[Results of implementation of a perioperative Patient Blood Management program in cardiovascular surgery]. / Resultados de la implementación de un programa de optimización de transfusión sanguínea en cirugía cardiovascular.

BACKGROUND AND OBJECTIVE: Cardiovascular surgery (CCV) patients have a high incidence of perioperative anemia and bleeding that determines a high rate of allogeneic blood transfusion (AST). This is associated with an increase in morbidity, mortality and prolongs length of stay in hospital. Unnecessary transfusion is one of the measures to avoid and Patient Blood Management (PBM) programs have proven their effectiveness. Our objective was to reduce the transfusion of patients in cardiac surgery, without inferior results in morbidity and mortality, length of stay in hospital and being cost-effective, through the implementation of a PBM program. MATERIAL AND METHODS: A mixed cohort study of 226 patients divided into 2 groups: retrospective pre-PBM (GP), from 2016, and intervention group (IG), prospective from 2018, with the results of the implementation of the guide. RESULTS: The clinical results obtained allowed reducing the TSA from 92.59% to 79.69% (P<.001), saving 2.59 units of CH and 2.5 of PFC per patient (P<.001). A decrease was found in patients with fever (12.35% vs 1.56% with P=.006) and the need to escalate antibiotics (64.8% vs 42.19%, P=.002). The rest of postoperative complications and mortality at 3months did not present statistically significant differences. The length of stay was reduced by an average 3.6days in the IG, (95%CI: -8.10 to 0.9, P=.18). The cost decreased by 163.29€ per patient, taking into account exclusively the saving of blood components. CONCLUSION: The PBM program is effective in reducing TSA in cardiac surgery in a tertiary hospital with high complexity patients and high transfusion rate. There are signs suggestive of a decrease in infections and a tendency to decrease the length of stay and mortality. In the economic approximation carried out, the cost of the intervention was lower than the savings implied by the decrease in transfusion.

Actualización del protocolo de tratamiento de la hemorragia obstétrica: respuesta de los autores / An update of the obstetrics hemorrhage treatment protocol: Author's reply

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Técnicas analgésicas para el parto: alternativas en caso de fallo de la epidural / Analgesic techniques for labour: alternatives in case of epidural failure

La analgesia epidural es hoy día el método de elección para el tratamiento del dolor del trabajo de parto, el expulsivo y el alumbramiento. Sin embargo, esta técnica puede fallar y aliviar de forma inadecuada (o nula) a la parturienta. En el presente artículo se revisan los factores de riesgo, las posibles causas y las alternativas terapéuticas posibles a la analgesia inadecuada, ya sea mediante terapias farmacológicas (neuroaxiales, bloqueos periféricos o administración de analgésicos vía intravenosa o inhalatoria) o no farmacológicas (técnicas de relajación, psicológicas o mecánicas). En todos los casos posibles se revisan la eficacia y las indicaciones de las terapias alternativas en función de la literatura publicada, especialmente desde el punto de vista de la medicina basada en la evidencia. Se insiste en la necesidad de aplicar una aproximación terapéutica multifactorial a la embarazada, no limitándonos solo a eliminar el dolor del parto (AU)

Epidural analgesia is now the method of choice for the treatment of pain in labour and delivery. However, this technique may fail and provide inadequate or null alleviation to the mother. This paper reviews the risk factors, possible causes and possible therapeutic alternatives to inadequate analgesia, whether pharmacological therapies (neuroaxial, peripheral blocks or analgesic administration via intravenous or inhalational routes) or non-pharmacological ones (relaxation techniques, psychological or mechanical). In all possible cases the efficacy and indications of alternative therapies based on the published literature are reviewed, especially from the point of view of evidence-based medicine. The need is underscored of a multifactorial therapeutic approach to the pregnant woman, not just restricting ourselves to eliminating the pain of childbirth (AU)

Actualización del protocolo de tratamiento de la hemorragia obstétrica / An update of the obstetrics hemorrhage treatment protocol

