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

La transfusión de sangre alogénica (TSA) no es inocua, y como consecuencia han surgido múltiples alternativas a la misma (ATSA). Existe variabilidad respecto a las indicaciones y buen uso de las ATSA. Dependiendo de la especialidad de los médicos que tratan a los pacientes, el grado de anemia, la política transfusional, la disponibilidad de las ATSA y el criterio personal, estas se usan de forma variable. Puesto que las ATSA tampoco son inocuas y pueden no cumplir criterios de coste-efectividad, la variabilidad en su uso es inaceptable. Las sociedades españolas de Anestesiología y Reanimación (SEDAR), Hematología y Hemoterapia(SEHH), Farmacia Hospitalaria (SEFH), Medicina Intensiva y Unidades Coronarias(SEMICYUC), Trombosis y Hemostasia (SETH) y Transfusiones Sanguíneas (SETS) han elaborado un documento de consenso para el buen uso de la ATSA. Un panel de expertos de las 6sociedades ha llevado a cabo una revisión sistemática de la literatura médica y elaborado el 2013. Documento Sevilla de Consenso sobre Alternativas a la Transfusión de Sangre Alogénica. Solo se contempla las ATSA dirigidas a disminuir la transfusión de concentrado de hematíes. Se definen las ATSA como toda medida farmacológica y no farmacológica encaminada a disminuir la transfusión de concentrado de hematíes, preservando siempre la seguridad del paciente. La cuestión principal que se plantea en cada ítem se formula, en forma positiva o negativa, como: “La ATSA en cuestión reduce/no reduce la tasa transfusional». Para formular el grado de recomendación se ha usado la metodología Grades of Recommendation Assessment, Development and Evaluation (GRADE) (AU)

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 (AU)

[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.

[Management of direct action oral anticoagulants in the peri-operative period and invasive techniques]. / Manejo de los anticoagulantes orales de acción directa en el período perioperatorio y técnicas invasivas.

The new direct-acting oral anticoagulants (ACOD) in patients on prolonged treatment require the need to balance the risk of haemorrhage by administering them against the risk of thrombosis on withdrawing them. Recommendations for their management are proposed in the present article: A) Thromboprophylaxis and general anaesthesia: the performing of regional anaesthesia if administered with an ACOD as thromboprophylaxis requires some safety intervals based on their pharmacokinetic parameters; B) Management of ACOD in elective surgery: in patients with normal renal function and a low haemorrhage/thrombosis risk, stop the ACOD two days before the surgery; it the haemorrhage/thrombosis risk is high and/or renal function is impaired, therapy with a low molecular weight heparin is proposed from 5 days prior to the surgery, and C) Management of ACOD in urgent surgery and associated haemorrhage: the systematic prophylactic administration of haemostatics is recommended. In the event of acute bleeding that may place the life of the patient at risk (due to volume or location), the administration of concentrated prothrombin complex, fresh plasma, or factor VIIa, must be assessed, together with general control measures of acute haemorrhage. These recommendations should be considered in the context of the use drugs that do have a specific antidote, where their monitoring by the usual coagulation tests is not routine, and with those in which there is limited experience. We believe they need to be reviewed in the future, depending on further studies and clinical experience obtained.

[Outpatient or short-stay videothoracoscopy-assisted thoracic sympathectomy: anesthesia in 445 cases]. / Anestesia para simpatectomía torácica por videotoracoscopia en régimen ambulatorio o corta estancia: experiencia en 445 casos.

