Dexmedetomidine pharmacokinetics in the obese.

PURPOSE: This study aims to characterize the influence of body weight and composition on the pharmacokinetics of dexmedetomidine. METHODS: Twenty obese patients and 20 non-obese patients scheduled for elective laparoscopic surgery were given dexmedetomidine infusion schemes. Venous blood samples were taken during and after dexmedetomidine administration. Population pharmacokinetic modeling was undertaken to investigate fat free mass (FFM) and normal fat mass (NFM) as size descriptors of volumes and clearances using non-linear mixed effects modeling. NFM partitions total body weight into FFM and fat mass calculated from total body weight (TBW) minus FFM. The relative influence of fat mass compared to FFM is described by the fraction of fat mass that makes fat equivalent to FFM (Ffat). RESULTS: Theory-based allometric scaling using FFM best described weight and body composition differences in clearances and volumes A negative effect of fat mass of with an exponential parameter of -0.00541/kg (95 % CI -0.0118 to -0.00246) was estimated for clearance which indicates increased fat mass is associated with impairment of clearance. CONCLUSIONS: The use of theory-based allometry with predictions of fat free mass has been able to separate the influences of weight and body composition and indicates that size-normalized clearance of dexmedetomidine is impaired in patients who are obese.

Performance of propofol target-controlled infusion models in the obese: pharmacokinetic and pharmacodynamic analysis.

BACKGROUND: Obesity is associated with important physiologic changes that can potentially affect the pharmacokinetic (PK) and pharmacodynamic (PD) profile of anesthetic drugs. We designed this study to assess the predictive performance of 5 currently available propofol PK models in morbidly obese patients and to characterize the Bispectral Index (BIS) response in this population. METHODS: Twenty obese patients (body mass index >35 kg/m), aged 20 to 60 years, scheduled for laparoscopic bariatric surgery, were studied. Anesthesia was administered using propofol by target-controlled infusion and remifentanil by manually controlled infusion. BIS data and propofol infusion schemes were recorded. Arterial blood samples to measure propofol were collected during induction, maintenance, and the first 2 postoperative hours. Median performance errors (MDPEs) and median absolute performance errors (MDAPEs) were calculated to measure model performance. A PKPD model was developed using NONMEM to characterize the propofol concentration-BIS dynamic relationship in the presence of remifentanil. RESULTS: We studied 20 obese adults (mean weight: 106 kg, range: 85-141 kg; mean age: 33.7 years, range: 21-53 years; mean body mass index: 41.4 kg/m, range: 35-52 kg/m). We obtained 294 arterial samples and analyzed 1431 measured BIS values. When total body weight (TBW) was used as input of patient weight, the Eleveld allometric model showed the best (P < 0.0001) performance with MDPE = 18.2% and MDAPE = 27.5%. The 5 tested PK models, however, showed a tendency to underestimate propofol concentrations. The use of an adjusted body weight with the Schnider and Marsh models improved the performance of both models achieving the lowest predictive errors (MDPE = <10% and MDAPE = <25%; all P < 0.0001). A 3-compartment PK model linked to a sigmoidal inhibitory Emax PD model by a first-order rate constant (ke0) adequately described the propofol concentration-BIS data. A lag time parameter of 0.44 minutes (SE = 0.04 minutes) to account for the delay in BIS response improved the fit. A simulated effect-site target of 3.2 µg/mL (SE = 0.17 µg/mL) was estimated to obtain BIS of 50, in the presence of remifentanil, for a typical patient in our study. CONCLUSIONS: The Eleveld allometric PK model proved to be superior to all other tested models using TBW. All models, however, showed a trend to underestimate propofol concentrations. The use of adjusted body weight instead of TBW with the traditional Schnider and Marsh models markedly improved their performance achieving the lowest predictive errors of all tested models. Our results suggest no relevant effect of obesity on both the time profile of BIS response and the propofol concentration-BIS relationship.

Analysis of the Complexity of Palliative Care for Cancer Patients.

