Perioperative neuromuscular blockade. 2020 update of the SEDAR (Sociedad Española de Anestesiología y Reanimación) recommendations.

We present an update of the 2020 Recommendations on neuromuscular blockade of the SEDAR. The previous ones dated 2009. A modified Delphi consensus analysis (experts, working group, and previous extensive bibliographic revision) 10 recommendations were produced1: neuromuscular blocking agents were recommended for endotracheal intubation and to avoid faringo-laryngeal and tracheal lesions, including critical care patients.2 We recommend not to use neuromuscular blocking agents for routine insertion of supraglotic airway devices, and to use it only in cases of airway obstruction or endotracheal intubation through the device.3 We recommend to use a rapid action neuromuscular blocking agent with an hypnotic in rapid sequence induction of anesthesia.4 We recommend profound neuromuscular block in laparoscopic surgery.5 We recommend quantitative monitoring of neuromuscular blockade during the whole surgical procedure, provided neuromuscular blocking agents have been used.6 We recommend quantitative monitoring through ulnar nerve stimulation and response evaluation of the adductor pollicis brevis, acceleromyography being the clinical standard.7 We recommend a recovery of neuromuscular block of at least TOFr ≥ 0.9 to avoid postoperative residual neuromuscular blockade.8 We recommend drug reversal of neuromuscular block at the end of general anesthetic, before extubation, provided a TOFr ≥ 0.9 has not been reached.9 We recommend to choose anticholinesterases for neuromuscular block reversal only if TOF≥2 and a TOFr ≥ 0.9 has not been attained.10 We recommend to choose sugammadex instead of anticholinesterases for reversal of neuromuscular blockade induced with rocuronium.

Bloqueo neuromuscular perioperatorio. Actualización 2020 de las Recomendaciones de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR) / Perioperative neuromuscular blockade. 2020 update of the SEDAR (Sociedad Española de Anestesiología y Reanimación) recommendations

Se presenta la actualización 2020 de las Recomendaciones de bloqueo neuromuscular de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR). Las anteriores databan de 2009. Tras un análisis de consenso Delphi (expertos, grupo de trabajo y revisión bibliográfica previa) se generaron 10 recomendaciones: 1) Se recomienda el uso de fármacos bloqueantes neuromusculares (fbnm) para facilitar la intubación traqueal y evitar lesiones faringo-laringo-traqueales en cualquier paciente, incluidos pacientes críticos. 2) Se recomienda no utilizar fbnm para la inserción rutinaria de dispositivos supraglóticos y utilizar solo en caso de obstrucción de la vía aérea o intubación traqueal a través de este. 3) Se recomienda utilizar un fármaco bloqueante neuromuscular de inicio de acción rápido asociado al agente hipnótico en la inducción de secuencia rápida. 4) Se recomienda utilizar un nivel de bloqueo neuromuscular profundo en cirugía laparoscópica. 5) Se recomienda el uso de monitorización cuantitativa del bloqueo neuromuscular durante todo el procedimiento quirúrgico, siempre que se utilicen fbnm. 6) Se recomienda la monitorización cuantitativa mediante estimulación del nervio cubital y evaluación de la respuesta en el músculo aductor corto del pulgar, siendo el estándar clínico la aceleromiografía (AMG). 7) Se recomienda una recuperación del bloqueo neuromuscular al menos hasta alcanzar un TOFr ≥ 0,9 para evitar el bloqueo neuromuscular residual postoperatorio. 8) Se recomienda la reversión farmacológica del bloqueo neuromuscular al finalizar la anestesia general, previo a la extubación traqueal siempre que no se haya alcanzado un TOFr ≥ 0,9. 9) Se recomienda utilizar fármacos anticolinesterásicos para la reversión del bloqueo neuromuscular solo cuando el tren de cuatro estímulos (TOF) es ≥ 2 y no se haya alcanzado un TOFr ≥ 0,9. 10)...(AU)

We present an update of the 2020 Recommendations on neuromuscular blockade of the SEDAR. The previous ones dated 2009. A modified Delphi consensus analyisis (experts, working group, and previous extensive bibliographic revision) 10 recommendations were produced: (1) neuromuscular blocking agents were recommended for endotracheal intubation and to avoid faringo-laryngeal and tracheal lesions, including critical care patients. (2) We recommend not to use neuromuscular blocking agents for routine insertion of supraglotic airway devices, and to use it only in cases of airway obstruction or endotracheal intubation through the device. (3) SWe recommend to use a rapid action neuromuscular blocking agent with an hypnotic in rapid sequence induction of anesthesia. (4) We recommed profound neuromuscular block in laparoscopic surgery. (5) We recommend quantitative monitoring Sof neuromuscular blockade during the whole surgical procedure, provided neuromuscular blocking agents have been used. (6) We recommend quantitative monitoring through ulnar nerve stimulation and response evaluation of the adductor pollicis brevis, acceleromyography being the clinical standard. (7) We recommned a recovery of neuromuscular block of at least TOFr ≥ 0.9 to avoid postoperative residual neuromuscular blockade. (8) We recommend drug reversal of neuromuscular block at the end of general anesthetic, before extubation, provided a TOFr ≥ 0.9 has not been reached. (9) We recommend to choose anticholinesterases for neuromuscular block reversal only if TOF ≥ 2 and a TOFr ≥ 0.9 has not been atained. (10) We recommend to choose sugammadex instead of anticholinesterases for reversal of neuromuscular blockade induced with rocuronium.(AU)

