Clinical use of tranexamic acid: evidences and controversies

Abstract Tranexamic acid (TXA) significantly reduces blood loss in a wide range of surgical procedures and improves survival rates in obstetric and trauma patients with severe bleeding. Although it mainly acts as a fibrinolysis inhibitor, it also has an anti-inflammatory effect, and may help attenuate the systemic inflammatory response syndrome found in some cardiac surgery patients. However, the administration of high doses of TXA has been associated with seizures and other adverse effects that increase the cost of care, and the administration of TXA to reduce perioperative bleeding needs to be standardized. Tranexamic acid is generally well tolerated, and most adverse reactions are considered mild or moderate. Severe events are rare in clinical trials, and literature reviews have shown tranexamic acid to be safe in several different surgical procedures. However, after many years of experience with TXA in various fields, such as orthopedic surgery, clinicians are now querying whether the dosage, route and interval of administration currently used and the methods used to control and analyze the antifibrinolytic mechanism of TXA are really optimal. These issues need to be evaluated and reviewed using the latest evidence to improve the safety and effectiveness of TXA in treating intracranial hemorrhage and bleeding in procedures such as liver transplantation, and cardiac, trauma and obstetric surgery.

Clinical use of tranexamic acid: evidences and controversies.

Tranexamic acid (TXA) significantly reduces blood loss in a wide range of surgical procedures and improves survival rates in obstetric and trauma patients with severe bleeding. Although it mainly acts as a fibrinolysis inhibitor, it also has an anti-inflammatory effect, and may help attenuate the systemic inflammatory response syndrome found in some cardiac surgery patients. However, the administration of high doses of TXA has been associated with seizures and other adverse effects that increase the cost of care, and the administration of TXA to reduce perioperative bleeding needs to be standardized. Tranexamic acid is generally well tolerated, and most adverse reactions are considered mild or moderate. Severe events are rare in clinical trials, and literature reviews have shown tranexamic acid to be safe in several different surgical procedures. However, after many years of experience with TXA in various fields, such as orthopedic surgery, clinicians are now querying whether the dosage, route and interval of administration currently used and the methods used to control and analyze the antifibrinolytic mechanism of TXA are really optimal. These issues need to be evaluated and reviewed using the latest evidence to improve the safety and effectiveness of TXA in treating intracranial hemorrhage and bleeding in procedures such as liver transplantation, and cardiac, trauma and obstetric surgery.

Beneficial effect of corticosteroids in preventing mortality in patients receiving tocilizumab to treat severe COVID-19 illness.

OBJECTIVES: To assess the characteristics and risk factors for mortality in patients with severe coronavirus disease-2019 (COVID-19) treated with tocilizumab (TCZ), alone or in combination with corticosteroids (CS). METHODS: From March 17 to April 7, 2020, a real-world observational retrospective analysis of consecutive hospitalized adult patients receiving TCZ to treat severe COVID-19 was conducted at our 750-bed university hospital. The main outcome was all-cause in-hospital mortality. RESULTS: A total of 1,092 patients with COVID-19 were admitted during the study period. Of them, 186 (17%) were treated with TCZ, of which 129 (87.8%) in combination with CS. Of the total 186 patients, 155 (83.3 %) patients were receiving noninvasive ventilation when TCZ was initiated. Mean time from symptoms onset and hospital admission to TCZ use was 12 (±4.3) and 4.3 days (±3.4), respectively. Overall, 147 (79%) survived and 39 (21%) died. By multivariate analysis, mortality was associated with older age (HR = 1.09, p < 0.001), chronic heart failure (HR = 4.4, p = 0.003), and chronic liver disease (HR = 4.69, p = 0.004). The use of CS, in combination with TCZ, was identified as a protective factor against mortality (HR = 0.26, p < 0.001) in such severe COVID-19 patients receiving TCZ. No serious superinfections were observed after a 30-day follow-up. CONCLUSIONS: In patients with severe COVID-19 receiving TCZ due to systemic host-immune inflammatory response syndrome, the use of CS in addition to TCZ therapy, showed a beneficial effect in preventing in-hospital mortality.

Thromboelastometric Profile and Acute Coagulopathy of the Polytraumatized Patient: Clinical and Prognostic Implications. / Perfil tromboelastométrico y coagulopatía aguda del paciente politraumatizado: implicaciones clínicas y pronósticas.

