Second victim phenomenon in a surgical area: Online survey.

BACKGROUND AND AIM OF STUDY: An effective and accessible first source of support for second victims (SV) is usually the colleagues themselves, who should have tools to help emotionally and detect the unusual course of a SV. The aim of this work is to assess health professionals' perception of the phenomenon, as well as their capability to apply psychological first aid. MATERIAL AND METHODS: Observational descriptive study through online surveys answered anonymously. Participants were different health professionals from surgical area, mainly from a third-level hospital. RESULTS: 329 responses, 67 anaesthesiologists, 110 anaesthesiologists in training, 152 nurses. 78.4% had felt SV, more frequent among anaesthesiologists; however, 58% had never heard of the term. Guilt was the most frequent emotion. Residents were more afraid of judgmental colleagues and thought more about drop out their training. From those who sought help, most did it through a colleague, but most did not feel useful in helping a SV. 66% affirmed there is a still punitive, evasive or silent culture about medical incidents. CONCLUSIONS: Despite the frequency of the phenomenon there is still lack of knowledge of the term SV. Impact of the phenomenon is heterogenous and changes based on experience and responsibility. Colleagues are the first source of emotional help but there is a lack of tools to be able to provide it. Institutions are urged to create training programs so that professionals can guarantee «psychological first aid¼.

Second victim phenomenon in a surgical area: online survey. / El fenómeno de segunda víctima en un área quirúrgica: Encuesta online.

BACKGROUND AND AIM OF STUDY: An effective and accessible first source of support for second victims (SV) is usually the colleagues themselves, who should have tools to help emotionally and detect the unusual course of a SV. The aim of this work is to assess health professionals' perception of the phenomenon, as well as their capability to apply psychological first aid. MATERIAL AND METHODS: Observational descriptive study through online surveys answered anonymously. Participants were different health professionals from surgical area, mainly from a third-level hospital. RESULTS: 329 responses, 67 anaesthesiologists, 110 anaesthesiologists in training, 152 nurses. 78.4% had felt SV, more frequent among anaesthesiologists; however, 58% had never heard of the term. Guilt was the most frequent emotion. Residents were more afraid of judgmental colleagues and thought more about drop out their training. From those who sought help, most did it through a colleague, but most did not feel useful in helping a SV. 66% affirmed there is a still punitive, evasive or silent culture about medical incidents. CONCLUSIONS: Despite the frequency of the phenomenon there is still lack of knowledge of the term SV. Impact of the phenomenon is heterogenous and changes based on experience and responsibility. Colleagues are the first source of emotional help but there is a lack of tools to be able to provide it. Institutions are urged to create training programs so that professionals can guarantee «psychological first aid¼.

Complicaciones de la analgesia continua invasiva para el control del dolor agudo postoperatorio en un hospital de tercer nivel. Incidencia de complicaciones técnicas y uso de métodos de analgesia alternativos / Complications of continuous catheter analgesia for postoperative pain management in a tertiary care hospital. Incidence of technical complications and alternative analgesia methods used

Antecedentes: La analgesia continua invasiva es el método de referencia para el manejo del dolor postoperatorio en cirugía mayor pero no está exenta de posibles complicaciones. Existe poca información sobre las complicaciones de las técnicas analgésicas continuas con catéter (TACC) y su impacto en el control del dolor. Material y métodos: Diseñamos un estudio prospectivo longitudinal incluyendo a pacientes tratados mediante cirugía que recibieron una TACC postoperatoria. Se registraron el tipo de analgesia, la intensidad del dolor mediante escala NRS, las características de las TACC, sus complicaciones técnicas y la satisfacción de los pacientes. Se aplicó estadística descriptiva y análisis comparativo mediante t de Student. Resultados: Se registraron datos de 106 pacientes. La duración de las TACC fue 47,52 ± 21,23 h; 52 pacientes (49,1%) fueron controlados en hospitalización convencional y 54 (50,9%) en unidades de críticos o alta dependencia. La tasa global de complicaciones técnicas fue del 9,43%. Las complicaciones más frecuentes fueron desplazamiento del catéter (2,38%), inflamación en el punto de inserción del catéter IV (2,38%) y dosificación excesiva de analgésicos (2,38%). El valor medio de NRS fue ≤ 3 durante la permanencia de la TACC. La intensidad máxima de dolor fue mayor en los pacientes con complicaciones técnicas (media ± desviación estándar [x̅ ± DE]: 4,4 ± 2,8 vs. 2,9 ± 1,9; p < 0,05). La satisfacción con la comodidad de la técnica y la satisfacción global con el tratamiento del dolor se redujeron significativamente en presencia de complicaciones. Conclusiones: La incidencia de complicaciones técnicas de las TACC fue del 9,43% y tuvieron un impacto negativo en el control del dolor postoperatorio y en la satisfacción de los pacientes

