Research priorities in perioperative fluid therapy and hemodynamic monitoring: A Delphi Consensus Survey from the Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section (SHTF) of the Spanish Society of Anesthesiology and Critical Care (SEDAR).

BACKGROUND: Research in fluid therapy and perioperative hemodynamic monitoring is difficult and expensive. The objectives of this study were to summarize these topics and to prioritize these topics in order of research importance. METHODS: Electronic structured Delphi questionnaire over three rounds among 30 experts in fluid therapy and hemodynamic monitoring identified through the Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section of the Spanish Society of Anesthesiology and Critical Care. RESULTS: 77 topics were identified and ranked in order of prioritization. Topics were categorized into themes of crystalloids, colloids, hemodynamic monitoring and others. 31 topics were ranked as essential research priority. To determine whether intraoperative hemodynamic optimization algorithms based on the invasive or noninvasive Hypotension Prediction Index versus other management strategies could decrease the incidence of postoperative complications. As well as whether the use of renal stress biomarkers together with a goal-directed fluid therapy protocol could reduce hospital stay and the incidence of acute kidney injury in adult patients undergoing non-cardiac surgery, reached the highest consensus. CONCLUSIONS: The Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section of the Spanish Society of Anesthesiology and Critical Care will use these results to carry out the research.

Perioperative colloids: From theory to practice.

INTRODUCTION: Fluid administration is the cornerstone in hypovolemic patient's reanimation. Clinical guidelines restrict colloid administration favouring crystalloids. Currently, we don't know exactly which is the daily clinical practice during the perioperative period. The objective of this study is to describe perioperative use of colloids analysing possible reasons aiming to use them. MATERIAL AND METHODS: Prospective, cross-section, national, multicentre observational study. Fluid Day sub-study. We enrolled all patient's older than 18 years old who underwent surgery during the 24 h of the 2-days study (February, 2019, 18th and 20th). We registered demographic data, comorbidities, anaesthetic and surgical procedure data, fluids administered, perioperative bleeding and monitoring type used during the perioperative period. RESULTS: A total of 5928 cases were analysed and 542 patients (9.1%) received any type of colloids, being hydroxiethyl-starch the most frequently used (5.1%). Patients receiving colloids suffered more longing surgery (150 [90-255] vs. 75 [45-120] min), were urgently operated (13.7 vs. 7.5%) and were more frequent classified as high risk (22 vs. 4.8%). Their recovery was mostly in critical care units (45.1 vs.15.8%). Patients with bleeding less than 500 ml received colloids in a percentage of 5.9 versus 45.9% when this figure was overcome. Patients who received colloids were anaemic more frequently: 29.4 vs. 16.3%. Colloids administration had a higher risk for transfusion (OR 15.7). Advanced monitoring also increased the risk for receiving colloids (OR 9.43). CONCLUSIONS: In our environment with routine clinical practice, colloids administration is limited and close linked to perioperative bleeding.

Invasive pulmonary aspergillosis in patients with acute respiratory syndrome by COVID-19.

Patients with COVID-19 who are admitted to intensive care unit (ICU) are at high risk of developing secondary infections, including invasive fungal infections such as invasive pulmonary aspergillosis (IPA). The main purpose was to analyse the putative COVID-19 Associated Pulmonary Aspergillosis (CAPA) patients in our setting. In these patients, we performed mycological culture in bronchoalveolar lavage (BAL) for isolation of Aspergillus sp. We followed the AspICU algorithm to diagnose putative IPA. Moreover, we considered relevant the positivity of Galactomannan in BAL. We diagnosed putative IPA in 3 patients. The common features of these 3 patients were: more than 21 days of stay in ICU, severe acute respiratory distress syndrome (ARDS) and treatment with steroids (1 mg/kg per day). Therefore, CAPA has to be systematically considered although a new algorithm to diagnose it is needed to treat patients in early stages in order to avoid catastrophic outcomes.

