Description of Intensive Care and Intermediate Care resources managed by Anaesthesiology Departments in Spain and their adaptation capacity during the COVID-19 pandemic.

INTRODUCTION: It is essential to understand the strategic importance of intensive care resources in the sustainable organisation of healthcare systems. Our objective has been to identify the intensive and intermediate care beds managed by Anaesthesiology and Resuscitation Services (A-ICU and A-IMCU) in Spain, their human and technical resources, and the changes made to these resources during the COVID-19 pandemic. MATERIAL AND METHODS: Prospective observational study performed between December 2020 and July 2021 to register the number and characteristics of A-ICU and A-IMCU beds in hospitals listed in the catalogue published by the Spanish Ministry of Health. RESULTS: Data were obtained from 313 hospitals (98% of all hospitals with more than 500 beds, 70% of all hospitals with more than 100 beds). One hundred and forty seven of these hospitals had an A-ICU with a total of 1702 beds. This capacity increased to 2107 (124%) during the COVID-19 pandemic. Three hundred and eight hospitals had an A-IMCU with a total of 3470 beds, 52.9% (2089) of which provided long-term care. The hospitals had 1900 ventilators, at a ratio of 1.07 respirators per A-ICU; 1559 anaesthesiologists dedicated more than 40% of their working time to intensive care. The nurse-to-bed ratio in A-ICUs was 2.8. DISCUSSION: A large proportion of fully-equipped ICU and IMCU beds in Spanish hospitals are managed by the anaesthesiology service. A-ICU and A-IMCUs have shown an extraordinary capacity to adapt their resources to meet the increased demand for intensive care during the COVID-19 pandemic.

Lipoprotein (a) is increased in acute coronary syndromes (unstable angina pectoris and myocardial infarction), but it is not predictive of the severity of coronary lesions.

Lipoprotein (a) [Lp(a)] concentrations were determined in 365 patients undergoing coronary angiography for stable angina (n = 159), unstable angina (n = 99), recent myocardial infarction (n = 45), and nonischemic heart disease (cardiomyopathy or valvular disease, n = 62, non-IHD). Mean +/- SD and median Lp(a) concentrations in stable angina (29.9 +/- 29.2;22 mg/dl) did not differ from those in non-IHD (26.9 +/- 26.3; 17), but were significantly lower than in patients with unstable angina (52.7 +/- 36.6; 58) and myocardial infarction (44.8 +/- 36.4; 34) (p < 0.01). Coronary angiography revealed that 261 patients, including 4 patients in the non-IHD group, had significant (> or = 50%) coronary lesions. Lp(a) was higher in patients with (41 +/- 35; 32) than in those without (28 +/- 27; 19) angiographic evidence of significant coronary stenosis (p < 0.05) and showed a weak univariate correlation with the angiographic index (Total Score) of the severity of the disease (r = 0.106;p < 0.05). However, in the subgroup of 303 patients with stable/unstable angina or myocardial infarction, Lp(a) was predictive neither of angiographic presence nor of severity of coronary disease. Patients were then ranked according to the Total Score values. Among patients with comparable angiographic severity of coronary artery disease, Lp(a) appeared to be remarkably higher in patients with acute ischemic syndromes (unstable angina, myocardial infarction) than in patients with stable angina. In conclusion, Lp(a) was roughly twice as high in acute (unstable angina, myocardial infarction) than in chronic (stable angina) ischemic syndromes, but there was no difference between chronic stable angina and non-IHD.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiac diastolic abnormalities and atrial natriuretic factor in essential hypertension.

Cardiac function and plasma levels of atrial natriuretic factor (ANF) were studied in a group of 38 patients with untreated essential hypertension and in a group of 31 well matched normotensive controls. ANF was slightly but significantly higher in hypertensives and was directly correlated with mean arterial pressure and inversely with plasma renin activity (PRA). Hypertensives showed normal systolic function and higher cardiac mass compared to controls. ANF was inversely correlated to echocardiographic indexes of left ventricular performance in the former group. At Doppler echocardiographic evaluation, hypertensives showed an impairment in diastolic function which was correlated to the increase in ANF levels. Stepwise multiple regression analysis performed with ANF as the dependent variable and several biohumoral and echocardiographic parameters as the independent variables showed that only cardiac diastolic function and PRA significantly affect ANF levels in hypertensives. In conclusion, an impairment in cardiac diastolic function may be responsible together with other factors for the increased ANF levels encountered in essential hypertension.

