[2013: The Seville document on consensus on the alternatives to allogenic blood transfusion. Update to the Seville document. Spanish Societies of Anaesthesiology (SEDAR), Haematology and Haemotherapy (SEHH), Hospital Pharmacy (SEFH), Critical Care Medicine (SEMICYUC), Thrombosis and Haemostasis (SETH) and Blood Transfusion (SETS)]. / 2013: Documento «Sevilla¼ de Consenso sobre Alternativas a la Transfusión de Sangre Alogénica. Actualización del Documento Sevilla

As allogeneic blood transfusion (ABT) is not harmless, multiple alternatives to TSA (AABT) have emerged, but there is a huge variability with respect to their indications and appropriate use. This variability results from the interplay of a number of factors, which include physicians specialty, knowledge and preferences, degree of anaemia, transfusion policy, and AABT availability. Since the ABBT are not harmless and may not meet costeffectiveness criteria, such avariability is unacceptable. The Spanish Societies of Anaesthesiology (SEDAR), Haematology and Haemotherapy (SEHH), Hospital Pharmacy (SEFH), Critical Care Medicine (SEMICYUC), Thrombosis and Haemostasis (SETH) and Blood Transfusion (SETS) have developed a Consensus Document for the proper use of AABTs. A panel of experts convened by these six Societies have conducted a systematic review of the medical literature and developed the «2013. Seville Document of Consensus on Alternatives to Allogeneic Blood Transfusion¼, which only considers those AABT aimed to decrease the transfusion of packed red cells. The AABTs are defined as any pharmacological and non-pharmacological measure aimed to decrease the transfusion of of red blood cell concentrates, while preserving the patient safety. For each AABT, the main question is formulated, positively or negatively, as: «Does or does not this particular AABT reduce the transfusion rate?¼ All the recommendations on the use of AABTs were formulated according to the GRADE (Grades of Recommendation Assessment, Development and Evaluation) methodology.

La transfusión de sangre alogénica (TSA) no es inocua, y como consecuencia han surgido múltiples alternativas a la TSA (ATSA). Existe variabilidad respecto a las indicaciones y buen uso de las ATSA. Dependiendo de la especialidad de los médicos que tratan a los pacientes, grado de anemia, política transfusional, disponibilidad de las ATSA y criterio personal, las ATSA se usan de forma variable. Puesto que las ATSA tampoco son inocuas y pueden no cumplir criterios de coste-efectividad, la variabilidad en su uso es inaceptable. Las sociedades españolas de Anestesiología y Reanimación (SEDAR), Hematología y Hemoterapia (SEHH), Farmacia Hospitalaria (SEFH), Medicina Intensiva y Unidades Coronarias (SEMICYUC), Trombosis y Hemostasia (SETH) y Transfusiones Sanguíneas (SETS) han elaborado un documento de consenso para el buen uso de la ATSA. Un panel de expertos de las seis sociedades han llevado a cabo una revisión sistemática de la literatura médica y elaborado el «2013. Documento Sevilla de Consenso sobre Alternativas a la Transfusión de Sangre Alogénica¼. Solo se contempla las ATSA dirigidas a disminuir la transfusión de concentrado de hematíes. Se definen las ATSA como toda medida farmacológica y no farmacológica, encaminada a disminuir la transfusión de concentrado de hematíes, preservando siempre la seguridad del paciente. La cuestión principal que se plantea en cada ítem se formula, en forma positiva o negativa, como: «La ATSA en cuestión reduce / no reduce la Tasa Transfusional¼. Para formular el grado de recomendación se ha usado la metodología GRADE (Grades of Recommendation Assessment, Development and Evaluation).