INTRODUCTION: About 25-35% of polytraumatized patients have a profound alteration of hemostasis on arrival at the hospital (acute traumatic coagulopathy [CAT]). Viscoelastic tests (ROTEM®) measure the hemostatic capacity and provide an early detection of CAT. The objectives of this study are to describe the initial thromboelastogram of these patients and to determine the prevalence of CAT according to predefined thromboelastographic profiles. METHODS: Single-center, observational, prospective study in polytraumatic patients. Initial blood and thromboelastographic test (ROTEM®) were made, and pre-hospital, hospital, transfusion, initial surgical/angiographic interventions, cardiac arrest and mortality data were collected. ROTEM®-based, patients were classified as: normal, hypercoagulable, hypocoagulable, hipocoagulable +hyperfibrinolytic and isolated hyperfibrinolysis. RESULTS: One hundred and twenty-three patients were analyzed. 32 cases (26%) with CAT: 15 patients with hypocoagulability, 9 with hyperfibrinolysis alone and 8 with hypocoagulability +hyperfibrinolysis. The CAT group, related to the normal group, presented higher ISS (23 vs. 16, P<.01), higher blood products transfusion (2.5 vs. 0; P=.001), more cardiac arrest (19 vs. 1%, P<.01), and higher mortality (34 vs. 5%, P<.01). The subgroup with hypocoagulability/hyperfibrinolysis, related to the groups with hypocoagulability or hyperfibrinolysis alone, presented a higher ISS (41 vs. 25 vs. 15, P<.01), higher angiographic procedures (62% vs. 13% vs. 0%, P<.01) and higher mortality (75% vs. 33% vs. 0%, P=.05). CONCLUSIONS: Twenty-six percent of the polytrauma patients presented early coagulopathy assessed by thromboelastography. It is associated with higher consumption of blood products and lower survival. The presence of hypocoagulability +hyperfibrinolysis is associated with greater severity and a higher requirement of blood products.

Anesthetic requirements measured by bilateral bispectral analysis and femoral blockade in total knee arthroplasty / Necessidade de anestésicos avaliada com a análise do índice bispectral bilateral e bloqueio femoral em artroplastia total de joelho

Abstract Background and objectives A continuous peripheral nerve blockade has proved benefits on reducing postoperative morphine consumption; the combination of a femoral blockade and general anesthesia on reducing intraoperative anesthetic requirements has not been studied. The objective of this study was to determine the relevance of timing in the performance of femoral block to intraoperative anesthetic requirements during general anesthesia for total knee arthroplasty. Methods A single-center, prospective cohort study on patients scheduled for total knee arthroplasty, were sequentially allocated to receive 20 mL of 2% mepivacaine throughout a femoral catheter, prior to anesthesia induction (Preoperative) or when skin closure started (Postoperative). An algorithm based on bispectral values guided intraoperative anesthetic management. Postoperative analgesia was done with an elastomeric pump of levobupivacaine 0.125% connected to the femoral catheter and complemented with morphine patient control analgesia for 48 hours. The Kruskall Wallis and the chi-square tests were used to compare variables. Statistical significance was set at p < 0.05. Results There were 94 patients, 47 preoperative and 47 postoperative. Lower fentanyl and sevoflurane were needed intraoperatively in the Preoperative group; median values and range: 250 (100-600) vs 450 (200-600) µg and 21 (12-48) vs 32 (18-67) mL p = 0.001, respectively. There were no differences in the median verbal numeric rating scale values 4 (0-10) vs 3 (0-10); and in median morphine consumption 9 (2-73) vs 8 (0-63) mg postoperatively. Conclusions A preoperative femoral blockade is useful in decreasing anesthetic requirements in total knee arthroplasty surgery but no added effect in the postoperative analgesic control.

Resumo Justificativa e objetivos O bloqueio contínuo de nervos periféricos provou ser benéfico para reduzir o consumo de morfina no pós-operatório. A combinação de um bloqueio femoral e anestesia geral para reduzir a necessidade de anestésicos no intraoperatório ainda não foi avaliada. O objetivo deste estudo foi determinar a relevância do momento propício durante o bloqueio femoral para a necessidade de anestésicos no intraoperatório durante a anestesia geral para artroplastia total de joelho (ATJ). Métodos Estudo prospectivo de coorte de pacientes agendados para ATJ. Os pacientes foram sequencialmente alocados em grupos para receber mepivacaína a 2% (20 mL) durante a inserção do cateter femoral, antes da indução da anestesia (pré-operatório) ou no início do fechamento da pele (pós-operatório). Um algoritmo com base nos valores do BIS orientou o manejo da anestesia no intraoperatório. Analgesia no pós-operatório foi administrada via bomba elastomérica de levobupivacaína a 0,125% conectada ao cateter femoral e complementada com analgesia (morfina) controlada pelo paciente durante 48 horas. Os testes de Kruskall-Wallis e do qui-quadrado foram usados para comparar as variáveis. A significância estatística foi estabelecida em p < 0,05. Resultados Foram estudados 94 pacientes, 47 no pré-operatório e 47 no pós-operatório. Houve menos necessidade de fentanil e sevoflurano durante o período intraoperatório no grupo pré-operatório; medianas e variações dos valores: 250 (100-600) vs. 450 (200-600) µg e 21 (12-48) vs. 32 (18-67) mL p = 0,001, respectivamente. Não houve diferenças nas medianas dos valores das escalas de classificação numérica e verbal, 4 (0-10) vs. 3 (0-10), e nas medianas do consumo de morfina, 9 (2-73) vs. 8 (0-63) mg no pós-operatório. Conclusões O bloqueio femoral no pré-operatório é útil para diminuir a necessidade de anestésicos em ATJ, mas não tem efeito adicional no controle da analgesia no pós-operatório.

