Adaptation and validation of the Stanford Presenteeism Scale-6 in healthcare professionals.

AIM: To develop and psychometrically test the Stanford Presenteeism Scale-6 to assess presenteeism in the Spanish healthcare population. BACKGROUND: Presenteeism, referring to going to work despite being ill, has been associated with job stress, productivity losses, reduced patient safety and increased health problems among the professionals who suffer from it. INTRODUCTION: The highest prevalence of presenteeism in the healthcare sector is among nurses. Their decision to attend work while ill has been related to role overload, lack of supervisor support, mental health and physical conditions. METHODS: A cross-sectional and validation study was conducted between September 2015 and June 2016 in a hospital in Asturias, Spain. Four hundred and ninety-five healthcare professionals voluntarily agreed to participate (281 nurses, 122 physicians and 92 nursing assistants). RESULTS: Presenteeism prevalence was high; the majority of it being in the nursing category. Bartlett's test and the Kaiser-Meyer-Olkin test indicated that the data meet the conditions for factorial analysis, evidencing a small variability in the median of each sample item and a significant standard deviation. Adjustment rates obtained in the exploratory factor analysis showed adequacy, and reliability rates also showed adequacy for both factors. It was verified by a confirmatory analysis that the factors of presenteeism are positively associated with burnout. CONCLUSION: The Stanford Presenteeism Scale-6 showed good psychometric properties to study presenteeism in the Spanish healthcare sector. IMPLICATIONS FOR NURSING AND HEALTH POLICY: Nursing leaders must develop measurements to assess and control psychosocial risks in order to improve the physical and mental health of professionals and reduce patient safety risks.

Cohort study to assess the prevalence of prolonged QT and arrhythmias in critically ill patients during the early phase of the COVID-19 pandemic.

INTRODUCTION: Patients with SARS-CoV-2 infection may present cardiovascular involvement including myocarditis, arrhythmias and QT interval prolongation. Our objective was to evaluate the impact of COVID-19 and its treatment on ventricular repolarization and development of arrhythmias in critically ill patients. METHODS: Retrospective cohort study of critically ill COVID-19 patients during a 3-month period in whom at least one ECG was available. Relevant clinical data and specific treatment administered for COVID-19 were recorded. Prolonged QTc was considered prolonged when it measured ≥ 460 ms in women and ≥450 ms in men. The incidence and type of arrhythmias during the same period were recorded. RESULTS: A total of 77 patients with a mean age of 62 ±â€¯13 years, 20 women and 57 men, were evaluated. Sixty percent of the patients were hypertensive, 52% had a BMI > 30, and 70% developed acute renal failure during admission. Some 56% of the patients presented QTc prolongation. Forty-four percent presented some type of arrhythmia during their stay in the ICU, 21% of which were atrial arrhythmias. Overall mortality was 53%, with no differences between patients with or without prolonged QTc. CONCLUSIONS: In our series, a high proportion of critical patients with COVID-19 presented prolonged QTc and arrhythmias. The factors involved have been related to the elevation of cardiac biomarkers, the myocardial involvement of the virus and concomitant medication received in the ICU.

Lipid emulsions in the treatment of intoxications by local anesthesics and other drugs. Review of mechanisms of action and recommendations for use.

Intravenous lipid emulsions (ILEs) have been used widely for the treatment of local anesthetic (LA) poisoning and have been proposed as a treatment for intoxication by other drugs. However, the degree of evidence for this kind of therapy is not strong, as it comes mostly from clinical cases. The aim of this narrative review is to describe the proposed mechanisms of action for ILEs in poisoning by LA and other drugs and to evaluate recent studies in animals that support the recommendations for their use and the experience in humans that support the use of ILESs in both LA and other drug poisoning. For this purpose, a search was performed in the Embase, Medline and Google Scholar databases covering relevant articles over the last 10 years. In the case of AL poisoning, we recommend applying the protocols dictated by international guidelines, knowing that the degree of evidence is not very high. In poisoning by other drugs, ILEs are recommended in serious situations induced by liposoluble xenobiotics that do not respond to standard treatment.