La hemorragia obstétrica es aún hoy día una importante causa de morbimortalidad maternofetal en los países desarrollados. Se trata de un problema infraestimado, que generalmente aparece de forma impredecible. La morbimortalidad de la hemorragia obstétrica se considera evitable en una elevada proporción si el manejo es adecuado. Las guías clínicas de mayor difusión mundial recomiendan por consenso protocolizar el manejo, adaptarlo al ámbito local y mantenerlo actualizado en función de la experiencia y de las nuevas publicaciones científicas. Exponemos un protocolo actualizado conforme a las últimas recomendaciones y a nuestra propia experiencia, para que pueda ser utilizado como elemento base por aquellos anestesiólogos que así lo deseen, adaptado a su ámbito local de trabajo diario. Este último aspecto es muy importante para que sea eficaz, y es una labor que debe realizarse en cada centro conforme a la disponibilidad de medios, personal y características arquitectónicas (AU)

Obstetric hemorrhage is still a major cause of maternal and fetal morbimortality in developed countries. This is an underestimated problem, which usually appears unpredictably. A high proportion of the morbidity of obstetric hemorrhage is considered to be preventable if adequately managed. The major international clinical guidelines recommend producing consensus management protocols, adapted to local characteristics and keep them updated in the light of experience and new scientific publications. We present a protocol updated, according to the latest recommendations, and our own experience, in order to be used as a basis for those anesthesiologists who wish to use and adapt it locally to their daily work. This last aspect is very important to be effective, and is a task to be performed at each center, according to the availability of resources, personnel and architectural features (AU)

The effect of intravenous ondansetron on maternal haemodynamics during elective caesarean delivery under spinal anaesthesia: a double-blind, randomised, placebo-controlled trial.

BACKGROUND: Spinal anaesthesia for caesarean delivery is frequently associated with adverse effects such as maternal hypotension and bradycardia. Prophylactic administration of ondansetron has been reported to provide a protective effect. We studied the effect of different doses of ondansetron in obstetric patients. METHODS: This prospective double-blind, randomised, placebo-controlled study included 128 healthy pregnant women scheduled for elective caesarean delivery under spinal anaesthesia. Women were randomly allocated into four groups (n=32) to receive either placebo or ondansetron 2, 4 or 8 mg intravenously before induction of spinal anaesthesia. Demographic, obstetric, intraoperative timing and anaesthetic variables were assessed at 16 time points. Anaesthetic variables assessed included blood pressure, heart rate, oxygen saturation, nausea, vomiting, electrocardiographic changes, skin flushing, discomfort or pruritus and vasopressor requirements. RESULTS: There were no differences in the number of patients with hypotension in the placebo (43.8%) and ondansetron 2mg (53.1%), 4 mg (56.3%) and 8 mg (53.1%) groups (P=0.77), nor the percentage of time points with systolic hypotension (7.3% in the placebo group and 11.1%, 15.7% and 12.6% in the ondansetron 2, 4 and 8 mg groups, respectively, P=0.32). There were no differences between groups in ephedrine (P=0.11) or phenylephrine (P=0.89) requirements and the number of patients with adverse effects. CONCLUSIONS: In our study, prophylactic ondansetron had little effect on the incidence of hypotension in healthy parturients undergoing spinal anaesthesia with bupivacaine and fentanyl for elective caesarean delivery.

[An update of the obstetrics hemorrhage treatment protocol]. / Actualización del protocolo de tratamiento de la hemorragia obstétrica.

Obstetric hemorrhage is still a major cause of maternal and fetal morbimortality in developed countries. This is an underestimated problem, which usually appears unpredictably. A high proportion of the morbidity of obstetric hemorrhage is considered to be preventable if adequately managed. The major international clinical guidelines recommend producing consensus management protocols, adapted to local characteristics and keep them updated in the light of experience and new scientific publications. We present a protocol updated, according to the latest recommendations, and our own experience, in order to be used as a basis for those anesthesiologists who wish to use and adapt it locally to their daily work. This last aspect is very important to be effective, and is a task to be performed at each center, according to the availability of resources, personnel and architectural features.

[Analgesic techniques for labour: alternatives in case of epidural failure]. / Técnicas analgésicas para el parto: alternativas en caso de fallo de la epidural.

