Documento multidisciplinar de consenso sobre el manejo de la hemorragia masiva (documento HEMOMAS) / Multidisciplinary consensus document on the management of massive haemorrhage (HEMOMAS document)

La hemorragia masiva es una entidad frecuente que se asocia a una elevada morbimortalidad. Ante la necesidad de la implementación y estandarización de su manejo, se realizó una revisión sistemática de la literatura, con extracción de recomendaciones en base a las evidencias existentes. A partir de las mismas se redactó un documento de consenso multidisciplinar. Desde las definiciones de hemorragia masiva y transfusión masiva, se establecen recomendaciones de actuación estructuradas en las medidas generales de manejo de las mismas (valoración clínica de la hemorragia, manejo de la hipotermia, reposición de la volemia, reanimación hipotensiva y cirugía de contención de daños), monitorización de la volemia, administración de hemocomponentes (concentrado de hematíes, plasma fresco, plaquetas, y óptima relación de administración entre ellos), y de hemostáticos (complejo protrombínico, fibrinógeno, factor VIIa, antifibrinolíticos) (AU)

Massive haemorrhage is common and often associated with high morbidity and mortality. We perform a systematic review of the literature, with extraction of the recommendations from the existing evidences because of the need for its improvement and the management standardization. From the results we found, we wrote a multidisciplinary consensus document. We begin with the agreement in the definitions of massive haemorrhage and massive transfusion, and we do structured recommendations on their general management (clinical assessment of bleeding, hypothermia management, fluid therapy, hypotensive resuscitation and damage control surgery), blood volume monitoring, blood products transfusion (red blood cells, fresh frozen plasma, platelets and their best transfusion ratio), and administration of hemostatic components (prothrombin complex, fibrinogen, factor VIIa, antifibrinolytic agents) (AU)

[Multidisciplinary consensus document on the management of massive haemorrhage (HEMOMAS document)]. / Documento multidisciplinar de consenso sobre elmanejo de la hemorragia masiva (document HEMOMAS)

Massive haemorrhage is common and often associated with high morbidity and mortality. We perform a systematic review of the literature, with extraction of the recommendations from the existing evidences because of the need for its improvement and the management standardization. From the results we found, we wrote a multidisciplinary consensus document. We begin with the agreement in the definitions of massive haemorrhage and massive transfusion, and we do structured recommendations on their general management (clinical assessment of bleeding, hypothermia management, fluid therapy, hypotensive resuscitation and damage control surgery), blood volume monitoring, blood products transfusion (red blood cells, fresh frozen plasma, platelets and their best transfusion ratio), and administration of hemostatic components (prothrombin complex, fibrinogen, factor VIIa, antifibrinolytic agents).

Documento multidisciplinar de consenso sobre el manejo de la hemorragia masiva (documento HEMOMAS) / Multidisciplinary consensus document on the management of massive hemorrhage (HEMOMAS document)

La hemorragia masiva es una entidad frecuente que se asocia a una elevada morbimortalidad. Ante la necesidad de la implementación y estandarización de su manejo, se realizó una revisión sistemática de la literatura, con extracción de recomendaciones en base a las evidencias existentes. A partir de las mismas se redactó un documento de consenso multidisciplinar. Desde las definiciones de hemorragia masiva y transfusión masiva, se establecen recomendaciones de actuación estructuradas en las medidas generales de manejo de las mismas (valoración clínica de la hemorragia, manejo de la hipotermia, reposición de la volemia, reanimación hipotensiva y cirugía de contención de daños), monitorización de la volemia, administración de hemocomponentes (concentrado de hematíes, plasma fresco, plaquetas, y óptima relación de administración entre ellos), y de hemostáticos (complejo protrombínico, fibrinógeno, factor VIIa, antifibrinolíticos) (AU)