[Anesthetic requirements measured by bilateral bispectral analysis and femoral blockade in total knee arthroplasty]. / Necessidade de anestésicos avaliada com a análise do índice bispectral bilateral e bloqueio femoral em artroplastia total de joelho.

BACKGROUND AND OBJECTIVES: A continuous peripheral nerve blockade has proved benefits on reducing postoperative morphine consumption; the combination of a femoral blockade and general anesthesia on reducing intraoperative anesthetic requirements has not been studied. The objective of this study was to determine the relevance of timing in the performance of femoral block to intraoperative anesthetic requirements during general anesthesia for total knee arthroplasty. METHODS: A single-center, prospective cohort study on patients scheduled for total knee arthroplasty, were sequentially allocated to receive 20mL of 2% mepivacaine throughout a femoral catheter, prior to anesthesia induction (Preoperative) or when skin closure started (Postoperative). An algorithm based on bispectral values guided intraoperative anesthetic management. Postoperative analgesia was done with an elastomeric pump of levobupivacaine 0.125% connected to the femoral catheter and complemented with morphine patient control analgesia for 48hours. The Kruskall Wallis and the chi-square tests were used to compare variables. Statistical significance was set at p<0.05. RESULTS: There were 94 patients, 47 preoperative and 47 postoperative. Lower fentanyl and sevoflurane were needed intraoperatively in the Preoperative group; median values and range: 250 (100-600) vs 450 (200-600)µg and 21 (12-48) vs 32 (18-67)mL p=0.001, respectively. There were no differences in the median verbal numeric rating scale values 4 (0-10) vs 3 (0-10); and in median morphine consumption 9 (2-73) vs 8 (0-63)mg postoperatively. CONCLUSIONS: A preoperative femoral blockade is useful in decreasing anesthetic requirements in total knee arthroplasty surgery but no added effect in the postoperative analgesic control.

The bilateral bispectral and the composite variability indexes during anesthesia for unilateral surgical procedure.

BACKGROUND: The composite variability index (CVI), derived from the bispectral analysis (BIS), has been designed to detect nociception; however, there is no evidence that bilateral BIS and CVI show intrapatient reproducibility or variability. METHODS: We conducted an observational study in patients who underwent for total knee arthroplasty. A BIS Bilateral Sensor was applied and continuously recorded at different points of the anesthesia procedure. Bland-Altman limits of agreement and dispersion for BIS and for CVI were applied. RESULTS: Forty-nine right-handed patients were studied. There were differences between the right and left BIS values after tracheal intubation (which was higher on the right side) and at surgical stimulus (higher on the left side). The maximum BIS and minimum, mean, and maximum CVI scores were higher on the left side for left-side procedures, but there were no differences in any indexes for the right-side procedures. Except for the baseline measurements, both CVI and BIS scores presented high interpatient variability. Although the right to left bias was < 3% for the BIS index, dispersion was large at different stages of the anesthesia. The right to left bias for the CVI was 3.8% at tracheal intubation and 5.7% during surgical stimulus. CONCLUSIONS: Our results indicate that the large interindividual variability of BIS and CVI limits their usefulness. We found differences between the left and right measurements in a right-handed series of patients during surgical stimuli though they were not clinically relevant.

[Process indicators: tools for monitoring the management of severe trauma cases in Catalonia]. / Indicadores de proceso como herramienta para monitorizar la asistencia al paciente con traumatismo grave en Cataluña.