Epidural analgesia is now the method of choice for the treatment of pain in labour and delivery. However, this technique may fail and provide inadequate or null alleviation to the mother. This paper reviews the risk factors, possible causes and possible therapeutic alternatives to inadequate analgesia, whether pharmacological therapies (neuroaxial, peripheral blocks or analgesic administration via intravenous or inhalational routes) or non-pharmacological ones (relaxation techniques, psychological or mechanical). In all possible cases the efficacy and indications of alternative therapies based on the published literature are reviewed, especially from the point of view of evidence-based medicine. The need is underscored of a multifactorial therapeutic approach to the pregnant woman, not just restricting ourselves to eliminating the pain of childbirth.

[Clinical and pharmacological study of the efficacy of carbetocin in elective caesareans compared to low and usual doses of oxytocin]. / Estudio clínico y farmacoeconómico de la eficacia de la carbetocina en cesáreas electivas respecto a la oxitocina a dosis bajas y a dosis habituales.

OBJECTIVES: To evaluate uterine contractility, bleeding, haemodynamic performance, and side effects of different doses of oxytocin after delivery under spinal anaesthesia in caesarean section without prior labour in childbirth. We also perform a pharmacoeconomic evaluation. MATERIAL AND METHODS: A randomised, descriptive, observational and multicentre prospective study was conducted, which included 104 ASA 1 patients divided into 3 groups. Group 1 (n=52) received after removal of the foetus and coinciding with foetal umbilical cord clamping, 1 IU of oxytocin followed by an infusion of 2.5 UI×h(-1); Group 2 (n=52) a continuous infusion of 20IU oxytocin at a rate of 700mUI×min(-1) followed later by 10UI×h(-1), and group 3, 100µg bolus dose of carbetocin only. RESULTS: There were no statistical differences between groups in anthropometric, obstetric or anaesthetic variables. Significant differences in uterine contraction in vaginal bleeding and the incidence of side effects, particularly headache and tremor, were more pronounced in the carbetocin group. CONCLUSIONS: With these results, we cannot recommend the routine use of carbetocin in caesarean sections, because it is accompanied by an increased incidence of side effects without any improvement in the prevention of obstetric haemorrhage. Finally, it is economically more expensive than the use of low doses of oxytocin, which may be the trend that should be considered in the future, due to the clinical outcomes, and its lower cost.

[Pharmacoeconomics: basic concepts and applications to clinical anesthesia]. / Fundamentos de farmacoeconomía y su aplicación en anestesia clínica.

The economic evaluation of medications and health care technology has gained importance in recent years. Health care resources are limited and their use must be optimized so that we can take the greatest possible advantage. Pharmacoeconomics seeks to analyze the best therapeutic drug choices to obtain the desired outcome in specific cases or in populations. The 4 approaches used in pharmacoeconomics are cost-minimization analysis, cost-benefit analysis, cost-effectiveness analysis, and cost-utility analysis. This review examines the characteristics of each type of study using examples from anesthesiology, a field in which pharmacoeconomics is beginning to play a role.

Fundamentos de farmacoeconomía y su aplicación en anestesia clínica / Pharmacoeconomics: basic concepts and applications to clinical anesthesia

La evaluación económica de medicamentos y tecnologías sanitarias es una disciplina en auge en nuestros tiempos. Los recursos sanitarios son limitados y debemos aprovecharlos del mejor modo posible. La Farmacoeconomía se encarga especificamente del análisis de la mejor opción farmacológicaterapéutica, para aplicar a un determinado paciente o población con el objetivo de obtener un efecto deseado. Hay fundamentalmente cuatro tipos de estudios empleados en Farmacoeconomía: los estudios de minimización de costes, análisis coste-beneficio, análisis coste-efectividad y análisis costeutilidad. En el presente artículo se revisan sus características y ejemplos de su aplicación en Anestesiología, un campo aun incipiente en nuestra especialidad(AU)

The economic evaluation of medications and health care technology has gained importance in recent years. Health care resources are limited and their use must be optimized so that we can take the greatest possible advantage. Pharmacoeconomics seeks to analyze the best therapeutic drug choices to obtain the desired outcome in specific cases or in populations. The 4 approaches used in pharmacoeconomics are cost-minimization analysis, cost-benefit analysis, cost-effectiveness analysis, and cost-utility analysis. This review examines the characteristics of each type of study using examples from anesthesiology, a field in which pharmacoeconomics is beginning to play a role(AU)

[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.

