Perioperative neuromuscular blockade. 2020 update of the SEDAR (Sociedad Española de Anestesiología y Reanimación) recommendations.

We present an update of the 2020 Recommendations on neuromuscular blockade of the SEDAR. The previous ones dated 2009. A modified Delphi consensus analysis (experts, working group, and previous extensive bibliographic revision) 10 recommendations were produced1: neuromuscular blocking agents were recommended for endotracheal intubation and to avoid faringo-laryngeal and tracheal lesions, including critical care patients.2 We recommend not to use neuromuscular blocking agents for routine insertion of supraglotic airway devices, and to use it only in cases of airway obstruction or endotracheal intubation through the device.3 We recommend to use a rapid action neuromuscular blocking agent with an hypnotic in rapid sequence induction of anesthesia.4 We recommend profound neuromuscular block in laparoscopic surgery.5 We recommend quantitative monitoring of neuromuscular blockade during the whole surgical procedure, provided neuromuscular blocking agents have been used.6 We recommend quantitative monitoring through ulnar nerve stimulation and response evaluation of the adductor pollicis brevis, acceleromyography being the clinical standard.7 We recommend a recovery of neuromuscular block of at least TOFr ≥ 0.9 to avoid postoperative residual neuromuscular blockade.8 We recommend drug reversal of neuromuscular block at the end of general anesthetic, before extubation, provided a TOFr ≥ 0.9 has not been reached.9 We recommend to choose anticholinesterases for neuromuscular block reversal only if TOF≥2 and a TOFr ≥ 0.9 has not been attained.10 We recommend to choose sugammadex instead of anticholinesterases for reversal of neuromuscular blockade induced with rocuronium.

Bloqueo neuromuscular perioperatorio. Actualización 2020 de las Recomendaciones de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR) / Perioperative neuromuscular blockade. 2020 update of the SEDAR (Sociedad Española de Anestesiología y Reanimación) recommendations

Se presenta la actualización 2020 de las Recomendaciones de bloqueo neuromuscular de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR). Las anteriores databan de 2009. Tras un análisis de consenso Delphi (expertos, grupo de trabajo y revisión bibliográfica previa) se generaron 10 recomendaciones: 1) Se recomienda el uso de fármacos bloqueantes neuromusculares (fbnm) para facilitar la intubación traqueal y evitar lesiones faringo-laringo-traqueales en cualquier paciente, incluidos pacientes críticos. 2) Se recomienda no utilizar fbnm para la inserción rutinaria de dispositivos supraglóticos y utilizar solo en caso de obstrucción de la vía aérea o intubación traqueal a través de este. 3) Se recomienda utilizar un fármaco bloqueante neuromuscular de inicio de acción rápido asociado al agente hipnótico en la inducción de secuencia rápida. 4) Se recomienda utilizar un nivel de bloqueo neuromuscular profundo en cirugía laparoscópica. 5) Se recomienda el uso de monitorización cuantitativa del bloqueo neuromuscular durante todo el procedimiento quirúrgico, siempre que se utilicen fbnm. 6) Se recomienda la monitorización cuantitativa mediante estimulación del nervio cubital y evaluación de la respuesta en el músculo aductor corto del pulgar, siendo el estándar clínico la aceleromiografía (AMG). 7) Se recomienda una recuperación del bloqueo neuromuscular al menos hasta alcanzar un TOFr ≥ 0,9 para evitar el bloqueo neuromuscular residual postoperatorio. 8) Se recomienda la reversión farmacológica del bloqueo neuromuscular al finalizar la anestesia general, previo a la extubación traqueal siempre que no se haya alcanzado un TOFr ≥ 0,9. 9) Se recomienda utilizar fármacos anticolinesterásicos para la reversión del bloqueo neuromuscular solo cuando el tren de cuatro estímulos (TOF) es ≥ 2 y no se haya alcanzado un TOFr ≥ 0,9. 10)...(AU)