INTRODUCTION: The Spanish National Health System has defined complexity as a set of factors of increased difficulty that require the intervention of a palliative care team. Palliative care aims to improve the quality of life of patients with chronic terminal illnesses. This study aims to describe the degree of complexity of cancer patients in palliative care, to determine which elements of complexity are most prevalent and to determine which other hospital clinical factors are associated with the level of complexity. METHODS: This study is a descriptive, observational, and cross-sectional analysis that included patients diagnosed with advanced oncological pathology undergoing palliative treatment who were admitted to the Medical Oncology ward of the Miguel Servet University Hospital between March and April 2023. RESULT: A total of 100 patients were selected for the study. According to the IDC-Pal, 68% of patients were classified as highly complex, 26% of patients were complex and only 6% of patients were classified as non-complex. The presence of pain (P < .001), nausea and vomiting (P = .027), depression (P = .033) and functional status (P = .011) were statistically independent predictors of high complexity. DISCUSSION: This study has shown that a high proportion of hospitalized palliative care cancer patients have high complexity, suggesting a good matching of healthcare resources to patient complexity. Four factors related to complexity have been identified, namely pain, nausea and vomiting, depression and a bedridden functional state. The presence of any of the 4 factors could help healthcare professionals to identify patients for early specialized palliative care.

Prevalence of abdominal aortic aneurysm is still high in certain areas of southern Europe.

BACKGROUND: Ultrasound screening of abdominal aortic aneurysm (AAA) has proved to reduce mortality from AAA rupture and has been implemented in several countries. Recent reports show a decreasing prevalence of AAA in Western countries. We report the results from a screening program among 65-year-old men in a defined area in the North of Spain. METHODS: We invited the 1,413 men born in 1943 and registered in the health area under our care to participate in the study. We registered their medical history and cardiovascular risk factors and we performed an abdominal ultrasound scan. We diagnosed an AAA when the infrarenal aortic diameter was ≥3 cm. We performed univariate and multivariate analysis to assess independent factors associated with the development of an AAA, using logistic regression. RESULTS: The participation rate was 70.8%. The prevalence of active smoking, hypertension, diabetes, and hypercholesterolemia was 19.6%, 52.1%, 25.7%, and 76.9%, respectively. Including 3 previously known and repaired AAAs, the total prevalence of AAA was 4.7% (n=37). The mean diameter of the AAA was 35.7±7.9 mm (range, 30-62 mm). Multivariate analysis confirmed the independent impact of active smoking (Exp[B], 3.47 [95% confidence interval {CI}: 1.67-7.22]), hypertension (Exp[B], 2.43 [95% CI: 1.08-5.45]), and peripheral arterial disease (Exp[B], 3.00 [95% CI: 1.16-7.80]) on the incidence of AAA. CONCLUSIONS: The prevalence of AAA remains high in the studied area in the North of Spain. The potential benefit of lowering smoking rates has not been observed yet. The current international recommendations of screening for 65-year-old men are still applicable in our population.

Fixed-dose-rate gemcitabine infusion in patients with advanced pancreatic or biliary tree adenocarcinoma.

AIMS AND BACKGROUND: Gemcitabine is an effective agent in pancreatic adenocarcinoma. Fixed-dose-rate gemcitabine has an interesting biological and clinical rationale, with successful results in previous studies. We conducted a trial to confirm efficacy and toxicity of fixed-dose-rate gemcitabine in patients with pancreatic or biliary tree adenocarcinoma. METHODS: Eligible patients with locally advanced or metastatic pancreatic or biliary tree adenocarcinoma received fixed-dose-rate gemcitabine at a dose of 1500 mg/m(2) at a rate of 10 mg/m(2)/min weekly for 3 weeks every 28 days. Efficacy measures were overall survival, response rate and progression-free survival. RESULTS: Sixty-two patients were enrolled, and 59 were assessable for response. Seven patients (11.3%) had a partial response, 26 stable disease (41.9%) and 26 progressive disease (41.9%). Median time to progression was 21 weeks and median overall survival, 37.71 weeks. Main toxicities were grade 3-4 neutropenia (45.2%) and grade 2-3 asthenia (54.8%). No toxic deaths were documented. CONCLUSIONS: Fixed-dose-rate gemcitabine has a relevant antitumor activity but with significant toxicity. It represents an interesting schedule and could be combined with other biological or chemotherapeutic agents.

Dural puncture epidural analgesia for labor: a randomized comparison between 25-gauge and 27-gauge pencil point spinal needles.

