[Prevention, diagnosis and treatment of bleeding in cardiac surgery]. / Prevención, diagnóstico y tratamiento de la hemorragia en cirugía cardiaca.

Patients undergoing cardiac surgery are at high risk of bleeding and transfusion. This risk has increased in recent years and is associated with increased morbidity and mortality. Moreover, despite being one of the most common complications associated with this surgery, there remains a large variability in its management between institutions. Implementation of algorithms for coagulation management has been shown to reduce transfusion requirements and therefore it seems essential to establish protocols that include preventive measures, effective mechanisms for diagnosis and treatment algorithms. On the other hand, the emergence of new drugs and the use of point of care coagulation monitoring systems, is changing our diagnostic and therapeutic options. This paper reviews several aspects related to the causes, diagnosis and treatment of bleeding associated with cardiac surgery and presents an algorithm for its management.

Incidence and predictors of major perioperative adverse cardiac and cerebrovascular events in non-cardiac surgery.

BACKGROUND: Major adverse cardiac and cerebrovascular events (MACCE) represent the most common cause of serious perioperative morbidity and mortality. Our aim was to identify risk factors for MACCE in a broad surgical population with intermediate-to-high surgery-specific risk and to build and validate a model to predict the risk of MACCE. METHODS: A prospective, multicentre study of patients undergoing surgical procedures under general or regional anaesthesia in 23 hospitals. The main outcome was the occurrence of at least one perioperative MACCE, defined as any of the following complications from admittance to discharge: cardiac death, cerebrovascular death, non-fatal cardiac arrest, acute myocardial infarction, congestive heart failure, new cardiac arrhythmia, angina, or stroke. The MACCE predictive index was based on ß-coefficients and validated in an external data set. RESULTS: Of 3387 patients recruited, 146 (4.3%) developed at least one MACCE. The regression model identified seven independent risk factors for MACCE: history of coronary artery disease, history of chronic congestive heart failure, chronic kidney disease, history of cerebrovascular disease, preoperative abnormal ECG, intraoperative hypotension, and blood transfusion. The area under the receiver-operating characteristic curve was 75.9% (95% confidence interval, 71.2-80.6%). CONCLUSIONS: The risk score based on seven objective and easily assessed factors can accurately predict MACCE occurrence after non-cardiac surgery in a population at intermediate-to-high surgery-specific risk.

Acute kidney injury after cardiac surgery: prevalence, impact and management challenges.

Acute kidney injury (AKI) is a major medical problem that is of particular concern after cardiac surgery. Perioperative AKI is independently associated with an increase in short-term morbidity, costs of treatment, and long-term mortality. In this review, we explore the definition of cardiac surgery-associated acute kidney injury (CSA-AKI) and identify diverse mechanisms and risk factors contributing to the renal insult. Current theories of the pathophysiology of CSA-AKI and description of its clinical course will be addressed in this review. Data on the most promising renal protective strategies in cardiac surgery, from well-designed studies, will be scrutinized. Furthermore, diagnostic tools such as novel biomarkers of AKI and their potential utility will be discussed.

[Two cases of early postoperative massive pulmonary thromboembolism after gastric bypass surgery]. / Dos casos de tromboembolismo pulmonar masivo precoz en el postoperatorio de cirugía bariáitrica.

Pulmonary thromboembolism in the early postoperative period is rare. We present 2 cases of massive embolism that occurred soon after gastric bypass surgery. The first patient was a 32-year-old man, a smoker with a body mass index (BMI) of 52 kg/m2, obstructive sleep apnea-hypopnea syndrome and venous insufficiency in the lower extremities. Fatal cardiorespiratory arrest occurred 22 hours after surgery. Autopsy confirmed massive pulmonary thromboembolism. The second patient was a 48-year-old woman with a BMI of 40 kg/m2 who had undergone abdominal hysterectomy 2 months earlier. She survived cardiorespiratory arrest occurring 11 hours after surgery. There were no sequelae. The diagnosis of pulmonary thromboembolism was confirmed by transesophageal echocardiography. These patients undoubtedly had asymptomatic deep vein thrombosis before the operations. Prevention of pulmonary embolism is essential in high risk patients. The prophylactic measures usually applied are administration of low molecular weight heparin to prevent thrombosis, early ambulation, and the use of elastic compression stockings or intermittent pneumatic compression.