We present an update of the 2020 Recommendations on neuromuscular blockade of the SEDAR. The previous ones dated 2009. A modified Delphi consensus analyisis (experts, working group, and previous extensive bibliographic revision) 10 recommendations were produced: (1) neuromuscular blocking agents were recommended for endotracheal intubation and to avoid faringo-laryngeal and tracheal lesions, including critical care patients. (2) We recommend not to use neuromuscular blocking agents for routine insertion of supraglotic airway devices, and to use it only in cases of airway obstruction or endotracheal intubation through the device. (3) SWe recommend to use a rapid action neuromuscular blocking agent with an hypnotic in rapid sequence induction of anesthesia. (4) We recommed profound neuromuscular block in laparoscopic surgery. (5) We recommend quantitative monitoring Sof neuromuscular blockade during the whole surgical procedure, provided neuromuscular blocking agents have been used. (6) We recommend quantitative monitoring through ulnar nerve stimulation and response evaluation of the adductor pollicis brevis, acceleromyography being the clinical standard. (7) We recommned a recovery of neuromuscular block of at least TOFr ≥ 0.9 to avoid postoperative residual neuromuscular blockade. (8) We recommend drug reversal of neuromuscular block at the end of general anesthetic, before extubation, provided a TOFr ≥ 0.9 has not been reached. (9) We recommend to choose anticholinesterases for neuromuscular block reversal only if TOF ≥ 2 and a TOFr ≥ 0.9 has not been atained. (10) We recommend to choose sugammadex instead of anticholinesterases for reversal of neuromuscular blockade induced with rocuronium.(AU)

Implementation of an enhanced recovery after surgery program including a patient school: Impact on quality of life results.

INTRODUCTION: Enhanced Recovery After Surgery (ERAS) protocols and educational programmes have been shown to accelerate orthopaedic surgery recovery with fewer complications, and improve patient-reported outcomes (PROs) for different types of surgery. The objective was to evaluate the impact of an ERAS programme including a patient school on health outcomes and PROs for Total Knee Replacement (TKR) surgery. MATERIAL AND METHODS: A multidisciplinary group created the programme and the patient school (preoperative consultations where the patients' surgical processes are explained and are also given instructions for an appropriate perioperative care management). An observational, prospective study was conducted on all patients operated for TKR from March 2021 to March 2022. Main health outcomes were: hospital stay length, surgical complications and surgery cancellations due to a wrong preoperative medication management. PROs evaluated were: patient satisfaction with pain management, the school, and quality of life before and after surgery (EQ-5D). RESULTS: One hundred thirty-three patients were included. Median hospital stay length was 3 days (IQR 3-5). Rate of surgical complications was 25.6%. No surgery was cancelled. Patient satisfaction rates with pain management and with the school were 8.10/10 and 9.89/10, respectively. Concerning quality of life, mean improvement in mobility and knee pain after the surgery was 0.66 (p < 0.05) and 0.84 (p < 0.05), respectively. CONCLUSIONS: The ERAS programme including a patient school was highly successful with a fast recovery, a short hospital stay length, no surgery cancellations, and improved PROs.

The Society for Translational Medicine: clinical practice guidelines for mechanical ventilation management for patients undergoing lobectomy.

Patients undergoing lobectomy are at significantly increased risk of lung injury. One-lung ventilation is the most commonly used technique to maintain ventilation and oxygenation during the operation. It is a challenge to choose an appropriate mechanical ventilation strategy to minimize the lung injury and other adverse clinical outcomes. In order to understand the available evidence, a systematic review was conducted including the following topics: (I) protective ventilation (PV); (II) mode of mechanical ventilation [e.g., volume controlled (VCV) versus pressure controlled (PCV)]; (III) use of therapeutic hypercapnia; (IV) use of alveolar recruitment (open-lung) strategy; (V) pre-and post-operative application of positive end expiratory pressure (PEEP); (VI) Inspired Oxygen concentration; (VII) Non-intubated thoracoscopic lobectomy; and (VIII) adjuvant pharmacologic options. The recommendations of class II are non-intubated thoracoscopic lobectomy may be an alternative to conventional one-lung ventilation in selected patients. The recommendations of class IIa are: (I) Therapeutic hypercapnia to maintain a partial pressure of carbon dioxide at 50-70 mmHg is reasonable for patients undergoing pulmonary lobectomy with one-lung ventilation; (II) PV with a tidal volume of 6 mL/kg and PEEP of 5 cmH2O are reasonable methods, based on current evidence; (III) alveolar recruitment [open lung ventilation (OLV)] may be beneficial in patients undergoing lobectomy with one-lung ventilation; (IV) PCV is recommended over VCV for patients undergoing lung resection; (V) pre- and post-operative CPAP can improve short-term oxygenation in patients undergoing lobectomy with one-lung ventilation; (VI) controlled mechanical ventilation with I:E ratio of 1:1 is reasonable in patients undergoing one-lung ventilation; (VII) use of lowest inspired oxygen concentration to maintain satisfactory arterial oxygen saturation is reasonable based on physiologic principles; (VIII) Adjuvant drugs such as nebulized budesonide, intravenous sivelestat and ulinastatin are reasonable and can be used to attenuate inflammatory response.