Massive haemorrhage is common and often associated with high morbidity and mortality. We perform a systematic review of the literature, with extraction of the recommendations from the existing evidences because of the need for its improvement and the management standardization. From the results we found, we wrote a multidisciplinary consensus document. We begin with the agreement in the definitions of massive haemorrhage and massive transfusion, and we do structured recommendations on their general management (clinical assessment of bleeding, hypothermia management, fluid therapy, hypotensive resuscitation and damage control surgery), blood volume monitoring, blood products transfusion (red blood cells, fresh frozen plasma, platelets and their best transfusion ratio), and administration of hemostatic components (prothrombin complex, fibrinogen, factor VIIa, antifibrinolytic agents) (AU)

Multidisciplinary consensus document on the management of massive haemorrhage (HEMOMAS document).

Massive haemorrhage is common and often associated with high morbidity and mortality. We perform a systematic review of the literature, with extraction of the recommendations from the existing evidences because of the need for its improvement and the management standardization. From the results we found, we wrote a multidisciplinary consensus document. We begin with the agreement in the definitions of massive haemorrhage and massive transfusion, and we do structured recommendations on their general management (clinical assessment of bleeding, hypothermia management, fluid therapy, hypotensive resuscitation and damage control surgery), blood volume monitoring, blood products transfusion (red blood cells, fresh frozen plasma, platelets and their best transfusion ratio), and administration of hemostatic components (prothrombin complex, fibrinogen, factor VIIa, antifibrinolytic agents).

Impaired executive functioning influences verbal memory in anorexia nervosa.

BACKGROUND: How executive functioning affects delayed verbal recall in AN has never been tested. We investigated the influence of speed of information processing (SIP) and inhibition on delayed verbal recall in females with AN. METHODS: Measures of SIP and inhibition from 35 females with AN were analyzed using hierarchical multiple regression after controlling for age, depressive symptomatology and body mass index. Each predictor was evaluated using structure coefficients, common variance and dominance weights. RESULTS: The combination of measures of SIP and inhibition accounted for almost 80% of the variance on the delayed recall of the story recall task. When the rest of the variables were partialled out, SIP and inhibition accounted for more than 50% of the variance. CONCLUSIONS: As it occurs with visuospatial abilities in AN, basic cognitive abilities such as speed of information processing and cognitive inhibition may affect other cognitive functions such as delayed verbal memory regardless of immediate recall. These findings may help interpret performance on cognitive tests in future research.

Fondaparinux como alternativa a la anticoagulación en una paciente con dispositivo de asistencia ventricular y trombocitopenia inducida por heparina / Fondaparinux as an alternative anticoagulant in heparin-induced thrombocytopenia in the patient with a ventricular assist device

La trombocitopenia inducida por heparina es una reacción asociada al tratamiento con dicho fármaco. Se da hasta en el 3% de los pacientes tratados al menos 5 días. Su tratamiento es la suspensión, y si el paciente lo precisa, sustitución por otro anticoagulante. Presentamos el caso de un paciente trasplantado de corazón y con dispositivo de asistencia ventricular derecho que desarrolló trombocitopenia inducida por heparina en el postoperatorio. Se describe el manejo de la anticoagulación con fondaparinux. Se describen las complicaciones perioperatorias y el manejo de la anticoagulación (AU)

Heparin-induced thrombocytopenia is a reaction associated with the use of this drug. It occurs in up to 3% of patients treated for at least 5 days. Its treatment is to stop the heparin, and according to patient needs, replace it with another anticoagulant.We present a patient who, after a heart transplant, and the need for a ventricular assist device, required anticoagulation. The patient developed heparin-induced thrombocytopenia. Heparin was stopped and anticoagulation was replaced by fondaparinux. The peri-operative complications and the management of the coagulation are described (AU)

Hemorragia masiva después de anticoagulación con bivalirudina en 2 casos de pacientes con trasplante cardiaco / Massive haemorrhage after bivalirudin anticoagulation in two heart transplant patients