[Gas embolism secondary to intraoperative use of hydrogen peroxide]. / Embolismo gaseoso secundario al uso intraoperatorio de peróxido de hidrógeno.

Hydrogen peroxide solution (H2O2) is used to irrigate and clean wounds. When applied to tissue hydrogen peroxide decomposes rapidly as a result of the action of catalases, releasing oxygen in the process. High pressure irrigation of the washing of closed cavities can cause serious complications. We report a case of gas embolism arising from the use of hydrogen peroxide during surgery for hydatidosis of the liver. A 64-year-old woman underwent surgery for removal of a hydatid cyst of the liver. When pressurized injection of 10 ml of 3% hydrogen peroxide was applied to the cystic cavity, cardiac arrhythmias were observed, a long with decreased PetCO2, hypotension and a "water mill" heart murmur. Gas embolism was suspected and treatment was instated immediately. Clinical course was good and without complications. We wish to warn against the potential dangers of using peroxide during surgery and of the importance of capnography for early diagnosis of gas embolism.

[Postoperative patient-controlled analgesia is more effective with epidural methadone than with intravenous methadone in thoracic surgery]. / La analgesia postoperatoria controlada por el paciente es más efectiva con metadona epidural que con metadona endovenosa en la cirugía torácica.

OBJECTIVE: To compare the efficacy and side effects of epidural and intravenous methadone for postoperative patient-controlled analgesia (PCA) after thoracic surgery. PATIENTS AND METHODS: A randomized, single-blind trial enrolling 30 patients distributed in 2 groups to receive intravenous methadone (ivPCA group) or epidural methadone (epPCA group). Patients in both groups were administered a loading dose of 0.05 mg.kg-1 followed by infusion of 0.5 mg.h-1. The patients could self-dose 0.5 mg with a lock-out interval of 10 minutes and a maximum of 4 doses per hour. Patient characteristics, type and duration of surgery and fentanyl dose were recorded. Pain was assessed on a visual analog scale (VAS). Level of sedation, respiratory rate and occurrence of nausea, vomiting and pruritus were also recorded over the first 24 hours. RESULTS: The 2 groups were comparable. Pain was greater in the ivPCA group than in the epPCA group in the second hour (VAS 3.93 +/- 1.9 and 2.4 +/- 1.65, respectively; P < .05) and the third hour (VAS 3.57 +/- 1.65 and 1.5 +/- 1.16, respectively; P < .05). The total dose of methadone administered was 25.34 +/- 5.65 mg in the ivPCA group and 18.82 +/- 3.52 mg in the epPCA group (P < .002). There were no significant differences in side effects. CONCLUSIONS: The results suggest that epidural methadone has an intrinsic spinal effect regardless of whether or not there is extra-spinal action arising from syste mic absorption. Epidural methadone provides a more adequate analgesic effect in less time and at a lower dose. Both approaches provide good postoperative analgesia with few side effects.

[Abdominal compartmental syndrome in non-injured patients]. / Síndrome compartimental abdominal en pacientes no traumáticos.

Abdominal compartment syndrome (ACS) is characterized by increased intraabdominal pressure and a set of secondary pathophysiological changes in the abdominal. ACS has reappeared in the literature recently in relation to the surgical concept to damage control, applied particularity in contexts of severe abdominal injury polytraumatized patients. We report two cases of ACS that appeared after scheduled abdominal surgery: one after repair of a large eventration and the other in the context of septic shock due to fecaloid peritonitis. Both patients died of multisystem organ failure in spite of surgical decompression. We wish to emphasize that ACS can appear in contexts other than surgery for damage control, and we stress the need to measure intravesical pressure as a reflection of intraabdominal pressure, particularly in certain high risk patients in the postoperative recovery ward. Finally, we review the pathophysiology of ACS and its management, which is based on early treatment to prevent multisystem organ failure with an associated high risk of death.