The Society for Translational Medicine: clinical practice guidelines for the postoperative management of chest tube for patients undergoing lobectomy.

The Society for Translational Medicine and The Chinese Society for Thoracic and Cardiovascular Surgery conducted a systematic review of the literature in an attempt to improve our understanding in the postoperative management of chest tubes of patients undergoing pulmonary lobectomy. Recommendations were produced and classified based on an internationally accepted GRADE system. The following recommendations were extracted in the present review: (I) chest tubes can be removed safely with daily pleural fluid of up to 450 mL (non-chylous and non-sanguinous), which may reduce chest tube duration and hospital length of stay (2B); (II) in rare instances, e.g., persistent abundant fluid production, the use of PrRP/B <0.5 when evaluating fluid output to determine chest tube removal might be beneficial (2B); (III) it is recommended that one chest tube is adequate following pulmonary lobectomy, except for hemorrhage and space problems (2A); (IV) chest tube clearance by milking and stripping is not recommended after lung resection (2B); (V) chest tube suction is not necessary for patients undergoing lobectomy after first postoperative day (2A); (VI) regulated chest tube suction [-11 (-1.08 kPa) to -20 (1.96 kPa) cmH2O depending upon the type of lobectomy] is not superior to regulated seal [-2 (0.196 kPa) cmH2O] when electronic drainage systems are used after lobectomy by thoracotomy (2B); (VII) chest tube removal recommended at the end of expiration and may be slightly superior to removal at the end of inspiration (2A); (VIII) electronic drainage systems are recommended in the management of chest tube in patients undergoing lobectomy (2B).

Transfusión de sangre. Un tesoro que hay que reservar para las crisis / No disponible

No disponible

Resucitación hipotensiva en el paciente politraumatizado con shock hemorrágico / Hypotensive resuscitation of the polytrauma patient with hemorrhagic shock

El shock hemorrágico constituye una importante causa de mortalidad en nuestro medio. A pesar de ello en los últimos 40 años ha habido pocos cambios en su tratamiento en el periodo previo a la hemostasia quirúrgica definitiva. El actual estándar de tratamiento, la reanimación con fluidos que busca la normotensión y normovolemia, se basa en trabajos con modelos animales de los años 50 y 60, que se resumen en esta publicación. En las últimas tres décadas han surgido nuevos modelos de shock hemorrágico experimentales más parecidos a las situaciones reales, basados en una hemorragia “incontrolada”. Estos estudios han demostrado un aumento de la supervivencia cuando se permite una hipotensión moderada durante este tipo de shock en pacientes politraumatizados. Esta terapéutica se denomina reanimación (resucitación) hipotensiva. Finalmente se revisan los ensayos clínicos publicados sobre la reanimación hipotensiva en el shock hemorrágico, así como otros indirectamente relacionados. Los autores consideramos la reanimación hipotensiva como una opción de tratamiento tanto extrahospitalaria como intrahospitalaria, prometedora en el shock hemorrágico, pero creemos necesarios más ensayos clínicos sobre el tema para convertirla en un estándar de tratamiento(AU)

Hemorrhagic shock is a significant cause of death in hospital practice, yet the management of this event in the period prior to definitive surgical hemostasis has changed little in 40 years. Currently, the standard treatment of resuscitation by means of fluid therapy to re-establish normal pressure and volume is based on animal models from the 1950s and 1960s; these studies will be reviewed in this article. However, new experimental models of hemorrhagic shock that have emerged in the last 3 decades are based on uncontrolled bleeding and are more similar to real-life situations. Recent studies using these models have demonstrated increased survival when polytrauma patients with hemorrhagic shock are deliberately allowed to remain in a moderate level of hypotension, a strategy referred to as hypotensive resuscitation. Finally, we review clinical trials of hypotensive resuscitation in hemorrhagic shock as well as studies indirectly related to this management approach. We conclude that hypotensive resuscitation is a promising treatment for use in cases of hemorrhagic shock that occur either in or out of hospital; however, we believe that more trials should be done before it can be considered a standard treatment(AU)

[Comparison of hemostatic markers under different techniques for anesthesia-analgesia in total hip or knee replacement]. / Comparación de los marcadores de la hemostasia dependiendo de la técnica anestésica/analgésica empleada en cirugía de prótesis de rodilla y cadera.