Anestesia y analgesia epidural en la resección hepática: seguridad y efectividad / Epidural anesthesia and analgesia in liver resection: safety and effectiveness

Objetivos. La analgesia epidural perioperatoria (AE) en la cirugía hepática proporciona una analgesia dinámica óptima. Las alteraciones de la coagulación que se producen en el postoperatorio, añaden un riesgo de complicaciones tras la retirada de los catéteres epidurales. El objetivo de este estudio es evaluar la efectividad y las complicaciones de la AE, así como el retraso en la retirada de los catéteres epidurales asociado a coagulopatía postoperatoria. Métodos. Estudio retrospectivo de los 114 pacientes sometidos a cirugía hepática abierta y AE, de marzo 2012 a febrero 2015. Se analizó la evolución postoperatoria de la intensidad del dolor, de los parámetros de la coagulación y la retirada aplazada de catéteres. Resultados. De los 114 pacientes intervenidos, 73 cumplieron criterios de inclusión. Un 59% de pacientes con hepatectomía mayor (resección ≥ 3 segmentos) y un 15% con cirrosis hepática Child A (11/73). El 96% de los catéteres funcionaron adecuadamente. Un 89% de los pacientes tuvo dolor controlado (escala numérica <3) en reposo y un 8,2% (6 pacientes) presentaron dolor intenso (escala numérica>6) al movimiento. El INR se incrementó en el 2.° día postoperatorio, 1,41 [0,99-2,30], normalizándose en la mayoría de los pacientes al 3.er día postoperatorio, 1,26 [0,90 - 2,20]. El tiempo medio de permanencia del catéter fue de 3,6 (±1,1) días. En 6 pacientes (8%), se aplazó la retirada por alteraciones de la coagulación. Conclusiones. La AE en la hepatectomía resultó una práctica segura, que produjo un óptimo control del dolor postoperatorio. El porcentaje de retiradas aplazadas de catéter por coagulopatía postoperatoria fue bajo, no requiriendo trasfusión de hemoderivados (AU)

Objectives. Perioperative epidural analgesia in liver resection provides optimal dynamic pain relief. Coagulation disorders occurring in the postoperative period can lead to greater risk of complications during epidural catheter removal. The aim of this study is to evaluate the effectiveness and complications of epidural analgesia and delayed epidural catheter removal due to postoperative coagulopathy. Methods. A retrospective study of 114 patients undergoing open liver resection and epidural analgesia, from March 2012 to February 2015. Postoperative course of pain intensity, coagulation parameters and delayed catheter removal was analyzed. Results. Of the 114 operated patients, 73 met the inclusion criteria. 59% of patients received major hepatectomy (resection ≥ 3 segments) and 15% had Child's Class A cirrhosis (11/73). 96% of catheters functioned properly. 89% of patients had controlled pain (numerical rate scale <3) at rest and 8.2% (6 patients) had severe pain (numerical rate scale > 6) with movement. The INR peaked on postoperative day 2, 1.41 [0.99-2.30], and gradually returned to normal values in most patients by postoperative day 4, 1.26 [0.90 - 2.20]. The catheters were left in place 3.6 (± 1.1) days. In 6 patients (8%), catheter removal was postponed due to coagulation disorders. Conclusions. Epidural analgesia for liver resection was a safe practice, which produced optimal control of postoperative pain. The percentage of delayed catheter removal due to postoperative coagulopathy was low, not requiring transfusion of blood products (AU)

Epidural anesthesia and analgesia in liver resection: Safety and effectiveness. / Anestesia y analgesia epidural en la resección hepática: seguridad y efectividad.