Background: Continuous invasive analgesia remains the gold-standard method for managing acute post-operative pain after major surgery. However, this procedure is not exempt from complications that may have detrimental effects on the patient and affect the post-operative recovery process. Data of the complications of continuous catheter analgesic techniques (CCATs) and their impact on pain relief are scarce in the literature. Material and methods: We conducted a prospective longitudinal study and patients who underwent a surgical procedure and received continuous invasive analgesia after surgery were included. Post-operative analgesic strategy, pain scores (NRS), CCAT's characteristics and technical complications were recorded. Patient satisfaction was determined. Descriptive statistics and Student's t-tests were applied for the comparative analyses. Results: We collected data from 106 patients. Mean duration of the CCAT was 47.52±21.23hours and 52 patients (49.1%) were controlled in conventional hospitalisation units whereas 54 patients (50.9%) were controlled on intensive or high-dependency care units. The overall incidence of technical complications was 9.43%. The most common complications were catheter displacement (2.38%), inflammation at the IV catheter insertion point (2.38%) and excessive dosing of analgesic drugs (2.38%). Mean NRS scores were ≤3 during the permanence of CCATs. Maximum pain intensity was significantly higher in patients who suffered technical complications (mean±standard deviation [x̅ ± SD]: 4.4 ± 2.8 vs. 2.9 ± 1.9; P<0.05). Satisfaction levels with the technique and overall satisfaction with the pain management strategy were negatively impacted by the occurrence of complications. Conclusions: The incidence of technical complications of CCATs was 9.43% and had a negative impact in pain control and patient's satisfaction

Complications of continuous catheter analgesia for postoperative pain management in a tertiary care hospital. Incidence of technical complications and alternative analgesia methods used. / Complicaciones de la analgesia continua invasiva para el control del dolor agudo postoperatorio en un hospital de tercer nivel. Incidencia de complicaciones técnicas y uso de métodos de analgesia alternativos.

BACKGROUND: Continuous invasive analgesia remains the gold-standard method for managing acute post-operative pain after major surgery. However, this procedure is not exempt from complications that may have detrimental effects on the patient and affect the post-operative recovery process. Data of the complications of continuous catheter analgesic techniques (CCATs) and their impact on pain relief are scarce in the literature. MATERIAL AND METHODS: We conducted a prospective longitudinal study and patients who underwent a surgical procedure and received continuous invasive analgesia after surgery were included. Post-operative analgesic strategy, pain scores (NRS), CCAT's characteristics and technical complications were recorded. Patient satisfaction was determined. Descriptive statistics and Student's t-tests were applied for the comparative analyses. RESULTS: We collected data from 106 patients. Mean duration of the CCAT was 47.52±21.23hours and 52 patients (49.1%) were controlled in conventional hospitalisation units whereas 54 patients (50.9%) were controlled on intensive or high-dependency care units. The overall incidence of technical complications was 9.43%. The most common complications were catheter displacement (2.38%), inflammation at the IV catheter insertion point (2.38%) and excessive dosing of analgesic drugs (2.38%). Mean NRS scores were ≤3 during the permanence of CCATs. Maximum pain intensity was significantly higher in patients who suffered technical complications (mean±standard deviation [x̅ ± SD]: 4.4 ± 2.8 vs. 2.9 ± 1.9; P<0.05). Satisfaction levels with the technique and overall satisfaction with the pain management strategy were negatively impacted by the occurrence of complications. CONCLUSIONS: The incidence of technical complications of CCATs was 9.43% and had a negative impact in pain control and patient's satisfaction.

Estudio de la prevalencia y la caracterización del dolor postoperatorio inmediato en la Unidad de Recuperación Postanestésica / Prevalence and characterization of postoperative pain in the Postanaesthesia Care Unit

Introducción. El dolor postoperatorio inmediato es aquel que se produce inmediatamente tras la cirugía, mientras el paciente permanece en la Unidad de Recuperación Postanestésica. Son pocos los estudios que evalúan y caracterizan el dolor postoperatorio en esta fase tan temprana. Objetivo. Estudio transversal de la prevalencia y las características del dolor postoperatorio inmediato. Material y métodos. Se analizaron 503 pacientes entre agosto de 2014 y febrero de 2015 que ingresaron en la Unidad de Recuperación Postanestésica. Se usó la escala visual analógica (EVA; rango 0-10) y se aplicó en 5 tiempos tras la cirugía, recogiéndose medidas procedentes del paciente y el investigador. Se analizaron los factores que influyen en la aparición y el mantenimiento del dolor (edad, sexo, tipo de cirugía, tipo de anestesia y analgesia), la variación de las constantes vitales y los efectos secundarios. Resultados. Globalmente, la media de la EVA valorada por el paciente fue 2,2±2,8. El tiempo de dolor más intenso fue a los 20min de llegar a la Unidad de Recuperación Postanestésica (p<0,001). Los valores de EVA del investigador (1,4±2,0) fueron inferiores a los del paciente, con buena correlación (R2=0,82; p<0,001) y distribución paralela aunque con concordancia moderada (kappa = 0,4). Cirugía plástica y neurocirugía fueron las especialidades con valores de EVA superiores. Las técnicas de bloqueo regional registraron valores más bajos de EVA. El sexo masculino y la edad avanzada registraron valores de EVA inferiores (p < 0,001). Conclusiones. El estudio de las características del dolor postoperatorio inmediato permitiría una mejor gestión en la prevención del dolor postoperatorio. Ayudaría a predecir, de acuerdo con el tipo de cirugía y anestesia utilizada, aquellos pacientes en los que pueden aparecer valores más altos de EVA para adaptar la analgesia (AU)