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

En recientes publicaciones han aparecido múltiplesestudios sobre la importancia de la monitorizaciónneuromuscular cuantitativa y la alta incidencia delbloqueo residual en la práctica clínica, a pesar de lautilización de fármacos bloqueantes neuromusculares nodespolarizantes de duración intermedia. El uso de lamonitorización neuromuscular permite realizar unaparálisis muscular a medida y recuperar al pacienteadecuadamente al final de la cirugía, evitando ocontrolando el bloqueo residual, y sirviendo de guía parala utilización de los reversores de dicho bloqueo. Estarevisión describe específicamente la fisiología de la uniónneuromuscular, principios, patrones de estimulación ypráctica de la monitorización neuromuscular en laclínica. Además de la propia experiencia de los autoresen el uso de la monitorización neuromuscular, se harealizado una revisión de la literatura médica existentehasta diciembre de 2008 mediante una búsqueda en lasbases de datos de medicina basada en la evidencia, y enlas bases de datos bibliográficas. La mayor parte de lasreferencias encontradas son series de casos y revisiones.La monitorización cuantitativa es una práctica basadaen la evidencia que debe consecuentemente utilizarsesiempre que se utiliza un bloqueo neuromuscular(AU)

Many recent studies have underlined the importanceof quantitative neuromuscular monitoring and the highincidence of residual block in clinical practice in spite ofthe use of nondepolarizing neuromuscular blockers ofintermediate duration. Neuromuscular monitoringfacilitates the tailoring of the muscular paralysis andappropriate patient recovery at the end of surgery.Monitoring also controls or prevents residual block andserves to guide the use of reversing agents. This reviewdescribes the physiology of neuromuscular junctions aswell as the principles and patterns of nerve stimulationand clinical monitoring. In addition to drawing on theirown experience, the authors have reviewed the literatureavailable through evidence-based indexes and otherdatabases up to December 2008. Most references foundwere case series and reviews. Quantitative monitoring isan evidence-based practice that should be applied in allsituations in which a neuromuscular block is established(AU)

Monitorización del bloqueo neuromuscular. 2ª parte / No disponible

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[Effects of changes in ion concentrations, osmolarity, and pH on recovery from atracurium- or vecuronium-induced neuromuscular blockade]. / Efecto de las variaciones iónicas, la osmolaridad y el pH sobre la recuperación del bloqueo neuromuscular no despolarizante por atracurio y vecuronio.

OBJECTIVES: To determine changes in sodium, potassium, calcium, magnesium and chloride ion concentrations in blood, osmolarity, and pH during surgery, and to assess the influence of such changes on atracurium- or vecuronium-induced neuromuscular blockade under inhaled or intravenous anesthesia. MATERIAL AND METHODS: Prospective study randomizing 119 ASA 1-2 patients; 52.1% of the patients received atracurium (26.8%, with isoflurane; 25.2%, with propofol) and 47.9% received vecuronium (23.5%, with isoflurane; 24.3%, with propofol). The neuromuscular blockade was confirmed by electromyography of the adductor pollicis muscle (stimuli delivered to the cubital nerve). Two venous blood samples were extracted to measure ureic nitrogen, creatinine, glucose, ion concentrations (sodium, chloride, potassium, calcium, and magnesium), and osmolarity. Arterial blood gases and pH were also assessed. The first blood sample was extracted on inserting the venous catheter and the second on recovery of 25% of the first train-of-four twitch. RESULTS: The onset and duration of action for equipotent doses of atracurium and vecuronium were similar. Likewise, recovery was also similar. Plasma chloride ion and glucose levels tended to rise during surgery, while sodium, potassium and magnesium ion concentrations fell. Both total and effective plasma osmolarities also decreased. Fluid replacement therapy during surgery was at least partly responsible for these changes. Low calcium and magnesium concentrations and alkalosis prolonged some phases of atracurium recovery, while low sodium levels shortened the duration of some atracurium-induced blockade recovery phases. The effect of changes in chloride ion concentrations on recovery was variable. High chloride, low calcium, and especially low sodium ion concentrations shortened some phases of the vecuronium-induced blockade, while alkalosis prolonged its duration. CONCLUSIONS: Changes in electrolyte concentrations and pH as a result of standard fluid replacement therapy are moderate, well tolerated, and do not exercise a strong effect on the behavior of the neuromuscular blockade.