OBJECTIVES: Perioperative epidural analgesia in liver resection provides optimal dynamic pain relief. Coagulation disorders occurring in the postoperative period can lead to greater risk of complications during epidural catheter removal. The aim of this study is to evaluate the effectiveness and complications of epidural analgesia and delayed epidural catheter removal due to postoperative coagulopathy. METHODS: A retrospective study of 114 patients undergoing open liver resection and epidural analgesia, from March 2012 to February 2015. Postoperative course of pain intensity, coagulation parameters and delayed catheter removal was analyzed RESULTS: Of the 114 operated patients, 73 met the inclusion criteria. 59% of patients received major hepatectomy (resection ≥ 3 segments) and 15% had Child's Class A cirrhosis (11/73). 96% of catheters functioned properly. 89% of patients had controlled pain (numerical rate scale <3) at rest and 8.2% (6 patients) had severe pain (numerical rate scale > 6) with movement. The INR peaked on postoperative day 2, 1.41 [0.99-2.30], and gradually returned to normal values in most patients by postoperative day 4, 1.26 [0.90 - 2.20]. The catheters were left in place 3.6 (± 1.1) days. In 6 patients (8%), catheter removal was postponed due to coagulation disorders. CONCLUSIONS: Epidural analgesia for liver resection was a safe practice, which produced optimal control of postoperative pain. The percentage of delayed catheter removal due to postoperative coagulopathy was low, not requiring transfusion of blood products.

¿Influye la anestesia en los resultados de la cirugía oncológica? / Does the anesthesia have any influence on surgical outcome?

Los criterios de calidad en la cirugía oncológica radical se basan en la extirpación completa del tumor, con márgenes libres, sin enfermedad macroscópica residual, en una linfadenectomía adecuada y en la mínima manipulación tumoral posible. A pesar de conseguir estos objetivos, tras la extirpación puede quedar enfermedad residual no visible o micrometástasis, con potencial de crecimiento y diseminación, dependiendo de la capacidad tumoral y de las defensas del huésped. Tres factores perioperatorios pueden desplazar potencialmente el equilibrio hacia la progresión de la enfermedad residual mínima: a) la cirugía, por la manipulación, libera células tumorales a la circulación, deprime la inmunidad celular (IC), incluyendo la actividad citotóxica de las células Th1 (T helper) y las NK (natural killer), reduce los factores anti-angiogénicos e incrementa los pro-angiogénicos; b) los anestésicos generales, excepto el propofol, disminuyen la IC; y c) los opioides inhiben la IC y humoral y promueven el crecimiento tumoral. La anestesia y la analgesia regional bloquean las aferencias nociceptivas intraoperatorias y disminuyen o eliminan el dolor agudo postoperatorio. Combinada con la anestesia general, disminuiría el consumo de anestésicos volátiles, potencialmente inmunosupresores. Estas acciones preservan la inmunidad al disminuir la respuesta neuroendocrina e inflamatoria al estrés y el consumo de opioides. Los estudios experimentales apoyan esta hipótesis. Los estudios clínicos presentan resultados contradictorios. Desde el año 2000, se han realizado 21 estudios en cáncer de mama, próstata, colon y recto, pulmón, hígado y melanoma. Dieciséis son retrospectivos, 5 muestran resultados positivos en cuanto a la asociación de la analgesia epidural y la disminución de la recurrencia oncológica. Otros 5 muestran resultados parciales, y 6 estudios no mostraron ninguna asociación. Los 5 estudios prospectivos también muestran resultados variables. Los diferentes resultados clínicos pueden deberse a múltiples factores de confusión, como distintos grados histológicos, radioterapia y quimioterapia previas, diversos grados de dificultad y de radicalidad quirúrgica, la presencia de anemia previa, sangrado, transfusión o hipotermia. También pueden existir diferencias entre las técnicas anestésicas y el uso o no de la analgesia epidural en el intraoperatorio. La administración de fármacos potencialmente inmunoprotectores, como AINE, tramadol, β-bloqueantes y estatinas, pueden contribuir a enmascarar los resultados. Existen además problemas metodológicos, como tamaños de muestra pequeños para un potencial efecto positivo inferior al 30 %, mezclas heterogéneas de pacientes, de procedimientos quirúrgicos y de series antiguas y finalmente la dificultad de aislar un efecto dentro del entorno perioperatorio complejo y multifactorial. Quedan muchas preguntas pendientes, a la espera de ensayos prospectivos que acabarán dentro de 3 a 7 años. Los nuevos abordajes laparoscópicos, la cirugía mínimamente invasiva y la neoadyuvancia, han cambiado radicalmente el grado de agresión quirúrgica y probablemente también el impacto de las técnicas anestésicas inmunoprotectoras en la recurrencia quirúrgica. En la actualidad no hay evidencia que apoye una técnica anestésica sobre otra en la supervivencia oncológica

