Research priorities in perioperative fluid therapy and hemodynamic monitoring: A Delphi Consensus Survey from the Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section (SHTF) of the Spanish Society of Anesthesiology and Critical Care (SEDAR).

BACKGROUND: Research in fluid therapy and perioperative hemodynamic monitoring is difficult and expensive. The objectives of this study were to summarize these topics and to prioritize these topics in order of research importance. METHODS: Electronic structured Delphi questionnaire over three rounds among 30 experts in fluid therapy and hemodynamic monitoring identified through the Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section of the Spanish Society of Anesthesiology and Critical Care. RESULTS: 77 topics were identified and ranked in order of prioritization. Topics were categorized into themes of crystalloids, colloids, hemodynamic monitoring and others. 31 topics were ranked as essential research priority. To determine whether intraoperative hemodynamic optimization algorithms based on the invasive or noninvasive Hypotension Prediction Index versus other management strategies could decrease the incidence of postoperative complications. As well as whether the use of renal stress biomarkers together with a goal-directed fluid therapy protocol could reduce hospital stay and the incidence of acute kidney injury in adult patients undergoing non-cardiac surgery, reached the highest consensus. CONCLUSIONS: The Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section of the Spanish Society of Anesthesiology and Critical Care will use these results to carry out the research.

Perioperative colloids: From theory to practice.

INTRODUCTION: Fluid administration is the cornerstone in hypovolemic patient's reanimation. Clinical guidelines restrict colloid administration favouring crystalloids. Currently, we don't know exactly which is the daily clinical practice during the perioperative period. The objective of this study is to describe perioperative use of colloids analysing possible reasons aiming to use them. MATERIAL AND METHODS: Prospective, cross-section, national, multicentre observational study. Fluid Day sub-study. We enrolled all patient's older than 18 years old who underwent surgery during the 24 h of the 2-days study (February, 2019, 18th and 20th). We registered demographic data, comorbidities, anaesthetic and surgical procedure data, fluids administered, perioperative bleeding and monitoring type used during the perioperative period. RESULTS: A total of 5928 cases were analysed and 542 patients (9.1%) received any type of colloids, being hydroxiethyl-starch the most frequently used (5.1%). Patients receiving colloids suffered more longing surgery (150 [90-255] vs. 75 [45-120] min), were urgently operated (13.7 vs. 7.5%) and were more frequent classified as high risk (22 vs. 4.8%). Their recovery was mostly in critical care units (45.1 vs.15.8%). Patients with bleeding less than 500 ml received colloids in a percentage of 5.9 versus 45.9% when this figure was overcome. Patients who received colloids were anaemic more frequently: 29.4 vs. 16.3%. Colloids administration had a higher risk for transfusion (OR 15.7). Advanced monitoring also increased the risk for receiving colloids (OR 9.43). CONCLUSIONS: In our environment with routine clinical practice, colloids administration is limited and close linked to perioperative bleeding.

Invasive pulmonary aspergillosis in patients with acute respiratory syndrome by COVID-19.

Patients with COVID-19 who are admitted to intensive care unit (ICU) are at high risk of developing secondary infections, including invasive fungal infections such as invasive pulmonary aspergillosis (IPA). The main purpose was to analyse the putative COVID-19 Associated Pulmonary Aspergillosis (CAPA) patients in our setting. In these patients, we performed mycological culture in bronchoalveolar lavage (BAL) for isolation of Aspergillus sp. We followed the AspICU algorithm to diagnose putative IPA. Moreover, we considered relevant the positivity of Galactomannan in BAL. We diagnosed putative IPA in 3 patients. The common features of these 3 patients were: more than 21 days of stay in ICU, severe acute respiratory distress syndrome (ARDS) and treatment with steroids (1 mg/kg per day). Therefore, CAPA has to be systematically considered although a new algorithm to diagnose it is needed to treat patients in early stages in order to avoid catastrophic outcomes.

