience and Literature Review.

BACKGROUND: Bladder cancer is highly prevalent even though its incidence is considerably lower in patients younger than 40 years, thus raising the issue of the influence of age at diagnosis on the natural history of this disease. This study aimed to evaluate the characteristics and progression of young patients with urothelial bladder carcinoma with at least 10 years of follow-up and to compare the results with those of previously reported studies. MATERIAL AND METHODS: A retrospective study between 1990 and 2007 was conducted. The medical records and tissue samples of patients with urothelial bladder tumours were reviewed, and patients with a first diagnosis of urothelial carcinoma of the bladder at age 40 years or younger were selected. Their clinical and pathological data and disease-free survival were analysed. RESULTS: This study included 43 patients, with a median follow-up of 152 months (interquartile range (IQR): 96-222) and a mean age at diagnosis of 34 years (SD: 4.6). Thirty-five patients (81.4%) had non-muscle invasive tumours at diagnosis, and 53.5%, 27.9% and 18.6% had tumour grades of G1, G2 and G3, respectively. Fifteen patients (34.9%) experienced recurrence, and eight (18.6%) progressed. At 24 and 60 months, the recurrence-free survival rates were 84.8% (95% confidence interval (CI): 69.2%-92.9%) and 68.9% (95% CI: 51.7%-81%), respectively, and the progression-free survival rates were 94.9% (95% CI: 81%-98.7%) and 92.2% (95% CI: 77.8%-97.4%), respectively. CONCLUSIONS: Bladder cancer is an uncommon disease in young patients. In most cases, it consists of non-muscle-invasive tumours, with a low rate of recurrence and progression. The prognosis is based on the tumour's characteristics and not on the patient's age.

Executive Summary of the Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR) Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management.

The Airway section of the Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) present the Guidelines for the integral management of difficult airway in adult patients. This document provides recommendations based on current scientific evidence, theoretical-educational tools and implementation tools, mainly cognitive aids, applicable to the treatment of the airway in the field of anesthesiology, critical care, emergencies and prehospital medicine. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations and optimization in the progression of the application of strategies to preserve adequate alveolar oxygenation in order to improve safety and quality of care.

Implementation of a maternal early warning system during early postpartum. A prospective observational study.

OBJECTIVE: To evaluate the implementation of a maternal early warning system (MEWS) for monitoring patients during the first two hours after delivery in a tertiary level hospital. METHODS: Implementation of the criteria between 15 March and 15 September 2018 was evaluated in 1166 patients. The parameters collected were systolic and diastolic blood pressure, heart rate, oxygen saturation, urine output, uterine involution, and bleeding. Out-of-range values of any of these parameters triggered a warning, and an obstetrician was called to examine the patient. The obstetrician then decided whether to call the anesthesiologist. We carried out a sensitivity-specificity study of triggers and a multivariate analysis of the factors involved in developing potentially fatal disorders (PFD), reintervention, critical care admission, and stay. RESULTS: The MEWS was triggered in 75 patients (6.43%). Leading trigger was altered systolic blood pressure in 32 patients (42.7%), and 11 patients had a PFD. Twenty-eight triggers were false-negatives. Sensitivity and specificity of the system was 0.28 (0.15, 0.45) and 0.94 (0.93, 0.96), respectively. The multivariate analysis showed a correlation between trigger activation and PFD. CONCLUSION: Our MEWS presented low sensitivity and high specificity, with a significant number of false-negatives.

Effect of ultrasound image enhancement software on the quality of vision of regional anesthesia needles.

BACKGROUND: Our objective was to evaluate and compare the visualization of different types of needles with or without ultrasound image enhancement software, both in biological tissues and artificial models. METHODS: This is an observational study on fresh porcine tissue and gelatin models. Six types of plexus needles were studied. The same anesthesiologist performed in-plane punctures with each needle at 30°, 40° and 50° in both 2D mode and using software-based enhanced mode without changing position, generating 72 images. The images were evaluated blind by 38 anesthesiologists with at least two years of experience in ultrasound and rated from 0 to 10. A univariate and multivariate analysis was performed to identify differences between the images according to needle, mode, angle and experimental model. We described the results as mean (standard deviation). RESULTS: The Echoplex needle, 8.31 (1.94), was significantly better than the Sonoplex needle, 7.53 (2.16), P=0.0003, and both were significantly better than the other needles (P<0.0001). Significant differences were also found in favor of the gelatin model, 7.26 (2.48) vs. 6.24 (3.67), P<0.0001, and with ultrasound image enhancement software, 8.59 (1.55) vs. 4.91 (3.31), P<0.0001. These differences were confirmed by multivariate analysis. CONCLUSIONS: Although there are differences between the different types of needles used with ultrasound visualization strategies, ultrasound image enhancement software provides good visualization, regardless of the model chosen.