Aspergilosis pulmonar invasiva en pacientes con síndrome de distrés respiratorio por COVID-19 / Invasive pulmonary aspergillosis in patients with acute respiratory syndrome by COVID-19

Los pacientes con COVID-19 que ingresan en una unidad de cuidados intensivos (UCI), tienen un alto riesgo de desarrollar infecciones secundarias, incluyendo infecciones fúngicas invasivas como aspergilosis pulmonar invasiva (API). El objetivo principal fue el análisis de los casos con sospecha de COVID-19 Associated Pulmonary Aspergillosis (CAPA) en nuestra unidad. En estos pacientes realizamos cultivo micológico en el lavado broncoalveolar como métodos de aislamiento de Aspergillus sp. Se siguió el algoritmo AspICU para establecer el diagnóstico de API probable. Además, considerando también relevante la positividad del antígeno de galactomanano. Se confirmó API probable en 3 de ellos. Los 3 pacientes permanecieron ingresados más de 21 días por SDRA grave, y recibieron corticoterapia (1mg/kg/día). Por tanto, la CAPA se debe considerar de forma sistemática, aunque se necesita un nuevo algoritmo diagnóstico que permita tratamiento precoz por las consecuencias deletéreas que puede implicar en los pacientes críticos.(AU)

Patients with COVID-19 who are admitted to intensive care unit (ICU) are at high risk of developing secondary infections, including invasive fungal infections such as invasive pulmonary aspergillosis (IPA). The main purpose was to analyse the putative COVID-19 Associated Pulmonary Aspergillosis (CAPA) patients in our setting. In these patients, we performed mycological culture in bronchoalveolar lavage (BAL) for isolation of Aspergillus sp. We followed the AspICU algorithm to diagnose putative IPA. Moreover, we considered relevant the positivity of galactomannan in BAL. We diagnosed putative IPA in 3 patients. The common features of these 3 patients were: more than 21 days of stay in ICU, severe acute respiratory distress syndrome (ARDS) and treatment with steroids (1mg/kg per day). Therefore, CAPA has to be systematically considered although a new algorithm to diagnose it is needed to treat patients in early stages in order to avoid catastrophic outcomes.(AU)

[Invasive pulmonary aspergillosis in patients with acute respiratory syndrome by COVID-19]. / Aspergilosis pulmonar invasiva en pacientes con síndrome de distrés respiratorio por COVID-19.

Patients with COVID-19 who are admitted to intensive care unit (ICU) are at high risk of developing secondary infections, including invasive fungal infections such as invasive pulmonary aspergillosis (IPA). The main purpose was to analyse the putative COVID-19 Associated Pulmonary Aspergillosis (CAPA) patients in our setting. In these patients, we performed mycological culture in bronchoalveolar lavage (BAL) for isolation of Aspergillus sp. We followed the AspICU algorithm to diagnose putative IPA. Moreover, we considered relevant the positivity of galactomannan in BAL. We diagnosed putative IPA in 3 patients. The common features of these 3 patients were: more than 21 days of stay in ICU, severe acute respiratory distress syndrome (ARDS) and treatment with steroids (1 mg/kg per day). Therefore, CAPA has to be systematically considered although a new algorithm to diagnose it is needed to treat patients in early stages in order to avoid catastrophic outcomes.

Invasive pulmonary aspergillosis in patients with acute respiratory syndrome by COVID-19. / Aspergilosis pulmonar invasiva en pacientes con síndrome de distrés respiratorio por COVID-19.

Patients with COVID-19 who are admitted to intensive care unit (ICU) are at high risk of developing secondary infections, including invasive fungal infections such as invasive pulmonary aspergillosis (IPA). The main purpose was to analyse the putative COVID-19 Associated Pulmonary Aspergillosis (CAPA) patients in our setting. In these patients, we performed mycological culture in bronchoalveolar lavage (BAL) for isolation of Aspergillus sp. We followed the AspICU algorithm to diagnose putative IPA. Moreover, we considered relevant the positivity of galactomannan in BAL. We diagnosed putative IPA in 3 patients. The common features of these 3 patients were: more than 21 days of stay in ICU, severe acute respiratory distress syndrome (ARDS) and treatment with steroids (1mg/kg per day). Therefore, CAPA has to be systematically considered although a new algorithm to diagnose it is needed to treat patients in early stages in order to avoid catastrophic outcomes.