Aspergilosis pulmonar invasiva en pacientes con síndrome de distrés respiratorio por COVID-19 / Invasive pulmonary aspergillosis in patients with acute respiratory syndrome by COVID-19

Los pacientes con COVID-19 que ingresan en una unidad de cuidados intensivos (UCI), tienen un alto riesgo de desarrollar infecciones secundarias, incluyendo infecciones fúngicas invasivas como aspergilosis pulmonar invasiva (API). El objetivo principal fue el análisis de los casos con sospecha de COVID-19 Associated Pulmonary Aspergillosis (CAPA) en nuestra unidad. En estos pacientes realizamos cultivo micológico en el lavado broncoalveolar como métodos de aislamiento de Aspergillus sp. Se siguió el algoritmo AspICU para establecer el diagnóstico de API probable. Además, considerando también relevante la positividad del antígeno de galactomanano. Se confirmó API probable en 3 de ellos. Los 3 pacientes permanecieron ingresados más de 21 días por SDRA grave, y recibieron corticoterapia (1mg/kg/día). Por tanto, la CAPA se debe considerar de forma sistemática, aunque se necesita un nuevo algoritmo diagnóstico que permita tratamiento precoz por las consecuencias deletéreas que puede implicar en los pacientes críticos.(AU)

Patients with COVID-19 who are admitted to intensive care unit (ICU) are at high risk of developing secondary infections, including invasive fungal infections such as invasive pulmonary aspergillosis (IPA). The main purpose was to analyse the putative COVID-19 Associated Pulmonary Aspergillosis (CAPA) patients in our setting. In these patients, we performed mycological culture in bronchoalveolar lavage (BAL) for isolation of Aspergillus sp. We followed the AspICU algorithm to diagnose putative IPA. Moreover, we considered relevant the positivity of galactomannan in BAL. We diagnosed putative IPA in 3 patients. The common features of these 3 patients were: more than 21 days of stay in ICU, severe acute respiratory distress syndrome (ARDS) and treatment with steroids (1mg/kg per day). Therefore, CAPA has to be systematically considered although a new algorithm to diagnose it is needed to treat patients in early stages in order to avoid catastrophic outcomes.(AU)

[Invasive pulmonary aspergillosis in patients with acute respiratory syndrome by COVID-19]. / Aspergilosis pulmonar invasiva en pacientes con síndrome de distrés respiratorio por COVID-19.

Patients with COVID-19 who are admitted to intensive care unit (ICU) are at high risk of developing secondary infections, including invasive fungal infections such as invasive pulmonary aspergillosis (IPA). The main purpose was to analyse the putative COVID-19 Associated Pulmonary Aspergillosis (CAPA) patients in our setting. In these patients, we performed mycological culture in bronchoalveolar lavage (BAL) for isolation of Aspergillus sp. We followed the AspICU algorithm to diagnose putative IPA. Moreover, we considered relevant the positivity of galactomannan in BAL. We diagnosed putative IPA in 3 patients. The common features of these 3 patients were: more than 21 days of stay in ICU, severe acute respiratory distress syndrome (ARDS) and treatment with steroids (1 mg/kg per day). Therefore, CAPA has to be systematically considered although a new algorithm to diagnose it is needed to treat patients in early stages in order to avoid catastrophic outcomes.

Invasive pulmonary aspergillosis in patients with acute respiratory syndrome by COVID-19. / Aspergilosis pulmonar invasiva en pacientes con síndrome de distrés respiratorio por COVID-19.

Patients with COVID-19 who are admitted to intensive care unit (ICU) are at high risk of developing secondary infections, including invasive fungal infections such as invasive pulmonary aspergillosis (IPA). The main purpose was to analyse the putative COVID-19 Associated Pulmonary Aspergillosis (CAPA) patients in our setting. In these patients, we performed mycological culture in bronchoalveolar lavage (BAL) for isolation of Aspergillus sp. We followed the AspICU algorithm to diagnose putative IPA. Moreover, we considered relevant the positivity of galactomannan in BAL. We diagnosed putative IPA in 3 patients. The common features of these 3 patients were: more than 21 days of stay in ICU, severe acute respiratory distress syndrome (ARDS) and treatment with steroids (1mg/kg per day). Therefore, CAPA has to be systematically considered although a new algorithm to diagnose it is needed to treat patients in early stages in order to avoid catastrophic outcomes.

