Patient Blood Management en artroplastia primaria de cadera y rodilla. Encuesta entre los investigadores del estudio POWER.2 / Patient Blood Management for primary hip and knee replacement. A survey among POWER.2 study researchers

ANTECEDENTES: La implementación de los programas Patient Blood Management (PBM) es variable en Europa, incluso en centros en los que estos programas están bien establecidos, donde existe variabilidad en cuanto a prácticas transfusionales. OBJETIVOS Y MÉTODOS: Realizamos una encuesta para valorar la práctica actual sobre PBM perioperatoria en pacientes programados para artroplastia total de cadera y rodilla, entre los investigadores involucrados en el Estudio POWER.2 en España (estudio observacional prospectivo que evaluaba las vías de recuperación intensificada en cirugía ortopédica). RESULTADOS: Se obtuvo un total de 322 respuestas (37,8%). El 50% de los respondedores revisaban los niveles de hemoglobina, al menos 4 semanas antes de la cirugía; el 35% trataba a todos los pacientes anémicos, aunque el 99,7% consideraba que la detección y tratamiento de la anemia preoperatoria podrían influir en los resultados postoperatorios. La falta de infraestructuras (76%) y la falta de tiempo (51%) fueron los principales motivos para no tratar a los pacientes anémicos. El estatus del hierro es revisado antes de la cirugía por el 19% de manera rutinaria, y el 36% lo evalúa únicamente en pacientes anémicos. Hb<9,9g/dl es el valor umbral para demorar la cirugía para el 61% de los clínicos, y el 22% consideraría transfundir preoperatoriamente a los pacientes clínicamente estables sin sangrado activo. El valor umbral para transfundir a los pacientes sin enfermedad cardiovascular es 8g/dl para el 43% y 7g/dl para el 34% de los respondedores; el 75% de los facultativos considera que utiliza «umbrales restrictivos», y el 90% sigue la política transfusional uno a uno (single unit). CONCLUSIONES: Los resultados de nuestra encuesta muestran la variabilidad en la práctica clínica en PBM en cirugía ortopédica mayor, a pesar de ser el tipo de cirugía con más tradición en estos programas

BACKGROUND: Implementation of Patient Blood Management programs remain variable in Europe, and even in centres with well-established PBM programs variability exists in transfusion practices. OBJECTIBES AND METHODS: We conducted a survey in order to assess current practice in perioperative Patient Blood Management in patients undergoing total hip and knee replacement among researchers involved in POWER.2 Study in Spain (an observational prospective study evaluating enhanced recovery pathways in orthopaedic surgery). RESULTS: A total of 322 responses were obtained (37.8%). Half of responders check Haemoglobin levels in patients at least 4 weeks before surgery; 35% treat all anaemic patients, although 99.7% consider detection and treatment of preoperative anaemia could influence the postoperative outcomes. Lack of infrastructure (76%) and lack of time (51%) are the main stated reasons not to treat anaemic patients. Iron status is routinely checked by 19% before surgery, and 36% evaluate it solely in the anaemic patient. Hb<9.9 g/dl is the threshold to delay surgery for 61% of clinicians, and 22% would consider transfusing preoperatively clinically stable patients without active bleeding. The threshold to transfuse patients without cardiovascular disease is 8 g/dl for 43%, and 7 g/dl for 34% of the responders; 75% of clinicians consider they use "restrictive thresholds", and 90% follow the single unit transfusion policy. CONCLUSIONS: The results of our survey show variability in clinical practice in Patient Blood Management in major orthopaedic surgery, despite being the surgery with the greatest tradition in these programs

Patient Blood Management for primary hip and knee replacement. A survey among POWER.2 study researchers. / Patient Blood Management en artroplastia primaria de cadera y rodilla. Encuesta entre los investigadores del estudio POWER.2.

BACKGROUND: Implementation of Patient Blood Management programs remain variable in Europe, and even in centres with well-established PBM programs variability exists in transfusion practices. OBJECTIVES AND METHODS: We conducted a survey in order to assess current practice in perioperative Patient Blood Management in patients undergoing total hip and knee replacement among researchers involved in POWER.2 Study in Spain (an observational prospective study evaluating enhanced recovery pathways in orthopaedic surgery). RESULTS: A total of 322 responses were obtained (37.8%). Half of responders check Haemoglobin levels in patients at least 4 weeks before surgery; 35% treat all anaemic patients, although 99.7% consider detection and treatment of preoperative anaemia could influence the postoperative outcomes. Lack of infrastructure (76%) and lack of time (51%) are the main stated reasons not to treat anaemic patients. Iron status is routinely checked by 19% before surgery, and 36% evaluate it solely in the anaemic patient. Hb<9.9 g/dl is the threshold to delay surgery for 61% of clinicians, and 22% would consider transfusing preoperatively clinically stable patients without active bleeding. The threshold to transfuse patients without cardiovascular disease is 8 g/dl for 43%, and 7 g/dl for 34% of the responders; 75% of clinicians consider they use "restrictive thresholds", and 90% follow the single unit transfusion policy. CONCLUSIONS: The results of our survey show variability in clinical practice in Patient Blood Management in major orthopaedic surgery, despite being the surgery with the greatest tradition in these programs.