OBJECTIVES: Process indicators have been widely used to monitor the way trauma care is provided. We aimed to analyze whether data from a hospital's severe trauma register could facilitate the evaluation of aspects of the initial management of severe injuries. MATERIAL AND METHODS: Observational, retrospective population-based study. A working group of experts selected a set of trauma care process indicators relevant to some aspects of initial care, diagnosis, and treatment of severely injured patients. Four of the indicators referred to prehospital care and 5 to hospital care. We calculated the observed and expected compliance rates for all the indicators. RESULTS: A total of 1526 cases (44.4%) were analyzed for 2013; 1908 (55.6%) were analyzed for 2014. We were able to evaluate 3 of the 4 prehospital process indicators: endotracheal intubation in patients with a score of 􀀀 8 on the Glasgow coma scale (GCS) (84% compliance), venous access established before hospital arrival (83.4%), and placement of a neck collar to immobilize the cervical spine (72.7%). Compliance for the hospital-phase indicators were as follows: performance of a computed tomography scan of the head within 60 minutes in cases with a GCS of 􀀀 13 (5.3% compliance, craniotomy in candidate patients within 2 hours of diagnosis (65%), diagnostic examination for abdominal injuries within 60 minutes in patients with systolic blood pressure 􀀀 90 mm Hg (89.3%), and therapeutic laparotomy or angiography within 4 hours of abdominal injury in candidate patients with systolic blood pressure 􀀀 90 mm Hg (51.7%). Compliance was 69.9% for the last process indicator: surgical treatment of open fractures within 8 hours of an accident. CONCLUSION: Our findings show that a hospital trauma register provides data about care process indicators that can allow us to monitor the quality of care of severely injured patients.

OBJETIVO: Los indicadores de proceso (IP) se han utilizado ampliamente para monitorizar los procesos asistenciales al paciente traumático. Nuestro objetivo es analizar la capacidad de un registro hospitalario de traumatismo grave para evaluar algunos aspectos de la atención inicial al traumatismo grave. METODO: Observacional, retrospectivo de datos incluidos en un registro poblacional. A partir de un consenso de expertos se seleccionaron una serie de IP que se aplicaron a una población de accidentados. Los IP seleccionados analizan algunos aspectos de la atención inicial, diagnósticos y terapéuticos. Cuatro de ellos se refieren a la fase prehospitalaria y 5 a la fase hospitalaria. Para todos ellos se calculó la tasa de cumplimiento (observados vs esperados). RESULTADOS: Fueron analizados 1.526 casos (44,4%) correspondientes al año 2013 y 1.908 (55,6%) del 2014. Tres de los cuatro IP relacionados con la atención prehospitalaria pudieron ser analizados: intubación orotraqueal en paciente con puntuación de la Escala del Coma de Glasgow (GCS) 8 (84% de cumplimiento); acceso vascular canalizado antes de la llegada al hospital (83,4% de cumplimiento); y contención cervical aplicada in situ (72,7% de cumplimiento). En la fase hospitalaria: realización de tomografía computarizada (TC) craneal en los primeros 60 min en GCS ô€€€ 13 (5,3% de cumplimiento); craneotomía en paciente candidato en las primeras 2 horas después del diagnóstico (65% de cumplimiento); exploración diagnóstica en traumatismo abdominal en los primeros 60 minutos en pacientes con presión arterial sistólica (PAS) 90 mmHg (89,3% de cumplimiento); y laparotomía o angiografía terapéutica en paciente candidato en las 4 primeras horas tras el trauma abdominal y PAS 90 (51,7% de cumplimiento). El último indicador, cirugía de fractura abierta en las primeras 8 horas tras el accidente, presentó un 69,9% de cumplimiento. CONCLUSIONES: Nuestro estudio muestra las posibilidades y dificultades que un registro de traumatismo en base hospitalaria ofrece para evaluar la asistencia al paciente traumático a través de indicadores de proceso establecidos.

[Study on the improvement of trauma patient care: TRAUMACAT project]. / Estudio para la mejoría de la atención hospitalaria inicial del paciente politraumatizado: proyecto TRAUMACAT.

