A simple algorithm for differential diagnosis in hemodynamic shock based on left ventricle outflow tract velocity-time integral measurement: a case series.

Echocardiography has gained wide acceptance among intensive care physicians during the last 15 years. The lack of accredited formation, the long learning curve required and the excessive structural orientation of the present algorithms to evaluate hemodynamically unstable patients hampers its daily use in the intensive care unit. The aim of this article is to show 4 cases where the use of our simple algorithm based on VTI, was crucial. Subsequently, to explain the benefit of using the proposed algorithm with a more functional perspective, as a means for clinical decision-making. A simple algorithm based on left ventricle outflow tract velocity-time integral measurement for a functional hemodynamic monitoring on patients suffering hemodynamic shock or instability is proposed by Spanish Critical Care Ultrasound Network Group. This algorithm considers perfusion and congestion variables. Its simplicity might be useful for guiding physicians in their daily decision-making managing critically ill patients in hemodynamic shock.

Documento de consenso de la Sociedad Española de Anestesiología y Reanimación (SEDAR) y la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES) para la adquisición de competencias y obtención del diploma acreditativo en el uso de la Ecocardiografía básica en Cuidados Intensivos y Urgencias / Diploma on Basic Echocardiography training and competencies for Intensive Care and Emergency medicine: Consensus document of the Spanish Society of Anesthesiology and Critical Care (SEDAR) and the Spanish Society of Emergency Medicine (SEMES)

El uso de la ecocardiografía a pie de cama se ha convertido en una herramienta indispensable en la monitorización hemodinámica y diagnóstico en el paciente crítico. Su conocimiento, manejo e indicaciones requieren por parte de las sociedades científicas una implicación para una formación reglada que capacite al profesional. El grupo de trabajo de Ecografía Clínica en Cuidados Intensivos de la Sociedad Española de Anestesiología y Reanimación (SEDAR) y el grupo de trabajo de Ecografía Clínica de la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES) han desarrollado un documento de consenso en el que se definen los objetivos de aprendizaje y los requisitos necesarios para adquirir las competencias recomendadas en relación con el uso de la Ecocardiografía básica en Cuidados Intensivos y Urgencias, y así poder obtener un diploma acreditativo en Ecocardiografía básica en Cuidados Intensivos y Urgencias. En este documento se definen las competencias y el programa de formación para alcanzar el nivel básico en Ecocardiografía en Cuidados Intensivos y Urgencias, como parte del Diploma Completo en Ecografía en Cuidados Intensivos y Urgencias de la SEDAR y SEMES. La Sociedad Española de Anestesiología y Reanimación (SEDAR), junto con la Sociedad Española de Medicina Interna (SEMI) y la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES), ha desarrollado un documento de consenso determinando las competencias y un programa formativo para la adquisición de un diploma en ecografía (pulmonar, vascular y abdominal) en Cuidados Intensivos y Urgencias. Solo cuando se obtenga el Diploma en Ecocardiografía básica y el Diploma en Ecografía pulmonar, vascular, abdominal de la SEDAR, SEMI y SEMES se podrá adquirir el Diploma Completo de Ecografía en Cuidados Intensivos y Urgencias de la SEDAR y SEMES.(AU)

Cardiac ultrasound has become an essential tool for diagnosis and hemodynamic monitoring in critically ill patients. Scientific societies need to work toward developing a training program that will allow clinicians to acquire competence in performing cardiac ultrasound and understanding its indications. The Clinical Ultrasound for Intensive Care task force of the Spanish Society of Anesthesiology and Critical Care (SEDAR) and the Spanish Society of Emergency Medicine (SEMES) have drawn up this position statement defining the learning objectives and training required to acquire the competencies recommended for basic ultrasound management in the intensive care and emergency setting in order to obtain a diploma in Basic Ultrasound in Intensive Care and Emergency Medicine. This document defines the training program and the competencies needed for basic skills in ultrasound in Intensive Care and Emergency Medicine - part of the Diploma in Ultrasound for Intensive Care and Emergency Medicine awarded by SEDAR/SEMES. The Spanish Society of Anesthesia (SEDAR), Spanish Society of Internal Medicine (SEMI) and Spanish Society of Emergency Medicine (SEMES) have drawn up a position statement determining the competencies and training program for a diploma in ultrasound (lung, abdominal and vascular) in Intensive Care and Emergency Medicine. To obtain the SEDAR/SEMES Diploma in Ultrasound in Intensive Care and Emergency Medicine, clinicians must have completed the SEDAR, SEMI and SEMES Diploma in basic ultrasound and the Diploma in lung, abdominal, and vascular ultrasound.(AU)