[Obstetric bleeding: an update]. / La hemorragia obstétrica. Actualización.

Massive bleeding in obstetrics still ranks among the most frequent causes of maternal morbidity and mortality worldwide. The most frequent type is primary postpartum hemorrhage, which is usually the result of an atonic uterus. The clinical priorities are to assure hemodynamic stability and to correct coagulation abnormalities. If pharmacologic treatment cannot achieve these goals, invasive methods such as interventional vascular radiology or artery ligation must be used. Hysterectomy is the last resort when the previous methods fail. For the best prognosis, in terms of preventing death, maintaining maternal fertility and minimizing morbidity, every maternity ward should have a well-defined multidisciplinary protocol that facilitates diagnosis and immediate treatment.

La hemorragia obstétrica. Actualización / Obstetric bleeding: an update

La hemorragia obstétrica masiva sigue siendo una delas causas más frecuentes de morbi-mortalidad maternaen todo el mundo. La hemorragia postparto primaria esla más frecuente siendo la atonía uterina su etiologíamás común. Es prioritario garantizar la estabilidadhemodinámica de la paciente y corregir las alteracionesde la coagulación. Si el tratamiento farmacológico resultainsuficiente se deben emplear métodos invasivos comola radiología vascular intervensionista o la ligadura delos vasos arteriales. La histerectomía es la última opcióncuando fracasan las medidas anteriores. Para que el pronósticosea favorable, ya no sólo en términos de mortalidadsino en mantener la fertilidad de la madre y minimizarla morbilidad, es fundamental que cada unidadmaternal cuente con un protocolo de actuación bien definidoy multidisciplinar que facilite el diagnóstico y eltratamiento inmediato(AU)

Massive bleeding in obstetrics still ranks among themost frequent causes of maternal morbidity andmortality worldwide. The most frequent type isprimary postpartum hemorrhage, which is usually theresult of an atonic uterus. The clinical priorities are toassure hemodynamic stability and to correctcoagulation abnormalities. If pharmacologictreatment cannot achieve these goals, invasivemethods such as interventional vascular radiology orartery ligation must be used. Hysterectomy is the lastresort when the previous methods fail. For the bestprognosis, in terms of preventing death, maintainingmaternal fertility and minimizing morbidity, everymaternity ward should have a well-definedmultidisciplinary protocol that facilitates diagnosisand immediate treatment(AU)

Estudios clínicos con dabigatrán / No disponible

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Respuesta a la carta al director “consideraciones sobre la nueva guía de fármacos inhibidores de la hemostasia y anestesia regional neuroaxial” / Author´s reply to "çOn the new guidelines for inhibitors of hemostasis and regional neuraxial anesthesia"

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Fármacos que alteran la hemostasia y técnicas regionales anestésicas y analgésicas: recomendaciones de seguridad / Hemostasis-altering drugs and techniques for regional anesthesia and analgesia: safety recommendations

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[Hemostasis-altering drugs and regional anesthetic techniques: safety guidelines]. / Fármacos que alteran la hemostasia y técnicas regionales anestésicas y analgésicas: recomendaciones de seguridad.

New developments--in the form of emerging clinical settings for regional anesthesia as well as problems arising with the concomitant use of regional techniques and hemostasis-altering drugs--require the ongoing revision of safety guidelines. The annual meeting of ESRA held in Spain in 2003 saw the discussion and clarification of a variety of issues of current concern, including conclusions reached on the estimated risk of spinal hematoma when published safety guidelines are followed or not, precautions to take in epidural anesthesia during cardiac surgery, guidelines for using fondaparinux for thromboprophylaxis, the circumstances under which neuroaxial techniques can be used safely in patients under the effects of platelet aggregation inhibitors such as thienopyridine, and the application of epidural anesthesia in parturients with eclampsia who have received platelet aggregation inhibitors. Conclusions drawn at the meeting enrich and clarify certain important safety issues related to local and regional anesthesia in patients receiving antiplatelet drugs and/or anticoagulants.