UNLABELLED: Multiple injuries are a major source of morbidity and mortality in young people. The aim of this study was to evaluate the effect of a collaborative strategy to improve the implementation of six clinical indicators, recognized internationally, for the treatment of trauma patient. Prospective, multicentre, pre-and post-intervention study, in ten referral hospitals, offering polytrauma care in Catalonia. 378 patients were recruited for the pre-intervention study and 501 for the post-intervention study. All patients had a history of high-energy trauma requiring admission to critical or semi-critical care unit. INTERVENTION: collaborative strategy aimed at participating professionals, involving the creation of a panel of experts, appointment of monitors to encourage improvements at each centre, training, distribution of information, material and meetings, to exchange impressions. MAIN OUTCOME MEASURES: frequency and characteristics of trauma and percentage of compliance with clinical indicators. Study of 879 trauma patients. The injury mechanism was overall blunt trauma, in both pre and post intervention phases. The medium ISS (injury severity score) was 21 ± 12,8 and the medium TRISS (trauma and injury severity score) was 26,4 ± 11,4. We didn't find differences between both study phases, in relation to the severity of injury. The mortality rate was 11.5%. We observed significant improvement in the performance of chest X-rays (45% vs. 62%) and pelvis X-rays (27% vs. 62%) in the trauma box and in the fixation of the pelvis in patients with a fracture at this site (24% vs. 49%). The use of diagnostic radiology in hemodynamically unstable patients remained low (33%). The collaborative strategy was effective in improving certain indicators of clinical management.

Do the severity and the body region of injury correlate with long-term outcome in the severe traumatic patient?

BACKGROUND AND OBJECTIVES: To investigate if the Injury Severity Score (ISS) and the Abbreviated Injury Score (AIS) are correlated with the long-term quality of life in severe trauma patients. METHODS: Patients injured from 2005 to 2007 with an ISS≥15 were surveyed 16-24 months after injury. The Health Assessment Questionnaire (HAQ-DI) was used for measuring the functional status and the Short Form-12 (SF-12) was used for measuring the health status divided into its two components, the PCS (Physical Component Summary) and the MCS (Mental Component Summary). The results of the questionnaires were compared with the ISS and AIS components. Results of the SF-12 were compared with the values expected from the general population. RESULTS: Seventy-four patients filled the questionnaires (response rate 28%). The mean scores were: PCS 42.6±13.3; MCS 49.4±1.4; HAQ-DI 0.5±0.7. Correlation was observed with the HAQ-DI and the PCS (Spearman's Rho: -0.83; p<0.05) and no correlation between the HAQ-DI and the MCS neither between the MCS and PCS (Spearman's Rho=-0.21; and 0.01 respectively). The cutaneous-external and extremities-pelvic AIS punctuation were correlated with The PCS (Spearman's Rho: -0.39 and -0.34, p<0.05) and with the HAQ-DI (Spearman's Rho: 0.31 and 0.23; p<0.05). The physical condition compared with the regular population was worse except for the groups aged between 65-74 and 55-64. CONCLUSIONS: Patients with extremities and pelvic fractures are more likely to suffer long-term disability. The severity of the external injuries influenced the long-term disability.

A gravidade e a região da lesão corporal correlacionam com resultados a longo prazo em paciente com traumatismo grave? / Do the severity and the body region of injury correlate with long-term outcome in the severe traumatic patient? / ¿La gravedad y la región de la lesión corporal se correlacionan conlos resultados a largo plazo en un paciente con traumatismo grave?

Justificativa e objetivos: investigar se o índice de gravidade da lesão (ISS) e a escala abreviada de lesões (AIS) estão correlacionados com a qualidade de vida em longo prazo em pacientes com traumatismo grave. Métodos: pacientes que sofreram lesões de 2005 a 2007, com IGL≥15, foram pesquisados 16-24 meses após as lesões. O questionário de avaliação da saúde (HAQ-DI) foi usado para medir o estado funcional e o modelo abreviado do questionário com 12 itens (Short Form-12 [SF-12]) foi usado para medir o estado de saúde dividido em seus dois componentes: o resumo do componente saúde física (PCS) e o resumo do componente saúde mental (MCS). Os resultados dos questionários foram comparados com os componentes do ISS e da AIS. Os resultados do SF-12 foram comparados com os valores esperados da população geral. Resultados: preencheram os questionários 74 pacientes (taxa de resposta de 28%). A média dos escores foi: PCS 42,6 ± 13,3; MCS 49,4 ± 1,4; HAQ-DI 0,5 ±0,7. Houve correlação com HAQ-DI e PCS (Rho de Spearman: -0,83; p < 0,05) e nenhuma correlação entre HAQ-DI e MCS ou entre MCS e PCS (Rho de Spearman = -0,21 e 0,01, respectivamente). Os escores cutâneo-externo e extremidades-pélvico da AIS correlacionaram com o PCS (Rho de Spearman: -0,39 e -0,34, p < 0,05) e com o HAQ-DI (Rho de Spearman: 0,31 e 0,23; p < 0,05). A condição física em comparação com a população normal foi pior, exceto para os grupos com idades entre 65-74 e 55-64 anos. Conclusões: os pacientes com fraturas pélvicas e de extremidades são mais propensos a apresentar incapacidade em longo prazo. A gravidade das lesões externas influenciou a deficiência em longo prazo. .