BACKGROUND: This double-blind, randomized trial compared dural puncture epidural analgesia (DPEA) for labor using 25-gauge and 27-gauge pencil point spinal needles. We hypothesized that both needle sizes would result in similar onset time (equivalence margin=2.5 min) and therefore designed the study as an equivalence trial. METHODS: One hundred and forty patients undergoing labor were randomized to DPEA with 25-gauge (n=70) or 27-gauge (n=70) pencil point spinal needles. After the placement of the epidural catheter, a bolus of 20 mL of bupivacaine 0.125% and fentanyl 2 µg/mL was administered to all subjects. Thereafter, patients received boluses of 12 mL of bupivacaine 0.125% every 2 hours as needed.A blinded investigator recorded the onset time (defined as the temporal interval required to achieve a pain score ≤1 on a 0-10 scale), S2 block, sensory block height (30 min after the initial bolus of local anesthetic), presence of motor block (30 min after the initial bolus of local anesthetic), number of top-up doses required during labor and incidence of postural headache. RESULTS: Out of the 140 recruited patients, 135 were retained for analysis. Compared with their 27-gauge counterparts, 25-gauge pencil point spinal needles provided a 1.6 min shorter DPEA onset (95% CI of the difference of the means: -3.2 to -0.1 min). However, there were no intergroup differences in terms of S2 block, sensory block height, motor block, number of top-up doses and incidence of postural headache. CONCLUSION: Dural puncture epidural analgesia with 25-gauge pencil point spinal needles provides a 1.6 min shorter onset time than DPEA with 27-gauge spinal needles. Although statistically significant, such a difference may not be clinically relevant. Further investigation is required to compare 25-gauge and 27-gauge spinal needles for DPEA in the setting of different local anesthetic infusion strategies. TRIAL REGISTRATION NUMBER: NCT03389945.

Spanish Clinical Guidelines on Vascular Access for Haemodialysis. / Guía Clínica Española del Acceso Vascular para Hemodiálisis.

Vascular access for haemodialysis is key in renal patients both due to its associated morbidity and mortality and due to its impact on quality of life. The process, from the creation and maintenance of vascular access to the treatment of its complications, represents a challenge when it comes to decision-making, due to the complexity of the existing disease and the diversity of the specialities involved. With a view to finding a common approach, the Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology [S.E.N.], vascular surgery [SEACV], vascular and interventional radiology [SERAM-SERVEI], infectious diseases [SEIMC] and nephrology nursing [SEDEN]), along with the methodological support of the Cochrane Center, has updated the Guidelines on Vascular Access for Haemodialysis, published in 2005. These guidelines maintain a similar structure, in that they review the evidence without compromising the educational aspects. However, on one hand, they provide an update to methodology development following the guidelines of the GRADE system in order to translate this systematic review of evidence into recommendations that facilitate decision-making in routine clinical practice, and, on the other hand, the guidelines establish quality indicators which make it possible to monitor the quality of healthcare.

Assessment of central venous catheterization in a simulated model using a motion-tracking device: an experimental validation study.

BACKGROUND: Central venous catheterization (CVC) is a basic requirement for many medical specialties. Simulated training in CVC may allow the acquisition of this competency but few reports have established a valid methodology for learning and acquiring procedural skills for CVC. This study aims to validate the use of a tracking motion device, the imperial college surgical assessment device (ICSAD), by comparing it with validated global rating scales (GRS) to measure CVC performance in a simulated torso. METHODS: Senior year medical students, first and last year residents (PGY1, LYR), and expert anesthesiologists performed a jugular CVC assessment in a simulated model (Laerdal IV Torso). A validated GRS for objective assessment of technical skills and motion analysis by ICSAD was used. Statistical analysis was performed through Mann-Whitney and Kruskal-Wallis tests for construct validity and Spearman correlation coefficients between the ICSAD and GRS scores for concurrent validity between both. RESULTS: 32 subjects were recruited (10 medical students, 8 PGY1, 8 LYR and 8 experts). Total path length measured with ICSAD and GRS scores were significantly different between all groups, except for LYR compared to experts (p = 0.664 for GRS and p = 0.72 for ICSAD). Regarding jugular CVC procedural time, LYR and experts were faster than PGY1 and MS (p < 0.05). Spearman correlation coefficient was -0.684 (p < 0.001) between ICSAD and GRS scores. CONCLUSIONS: ICSAD is a valid tool for assessment of jugular CVC since it differentiates between expert and novice subjects, and correlates with a validated GRS for jugular CVC in a simulated torso.

Effect of acute arterial hypertension on morphine requirements and postsurgical pain.