Lipid emulsions in the treatment of intoxications by local anesthesics and other drugs. Review of mechanisms of action and recommendations for use. / Emulsiones lipídicas en la intoxicación por anestésicos locales y otros fármacos. Revisión sobre mecanismos de acción y recomendaciones de uso.

Intravenous lipid emulsions (ILEs) have been used widely for the treatment of local anesthetic (LA) poisoning and have been proposed as a treatment for intoxication by other drugs. However, the degree of evidence for this kind of therapy is not strong, as it comes mostly from clinical cases. The aim of this narrative review is to describe the proposed mechanisms of action for ILEs in poisoning by LA and other drugs and to evaluate recent studies in animals that support the recommendations for their use and the experience in humans that support the use of ILESs in both LA and other drug poisoning. For this purpose, a search was performed in the Embase, Medline and Google Scholar databases covering relevant articles over the last 10 years. In the case of AL poisoning, we recommend applying the protocols dictated by international guidelines, knowing that the degree of evidence is not very high. In poisoning by other drugs, ILEs are recommended in serious situations induced by liposoluble xenobiotics that do not respond to standard treatment.

A multicenter and observational study of the Ambu™ AuraGain™ laryngeal mask in adult patients. / Estudio multicéntrico observacional de la mascarilla Ambu® AuraGain® en pacientes adultos.

PURPOSE: The main objective of this study was to evaluate the performance of the Ambu™ AuraGain™ device by determining its main parameters of use and complications. METHODS: A total of 250 adult ASA physical status i to iii patients from five hospitals in Spain who received general anaesthesia with a supraglottic airway (SGA) device were enrolled in this study. RESULTS: The primary outcome was analysed for 244 patients and a median OLP of 32 cm H2O (IQR 28-36 cm H2O) was obtained. Insertion was achieved at first attempt in 85% of cases, and overall in 98% of cases, in a median time of 15 s (12-22.5). We applied manoeuvres in 61% of patients to facilitate the process. Ventilation was effective in 97.2% of the interventions (95% CI 0.99-0.94) throughout the procedure. Insertion of the gastric tube was easily performed in 99.6% of the patients, and the vocal cords were viewed by fibrobronchoscopy in 96.3% of cases. Logistic regression analysis identified the use of sizes smaller than those recommended as a risk factor for low OLP (< 25 cm H2O). The main complication recorded was the presence of blood when withdrawing the SGA device (15%). CONCLUSIONS: Our results confirm that the use of AuraGain allows airway management in a reliable and effective way achieving high OLP and low incidence of associated complications, establishing it as a useful alternative in the routine clinical setting of anaesthesiologists. AuraGain performance was consistent in all five centres.

Analysis of Emergency Healthcare Demand in a Prison.

OBJECTIVE: To analyze the reasons for seeking emergency medical care amongst prison inmates and their relationship to sociodemographic characteristics. MATERIAL AND METHOD: An observational, descriptive and retrospective study was carried out. We collected the sociodemographic variables of inmates and their healthcare needs at the referral hospital over nine years. RESULTS: A total of 972 hospital visits were included. The most common healthcare needs, in descending order, were multiple trauma, limb problems and dyspnea. Mondays and Wednesdays were found to be the busiest days (P <0.001). The average stay in cases of hospitalization was 6.1 (SD: 4.3) days; patients with nontraumatic healthcare needs required a longer stay. The majority of the inmates native to Africa, Asia and America received emergency healthcare services due to traumatic injuries; by contrast the most common injuries among Europeans were non-traumatic and unrelated to suicide attempts (P <0.001). European inmates were on average 4.2 years older than Africans and 4.7 years older than American inmates (P <0.001). DISCUSSION: The reasons for seeking emergency care are clearly differentiated according to the inmates' nationality, one notable outcome was the greater longevity of European internees. These results highlight the importance of understanding healthcare demand within the prison system in order to better address considerations such as prevention, organization and the location of healthcare units.

[Parents' satisfaction in onco-hematology units]. / Satisfacción de los padres en unidades de oncohematología.