Efecto de las variaciones iónicas, la osmolaridad y el pH sobre la recuperación del bloqueo neuromuscular no despolarizante por atracurio y vecuronio / Effects of changes in ion concentrations, osmolarity, and pH on recovery from atracurium- or vecuronium-induced neuromuscular blockade

OBJETIVOS: Cuantificar las variaciones del sodio,potasio, calcio, magnesio, cloro, osmolaridad y pH en elintraoperatorio y valorar su influencia sobre el bloqueoneuromuscular (atracurio y vecuronio) durante anestesiainhalatoria o intravenosa.MATERIAL Y MÉTODOS: Estudio prospectivo aleatorizado.Se incluyeron 119 pacientes ASA I-III. El 52,1% recibieronatracurio (atracurio e isoflurano, 26,8%, atracurioy propofol, 25,2%) y 47,9% vecuronio (vecuronio eisoflurano, 23,5%, vecuronio y propofol, 24,3%) respectivamente.El BNM se objetivó mediante electromiografíadel músculo adductor pollicis con estimulación delnervio cubital. Se extrajeron dos muestras venosas,determinando BUN (nitrógeno ureico en sangre), creatinina,glucosa, iones (sodio, cloro, potasio, calcio y magnesio)la osmolaridad y una gasometría arterial. La primeramuestra se obtuvo al canalizar la vía y la segundacoincidiendo con recuperación del BNM correspondientea la duración de acción del 25%.RESULTADOS: Atracurio o vecuronio, a dosis equipotentespresentan un inicio de acción, duración y recuperaciónsimilares. Durante la cirugía existe una tendenciaal aumento de los niveles plasmáticos de cloro y glucosa,y a la disminución de los de sodio, potasio, magnesio y dela osmolaridad plasmática efectiva y total, siendo la fluidoterapiaintraoperatoria responsable, al menos en parte,de ello. La hipocalcemia, la hipomagnesemia y laalcalosis prolongan al menos algunas fases de la recuperacióndel atracurio, mientras que la hiponatremia loacorta y las variaciones de la cloremia ejercen un efectoerrático. Para el vecuronio, la hipercloremia, la hipocalcemiay sobre todo la hiponatremia, acortan algunasfases del bloqueo, mientras que la alcalosis prolonga suduración...(AU)

OBJECTIVES: To determine changes in sodium,potassium, calcium, magnesium and chloride ionconcentrations in blood, osmolarity, and pH duringsurgery, and to assess the influence of such changes onatracurium- or vecuronium-induced neuromuscularblockade under inhaled or intravenous anesthesia.MATERIAL AND METHODS: Prospective study randomizing119 ASA 1-2 patients; 52.1% of the patients receivedatracurium (26.8%, with isoflurane; 25.2%, with propofol)and 47.9% received vecuronium (23.5%, with isoflurane;24.3%, with propofol). The neuromuscular blockade wasconfirmed by electromyography of the adductor pollicismuscle (stimuli delivered to the cubital nerve). Two venousblood samples were extracted to measure ureic nitrogen,creatinine, glucose, ion concentrations (sodium, chloride,potassium, calcium, and magnesium), and osmolarity.Arterial blood gases and pH were also assessed. The firstblood sample was extracted on inserting the venouscatheter and the second on recovery of 25% of the firsttrain-of-four twitch.RESULTS: The onset and duration of action forequipotent doses of atracurium and vecuronium weresimilar. Likewise, recovery was also similar. Plasmachloride ion and glucose levels tended to rise duringsurgery, while sodium, potassium and magnesium ionconcentrations fell. Both total and effective plasmaosmolarities also decreased. Fluid replacement therapyduring surgery was at least partly responsible for thesechanges. Low calcium and magnesium concentrationsand alkalosis prolonged some phases of atracurium recovery, while low sodium levels shortened the durationof some atracurium-induced blockade recovery phases.The effect of changes in chloride ion concentrations onrecovery was variable. High chloride, low calcium, andespecially low sodium ion concentrations shortened somephases of the vecuronium-induced blockade, whilealkalosis prolonged its duration...(AU)