BACKGROUND AND OBJECTIVE: Surgery promotes a state of hypercoagulability, predisposing to the possibility of postoperative thromboembolic complications. Our aim was to determine whether certain combinations of techniques (neuraxial, intravenous or both) for anesthesia and analgesia might be associated with attenuation of the prethrombotic state following total hip or knee replacement. METHODS: Prospective longitudinal study of 45 patients undergoing elective hip or knee prosthetic surgery. The patients were randomized to 3 groups to receive different anesthesia-analgesia combinations: spinal-intravenous, spinal-epidural, or general-intravenous. From induction until 36 hours after surgery, we recorded the postoperative time course of the following markers of coagulation and fibrinolysis: platelet count; fibrinogen level; activated partial thromboplastin time; international normalized ratio; and levels of prothrombin activation fragments 1 and 2, thrombin-antithrombin III complex, and D-dimer. RESULTS: No statistically significant between-group differences were found in patient demographic, clinical, surgical or postoperative data. No symptomatic thromboembolic complications or deaths were recorded in the 30 days after surgery. Statistically significant differences were found in laboratory results for samples taken 36 hours after surgery. Patients who received spinal-epidural anesthesia and analgesia had lower levels of prothrombin activation fragments 1 and 2 and longer activated partial thromboplastin times than the group receiving the spinal-intravenous combination. CONCLUSIONS: The anesthetic technique used during surgery did not affect hemostasis. However, continuous epidural analgesia in the postoperative recovery period attenuated some markers of hypercoagulability.

Comparación de los marcadores de la hemostasia dependiendo de la técnica anestésica/analgésica empleada en cirugía de prótesis de rodilla y cadera / Comparison of hemostatic markers under different techniques for anesthesia-analgesia in total hip or knee replacement

INTRODUCCIÓN Y OBJETIVO: La cirugía provoca unestado de hipercoagulabilidad en el postoperatorio quepuede predisponer a complicaciones tromboembólicas.El objetivo de este estudio es determinar si una combinaciónde técnicas anestésicas/analgésicas (neuroaxialeso intravenosas o ambas) se asocia con una atenuacióndel estado pretrombótico en el postoperatorio de cirugíade prótesis total de rodilla y cadera.MÉTODOS: Estudio longitudinal y prospectivo con 45pacientes sometidos a cirugía electiva ortopédica de rodillao cadera. Los pacientes fueron distribuidos aleatoriamentea 3 grupos dependiendo de las técnicas anestésicas/analgésicas empleadas: subaracnoidea/intravenosa,subaracnoidea/epidural y general/intravenosa. Se siguióla evolución temporal de los siguientes marcadores deactivación de la coagulación y fibrinolisis, desde elmomento previo a la inducción hasta 36 horas después dela cirugía: número de plaquetas, fibrinógeno, tiempo detromboplastina parcial activada, relación normalizadainternacional, fragmento de activación de protrombinaF1+2, complejo trombina-antitrombina III y dímero-D.RESULTADOS: No encontramos ninguna diferenciaestadísticamente significativa entre los grupos en términosde características demográficas, datos intraoperatorioso postoperatorios. No hubo complicaciones tromboembólicasclínicamente sintomáticas, ni fallecimientos enlos primeros 30 días del postoperatorio. Encontramosdiferencias estadísticamente significativas entre los gruposen las muestras obtenidas 36 h después de la cirugía,donde el grupo de pacientes anestesiados con anestesiasubaracnoidea/epidural presentaba menores cifras defragmentos F1+2 y un tiempo de tromboplastina parcialactivada más prolongado, comparado con el grupo anestesiadocon anestesia subaracnoidea/intravenosa...(AU)