The following quality criteria management is considered in radical surgery for cancer, complete eradication of the tumor with negative surgical margins and without macroscopic residual tumor, adequate removal of lymph nodes and minimal manipulation of the tumor. Despite getting all these objectives, residual non-visible tumor or micrometastasis may persist after tumor resection therefore cancer cells can growth and disseminate depending on the aggressiveness of the tumor and host defenses. Three perioperative factors can contribute to cancer advance: a) Surgical manipulation that releases cancer cells to the bloodstream, diminishes cellular immunity, including T helper 1 (TH1) and natural killer (NK) cell activity, decreases anti-angiogenic factors and increases pro-angiogenic factors; b) general anaesthetics, except propofol, diminish cellular immunity; and c) opioids inhibit cellular and humoral immunity and promote cancer cell growth. Regional anaesthesia and analgesia block nociceptive afferents and decrease or eliminate acute postoperative pain. Combined with general anaesthesia would reduce the consumption of volatile anesthetics, potentially immunosuppressive. These actions preserve immunity due to the decrease of neuroendocrine and inflammatory response to stress and the consumption of opioids. Experimental studies support this hypothesis. Clinical studies show contradictory results. Since the year 2000, twenty one cancer studies for many types of cancer (breast, prostate, colon and rectum, lung, liver and melanoma) have been published. Sixteen studies are retrospective, 5 studies show positive correlation between epidural analgesia and decrease of cancer recurrence risk. Five studies show partial results and 6 studies did not show any association. Data from 5 prospective studies also show variable results. Differences in clinical studies results may be due to several confounding factors like different histological grading, radiotherapy and chemotherapy used previously, different technical difficulty and radical surgery grade, perioperative anaemia, bled, transfusion or hypothermia. Other causes of conflicting results are related to anaesthetic technique and the use or not of intraoperative epidural analgesia. The administration of drugs with potential immunosuppressive effects like non-steroidal anti-inflammatory drugs, tramadol, beta blockers and statins can also mask the results. There exist moreover methodological problems like small sample size to get a potential positive effect less than 30 %, patients, surgical procedures and old series heterogeneity and finally difficulty to isolate an effect from the complex and multifactorial perioperative environment. Many outstanding questions are waiting for prospective trials that end within 3 to 7 years. The new laparoscopic approaches, minimally invasive surgery and neoadjuvancy have radically changed the degree of surgical aggression and probably also the impact of the immunoprotective anesthetic techniques on surgical recurrence. Currently there is no evidence that supports one anesthetic technique over another in cancer survival (AU)

¿Influyen las técnicas anestésicas en los resultados postoperatorios? Parte II / Do anesthetic techniques influence postoperative outcomes? Part II

Conocer hasta qué punto nuestras técnicas anestésicas pueden modificar los resultados postoperatorios ha abierto en los últimos años un gran campo de investigación. En esta segunda parte, revisamos las principales controversias que plantea la literatura sobre el impacto de las técnicas anestésicas en los resultados postoperatorios, en 6 áreas principales: disfunción cognitiva postoperatoria, dolor crónico postoperatorio, recurrencia oncológica, náuseas/vómitos postoperatorios, resultados quirúrgicos y consumo de recursos. El desarrollo de estrategias anestésicas protectoras y preventivas frente a complicaciones postoperatorias a corto y largo plazo ocupará probablemente un papel importante en nuestra práctica anestésica diaria. El control del dolor dinámico postoperatorio es uno de los requisitos básicos de los programas de recuperación postoperatoria acelerada (cirugía fast-track). Además es un factor preventivo del desarrollo de dolor crónico postoperatorio. El peso de la técnica anestésica en la inmunosupresión postoperatoria está pendiente de definir. La posibilidad de que la anestesia influya en la recurrencia oncológica, es un área de investigación muy controvertida. Las pautas clásicas de fluidoterapia pueden incrementar las complicaciones postoperatorias. Por otro lado, el mantenimiento de la normoglucemia y de la normotermia se relaciona con una disminución de la morbilidad postoperatoria. El gran volumen de intervenciones quirúrgicas hace que la adecuación de los recursos humanos, organizativos y tecnológicos tenga un gran impacto en los costes totales(AU)

The knowledge of the influence of anesthetic techniques in postoperative outcomes has opened a large field of research in recent years. In this second part, we review some of the major controversies arising from the literature on the impact of anesthetic techniques on postoperative outcomes in 6 areas: postoperative cognitive dysfunction, chronic postoperative pain, cancer recurrence, postoperative nausea/vomiting, surgical outcomes, and resources utilization. The development of protective and preventive anesthetic strategies against short and long-term postoperative complications will probably occupy an important role in our daily anesthetic practice. Dynamic postoperative pain control has been confirmed as one of the basic requirements of accelerated postoperative recovery programs («fast-track surgery»), and it is also a preventive factor for development of chronic postoperative pain. The weight of anesthetic technique on postoperative immunosuppression is to be defined. The potential influence of anesthesia on cancer recurrence, is a highly controversial area of research. The classic pattern of perioperative fluid therapy may increase postoperative complications. On the other hand, the maintenance of normoglycemia and normothermia was associated with a decreased postoperative morbidity. The high volume of surgical procedures means that the adequacy of human, organizational and technological resources have a major impact on overall costs(AU)