2013. Documento Sevilla de Consenso sobre Alternativas a la Transfusión de Sangre Alogénica. Actualización del Documento Sevilla / The 2013 Seville Consensus Document on alternatives to allogenic blood transfusion. An update on the Seville Document

La transfusión de sangre alogénica (TSA) no es inocua, y como consecuencia han surgido múltiples alternativas a la misma (ATSA). Existe variabilidad respecto a las indicaciones y buen uso de las ATSA. Dependiendo de la especialidad de los médicos que tratan a los pacientes, el grado de anemia, la política transfusional, la disponibilidad de las ATSA y el criterio personal, estas se usan de forma variable. Puesto que las ATSA tampoco son inocuas y pueden no cumplir criterios de coste-efectividad, la variabilidad en su uso es inaceptable. Las sociedades españolas de Anestesiología y Reanimación (SEDAR), Hematología y Hemoterapia(SEHH), Farmacia Hospitalaria (SEFH), Medicina Intensiva y Unidades Coronarias(SEMICYUC), Trombosis y Hemostasia (SETH) y Transfusiones Sanguíneas (SETS) han elaborado un documento de consenso para el buen uso de la ATSA. Un panel de expertos de las 6sociedades ha llevado a cabo una revisión sistemática de la literatura médica y elaborado el 2013. Documento Sevilla de Consenso sobre Alternativas a la Transfusión de Sangre Alogénica. Solo se contempla las ATSA dirigidas a disminuir la transfusión de concentrado de hematíes. Se definen las ATSA como toda medida farmacológica y no farmacológica encaminada a disminuir la transfusión de concentrado de hematíes, preservando siempre la seguridad del paciente. La cuestión principal que se plantea en cada ítem se formula, en forma positiva o negativa, como: “La ATSA en cuestión reduce/no reduce la tasa transfusional». Para formular el grado de recomendación se ha usado la metodología Grades of Recommendation Assessment, Development and Evaluation (GRADE) (AU)

Since allogeneic blood transfusion (ABT) is not harmless, multiple alternatives to ABT (AABT) have emerged, though there is great variability in their indications and appropriate use. This variability results from the interaction of a number of factors, including the specialty of the physician, knowledge and preferences, the degree of anemia, transfusion policy, and AABT availability. Since AABTs are not harmless and may not meet cost-effectiveness criteria, such variability is unacceptable. The Spanish Societies of Anesthesiology (SEDAR), Hematology and Hemotherapy (SEHH), Hospital Pharmacy (SEFH), Critical Care Medicine (SEMICYUC), Thrombosis and Hemostasis (SETH)and Blood Transfusion (SETS) have developed a Consensus Document for the proper use of AABTs. A panel of experts convened by these 6 Societies have conducted a systematic review of the medical literature and have developed the 2013 Seville Consensus Document on Alternatives to Allogeneic Blood Transfusion, which only considers those AABT aimed at decreasing the transfusion of packed red cells. AABTs are defined as any pharmacological or non-pharmacological measure aimed at decreasing the transfusion of red blood cell concentrates, while preserving patient safety. For each AABT, the main question formulated, positively or negatively, is: “Does this particular AABT reduce the transfusion rate or not? “All the recommendations on the use of AABTs were formulated according to the Grades of Recommendation Assessment, Development and Evaluation(GRADE) methodology (AU)

2013. Documento Sevilla de Consenso sobre Alternativas a la Transfusión de Sangre Alogénica. Actualización del Documento Sevilla / The 2013 Seville Consensus Document on alternatives to allogenic blood transfusion. An update on the Seville Document