[Comparative study of 3 techniques for total intravenous anesthesia: midazolam-ketamine, propofol-ketamine, and propofol-fentanyl]. / Estudio comparativo de tres técnicas de anestesia total intravenosa: midazolam-ketamina, propofol-ketamina y propofol-fentanilo.

OBJECTIVE: To compare the characteristics of induction, maintenance and awakening for three techniques of combined total intravenous anesthesia (TIVA): propofol-ketamine, midazolam-ketamine and propofol-fentanyl. PATIENTS AND METHODS: Sixty patients were randomly assigned to three TIVA groups. Group 1 (n = 20) received midazolam, ketamine and vecuronium. Group 2 (n = 20) received propofol, ketamine and vecuronium. Group 3 (n = 20) received propofol, fentanyl and vecuronium. The variables compared were hemodynamic changes during induction and maintenance and upon awakening; time until awakening; and the incidence of postanesthetic complications. We also assessed whether propofol was better than midazolam at preventing the psychomimetic effects of ketamine. RESULTS: The demographic characteristics of the three groups were similar. Hemodynamic variables were most stable in group 2. Perfusion of midazolam-ketamine was accompanied by a significantly higher number of hypertensive peaks. Time to awakening was significantly shorter in Group I (11.8 +/- 5 min) than in group 2 (20.2 +/- 12.5 min); in group 2 time to awakening was 16.6 +/- 5.6 min. Eight patients in group 1, 5 in group 2 and 1 in group 3 reported having bad dreams, the difference between groups 1 and 3 reaching statistical significance. No patient experienced hallucinations and all reported satisfaction with the anesthetic technique used. CONCLUSIONS: TIVA with ketamine and propofol is comparable to the most commonly used combination of propofol and fentanyl and may be an appropriate choice when hemodynamic stability is of great importance; withdrawal 15 min before ending surgery prevents prolonged awakening. Perfusion of midazolam-ketamine is not recommendable for scheduled surgery because it induces too many hypertensive peaks. Although neither midazolam nor propofol completely prevents the psychomimetic effects of ketamine, such effects are not so severe that patients reject the anesthetic technique used.

[Hemodynamic response to intubation with Macintosh and McCoy blades]. / Respuesta hemodinámica a la intubación con las palas de Macintosh y McCoy.

INTRODUCTION: The McCoy laryngoscope incorporates a modification of the Macintosh blade designed to facilitate laryngoscopy and difficult intubation. One end is articulated to allow better viewing of the larynx. Use of this blade reduces pressure placed on tissues in the supraglottic area during laryngoscopy. OBJECTIVE: We designed this study to compare the hemodynamic repercussions of laryngoscopy and tracheal intubation (LTI) performed with either a Macintosh or the McCoy blade. PATIENTS AND METHOD: Sixty ASA I-II patients scheduled for elective surgery requiring LTI were randomly assigned to 2 groups of 30 patients each. In both groups anesthetic induction was achieved with 0.04 mg.kg-1 midazolam, 0.002 mg.kg-1 fentanyl, 2 mg.kg-1 propofol and 0.1 mg.kg-1 vecuronium. In group 1 LTI laryngoscopy and intubation were performed using the Macintosh size 3 blade and in group 2 the McCoy size 3 blade was used. Systolic and diastolic arterial pressures and heart rate were recorded in each patient before anesthetic induction (baseline), 1 minute after induction and 5 minutes after start of LTI. RESULTS: We found no significant differences between the 2 groups at any of the recording times. CONCLUSION: The data obtained do not allow us to assert that there is any difference in hemodynamic response to LTI associated to type of blade used.

