Intraoperative Fascial Plane Blocks Facilitate Earlier Tracheal Extubation and Intensive Care Unit Discharge After Cardiac Surgery: A Retrospective Cohort Analysis.

OBJECTIVES: Novel fascial plane blocks may allow early tracheal extubation and discharge from the intensive care unit (ICU). The present study primarily aimed to determine whether fascial plane blocks, in comparison with intravenous analgesia alone, significantly shortened tracheal extubation times in patients undergoing cardiac surgery. The secondary objectives were to compare each block's performance with that of intravenous analgesia alone in terms of the individual tracheal extubation time and length of ICU stay. DESIGN: Retrospective observational study. SETTING: Single-center study. PARTICIPANTS: Patients who underwent cardiac surgery between 2018 and 2019 were identified from a prospective clinical registry. After obtaining ethics approval, the clinical and electronic records of patients undergoing cardiac surgery in 2018 were analyzed. Data of patients receiving fascial plane blocks (erector spinae plane [ESP], pectoral plane I and II [PECs], and serratus anterior plane [SAP] blocks) with intravenous analgesia were compared with those of patients receiving only intravenous analgesia. A propensity score (PS) model was used to control for differences in the baseline characteristics. Adjusted p < 0.05 was considered statistically significant. MEASUREMENTS AND MAIN RESULTS: Of the 589 patients screened, 532 met the inclusion criteria; 404 received a fascial plane block. After PS matching, weighted linear regression revealed that by receiving a block, the predicted extubation time difference was 9.29 hours (b coefficient; 95% CI: -11.98, -6.60; p = 0.022). Similar results were obtained using PS weighting, with a reduction of 7.82 hours (b coefficient; 95% CI: -11.89, -3.75; p < 0.001) in favor of the block. In the fascial-plane-block group, ESP block achieved the best performance. The length of ICU stay decreased by 1.1 days (b coefficient; 95% CI: -1.43, -0.79; p = 0.0001) in the block group. No complications were reported. CONCLUSIONS: Fascial plane block is associated with reduced extubation times and lengths of ICU stay. ESP block achieved the best performance, followed by PECs and SAP blocks. After PS matching, only ESP block reduced the extubation time.

Parche de sangre cervical para tratamiento de síndrome de hipotensión/ hipovolumen de líquido cefalorraquídeo espontáneo. Reporte de un caso / Cervical blood patch for the treatment of spontaneous cerebrospinal fluid hypotension/hypovolume syndrome. A case report

Presentamos el tratamiento eficaz de una filtración espontánea de líquido cefalorraquídeo (LCR) asociada a un síndrome de hipoten-sión/hipovolumen de LCR a nivel cervical alto, caracterizado por delirio y hematomas subdurales secundarios, refractarios al drenaje quirúrgico, que se resolvió con dos parches de sangre epidurales cervicales consecutivos.

We present the case of a cerebrospinal fluid (CSF) hypotension/hypovolume syndrome due to a spontaneous CSF fistula at the upper cervical level characterized by loss of consciousness and bilateral subdural hematomas refractory to two drainage surgeries that resolved with two consecutive blood patches on the leak site.

Paro cardiorrespiratorio en la embarazada y cesárea perimortem / Maternal cardiac arrest and perimortem cesarean delivery

Resumen El paro cardiorrespiratorio (PCR) en la mujer embarazada es una situación infrecuente, grave y de manejo multidisciplinario. La reanimación cardiopulmonar requiere consideraciones y particularidades propias de la embarazada, centradas en la fisiología y la anatomía, teniendo especial consideración la compresión aortocava, la intubación-ventilación difícil, la presencia de estómago lleno y el hecho que hay dos vidas involucradas. Las principales causas de PCR son las hemorrágicas, seguidas de las embólicas, cardiovasculares, anestésicas e infecciosas. Las principales acciones incluyen activación del código azul obstétrico con respuesta rápida para una eventual realización de histerotomía de emergencia oportuna en el mismo sitio evitando el traslado al quirófano, compresiones torácicas de buena calidad, desviación manual uterina a la izquierda, intubación endotraqueal y manejo avanzado de la vía aérea, todo esto con el fin de mejorar la sobrevida materno-fetal. La cesárea perimortem es un pilar en el manejo, favoreciendo el desenlace materno y eventualmente el fetal. Se debe realizar a los 4 minutos de una reanimación cardiopulmonar no exitosa. Sin embargo, aún hay retardo a la hora de indicarla, por lo que se debe incentivar el entrenamiento, la simulación en resucitación cardiopulmonar materna y las guías clínicas para todo el personal involucrado en la atención de pacientes obstétricas.

Abstract Cardiopulmonary arrest is a rare event during pregnancy and labor. It involves many subspecialties and allied health providers. Besides it requires knowledge of maternal physiology as it relates to resuscitation, particularly aortocaval compression, difficult airway, full stomach and the fact that there are two lives involved. The most frequent causes of cardiac arrest during pregnancy include bleeding, followed by embolism, infection, anesthesia complications and heart failure. The main steps required are: obstetric code activation with appropriate response for performing timely emergent hysterotomy in the same place avoiding the transfer to operating room; good-quality chest compressions; manual uterine displacement to the left, advanced pharmacological and airway management; and optimal care after resuscitation to improve maternal and fetal outcomes. Although current recommendations for maternal resuscitation include the performance of perimortem cesarean section after four minutes of unsuccessful cardiopulmonary resuscitation, deficits in knowledge about this procedure are common. Therefore, training and available evidence-based guidelines should be put in place for all obstetric caregivers.