La transfusión de sangre alogénica (TSA) no es inocua, y como consecuencia han surgido múltiples alternativas a la misma (ATSA). Existe variabilidad respecto a las indicaciones y buen uso de las ATSA. Dependiendo de la especialidad de los médicos que tratan a los pacientes, el grado de anemia, la política transfusional, la disponibilidad de las ATSA y el criterio personal, estas se usan de forma variable. Puesto que las ATSA tampoco son inocuas y pueden no cumplir criterios de coste-efectividad, la variabilidad en su uso es inaceptable. Las sociedades españolas de Anestesiología y Reanimación (SEDAR), Hematología y Hemoterapia (SEHH), Farmacia Hospitalaria (SEFH), Medicina Intensiva y Unidades Coronarias (SEMICYUC), Trombosis y Hemostasia (SETH) y Transfusiones Sanguíneas (SETS) han elaborado un documento de consenso para el buen uso de la ATSA. Un panel de expertos de las 6 sociedades ha llevado a cabo una revisión sistemática de la literatura médica y elaborado el 2013. Documento Sevilla de Consenso sobre Alternativas a la Transfusión de Sangre Alogénica. Solo se contempla las ATSA dirigidas a disminuir la transfusión de concentrado de hematíes. Se definen las ATSA como toda medida farmacológica y no farmacológica encaminada a disminuir la transfusión de concentrado de hematíes, preservando siempre la seguridad del paciente. La cuestión principal que se plantea en cada ítem se formula, en forma positiva o negativa, como: «La ATSA en cuestión reduce/no reduce la tasa transfusional». Para formular el grado de recomendación se ha usado la metodología Grades of Recommendation Assessment, Development and Evaluation (GRADE) (AU)

Since allogeneic blood transfusion (ABT) is not harmless, multiple alternatives to ABT (AABT) have emerged, though there is great variability in their indications and appropriate use. This variability results from the interaction of a number of factors, including the specialty of the physician, knowledge and preferences, the degree of anemia, transfusion policy, and AABT availability. Since AABTs are not harmless and may not meet cost-effectiveness criteria, such variability is unacceptable. The Spanish Societies of Anesthesiology (SEDAR), Hematology and Hemotherapy (SEHH), Hospital Pharmacy (SEFH), Critical Care Medicine (SEMICYUC), Thrombosis and Hemostasis (SETH) and Blood Transfusion (SETS) have developed a Consensus Document for the proper use of AABTs. A panel of experts convened by these 6 Societies have conducted a systematic review of the medical literature and have developed the 2013 Seville Consensus Document on Alternatives to Allogeneic Blood Transfusion, which only considers those AABT aimed at decreasing the transfusion of packed red cells. AABTs are defined as any pharmacological or non-pharmacological measure aimed at decreasing the transfusion of red blood cell concentrates, while preserving patient safety. For each AABT, the main question formulated, positively or negatively, is: "Does this particular AABT reduce the transfusion rate or not?" All the recommendations on the use of AABTs were formulated according to the Grades of Recommendation Assessment, Development and Evaluation (GRADE) methodology (AU)

[The 2013 Seville Consensus Document on alternatives to allogenic blood transfusion. An update on the Seville Document]. / 2013. Documento Sevilla de Consenso sobre Alternativas a la Transfusión de Sangre Alogénica. Actualización del Documento Sevilla.

Since allogeneic blood transfusion (ABT) is not harmless, multiple alternatives to ABT (AABT) have emerged, though there is great variability in their indications and appropriate use. This variability results from the interaction of a number of factors, including the specialty of the physician, knowledge and preferences, the degree of anemia, transfusion policy, and AABT availability. Since AABTs are not harmless and may not meet cost-effectiveness criteria, such variability is unacceptable. The Spanish Societies of Anesthesiology (SEDAR), Hematology and Hemotherapy (SEHH), Hospital Pharmacy (SEFH), Critical Care Medicine (SEMICYUC), Thrombosis and Hemostasis (SETH) and Blood Transfusion (SETS) have developed a Consensus Document for the proper use of AABTs. A panel of experts convened by these 6 Societies have conducted a systematic review of the medical literature and have developed the 2013 Seville Consensus Document on Alternatives to Allogeneic Blood Transfusion, which only considers those AABT aimed at decreasing the transfusion of packed red cells. AABTs are defined as any pharmacological or non-pharmacological measure aimed at decreasing the transfusion of red blood cell concentrates, while preserving patient safety. For each AABT, the main question formulated, positively or negatively, is: « Does this particular AABT reduce the transfusion rate or not?¼ All the recommendations on the use of AABTs were formulated according to the Grades of Recommendation Assessment, Development and Evaluation (GRADE) methodology.

[The 2013 Seville Consensus Document on alternatives to allogenic blood transfusion. An update on the Seville Document]. / 2013. Documento Sevilla de Consenso sobre Alternativas a la Transfusión de Sangre Alogénica. Actualización del Documento Sevilla.