La trombopenia inducida por heparina es una complicación autoinmunitaria frecuente. Se trata de un estado protrombótico debido a la formación de anticuerpos contra los complejos heparina/factor plaquetario 4. Ante esta situación es necesario el empleo de fármacos alternativos a la heparina para la anticoagulación durante la circulación extracorpórea. Se exponen 2 casos de trasplante cardiaco en los que se empleó bivalirudina como anticoagulante durante la circulación extracorpórea. En ambos pacientes se observó la aparición de complicaciones hemorrágicas severas. Es necesario mejorar el diagnóstico de la trombopenia inducida por heparina y desarrollar protocolos de empleo de nuevos fármacos alternativos a la heparina. Por ello revisamos los protocolos de actuación y las alternativas terapéuticas a la heparina(AU)

Heparin-induced thrombopenia is a common autoimmune complication. It is a prothrombotic state due to the formation of antibodies against heparin/platelet factor 4 complexes. In this situation drugs other than heparin must be used for anticoagulation during extracorporeal circulation (bypass) surgery. Two cases of heart transplantation are presented in whom bivalirudin was used as an anticoagulant during the cardiopulmonary bypass. Severe bleeding complications were observed in both patients. The diagnosis of heparin-induced thrombopenia needs to be improved, as well as the development of protocols for using new drugs other than heparin. For this reason, we have reviewed current protocols and alternative therapies to heparin(AU)

Comentarios analíticos del estudio VISION (evaluación de cohorte de eventos vasculares en pacientes de cirugía no cardiaca): asociación entre la troponina T y la mortalidad a los 30 días en pacientes de cirugía no cardiaca / Analytic comments of the initial results of the VISION ( V ascular events I n noncardiac S urgery pat I ents c O hort evaluatio N ): Association between troponin T and mortality at 30 days in noncardiac surgery patients

No disponible

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)

[Fondaparinux as an alternative anticoagulant in heparin-induced thrombocytopenia in the patient with a ventricular assist device]. / Fondaparinux como alternativa a la anticoagulación en una paciente con dispositivo de asistencia ventricular y trombocitopenia inducida por heparina.

Heparin-induced thrombocytopenia is a reaction associated with the use of this drug. It occurs in up to 3% of patients treated for at least 5 days. Its treatment is to stop the heparin, and according to patient needs, replace it with another anticoagulant. We present a patient who, after a heart transplant, and the need for a ventricular assist device, required anticoagulation. The patient developed heparin-induced thrombocytopenia. Heparin was stopped and anticoagulation was replaced by fondaparinux. The peri-operative complications and the management of the coagulation are described.

[Massive haemorrhage after bivalirudin anticoagulation in two heart transplant patients]. / Hemorragia masiva después de anticoagulación con bivalirudina en 2 casos de pacientes con trasplante cardiaco.

Heparin-induced thrombopenia is a common autoimmune complication. It is a prothrombotic state due to the formation of antibodies against heparin/platelet factor 4 complexes. In this situation drugs other than heparin must be used for anticoagulation during extracorporeal circulation (bypass) surgery. Two cases of heart transplantation are presented in whom bivalirudin was used as an anticoagulant during the cardiopulmonary bypass. Severe bleeding complications were observed in both patients. The diagnosis of heparin-induced thrombopenia needs to be improved, as well as the development of protocols for using new drugs other than heparin. For this reason, we have reviewed current protocols and alternative therapies to heparin.

[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.

Stage pT3a of renal clear cell carcinoma: do tumors with sinus fat involvement behave the same as those with perinephric fat involvement?