STUDY OBJECTIVE: The study objective was to establish the impact of acute hypertension on morphine's requirements after laparoscopic cholecystectomy. DESIGN: The design was a randomized, simple blinded study. SETTING: The settings were operating room, postoperative recovery area, and first postoperative day. PATIENTS: There were 50 patients, American Society of Anesthesiologists I-II, aged 18-50 years, undergoing elective laparoscopic cholecystectomy with general anesthesia. INTERVENTIONS: Anesthetic management was standardized using propofol for induction, isoflurane for bispectral index (BIS) ranging between 40 and 60, and remifentanil maintained at a constant rate of 0.4 µg kg per minute throughout surgery in all patients. Once intubated, patients were randomly allocated to 1 of 2 groups: hypertensive group: systolic arterial blood pressure was maintained with phenylephrine infusion 20%-30% over baseline; control group: systolic arterial blood pressure was maintained 20%-30% below baseline. All surgical incisions were infiltrated with bupivacaine 0.5%, and every patient received ketorolac 60 mg intravenous. Patient-controlled analgesia with morphine intravenous was used for postoperative analgesia. MEASUREMENTS: Pain visual analogue scale scores, arterial blood pressure, and hyperalgesia were assessed at recovery room every 15 minutes during the first 2 postoperative hours and then at 6, 12, and 24 postoperative hours. Cumulative morphine consumption was registered at 2 and 24 postoperative hours. MAIN RESULTS: The cumulative morphine consumption in the control group was around 18 mg compared with 6 mg in the hypertensive group (P = .019). During the first 75 minutes after surgery, the control group had higher visual analogue scale score pain compared with hypertensive group (P = .005). CONCLUSIONS: The intraoperative acute generation of mild hypertension with phenylephrine reduced postoperative morphine consumption and pain scores after laparoscopic cholecystectomy.

Efecto del fentanilo intratecal en hiperlagesia secundaria posoperatoria de cirugía ligamento cruzado anterior de rodilla / Effect of Intrathecal fentanyl on secondary hyperalgesia, in patients undergoing anterior cruciate ligament repair

BACKGROUND AND OBJECTIVES: Fentanyl addition is a common practice when administering spinal anesthesia. Intrathecal fentanyl has been associated to increased postoperative pain and increase morphine consumption, but considered to be related to acute opioid tolerance. This prospective, randomized, blind study evaluates the effect of intrathecal fentanyl in the development of secondary hyperalgesia, measured with Von Frey filaments, in patients undergoing anterior cruciate ligament repair. METHODS: 46 patients having anterior cruciate ligament repair, received intrathecal hyperbaric bupivacaine 13.5 mg with fentanyl 20 mcg or no fentanyl addition. Light touch pain threshold was measured with von Frey filaments before anesthesia, at 6 and 24 hours post anesthesia in the non-operated thigh and in the forearm. Visual analogue pain scores and morphine consumption were also measured at the same time. RESULTS: Baseline thresholds to mechanical stimuli were similar in both groups. In the forearm, analysis showed a decreased threshold for the non-fentanyl group at 24 h p = 0.036. In the lower extremity, control and treatment group showed lower thresholds (secondary hyperalgesia) p = 0.002 but no difference between them p = 0.795. VAS score and morphine consumption did not differ among groups. CONCLUSIONS: Spinal fentanyl added to hyperbaric bupivacaine showed no evidence of an augmented state of hyperalgesia after ACL repair, neither by pain threshold modification nor clinical outcomes. On the contrary, at 24 h, fentanyl may have a protective effect at levels above the spinal block.

