Intraoperative transesophageal echocardiography in cardiovascular surgery. Consensus document from the Spanish Society of Anesthesia and Critical Care (SEDAR) and the Spanish Society of Endovascular and Cardiovascular Surgery (SECCE). / Ecocardiografía transesofágica intraoperatoria en cirugía cardiovascular. Documento de consenso de la Sociedad Española de Anestesiología y Reanimación (SEDAR) y Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE).

Transesophageal echocardiography is a semi-invasive technique that allows an evaluation of cardiac morphology and function in real time and it is a quality standard in cardiovascular surgery. It has become a fundamental tool for both monitoring and diagnosis in the intraoperative period that allows decide the correct surgical planning and pharmacological management. The goal of this document is to answer the questions of when and how the perioperative TEE should be performed in cardiovascular surgery, what are their applications in the intraoperative, who should perform it and how the information should be transmitted. The authors made a systematic review of international guidelines, review articles and clinical trials to answer by consensus to these questions.

Perforation of the left ventricle wall due to the insertion of a pulmonary artery catheter. A case report. / Perforación de la pared del ventrículo izquierdo por catéter de arteria pulmonar Swan-Ganz. A propósito de un caso.

Despite the widespread and frequent use in our setting of pulmonary artery catheters for haemodynamic management in critically ill patients, particularly after heart surgery, some experts continue to question the need for these devices. Clinicians need to weigh up the risks and benefits of pulmonary artery catheters placement and bear in mind the potential complications which, though rare, can be potentially fatal. We present a pulmonary artery catheters-related complication not hitherto described in the literature, involving perforation of the interventricular septum and left ventricular free wall caused by a kink in the pulmonary artery catheters that was not suspected, and only diagnosed by direct vision of the heart after pericardial opening. In the interest of patient safety, we must consider the impact of adverse events; improving our situational awareness and our understanding of the mechanisms behind such events can help reduce the likelihood of repetitions in the future.

Routine aspiration of subglottic secretions after major heart surgery: impact on the incidence of ventilator-associated pneumonia.

Aspiration of subglottic secretions (ASS) is recommended in patients requiring mechanical ventilation for ≥48h. We assessed the impact of the introduction of ASS routinely in all patients after major heart surgery in an ecological study comparing ventilator-acquired pneumonia (VAP) incidence, days of mechanical ventilation, and cost of antimicrobial agents before and after the implementation of ASS. Before and after the intervention the results (per 1000 days) were: VAP incidence, 23.92 vs 16.46 (P = 0.04); cost of antimicrobials, €71,384 vs €63,446 (P = 0.002); and days of mechanical ventilation, 507.5 vs 377.5 (P = 0.009). From the moment of induction of anaesthesia all patients undergoing major heart surgery should routinely receive ASS.

[Neuromuscular blockade monitoring. Part 1]. / Monitorización del bloqueo neuromuscular. 1a parte.

Many recent studies have underlined the importance of quantitative neuromuscular monitoring and the high incidence of residual block in clinical practice in spite of the use of nondepolarizing neuromuscular blockers of intermediate duration. Neuromuscular monitoring facilitates the tailoring of the muscular paralysis and appropriate patient recovery at the end of surgery. Monitoring also controls or prevents residual block and serves to guide the use of reversing agents. This review describes the physiology of neuromuscular junctions as well as the principles and patterns of nerve stimulation and clinical monitoring. In addition to drawing on their own experience, the authors have reviewed the literature available through evidence-based indexes and other databases up to December 2008. Most references found were case series and reviews. Quantitative monitoring is an evidence-based practice that should be applied in all situations in which a neuromuscular block is established.

Nasal carriage of S. aureus increases the risk of surgical site infection after major heart surgery.

Staphylococcus aureus is the main cause of surgical site infection (SSI) after major heart surgery (MHS), with the patient's endogenous flora as the principal source. However, the influence of nasal carriage of S. aureus on the development of SSI after MHS has not been established and Centers for Disease Control and Prevention guidelines do not make a recommendation for or against decolonisation. We performed a one-year observational study in which patients undergoing MHS were screened for nasal carriage of S. aureus before surgery. Cases of SSI were recorded and the risk factors of patients with and without SSI were analysed. During the study period, 357 patients were included in the protocol. Ninety-six patients (27%) were found to be nasal carriers of S. aureus and nine (9.4%) of these had meticillin-resistant (MRSA) strains. The overall incidence of SSI was 6.4%, with 4.2% for mediastinitis and 2.2% for superficial SSI. Nasal carriers of S. aureus had a significantly higher incidence of SSI than non-carriers (12.5% vs 5%, P=0.01). Among MRSA carriers, the incidence of SSI reached 33% (P<0.001). S. aureus was responsible for 64% of SSIs. Multivariate analysis showed that the independent factors for SSI were S. aureus nasal carriage [relative risk (RR): 3.1; 95% confidence interval (CI): 1.4-7.3; P=0.009], reoperation (RR: 3.1; 95% CI: 1.8-19.2; P=0.04) and diabetes mellitus (RR: 5.9; 95% CI: 1.8-19.2; P=0.003). Nasal carriage of S. aureus significantly increases the rate of nosocomial SSI after MHS and decolonisation strategies should be implemented in this population.