INTRODUCTION: In this report, we review our series of patients with pT3a clear cell renal carcinoma (CCRC) and comment on their outcome. MATERIALS AND METHODS: We have reviewed 260 cases of CCRC operated in the Móstoles General Hospital, Madrid, between 2000 and 2004. We have found 30 cases with pT3a tumors. Eleven of them were invading the perinephric fat, nine were invading the renal sinus fat and ten were pT3a locally but showed metastasis at the moment of diagnosis (cM1, TNM stage IV). We have analyzed the prognostic influence of histopathological parameters (vascular invasion, size, Fuhrman grade) and also immunohistochemical ones (p53, cyclin D1, proliferation index with Ki67, bcl-2 and vascular density with CD34). RESULTS: Only six of 10 patients with perinephric fat involvement died of disease compared with all the patients with sinus fat involvement, suggesting a worse prognosis for the latter. However, this difference did not reach statistical significance, probably due to the small number of cases. Of all the clinical, histological and immunohistochemical factors analyzed, only cyclin D1 was a strong indicator of worse prognosis in pT3a CCRC (p=0.02). We could not show any statistically significant relation between vascular density and prognosis. Vascular invasion was the only histological parameter that showed a trend toward significance (p=0.09). CONCLUSIONS: Sinus fat involvement might be underestimated in some series. A protocol for nephrectomy specimen handling could improve the detection rate of sinus fat involvement and allow the performance of randomized prospective studies to determine whether these tumors behave similarly.

Desempenho e características da carcaça de novilhos terminados em pastejo rotacionado ou em confinamento / Performance and carcass characteristics of steers finished in rotational grassing or feedlot

Foram avaliados o desempenho e as características de carcaça de 36 novilhos Brahman (Bh), Brangus (Bg) e Hereford adaptado (He), terminados em pastejo com suplementação (PSu) ou em confinamento (Conf). Os animais foram abatidos quando apresentavam espessura de gordura maior do que 4mm. Na dieta do Conf, a relação volumoso:concentrado foi de 60:40 (com base na matéria seca), continha 13 por cento de proteína bruta (PB) e 62 por cento de nutrientes digestíveis totais (NDT). O capim-mombaça continha, em média, 7 por cento de PB e 54 por cento de NDT, e o suplemento 24 por cento de PB e 76 por cento de NDT. Foi observada diferença (P<0,05) no sistema de terminação para o ganho de peso médio diário, com 1,200kg/cab/dia para Conf e 0,675kg/cab/dia para Psu. Os novilhos Bh e Bg pesaram, em média, 445,8kg, e o rendimento da carcaça quente foi de 58,4 por cento, valores maiores que os 399,1kg e 55,4 por cento obtidos pelos animais He. A área de olho de Longissimus foi maior para os animais Bg, 76,42cm². A maciez, 3,71 vs 4,89, e a espessura de gordura subcutânea, 4,64 vs 3,39, foram melhores nos animais terminados em Conf do que nos animais em Psu, respectivamente.

The productive performance and carcass of the 36 Brahman (Bh), Brangus (Bg) and adapted Hereford (He) steers finished on feedlot (FD) or on rotational grazing with supplementation system (GS) were evaluated. The animals were slaughtered when the subcutaneous fat thickness was over 4mm. The feedlot diet had a forage: concentrate of 60:40 (in dry matter) 13 percent crude protein (CP), 62 percent of NDT. The mombaça gras CP level was 7 percent and 54 percent of NDT. The supplement had supplied 24 percent of CP and 76 percent of NDT. A significant difference was observed for the average daily gain, being 1,200kg/head/day for FD steers and 0.675kg/head/day for GS steers. The effect of breed on slaughter weight was observed, being 445.8kg for Bh and Bg and 399.19kg for He. The hot dressing percentage was higher for Bh and Bg than for He, 58.4 percent vs 55.4 percent. The rib eye area was higher for Bg, 76.42cm² and tenderness measured by the shear force was lower for FD steers, at 3.71 than for GS steers, at 4.89. The subcutaneous fat thickness was higher for FD steers, at 4.64 than for GS steers, at 3.39mm.