[The echocardiographic evaluation of valve prostheses]. / Valutazione ecocardiografica delle protesi valvolari.

Transthoracic and transesophageal echocardiography were used to demonstrate prosthetic valve dysfunction in 134 patients with cardiac prosthetic valves in aortic, mitral and tricuspid position. Transthoracic echocardiography showed a high accuracy in the diagnosis of prosthetic valve dysfunction, especially in aortic position or when a stenosis was present. Transesophageal echocardiography allowed to verify the etiology and site of dysfunction and to show even minor leaks. Sixty-six patients underwent reoperation while 68 underwent a clinical and echocardiographic follow-up because only mild symptoms were present. Thus echocardiography represents the technique of choice in the follow-up of patients with prosthetic valves and it is able to help in decision making. However, cardiac catheterization is mandatory if a disagreement between clinical and echocardiographic data is present or when coronary artery disease is suspected or present.

[The effects of pharmacological treatment in asymptomatic left ventricular dysfunction]. / Effetti del trattamento farmacologico nella disfunzione ventricolare sinistra asintomatica.

It is clearly settled that the management of overt heart failure offers poor prognostic impact due to the advanced setting of the disease. Relief of symptoms, objective benefits, as testified by short-term hemodynamic improvements, are as a matter of fact not reliable prognostic markers. Myocardial dysfunction starts early in the natural history of many cardiac diseases, and runs through the steps of progressive wall remodeling, witnessed by quantitative and qualitative changes in cells, interstitium and connective tissue. Experimental studies offered keys to interventions modulated to oppose the pathophysiological changes present in early myocardial dysfunction. At present, medical therapy has made great strides in testing early myocardial dysfunction. Angiotensin-converting enzyme inhibitors, which retard ventricular dilatation and thus may lower myocardial oxygen consumption requirements seem to offer a unique prognostic profile. Preliminary pilot studies on them and some of many large-scale multicentre trials still in progress reached evidence that this class of drugs is by this time a cornerstone of medical therapy, useful to lower cardiac events-rate in patients with heart failure.

[The usefulness of echocardiography in the diagnosis of prosthetic valve endocarditis: a comparison between the transthoracic and transesophageal approaches]. / Utilità dell'ecocardiografia nella diagnosi di endocardite su protesi valvolare: confronto tra approccio transtoracico e transesofageo.

Transesophageal echocardiography is a new semi-invasive procedure whose practical application has yet to be precisely defined. The diagnosis of prosthetic valve endocarditis is particularly difficult with the transthoracic approach, either by thoracic conformation of patients who underwent cardiac surgery, or ultrasound attenuation caused by the prosthetic material. Transesophageal echocardiography is useful to overcome such limits with a new acoustic window, due to the proximity of the esophagus and the heart. During 15 months 18 patients with suspected prosthetic valve endocarditis were studied using both procedures. In patients with mitral prosthetic valves, transesophageal echocardiography provided information unobtainable by using the transthoracic procedure, while in patients with aortic prosthetic valves it only showed additional information in 1 case of abscess of the posterior valve ring. In conclusion, transesophageal echocardiography is useful to diagnose all patients with suspected prosthetic mitral valve endocarditis and might be performed in patients with aortic valve prostheses if the quality of the transthoracic procedure is poor.

[Role of transesophageal echocardiography in the diagnosis of diseases of the thoracic aorta]. / Ruolo dell'ecocardiografia transesofagea nella diagnosi di patologie dell'aorta toracica.