Introduction. Immediate postoperative pain occurs initially after surgery, while the patient is in the Post-Anaesthesia Recovery Unit. Very few studies assess this pain in this most immediate phase. Objective. Cross-sectional study of the prevalence and characteristics of immediate postoperative pain in patients after surgery. Material and methods. Between August 2014 and February 2015, a sample of 503 patients from the Post-Anaesthesia Recovery Unit was followed. Immediate postoperative pain was assessed (by the patient and the researcher) using the visual analogue scale (VAS; range 0-10) on 5 occasions after surgery. The impact of numerous factors (age, gender, type of surgery, type of anaesthesia and analgesic) on the pain, as well as variation in vital signs and the presence of side effects, were analysed. Results. Assessment of the pain showed overall VAS values of 2.2±2.8 on all occasions. Pain was reported to be of greatest intensity 20min after the patients’ arrival in the Post-Anaesthesia Recovery Unit (P<.001). The VAS values reported by the researcher (1.4±2.0) were lower than those reported by the patients. Although there was a very strong correlation (R2=0.82; P<.001) and they followed a parallel distribution, there was moderate concordance (kappa=0.4). Plastic surgery and neurosurgery were the specialties with the highest percentages of VAS values in the strong intensity range (8-10). Patients with regional block techniques (with or without general anaesthesia) had lower VAS values than other general anaesthesia groups. Male patients and older patients displayed less pain than female and young patients, respectively (P<.001). Conclusions. Studying the characteristics of postoperative pain at such an early stage allows for improved management. It helps to predict, according to the type of surgery and the anaesthesia used, those patients in which higher VAS values may be seen and to better adapt analgesic therapy (AU)

Localizaciones del dolor en el postoperatorio de cirugía cardiaca: cronología del dolor y respuesta al tratamiento / Pain locations in the postoperative period after cardiac surgery: chronology of pain and response to treatment

Introducción. Tras la cirugía cardiaca (CC) el dolor postoperatorio procede de varios focos, además de la esternotomía. Métodos. Estudio prospectivo, descriptivo y longitudinal sobre la evolución cronológica del dolor en 11 localizaciones tras CC. Se incluyeron pacientes operados consecutivamente de CC por esternotomía. Los objetivos fueron establecer los principales focos del dolor, su evolución cronológica durante la primera semana, correlacionar la intensidad del dolor con otras variables y describir las características del dolor de la esternotomía. Se utilizó la escala de valoración numérica Numerical Pain Rate Scale de 0-10 en reposo y en movimiento en los días postoperatorios 1, 2, 4 y 6. Una puntuación>3 en la Numerical Pain Rate Scale fue considerado dolor moderado. Los datos se sometieron a las pruebas U de Mann-Whitney, Chi cuadrado, exacta de Fisher y la correlación de Pearson. Resultados. Se incluyeron 47 pacientes. En 4 de las 11 localizaciones del dolor este fue valorado como una puntuación>3 en la Numerical Pain Rate Scale (esternotomía, orofaringe, safenectomía y hombros y espalda). La máxima intensidad de dolor se registró en la esternotomía en los días postoperatorios 1 y 2, mientras que en los días postoperatorios 4 y 6 fue en la safenectomía. El dolor en movimiento fue significativamente mayor que en reposo en la esternotomía, las extremidades inferiores y en la orofaringe. El movimiento no aumentó el dolor en espalda y hombros ni en la entrada del catéter venoso central. El dolor en la esternotomía fue descrito como opresivo. Los pacientes con artrosis y los más jóvenes presentaron dolor más intenso (p=0,049 y p=0,004, respectivamente). Conclusiones. Los principales focos del dolor tras CC fueron la esternotomía, la orofaringe, la safenectomía y el osteoarticular en hombros y espalda. Los focos de dolor mostraron diferente cronología y distinta influencia del movimiento (AU)

Introduction. Postoperative pain after cardiac surgery (CS) can be generated at several foci besides the sternotomy. Methods. Prospective descriptive longitudinal study on the chronological evolution of pain in 11 sites after CS including consecutive patients submitted to elective CS through sternotomy. The primary endpoints were to establish the main origins of pain, and to describe its chronological evolution during the first postoperative week. Secondary endpoints were to describe pain characteristics in the sternotomy area and to correlate pain intensity with other variables. Numerical Pain Rating Scale from 0 to 10 at rest and at movement on postoperative days 1, 2, 4 and 6. Numerical Pain Rating Scale>3 was considered moderate pain. Statistical analysis consisted in Mann-Whitney U-test, a Chi-squared, a Fisher exact text and Pearson's correlations. Results. Forty-seven patients were enrolled. In 4 of 11 locations pain was reported as Numerical Pain Rating Scale>3 (sternotomy, oropharynx, saphenectomy and musculoskeletal pain in the back and shoulders). Maximum intensity of pain on postoperative days 1 and 2 was reported in the sternotomy area, while on postoperative days 4 and 6 it was reported at the saphenectomy. Pain at rest and at movement differed considerably in the sternotomy, saphenectomy and oropharynx. Pain at back and shoulders and at central venous catheter entry were not influenced by movement. Pain in the sternotomy was mainly described as oppressive. Patients with arthrosis and younger patients presented higher intensity of pain (P=.004; P=.049, respectively). Conclusions. Four locations were identified as the main sources of pain after CS: sternotomy, oropharynx, saphenectomy, and back and shoulders. Pain in different focuses presented differences in chronologic evolution and was differently influenced by movement (AU)

Prevalence and characterization of postoperative pain in the Postanaesthesia Care Unit. / Estudio de la prevalencia y la caracterización del dolor postoperatorio inmediato en la Unidad de Recuperación Postanestésica.