Since allogeneic blood transfusion (ABT) is not harmless, multiple alternatives to ABT (AABT) have emerged, though there is great variability in their indications and appropriate use. This variability results from the interaction of a number of factors, including the specialty of the physician, knowledge and preferences, the degree of anemia, transfusion policy, and AABT availability. Since AABTs are not harmless and may not meet cost-effectiveness criteria, such variability is unacceptable. The Spanish Societies of Anesthesiology (SEDAR), Hematology and Hemotherapy (SEHH), Hospital Pharmacy (SEFH), Critical Care Medicine (SEMICYUC), Thrombosis and Hemostasis (SETH) and Blood Transfusion (SETS) have developed a Consensus Document for the proper use of AABTs. A panel of experts convened by these 6 Societies have conducted a systematic review of the medical literature and have developed the 2013 Seville Consensus Document on Alternatives to Allogeneic Blood Transfusion, which only considers those AABT aimed at decreasing the transfusion of packed red cells. AABTs are defined as any pharmacological or non-pharmacological measure aimed at decreasing the transfusion of red blood cell concentrates, while preserving patient safety. For each AABT, the main question formulated, positively or negatively, is: "Does this particular AABT reduce the transfusion rate or not?" All the recommendations on the use of AABTs were formulated according to the Grades of Recommendation Assessment, Development and Evaluation (GRADE) methodology.

Changes in visceral flow induced by laparoscopic and open living-donor nephrectomy: experimental model.

Increased intra-abdominal pressure during laparoscopy changes visceral flow. The objective of the present study was to analyze the changes in peripheral and intra-abdominal flow induced by laparoscopic living-donor nephrectomy in an experimental model. Twenty pigs underwent left-sided nephrectomy, 10 at laparoscopy and 10 in an open approach. Renal blood flow (RBF), hepatic arterial flow (HAF), portal flow (PF), and carotid flow (CF) were measured using an electromagnetic probe placed around these vessels. Comparative analysis between the groups demonstrated increased CF (mean [SD], 125.73 [41.69] vs 291.70 [51.52] mL/min; P < .001) and decreased PF (973.67 [131.70] vs 546.83 [217.53] mL/min; P = .001) and HAF (278.00 [94.71] vs 133.33 [112.32] mL/min; P = .03) in pigs that underwent laparoscopy compared with those who underwent open surgery; no significant differences were observed in RBF. In conclusion, laparoscopic nephrectomy induces increased CF and decreased total hepatic flow, at the expense of PF and HAF. With adequate intravascular volume expansion, no differences were observed in RBF between the laparoscopic and open approaches.

Immunohumoral response during laparoscopic and open living donor nephrectomy: an experimental model.

Measurement of interleukins (IL) and C-reactive protein (CRP) have demonstrated that a laparoscopic approach may induce less surgical stress than an open approach. The potential influence of this observation in living donor nephrectomy has scarcely been analyzed. The aim of the study was to analyze the immunohumoral response induced by laparoscopic versus open donor nephrectomy in an experimental model. Twenty pigs underwent left nephrectomy, 10 by laparoscopy and 10 by an open approach. In both groups the following parameters were measured: CRP, IL-2, IL-10, tumour necrosis factor alpha (TNF alpha), and endothelin-1 (ET-1). The determinations were done at different times: basal, immediately as well as on the first, third, fifth, and seventh days after the procedure. A comparative analysis between groups demonstrated a significant increases among the open group in the following markers: CRP (1.44 +/- 0.88 vs 1.32 +/- 0.14 mg/dL, P = .046); TNF alpha (131.14 +/- 41.37 vs 57.19 +/- 23.71 pg/mL; P > .001); and ET-1 (0.91 +/- 0.49 vs 0.56 +/- 0.5 fmol/mL; P = .001). The laparoscopic group showed higher levels of IL-2 than the open group. In conclusion, open donor nephrectomy produced a greater immunohumoral response than a laparoscopic approach. The influence of these observations on ischemia-reperfusion injury or on immediate graft function after kidney transplantation has not been clearly established.