¿Influyen las técnicas anestésicas en los resultados postoperatorios? Parte I / Do anesthetic techniques influence postoperative outcomes? Part I

La pregunta sobre si nuestras técnicas anestésicas pueden modificar los resultados postoperatorios ha abierto en los últimos años un gran campo de investigación. Los pacientes con riesgo sometidos a cirugía no cardíaca son los que presentan mayor incidencia de complicaciones postoperatorias y de mortalidad. Definir adecuadamente este grupo de pacientes permitiría concentrar esfuerzos y recursos para mejorar los resultados. La disminución progresiva de la mortalidad y de las complicaciones en los últimos 20 años está modificando el enfoque de la investigación en el área perioperatoria. La evaluación de los resultados intermedios postoperatorios probablemente discrimine mejor las diferencias de efectividad de las distintas modalidades anestésicas. Revisamos las principales controversias que plantea la literatura sobre el impacto de las técnicas anestésicas en los resultados postoperatorios. Para ello hemos definido 9 áreas principales en el campo de la investigación de resultados postoperatorios: mortalidad, complicaciones cardiovasculares, complicaciones respiratorias, disfunción cognitiva postoperatoria, dolor crónico postoperatorio, recurrencia oncológica, náuseas/vómitos postoperatorios, resultados quirúrgicos y consumo de recursos. En esta primera parte de la revisión, abordamos las bases de la investigación de resultados postoperatorios, la mortalidad, las complicaciones cardiovasculares y las respiratorias (AU)

The influence of anesthetic technique on postoperative outcomes has opened a wide field of research in recent years. High-risk patients undergoing non-cardiac surgery are those who have higher incidence of postoperative complications and mortality. A proper definition of this group of patients should focus maximal efforts and resources to improve the results. In view of the significant reduction in postoperative mortality and morbidity in last 20 years, perioperative research should take into account new indicators to investigate the role of anesthetic techniques on postoperative outcomes. Studies focused on the evaluation of intermediate outcomes would probably discriminate better effectiveness differences between anesthetic techniques. We review some of the major controversies arising in the literature about the impact of anesthetic techniques on postoperative outcomes. We have grouped the impact of these techniques into 9 major investigation areas: mortality, cardiovascular complications, respiratory complications, postoperative cognitive dysfunction, chronic postoperative pain, cancer recurrence, postoperative nausea/vomiting, surgical outcomes and resources utilization. In this first part of the review, we discuss the basis on postoperative outcomes research, mortality, cardiovascular and respiratory complications (AU)

[Do anesthetic techniques influence postoperative outcomes? Part II]. / ¿Influyen las técnicas anestésicas en los resultados postoperatorios? Parte II.

The knowledge of the influence of anesthetic techniques in postoperative outcomes has opened a large field of research in recent years. In this second part, we review some of the major controversies arising from the literature on the impact of anesthetic techniques on postoperative outcomes in 6 areas: postoperative cognitive dysfunction, chronic postoperative pain, cancer recurrence, postoperative nausea/vomiting, surgical outcomes, and resources utilization. The development of protective and preventive anesthetic strategies against short and long-term postoperative complications will probably occupy an important role in our daily anesthetic practice. Dynamic postoperative pain control has been confirmed as one of the basic requirements of accelerated postoperative recovery programs ("fast-track surgery"), and it is also a preventive factor for development of chronic postoperative pain. The weight of anesthetic technique on postoperative immunosuppression is to be defined. The potential influence of anesthesia on cancer recurrence, is a highly controversial area of research. The classic pattern of perioperative fluid therapy may increase postoperative complications. On the other hand, the maintenance of normoglycemia and normothermia was associated with a decreased postoperative morbidity. The high volume of surgical procedures means that the adequacy of human, organizational and technological resources have a major impact on overall costs.

[Do anesthetic techniques influence postoperative outcomes? Part I]. / ¿Influyen las técnicas anestésicas en los resultados postoperatorios? Parte I.

The influence of anesthetic technique on postoperative outcomes has opened a wide field of research in recent years. High-risk patients undergoing non-cardiac surgery are those who have higher incidence of postoperative complications and mortality. A proper definition of this group of patients should focus maximal efforts and resources to improve the results. In view of the significant reduction in postoperative mortality and morbidity in last 20 years, perioperative research should take into account new indicators to investigate the role of anesthetic techniques on postoperative outcomes. Studies focused on the evaluation of intermediate outcomes would probably discriminate better effectiveness differences between anesthetic techniques. We review some of the major controversies arising in the literature about the impact of anesthetic techniques on postoperative outcomes. We have grouped the impact of these techniques into 9 major investigation areas: mortality, cardiovascular complications, respiratory complications, postoperative cognitive dysfunction, chronic postoperative pain, cancer recurrence, postoperative nausea/vomiting, surgical outcomes and resources utilization. In this first part of the review, we discuss the basis on postoperative outcomes research, mortality, cardiovascular and respiratory complications.