Background and objectives: To investigate if the Injury Severity Score (ISS) and the Abbreviated Injury Score (AIS) are correlated with the long-term quality of life in severe trauma patients. Methods: Patients injured from 2005 to 2007 with an ISS ≥ 15 were surveyed 16-24 months after injury. The Health Assessment Questionnaire (HAQ-DI) was used for measuring the functional status and the Short Form-12 (SF-12) was used for measuring the health status divided into its two components, the PCS (Physical Component Summary) and the MCS (Mental Component Summary). The results of the questionnaires were compared with the ISS and AIS components. Results of the SF-12 were compared with the values expected from the general population. Results: Seventy-four patients filled the questionnaires (response rate 28%). The mean scores were: PCS 42.6 ± 13.3; MCS 49.4 ± 1.4; HAQ-DI 0.5 ± 0.7. Correlation was observed with the HAQ-DI and the PCS (Spearman's Rho: -0.83; p < 0.05) and no correlation between the HAQ-DI and the MCS neither between the MCS and PCS (Spearman's Rho = -0.21; and 0.01 respectively). The cutaneous-external and extremities-pelvic AIS punctuation were correlated with The PCS (Spearman's Rho: -0.39 and -0.34, p < 0.05) and with the HAQ-DI (Spearman's Rho: 0.31 and 0.23; p < 0.05). The physical condition compared with the regular population was worse except for the groups aged between 65 -74 and 55 -64. Conclusions: Patients with extremities and pelvic fractures are more likely to suffer long-term disability. The severity of the external injuries influenced the long-term disability. .

Justificación y objetivos: investigar si el Índice de Gravedad de la Lesión (Injury Severity Score [ISS]) y la Escala Abreviada de Lesiones (Abbreviated Injury Score [AIS]) están correlacionados con la calidad de vida a largo plazo en pacientes con traumatismo grave. Métodos: pacientes que sufrieron lesiones entre 2005 y 2007, con un ISS ≥ 15, fueron encuestados 16-24 meses después de las lesiones. Se usó el Cuestionario de Evaluación de la Salud-Índice de Incapacidad (Health Assessment Questionnaire-Disability Index [HAQ-DI]) para medir el estado funcional, y el modelo abreviado del cuestionario con 12 ítems (Short Form-12 [SF-12]) para medir el estado de salud dividido en 2 componentes: el índice de salud física (Physical Component Summary [PCS]) y el índice de salud mental (Mental Component Summary [MCS]). Los resultados de los cuestionarios fueron comparados con los componentes del ISS y del AIS. Los resultados del SF-12 fueron comparados con los valores esperados en la población general. Resultados: setenta y cuatro pacientes rellenaron los cuestionarios (tasa de respuesta de un 28%). Las puntuaciones medias fueron: PCS 42,6 ± 13,3; MCS 49,4 ± 1,4; HAQ-DI 0,5 ± 0,7. Se registró una correlación con HAQ-DI y PCS (rho de Spearman: −0,83; p < 0,05) y ninguna correla-ción entre HAQ-DI y MCS o entre MCS y PCS (rho de Spearman = −0,21; y 0,01, respectivamente). Las puntuaciones cutáneo-externas y extremidades-pélvicas de la AIS se correlacionaron con el PCS (rho de Spearman: −0,39 y −0,34; p < 0,05) y con el HAQ-DI (rho de Spearman: 0,31 y 0,23; p < 0,05). La condición física en comparación con la población normal fue peor, excepto para los grupos con edades entre 65-74 y 55-64 años. Conclusiones: los pacientes con fracturas pélvicas y de extremidades ...

Risk factors and mortality after elective and emergent laparatomies for oncological procedures in 899 patients in the intensive care unit: a retrospective observational cohort study.