Diploma on Basic Echocardiography training and competencies for Intensive Care and Emergency medicine: Consensus document of the Spanish Society of Anesthesiology and Critical Care (SEDAR) and the Spanish Society of Emergency Medicine (SEMES).

Cardiac ultrasound has become an essential tool for diagnosis and hemodynamic monitoring in critically ill patients. Scientific societies need to work toward developing a training program that will allow clinicians to acquire competence in performing cardiac ultrasound and understanding its indications. The Clinical Ultrasound for Intensive Care task force of the Spanish Society of Anesthesiology and Critical Care (SEDAR) and the Spanish Society of Emergency Medicine (SEMES) have drawn up this position statement defining the learning objectives and training required to acquire the competencies recommended for basic ultrasound management in the intensive care and emergency setting in order to obtain a diploma in Basic Ultrasound in Intensive Care and Emergency Medicine. This document defines the training program and the competencies needed for basic skills in ultrasound in Intensive Care and Emergency Medicine-part of the Diploma in Ultrasound for Intensive Care and Emergency Medicine awarded by SEDAR/SEMES. The Spanish Society of Anesthesia (SEDAR), Spanish Society of Internal Medicine (SEMI) and Spanish Society of Emergency Medicine (SEMES) have drawn up a position statement determining the competencies and training program for a diploma in ultrasound (lung, abdominal and vascular) in Intensive Care and Emergency Medicine. To obtain the SEDAR/SEMES Diploma in Ultrasound in Intensive Care and Emergency Medicine, clinicians must have completed the SEDAR, SEMI and SEMES Diploma in basic ultrasound and the Diploma in lung, abdominal, and vascular ultrasound.

Diploma on Ultrasound training and competency for Intensive Care and Emergency Medicine: Consensus document of the Spanish Society of Anesthesia (SEDAR), Spanish Society of Internal Medicine (SEMI) and Spanish Society of Emergency Medicine (SEMES). / Documento de consenso de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Sociedad Española de Medicina Interna (SEMI) y Sociedad Española de Medicina de Urgencias y Emergencias (SEMES) para la definición de competencias mínimas de ecografía en Cuidados Intensivos y Urgencias y la obtención del Diploma acreditativo.

The use of ultrasound as a clinical diagnostic tool and guide of bedside procedures has become an indispensable examination in the acute critically ill patient. The training of professionals in minimum skills of knowledge, management and indications of use of ultrasound required to be defined by the Scientific Societies. The Intensive Care Ultrasound Working Group of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), of the Spanish Society of Internal Medicine (SEMI) and the Spanish Society of Emergency Medicine (SEMES) has developed this consensus document in which the recommended training program and the minimum competencies to be achieved with regard to the use of Ultrasound in Intensive Care, Anesthesia and Emergency medicine are defined. This document defines the training program and the skills to acquire in order to achieve the diploma in lung, abdominal and vascular ultrasound. This document can serve as a guide to define the skills to be acquired in the training programs of residents (MIRs) of specialists working in intensive care, anesthesia, and emergency medicine.

Big data techniques for the secondary use of clinical data in the generation of medical knowledge. The MIMIC solution / Técnicas Big data para el uso secundario de datos clínicos para la creación de conocimiento medico. La solución MIMIC

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Systolic anterior motion of the mitral valve with left ventricular outflow tract obstruction: A case report in the perioperative setting / Movimiento sistólico anterior de la válvula mitral con obstrucción del tracto de salida del ventrículo izquierdo: un caso clínico en el perioperatorio

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[An established anesthesia team-care model: over 12000 cases in a digestive endoscopy unit]. / Consolidación de un modelo asistencial basado en un equipo de anestesia: experiencia en más de 12.000 casos en una Unidad de Endoscopia Digestiva.