[Reduction of blood transfusion need with aprotinin in orthopedic surgery. Spanish Study Group on the Use of Aprotinin in Hip Arthroplasty (GEEEAAC)]. / Reducción de las necesidades transfusionales con aprotinina en cirugía ortopédica. Grupo Español de Estudio del Empleo de Aprotinina en Artroplastia de Cadera (GEEEAAC).

Aprotinin is a protease inhibitor of interest for its antifibrinolytic effect of reducing perioperative bleeding in certain types of surgery, with wide use in heart surgery, liver transplantation and vascular surgery. The application of aprotinin during orthopedic surgery has recently been suggested. Such use is controversial, as there is lack of consensus as to the type of patient for whom aprotinin administration would be indicated, the surgical procedure during which it would be most effective (hip or knee arthroplasty, spinal arthrodesis, major tumor or septic surgery), the doses to administer, its safety and its real efficacy for conserving homologous blood. That is to say, there is no agreement as to the cost/benefit relation of aprotinin for the various types of orthopedic surgery. This critical review of the literature leads to the conclusion that aprotinin is a promising drug for use in orthopedic surgery, given that published studies have established the benefit in blood product savings and decreased blood loss during surgery.

Reducción de las necesidades transfusionales con aprotinina en cirugía ortopédica / Reduced transfusional requirements with aprotinin in orthopedic surgery

La aprotinina es un inhibidor de las proteasas que tiene interés en la actualidad en su calidad de antifibrinolítico para disminuir el sangrado perioperatorio en determinados tipos de cirugía, y su uso está admitido ampliamente en cirugía cardíaca, en el trasplante hepático y en cirugía vascular.Recientemente se ha propuesto su empleo en cirugía ortopédica. Se trata de una indicación controvertida por la falta de unanimidad en el tipo de paciente en el que la aprotinina estaría indicada, en el procedimiento quirúrgico en el que se conseguiría una mayor efectividad (artroplastia de cadera, artroplastia de rodilla, artrodesis raquídea, cirugía mayor tumoral o séptica), en las dosis que se deben administrar, en la seguridad de su empleo y en la eficacia real en el ahorro de sangre homóloga. Es decir, no hay acuerdo en cuanto al rendimiento de la relación coste/beneficio del fármaco en los diferentes procedimientos de cirugía ortopédica.En esta revisión se hace un estudio crítico de las publicaciones al respecto, concluyendo finalmente que se trata de un fármaco prometedor en cirugía ortopédica, dado que en los estudios publicados se ha obtenido un beneficio en relación con el ahorro de hemoderivados y con la disminución de sangrado perioperatorio (AU)

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[Transfusion practice of anesthesiologists in Spain]. / Práctica transfusional entre los anestesiólogos en España.

OBJECTIVE: To determine the packed red cell transfusion practices of Spanish anesthesiologists and the importance they placed on techniques for reducing blood product use. MATERIAL AND METHODS: One hundred letters with five copies of a questionnaire were sent to an equal number of anesthesiology and intensive care recovery departments of randomly chosen Spanish hospitals. RESULTS: Forty-seven hospitals responded with 208 completed questionnaires. Responses following the questionnaire form were considered valid. Transfusions are regularly given when hematocrit falls 24% (39.4%) or 27% (37.8%) or when hemoglobin falls below 8 g% (37%) or 9 g% (30%). Most respondents considered that certain clinical situations can affect the need for transfusion: age (86.5%), coexistence of heart disease (95%) or respiratory disease (72.3%) and prior hematocrit or hemoglobin levels (88%). The most frequently applied technique for reducing the need for blood product transfusion of blood derivatives is normovolemic hemodilution, followed by autologous self-transfusion and controlled hypotension. Clinical judgement and prior blood test results are highly valued as indicators for transfusion (8.68 and 7.48 points out of 10, respectively). The respondents suggested the need for greater coordination of medical and surgical department transfusion policy, as well as the need to hold a consensus conference. CONCLUSIONS: Perioperative transfusions of packed blood cells are mainly performed at 8 to 9 g% of hemoglobin, although need is often based on certain clinical features.