INTRODUCTION: patient satisfaction is a quality of care predictor that allows to identify specific areas of improvement. Frequently, parents are who provide this information when their children are too young or cannot communicate. The aim of the study was to determine parents' satisfaction with paediatric oncology care and its relationship with sociodemographic variables. MATERIAL AND METHODS: a cross-sectional observational study was carried out. Parents whose children suffered from cancer and were treated in the oncology ward and oncology day hospital in Asturias were included. A questionnaire with sociodemographic variables and the Cuestionario de Calidad de Cuidados de Enfermería (CUCACE), that evaluates experience and satisfaction with care through two dimensions (range from 0 to 100), were used. RESULTS: 24 parents agreed to particape. The average in experience dimension of CUCACE was 88,99 and 87,01 in satisfaction. All participants referred as positive the treat received at the units, however, 41,7% declared it should be enhanced. No relationship between satisfaction and sociodemographic variables were found. CONCLUSIONS: Parents of children with cancer demonstrated high satisfaction with care. Information and communication with medical staff need to be strengthened.

Liver transplant with controlled donors after circulatory death with normothermic regional perfusion and brain dead donors: A multicenter cohort study of transfusion, one-year graft survival and mortality.

BACKGROUND: Controlled donation after circulatory death (cDCD) has expanded the donor pool for liver transplantation (LT). However, transfusion requirements and perioperative outcomes should be elucidated. The aim of this multicenter study was to assess red blood cell (RBC) transfusions, one-year graft and patient survival after LT after cDCD with normothermic regional perfusion (NRP) compared with donors after brain death (DBD). METHODS: 591 LT carried out in ten centers during 2019 were reviewed. Thromboelastometry was used to manage coagulation and blood product transfusion in all centers. Normothermic regional perfusion was the standard technique for organ recovery. RESULTS: 447 patients received DBD and 144 cDCD with NRP. Baseline MCF Extem was lower in the cDCD group There were no differences in the percentage of patients (63% vs. 61% p = 0.69), nor in the number of RBC units transfused (4.7 (0.2) vs 5.5 (0.4) in DBD vs cDCD, p = 0.11. Twenty-six patients (6%) died during admission for LT in the DBD group compared with 3 patients (2%) in the cDCD group (p = 0.15). To overcome the bias due to a worse coagulation profile in cDCD recipients, matched samples were compared. No differences in baseline laboratory data, or in intraoperative use of RBC or one-year outcome data were observed between DBD and cDCD recipients. CONCLUSIONS: cDCD with NRP is not associated with increased RBC transfusion. No differences in graft and patient survival between cDCD and DBD were found. Donors after controlled circulatory death with NRP can increasingly be utilized with safety, improving the imbalance between organ donors and the ever-growing demand.

In vitro study of magnetic resonance imaging artefacts of six supraglottic airway devices.

We investigated the artefacts created during magnetic resonance imaging by five different laryngeal mask airways: the Classic (cLMA); the LMA ProSeal; the LMA Unique; the Ambu Disposable Laryngeal Mask; the LMA Supreme; and one other supraglottic airway device, the i-gel supraglottic airway. The devices were placed on top of and inside a phantom simulator to resemble the position in vivo. The artefacts with the cLMA, Unique and Supreme were similar and related to ferromagnetic material in the pilot balloon valve. Artefacts were more prominent with the ProSeal. There were no artefacts with the Ambu Disposable Laryngeal Mask or the i-gel.

Cardiac electrophysiological effects of remifentanil: study in a closed-chest porcine model.

