Guidelines for enhanced recovery after cardiac surgery. Consensus document of Spanish Societies of Anesthesia (SEDAR), Cardiovascular Surgery (SECCE) and Perfusionists (AEP). / Vía clínica de recuperación intensificada en cirugía cardiaca. Documento de consenso de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), la Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE) y la Asociación Española de Perfusionistas (AEP).

The ERAS guidelines are intended to identify, disseminate and promote the implementation of the best, scientific evidence-based actions to decrease variability in clinical practice. The implementation of these practices in the global clinical process will promote better outcomes and the shortening of hospital and critical care unit stays, thereby resulting in a reduction in costs and in greater efficiency. After completing a systematic review at each of the points of the perioperative process in cardiac surgery, recommendations have been developed based on the best scientific evidence currently available with the consensus of the scientific societies involved.

Clinical Practice Guideline (CPG). Recommendations on strategy for reducing risk of heart failure patients requiring noncardiac surgery

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A comparison of dobutamine and levosimendan on hepatic blood flow in patients with a low cardiac output state after cardiac surgery: a randomised controlled study.

Liver dysfunction due to a low cardiac output state after cardiac surgery is associated with a poor prognosis, but whether one inotrope is superior to another in improving hepatic perfusion remains uncertain. This study compared the systemic and hepatic haemodynamic effects of levosimendan to dobutamine in patients with a low cardiac output state (cardiac index < 2.2 l/min/m2) after on-pump cardiac surgery. A total of 25 patients were randomised to receive either an intravenous bolus of levosimendan (12 µg/kg) over 15 minutes, followed by an infusion of 0.2 µg/kg/min for 24 hours, or an infusion of dobutamine 7.5 µg/kg/min for 24 hours and completed the study. The systemic and hepatic haemodynamics at 24 and 48 hours were all better after levosimendan than dobutamine (dobutamine group: cardiac index (l/min/m2)=2.51 [standard deviation ±0.29], 2.40±0.23; portal vein flow (ml/min): 614.0±124.7, 585.9±144.8; pulsatility index: 2.02±0,28, 2.98±0.27 versus the levosimendan group: cardiac index: 3.02± 0.27, 2.98± 0.30; portal vein flow: 723.0± 143.5, 702.9±117.8; pulsatility index: 1.71±0.26, 1.73±0.27). The improvement in portal vein blood flow at 48 hours was significantly better after levosimendan than dobutamine (41% vs. 11% increment from baseline, P<0.05). In addition, there was a significant reduction in hepatic artery resistance after levosimendan but not dobutamine (resistance index reduction 6.5% vs. 0%, P<0.05). In summary, levosimendan can be considered as a selective liver vasodilator and can improve hepatic blood flow through both the hepatic artery and portal venous system, whereas dobutamine can only improve the portal venous blood flow without vasodilating the hepatic artery.

Uso del levosimendán en el paciente quirúrgico crítico / Levosimendan use in critical surgical patient

El levosimendán es el único sensibilizante del calcio utilizado actualmente en la clínica. Su indicación fundamental es la descompensación de la insuficiencia cardiaca, y aunque su eficacia está demostrada en el paciente médico, su uso en el paciente quirúrgico ha sido mucho más restringido, a pesar de lo que ha ido apareciendo en publicaciones en situaciones de evidente riesgo para los enfermos, como son el shock séptico y el shock cardiogénico, y se han descrito algunos efectos, que en nuestra opinión merecen más atención como el efecto cardioprotector y antiaturdimiento miocárdico. A lo largo de esta revisión, pretendemos analizar las nuevas aportaciones aparecidas sobre este fármaco complejo sin duda, pero en nuestra opinión muy útil en algunas situaciones (AU)

Levosimendan is the only calcium sensitiser currently used at clinical level. Its primary indication is decompensated heart failure, and although its effectiveness has been demonstrated in the medical patient, use in the surgical patient has been more restricted. Nevertheless, new publications have appeared in high risk situations, such as septic shock and cardiogenic shock. Other drug effects has been reported, which we believe deserve more attention, as the cardioprotective effect and the anti-myocardial stunning effect. Throughout this review, we intend to analyse the new contributions of this undoubtedly complex drug but, in our opinion, very useful in some situations (AU)

Manejo anestésico de 20 pacientes programados para peritonectomía y quimioterapia intraperitoneal caliente / Anesthetic management for scheduled peritonectomy and hyperthermic intraperitoneal chemotherapy in 20 patients

OBJETIVOS: El objetivo de este trabajo es comunicarnuestro protocolo de actuación y los resultados obtenidosen pacientes sometidos a peritonectomía y quimioterapiaintraperitoneal caliente.MÉTODOS: Se estudiaron pacientes ASA II-III diagnosticadosde carcinomatosis peritoneal. Realizamosmonitorización invasiva y colocamos catéter epiduraltorácico. Se valoró el tiempo quirúrgico, las alteracioneshemodinámicas y el uso de fármacos vasoconstrictores,la necesidad de líquidos intraoperatorios, la transfusiónde derivados hemáticos, la diuresis y el uso de diuréticos.RESULTADOS: Incluimos 20 pacientes. En 3 casos no sepudo realizar la peritonectomía, decidiéndose su exclusiónde los resultados del estudio con el fin de evitar sesgos.La duración media de la intervención fue de 543±98minutos. Se emplearon fármacos vasoconstrictores en 7de 17 pacientes (41%). En 10 de los 17 casos se utilizarondiuréticos (58%). La media de administración defluidos intraoperatorios fue de 7,9±2 litros de cristaloidesy 2,3±06 litros de coloides. En 9 casos se transfundieronconcentrados de hematíes y sólo 1 paciente requirióplasma fresco congelado. La temperatura aumentóde 1-1,5ºC durante la administración de la quimioterapiacaliente, se controló sin problemas con la infusión delíquidos fríos y la manta térmica a 32-34ºC. El 41% delos casos se extubó en quirófano. Dos pacientes desarrollaronproblemas respiratorios postoperatorios, unpaciente insuficiencia renal y otro fue reintervenido porsangrado.CONCLUSIONES: Con el protocolo empleado se consiguerealizar esta cirugía sin complicaciones reseñables, salvohipotensión que responde al uso de vasoconstrictores