INTRODUCTION: Immediate postoperative pain occurs initially after surgery, while the patient is in the Post-Anaesthesia Recovery Unit. Very few studies assess this pain in this most immediate phase. OBJECTIVE: Cross-sectional study of the prevalence and characteristics of immediate postoperative pain in patients after surgery. MATERIAL AND METHODS: Between August 2014 and February 2015, a sample of 503 patients from the Post-Anaesthesia Recovery Unit was followed. Immediate postoperative pain was assessed (by the patient and the researcher) using the visual analogue scale (VAS; range 0-10) on 5 occasions after surgery. The impact of numerous factors (age, gender, type of surgery, type of anaesthesia and analgesic) on the pain, as well as variation in vital signs and the presence of side effects, were analysed. RESULTS: Assessment of the pain showed overall VAS values of 2.2±2.8 on all occasions. Pain was reported to be of greatest intensity 20min after the patients' arrival in the Post-Anaesthesia Recovery Unit (P<.001). The VAS values reported by the researcher (1.4±2.0) were lower than those reported by the patients. Although there was a very strong correlation (R2=0.82; P<.001) and they followed a parallel distribution, there was moderate concordance (kappa=0.4). Plastic surgery and neurosurgery were the specialties with the highest percentages of VAS values in the strong intensity range (8-10). Patients with regional block techniques (with or without general anaesthesia) had lower VAS values than other general anaesthesia groups. Male patients and older patients displayed less pain than female and young patients, respectively (P<.001). CONCLUSIONS: Studying the characteristics of postoperative pain at such an early stage allows for improved management. It helps to predict, according to the type of surgery and the anaesthesia used, those patients in which higher VAS values may be seen and to better adapt analgesic therapy.

Pain locations in the postoperative period after cardiac surgery: Chronology of pain and response to treatment. / Localizaciones del dolor en el postoperatorio de cirugía cardiaca: cronología del dolor y respuesta al tratamiento.

INTRODUCTION: Postoperative pain after cardiac surgery (CS) can be generated at several foci besides the sternotomy. METHODS: Prospective descriptive longitudinal study on the chronological evolution of pain in 11 sites after CS including consecutive patients submitted to elective CS through sternotomy. The primary endpoints were to establish the main origins of pain, and to describe its chronological evolution during the first postoperative week. Secondary endpoints were to describe pain characteristics in the sternotomy area and to correlate pain intensity with other variables. Numerical Pain Rating Scale from 0 to 10 at rest and at movement on postoperative days 1, 2, 4 and 6. Numerical Pain Rating Scale>3 was considered moderate pain. Statistical analysis consisted in Mann-Whitney U-test, a Chi-squared, a Fisher exact text and Pearson's correlations. RESULTS: Forty-seven patients were enrolled. In 4 of 11 locations pain was reported as Numerical Pain Rating Scale>3 (sternotomy, oropharynx, saphenectomy and musculoskeletal pain in the back and shoulders). Maximum intensity of pain on postoperative days 1 and 2 was reported in the sternotomy area, while on postoperative days 4 and 6 it was reported at the saphenectomy. Pain at rest and at movement differed considerably in the sternotomy, saphenectomy and oropharynx. Pain at back and shoulders and at central venous catheter entry were not influenced by movement. Pain in the sternotomy was mainly described as oppressive. Patients with arthrosis and younger patients presented higher intensity of pain (P=.004; P=.049, respectively). CONCLUSIONS: Four locations were identified as the main sources of pain after CS: sternotomy, oropharynx, saphenectomy, and back and shoulders. Pain in different focuses presented differences in chronologic evolution and was differently influenced by movement.

Manejo perioperatorio de los anticoagulantes orales directos en cirugía urgente y sangrado. Monitorización y tratamiento hemostático / Perioperative management of direct oral anticoagulant in emergency surgery and bleeding. Haemostasis monitoring and treatment

Existe un amplio consenso sobre el manejo perioperatorio de los pacientes tratados con los nuevos anticoagulantes orales directos (dabigatrán, ribaroxabán y apixabán) en cirugía programada. Por el contrario, en la actualidad no existe este nivel de acuerdo en cirugía urgente, especialmente en el paciente sangrante. Por este motivo, se ha realizado una revisión bibliográfica a través del buscador PubMed en la base de datos MEDLINE de los artículos publicados entre 2000-2014 referidos a los términos «monitorización» y «reversión» de los fármacos mencionados. Guías de práctica clínica, revisiones sistemáticas, revisiones y artículos sobre la materia se incluyeron en la búsqueda. Se verifica un limitado papel de los test rutinarios de coagulación (tiempo de protrombina y tiempo parcial de tromboplastina activado) en el manejo perioperatorio de estos pacientes. Así mismo, muestran la ausencia de antídotos específicos, aunque plantean la posibilidad de usar concentrado de complejo protrombínico y factor vii activado recombinante en la reversión urgente de su efecto anticoagulante (AU)