La transición de dolor agudo postoperatorio a crónico: ¿qué sabemos? / No disponible

La transición del dolor agudo postoperatorio a crónico es un proceso complejo, poco conocido y de interés creciente en los últimos años. Los cuadros dolorosos crónicos derivados de determinados procedimientos quirúrgicos como la toracotomía, la mastectomía o la amputación se asocian a una elevada prevalencia. Sin embargo, han sido identificados una serie de factores pronósticos o predictivos relacionados con la aparición de dichos cuadros dolorosos. Su detección precoz permitiría iniciar tratamientos analgésicos preventivos con el objetivo de evitar dicha transición (AU)

The transition from acute to chronic postoperative pain is a complex process, little well known process and of increasing interest in the last years. Certain surgical procedures such as thoracotomy, mastectomy or amputation are associated to high prevalence of painfull chronic syndromes. Nevertheless, series of predictive factors have been identified in development of chronic postoperative pain. Its early detection would allow initiating analgesic preventive treatments with the aim of avoiding this transition (AU)

Atención del dolor agudo postoperatorio: evaluación de resultados en las salas de hospitalización quirúrgicas / Treating acute postoperative pain: evaluation of results on the surgical ward

Objetivos: Describir el tratamiento global del dolor agudo postoperatorio en las salas de hospitalización quirúrgicas. Relacionar el grado de dolor con los distintos tipos de abordajes y procedimientos quirúrgicos. Por último, registrar el grado de información, las expectativas y la satisfacción de los pacientes con la atención recibida en el tratamiento del dolor postoperatorio. Pacientes y Métodos: Estudio observacional transversal mediante entrevista y revisión de historia clínica. Se evaluaron 234 pacientes, incluyendo todos los pacientes postoperados ingresados más de 24 horas a partir del día de la intervención quirúrgica, de cirugía programada o urgente. Los principales parámetros registrados fueron, la intensidad del dolor en reposo y en movimiento, el día del postoperatorio, el tipo de abordaje y el procedimiento quirúrgico. Resultados: El registro del dolor agudo postoperatorio en las salas quirúrgicas, mostró una prevalencia de dolor en reposo (valor en la escala numérica > 3) del 33% y en movimiento del 66%. El porcentaje de dolor intenso (valor en la escala numérica > 6) en reposo fue de 1,7% y en movimiento de 7,3%. Los factores que se relacionaron con la mayor intensidad del dolor fueron, el primer día del postoperatorio, en el que el 74,4% de los pacientes presentaron los valores máximos de dolor, el tipo de abordaje y procedimiento quirúrgico (p < 0,004), y finalmente las expectativas de sufrir dolor moderado o intenso (p < 0,001). Conclusiones: Registrar la prevalencia del dolor postoperatorio en las salas de hospitalización quirúrgicas nos permite conocer el estado actual del tratamiento del dolor agudo postoperatorio. El dolor al movimiento es uno de los principales indicadores para detectar grupos de pacientes en los que es posible mejorar las pautas analgésicas. El abordaje y el tipo de procedimiento quirúrgico es un factor básico a tener en cuenta para poder comparar resultados analgésicos(AU)

Objective: To describe management of acute postoperative pain on the surgical ward. To study the relationship between pain and a variety of surgical procedures and approaches. To determine the level of information patients received, their expectations, and their satisfaction with treatment of postoperative pain. Patients and methods: Cross-sectional observational study by survey and review of patient records. We studied 234 patients, including all who were hospitalized for more than 24 hours after scheduled or emergency operations. The main variables recorded were pain intensity at rest and during movement, including on the day after surgery, and the surgical procedure and approach. Results: The prevalence of pain (>3 on a numerical scale) on the surgical ward was 33% at rest and 66% during movement. The prevalence of intense pain (>6 on the numerical scale) was 1.7% at rest and 7.3% during movement. Factors related to greater pain intensity were timing, that is, the first day after surgery, when 74.4% of patients experienced their most intense pain; type of surgery and approach (P<.004); and expecting to experience moderate or intense pain (P<.001). Conclusions: Recording the prevalence of postoperative pain on a surgical ward provides information about the real situation of acute postoperative pain control. Pain on movement is a principal indicator for detecting groups of patients for whom analgesic protocols could be improved. Type of surgery and approach is a fundamental factor to consider when comparing the results of analgesic protocols(AU)

[Treating acute postoperative pain: evaluation of results on the surgical ward]. / Atencióón del dolor agudo postoperatorio: evaluación de resultados en las salas de hospitalizacidón quirúrgicas.