OBJETIVE: The aim of this study was to describe ourprotocol for the anesthetic management for peritonectomyand hyperthermic intraperitoneal chemotherapyand to report the results from a series of 20 patients.METHODS: The patients were diagnosed with peritonealcarcinomatosis and classified ASA 1-3. A thoracicepidural catheter was inserted for invasive monitoring.We recorded duration of surgery, hemodynamic changesand the use of vasoconstrictors, requirement for intraoperativefluid replacement or blood product transfusion,diuresis, and use of diuretics.RESULTS: Twenty patients were studied. Peritonectomycould not be performed in 3 patients and their datawas excluded in order to avoid skewing. The mean (SD)duration of the intervention was 543 (98) minutes. Vasoconstrictorswere used in 7 out of 17 patients (41%).Diuretics were used in 10 out of 17 patients (58%).Fluids infused during surgery were a mean of 7.9 (2) Lof crystalloid solution and 2.3 (0.6) L of colloid solution.Packed red blood cells were transfused in 9 cases andonly 1 patient required fresh frozen plasma. The temperaturerose from 1-1.5ºC during administration of thehyperthermic chemotherapy and was controlled withoutcomplications with the infusion of cold liquids and aheating blanket set at 32-34ºC. Extubation inside theoperating room was possible in 41% of the cases. Twopatients developed postoperative respiratory problemsand 1 patient, renal failure. One patient was reoperatedfor bleeding.CONCLUSIONS: The described anesthetic managementprotocol allowed the intervention to be carried outwithout complications other than hypotension, whichresponded to vasoconstrictor therapy

High thoracic epidural blockade increases myocardial oxygen availability in coronary surgery patients.

BACKGROUND: High thoracic epidural techniques are increasingly being used in patients scheduled for cardiothoracic surgery, including coronary artery bypass grafting. In the present study, we evaluated the acute effects of the epidural blockade on myocardial oxygen availability by means of tissue oxygen pressure monitoring in patients submitted for surgical revascularization. METHODS: Fifty adult patients were included in a prospective, randomized, double-blind study. After placement of an epidural catheter in thoracic space T1-T2, and under general anesthesia, 5-10 ml of either normal saline or 0.3% ropivacaine was injected through the epidural catheter. Hemodynamic parameters and the intramyocardial oxygen partial pressure were recorded before and 20 min after the epidural injection. RESULTS: There were no demographic or hemodynamic differences between the groups before intervention. A significant increase in intramyocardial partial oxygen pressure was observed in the ropivacaine group (14.6 mmHg vs. 25.1 mmHg, P < 0.0005). CONCLUSION: High thoracic epidural blockade with 5-10 ml of 0.3% ropivacaine increases myocardial oxygen availability in coronary diseased patients prior to surgical revascularization without deleterious hemodynamic disturbances.

[Anesthetic management for scheduled peritonectomy and hyperthermic intraperitoneal chemotherapy in 20 patients]. / Manejo anestésico de 20 pacientes programados para peritonectomía y quimioterapia intraperitoneal caliente.

OBJECTIVE: The aim of this study was to describe our protocol for the anesthetic management for peritonectomy and hyperthermic intraperitoneal chemotherapy and to report the results from a series of 20 patients. METHODS: The patients were diagnosed with peritoneal carcinomatosis and classified ASA 1-3. A thoracic epidural catheter was inserted for invasive monitoring. We recorded duration of surgery, hemodynamic changes and the use of vasoconstrictors, requirement for intraoperative fluid replacement or blood product transfusion, diuresis, and use of diuretics. RESULTS: Twenty patients were studied. Peritonectomy could not be performed in 3 patients and their data was excluded in order to avoid skewing. The mean (SD) duration of the intervention was 543 (98) minutes. Vasoconstrictors were used in 7 out of 17 patients (41%). Diuretics were used in 10 out of 17 patients (58%). Fluids infused during surgery were a mean of 7.9 (2) L of crystalloid solution and 2.3 (0.6) L of colloid solution. Packed red blood cells were transfused in 9 cases and only 1 patient required fresh frozen plasma. The temperature rose from 1-1.5 degrees C during administration of the hyperthermic chemotherapy and was controlled without complications with the infusion of cold liquids and a heating blanket set at 32-34 degrees C. Extubation inside the operating room was possible in 41% of the cases. Two patients developed postoperative respiratory problems and 1 patient, renal failure. One patient was reoperated for bleeding. CONCLUSIONS: The described anesthetic management protocol allowed the intervention to be carried out without complications other than hypotension, which responded to vasoconstrictor therapy.