Parestesias con diferentes técnicas de anestesia subaracnoidea en la cesárea / Paresthesia in various spinal anesthesia techniques for cesarean section

OBJETIVO: Determinar el porcentaje de parestesiasusando diferentes técnicas de punción subaracnoideacon una aguja Whitacre 27-G.MATERIAL Y MÉTODO: Se realizaron diferentes técnicasde punción subaracnoidea en 224 cesáreas electivas.Estudio simple ciego, prospectivo y aleatorizado distribuido en 4 grupos de 56 pacientes cada uno. Grupo-1: punción epidural-subaracnoidea combinada, usandoaguja espinal con fiador; grupo 2: punción epiduralsubaracnoidea combinada, usando aguja espinal sin fiador; grupo 3: punción subaracnoidea con fiador; grupo 4: punción subaracnoidea con fiador hasta milímetros antes de llegar al saco dural, en que se retira el fiador.RESULTADOS: Los pacientes que presentaron parestesiasfueron 23, 11, 16 y 5 en los grupos 1, 2, 3 y 4 respectivamente. Las parestesias afectaron a diferentes raíces nerviosas. En 2, 11, 29 y 13 casos afectaron a lasraíces nerviosas cuarta y quinta lumbar, primera ysegunda sacra respectivamente. El riesgo de parestesiasfue 7; 2,5 y 4 veces mayor en los grupos 1, 2 y 3 con respecto al grupo 4.CONCLUSIONES: La punción epidural-subaracnoideacombinada presenta mayor número de parestesias que lapunción subaracnoidea simple, posiblemente porque lapunción lumbar se realiza sobre un saco dural, previamente deformado por el “efecto tienda” que origina previamente la aguja epidural. La punción subaracnoidealenta e ininterrumpida, retirando el fiador milímetrosantes de llegar al saco dural origina un menor númerode parestesias

OBJECTIVE: To determine the incidence of paresthesiawith different spinal puncture techniques using a 27-gauge Whitacre needle.MATERIAL AND METHODS: Spinal puncture wasperformed in 224 elective cesarean sections usingdifferent techniques in this single-blind, prospectivetrial. Patients were randomized to 4 groups: group 1,combined epidural and subarachnoid puncture using anintroducer needle; group 2, combined epidural andsubarachnoid puncture without an introducer; group 3,subarachnoid puncture with an introducer; and group 4,subarachnoid puncture with an introducer to within afew millimeters of the dural sac, at which point theintroducer was withdrawn.RESULTS: Paresthesia developed in 23, 11, 16 and 5patients in groups 1, 2, 3 and 4, respectively. Variousnerve roots were affected. In 2 and 11 cases the fourth and fifth lumbar nerve roots were affected; in 29 and 13 cases, the first and second sacral nerve roots were involved. In comparison with group 4, the risk of paresthesia was 7, 2.5 and 4 times greater in groups 1, 2 and 3, respectively.CONCLUSIONS: Combined epidural-subarachnoidpuncture leads to a higher incidence of paresthesia incomparison with simple spinal puncture, probablybecause the lumbar puncture is performed on a duralsac that has been previously deformed due to the "tenteffect" caused by the epidural needle. Fewer cases ofparesthesia occur when the subarachnoid puncture isslow and steady and the introducer needle is withdrawnmillimeters before it reaches the dural sac

Implicaciones anestésicas en dos casos de inversión uterina / Anesthetic implications of uterine inversion: 2 cases

No disponible