BACKGROUND AND OBJECTIVE: The growing demand for digestive and other endoscopic procedures outside the operating room, both in terms of type of endoscopy and number of patients, requires reorganization of the anesthesiology department's workload. We describe 2 years of our hospital digestive endoscopy unit's experience with a now well-established care model involving both anesthesiologists and nurse anesthetists. MATERIAL AND METHODS: After previously reviewing the medical records of outpatients and conducting a telephone interview about state of health, nurse anesthetists administered a combination of propofol and remifentanil through a target-controlled infusion system under an anesthesiologist's direct supervision. RESULTS: The ratio of anesthesiologists to nurses ranged from 1:2 to 1:3 according to the complexity of the examination procedure. Over 12000 endoscopies (simple to advanced) in a total of 11853 patients were performed under anesthesia during the study period. Airway management maneuvers were required by 4.9% of the patients; 0.18% required bag ventilation for respiratory depression, and 0.084% required bolus doses of a vasopressor to treat hypotension or atropine to treat bradycardia. The procedure had to be halted early in 9 patients (0.07%). No patient required orotracheal intubation and none died. Nor were any complications related to sedation recorded. CONCLUSION: The results suggest that this care model can safely accommodate a large caseload in anesthesia at an optimum level of quality.

[Objectives of hemodynamic resuscitation]. / Objetivos de la reanimación hemodinámica.

Cardiovascular failure or shock, of any etiology, is characterized by ineffective perfusion of body tissues, inducing derangements in the balance between oxygen delivery and consumption. Impairment in oxygen availability on the cellular level causes a shift to anaerobic metabolism, with an increase in lactate and hydrogen ion production that leads to lactic acidosis. The degree of hyperlactatemia and metabolic acidosis will be directly correlated to the development of organ failure and poor outcome of the individuals. The amount of oxygen available at the tissues will depend fundamentally on an adequate level of perfusion pressure and oxygen delivery. The optimization of these two physiologic parameters can re-establish the balance between oxygen delivery and consumption on the cellular level, thus, restoring the metabolism to its aerobic paths. Monitoring variables such as lactate and oxygen venous saturations (either central or mixed) during the initial resuscitation of shock will be helpful to determine whether tissue hypoxia is still present or not. Recently, some new technologies have been developed in order to evaluate local perfusion and microcirculation, such as gastric tonometry, near-infrared spectroscopy and videomicroscopy. Although monitoring these regional parameters has demonstrated its prognostic value, there is a lack of evidence regarding to its usefulness during the resuscitation process. In conclusion, hemodynamic resuscitation is still based on the rapid achievement of adequate levels of perfusion pressure, and then on the modification of oxygen delivery variables, in order to restore physiologic values of ScvO(2)/SvO(2) and resolve lactic acidosis and/or hyperlactatemia.

Modeling the effect of propofol and remifentanil combinations for sedation-analgesia in endoscopic procedures using an Adaptive Neuro Fuzzy Inference System (ANFIS).