Prevención, diagnóstico y tratamiento de la hemorragia en cirugía cardiaca / Prevention, diagnosis and treatment of bleeding in cardiac surgery

Los pacientes operados de cirugía cardiaca tienen un riesgo elevado de hemorragia y transfusión. Este riesgo ha ido aumentando en las últimas décadas y, pese a ser una de las complicaciones más frecuentes y con mayor morbimortalidad asociadas a esta cirugía, sigue existiendo una gran variabilidad en cuanto a su manejo entre las instituciones. El uso de algoritmos de manejo de la hemorragia ha demostrado que disminuye los requerimientos de transfusión y por tanto parece imprescindible establecer protocolos que incluyan medidas preventivas, mecanismos eficaces de diagnóstico y algoritmos de tratamiento. Por otra parte, la aparición de nuevos fármacos procoagulantes y de nuevos sistemas de monitorización de la hemostasia están cambiando nuestras posibilidades diagnósticas y terapéuticas. En este trabajo se revisan varios aspectos relacionados con las causas, la prevención, el diagnóstico y el tratamiento de la hemorragia asociada a la cirugía cardiaca y se presenta una propuesta de algoritmo para su manejo(AU)

Patients undergoing cardiac surgery are at high risk of bleeding and transfusion. This risk has increased in recent years and is associated with increased morbidity and mortality. Moreover, despite being one of the most common complications associated with this surgery, there remains a large variability in its management between institutions. Implementation of algorithms for coagulation management has been shown to reduce transfusion requirements and therefore it seems essential to establish protocols that include preventive measures, effective mechanisms for diagnosis and treatment algorithms. On the other hand, the emergence of new drugs and the use of point of care coagulation monitoring systems, is changing our diagnostic and therapeutic options. This paper reviews several aspects related to the causes, diagnosis and treatment of bleeding associated with cardiac surgery and presents an algorithm for its management(AU)

Dos casos de tromboembolismo pulmonar masivo precoz en el postoperatorio de cirugía bariátrica / Two cases of early postoperative massive pulmonary thromboembolism after gastric bypass surgery

El tromboembolismo pulmonar (TEP) en las primeras horas del postoperatorio es poco habitual. Presentamos dos casos de TEP masivo precoz que ocurrieron en las primeras horas después de cirugía bariátrica. El primer caso era un varón de 32 años, fumador, con índice de masa corporal (IMC) 52 kg/m2, síndrome de apnea obstructiva del sueño e insuficiencia venosa en extremidades inferiores. A las 22 horas del postoperatorio presentó colapso cardiorrespiratorio mortal. La necropsia confirmó TEP masivo. El segundo caso era una mujer de 48 años con IMC 40 kg/m2, operada dos meses antes de histerectomía abdominal. A las 11 horas postcirugía presentó colapso cardiopulmonar del cual sobrevivió sin secuelas. La ecocardiografía transesofágica confirmó el diagnóstico de TEP masivo. Seguramente estos pacientes presentaban trombosis venosa profunda asintomática preoperatoria. La prevención del TEP es fundamental en pacientes de alto riego, las medidas más comúnmente usadas son la tromboprofilaxis con heparina de bajo peso molecular, combinada con la deambulación precoz, medias de compresión elástica o compresión neumática intermitente (AU)

Pulmonary thromboembolism in the early postoperative period is rare. We present 2 cases of massive embolism that occurred soon after gastric bypass surgery. The first patient was a 32-year-old man, a smoker with a body mass index (BMI) of 52 kg/m2, obstructive sleep apnea–hypopnea syndrome and venous insufficiency in the lower extremities. Fatal cardiorespiratory arrest occurred 22 hours after surgery. Autopsy confirmed massive pulmonary thromboembolism. The second patient was a 48-year-old woman with a BMI of 40 kg/m2 who had undergone abdominal hysterectomy 2 months earlier. She survived cardiorespiratory arrest occurring 11 hours after surgery. There were no sequelae. The diagnosis of pulmonary thromboembolism was confirmed by transesophageal echocardiography. These patients undoubtedly had asymptomatic deep vein thrombosis before the operations. Prevention of pulmonary embolism is essential in high risk patients. The prophylactic measures usually applied are administration of low molecular weight heparin to prevent thrombosis, early ambulation, and the use of elastic compression stockings or intermittent pneumatic compression (AU)