OBJECTIVE: To demonstrate the safety of outpatient or short-stay bilateral videothoracoscopy-assisted thoracic sympathectomy. PATIENTS AND METHODS: The medical records of 445 who underwent bilateral videothoracoscopy-assisted thoracic sympathectomy were reviewed; the same protocols were used to guide these outpatient or short-stay procedures in all cases. Intravenous anesthesia was provided. An orotracheal tube allowed for carrying out the sympathectomy procedure during short periods of apnea. A 2% lidocaine solution was infused through the thoracic drains, which were removed soon after surgery. Data on intraoperative respiratory variables, pain, and intra- and postoperative complications were gathered. The data for patients undergoing the procedure on an outpatient or short-stay basis were compared. RESULTS: No significant differences in demographic or perioperative variables were found between the 2 groups. In 3.6% of the patients in the series, there was a record of a postoperative pulmonary complication: 4 therapeutic minithoracotomies; 1 subcutaneous emphysema without radiologic changes; 9 residual pneumothoraces, 2 requiring pleural drainage; 1 chylothorax; and 1 delayed hemothorax. With the exception of the late-developing hemothorax, all complications were diagnosed and treated in the immediate postoperative period. In the outpatient surgery group, unplanned admissions because of patient refusal to leave occurred in 6.5% of the cases. CONCLUSION: The low incidence of complications, and especially the finding that complications are detected in the early recovery period, indicate that this procedure can be performed on an outpatient basis.

[Drugs that alter hemostasis and regional anesthetic techniques: safety guidelines. Consensus conference]. / Fármacos que alteran la hemostasia y técnicas regionales anestésicas:recomendaciones de seguridad. Foro de consenso.

Patients about to undergo surgery are often taking drugs that alter hemostasis and affect anesthesia, particularly when neuroaxial techniques are used for subarachnoid or epidural anesthesia. The aim of this paper is to provide safety guidelines for regional anesthesia in patients receiving hemostasis-altering drugs, in order to reduce the risk of bleeding. We offer a detailed discussion of patients treated with inhibitors of platelet aggregation (emphasizing that such treatment alone is not a contraindication for neuroaxial blockade although certainly guidelines must be followed), unfractionated heparin (anesthesia should be started at least 4 hours after administration of this drug or 30 minutes before, provided pulmonary arterial pressure is normal), low molecular weight heparin (which should be administered 12 hours before or 12 hours after the anesthetic technique), and oral anticoagulants (provision of regional anesthesia depends mainly on International Normalized Ratio monitoring). We also stress that removal of catheters should follow criteria similar to those listed above, that the risk of complications due to bleeding increases considerably in association with these drugs, and that adequate neurological monitoring is essential during postoperative recovery. Overall, the final decision to use regional anesthesia in patients receiving drugs that alter hemostasis must be made on an individual basis after assessment of benefit and risk.

Fármacos que alteran la hemostasia y técnicas regionales anestésicas: recomendaciones de seguridad. foro de consenso / Drugs that alter hemostasis and regional anesthetic techniques: safety guidelines

No es infrecuente que los pacientes que van a ser intervenidos quirúrgicamente estén tratados con fármacos que alteran la hemostasia, cuyas implicaciones afectan a la actuación del anestesiólogo, sobre todo cuando están indicadas las técnicas neuroaxiales para la realización de una anestesia subaracnoidea o epidural.El objetivo de este documento es ofrecer unas recomendaciones de seguridad sobre cómo realizar las técnicas regionales anestésicas en los pacientes con alteraciones farmacológicas de la hemostasia, para minimizar el riesgo de complicaciones hemorrágicas.Para ello se analiza de manera pormenorizada a los pacientes tratados con antiagregantes plaquetarios (se recalca que la terapia antiagregante aislada no contraindica la realización de un bloqueo neuroaxial, si bien es aconsejable mantener unas recomendaciones generales), heparina no fraccionada (la técnica debe posponerse al menos 4 h o realizarse 30 min antes de su administración, contando siempre con un TPTA normal), heparina de bajo peso molecular (administración del fármaco 12 h antes o 12 h después de la técnica anestésica) y anticoagulantes orales (la realización de una anestesia regional depende, sobre todo, del resultado de la monitorización del INR). Del mismo modo se destaca que para la retirada de los catéteres se deben seguir recomendaciones similares a las citadas, que el riesgo de complicaciones hemorrágicas en los casos de asociación de fármacos se incrementa considerablemente y que es imprescindible una monitorización neurológica adecuada en el período postoperatorio inmediato.Con todo, la decisión final de la realización de una técnica anestésica regional en estos pacientes debe ser individualizada, después de la valoración particular de la relación beneficio/riesgo en cada uno de ellos (AU)

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[Learning cardiopulmonary resuscitation using conventional external cardiac massage or active compression-decompression in simulated cardiopulmonary resuscitation]. / Aprendizaje de la reanimación cardíaca mediante masaje cardíaco externo convencional o compresión-descompresión activa en reanimación cardiopulmonar simulada.