Association Between Use of Enhanced Recovery After Surgery Protocol and Postoperative Complications in Colorectal Surgery: The Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol (POWER) Study.

Importance: Enhanced Recovery After Surgery (ERAS) care has been reported to be associated with improvements in outcomes after colorectal surgery compared with traditional care. Objective: To determine the association between ERAS protocols and outcomes in patients undergoing elective colorectal surgery. Design, Setting, and Participants: The Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol (POWER) Study is a multicenter, prospective cohort study of 2084 consecutive adults scheduled for elective colorectal surgery who received or did not receive care in a self-declared ERAS center. Patients were recruited from 80 Spanish centers between September 15 and December 15, 2017. All patients included in this analysis had 1 month of follow-up. Exposures: Colorectal surgery and perioperative management were the exposures. Twenty-two individual ERAS items were assessed in all patients, regardless of whether they were included in an established ERAS protocol. Main Outcomes and Measures: The primary study outcome was moderate to severe postoperative complications within 30 days after surgery. Secondary outcomes included ERAS adherence, mortality, readmissions, reoperation rates, and hospital length of stay. Results: Between September 15 and December 15, 2017, 2084 patients were included in the study. Of these, 1286 individuals (61.7%) were men; mean age was 68 years (interquartile range [IQR], 59-77). A total of 879 patients (42.2%) presented with postoperative complications and 566 patients (27.2%) developed moderate to severe complications. The number of patients with moderate or severe complications was lower in the ERAS group (25.2% vs 30.3%; odds ratio [OR], 0.77; 95% CI, 0.63-0.94; P = .01). The overall rate of adherence to the ERAS protocol was 63.6% (IQR, 54.5%-77.3%), and the rate for patients from hospitals self-declared as ERAS was 72.7% (IQR, 59.1%-81.8%) vs non-ERAS institutions, which was 59.1% (IQR, 50.0%-63.6%; P < .001). Adherence quartiles among patients receiving the highest and lowest ERAS components showed that the patients with the highest adherence rates had fewer moderate to severe complications (OR, 0.34; 95% CI, 0.25-0.46; P < .001), overall complications (OR, 0.33; 95% CI, 0.26-0.43; P < .001), and mortality (OR, 0.27; 95% CI, 0.07-0.97; P = .06) compared with those who had the lowest adherence rates. Conclusions and Relevance: An increase in ERAS adherence appears to be associated with a decrease in postoperative complications.

Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol in Elective Total Hip and Knee Arthroplasty. POWER.2 Study: Study Protocol for a Prospective, Multicentre, Observational Cohort Study.

OBJECTIVE: The number of indications for total hip replacement (THR) and total knee replacement (TKR) surgery is increasing. Enhanced recovery after surgery (ERAS) represents the next step in the evolution of standardised care. The primary aim of this study is to measure the in-hospital 30-day medical and surgical postoperative complications rate. The study's secondary aims are to determine the length of stay, 30-day mortality rate, 30-day reoperation and readmission rates, the ERAS overall compliance and predefined ERAS individual items compliance. METHODS: This multicentre, prospective, observational study will include adult patients (aged >18 years) undergoing elective THR and TKR surgery. Consecutive patients undergoing surgery within the 2-month data collection period will be included. Centres that offer the THR and/or TKR surgery will be eligible to participate. The data collection will be done through an online data collection form via a secure, password-protected platform at each centre with predefined data fields. RESULTS: Ethical approval for this study has been obtained from the Comité de Ética de la Investigación de la Comunidad Autónoma de Aragón (C.P.-C.I. PI18/135; on 23 May 2018). It was prospectively registered on 27 June 2018, at www.clinicaltrials.gov with identification no. NCT03570944. CONCLUSION: The study will be disseminated through the SPARN-RedGERM, SEDAR, GERM and through social media. Peer-reviewed publications will be published under corporate authorship, including POWER.2 Study Group and SPARN-RedGERM.