There is an almost unanimous consensus on the management of the direct new oral anticoagulants, dabigatran, rivaroxaban, and apixaban in elective surgery. However, this general consensus does not exist in relation with the direct new oral anticoagulants use in emergency surgery, especially in the bleeding patient. For this reason, a literature review was performed using the MEDLINE-PubMed. An analysis was made of the journal articles, reviews, systematic reviews, and practices guidelines published between 2000 and 2014 using the terms “monitoring” and “reversal”. From this review, it was shown that the routine tests of blood coagulation, such as the prothrombin time and activated partial thromboplastin time, have a limited efficacy in the perioperative control of blood coagulation in these patients. There is currently no antidote to reverse the effects of these drugs, although the possibility of using concentrated prothrombin complex and recombinant activated factor vii has been suggested for the urgent reversal of the anticoagulant effect (AU)

[Perioperative management of direct oral anticoagulant in emergency surgery and bleeding. Haemostasis monitoring and treatment]. / Manejo perioperatorio de los anticoagulantes orales directos en cirugía urgente y sangrado. Monitorización y tratamiento hemostático.

There is an almost unanimous consensus on the management of the direct new oral anticoagulants, dabigatran, rivaroxaban, and apixaban in elective surgery. However, this general consensus does not exist in relation with the direct new oral anticoagulants use in emergency surgery, especially in the bleeding patient. For this reason, a literature review was performed using the MEDLINE-PubMed. An analysis was made of the journal articles, reviews, systematic reviews, and practices guidelines published between 2000 and 2014 using the terms "monitoring" and "reversal". From this review, it was shown that the routine tests of blood coagulation, such as the prothrombin time and activated partial thromboplastin time, have a limited efficacy in the perioperative control of blood coagulation in these patients. There is currently no antidote to reverse the effects of these drugs, although the possibility of using concentrated prothrombin complex and recombinant activated factor vii has been suggested for the urgent reversal of the anticoagulant effect.

Importancia de la ecocardiografía transesofágica intraoperatoria en la decisión quirúrgica en cirugía cardiaca / The importance of intraoperative transesophageal echocardiography in the surgical decision in cardiac surgery

Objetivo. Determinar la importancia de la ecocardiografía transesofágica (ECOTE) intraoperatoria en la decisión quirúrgica en pacientes intervenidos de cirugía cardiaca. Pacientes y método. Estudio prospectivo observacional en pacientes de cirugía cardiaca intervenidos desde enero de 2009 hasta mayo de 2012, a los que se monitorizó con ECOTE por el anestesiólogo responsable. Los datos recogidos fueron: 1) tipo de cirugía; 2) diagnóstico ecocardiográfico preoperatorio (ECO basal); 3) diagnóstico ecocardiográfico antes de entrar en circulación extracorpórea (CEC) (ECOTE pre-CEC); 4) si había diferencias entre la ECO basal y la ECOTE pre-CEC (hallazgo nuevo pre-CEC) y si estas diferencias modificaban la cirugía planeada, y 5) diagnóstico ecocardiográfico después de la desconexión de CEC (hallazgo no esperado pos-CEC) y si estos hallazgos ecocardiográficos pos-CEC hacían reinstaurarla. Para el análisis de datos se utilizó el programa de software SPSS(R). Resultados. El total de pacientes estudiados fue de 1.273; la monitorización con ECOTE mostró «hallazgos nuevos pre-CEC» en 98 pacientes (7,7%) y en 43,8% de estos modificó la cirugía programada; de estos hallazgos, los más frecuentes fueron alteraciones de la válvula mitral que no habían sido diagnosticadas, lo que determinó la sustitución o reparación de la misma que no estaba programada. La incidencia de «hallazgos no esperados pos-CEC» fue del 6,2% (79 pacientes), y de estos, en el 46,8% se requirió reinstaurar la CEC y modificar la cirugía realizada. Las reparaciones valvulares fallidas y las prótesis valvulares disfuncionantes fueron las causas principales que motivaron la reentrada en CEC. En los 42 pacientes restantes, con «hallazgos no esperados pos-CEC», no hubo cambios en la conducta quirúrgica, ya que se consideró que el hallazgo ecocardiográfico no era lo suficientemente significativo como para reinstaurar la CEC y revisar o cambiar el procedimiento quirúrgico. Conclusión. En cirugía cardiaca, la monitorización intraoperatoria con ECOTE por el anestesiólogo aporta información importante antes y después de la CEC que modificó el manejo quirúrgico (AU)