BACKGROUND AND OBJECTIVE: Surgery promotes a stateof hypercoagulability, predisposing to the possibility ofpostoperative thromboembolic complications. Our aimwas to determine whether certain combinations oftechniques (neuraxial, intravenous or both) foranesthesia and analgesia might be associated withattenuation of the prethrombotic state following total hipor knee replacement.METHODS: Prospective longitudinal study of 45 patientsundergoing elective hip or knee prosthetic surgery. Thepatients were randomized to 3 groups to receive differentanesthesia–analgesia combinations: spinal–intravenous,spinal–epidural, or general–intravenous. From inductionuntil 36 hours after surgery, we recorded thepostoperative time course of the following markers ofcoagulation and fibrinolysis: platelet count; fibrinogenlevel; activated partial thromboplastin time; internationalnormalized ratio; and levels of prothrombin activationfragments 1 and 2, thrombin-antithrombin III complex,and D-dimer.) RESULTS: No statistically significant between-groupdifferences were found in patient demographic, clinical,surgical or postoperative data. No symptomaticthromboembolic complications or deaths were recordedin the 30 days after surgery. Statistically significantdifferences were found in laboratory results for samplestaken 36 hours after surgery. Patients who receivedspinal–epidural anesthesia and analgesia had lowerlevels of prothrombin activation fragments 1 and 2 andlonger activated partial thromboplastin times than thegroup receiving the spinal–intravenous combination.CONCLUSIONS: The anesthetic technique used duringsurgery did not affect hemostasis. However, continuousepidural analgesia in the postoperative recovery periodattenuated some markers of hypercoagulability(AU)

Concentraciones de colesterol y ácido úrico durante la misión en Kosovo (KSPAGT XI) y su relación con la dieta y la actividad física / Cholesterol and uric acid blood levels during the deployment in Kosovo (KSPAGT XI) and their relationship with diet and physical activity

Introducción: Las concentraciones altas de colesterol y ácido úrico, el sedentarismo y la dieta hipercalórica cuando produce un aumento de peso, son factores de riesgo relacionados entre sí y que pueden predecir enfermedades cardiovasculares. Material y Métodos: En este trabajo se han estudiado y comparado las concentraciones plasmáticas de colesterol y ácido úrico obtenidas en el reconocimiento médico antes y después de la misión en un grupo de 270 militares, hombres y mujeres desplazados a Kosovo desde Abril a Octubre 2004. Se correlacionaron estos datos con la dieta y el ejercicio físico realizados durante el tiempo desplazados fuera de territorio nacional. Resultados: Los datos muestran un aumento de la colesterolemia y uricemia en relación con la dieta, el sedentarismo y el índice de masa corporal (IMC) que presentaba la población del estudio. Conclusiones: La suma de otros factores generales de riesgo cardiovascular, como el estrés que estas misiones generan, o individuales como tabaquismo e hipertensión, podrían hacer que esta población tuviera una mayor predisposición al desarrollo de enfermedades cardiovasculares (AU)

Introduction: the high levels of cholesterol and uric acid, sedentary lifestyle, and the hypercaloric diet when it causes a weight gain, are interrelated risk factors which can predict cardiovascular disease. Material and Methods: we have studied and compared the blood levels of cholesterol and uric acid in the medical exams of a group of 270 service members, male and female, before and after the deployment in Kosovo from April to October 2004. These data were correlated with diet and physical activity during the deployment abroad. Results: the data show an increase of cholesterol and uric acid levels in relationship with the diet, sedentary lifestyle and body mass index (BMI) of the studied population. Conclusions: the addition of other general factors of cardiovascular risk, such as the stress of these deployments, or individual factors as smoking and hypertension, could increase the predisposition of this population to developing cardiovascular disease (AU)

[Hypotensive resuscitation of the polytrauma patient with hemorrhagic shock]. / Resucitación hipotensiva en el paciente politraumatizado con shock hemorrágico.