OBJECTIVE: To describe management of acute postoperative pain on the surgical ward. To study the relationship between pain and a variety of surgical procedures and approaches. To determine the level of information patients received, their expectations, and their satisfaction with treatment of postoperative pain. PATIENTS AND METHODS: Cross-sectional observational study by survey and review of patient records. We studied 234 patients, including all who were hospitalized for more than 24 hours after scheduled or emergency operations. The main variables recorded were pain intensity at rest and during movement, including on the day after surgery, and the surgical procedure and approach. RESULTS: The prevalence of pain (>3 on a numerical scale) on the surgical ward was 33% at rest and 66% during movement. The prevalence of intense pain (>6 on the numerical scale) was 1.7% at rest and 7.3% during movement. Factors related to greater pain intensity were timing, that is, the first day after surgery, when 74.4% of patients experienced their most intense pain; type of surgery and approach (P<.004); and expecting to experience moderate or intense pain (P<.001). CONCLUSIONS: Recording the prevalence of postoperative pain on a surgical ward provides information about the real situation of acute postoperative pain control. Pain on movement is a principal indicator for detecting groups of patients for whom analgesic protocols could be improved. Type of surgery and approach is a fundamental factor to consider when comparing the results of analgesic protocols.

Atención del dolor agudo postoperatorio: evaluación de resultados en las salas de hospitalización quirúrgicas / Treating acute postoperative pain: evaluation of results on the surgical ward

Objetivos: Describir el tratamiento global del dolor agudo postoperatorio en las salas de hospitalización quirúrgicas. Relacionar el grado de dolor con los distintos tipos de abordajes y procedimientos quirúrgicos. Por último, registrar el grado de información, las expectativas y la satisfacción de los pacientes con la atención recibida en el tratamiento del dolor postoperatorio. Pacientes y Métodos: Estudio observacional transversal mediante entrevista y revisión de historia clínica. Se evaluaron 234 pacientes, incluyendo todos los pacientes postoperados ingresados más de 24 horas a partir del día de la intervención quirúrgica, de cirugía programada o urgente. Los principales parámetros registrados fueron, la intensidad del dolor en reposo y en movimiento, el día del postoperatorio, el tipo de abordaje y el procedimiento quirúrgico. Resultados: El registro del dolor agudo postoperatorio en las salas quirúrgicas, mostró una prevalencia de dolor en reposo (valor en la escala numérica > 3) del 33% y en movimiento del 66%. El porcentaje de dolor intenso (valor en la escala numérica > 6) en reposo fue de 1,7% y en movimiento de 7,3%. Los factores que se relacionaron con la mayor intensidad del dolor fueron, el primer día del postoperatorio, en el que el 74,4% de los pacientes presentaron los valores máximos de dolor, el tipo de abordaje y procedimiento quirúrgico (p < 0,004), y finalmente las expectativas de sufrir dolor moderado o intenso (p < 0,001). Conclusiones: Registrar la prevalencia del dolor postoperatorio en las salas de hospitalización quirúrgicas nos permite conocer el estado actual del tratamiento del dolor agudo postoperatorio. El dolor al movimiento es uno de los principales indicadores para detectar grupos de pacientes en los que es posible mejorar las pautas analgésicas. El abordaje y el tipo de procedimiento quirúrgico es un factor básico a tener en cuenta para poder comparar resultados analgésicos(AU)

Objective: To describe management of acute postoperative pain on the surgical ward. To study the relationship between pain and a variety of surgical procedures and approaches. To determine the level of information patients received, their expectations, and their satisfaction with treatment of postoperative pain. Patients and methods: Cross-sectional observational study by survey and review of patient records. We studied 234 patients, including all who were hospitalized for more than 24 hours after scheduled or emergency operations. The main variables recorded were pain intensity at rest and during movement, including on the day after surgery, and the surgical procedure and approach. Results: The prevalence of pain (>3 on a numerical scale) on the surgical ward was 33% at rest and 66% during movement. The prevalence of intense pain (>6 on the numerical scale) was 1.7% at rest and 7.3% during movement. Factors related to greater pain intensity were timing, that is, the first day after surgery, when 74.4% of patients experienced their most intense pain; type of surgery and approach (P<.004); and expecting to experience moderate or intense pain (P<.001). Conclusions: Recording the prevalence of postoperative pain on a surgical ward provides information about the real situation of acute postoperative pain control. Pain on movement is a principal indicator for detecting groups of patients for whom analgesic protocols could be improved. Type of surgery and approach is a fundamental factor to consider when comparing the results of analgesic protocols(AU)