Linking flow-stream variability to grain size distribution of suspended sediment from a satellite-based analysis of the Tiber River plume (Tyrrhenian Sea).

Several coastal regions on Earth have been increasingly affected by intense, often catastrophic, flash floods that deliver significant amounts of sediment along shorelines. One of the critical questions related to the impact of these impulsive runoffs is "are flash floods more efficient in delivering non-cohesive sandy sediment along the coasts?" Here we relate flow stages (i.e., from erratic to persistent) to the grain size distribution of the suspended load, by performing a synergic analysis of in-situ river discharge and satellite-retrieved grain size distribution, from 2002 to 2014, covering the 2012 Tiber River (Italy) exceptional flood event. Our analysis shows novel and promising results regarding the capability of remote sensing in characterizing suspended sediment in terms of grain size distribution and reveals that erratic stages favour delivering of non-cohesive sandy sediment more than the persistent stages. This conclusion is supported by numerical simulations and is consistent with previous studies on suspended sediment rating curves.

Absorption correction and phase function shape effects on the closure of apparent optical properties.

We present a closure experiment between new inherent optical properties (IOPs: absorption a, scattering b, backscattering bb) and apparent optical properties (AOPs: remote-sensing reflectance Rrs, irradiance reflectance R, and anisotropic factor at nadir Qn) data of Ionian and Adriatic seawaters, from very clear to turbid waters, ranging across one order of magnitude in Rrs. The internal consistency of the IOP-AOP matchups was investigated though radiative transfer closure. Using the in situ IOPs, we predicted the AOPs with the commercial radiative transfer solver Hydrolight. Closure was limited by two unresolved issues, one regarding processing of in situ data and the other related to radiative transfer modeling. First, different correction methods of the absorption data measured by the Wetlabs ac-s produced high variations in simulated reflectances, reaching 40% for the highest reflectances in our dataset. Second, the lack of detailed volume scattering function measurements forces us to adopt analytical functions that are consistent with a given particle backscattering ratio. The analytical phase functions named Fournier-Forand and two-term Kopelevich presented reasonable angular shapes with respect to measurements at a few backward angles. Between these phase functions, induced changes were within 4% for Rrs, within 11% for R, and within 10% for Qn. Additionally, closure of Qn was generally not successful considering radiometric uncertainties. Simulated Qn overestimated low values and underestimated high values, especially at 665 nm, where Hydrolight was unable to predict measured Qn values greater than 6 sr. The physical nature of Qn makes this mismatch almost independent of the measured IOPs, thus precluding Qn tuning by varying the former. The non-closure of Qn might be caused by an inaccurate phase function and, to a lesser extent, by the modeling of the incoming radiance. For the future, this remains the task of accurate absorption and phase function measurements, especially at red wavelengths.

Intraoperative transfusion practices in Europe.

BACKGROUND: Transfusion of allogeneic blood influences outcome after surgery. Despite widespread availability of transfusion guidelines, transfusion practices might vary among physicians, departments, hospitals and countries. Our aim was to determine the amount of packed red blood cells (pRBC) and blood products transfused intraoperatively, and to describe factors determining transfusion throughout Europe. METHODS: We did a prospective observational cohort study enrolling 5803 patients in 126 European centres that received at least one pRBC unit intraoperatively, during a continuous three month period in 2013. RESULTS: The overall intraoperative transfusion rate was 1.8%; 59% of transfusions were at least partially initiated as a result of a physiological transfusion trigger- mostly because of hypotension (55.4%) and/or tachycardia (30.7%). Haemoglobin (Hb)- based transfusion trigger alone initiated only 8.5% of transfusions. The Hb concentration [mean (sd)] just before transfusion was 8.1 (1.7) g dl(-1) and increased to 9.8 (1.8) g dl(-1) after transfusion. The mean number of intraoperatively transfused pRBC units was 2.5 (2.7) units (median 2). CONCLUSION: Although European Society of Anaesthesiology transfusion guidelines are moderately implemented in Europe with respect to Hb threshold for transfusion (7-9 g dl(-1)), there is still an urgent need for further educational efforts that focus on the number of pRBC units to be transfused at this threshold. CLINICAL TRIAL REGISTRATION: NCT 01604083.