Hemorrhagic shock is a significant cause of death in hospital practice, yet the management of this event in the period prior to definitive surgical hemostasis has changed little in 40 years. Currently, the standard treatment of resuscitation by means of fluid therapy to re-establish normal pressure and volume is based on animal models from the 1950s and 1960s; these studies will be reviewed in this article. However, new experimental models of hemorrhagic shock that have emerged in the last 3 decades are based on uncontrolled bleeding and are more similar to real-life situations. Recent studies using these models have demonstrated increased survival when polytrauma patients with hemorrhagic shock are deliberately allowed to remain in a moderate level of hypotension, a strategy referred to as hypotensive resuscitation. Finally, we review clinical trials of hypotensive resuscitation in hemorrhagic shock as well as studies indirectly related to this management approach. We conclude that hypotensive resuscitation is a promising treatment for use in cases of hemorrhagic shock that occur either in or out of hospital; however, we believe that more trials should be done before it can be considered a standard treatment.

[Gastrointestinal tonometry: a new tool for the anesthesiologist]. / Tonometría gastrointestinal: una nueva herramienta para el anestesiólogo.

Intestinal hypoperfusion is among the factors implicated in sepsis and multiorgan failure. Splanchnic blood flow may be sacrificed to maintain supply to vital organs, even when hemodynamic alterations are minor. The sensitivity of invasive hemodynamic monitoring for detecting intestinal hypoperfusion is low. This paper aims to review current knowledge about indirect measurement of splanchnic perfusion by way of gastrointestinal tonometry. We review the pathophysiology of ischemic intestinal lesions, the basis for gastrointestinal tonometry, and the method. Finally we discuss clinical applications (early diagnosis of ischemic colitis and ischemia of the flap after esophageal reconstruction, weaning from mechanical ventilation, abdominal compartment syndrome, liver transplant, heart surgery, prognostic factors and care of the critically ill patient). An adequate understanding of this monitoring technique and management of information it provides can give an early warning of the intestinal hypoperfusion that precedes other serious systemic complications.

Tonometría gastrointestinal: una nueva herramienta para el anestesiólogo / Gastrointestinal tonometry: a new tool for the anesthesiologist

La hipoperfusión intestinal es uno de los factores implicados en el desarrollo de sepsis y disfunción multiorgánica. El flujo sanguíneo esplácnico puede ser sacrificado para mantener el aporte a órganos vitales, incluso ante alteraciones hemodinámicas menores. La monitorización hemodinámica invasiva es poco sensible en la detección de hipoperfusión intestinal. El presente artículo pretende revisar los conocimientos actuales sobre la medición indirecta de la perfusión esplácnica mediante el uso de la tonometría gastrointestinal. Para ello, realizamos un repaso de la fisiopatología de la lesión intestinal isquémica, fundamentos y metodología de la tonometría gastrointestinal, finalizando con aplicaciones clínicas (diagnóstico precoz de colitis isquémica e isquemia de la plastia post-esofaguectomía, retirada de la ventilación mecánica, síndrome compartimental abdominal, trasplante hepático, cirugía cardiaca, factor pronóstico y terapéutico en el paciente crítico).El adecuado conocimiento y manejo de la información aportada por esta monitorización podría alertar precozmente del inicio de situaciones de hipoperfusión intestinal que preceden a otras graves complicaciones sistémicas (AU)

Cardiac output by femoral arterial thermodilution-calibrated pulse contour analysis during liver transplantation: comparison with pulmonary artery thermodilution.

PURPOSE: The continuous monitoring of the cardiac output during liver transplantation (LT) is an essential part of the intraoperative management of the patient's hemodynamics. To verify the accuracy of a new method based on femoral artery thermodilution-calibrated pulse contour analysis (PCCO) during LT, we compared the technique with the results of an intermittent pulmonary artery thermodilution method (ICO). METHOD: A prospective study included 314 paired cardiac output measurements at 10 sampling times in 35 patients undergoing LT. After initial calibration of the pulse contour analysis, no further recalibrations were performed. Bland and Altman's statistical method, one-way ANOVA, and one sample t tests were used for the analysis of the data. A P<.05 was considered significant. RESULTS: There was a small bias 0.18 L x min(-1) (6.29% from the ICO) for the whole sample of paired measurements, associated with 95% limits of agreement of +/-4.72 (68.89%) L x min(-1). The additional analysis showed comparable biases and limits of agreement for any single time in the study period. The difference PCCO-ICO showed a negative sign for ICO >10 L x min(-1) (P<.001) and a positive sign for ICO <5 L x min(-1) (P<.001). It was greater during infusion of a vasoactive drug (P<.001). CONCLUSION: The pulse contour analysis was found to be an unsatisfactory substitute for intermittent thermodilution measurement of cardiac output during the LT.