OBJECTIVE: To compare medical students' simulated learning of two different techniques of cardiopulmonary resuscitation (CPR). One was conventional external cardiac massage (ECM) and the other was active compression-decompression (ACD-CPR). MATERIAL AND METHODS: The study group (group S) comprised 111 students enrolled in their fourth year of medical studies who had no prior experience of CPR. Group R, the control group, was made up of 32 medical residents in anesthesiology and post-anesthetic intensive care. Before the study, group S received 5 hours of theoretical classes on CPR and both groups saw a video explaining each technique just before performing the test. All subjects applied each method to an adult dummy for one minute. The variables evaluated were frequency of complete and effective thoracic compressions and the body weight of the resuscitator. RESULTS: Each group performed similarly using the two techniques in terms of frequency of total compressions achieved. For each technique, the number of effective compressions achieved by group S (49.4 +/- 22.9 with ECM and 42.5 +/- 20.7 with ACD-CPR) was significantly lower (p < 0.05) than the number attained by group R (71.2 +/- 18.6 with ECM and 58.8 +/- 12 with ACD-CPR). Group R's frequency of effective compressions was significantly higher (p < 0.05) with CPR than with ACD-CPR. Body weight had no influence on the number of total compressions or efficacy in group R, whereas lower body weight in group S was significantly related to lower frequency of effective compressions with ECM p < 0.05). Neither group achieved a frequency of 80 total compressions in one minute. CONCLUSIONS: With the present teaching method, the medical students' performance was poor for both types of CPR and was affected by body weight. The residents' performance was less effective with ACD-CPR, a technique that was new to them, than with conventional ECM, with which they were expert and on which body weight had no impact.

Nimodipine fails to enhance the analgesic effect of slow release morphine in the early phases of cancer pain treatment.

We assessed nimodipine's ability to increase the analgesic effect of morphine in 32 patients suffering from cancer pain in a double-blind, placebo controlled cross-over study. Morphine administration began a few days before the start of the study. The analgesic effects of two combinations were compared: morphine (M) plus placebo (P) and morphine plus 90 mg/24 h of nimodipine (N). The study lasted 8 days, including the wash-out period, and the following sequence of treatments was applied: M + P or M + N on days 1, 2 and 3; only M on days 4 and 5; and M + N or M + P on days 6, 7 and 8. Morphine dose was individualised according to the intensity of the patient's pain and the same dose was maintained throughout the study period. Analgesic response was evaluated using four 10 cm visual analogue scales of quantitative variables for pain intensity, pain relief, sleep quality and mood. A verbal rating of qualitative variables was also scored following validated descriptors of pain in the Spanish language. No significant statistical differences were found in analgesic effect between combined treatment with nimodipine or placebo, as measured on any of the scales. In order to take into account both the short duration of treatment (8 days), and nimodipine's pharmacokinetic characteristics (half-life of 6 h and steady state of 36 h), we compared treatment with nimodipine or placebo on the third day of use, at which time, likewise, there were no statistically significant differences on any of the scales. However, when the same statistical tests were used for comparison of results with pre-treatment baseline values, highly significant differences between mean scores on the scales for pain relief and pain intensity were found. Based on these negative results we conclude that nimodipine given orally at a dose of 30 mg every 8 h does not enhance analgesia when associated with morphine in the early phases of treatment for cancer pain. Our study also gives clear evidence of a placebo effect.