Objective. To determine the importance of intraoperative transesophageal echocardiography (IOTEE) in the surgical decision in patients undergoing cardiac surgery. Patients and method. Prospective observational study of patients undergoing cardiac surgery from January 2009 to May 2012, which was monitored with IOTEE by the anesthesiologist in charge. The data collected were: 1) type of surgery; 2) preoperative echocardiographic diagnosis (baseline ECHO); 3) echocardiographic diagnosis before entering cardiopulmonary bypass (CPB) (pre-CPB IOTEE); 4) any differences between the baseline ECHO and the pre-CPB IOTEE (new pre-CPB finding) and whether these differences modified the planned surgery, and 5) echocardiographic diagnosis after disconnection of CPB (unexpected post-CPB finding) and whether these post-CPB echocardiographic findings led to reinstating it. The software program SPSS(R) was used for data analysis. Results. The total number of patients studied was 1,273. Monitoring with IOTEE showed 'new pre-CPB' findings in 98 patients (7.7%), and 43.8% of these led to a change in the scheduled surgery. Of these findings, the most frequent were abnormalities of the mitral valve that had not been diagnosed, and which led to a replacement or repair that had not been scheduled. The incidence of 'unexpected post-CPB findings' was 6.2% (79 patients), and 46.8% of those required reinstating the CPB and modifying the surgery performed. The failed valve repairs and dysfunctional valve prostheses were the main causes that led to re-entry into CPB. In the remaining 42 patients, with 'unexpected post-CPB findings', there were no changes in the surgical procedure as the echocardiographic findings were not considered to be significant enough to re-establish CPB and revise or change the surgical procedure. Conclusion. Intraoperative monitoring with IOTEE by the anesthesiologist during surgery provides important information before and after the CPB that resulted in modifying surgical management (AU)

[The importance of intraoperative transesophageal echocardiography in the surgical decision in cardiac surgery]. / Importancia de la ecocardiografía transesofágica intraoperatoria en la decisión quirúrgica en cirugía cardiaca.

OBJECTIVE: To determine the importance of intraoperative transesophageal echocardiography (IOTEE) in the surgical decision in patients undergoing cardiac surgery. PATIENTS AND METHOD: Prospective observational study of patients undergoing cardiac surgery from January 2009 to May 2012, which was monitored with IOTEE by the anesthesiologist in charge. The data collected were: 1) type of surgery; 2) preoperative echocardiographic diagnosis (baseline ECHO); 3) echocardiographic diagnosis before entering cardiopulmonary bypass (CPB) (pre-CPB IOTEE); 4) any differences between the baseline ECHO and the pre-CPB IOTEE (new pre-CPB finding) and whether these differences modified the planned surgery, and 5) echocardiographic diagnosis after disconnection of CPB (unexpected post-CPB finding) and whether these post-CPB echocardiographic findings led to reinstating it. The software program SPSS(®) was used for data analysis. RESULTS: The total number of patients studied was 1,273. Monitoring with IOTEE showed "new pre-CPB" findings in 98 patients (7.7%), and 43.8% of these led to a change in the scheduled surgery. Of these findings, the most frequent were abnormalities of the mitral valve that had not been diagnosed, and which led to a replacement or repair that had not been scheduled. The incidence of "unexpected post-CPB findings" was 6.2% (79 patients), and 46.8% of those required reinstating the CPB and modifying the surgery performed. The failed valve repairs and dysfunctional valve prostheses were the main causes that led to re-entry into CPB. In the remaining 42 patients, with "unexpected post-CPB findings", there were no changes in the surgical procedure as the echocardiographic findings were not considered to be significant enough to re-establish CPB and revise or change the surgical procedure. CONCLUSION: Intraoperative monitoring with IOTEE by the anesthesiologist during surgery provides important information before and after the CPB that resulted in modifying surgical management.

Manejo perioperatorio de la fibrilación auricular / Perioperative management of atrial fibrillation

La fibrilación auricular es una complicación frecuente en el periodo perioperatorio, y cuando aparece se incrementa el riesgo de morbimortalidad perioperatoria debido a ACV, tromboembolismo, fallo cardiaco, IAM, hemorragia debida a anticoagulación y reingresos hospitalarios. En el presente artículo se recogen las recomendaciones para el manejo de la fibrilación auricular perioperatoria basándose en las últimas Guías de Práctica Clínica de la fibrilación auricular publicadas por la Sociedad Europea de Cardiología y la Sociedad Española de Cardiología, prestando atención tanto a su optimización preoperatoria, como al manejo del episodio agudo perioperatorio. En este sentido se incluyen las últimas recomendaciones para control de la frecuencia cardiaca, control del ritmo y anticoagulación (AU)

Atrial fibrillation is a frequent complication in the perioperative period. When it appears there is an increased risk of perioperative morbidity due to stroke, thromboembolism, cardiac arrest, myocardial infarction, anticoagulation haemorrhage, and hospital readmissions. The current article focuses on the recommendations for the management of perioperative atrial fibrillation based on the latest Clinical Practice Guidelines on atrial fibrillation by the European Society of Cardiology and the Spanish Society of Cardiology. This article pays special attention to the preoperative management, as well as to the acute perioperative episode. For this reason, the latest recommendations for the control of cardiac frequency, antiarrhythmic treatment and anticoagulation are included (AU)

[Perioperative management of atrial fibrillation]. / Manejo perioperatorio de la fibrilación auricular.