Influence of polymorphisms in the prion protein gene on the pathogenesis and neuropathological phenotype of sheep scrapie after oral infection.

The prion protein gene (Prnp) plays a crucial role in the susceptibility of sheep to scrapie in terms of attack rate and/or incubation period. However, the influence of Prnp on the pathogenesis of the disease, specifically the involvement of tissues of the lymphoreticular system (LRS), pathways of neuroinvasion and neuropathological phenotypes, remains controversial. This study reports the onset and progression of disease-associated prion protein (PrP(d)) accumulation in the LRS and nervous tissues of sheep of six different Prnp genotypes infected by oral administration of the same mixed scrapie brain homogenate. Sheep homozygous for glutamine (Q) at codon 171 of PrP, with either valine (V) or alanine (A) at codon 136 (i.e. VRQ/VRQ, VRQ/ARQ and ARQ/ARQ), showed early and consistent PrP(d) accumulation in LRS tissues of the pharynx and gut. In contrast, LRS involvement was minimal, inconsistent and occurred late in the incubation period in sheep heterozygous for arginine (R) at codon 171 (i.e. VRQ/ARR and ARQ/ARR). Despite this difference, all five groups were susceptible to infection and developed clinical disease, albeit with significantly different incubation periods (shortest in VRQ/VRQ and longest in ARQ/ARR sheep). The remaining group of ARR/ARR homozygous sheep did not show evidence of infection at the end of the experiment or at previous predetermined time points. As for LRS tissues, the sites of initial PrP(d) accumulation in the brain were determined immunohistochemically. These were the same in all susceptible sheep (except for ARR/ARR sheep), regardless of their Prnp genotype which, together with an early and consistent accumulation of PrP(d) in circumventricular organs and a late or inconsistent involvement of the enteric and autonomic nervous system and of the spinal cord, suggests neuroinvasion occurring via the blood. The neuropathological phenotype (PrP(d) profile in the central nervous system) of clinically affected sheep was similar in the three V136 carrier groups, but showed some differences in the two A136 homozygous groups, suggesting a codon 136-driven selection of different strains from the mixture contained in the inoculum. ARQ/ARR sheep showed an irregular distribution of brain PrP(d), contrasting with the more widespread distribution of the other four groups. The results indicate that (1) ARQ/ARR sheep are more susceptible to oral scrapie infection than would be predicted from incidence figures in natural disease, (2) amplification and accumulation of PrP(d) in LRS tissues is host genotype dependent, but does not necessarily have a marked effect on the outcome of the infection and (3) the neuropathological phenotype of scrapie is related to the host genotype, but possibly in combination with the infecting source.

Identical pathogenesis and neuropathological phenotype of scrapie in valine, arginine, glutamine/valine, arginine, glutamine sheep infected experimentally by the oral and conjunctival routes.