Hemorragia obstétrica de causa inesperada. Tumor de Krukenberg / Unexpected obstetric haemorrhage. Krukenberg tumour

La hemorragia obstétrica puede poner en riesgo la vida de la madre y del feto y a menudo se presenta de forma inesperada sin claros factores de riesgo. Su identificación precoz contribuye a no demorar las medidas de reanimación. Se presenta el caso de una rotura de metástasis ovárica durante el trabajo de parto responsable de sangrado masivo que obligó a una cesárea por pérdida de bienestar fetal, un inicio no descrito previamente en el tumor de Krukenberg. Los tumores malignos del embarazo son infrecuentes y difíciles de diagnosticar ya que sus manifestaciones clínicas a menudo se solapan con las del propio embarazo (dispepsia, náuseas y distensión abdominal). Un retraso en el diagnóstico comporta un pronóstico infausto a largo plazo. Se revisan las causas de sangrado obstétrico, subrayando la rareza del tumor de Krukenberg concomitante al embarazo (AU)

Obstetric haemorrhage can endanger the lives of mother and foetus. It often occurs unexpectedly without clear predictors. A high degree of suspicion helps to avoid delaying resuscitation measures. We present the case of a ruptured ovarian metastasis that occurred during labour. It caused a massive bleed forcing a caesarean section due to non-reassuring foetal status. This was an unprecedented and undescribed onset of Krukenberg tumour formation. Malignant tumours in pregnancy are rare and difficult to diagnose due to their clinical manifestations which often overlap with those of pregnancy itself (dyspepsia, nausea and bloating). Despite the available therapeutic measures, a delay in diagnosis is a determining factor for long-term prognosis. We review the causes of obstetric bleeding, and underline how rare Krukenberg tumours concomitant to pregnancy are (AU)

Unexpected obstetric haemorrhage. Krukenberg tumour. / Hemorragia obstétrica de causa inesperada. Tumor de Krukenberg.

Obstetric haemorrhage can endanger the lives of mother and foetus. It often occurs unexpectedly without clear predictors. A high degree of suspicion helps to avoid delaying resuscitation measures. We present the case of a ruptured ovarian metastasis that occurred during labour. It caused a massive bleed forcing a caesarean section due to non-reassuring foetal status. This was an unprecedented and undescribed onset of Krukenberg tumour formation. Malignant tumours in pregnancy are rare and difficult to diagnose due to their clinical manifestations which often overlap with those of pregnancy itself (dyspepsia, nausea and bloating). Despite the available therapeutic measures, a delay in diagnosis is a determining factor for long-term prognosis. We review the causes of obstetric bleeding, and underline how rare Krukenberg tumours concomitant to pregnancy are.

Bloqueo bilateral del plexo braquial por vía axilar para ligamentotaxis de fractura bilateral conminuta de extremidad distal del radio en paciente cardiópata con politraumatismo / Bilateral axillary trachial plexus block for ligamentotaxis of comminuted bilateral distal of the radius in a heart failure patient with polytraumatism

Se presenta el caso de un paciente longevo que es llevado al hospital tras una caída casual. Como consecuencia de esta, presenta traumatismo facial y craneal, junto con fractura con minutameta fisaria distal del radio en ambas muñecas, que requieren reducción manual y ligamentotaxis mediante fijación externa ósea (Ebifix®). Debido al trauma craneofacial y al problema cardio vascular del paciente (prótesis aórtica y tres puentes aorto coronarios), se opta por un bloqueo bilateral del plexo braquial por vía axilar. El procedimiento se realiza en el miembro superior derecho mediante electroneuro estimulación múltiple con búsqueda de respuesta motora (nervios: musculo cutáneo, radial, mediano y cubital); y en el miembro superior izquierdo mediante técnica perivascular con inserción de un catéter no estimulante para infusión continua. La cirugía y el postoperatorio transcurren sin incidencias ni complicaciones (AU)

A case of a long-lived patient who is taken to the hospital after a fortuitous fall was presented. As consequence, he presented facial and cranial traumatism, together with fracture conminuta metafisaria distal of the radius in both wrists, which needed manual reduction and ligamentotaxis by means of external bone fixation (Ebifix™).Due to the craniofacial trauma and the cardiovascular problem of the patient (aortic prosthesis and three aorto-coronary bypasses), he was chosen for a bilateral blockade of the brachial plexus by axillary way. The procedure was performed in the right limb by means of multiple electroneural stimulation searching for motor responses (nerves: musculo cutaneous, radial, medium and ulnar); and in the left limb by means of perivascular insertion of a non stimulant catheter for continuous infusion. The surgery and the postoperatory were without incidents (AU)