Prevalence of peripheral arterial disease and prior stroke in octogenarians with symptomatic severe aortic stenosis or severe coronary artery disease: influence in management and outcome.

AIM: Severe aortic stenosis (SAS) and severe coronary artery disease (SCAD) are the most frequent reasons to perform cardiac surgery in octogenarians. Non-coronary vascular disease is frequently present in these patients. METHODS: We assessed the prevalence and impact of previous stroke (PS) and peripheral arterial disease (PAD) on the management and outcome of 130 consecutive symptomatic patients (80 years old with SAS or SCAD. RESULTS: Mean age was 82.8+/-3.1 years. PS was present in 24 patients (18.5%) and PAD in 15 (11.5%). We found a non-significant trend to a higher prevalence of PAD in patients with SCAD than in patients with SAS (14.5% vs 6.4%, P=0.13), while no relevant differences were seen for PS prevalence (19.3% vs 17%, P=0.75). Patients with PS tended to be operated less frequently than patients without PS (20.8% vs 37.7%, P=0.08), while no relevant differences were seen for patients with and without PAD (26.7% vs 35.7%, P=0.5). Thirty-nine patients (30%) died during follow-up, mean of 1.1(0.7 years (median 1 years; 100% complete). There was a trend to a worse prognosis in patients with PAD (adjusted hazard ratio [HR] 2.2; 95% confidence interval [CI] 0.96-4.8; P=0.06), while PS showed no independent influence on survival (adjusted HR 1.3, 95% CI 0.6-2.8, P=0.53). CONCLUSIONS: PS and PAD are frequently present in octogenarians with SAS or SCAD. Patients with PS show a similar long-term mortality, but tend to be operated less frequently. On the other hand, PAD did not influence the decision of surgical treatment, but is associated with a lower survival rate.

The influence of linear elements on plant species diversity of Mediterranean rural landscapes: assessment of different indices and statistical approaches.

This paper mainly aims to study the linear element influence on the estimation of vascular plant species diversity in five Mediterranean landscapes modeled as land cover patch mosaics. These landscapes have several core habitats and a different set of linear elements--habitat edges or ecotones, roads or railways, rivers, streams and hedgerows on farm land--whose plant composition were examined. Secondly, it aims to check plant diversity estimation in Mediterranean landscapes using parametric and non-parametric procedures, with two indices: Species richness and Shannon index. Land cover types and landscape linear elements were identified from aerial photographs. Their spatial information was processed using GIS techniques. Field plots were selected using a stratified sampling design according to relieve and tree density of each habitat type. A 50x20 m2 multi-scale sampling plot was designed for the core habitats and across the main landscape linear elements. Richness and diversity of plant species were estimated by comparing the observed field data to ICE (Incidence-based Coverage Estimator) and ACE (Abundance-based Coverage Estimator) non-parametric estimators. The species density, percentage of unique species, and alpha diversity per plot were significantly higher (p < 0.05) in linear elements than in core habitats. ICE estimate of number of species was 32% higher than of ACE estimate, which did not differ significantly from the observed values. Accumulated species richness in core habitats together with linear elements, were significantly higher than those recorded only in the core habitats in all the landscapes. Conversely, Shannon diversity index did not show significant differences.

[Aortic coarctation and postcoarctation mycotic aneurysm in a woman 20 weeks pregnant: anesthetic management]. / Coartación aórtica y aneurisma micótico postcoartación en gestante de 20 semanas: manejo anestésico.

A 28-year-old woman, 20 weeks pregnant, was diagnosed with aortic coarctation and postcoarctation mycotic aneurysm. After anesthetic induction, blood pressure was monitored in the radial artery of the right arm and the femoral artery of the right leg for two purposes: to verify hemodynamic stability as required in this type of operation and to determine the pressure gradient between the upper and lower limbs, which was approximately 40 mm Hg. To prevent spinal cord ischemia, an intradural catheter was inserted into the fourth and fifth lumbar space for spinal fluid drainage. A double lumen tube was used for intubation so that the left lung could be blocked, and a centrifugal pump was used instead of extracorporeal circulation. The aneurysm was resected through a left thoracotomy and an aortic prosthesis was placed. Satisfactory outcome was indicated by resolution of the pressure gradient, and fetal viability was verified by ultrasound. The mother suffered no neurological complications and the pregnancy continued to term uneventfully. We review the anesthetic procedure to follow in such cases.