Implementation of an ERAS program in patients undergoing thoracic surgery at a third-level university hospital: an ambispective cohort study

Abstract Objective To analyze the effects of an ERAS program on complication rates, readmission, and length of stay in patients undergoing pulmonary resection in a tertiary university hospital. Methods Ambispective cohort study with a prospective arm of 50 patients undergoing thoracic surgery within an ERAS program (ERAS group) versus a retrospective arm of 50 patients undergoing surgery before the protocol was implemented (Standard group). The primary outcome was the number of patients with 30-day surgical complications. Secondary outcomes included ERAS adherence, non-surgical complications, mortality, readmission, reintervention rate, pain, and hospital length of stay. We performed a multivariate logistic analysis to study the correlation between outcomes and ERAS adherence. Results In the univariate analysis, we found no difference between the two groups in terms of surgical complications (Standard 18 [36%] vs. ERAS 12 [24%], p = 0.19). In the ERAS group, only the readmission rate was significantly lower (Standard 15 [30%] vs. ERAS 6 [12%], p = 0.03). In the multivariate analysis, ERAS adherence was the only factor associated with a reduction in surgical complications (OR [95% CI] = 0.02 [0.00, 0.59], p = 0.03) and length of stay (HR [95% CI] = 18.5 [4.39, 78.4], p < 0.001). Conclusions The ERAS program significantly reduced the readmission rate at our hospital. Adherence to the ERAS protocol reduced surgical complications and length of stay.

[Enhanced recovery after surgery protocol versus conventional perioperative care in colorectal surgery. A single center cohort study]. / Aceleração da recuperação após protocolo cirúrgico versus cuidados perioperatórios convencionais em cirurgia colorretal. Um estudo de coorte em centro único.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols consist of a set of perioperative measures aimed at improving patient recovery and decreasing length of stay and postoperative complications. We assess the implementation and outcomes of an ERAS program for colorectal surgery. METHODS: Single center observational study. Data were collected from consecutive patients undergoing open or laparoscopic colorectal surgery during 2 time periods, 3 years before (Pre-ERAS) and 2 years after (Post-ERAS) the implementation of an ERAS protocol. Baseline characteristics of both groups were compared. The primary outcome was the number of patients with 180 days follow-up with moderate or severe complications; secondary outcomes were postoperative length of stay, and specific complications. Data were extracted from patient records. RESULTS: There were 360 patients in the Pre-ERAS group and 319 patients in the Post-ERAS Group. 214 (59.8%) patients developed at least one complication in the pre ERAS group, versus 163 patients in the Post-ERAS group (51.10%). More patients in the Pre-ERAS group developed moderate or severe complications (31.9% vs. 22.26%, p=0.009); and severe complications (15.5% vs. 5.3%; p<0.0001). The median length of stay was 13 (17) days in Pre-ERAS Group and 11 (10) days in the Post-ERAS Group (p=0.034). No differences were found on mortality rates (4.7% vs. 2.5%; p=0.154), or readmission (6.39% vs. 4.39%; p=0.31). Overall ERAS protocol compliance in the Post-ERAS cohort was 88%. CONCLUSIONS: The implementation of ERAS protocol for colorectal surgery was associated with a significantly reduction of postoperative complications and length of stay.

[Intraoperative goal directed hemodynamic therapy in noncardiac surgery: a systematic review and meta-analysis]. / Terapia hemodinâmica alvo-dirigida no intraoperatório de cirurgia não cardíaca: revisão sistemática e meta-análise.