BACKGROUND: Abdominal surgeries for cancer are associated with postoperative complications and mortality. A view of the success of anaesthetic, surgical and critical care can be gained by analyzing factors associated with mortality in patients admitted to intensive care units (ICUs). The objective of this study was to identify the postoperative mortality rate and the causes of perioperative death in high-risk patients after abdominal surgery for cancer. A secondary objective was to explore possible risk factors for death in scheduled and emergency surgeries, with a view to finding guidance on preventable risk factors. METHODS: An observational study, in a 12-bed surgical ICU of a tertiary hospital. Patients admitted after abdominal surgery for cancer to the ICU for more than 24 hours' care were included from January 1, 2008-December 31, 2009. Data were extracted from the minimum basic dataset. The main outcome considered was 90-day mortality. RESULTS: Of 899 patients included, 80 (8.9%) died. Seven died within 48 hours of surgery, 18 died between 2 and 7 days, and 55 died after 7 days. Non-survivors were older and had more respiratory comorbidity, chronic liver disease, metastasis, and underwent more palliative procedures. 112 patients underwent emergency surgery; mortality in these patients for resection surgery was 32.5%; in the 787 patients who underwent scheduled surgery, mortality was 4.7% for resection procedures. The estimated odds ratios (95% confidence interval) of preoperative patient factors in emergency surgery confirmed a negative association between survival and older age 0.96 (0.91-1), the presence of respiratory comorbidity 0.14 (0.02-0.77) and metastasis 0.18 (0.05-0.6). After scheduled surgery, survival was negatively associated with age 0.93 (0.90-0.96) and chronic liver disease 0.40 (0.17-0.91). Analysis of complications after emergency surgery also indicated a negative association with sepsis 0.03 (0.003-0.32), respiratory events 0.043 (0.011-0.17) and cardiac events 0.11 (0.027-0.45); after scheduled surgery, respiratory 0.03 (0.01-0.08) and cardiac 0.11 (0.02-0.45) events, renal failure 0.02 (0.006-0.14) and neurological events 0.06 (0.007-0.5). CONCLUSIONS: As most deaths occurred after discharge from the ICU, postoperative sepsis, respiratory and cardiac events should be watched carefully on the ward.

[Charlson index and the surgical risk scale in the analysis of surgical mortality]. / Valor de los índices de Charlson y la escala de riesgo quirúrgico en el análisis de la mortalidad operatoria.

INTRODUCTION: There is controversy over how to assess surgical mortality risks after different operations. The purpose of this study was to assess the surgical factors that influenced surgical mortality and the ability of the Charlson Index and The Surgical Risk Scale (SRS) to determine low risk patients. MATERIAL AND METHODS: All patients who died during the period 2004-2007 were included. The score of both indices (Charlson and SRS) were recorded. A score of «0¼ for the Charlson Index and «8¼ for the SRS were chosen as the cut-off point between a low and high probability of death. Three risk groups were established: Low when the Charlson was =0 and SRS was <8; Intermediate when the Charlson was >0 and the SRS <8 or Charlson=0 and SRS ≥8; and high when the Charlson was>0 and the SRS ≥8. The risks factors before, during and after surgery were compared between the groups. RESULTS: A total of 72,771 patients were surgically intervened, of which 7011 were urgent. One in every 1455 patients died during surgery and 1 in every 112 died during their hospital stay. Thirteen (2%) patients who died belonged to the low risk group, 199 (30.7%) to the intermediate risk group, and 434 (67.2%) to the high risk group. Heart disease was associated with the high risk group. The urgency of the operation was a determining factor associated with surgical complexity. Re-intervention and sepsis predominated as a cause of death in the low risk group, and in the rest of the groups a cardiac cause was the predominant factor. CONCLUSIONS: The combination of the Charlson Index and SRS detected those patients with a low risk of death, thus making it a useful tool to audit surgical results.

Quality improvement: ultrasonography-guided venous catheterization in organ transplantation.

PURPOSE OF REVIEW: Central venous catheterization (CVC) is a procedure, not exempt of risk. Transplantation patients represent by themselves a high-risk group for CVC. Ultrasonography provides us of the exact localization of the target vein and its relationship with artery and nerve structures, detecting anatomic variations and thromboses of vessels. A description of technical skills, a review of the clinical evidence of ultrasonography-guided CVC and basic training guidelines are presented. RECENT FINDINGS: The internal jugular vein is the most common target vein selected because it is easier and safer, therefore it is the target vein recommended for learning the ultrasonography procedure. For subclavian-axillar vein insertion, the more distal (deltoid) access is the preferred approach; the supraclavicular access has been described with high success in paediatric patients. Anatomic variations of the venous system are not uncommon; small size, overlap artery and tissue oedema around the neck are the main causes of CVC failure. Training guidelines for ultrasound-guided vascular catheterization are necessary, and skill maintenance is crucial. SUMMARY: Ultrasonography-guided venous catheterization is an easily learned technique for internal jugular vein insertion, with significant improvements in overall success in those patients in whom a difficult vein access can be anticipated.

Hemodynamic profile and tissular oxygenation in orthotopic liver transplantation: Influence of hepatic artery or portal vein revascularization of the graft.