Comparative analysis of the hemodynamic and respiratory parameters during laparoscopic versus open living donor nephrectomy: an experimental model.

Increased intrabdominal pressure induced by pneumoperitoneum induces modifications in cardiovascular and respiratory systems. The aim of the study was to analyze the hemodynamic and respiratory modifications produced by pneumoperitoneum during living donor nephrectomy in a porcine experimental model. Twenty pigs underwent left nephrectomy, 10 by laparoscopy and 10 by an open approach. The following parameters were measured: mean arterial pressure (MAP), central venous pressure, cardiac output (CO), systemic vascular resistance (SVR), end tidal CO2 (ETCO2), minute volume (MV), respiratory airway pressure (RAP), and "compliance." Both groups were monitored for cardiac and respiratory systems at basal, 5, 30, and 60 minutes as well as postsurgery. The comparative analysis demonstrated increased CO with a higher difference at 30 minutes (4.33 +/- 0.73 vs 8.54 +/- 1.26 L/min, P < .001); decreased SVR (1118.81 +/- 302.52 vs 663.37 +/- 81.45 dinas x s x cm(-5), P < .001), and elevated MAP among the laparoscopic group (66.5 +/- 11.52 vs 80.25 +/- 2.49 mm Hg, P = .004). Analysis of respiratory modifications showed an initial increase in ETCO2 (44.3 +/- 2.6 vs 54.1 +/- 12.56 mm Hg, P < .035) and a higher MV administered (5.6 +/- 0.1 vs 7.01 +/- 0.96 L/min, P = .03) to the laparoscopy group. An increased RAP was observed at 5 minutes (22.11 +/- 2.76 vs 28.8 +/- 3.68 mm Hg, P < .001), in the laparoscopic group and lower levels of "compliance" at the same moment in that group (16 +/- 1.66 vs 14.9 +/- 4.07 cm H2O). Laparoscopic nephrectomy caused an increase in CO and MAP and decreased SVR. Likewise there were elevations of RAP, ETCO2, and MV and a slight decrease in the "compliance."

[Warm air convection system and heat loss during vascular surgery]. / Sistema convectivo de aire caliente y pérdida de calor durante la cirugía vascular.

OBJECTIVES: To assess the efficacy of a warm air convection (WAC) system to supplement the usual physical means (electric blanket, warm i.v. fluids and covering of exposed surfaces) for preventing an correcting hypothermia during surgery in 2 patient groups scheduled for vascular surgery. PATIENTS AND METHODS: We studied 70 consecutive patients scheduled for vascular surgery. Group I: a WAC system, in addition to the usual methods, was used to attempt to maintain normal body temperatures in 35 consecutive patients. Fifteen were undergoing aortic surgery (group Ia) and 20 were undergoing revascularization of the lower extremities (group Ib). Group II: only the usual physical methods were used to maintain normal temperature in the remaining 35 patients, 15 of whom required aortic surgery (group IIa) and 20 of whom were undergoing revascularization of the lower extremities (group IIb). Type of anesthesia and monitoring were the same in all cases. Esophageal temperature (ET) and room temperatures were recorded at baseline and every 30 min until the end of surgery. ET was not allowed to fall below 35 degrees C in any patient and WAC was provided to patients in group II if they required it. RESULTS: All patients in group II experienced a gradual decrease in ET, which became significant 30 min after start of surgery in group IIa and 60 min after start of surgery in group IIb. Temperature was stable during surgery in all patients in group I. All patients with ET of 35 degrees C in group II experienced a rise in temperature, which was significant after 60 min. when WAC was used. CONCLUSIONS: In vascular surgery, whether aortic or peripheral, patient temperature fell in spite of use of the usual physical methods for warming. Adding WAC for upper body warming prevented loss of heat. The WAC system was also effective for patients who needed to be rewarmed.