BACKGROUND: Remifentanil has been implicated as causing intraoperative bradyarrhythmias, but little information is available regarding its cardiac electrophysiological effects. Thus, we evaluated the cardiac electrophysiological properties before and after remifentanil in a closed-chest porcine model. METHODS: Eighteen Landrace-Large pigs were premedicated with ketamine and anaesthetized with propofol (4.5 mg kg(-1) bolus followed by 13 mg kg(-1) h(-1)). After instrumentation, an electrophysiological evaluation was performed under propofol and repeated after remifentanil (bolus of 1 microg kg(-1), followed by an infusion of 0.5 microg kg(-1) min(-1)). We evaluated sinus node function [sinus node recovery time (SNRT) and sinoatrial conduction time (SACT)], atrioventricular (AV) nodal function [AH intervals during sinus rhythm (SR) and atrial pacing, Wenckebach cycle length (WCL), and effective refractory periods (ERP)], atrial, His-Purkinje, and ventricular conduction and refractoriness. Significant changes between 'propofol protocol' and 'propofol+remifentanil protocol' were evaluated. RESULTS: Remifentanil caused a significant increase in sinus cycle length (21%, P=0.001) and a significant prolongation of SNRT (43%, P=0.001), corrected SNRT (136%, P=0.003), SACT (40%, P=0.005), AH interval during SR (17%, P=0.02), AH interval during atrial pacing (25%, P=0.01), and ventricular ERP (12%, P=0.004). There was a tendency towards a prolongation of WCL and AV nodal refractoriness. Similar significant changes were observed in a reference group of seven animals in which sevoflurane was used instead of propofol. No significant changes were observed in atrial parameters, His-Purkinje function, parameters of intraventricular conduction, and QT intervals. CONCLUSIONS: Remifentanil depresses sinus node function and most parameters of AV nodal function. This contributes to an explanation for clinical observations of remifentanil-related severe bradyarrhythmias.

Bupivacaine Toxicity Increases Transmural Dispersion of Repolarization, Developing of a Brugada-like Pattern and Ventricular Arrhythmias, Which is Reversed by Lipid Emulsion Administration. Study in an Experimental Porcine Model.

Unintentional administration of bupivacaine may be associated with electrocardiogram changes that promote the development cardiac arrhythmias. Ventricular repolarization markers (corrected QT, QT dispersion, Tpeak-Tend and Tpeak-Tend dispersion) are useful to predict cardiac arrhythmias. We aim to investigate the effects of bupivacaine on the transmural dispersion of repolarization and their reversion following intravenous lipid emulsion (ILE) administration. Fourteen pigs were anaesthetized with thiopental and sevoflurane and underwent tracheal intubation. After instrumentation, a 4 mg kg-bolus of bupivacaine was administrated followed by an infusion of 100 µg kg-1 min-1. QT interval, QTc:QT corrected by heart rate, Tpeak-to-Tend interval and QT and Tpeak-to-Tend dispersion were determined in a sequential fashion: after bupivacaine (at 1 min, 5 min and 10 min) and after ILE (1.5 mL kg-1 over 1 min followed by an infusion of 0.25 mL kg-1 min-1). Three additional animals received only ILE (control group). Bupivacaine significantly prolonged QT interval (∆:36%), QT dispersion (∆:68%), Tpeak-to-Tend (∆:163%) and Tpeak-to-Tend dispersion (∆:98%), from baseline to 10 min. Dispersion of repolarization was related to lethal arrhythmias [three events, including asystole, sustained ventricular tachycardia (VT)] and repeated non-sustained VT (4/14, 28%). A Brugada-like-ECG pattern was visualized at V1-4 leads in 5/14 pigs (35%). ILE significantly decreased the alterations induced by bupivacaine, with the termination of VT within 10 min. No ECG changes were observed in control group. Bupivacaine toxicity is associated with an increase of transmural dispersion of repolarization, the occurrence of a Brugada-like pattern and malignant VA. ILE reverses the changes in dispersion of repolarization, favouring the disappearance of the Brugada-like pattern and VT.

Recommendations on Testing Before Outpatient Dermatologic Surgery. / Recomendaciones en la petición de pruebas preoperatorias en cirugía dermatológica ambulatoria.

INTRODUCTION: Short-duration ambulatory surgery for the removal of skin tumors under local anesthesia is increasingly common in dermatology. Preoperative assessment has traditionally targeted the identification of any unknown diseases or other health conditions that might lead to changes in plans for anesthesia or surgery. Hospitals and specialists differ greatly in the tests they order in patients about to undergo outpatient dermatologic surgery given that hardly any finding would be likely to contraindicate or lead to changes in the procedure. This study aimed to provide guidance for those ordering tests before outpatient dermatologic surgery. METHODS: In 2017 our hospital developed a protocol to standardize preoperative testing for outpatient dermatologic surgery. We designed an observational, descriptive, retrospective analysis of tests ordered for patients scheduled for such surgery before and after the protocol was applied. RESULTS: Fewer tests were ordered after the protocol was introduced. We detected no statistically significant differences in relation to type of surgery planned or postoperative complications. CONCLUSIONS: Patients about to undergo outpatient dermatologic surgery under local anesthesia who have no unusual health risks may not require preoperative testing.