Coartación aórtica y aneurisma micótico postcoartación en gestante de 20 semanas: manejo anestésico / Aortic coarctation and postcoarctation mycotic aneurysm in a woman 20 weeks pregnant: anesthetic management

Presentamos el caso de una paciente de 28 años de edad, gestante de 20 semanas, diagnosticada de coartación aórtica y aneurisma micótico post-coartación. Una vez realizada la inducción anestésica, se monito-rizó la arteria radial en el miembro superior derecho así como la arteria femoral en el miembro inferior derecho con el doble objetivo de tener la monitorización hemodinámica requerida siempre en este tipo de intervenciones y observar el gradiente de presión existente entre miembros superiores e inferiores, que era de unos 40 mmHg. Para intentar evitar la isquemia medular, se colocó un catéter intradural en el espacio L4-L5, para drenaje de líquido cefalorraquídeo. Se realizó intubación con tubo de doble luz, para bloqueo de pulmón izquierdo. Se usó bomba centrífuga en lugar de circulación extracorpórea. La resección aneurismática fue por toracotomía izquierda, colocándose una prótesis aórtica. El resultado final fue satisfactorio, pues desapareció el gradiente de presión y se demostró la viabilidad fetal por la ecografía. La paciente no presentó ninguna secuela neurológica y el embarazo finalizó sin problemas. Revisamos la conducta anestésica a seguir en estos casos

A 28-year-old woman, 20 weeks pregnant, was diagnosed with aortic coarctation and postcoarctation mycotic aneurysm. After anesthetic induction, blood pressure was monitored in the radial artery of the right arm and the fem-oral artery of the right leg for two purposes: to verify hemodynamic stability as required in this type of operation and to determine the pressure gradient between the upper and lower limbs, which was approximately 40 mm Hg. To prevent spinal cord ischemia, an intradural catheter was inserted into the fourth and fifth lumbar space for spinal fluid drainage. A double lumen tube was used for intubation so that the left lung could be blocked, and a centrifugal pump was used instead of extracorporeal circulation. The aneurysm was resected through a left thoracotomy and an aortic prosthesis was placed. Satisfactory outcome was indicated by resolution of the pressure gradient, and fetal viability was verified by ultrasound. The mother suffered no neurological complications and the pregnancy continued to term uneventfully. We review the anesthetic procedure to follow in such cases

Estimation of plant diversity at landscape level: a methodological approach applied to three Spanish rural areas.

Approaches linking biodiversity assessment with landscape structure are necessary in the framework of sustainable rural development. The present paper describes a methodology to estimate plant diversity involving landscape structure as a proportional weight associated with different plant communities found in the landscape mosaic. The area occupied by a plant community, its patch number or its spatial distribution of patches are variables that could be expressed in gamma plant diversity of a territory. The methodology applies (1) remote sensing information, to identify land cover and land use types; (2) aspect, to discriminate composition of plant communities in each land cover type; (3) multi-scale field techniques, to asses plant diversity; (4) affinity analysis of plant community composition, to validate the stratified random sampling design and (5) the additive model that partitions gamma diversity into its alpha and beta components. The method was applied to three Spanish rural areas and was able to record 150-260 species per ha. Species richness, Shannon information index and Simpson concentration index were used to measure diversity in each area. The estimation using Shannon diversity index and the product of patch number and patch interspersion as weighting of plant community diversity was found to be the most appropriate method of measuring plant diversity at the landscape level.

[Dental education and preclinical procedures to develop indirect vision]. / Enseñanza odontológica y procedimientos preclínicos para desarrollar la visión indirecta.

The technological advance and the development of the odontologic profession, requires the gradual incorporation of more accurate psycho-motrice methods. The aim of this report is the presentation of the systems elaborated for the development of the students' and odontologists' psycho-motive skill. This report describes the method known as "reflection box", for the learning of indirect vision. In order to achieve a training, for the correct odontologic practice, in ergonomic positions that prevent skeleton-muscle disorders resulted from inadequate professional practices, exercises in two and three dimensions should be carried out with said box.

Tumores glómicos: nuestra experiencia en 14 casos / Glomus tumors: our experience in 14 cases

Se presentan 14 casos de tumores glómicos (angioneuromioma), cuya localización más frecuente fue la subungeal (ocho casos). El tratamiento de todos ellos, previa anestesia locorregional, fue la extirpación quirúrgica completa del tumor, desapareciendo de esta forma el importance componente doloroso que motivó la ilegada de estos enfermos a nuestra consulta

Tumores glómicos: nuestra experiencia en 14 casos / Glomus tumors: our experience in 14 cases

Se presentan 14 casos de tumores glómicos (angioneuromioma), cuya localización más frecuente fue la subungeal (ocho casos). El tratamiento de todos ellos, previa anestesia locorregional, fue la extirpación quirúrgica completa del tumor, desapareciendo de esta forma el importance componente doloroso que motivó la ilegada de estos enfermos a nuestra consulta (AU)