Hipotensión arterial postoperatoria: el enemigo inadvertido / Postoperative arterial hypotension: The unnoticed enemy

La hipotensión postoperatoria es un problema de salud frecuentemente subestimado, asociado a una elevada morbimortalidad y a un mayor uso de recursos sanitarios. También plantea importantes retos clínicos, tecnológicos y humanos para la asistencia sanitaria. Al tratarse de un factor de riesgo modificable y evitable, este documento pretende aumentar su visibilidad, definiendo su impacto clínico y los retos tecnológicos que conlleva la optimización de su manejo, teniendo en cuenta aspectos clínico-tecnológicos, humanísticos y económicos.(AU)

Postoperative hypotension is a frequently underestimated health problem associated with high morbidity and mortality and increased use of health care resources. It also poses significant clinical, technological, and human challenges for healthcare. As it is a modifiable and avoidable risk factor, this document aims to increase its visibility, defining its clinical impact and the technological challenges involved in optimizing its management, taking clinical-technological, humanistic, and economic aspects into account.(AU)

Postoperative arterial hypotension: the unnoticed enemy.

Postoperative hypotension is a frequently underestimated health problem associated with high morbidity and mortality and increased use of health care resources. It also poses significant clinical, technological, and human challenges for healthcare. As it is a modifiable and avoidable risk factor, this document aims to increase its visibility, defining its clinical impact and the technological challenges involved in optimizing its management, taking clinical-technological, humanistic, and economic aspects into account.

Ultra-fast track extubation protocol following cardiovascular surgery: Predictors of failure and outcomes.

OBJECTIVES: Identifying independent predictor factors of failure of ultra-fast track (UFT) extubation and to compare in-hospital outcomes with UFT extubation versus fast track (FT) extubation after cardiovascular surgery in adults. MATERIAL AND METHODS: Retrospective analysis of 1498 consecutive patients aged over 18 years-old undergoing cardiovascular surgery at a single institution. Between December 2014 and December 2016, FT extubation was used (N = 713) while, between December 2016 and December 2018, all patients were preoperatively considered suitable for UFT extubation (N = 785). In this instance, a standardized anaesthetic protocol was applied in all cases. The decision to not extubate in the operating room (OR) was based on intraoperative haemodynamic and ventilation. RESULTS: Extubation in the OR was possible in 699 (89%) patients. Significant independent predictors factors of UFT extubation failure were: preoperative NYHA class III-IV, myocardial infarction within two days prior to surgery, preoperative intra-aortic balloon counterpulsation, urgent/emergent surgery, intraoperative transfusion of platelets and intraoperative inotropic and vasopressor support. UFT extubation was associated with lower rates of cardiovascular complications such as congestive cardiac insufficiency (OR: 1,57; 95% CI: 1,13-2,19; p = 0,008) and new-onset postoperatory atrial fibrillation (OR: 1,40; 95% CI: 1,06-1,86; p = 0,020). Patient extubated in the OR presented lower risk of overall complications, shorter intensive care unit stay and higher short-term survival, although, no statistically significance was found when performing the multivariate adjustment. CONCLUSIONS: A routine immediate extubation in the OR following adult cardiovascular surgery is a feasible and safe practice, associated with low cardiovascular morbidity.

Protocolo de extubación ultra-fast track tras cirugía cardiovascular: predictores de fracaso y resultados / Ultra-fast track extubation protocol following cardiovascular surgery: Predictors of failure and outcomes

Objetivos: Identificar los factores predictores independientes de fracaso de la extubación ultra-fast track (UFT) y comparar los resultados hospitalarios de la extubación UFT frente a la extubación fast track en pacientes adultos sometidos a cirugía cardiovascular. Material y métodos: Análisis retrospectivo de 1.498 pacientes consecutivos mayores de 18 años sometidos a cirugía cardiovascular en un solo centro. Entre diciembre 2014 y diciembre 2016 se utilizó la extubación fast track (n=713), mientras que, entre diciembre 2016 y diciembre 2018 todos los pacientes fueron considerados preoperatoriamente aptos para extubación UFT (n=785). En este caso se empleó el mismo protocolo anestésico estandarizado en todos los pacientes. La decisión de extubar o no en quirófano se basó exclusivamente en parámetros hemodinámicos y ventilatorios. Resultados: La extubación en quirófano fue posible en 699 (89%) pacientes. Los factores predictores independientes de fracaso de la extubación UFT fueron: clase funcional preoperatoria iii-iv de la NYHA, infarto agudo de miocardio dentro de los 2 días previos a la cirugía, balón de contrapulsación intraaórtico preoperatorio, cirugía urgente o emergente, transfusión intraoperatoria de plaquetas y soporte intraoperatorio con fármacos inotrópicos y vasopresores. La extubación UFT se asoció con una menor tasa de complicaciones cardiovasculares, como insuficiencia cardiaca congestiva (OR: 1,57; IC 95%: 1,13-2,19; p=0,008) y fibrilación auricular postoperatoria de novo (OR: 1,40; IC 95%: 1,06-1,86; p=0,020). Los pacientes extubados en quirófanos presentaron un menor riesgo de complicaciones globales, menor estancia en la UCI y mayor supervivencia a corto plazo, aunque no se encontraron diferencias estadísticamente significativas al realizarse el ajuste multivariante. Conclusiones: La extubación inmediata rutinaria en quirófano tras cirugía cardiovascular en adultos es una...(AU)

Objectives: Identifying independent predictor factors of failure of ultra-fast track (UFT) extubation and to compare in-hospital outcomes with UFT extubation versus fast track (FT) extubation after cardiovascular surgery in adults. Material and methods: Retrospective analysis of 1,498 consecutive patients aged over 18 years-old undergoing cardiovascular surgery at a single institution. Between December 2014 and December 2016, FT extubation was used (N=713) while, between December 2016 and December 2018, all patients were preoperatively considered suitable for UFT extubation (N=785). In this instance, a standardized anaesthetic protocol was applied in all cases. The decision to not extubate in the operating room (OR) was based on intraoperative haemodynamic and ventilation. Results: Extubation in the OR was possible in 699 (89%) patients. Significant independent predictors factors of UFT extubation failure were: preoperative NYHA class III-IV, myocardial infarction within two days prior to surgery, preoperative intra-aortic balloon counterpulsation, urgent/emergent surgery, intraoperative transfusion of platelets and intraoperative inotropic and vasopressor support. UFT extubation was associated with lower rates of cardiovascular complications such as congestive cardiac insufficiency (OR: 1,57; 95% CI: 1,13-2,19; P=0,008) and new-onset postoperatory atrial fibrillation (OR: 1,40; 95% CI: 1,06-1,86; P=0,020). Patient extubated in the OR presented lower risk of overall complications, shorter intensive care unit stay and higher short-term survival, although, no statistically significance was found when performing the multivariate adjustment. Conclusions: A routine immediate extubation in the OR following adult cardiovascular surgery is a feasible and safe practice, associated with low cardiovascular morbidity.(AU)

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.