Desflurane versus propofol in post-operative quality of recovery of patients undergoing day laparoscopic cholecystectomy. Prospective, comparative, non-inferiority study. / Desflurano versus propofol en la calidad de recuperación de pacientes intervenidos de colecistectomía laparoscópica ambulatoria. Estudio prospectivo, comparativo de no inferioridad.

OBJECTIVE: Recently, the evaluation of postoperative results has focused on the opinion of the patient as of great relevance. Our objective was to evaluate the quality of recovery by questionnaire (QoR-15) in patients undergoing laparoscopic cholecystectomy, comparing desflurane versus a total intravenous technique with propofol (TIVA). A non-inferiority hypothesis was proposed between both techniques. MATERIAL AND METHODS: Prospective longitudinal cohort study in patients undergoing laparoscopic cholecystectomy in which multimodal management was applied including low pneumoperitoneum pressures, deep neuromuscular block and pain prevention strategy and PONV. Anaesthesia maintenance was performed with either desflurane or propofol at the discretion of the anaesthesiologist. QoR-15 was evaluated pre-and 24hours after surgery. RESULTS: Sixty-one patients were evaluated: 29 in the desflurane group and 32 in the TIVA group with no differences in demographic parameters, ASA grade, and preoperative QoR-15 questionnaire. The duration of the intervention was superior in TIVA group, 55 ± 15 vs. 45 ± 9min in desflurane group; p =.05. The desflurane group received more fentanyl than the TIVA group: 200 ± 65 vs. 113 ± 38µg; p =.05. No differences in pain, PONV or time of stay between groups. QoR-15 at 24h decreased 7% relative to baseline, with no differences between groups. CONCLUSIONS: The quality of recovery evaluated by the patient was as favourable in the patients of the desflurane group as in those of the TIVA group in patients undergoing laparoscopic cholecystectomy as outpatients.

Air-Q® versus LMA Fastrach™ for fiberoptic-guided intubation: A randomized cross-over manikin trial. / Estudio aleatorizado cruzado para evaluar la intubación guiada con fibrobroncoscopio a través del dispositivo Air-Q® versus la mascarilla laríngea Fastrach™ en maniquís.

INTRODUCTION: Airway management is still a major cause of anesthesia-associated morbidity and mortality. Supraglottic devices are recommended in difficult airway management guidelines. The aim of this study was to compare the performance of the Air-Q® and the LMA Fastrach™ for fiberoptic guided tracheal intubation. METHODS: Thirty-three anesthesia trainees participated in this randomized crossover study. Time to insert the dedicated airways (insertion of the airway into the manikin and delivery of two breaths), time to tracheal intubation (fiberoptic-guided tracheal intubation), time to remove the dedicated airway (removal of the Air-Q®/LMA Fastrach™ over the tracheal tube) and the opinion of the ease of use of the anesthesia trainees were measured. RESULTS: There was 100% success rate for tracheal intubation with both devices on the first attempt. Time to insert the dedicated device and deliver two breaths was 10±3s for the Air-Q® and 11±3s for the LMA Fastrach™, P=.07. Time taken to intubate the trachea was shorter with the air-Q®, 38±15 s, than with the LMA Fastrach™, 47±19s, P=.017. Overall procedure time was significantly shorter with the Air-Q® as compared with the LMA Fastrach™, with a mean time of 74±21s and 87±28s respectively, P=.002. Air-Q® removal was considered easier than LMA Fastrach™ removal, P=.005. There were no tube dislodgements during the removal of the dedicated airways. CONCLUSIONS: Inexperienced anesthesia residents can perform fiberoptic-guided intubation through Air-Q® and LMA Fastrach™ in a clinically acceptable time with high success.