The most frequent diseases of thoracic aorta in the adult population, aneurysms and dissection, can lead to dramatic complications. Therefore in these cases an early and careful diagnosis is required for a correct therapeutic choice. The close distance of the thoracic aorta to the esophagus allows a better visualization by transesophageal echocardiography (TEE) compared with the transthoracic approach (TTE). Aim of this study is to evaluate the diagnostic accuracy of TEE versus surgical data in patients with suspected aneurysms and/or dissection of the thoracic aorta. Eighteen patients with aortic aneurysm, confirmed at surgery, underwent B-mode, pulsed Doppler and color echocardiographic examination either by TTE or by TEE. TEE was concordant with surgical findings in all the cases of fusiform (8 patients) and saccular (2 patients) aneurysms, visualizing aortic wall thrombosis in 4 patients. Furthermore TEE, diagnosed all the type I (4 patients) and type III (2 patients) dissection, and 1 type II, identifying in all cases the intimal tear and, in 3 patients, the false lumen thrombosis; it demonstrated the presence of severe aortic regurgitation in 3 patients and of mild pericardial effusion in 2 patients. Only in 1 case of type II dissection TEE was not diagnostic because it is not able to visualize completely the aortic arch. In our experience TEE allowed accurate information in patients with aortic aneurysm or dissection. TEE can be considered the first choice diagnostic tool in patients with suspected dissection of the thoracic aorta.

[Echocardiographic findings in interatrial septal aneurysm, Chiari's network and tricuspid valve prolapse. An unusual association]. / Riscontro ecocardiografico di aneurisma del setto interatriale, rete di Chiari e prolasso della valvola tricuspide. Una associazione originale.

In this report we discuss the case of a 55-year-old female who underwent echocardiographic and Doppler studies for the presence of systolic murmur at physical examination, in which echocardiography showed the concomitant presence of an atrial septal aneurysm, a Chiari network and a tricuspid valve prolapse, a hypothetic association not previously described. The association of atrial septal aneurysm, tricuspid valve prolapse and Chiari network suggests the possibility of a connective disorder involving fibrous tissue of the heart and a concomitant anomalous development of the valves of the sinus venosus.

[Morphologic and functional evaluation of the left ventricle in patients with acromegaly. An echocardiographic study]. / Valutazione morfologica e funzionale del ventricolo sinistro in pazienti con acromegalia. Studio ecocardiografico.

The aim of our study is to detect morphological and functional aspects of left ventricle with noninvasive M-B-Mode echocardiography in acromegalic patients (pz) with and without high blood pressure. We studied 19 acromegalic pz (group A) and 19 normal pz (group N). All subjects were evaluated for the following parameters: left ventricular mass index (MI); end diastolic volume index (EDVI); end systolic volume index (ESVI); ejection fraction (EF); end systolic stress (ESS). Group A vs group N shows an increase of cardiac mass (p less than 0.01), of EDVI (p less than 0.05) and of ESS (p less than 0.05). We found the asymmetrical septal hypertrophy, considered from other Authors one of the more evident markers of acromegaly, in only one patient. In conclusion, the acromegalic pz show an increase of cardiac mass and preload and a reduced capacity of adaptation to afterload variation independently of blood pressure values and of the duration of disease, even if they have normal indexes of global systolic function.

[Effects of isometric exercise on the right ventricular function and on the pulmonary circulation, in normal subjects (author's transl)]. / Effetti dell'esercizio isometrico sulla funzione del ventricolo destro e sull'emodinamica polmonare in soggetti normali.

The pulmonary circulatory response and right ventricular haemodynamics were assessed in normal subjects who sustained hand-grip exercise (HG) at 50% of the maximum voluntary contraction (M.V.C.) for 3 minutes. Ten normal subjects, aged 25 to 66 years, who underwent full right catheterization were studied. The following parameters were taken into consideration: heart rate (HR), end diastolic right ventricular pressure (EDRVP) end diastolic right ventricular volume (EDRVV), mean pulmonary arterial pressure (PAP), pulmonary wedge pressure (PWP), total pulmonary resistance (TPR), cardiac output (CO) and right ventricular sistolic work minute index (RVSWMI). These data were obtained by means of a tip-micromanometer connected with an polygraphic recorder and by means of thermodilution cardiac output computer. The statistical significance of the difference between the resting control values and those after isometric exercise was calculated with the Student's paired t test. A comparison of the control data with those obtained after isometric exercise, demonstrate a statistical significant (p less than 0,001) increase of the HR, PAP, PWP, TRP, CO, RVSWMI, a less significant (p less than 0.01) increase RVEDP. Our findings show that the HG causes changes in the pulmonary circulation and the right ventricular function. Our data seem to sustain that the pulmonary circulation respondes differently under isometric stress than it does under isotonic stress. The use of HG can thus be postulated as a useful means of evaluation of the response of the pulmonary circulation and right ventricular function.