Atrial fibrillation is a frequent complication in the perioperative period. When it appears there is an increased risk of perioperative morbidity due to stroke, thromboembolism, cardiac arrest, myocardial infarction, anticoagulation haemorrhage, and hospital readmissions. The current article focuses on the recommendations for the management of perioperative atrial fibrillation based on the latest Clinical Practice Guidelines on atrial fibrillation by the European Society of Cardiology and the Spanish Society of Cardiology. This article pays special attention to the preoperative management, as well as to the acute perioperative episode. For this reason, the latest recommendations for the control of cardiac frequency, antiarrhythmic treatment and anticoagulation are included.

The perioperative management of new direct oral anticoagulants: a question without answers.

New direct oral anticoagulant agents (DOAC) are currently licensed for thromboprophylaxis after hip and knee arthroplasty and for long-term prevention of thromboembolic events in non-valvular atrial fibrillation as well as treatment and secondary prophylaxis of venous thromboembolism. Some other medical indications are emerging. Thus, anaesthesiologists are increasingly likely to encounter patients on these drugs who need elective or emergency surgery. Due to the lack of experience and data, the management of DOAC in the perioperative period is controversial. In this article, we review available information and recommendations regarding the periprocedural management of the currently most clinically developed DOAC, apixaban, dabigatran, and rivaroxaban. We discuss two trends of managing patients on DOAC for elective surgery. The first is stopping the DOAC 1-5 days before surgery (depending on the drug, patient and bleeding risk) without bridging. The second is stopping the DOAC 5 days preoperatively and bridging with low-molecular-weight heparin. The management of patients on DOAC needing emergency surgery is also reviewed. As no data exist for the use of haemostatic products for the reversal of the anticoagulant effect in these cases, rescue treatment recommendations are proposed.

2013. Documento Sevilla de Consenso sobre Alternativas a la Transfusión de Sangre Alogénica. Actualización del Documento Sevilla / The 2013 Seville Consensus Document on alternatives to allogenic blood transfusion. An update on the Seville Document

La transfusión de sangre alogénica (TSA) no es inocua, y como consecuencia han surgido múltiples alternativas a la misma (ATSA). Existe variabilidad respecto a las indicaciones y buen uso de las ATSA. Dependiendo de la especialidad de los médicos que tratan a los pacientes, el grado de anemia, la política transfusional, la disponibilidad de las ATSA y el criterio personal, estas se usan de forma variable. Puesto que las ATSA tampoco son inocuas y pueden no cumplir criterios de coste-efectividad, la variabilidad en su uso es inaceptable. Las sociedades españolas de Anestesiología y Reanimación (SEDAR), Hematología y Hemoterapia(SEHH), Farmacia Hospitalaria (SEFH), Medicina Intensiva y Unidades Coronarias(SEMICYUC), Trombosis y Hemostasia (SETH) y Transfusiones Sanguíneas (SETS) han elaborado un documento de consenso para el buen uso de la ATSA. Un panel de expertos de las 6sociedades ha llevado a cabo una revisión sistemática de la literatura médica y elaborado el 2013. Documento Sevilla de Consenso sobre Alternativas a la Transfusión de Sangre Alogénica. Solo se contempla las ATSA dirigidas a disminuir la transfusión de concentrado de hematíes. Se definen las ATSA como toda medida farmacológica y no farmacológica encaminada a disminuir la transfusión de concentrado de hematíes, preservando siempre la seguridad del paciente. La cuestión principal que se plantea en cada ítem se formula, en forma positiva o negativa, como: “La ATSA en cuestión reduce/no reduce la tasa transfusional». Para formular el grado de recomendación se ha usado la metodología Grades of Recommendation Assessment, Development and Evaluation (GRADE) (AU)

Since allogeneic blood transfusion (ABT) is not harmless, multiple alternatives to ABT (AABT) have emerged, though there is great variability in their indications and appropriate use. This variability results from the interaction of a number of factors, including the specialty of the physician, knowledge and preferences, the degree of anemia, transfusion policy, and AABT availability. Since AABTs are not harmless and may not meet cost-effectiveness criteria, such variability is unacceptable. The Spanish Societies of Anesthesiology (SEDAR), Hematology and Hemotherapy (SEHH), Hospital Pharmacy (SEFH), Critical Care Medicine (SEMICYUC), Thrombosis and Hemostasis (SETH)and Blood Transfusion (SETS) have developed a Consensus Document for the proper use of AABTs. A panel of experts convened by these 6 Societies have conducted a systematic review of the medical literature and have developed the 2013 Seville Consensus Document on Alternatives to Allogeneic Blood Transfusion, which only considers those AABT aimed at decreasing the transfusion of packed red cells. AABTs are defined as any pharmacological or non-pharmacological measure aimed at decreasing the transfusion of red blood cell concentrates, while preserving patient safety. For each AABT, the main question formulated, positively or negatively, is: “Does this particular AABT reduce the transfusion rate or not? “All the recommendations on the use of AABTs were formulated according to the Grades of Recommendation Assessment, Development and Evaluation(GRADE) methodology (AU)