Radiological study to evaluate the spreading of two volumes (10 vs. 20ml) of radiological contrast in the block of cutaneous branches of intercostal nerves in medial axillary line (BRILMA) in a porcine experimental model. / Estudio radiológico para evaluar la difusión de dos volúmenes (10 vs. 20ml) de contraste radiopaco en el bloqueo de las ramas cutáneas de los nervios intercostales en la línea medio axilar (BRILMA) en un modelo experimental porcino.

OBJECTIVE: Interfascial blocks of the thoracic wall are being developed as an alternative to central blocks in breast surgery. However, there are few studies that have evaluated the anatomical extension of the local anaesthetic. The objective of this study was to analyse, using fluoroscopy, the spreading of two volumes (10 vs. 20ml) of radiological contrast in the serratus-intercostal plane block in an experimental pig model. MATERIAL AND METHODS: Ten Large-White breed pigs were selected to have a bilateral ultrasound serratus-intercostal plane block performed, with the administering of 10ml and 20ml of iopamidol in the right and left hemithorax, respectively. The spreading of contrast was analysed by fluoroscopy. The Spearman test correlation was used to evaluate the relationship between the administered volume and radiological spreading. A value of P<.05 was considered significant. RESULTS: Twenty anaesthetic blocks were performed, being able to analyse 18 of them. The administration of 10ml of contrast was associated with a mean spreading of 2.28±0.31 (95% CI; 2.01-2.54) intercostal spaces, while the administration of 20ml showed a spreading of 3±0.25 (95% CI; 2.81-3.18) intercostal spaces. There was a significant correlation between the injected volume and the spreading of the contrast (Spearman correlation coefficient of 0.81; P=.0001). CONCLUSION: The results showed a spreading of volume subject to the serratus-intercostal plane block, although not maintaining a 1:1 ratio. Doubling the volume increased the blocked segments by 31%. These findings, if corroborated in the clinical practice, would allow a more precise adjustment in the anaesthetic volume administered.

End-tidal desflurane concentration for tracheal extubation in adults. / Concentración al final de la espiración de desflurano requerida para la extubación en el paciente adulto.

OBJECTIVE: To determine the end-tidal desflurane concentration required for tracheal extubation in anaesthetised adults. MATERIAL AND METHODS: After hospital Ethics Committee approval, eighteen ASA I-II adult patients (19-65 years of age), who had been scheduled for elective ambulatory surgery were included in the study. Anaesthesia was induced with propofol 2.5mg.kg-1, fentanyl 2µg.kg-1, and rocuronium 0.6mg.kg-1 for intubation. Maintenance of anaesthesia was provided by desflurane in oxygen and air (40:60), and remifentanil at 0.05-0.25µg.kg-1.min1. Neuromuscular function was monitored with train-of-four (TOF) nerve stimulation and acceleromyography. At the end of the surgery neuromuscular blockade was reversed with sugammadex 2-4mg.kg-1 in accordance with the TOF ratio. The concentration of desflurane at which extubation was attempted was determined by using Dixon's up-and-down method with 0.5% as a step size. Smooth extubation was defined as one without coughing, teeth clenching, gross purposeful movements, and no breath-holding or laryngospasm within 1min of tracheal extubation. RESULTS: It was found that the end-tidal concentration of desflurane was 3.17±0.18% (95% CI: 3%-3.35%) for successful extubation in 50% of adults. CONCLUSION: Extubation in patients receiving desflurane may be feasible at 0.62 minimum alveolar concentration.

LifeQuestionnaire. A new tool for the evaluation of quality of life in patients with hearing loss-using WhatsApp.

OBJECTIVE: Develop an online application that sends questions at different times of the day over an interval set by the user. It consists of a web interface that sends out WhatsApp messages containing questions from already validated or customized questionnaires (previous license) and shows the evolution of each question and patient over time and their average. MATERIAL AND METHOD: The Laboratory of Psychoacoustics developed a platform that allows patients to answer surveys from remote locations. RESULTS: Hence, the developed tool allows to: (1) answer a test repeatedly under different personal situations and (2) evaluate the patient remotely. Hence, obtaining a more reliable assessment of the patient's QoL. CONCLUSION: Preliminary results using 5 teenagers aged 12-18 that answered the KINDL questionnaire is used to evidence the value of this new tool.

