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.

Intraoperative crystalloid utilization variability and association with postoperative outcomes: A post hoc analysis of two multicenter prospective cohort studies.

BACKGROUND: The optimal regimen for intravenous administration of intraoperative fluids remains unclear. Our goal was to analyze intraoperative crystalloid volume administration practices and their association with postoperative outcomes. METHODS: We extracted clinical data from two multicenter observational studies including adult patients undergoing colorectal surgery and total hip (THA) and knee arthroplasty (TKA). We analyzed the distribution of intraoperative fluid administration. Regression was performed using a general linear model to determine factors predictive of fluid administration. Patient outcomes and intraoperative crystalloid utilization were summarized for each surgical cohort. Regression models were developed to evaluate associations of high or low intraoperative crystalloid with the likelihood of increased postoperative complications, mainly acute kidney injury (AKI) and hospital length of stay (LOS). RESULTS: 7580 patients were included. The average adjusted intraoperative crystalloid infusion rate across all surgeries was to 7.9 (SD 4) mL/kg/h. The regression model strongly favored the type of surgery over other patient predictors. We found that high fluid volume was associated with 40% greater odds ratio (OR 1.40; 95% confidence interval 1.01-1.95, p = 0.044) of postoperative complications in patients undergoing THA, while we found no associations for the other types of surgeries, AKI and LOS CONCLUSIONS: A wide variability was observed in intraoperative crystalloid volume administration; however, this did not affect postoperative outcomes.

[Anesthetic conserving device (AnaConDa) used after cardiac surgery: experience in a postoperative recovery unit]. / Experiencia clínica de la utilización del sistema AnaConDa en una unidad de reanimación de cirugía cardiaca.

OBJECTIVE: To assess the safety and efficacy of using the Anesthetic Conserving Device (AnaConDa) when maintaining sedation after cardiac surgery. MATERIAL AND METHODS: Descriptive study of 46 consecutive patients in the postoperative recovery unit after cardiac surgery between January and April 2009. The patients were under sevoflurane sedation administered with the AnaConDa placed in the inhalation tube. No exclusion criteria were established before enrollment. The sevoflurane dose was set using the manufacturer's normogram and was later adjusted to give an end-tidal concentration of sevoflurane between 0.5% and 0.7% on the basis of data from a gas analyzer. Remifentanil was administered to all patients; a fast-track extubation protocol was used. The only criterion for excluding a patient's data from analysis was prolonged sedation (> 5 hours). RESULTS: The mean (SD) time patients were under sedation with the AnaConDa in place was 2588 (12.32) minutes. The end-tidal concentration of sevoflurane never exceeded 1%. Scores on the Richmond agitation-sedation scale were -5 at 60 minutes in all cases; there was some score variability at 120 minutes. Deeper sedation was desired for the first 60 minutes to avoid awakening related to rewarming. The mean time until awakening was 6.17 minutes (range, 1-30 minutes). The mean time until extubation was 43 (6.69) minutes. The most common adverse effect was arterial hypotension (12 cases). Hypotension was related to bleeding in 3 patients and to low cardiac output in 4 patients. CONCLUSION: Administering sevoflurane through the AnaConDa can be a safe, valid, and reliable method for sedating patients after cardiac surgery. With this device, it is possible to monitor the concentration administered.

Anestesia general en pacientes con discapacidad intelectualsometidos a cirugía dental / General anesthesia in mentally disabled patients undergoing dental surgery

OBJETIVO: Describir la técnica anestésica empleada,valorar la vía aérea y analizar las complicaciones perioperatoriasen pacientes con discapacidad intelectual (DI)sometidos a anestesia general para cirugía dental.MATERIAL Y MÉTODOS: Estudio prospectivo, descriptivoy comparativo de pacientes ASA II-III con DI. Se distribuyeronen dos grupos: DI leves-moderados y DI graves-muy graves. La inducción fue intravenosa oinhalatoria según la disponibilidad de acceso venoso. Elmantenimiento se realizó con oxígeno/aire, y sevofluoranoa concentración variable para mantener un BIS entre40-60. El análisis estadístico incluyó X2 de Mantel yHaensel, t de Student.RESULTADOS: Se incluyeron 47 pacientes. La técnicaanestésica mantuvo la estabilidad hemodinámica enambos grupos. No se encontraron diferencias estadísticamentesignificativas entre la clasificación Mallampati,la clasificación de Cormack-Lehane y el grado de discapacidad.La incidencia de complicaciones fue mayor enel grupo de mayor discapacidad, siendo la más frecuentela dificultad de intubación endotraqueal. La bradicardiafue la complicación más frecuente en los DI levesmoderados.CONCLUSIONES: La técnica anestésica empleada eneste tipo de pacientes se mostró segura y eficaz. Mayorgrado de DI conlleva peor exploración de la vía aérea ypeor laringoscopia directa. El BIS se mostró igualmenteeficaz que en la población sin discapacidad (AU)

OBJECTIVE: To describe the anesthetic technique used,the evaluation of airway patency, and the perioperativecomplications in patients with lower than averageintelligence (mentally disabled) who are administeredgeneral anesthesia for dental surgery.MATERIAL AND METHODS: We carried out a prospective,descriptive, comparative study of mentally disabled ASA 2-3 patients. The patients were distributed in 2 groups: mildto moderate mental disability and severe to very severemental disability. Induction was via intravenous or inhaledanesthesia depending on availability of venous access.Maintenance was with sevoflurane in oxygen and air atvariable concentrations in order to maintain a bispectralindex (BIS) between 40 and 60. Statistical comparisonswere based on the χ2 test, the log-rank test and the t test.RESULTS: Forty-seven patients were enrolled. Theanesthetic technique maintained hemodynamic stabilityin both groups. No statistically significant differenceswere found in Mallampati classification, Cormack-Lehane classification, or level of disability. The incidenceof complications was higher in the group with moresevere disability; the most common complication wasdifficult tracheal intubation. Bradycardia was the mostcommon complication in the group with mild tomoderate mental disability.CONCLUSIONS: The anesthetic technique used in thisstudy proved to be safe and effective in this type ofpatient. A higher degree of mental disability led to lesseffective examination of the airway and more difficultdirect laryngoscopy. BIS was as effective for monitoringin this population as it is in the general population (AU)

[Four patients with mucormycosis in a postoperative recovery unit]. / Estudio descriptivo de cuatro pacientes afectados de mucormicosis ingresados en nuestra unidad de reanimación.

Mucormycosis, a rare opportunistic infection caused by fungi belonging to the Mucorales order, is a potentially fatal disease. We describe 4 patients with mucormycosis. Risk factors (chronic renal insufficiency and chronic lung disease treated with corticosteroids) were identified for 2 of the patients who did not respond favorably to appropriate surgical and medical treatment. Of the 2 remaining patients, only the one with milder disease responded to treatment. The prognosis for this opportunistic infection, whose low incidence has increased in postoperative intensive care units, is very poor if early treatment is not given.

[Fulminant pulmonary lymphangioleiomyomatosis: a case report and review of the literature]. / Linfangioleiomiomatosis pulmonar: presentación de un caso de evolución fulminante y revisión de la literatura.

Pulmonary lymphangioleiomyomatosis is a very rare disease that affects women of childbearing age. It presents a challenge for the anesthesiologist during mechanical ventilation because of the restrictive pattern caused by the disease and because of such complications as recurrent pneumothorax and hemoptysis. We report the fulminant course of lymphangioleiomyomatosis in a 38-year-old woman with a history of recurrent spontaneous pneumothorax whose condition was unsuspected. The literature is reviewed.