[Utility of sigmoid intramucosal pH in the early diagnosis of ischemic colitis after aorta surgery]. / Utilidad del pH intramucoso sigmoideo en el diagnóstico precoz de la colitis isquémica postcirugía aórtica.

A 62-year-old man with grade III ischemia of the legs and occlusion of an aortofemoral shunt underwent axillofemoral bypass and bilateral profundoplasty. During surgery, an aneurysm in the aortic origin of the right common iliac artery ruptured, requiring ligation of the inferior vena cava, the iliac veins and the right common iliac artery. Upon transfer of the patient to the recovery unit, the sigmoid intramucosal pH (pHi) was 6.83 (arterial pH 7.35), the regional CO2 pressure (PrCO2) was 100 mmHg (arterial PCO2 35.2 mmHg), and the lactic acid concentration was 3.6 mmol/L. Ischemic colitis was suspected and colonoscopy confirmed the presence of severe rectal and moderate sigmoid inflammation. An extended sigmoidectomy was performed with colostomy. The patient died from multiorgan failure 48 hours after surgery. Ischemic colitis is a severe complication of aortic surgery. Sigmoid pHi monitoring is non-invasive and highly useful for the early diagnosis of ischemic colitis.

Utilidad del pH intramucoso sigmoideo en el diagnóstico precoz de la colitis isquémica postcirugía aórtica / Usefulness of sigmoid intramucosal pH for the early diagnosis of ischemic colitis after aortic surgery

Varón de 62 años de edad, con isquemia grado III de miembros inferiores y oclusión de derivación aortobifemoral, al que se practicó una derivación axilobifemoral más profundoplastia bilateral. Durante la intervención quirúrgica se produjo la rotura de un aneurisma situado en el origen aórtico de la arteria ilíaca común derecha, lo que obligó a ligar la vena cava inferior, las venas ilíacas y la arteria ilíaca común derecha. El paciente precisó un importante aporte de volumen y aminas vasoactivas. A su ingreso en la Unidad de Reanimación, tenía un pH intramucoso (pHi) sigmoideo de 6,83 (pH arterial 7,35) con presión regional de CO2 (PrCO2) de 100 mmHg (PCO2 arterial 35,2 mmHg) y ácido láctico 3,6 mmol/l. Ante la sospecha de colitis isquémica, se decidió realizar una colonoscopia, confirmándose la existencia de rectitis isquémica grave y sigmoiditis isquémica moderada. Se practicó sigmoidectomía ampliada más colostomía. Finalmente, el paciente falleció a las 48 horas como consecuencia de un cuadro de fracaso multiorgánico. La colitis isquémica es una grave complicación de la cirugía aórtica. La monitorización del pHi sigmoideo es un método no invasivo de gran utilidad en el diagnóstico precoz de la colitis isquémica (AU)

[Usefulness of meperidine in anesthesiology]. / Utilidad de la meperidina en anestesiología.

Meperidine was the first synthetic opioid agent. It acts mainly as an antagonist of mu (#m) receptors and has an analgesic potency ten times greater than that of morphine. Like other opioid drugs, meperidine causes nausea, vomiting, urinary retention and respiratory depression; a point of difference, however, is that it acts on nerve fibers and has properties similar to those of local anesthetics. It has therefore been used as an alternative to other opioids for anesthetic blockade. We review the indications and contraindications of meperidine administered by different routes. For pain, epidural administration has proven to be a good alternative to intravenous administration and epidural meperidine has been combined with local anesthetics using lower doses of both drugs and producing fewer side effects. Intradural meperidine has been used as the sole anesthetic agent in various types of surgery, its principal advantage being that it provides long-lasting postoperative analgesia. Spinal meperidine has the advantage over morphine of a lower incidence of respiratory depression, particularly late-occurring depression. An intravenous route has been used for treating moderate to severe pain, for regional anesthesia, for premedication and for analgesia during anesthesia. Meperidine's action on kappa receptors has meant that it is considered the most effective drug for treating postanesthetic trembling. Although meperidine has been used effectively to treat non-surgical pain, mainly from colic, this review focuses on its usefulness in the perioperative period.