ANTECEDENTES Y OBJETIVOS: El uso de fentanilo es una práctica común en la administración de anestesia espinal. Su aplicación se ha asociado a un aumento del dolor post operatorio y a un aumento en el uso de morfina; por otro lado, se ha vinculado a una tolerancia aguda a opioides. El siguiente estudio prospectivo, randomizado y ciego, evalúa los efectos del fentanilo intratecal en la aparición de hiperalgesia secundaria, medida a través de filamentos Von Frey, en pacientes operados de ligamento cruzado anterior. METODOLOGÍA: Se incluyeron a 46 pacientes operados de ligamento cruzado anterior (LCA) con una dosis intratecal de bupivacaína hiperbárica de 13,5 mg; con y sin la adición de fentanilo de 20 mcg. Se midió el umbral del dolor mecánico, a través de filamentos Von Frey, antes de la anestesia, a las 6 y 24 horas postanestesia en el muslo no operado y en el antebrazo. Al mismo tiempo, se midió la puntuación del dolor en la escala verbal numérica (EVN) y el consumo de morfina. RESULTADOS: Los umbrales basales ante la estimulación mecánica resultaron similares en ambos grupos. En el antebrazo, el análisis mostró una disminución del umbral en el grupo de pacientes sin fentanilo, a las 24 h, p = 0,036 comparado con uso de fentanilo. En el muslo, el grupo control y tratamiento mostró umbrales más bajos (hiperalgesia secundaria) p = 0,002; no obstante, no se mostraron diferencias entre ellos. No se mostraron diferencias entre las puntuaciones de la EVN y el consumo de morfina en los dos grupos. CONCLUSIÓN: No hay evidencia que la adición de fentanilo espinal, a la dosis de bupivacaína hiperbárica, haya contribuido a un aumento en la hiperalgesia tras la reparación del LCA, medido por la modificación del umbral del dolor, ni en los resultados clínicos. Al contrario a las 24 h fentanilo puede tener un efecto protector de la hiperalgesia secundaria sobre el nivel del bloqueo espinal.

Phase II study of docetaxel/vinorelbine in patients with non-small-cell-lung cancer previously treated with platinum-based chemotherapy.

The aim of this phase II trial was to assess the efficacy and tolerability of docetaxel/vinorelbine as second-line therapy. Thirty-two patients with a performance status (PS) of

[Prognostic and predictive factors of patients with cancer of unknown origin treated with a paclitaxel-based chemotherapy]. / Factores pronósticos y predictivos en pacientes con cáncer de origen desconocido tratados con un esquema de quimioterapia con paclitaxel.

BACKGROUND AND OBJECTIVE: Taxane-based combinations appear to be promising for the treatment of carcinoma of unknown primary site (CUPS). PATIENTS AND METHOD: Patients with CUPS not corresponding to any favourable subset were treated with paclitaxel, carboplatin and etoposide. Interaction between various factors with survival was analyzed. A regression model was applied to identify factors with independent prognostic significance. RESULTS: 48 patients were included and 15 responses were observed with a median overall survival of 7.4 months. In the multivariate analysis, performance status and hypoalbuminemia were negatively associated with overall survival. CONCLUSIONS: Some patients can achieve complete response and prolonged survival. This treatment cannot be recommended for patients with a regular performance status. A better knowledge of prognostic factors and a definition of more subgroups with favourable outcome are needed.

Estrogen receptor 1 gene expression and its combination with estrogen receptor 2 or aromatase expression predicts survival in non-small cell lung cancer.

The biological roles of estrogen receptor 1 (ERS1), estrogen receptor 2 (ERS2), and aromatase (CYP19A1) genes in the development of non-small cell lung cancer (NSCLC) is unclear, as is the use of their expression as a prognostic factor. The aim of this study was to investigate the prognostic value of estrogen receptors and aromatase mRNA expression, along with aromatase protein concentration, in resected NSCLC patients. Tumor and non-tumor lung tissue samples were analyzed for the mRNA expression of ERS1, ERS2 and CYP19A1 by RT-PCR. Aromatase concentration was measured with an ELISA. A total of 96 patients were included. ERS1 expression was significantly higher in non-tumor tissue than in tumor samples. Two gene expression categories were created for each gene (and protein): high and low. ERS1 high category showed increased overall survival (OS) when compared to the low expression category. Aromatase protein concentration was significantly higher in tumor samples. Higher ERS1 expression in tumor tissues was related to longer overall survival. The analysis of gene expression combinations provides evidence for longer OS when both ERS1 and ERS2 are highly expressed. ESR1, alone or in combination with ERS2 or CYP19A1, is the most determining prognostic factor within the analyzed 3 genes. It seems that ERS1 can play a role in NSCLC prognosis, alone or in combination with other genes such as ERS2 or Cyp19a1. ERS2 in combination with aromatase concentration could have a similar function.

Comparison of plasma concentrations of levobupivacaine with and without epinephrine for transversus abdominis plane block.