Analysis of the temporal regression of the QRS widening induced by bupivacaine after Intralipid administration. Study in an experimental porcine model.

OBJECTIVE: The principal mechanism of cardiac toxicity of bupivacaine relates to the blockade of myocardial sodium channels, which leads to an increase in the QRS duration. Recently, experimental studies suggest that lipid emulsion is effective in reversing bupivacaine cardiac toxicity. We aimed to evaluate the temporal evolution of the QRS widening induced by bupivacaine with the administration of Intralipid. MATERIAL AND METHODS: Twelve pigs were anesthetized with intravenous sodium thiopental 5mg kg(-1) and sevoflurane 1 MAC (2.6%). Femoral artery and vein were canalized for invasive monitoring, analysis of blood gases and determination of bupivacaine levels. After instrumentation and monitoring, a bupivacaine bolus of 4-6 mg kg(-1) was administered in order to induce a 150% increase in QRS duration (defined as the toxic point). The pigs were randomized into two groups of six individuals. Intralipid group (IL) received 1.5 mL kg(-1)of IL over one minute, followed by an infusion of 0.25 mL kg min(-1). Control group (C) received the same volume of a saline solution. The electrocardiographic parameters were recorded, and blood samples were taken after bupivacaine and 1, 5, 10 and 30 minutes after Intralipid/saline administration. RESULTS: Bupivacaine (4.33±0.81 mg/kg in IL group and 4.66±1.15 mg/kg in C group) induced similar electrocardiographic changes in both groups; mean maximal percent increase in QRS interval was 184±62% in IL group, and 230±56% in control group (NS). Lipid administration reversed the QRS widening previously impaired by bupivacaine. After ten minutes of the administration of IL, the mean QRS interval decreased to 132±56% vs. 15±76% relative to the maximum widening induced by bupivacaine, in IL and C group, respectively. CONCLUSION: Intralipid reversed the lengthening of QRS interval induced by the injection of bupivacaine. Time to normalization of electrocardiographic parameters can last more than 10 minutes. While the phenomena of cardiac toxicity persist, resuscitation measures and adequate monitoring should be continued until adequate heart conduction parameters are restored.

[Dual atrioventricular nodal conduction and arrhythmia with severe hemodynamic alterations during liver retransplantation]. / Arritmia por doble via intranodal con descompensación hemodinámica grave en un retrasplante hepático.

We report the case of a man who developed tachycardia caused by atrioventricular reentry related to dual nodal conduction during liver retransplantation. The hemodynamic alterations were severe. Arrhythmia and altered cardiac conduction are potential complications of liver transplantation. The development of tachyarrhythmias--atrial fibrillation as well as episodes of supraventricular and ventricular tachycardia and bradycardia--have been described. Such arrhythmias tend to occur particularly during reperfusion of the graft. Risk factors implicated are the severe ion imbalances, acid-base imbalance, and hypothermia that accompany the reperfusion of a new organ. A review of the possible pathogenic and etiological mechanisms that lead to arrhythmia in patients with end-stage liver disease is provided.

[Preoperative tests recommendations in adult patients for ambulatory surgery]. / Recomendaciones de pruebas preoperatorias en el paciente adulto para procedimientos en régimen de cirugía ambulatoria.

Anesthetic assessment traditionally included a series of laboratory tests intended to detect undiagnosed diseases, and to ensure that the patient undergoes surgery following safety criteria. These tests, without a specific clinical indication, are expensive, of questionable diagnostic value and often useless. In the context of outpatient surgery, recent evidence suggests that patients of any age without significant comorbidity, ASA physical status gradei and grade ii, do not need additional preoperative tests routinely. The aim of the present recommendations is to determine the general indications in which these tests should be performed in ASA gradei and grade ii patients undergoing ambulatory surgery.