Reacción anafiláctica al látex al finalizar la intervención y soltar el manguito de isquemia / Anaphylactic reaction to latex after surgery and release of the ischemic cuff

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La analgesia postoperatoria controlada por el paciente es más efectiva con metadona epidural que con metadona endovenosa en la cirugía torácica / Epidural methadone is more effective than intravenous methadone in postoperative patient-controlled analgesia after thoracic surgery

OBJETIVO: Comparar la efectividad y efectos secundarios de la metadona administrada por vía epidural y endovenosa en la analgesia postoperatoria controlada por el paciente (PCA) en toracotomías. PACIENTES Y MÉTODOS: Estudio prospectivo y simple ciego en 30 pacientes divididos aleatoriamente en dos grupos según la vía de administración de la metadona: grupo PCAEV endovenosa y grupo PCAEP epidural. En ambos grupos se administraba un bolo inicial de 0,05 mg-Kg-1 seguido de una infusión de 0,5 mg-h-1. Los pacientes se podían autoadministrar bolos de 0,5 mg, con intervalo de cierre de 10 minutos y un máximo de 4 bolos a la hora. Se recogieron variables demográficas, tipo y duración de la cirugía y dosis de fentanilo. Se registró el dolor según la escala visual analógica (EVA), el grado de sedación, la frecuencia respiratoria y la incidencia de náuseas, vómitos y prurito en las primeras 24 horas. RESULTADOS: Ambos grupos resultaron homogéneos. El dolor fue superior en el grupo PCAEV sobre el PCAEP en la segunda hora (EVA 3,93 ñ 1,9 y 2,42 ñ 1,65; p<0,05) y en la tercera hora (EVA 3,57 ñ 1,65 y 1,5 ñ 1,16; p<0,05); posteriormente el valor de EVA fue inferior a 3 en ambos grupos. La dosis total de metadona administrada en el grupo PCAEV fue 25,34 ñ 5,65 mg y 18,82 ñ 3,52 mg en el PCAEP (p<0,002). No hubo diferencias significativas en los efectos secundarios. CONCLUSIONES: Los resultados sugieren que la metadona epidural posee un efecto espinal intrínseco, independientemente de que se añada una acción indirecta supraespinal por absorción sistémica. La metadona epidural produce un nivel analgésico más adecuado en menos tiempo y con menos dosis. Ambas vías proporcionan una buena analgesia postoperatoria con pocos efectos secundarios (AU)

Síndrome compartimental abdominal en pacientes no traumáticos / Abdominal compartment syndrome in non-traumatized patients

El síndrome compartimental abdominal (SCA) es una entidad caracterizada por un aumento de la presión intraabdominal y un conjunto de alteraciones fisiopatológicas secundarias a la misma. Últimamente ha reaparecido asociado al concepto de cirugía de control de daños, aplicado sobre todo a situaciones de traumatismos abdominales graves en pacientes politraumatizados. Presentamos 2 casos de SCA aparecidos tras cirugía abdominal programada: uno después de la reparación de una eventración gigante, y el otro en el contexto de un shock séptico por peritonitis fecaloidea. En ambos casos, a pesar de la descompresión quirúrgica, los enfermos desarrollaron un fallo multiorgánico (FMO) que les ocasionó la muerte.Queremos destacar que el SCA también puede aparecer en otras situaciones que no sean la cirugía de control de daños. Asimismo, hacemos hincapié en la necesidad de medir la presión intravesical como reflejo de la presión intraabdominal, especialmente en determinados pacientes de riesgo ingresados en las unidades de reanimación postquirúrgica.Finalmente, revisamos la fisiopatología de este síndrome y el tratamiento, con el fin de actuar de forma precoz para evitar sus consecuencias deletéreas, que pueden desencadenar un FMO asociado a cifras de mortalidad elevadas (AU)