BACKGROUND: The increasing demand for anesthetic procedures in the gastrointestinal endoscopy area has not been followed by a similar increase in the methods to provide and control sedation and analgesia for these patients. In this study, we evaluated different combinations of propofol and remifentanil, administered through a target-controlled infusion system, to estimate the optimal concentrations as well as the best way to control the sedative effects induced by the combinations of drugs in patients undergoing ultrasonographic endoscopy. METHODS: One hundred twenty patients undergoing ultrasonographic endoscopy were randomized to receive, by means of a target-controlled infusion system, a fixed effect-site concentration of either propofol or remifentanil of 8 different possible concentrations, allowing adjustment of the concentrations of the other drug. Predicted effect-site propofol (C(e)pro) and remifentanil (C(e)remi) concentrations, parameters derived from auditory evoked potential, autoregressive auditory evoked potential index (AAI/2) and electroencephalogram (bispectral index [BIS] and index of consciousness [IoC]) signals, as well as categorical scores of sedation (Ramsay Sedation Scale [RSS] score) in the presence or absence of nociceptive stimulation, were collected, recorded, and analyzed using an Adaptive Neuro Fuzzy Inference System. The models described for the relationship between C(e)pro and C(e)remi versus AAI/2, BIS, and IoC were diagnosed for inaccuracy using median absolute performance error (MDAPE) and median root mean squared error (MDRMSE), and for bias using median performance error (MDPE). The models were validated in a prospective group of 68 new patients receiving different combinations of propofol and remifentanil. The predictive ability (P(k)) of AAI/2, BIS, and IoC with respect to the sedation level, RSS score, was also explored. RESULTS: Data from 110 patients were analyzed in the training group. The resulting estimated models had an MDAPE of 32.87, 12.89, and 8.77; an MDRMSE of 17.01, 12.81, and 9.40; and an MDPE of -1.86, 3.97, and 2.21 for AAI/2, BIS, and IoC, respectively, in the absence of stimulation and similar values under stimulation. P(k) values were 0.82, 0.81, and 0.85 for AAI/2, BIS, and IoC, respectively. The model predicted the prospective validation data with an MDAPE of 34.81, 14.78, and 10.25; an MDRMSE of 16.81, 15.91, and 11.81; an MDPE of -8.37, 5.65, and -1.43; and P(k) values of 0.81, 0.8, and 0.8 for AAI/2, BIS, and IoC, respectively. CONCLUSION: A model relating C(e)pro and C(e)remi to AAI/2, BIS, and IoC has been developed and prospectively validated. Based on these models, the (C(e)pro, C(e)remi) concentration pairs that provide an RSS score of 4 range from (1.8 µg·mL(-1), 1.5 ng·mL(-1)) to (2.7 µg·mL(-1), 0 ng·mL(-1)). These concentrations are associated with AAI/2 values of 25 to 30, BIS of 71 to 75, and IoC of 72 to 76. The presence of noxious stimulation increases the requirements of C(e)pro and C(e)remi to achieve the same degree of sedative effects.

[Using the CTrach Laryngeal Mask Airway in the awake patient with an expected difficult airway]. / Uso de la LMA CTrach en el paciente despierto con criterios de vía aérea difícil.

The method of choice for managing the expected difficult airway is tracheal intubation with an awake patient breathing spontaneously. The CTrach Laryngeal Mask Airway (LMA) is a modified version of the Fastrach LMA that incorporates a fiberoptic system that provides a view of the glottis during ventilation and intubation. We describe 2 cases of intubation in which the CTrach device was used in patients breathing spontaneously. In both cases difficult intubation was foreseen. The CTrach LMA facilitates management of the airway in these circumstances. It is well tolerated and enables a clear view of the airway and permits assisted ventilation when necessary.

Uso de la LMA CTrach® en el paciente despierto con criterios de vía aérea difícil / Using the CTrach Laryngeal Mask Airway in the awake patient with an expected difficult airway

El control de elección de la vía aérea difícil prevista esla intubación traqueal con el paciente despierto en ventilaciónespontánea. El dispositivo LMA CTrach® es unaadaptación de la LMA Fastrach® que incorpora un sistemade fibra óptica integrado en el equipo que proporcionauna visión directa de la glotis durante la ventilacióny la intubación. Presentamos dos casos deintubación con LMA CTrach® manteniendo la ventilaciónespontánea en pacientes con vía aérea difícil prevista.La LMA CTrach® es una buena alternativa al manejode la vía aérea difícil prevista con el pacientedespierto, ya que es bien tolerada, permite la intubaciónbajo visión directa y facilita la ventilación asistida si fueranecesario(AU)

The method of choice for managing the expecteddifficult airway is tracheal intubation with an awakepatient breathing spontaneously. The CTrach LaryngealMask Airway (LMA) is a modified version of theFastrach LMA that incorporates a fiberoptic system thatprovides a view of the glottis during ventilation andintubation. We describe 2 cases of intubation in whichthe CTrach device was used in patients breathingspontaneously. In both cases difficult intubation wasforeseen. The CTrach LMA facilitates management ofthe airway in these circumstances. It is well toleratedand enables a clear view of the airway and permitsassisted ventilation when necessary(AU)