BACKGROUND AND OBJECTIVES: The pharmacokinetics for levobupivacaine in transversus abdominis plane (TAP) blocks has not been previously reported. We aimed to determine the extent of the block and the effect on plasma concentrations of levobupivacaine with the addition of epinephrine. METHODS: We enrolled 11 healthy volunteers in this double-blind, 2-intervention, 2-period crossover study. The intervention periods were defined as a unilateral left TAP block with 20 mL of 0.25% levobupivacaine with (E) or without (no E) 5 µg/mL epinephrine. Subjects were randomized to E, followed by no E or no E followed by E, with 2-week washout period. Sensory dermatomal anesthesia was recorded. Blood samples were obtained for the measurement of plasma levobupivacaine levels. RESULTS: The median cranial-to-caudal spread of sensory blockade for sharp touch was T9 (interquartile range [IQR], T7-T10) to L1 (IQR, T12-L1) with epinephrine and T9 (IQR, T8-T10) to T12 (IQR, T11-L1) without epinephrine (P > 0.05). The mean maximum arterial levobupivacaine concentrations with epinephrine were 0.36 (95% bootstrap confidence interval [95% CI], 0.30-0.42) µg/mL and 0.63 (95% CI, 0.49-0.85) µg/mL without epinephrine (P = 0.014, difference in means of 0.27 [95% CI, 0.12-0.46]). The mean maximal venous levobupivacaine concentration was 0.32 (95% CI, 0.28-0.39) µg/mL and 0.49 (95% CI, 0.37-0.68) µg/mL, with and without epinephrine, respectively (P = 0.006, difference in means of 0.17 [95% CI, 0.08-0.33]). The mean duration of the blockade was 10.2 hours (95% CI, 8.5-12.5 hours) with epinephrine and 10.3 hours (95% CI, 8.7-12.4 hours) without epinephrine (P = 1.000). CONCLUSIONS: Adding epinephrine to levobupivacaine reduces its peak plasma concentration after unilateral TAP blocks, with no remarkable effects on block characteristics or duration.

Guía Clínica Española del Acceso Vascular para Hemodiálisis / Spanish Clinical Guidelines on Vascular Access for Haemodialysis

El acceso vascular para hemodiálisis es esencial para el enfermo renal tanto por su morbimortalidad asociada como por su repercusión en la calidad de vida. El proceso que va desde la creación y mantenimiento del acceso vascular hasta el tratamiento de sus complicaciones constituye un reto para la toma de decisiones debido a la complejidad de la patología existente y a la diversidad de especialidades involucradas. Con el fin de conseguir un abordaje consensuado, el Grupo Español Multidisciplinar del Acceso Vascular (GEMAV), que incluye expertos de las cinco sociedades científicas implicadas (nefrología [S.E.N.], cirugía vascular [SEACV], radiología vascular e intervencionista [SERAM-SERVEI], enfermedades infecciosas [SEIMC] y enfermería nefrológica [SEDEN]), con el soporte metodológico del Centro Cochrane Iberoamericano, ha realizado una actualización de la Guía del Acceso Vascular para Hemodiálisis publicada en 2005. Esta guía mantiene una estructura similar, revisando la evidencia sin renunciar a la vertiente docente, pero se aportan como novedades, por un lado, la metodología en su elaboración, siguiendo las directrices del sistema GRADE con el objetivo de traducir esta revisión sistemática de la evidencia en recomendaciones que faciliten la toma de decisiones en la práctica clínica habitual y, por otro, el establecimiento de indicadores de calidad que permitan monitorizar la calidad asistencial (AU)

Vascular access for haemodialysis is key in renal patients both due to its associated morbidity and mortality and due to its impact on quality of life. The process, from the creation and maintenance of vascular access to the treatment of its complications, represents a challenge when it comes to decision-making, due to the complexity of the existing disease and the diversity of the specialities involved. With a view to finding a common approach, the Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology [S.E.N.], vascular surgery [SEACV], vascular and interventional radiology [SERAM-SERVEI], infectious diseases [SEIMC] and nephrology nursing [SEDEN]), along with the methodological support of the Cochrane Center, has updated the Guidelines on Vascular Access for Haemodialysis, published in 2005. These guidelines maintain a similar structure, in that they review the evidence without compromising the educational aspects. However, on one hand, they provide an update to methodology development following the guidelines of the GRADE system in order to translate this systematic review of evidence into recommendations that facilitate decision-making in routine clinical practice, and, on the other hand, the guidelines establish quality indicators which make it possible to monitor the quality of healthcare (AU)