BACKGROUND: The goal directed hemodynamic therapy is an approach focused on the use of cardiac output and related parameters as end-points for fluids and drugs to optimize tissue perfusion and oxygen delivery. Primary aim: To determine the effects of intraoperative goal directed hemodynamic therapy on postoperative complications rates. METHODS: A meta-analysis was carried out of the effects of goal directed hemodynamic therapy in adult noncardiac surgery on postoperative complications and mortality using Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. A systematic search was performed in Medline PubMed, Embase, and the Cochrane Library (last update, October 2014). Inclusion criteria were randomized clinical trials in which intraoperative goal directed hemodynamic therapy was compared to conventional fluid management in noncardiac surgery. Exclusion criteria were trauma and pediatric surgery studies and that using pulmonary artery catheter. End-points were postoperative complications (primary) and mortality (secondary). Those studies that fulfilled the entry criteria were examined in full and subjected to quantifiable analysis, predefined subgroup analysis (stratified by type of monitor, therapy, and hemodynamic goal), and predefined sensitivity analysis. RESULTS: 51 RCTs were initially identified, 24 fulfilling the inclusion criteria. 5 randomized clinical trials were added by manual search, resulting in 29 randomized clinical trials in the final analysis, including 2654 patients. A significant reduction in complications for goal directed hemodynamic therapy was observed (RR: 0.70, 95% CI: 0.62-0.79, p<0.001). No significant decrease in mortality was achieved (RR: 0.76, 95% CI: 0.45-1.28, p=0.30). Quality sensitive analyses confirmed the main overall results. CONCLUSIONS: Intraoperative goal directed hemodynamic therapy with minimally invasive monitoring decreases postoperative complications in noncardiac surgery, although it was not able to show a significant decrease in mortality rate.

Perioperative Use of Clevidipine: A Systematic Review and Meta-Analysis.

BACKGROUND: Clevidipine is an ultrashort-acting drug for rapid reduction of blood pressure by selectively acting on the L-type Ca2+ channels on arteriolar smooth muscle. The drug's ultrashort action in reducing the blood pressure is due to its rapid hydrolysis by blood and extravascular tissue esterases, which does not depend on hepato-renal metabolism and excretion. An analysis of the perioperative management of blood pressure should be considered to compare with other intravenous antihypertensive agents. METHODS: Analyses of the available evidence in randomized clinical trials following the PRISMA methodology as well as clinical significance according to the GRADE system were conducted. Placebo versus other antihypertensive drugs studies were included. Statistical assessments were done using the X2 and I2 tests. RESULTS: Clevidipine was more effective in maintaining the blood pressure within pre-specified ranges compared with other antihypertensive drugs (MD, -17.87 CI 95%: -29.02 to -6.72; p = 0.02). The use of Clevidipine versus placebo and rescue antihypertensive intravenous drug showed a clear reduction in rates of treatment failure (RR 0.10; IC 95%; 0.05-0.18; p <0.0001). There was no difference in the incidence of adverse events compared with placebo (RR 1.47; 95% CI 0.89 to 2.43, p = 0.14) and with other antihypertensive drugs (RR 0.78, 95% CI 0.45 to 1.35; p = 0.37). In addition, there was no difference in the incidence of atrial fibrillation (AF) between clevidipine and control groups (RR 1.09, IC del 95%: 0.65 a 1.83; p = 0.73). CONCLUSIONS: Clevidipine is an ultrafast-acting drug that is highly effective for management of perioperative arterial hypertension. It is devoid of adverse effects associated with the use of other IV antihypertensives. Its favorable pharmacodynamic and pharmacokinetic properties make clevidipine the drug of choice for the management of acute perioperative hypertension. It is important to emphasize the need for further studies with a larger number of patients to confirm these findings and increase the degree of evidence.

Perioperative goal-directed hemodynamic therapy in noncardiac surgery: a systematic review and meta-analysis.

STUDY OBJECTIVE: Goal-directed fluid therapy (GDHT) has been proposed as a method to reduce complications and mortality. DESIGN: Meta-analysis of the effects of perioperative GDHT in adult noncardiac surgery on mortality and postoperative complications was performed using the PRISMA methodology. A systematic search was performed in MEDLINE, PubMed, EMBASE, and the Cochrane Library (last update, October 2014). Inclusion criteria were as follows: randomized clinical trials (RCTs) in which perioperative GDHT was compared with conventional fluid management in noncardiac surgery. Exclusion criteria were as follows: trauma and pediatric surgery studies. End points were mortality and number of patients with complications. SETTING: District general hospital. PATIENTS: Thirty-nine RCTs were initially identified, with 8 fulfilling the inclusion criteria. Two RCTs were added by manual search, resulting in 10 RCTs in the final analysis, including 1527 patients. MEASUREMENTS: Those studies that fulfilled the entry criteria were examined in full and subjected to quantifiable analysis, predefined subgroup analysis (stratified by supraphysiological or physiological hemodynamic goal and by time the intervention was carried out, perioperative or postoperative), and predefined sensitivity analysis. MAIN RESULTS: A significant reduction was observed in mortality associated with GDHT compared with conventional fluid therapy (risk ratio, 0.63; 95% confidence interval, 0.42-0.94; P = .02). However, no differences were found in the number of patients with complications (risk ratio, 0.75; 95% confidence interval, 0.50-1.17; P = .21), and the sensitivity analysis did not confirm the results. CONCLUSIONS: This meta-analysis, with its limitations, shows that the use of perioperative GDHT may reduce postoperative mortality, but it is unable to show a reduction in the number of patients with complications.