Valoración del peso, talla e IMC en niños, adolescentes y adultos jóvenes de la Comunidad Autónoma de Madrid / Evaluation of weight, height and BMI in children, adolescents and young adults from the Community of Madrid

Introducción: Recientemente se han fusionado los datos de 4 estudios de crecimiento realizados en poblaciones de Andalucía, Barcelona, Bilbao y Zaragoza, configurándose el estudio transversal español de crecimiento 2008.Con el objetivo de comprobar si existían o no diferencias entre la población de Madrid y las incluidas en el estudio español y de esta forma evaluar la aplicabilidad de este estándar de referencia también en nuestra comunidad autónoma, hemos realizado un estudio transversal en la Comunidad de Madrid valorando peso, talla e IMC en una muestra de sujetos. Pacientes y métodos: Hemos analizado una muestra de 6.463 sujetos (3.055 mujeres y 3.408 varones) con edades comprendidas entre 3 y 24 años. Todos estaban sanos, eran de raza caucásica y tenían origen español. Las diferencias entre los datos de Madrid y las poblaciones incluidas en el estudio transversal español 2008 se evaluaron mediante regresión lineal múltiple del logaritmo de la talla, el peso y el IMC ajustado por grupo de edad y por área geográfica de procedencia. Se ha utilizado el procedimiento de comparaciones múltiples de Tukey para los contrastes de los diferentes rangos de edad. El análisis estadístico se realizó mediante el paquete estadístico SAS versión 8.2. Resultados: Se exponen los valores de la media aritmética y desviación estándar de peso, talla e IMC por grupos de edades para varones y mujeres, así como su distribución percentilada. No encontramos diferencias de relevancia clínica para los valores de peso, talla e IMC de nuestra población y los correspondientes del estudio transversal español 2008. Respecto a otros estudios realizados hace más de 20 años observamos un incremento en los valores de todos los percentiles de peso y talla. Conclusiones: En resumen, los datos de referencia que ofrece el estudio español de crecimiento 2008 son aplicables en la Comunidad Autónoma de Madrid. Además teniendo en cuenta que la comparación de los estudios transversales recientes realizados en 5 comunidades autónomas (Andalucía, Aragón, Cataluña, Madrid y País Vasco) no mostraron diferencias significativas en las medias de los parámetros antropométricos de peso, talla, IMC, ni en la talla final, podría considerarse a la población española actual como una población homogénea desde el punto de vista antropométrico y extender por tanto la aplicabilidad del estudio español de crecimiento 2008 al resto del país (AU)

Introduction: The data of four growth studies involving populations from Andalusia, Barcelona, Bilbao and Zaragoza have recently been reported as part of the Spanish Cross-sectional Growth Study 2008 (SCGS).With the aim of detecting possible differences between the population of the Madrid region and those of the SCGS, and by so-doing assess the applicability of the conclusions of this reference work to the Madrid region, a cross-sectional study of the latter was undertaken, recording the weight, height and body mass index (BMI). Subjects and methods: We have analyzed 6463 subjects (3055 females and 3408 males) aged 3–24 years. All subjects were healthy, Caucasian, and of Spanish origin. Differences between the results of the Madrid and SCGS studies were sought by multiple linear regression analysis of the log of the height, weight and BMI data adjusted for age and geographical area. The Tukey multiple comparisons test was used to analyse differences in age ranges. All calculations were performed using SAS v. 8.2 software. Results: Means and standard deviations are provided for the weight, height and BMI of women and men; distributions by percentiles are also provided.No differences of clinical importance were seen in the weight, height or BMI between the subjects of the Madrid region and those of the SCGS. However, comparisons with the results of other studies performed more than 20 years ago revealed an increase in the weight and height values in all percentiles. Conclusions: In summary, the official Spanish SCGS reference data for 2008 are similar to those recorded for the Madrid region. Bearing in mind that recent cross-sectional studies undertaken in Andalusia, Aragon, Catalonia, the Basque Country and the present work show no significant differences in mean weights, heights or BMIs in any age group, nor in the final height attained by adults, the Spanish population would appear to be anthropometrically homogeneous. The conclusions of the SCGS may therefore be applicable to the entire country (AU)