[Intraoperative blood replacement in aortic surgery. Autotransfusion technics]. / Reposición sanguínea intraoperatoria en cirugía aórtica. Técnicas de autotransfusión.

INTRODUCTION: The performance of increasingly invasive surgical techniques involves higher consumption of blood products, along with associated immunological problems and infections. Measures intended to reduce the use of homologous blood products include autologous transfusion and the application of transfusion criteria. We describe our experience with a group of patients scheduled for aortic surgery. PATIENT AND METHODS: Three hundred fifty- eight patients were studied prospectively over a period of 60 months, during which various techniques for conserving blood were applied. Up to 2 units were donated before surgery by patients who had baseline hemoglobin (Hb) counts equal to or greater than 13 g/dl. The donated blood was stored in the form of packed red cells (PRC) and fresh frozen plasma (FFP). Plasmapheresis was performed before surgery whenever a loss of 1,200 ml was expected to occur. Intraoperative salvage of lost blood, with the "Cell- Saver" system, was also used in such cases. No patient was given PRC if Hb was equal to or greater than 10 g/dl; nor was plasma given unless analytical levels indicated need. RESULT: Between 25 and 33% of the patients, depending on age, required no blood products. In up to 55%, self- donated blood was used. Salvage during surgery conserved around 50% of estimated blood lost. The percentage of autologous blood replaced during surgery increase from 21% in 1989 to 38% in 1993. The amount of autologous plasma used also increased with time, reaching nearly 80% of total plasma infused thanks to the introduction of preoperative plasmapheresis. CONCLUSION: The establishment of strict protocols regarding use of blood products and the application of self-donation techniques provided a savings of homologous blood products during the period this study lasted. Preoperative donation of blood was accepted in all cases in which it was indicated and there were no adverse reactions when the autologous blood was replaced.

[Plasma histamine levels after the administration of atracurium or pancuronium in patients undergoing general anesthesia]. / Niveles plasmáticos de histamina tras la administración de atracurio o pancuronio en pacientes sometidos a anestesia general.

OBJECTIVES: To compare the release of histamine induced by atracurium and pancuronium. MATERIAL AND METHODS: We studied 20 patients ASA III undergoing vascular surgery under etomidate anesthesia. Patients were randomly treated with either 0.5 mg/kg of atracurium or 0.1 mg/kg of pancuronium as muscle relaxant agents. Plasma histamine concentration, heart rate, arterial blood pressure, PaO2, and PaCO2 were measured at the basal state and 1.2 and 5 min after administration of the muscle relaxant drug. RESULTS: Plasma histamine concentration at baseline were 0.691 +/- 0.6 ng/ml in the atracurium group and 0.756 +/- 0.612 ng/ml in the pancuronium group. These levels raised up to 2.748 +/- 6.278 ng/ml (atracurium) and 2.553 +/- 5.454 ng/ml (pancuronium). These differences were not statistically significant. The course of the remaining parameters studied in these patients was also comparable between the two groups. There were no clinical manifestations associated with the release of histamine. CONCLUSIONS: Plasma levels of histamine after administration of atracurium were not significantly different from those induced by pancuronium.

Positive end-expiratory pressure. Effect on arterial oxygenation during respiratory failure in chronic obstructive airway disease.

Changes induced in arterial oxygenation by positive end-expiratory pressure (PEEP) were analysed in twenty-nine instances in seven patients with chronic obstructive airway disease and acute respiratory failure, who were receiving IPPV. A significant decrease in mean PaO2 was found 4 hours after the removal of PEEP (P smaller than 0-01), but after its addition during the same period the PaO2 change was not significant. PaCO2 values were not modified by PEEP. The slight increase in mean PaO2 (20-9 mmHg) encountered during controlled ventilation with PEEP seems of doubtful clinical value. Alveolar-arterial oxygen gradient, while breathing oxygen 100%, was found to be elevated with a mean value of 276 mmHg. It appears from our results that PEEP is of little or no value in the routine ventilatory treatment of patients with chronic obstructive airway disease unless hypoxaemia is believed to be caused by a large intrapulmonary shunt.