Limitaciones en el uso de opiáceos mayores en dolor crónico no oncológico: ¿"errare humanum est" o procrastinación médica? / No disponible

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Controversias de las vías clínicas quirúrgicas. Propuesta de selección de puntos clave e indicadores de calidad y eficiencia / Controversies in clinical surgery. Proposals for the selection of key points and indicators of quality and efficiency

Proponemos un modelo general de vía clínica quirúrgica como base para su desarrollo y aplicación a un proceso quirúrgico determinado, en un contexto profesional, organizativo v de financiación específico. Este modelo está basado en nuestra experiencia en las fases de discusión y selección de los puntos críticos e indicadores de calidad y eficiencia de las vías clínicas implantadas en nuestro hospital. Planteamos diversas opciones de seguimiento y mostramos un resumen de los resultados preliminares de dos de las vías clínicas implantadas. Se discuten las controversias sobre la efectividad dula implantación de las vías. Concluimos que las vías clínicas son una herramienta para el análisis de: los procesos asistenciales desde el punto de vista clínico, organizativo y de la adecuación de recursos. El inicio de su implantación en el hospital, nos ha permitido definir el curso asistencial óptimo que debería seguir un paciente quirúrgico. Proponemos las líneas básicas que desde el punto de vista de la gestión de procesos, apoyarían el cambio cultural y organizativo necesario para modificar un sistema asistencial fragmentado (AU)

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Quality indicators in ambulatory surgery. A prospective study.

Introduction: Ambulatory Surgery has emerged and developed in Spain in a similar way as in other occidental countries. Once established as a model for surgical care, results must be improved using objective quality indicators to assure minimal morbidity, efficient use of resources and satisfaction of patients and family. Objective: To provide a list of quality assessment indicators in Ambulatory Surgery and to discuss the necessity of obtaining a general consensus regarding the complexity of both the operations and the patients undergoing surgery. Design: Prospective and descriptive study. Patients and Methods: The study was performed on 833 ambulatory patients operated on in the Ambulatory Surgical Unit of the Can Misses Hospital of Ibiza. Surgical specialities involved were General Surgery, Ophthalmology, Orthopaedics, Urology, Gynaecology, and E.N.T. All diagnoses and proceedings were classified according to the CIE-9 and DGR systems, showing as an example the codes related to the General Surgery department. Quality Indicators evaluated were: (a) unplanned admission index; (b) re-admission index; (c) emergency department consultations; (d) cancellation index; (e) substitution index; and (f) postoperative pain evaluation. Results: Specialities involved were: Ophthalmology 277 patients (33.2%), General Surgery 189 (22.8%), Orthopaedics 142 (17%), Urology 90 (10.8%), E.N.T. 79 (9.5%) and Gynaecology 56 (6.7%). Unplanned Admission Index was 7.2%; Re-Admission Index 0.4%; Emergency department consultation 1.6%; Cancellation Index 3.3% and Substitution Index 70%. The reasons for unplanned admission were due to specific complications in 36 cases (60.1%), followed by those secondary to an inadequate selection of the patient in 22 cases (36.6%). Conclusions: It is necessary to apply a series of Quality Indicators in Ambulatory Surgery. Their systematic evaluation may help us define national standards in order to continuously improve our results.

[Primary meningococcal conjunctivitis: implications beyond the conjunctiva]. / Conjuntivitis meningocócica primaria: implicaciones más allá de la conjuntiva.

BACKGROUND: Neisseria meningitidis is a uncommon cause of acute bacterial conjunctivitis. However, its diagnosis has important therapeutic implications. METHODS: From December 1993 to January 1984, a prospective study on acute bacterial conjunctivitis was performed at the Hospital Universitario Materno-Infantil Vall d'Hebron. Primary meningococcal conjunctivitis (PMC) was diagnosed in 34 patients. The diagnosis of PMC was made on the basis of consistent clinical manifestations together with isolation of Neisseria meningitidis from conjunctival exudate culture. RESULTS: There were 16 men and 18 women with a mean age of 3.5 +/- 3.3 years. PMC was bilateral in 7 patients and unilateral in 27. Initial therapy for PMC included only topical antibiotics in 24 patients and systemic antibiotic therapy in 10. Ten patients (29.4%) developed invasive meningococcal disease. None of the patients died neither developed ocular sequelae. Forty one percent of the patients who received only topical therapy and none [corrected] of those who received systemic therapy, developed invasive meningococcal disease (p = 0.04). CONCLUSIONS: PMC may represent the portal of entry for invasive meningococcal disease, which occurs in almost a third of patients. Patients with PMC and higher risk of developing invasive meningococcal disease are those treated only with topical antibiotic therapy.