We performed a prospective, randomized study of adult patients undergoing orthotopic liver transplantation, comparing hemodynamic and tissular oxygenation during reperfusion of the graft. In 30 patients, revascularization was started through the hepatic artery (i.e., initial arterial revascularization) and 10 minutes later the portal vein was unclamped; in 30 others, revascularization was started through the portal vein (i.e., initial portal revascularization) and 10 minutes later the hepatic artery was unclamped. The primary endpoints of the study were mean systemic arterial pressure and the gastric-end-tidal carbon dioxide partial pressure (PCO(2)) difference. The secondary endpoints were other hemodynamic and metabolic data. The pattern of the hemodynamic parameters and tissue oxygenation values during the dissection and anhepatic stages were similar in both groups At the first unclamping, initial portal revascularization produced higher values of mean pulmonary pressure (25 +/- 7 mm of Hg vs. 17 +/- 4 mm of Hg; P < 0.05) and wedge and central venous pressures. At the second unclamping, initial portal revascularization produced higher values of cardiac output and mean arterial pressure (87 +/- 15 mm of Hg vs. 79 +/- 15 mm of Hg; P < 0.05) and pulmonary blood pressure. Postreperfusion syndrome was present in 13 patients (42.5%) in the arterial group and in 11 patients (36%) in the portal group. During revascularization, the values of gastric and arterial pH decreased in both groups and recovered at the end of the procedure, but were more accentuated in the initial arterial revascularization group. In conclusion, we found that initial arterial revascularization of the graft increases pulmonary pressure less markedly, so it may be indicated for those patients with poor pulmonary and cardiac reserve. Nevertheless, for the remaining patients, initial portal revascularization offers more favorable hemodynamic and metabolic behavior, less inotropic drug use, and earlier normalization of lactate and pH values.

The prophylactic use of tranexamic acid and aprotinin in orthotopic liver transplantation: a comparative study.

The efficacy of tranexamic acid (TA) and aprotinin (AP) in reducing blood product requirements in orthotopic liver transplantation (OLT) was compared in a prospective, randomized and double-blind study. One hundred and twenty seven consecutive patients undergoing OLT were enrolled; TA was administered to 64 OLT patients at a dose of 10mg /kg/h and aprotinin was administered to 63 OLT patients at a loading dose of 2 x 10(6) KIU followed by an infusion of 500,000 KIU/h. The portocaval shunt could not be performed in 14 OLT patients in the TA group and in 13 OLT patients in the AP group. However, all OLT patients that received either drug were included in the analysis. Perioperative management was standardized. Hemogram, coagulation tests, and blood product requirements were recorded during OLT and during the first 24 hours. No differences in diagnosis, Child score, preoperative coagulation tests, and intraoperative data were found between groups. No significant differences were observed in hemogram and intraoperative coagulation tests with the exception of activated partial thromboplastin time (aPTT). Similarly, there were no intergroup differences in transfusion requirements. Thromboembolic events, reoperations and mortality were similar in both groups. In conclusion, administration of regular doses of TA and AP during OLT did not result in large differences between the two groups.

Sevoflurane requirements during coloproctologic surgery: difference between two different epidural regimens.

STUDY OBJECTIVE: To examine the influence of epidural morphine on the end-tidal sevoflurane concentration titrated to maintain bispectral index (BIS) values between 40 and 50. DESIGN: Prospective, double-blinded clinical trial. SETTINGS: Anesthesia department of a university hospital. PATIENTS: 40 ASA physical status I, II, and III patients scheduled for elective coloproctological surgery. INTERVENTIONS: Patients were randomized to receive via a thoracic epidural catheter either a) bupivacaine 0.25% (10 mL) and saline 0.9% (2 mL) as a bolus followed by an infusion of bupivacaine 0.25% (5 mL/hr) or b) bupivacaine 0.25% (10 mL) and morphine 0.1% (2 mL) as a bolus followed by an infusion of bupivacaine 0.25% plus morphine 0.025% (5 mL/hr). Anesthesia was induced with propofol, fentanyl 2 microg kg(-1) and atracurium and maintained with sevoflurane and nitrous oxide in oxygen. Sevoflurane level was titrated to maintain a BIS value between 40 and 50. After extubation, patients were asked about the presence of pain. MAIN RESULTS: There was no significant difference between groups of end-tidal sevoflurane concentrations at identical BIS values and hemodynamic values at any time in the study. However, the morphine group had a lower pain score level at extubation than did the plain bupivacaine group (no pain on movement, 79% vs. 31.5%, p < 0.01). CONCLUSIONS: Adding morphine to the bupivacaine epidural solution did not reduce sevoflurane requirements but did provide high-quality postoperative analgesia, mainly just after tracheal extubation.