2013. Documento Sevilla de Consenso sobre Alternativas a la Transfusión de Sangre Alogénica. Actualización del Documento Sevilla / The 2013 Seville Consensus Document on alternatives to allogenic blood transfusion. An update on the Seville Document

La transfusión de sangre alogénica (TSA) no es inocua, y como consecuencia han surgido múltiples alternativas a la misma (ATSA). Existe variabilidad respecto a las indicaciones y buen uso de las ATSA. Dependiendo de la especialidad de los médicos que tratan a los pacientes, el grado de anemia, la política transfusional, la disponibilidad de las ATSA y el criterio personal, estas se usan de forma variable. Puesto que las ATSA tampoco son inocuas y pueden no cumplir criterios de coste-efectividad, la variabilidad en su uso es inaceptable. Las sociedades españolas de Anestesiología y Reanimación (SEDAR), Hematología y Hemoterapia (SEHH), Farmacia Hospitalaria (SEFH), Medicina Intensiva y Unidades Coronarias (SEMICYUC), Trombosis y Hemostasia (SETH) y Transfusiones Sanguíneas (SETS) han elaborado un documento de consenso para el buen uso de la ATSA. Un panel de expertos de las 6 sociedades ha llevado a cabo una revisión sistemática de la literatura médica y elaborado el 2013. Documento Sevilla de Consenso sobre Alternativas a la Transfusión de Sangre Alogénica. Solo se contempla las ATSA dirigidas a disminuir la transfusión de concentrado de hematíes. Se definen las ATSA como toda medida farmacológica y no farmacológica encaminada a disminuir la transfusión de concentrado de hematíes, preservando siempre la seguridad del paciente. La cuestión principal que se plantea en cada ítem se formula, en forma positiva o negativa, como: «La ATSA en cuestión reduce/no reduce la tasa transfusional». Para formular el grado de recomendación se ha usado la metodología Grades of Recommendation Assessment, Development and Evaluation (GRADE) (AU)

Since allogeneic blood transfusion (ABT) is not harmless, multiple alternatives to ABT (AABT) have emerged, though there is great variability in their indications and appropriate use. This variability results from the interaction of a number of factors, including the specialty of the physician, knowledge and preferences, the degree of anemia, transfusion policy, and AABT availability. Since AABTs are not harmless and may not meet cost-effectiveness criteria, such variability is unacceptable. The Spanish Societies of Anesthesiology (SEDAR), Hematology and Hemotherapy (SEHH), Hospital Pharmacy (SEFH), Critical Care Medicine (SEMICYUC), Thrombosis and Hemostasis (SETH) and Blood Transfusion (SETS) have developed a Consensus Document for the proper use of AABTs. A panel of experts convened by these 6 Societies have conducted a systematic review of the medical literature and have developed the 2013 Seville Consensus Document on Alternatives to Allogeneic Blood Transfusion, which only considers those AABT aimed at decreasing the transfusion of packed red cells. AABTs are defined as any pharmacological or non-pharmacological measure aimed at decreasing the transfusion of red blood cell concentrates, while preserving patient safety. For each AABT, the main question formulated, positively or negatively, is: "Does this particular AABT reduce the transfusion rate or not?" All the recommendations on the use of AABTs were formulated according to the Grades of Recommendation Assessment, Development and Evaluation (GRADE) methodology (AU)

Competencias que actualmente se le exigen al anestesiólogo en anestesia cardiovascular / Current competences required by the anaesthesiologist in cardiovascular anaesthesia

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[The 2013 Seville Consensus Document on alternatives to allogenic blood transfusion. An update on the Seville Document]. / 2013. Documento Sevilla de Consenso sobre Alternativas a la Transfusión de Sangre Alogénica. Actualización del Documento Sevilla.

Since allogeneic blood transfusion (ABT) is not harmless, multiple alternatives to ABT (AABT) have emerged, though there is great variability in their indications and appropriate use. This variability results from the interaction of a number of factors, including the specialty of the physician, knowledge and preferences, the degree of anemia, transfusion policy, and AABT availability. Since AABTs are not harmless and may not meet cost-effectiveness criteria, such variability is unacceptable. The Spanish Societies of Anesthesiology (SEDAR), Hematology and Hemotherapy (SEHH), Hospital Pharmacy (SEFH), Critical Care Medicine (SEMICYUC), Thrombosis and Hemostasis (SETH) and Blood Transfusion (SETS) have developed a Consensus Document for the proper use of AABTs. A panel of experts convened by these 6 Societies have conducted a systematic review of the medical literature and have developed the 2013 Seville Consensus Document on Alternatives to Allogeneic Blood Transfusion, which only considers those AABT aimed at decreasing the transfusion of packed red cells. AABTs are defined as any pharmacological or non-pharmacological measure aimed at decreasing the transfusion of red blood cell concentrates, while preserving patient safety. For each AABT, the main question formulated, positively or negatively, is: « Does this particular AABT reduce the transfusion rate or not?¼ All the recommendations on the use of AABTs were formulated according to the Grades of Recommendation Assessment, Development and Evaluation (GRADE) methodology.