The pathogenesis of scrapie in sheep after natural or oral exposure to the infectious agent generally involves the early accumulation of disease-associated prion protein (PrP(d)) in the lymphoreticular system (LRS). This phase is followed by neuroinvasion, for which two routes, ascending neural and haematogenous, have been postulated. The present study reports the use of immunohistochemistry to track the tissue progression of PrP(d) deposition in sheep of a single, highly scrapie-susceptible PrP genotype administered by the oral or conjunctival routes. Regardless of the route of infection, the earliest detection of PrP(d) was in gut- and pharynx-associated LRS tissues. Subsequently, the brain became PrP(d) positive simultaneously with other LRS tissues, but before the spinal cord and peripheral nervous tissues of the enteric, parasympathetic and sympathetic systems. The sites of initial PrP(d) accumulation in the brain were the dorsal motor nucleus of the vagus and the hypothalamus and their related circumventricular organs (the area postrema and the median eminence, respectively). These were the same for both routes of infection. Rapid progression to clinical disease was observed in sheep infected orally or conjunctivally, with definite signs of scrapie recorded at around 6 and 8 months after infection, respectively. Longer incubation periods in sheep infected by the conjunctival route were probably due to them receiving a lower dose than those infected orally. Irrespective of the route of infection, clinically affected sheep showed the same pathological phenotype (PrP(d) profile) and PrP(d) distribution throughout the brain. The identical peripheral and central pathogenesis observed in sheep of both groups suggests early dissemination of the infectious agent in the bloodstream and a common neuroinvasion pathway. The late involvement of the enteric and autonomic nervous system supports a haematogenous route of infection to the brain.

[Obstetric bleeding: an update]. / La hemorragia obstétrica. Actualización.

Massive bleeding in obstetrics still ranks among the most frequent causes of maternal morbidity and mortality worldwide. The most frequent type is primary postpartum hemorrhage, which is usually the result of an atonic uterus. The clinical priorities are to assure hemodynamic stability and to correct coagulation abnormalities. If pharmacologic treatment cannot achieve these goals, invasive methods such as interventional vascular radiology or artery ligation must be used. Hysterectomy is the last resort when the previous methods fail. For the best prognosis, in terms of preventing death, maintaining maternal fertility and minimizing morbidity, every maternity ward should have a well-defined multidisciplinary protocol that facilitates diagnosis and immediate treatment.

La hemorragia obstétrica. Actualización / Obstetric bleeding: an update

La hemorragia obstétrica masiva sigue siendo una delas causas más frecuentes de morbi-mortalidad maternaen todo el mundo. La hemorragia postparto primaria esla más frecuente siendo la atonía uterina su etiologíamás común. Es prioritario garantizar la estabilidadhemodinámica de la paciente y corregir las alteracionesde la coagulación. Si el tratamiento farmacológico resultainsuficiente se deben emplear métodos invasivos comola radiología vascular intervensionista o la ligadura delos vasos arteriales. La histerectomía es la última opcióncuando fracasan las medidas anteriores. Para que el pronósticosea favorable, ya no sólo en términos de mortalidadsino en mantener la fertilidad de la madre y minimizarla morbilidad, es fundamental que cada unidadmaternal cuente con un protocolo de actuación bien definidoy multidisciplinar que facilite el diagnóstico y eltratamiento inmediato(AU)

Massive bleeding in obstetrics still ranks among themost frequent causes of maternal morbidity andmortality worldwide. The most frequent type isprimary postpartum hemorrhage, which is usually theresult of an atonic uterus. The clinical priorities are toassure hemodynamic stability and to correctcoagulation abnormalities. If pharmacologictreatment cannot achieve these goals, invasivemethods such as interventional vascular radiology orartery ligation must be used. Hysterectomy is the lastresort when the previous methods fail. For the bestprognosis, in terms of preventing death, maintainingmaternal fertility and minimizing morbidity, everymaternity ward should have a well-definedmultidisciplinary protocol that facilitates diagnosisand immediate treatment(AU)

Estudios clínicos con dabigatrán / No disponible

No disponible

Respuesta a la carta al director “consideraciones sobre la nueva guía de fármacos inhibidores de la hemostasia y anestesia regional neuroaxial” / Author´s reply to "çOn the new guidelines for inhibitors of hemostasis and regional neuraxial anesthesia"

No disponible

Fármacos que alteran la hemostasia y técnicas regionales anestésicas y analgésicas: recomendaciones de seguridad / Hemostasis-altering drugs and techniques for regional anesthesia and analgesia: safety recommendations

No disponible