Intraoperative goal directed hemodynamic therapy in noncardiac surgery: a systematic review and meta-analysis.

BACKGROUND: The goal directed hemodynamic therapy is an approach focused on the use of cardiac output and related parameters as end-points for fluids and drugs to optimize tissue perfusion and oxygen delivery. Primary aim: To determine the effects of intraoperative goal directed hemodynamic therapy on postoperative complications rates. METHODS: A meta-analysis was carried out of the effects of goal directed hemodynamic therapy in adult noncardiac surgery on postoperative complications and mortality using Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. A systematic search was performed in Medline PubMed, Embase, and the Cochrane Library (last update, October 2014). Inclusion criteria were randomized clinical trials in which intraoperative goal directed hemodynamic therapy was compared to conventional fluid management in noncardiac surgery. Exclusion criteria were trauma and pediatric surgery studies and that using pulmonary artery catheter. End-points were postoperative complications (primary) and mortality (secondary). Those studies that fulfilled the entry criteria were examined in full and subjected to quantifiable analysis, predefined subgroup analysis (stratified by type of monitor, therapy, and hemodynamic goal), and predefined sensitivity analysis. RESULTS: 51 RCTs were initially identified, 24 fulfilling the inclusion criteria. 5 randomized clinical trials were added by manual search, resulting in 29 randomized clinical trials in the final analysis, including 2654 patients. A significant reduction in complications for goal directed hemodynamic therapy was observed (RR: 0.70, 95% CI: 0.62-0.79, p<0.001). No significant decrease in mortality was achieved (RR: 0.76, 95% CI: 0.45-1.28, p=0.30). Quality sensitive analyses confirmed the main overall results. CONCLUSIONS: Intraoperative goal directed hemodynamic therapy with minimally invasive monitoring decreases postoperative complications in noncardiac surgery, although it was not able to show a significant decrease in mortality rate.

Restrictive versus liberal transfusion strategy for red blood cell transfusion in critically ill patients and in patients with acute coronary syndrome: a systematic review, meta-analysis and trial sequential analysis.

INTRODUCTION: The risks and benefits of transfusing critically ill patients continue to evoke controversy. Specifically, the critically ill patients with active ischemic cardiac disease continue to represent a "gray area" in the literature. EVIDENCE ACQUISITION: Meta-analysis of the effects of lower versus higher hemoglobin thresholds on mortality in critically ill patients was carried out using PRISMA methodology. A systematic research was performed in PubMed, Embase, and the Cochrane Library (last update, December 2014). INCLUSION CRITERIA: Anemic critically ill adult patients admitted to intensive care units and/or anemic patients with acute coronary syndrome in which a restrictive vs. liberal transfusion therapy was compared. PRIMARY ENDPOINT: mortality. Included studies were subjected to quantifiable analysis, predefined subgroup analysis, trial sequential analysis and predefined sensitivity analysis. EVIDENCE SYNTHESIS: Thirty RCT's were initially identified; 6 fulfilled the inclusion criteria, including 2156. There were no differences in mortality between the restrictive and liberal groups (RR: 0.86, 95% CI 0.70-1.05 P=0.14), neither in patients with chronic cardiovascular disease subgroup (RR: 1.13, 95% IC 0.88-1.46 P=0.34). However, there is a trend towards decreased mortality in the subgroup critically ill (RR: 0.86, 95% CI 0.73-1.01 P=0.06); while in the subgroup of patients with acute myocardial infarct seems like it might be a non-significant trend towards increased mortality (RR: 3.85, 95% CI 0.82-18.0 P=0.09). CONCLUSIONS: Restrictive strategy is at least as effective to liberal strategy in critically ill patients. Nevertheless, there is insufficient evidence to recommend a restrictive strategy for patients with acute coronary syndrome.