Anestesia para emergencias en obstetricia / Obstetric patient and anesthesia

Pregnancy induces changes in almost every body system, pushing their reserves to the limit. There is a decrease in systemic vascular resistance, a progressive increase in blood volume, heart rate and myocardial size, resulting in an increased cardiac output. It reduces the functional residual capacity and increases the tidal volume. Oxygen consumption increases, leading to a decrease in oxygen reserves and increased risk of hypoxemia under hypoventilation or apnea (more frequent due to difficult airway management as a result of edema). Important changes are also observed at the hematological, renal and intestinal levels. Uterineplacental blood flow increases progressively during pregnancy, elevating the risk of massive hemorrhage. When intrauterine resuscitation does not resolve acute fetal distress, urgent cesarean section should be performed. Neuraxial over general anesthesia is recommended. In emergency situations, general anesthesia or "Rapid Sequence Spinal Anesthesia" is suggested as an alternative. The requirements of both, hypnotics and inhalation agents, decrease during pregnancy. Obstetric hemorrhage may be the result of bleeding from placenta or a consequence of trauma to the genital tract during delivery. The most severe cases present hypovolemic shock. Along with controlling the source of bleeding, the treatment goals are: treat hypovolemia and acute trauma coagulopathy, preserve oxygen transport capacity, repair the endothelium and prevent dilutional coagulopathy. Management of placenta accreta must be multidisciplinary. Preoperative diagnosis is essential for adequate preparation. Combined spinal-epidural technique is recommended. When hysterectomy becomes necessary, conversion to general anesthesia should be considered. Amniotic fluid embolism in its early stage produces right ventricular dysfunction due to acute pulmonary hypertension and, in its late stage, left ventricular dysfunction. In 40% of cases, multifactorial coagulopathy is observed. The diagnostic criteria are: 1) hypotension or cardiac arrest, hypoxia and coagulopathy; 2) during labor, caesarean section, uterine curettage or in the first 30 minutes postpartum; 3) in the absence of another diagnosis that explains the symptoms. Treatment is supportive, besides termination of pregnancy. Resuscitation during pregnancy must be led by a professional who understands the complexities of the situation. Maternal well-being is the best predictor of fetal well-being. A perimortem cesarean may become necessary.

El embarazo induce cambios en casi todos los sistemas corporales, llevando al límite las reservas a cada uno de ellos. Hay disminución de la resistencia vascular sistémica, aumento progresivo de la volemia, frecuencia cardiaca y tamaño miocárdico, lo que produce un aumento del débito cardiaco. Se reduce de la capacidad residual funcional y aumenta del volumen corriente. Aumenta el consumo de oxígeno, lo que conlleva disminución de la reserva de oxígeno y aumenta el riesgo de hipoxemia frente a hipoventilación o apnea (más frecuente dificultad en el manejo de vía aérea por edema). También se observan importantes cambios a nivel hematológico, renal e intestinal. El aumento progresivo de flujo úteroplacentario propicia el desarrollo de hemorragias masivas. Cuando la reanimación intrauterina no resuelve el sufrimiento fetal agudo se debe proceder a la cesárea de urgencia. En dicho caso, se privilegia la anestesia neuroaxial por sobre la general. En la cesárea de emergencia se recomienda anestesia general o "anestesia espinal en secuencia rápida" como alternativa. Los requerimientos tanto de hipnóticos como de agentes inhalatorios disminuyen en el embarazo. La hemorragia obstétrica resulta del sangrado del lecho placentario o como consecuencia del traumatismo al tracto genital durante el parto. La forma de presentación de los casos graves generalmente es con hipovolémico. Junto con controlar la fuente del sangrado los objetivos son: tratar la hipovolemia, tratar la coagulopatía aguda del trauma, preservar la capacidad de transporte de oxígeno, reparar el endotelio y prevenir la coagulopatía dilucional. El manejo de la placenta acreta es multidisciplinario. El diagnóstico preoperatorio es imprescindible para la adecuada preparación. Es recomendable una técnica combinada espinal-epidural y conversión a anestesia general en caso de histerectomía. La embolia de líquido amniótico en su etapa temprana produce disfunción ventricular derecha, por hipertensión pulmonar aguda y en su etapa tardía, disfunción ventricular izquierda. En el 40% de los casos, se observa coagulopatía multifactorial. Los criterios diagnósticos son: 1) hipotensión o paro cardíaco, hipoxia y coagulopatía; 2) durante el trabajo de parto, cesárea, legrado uterino o en los primeros 30 min posparto; 3) en ausencia de otro cuadro que explique los síntomas. El tratamiento es de soporte y la interrupción del embarazo. La reanimación durante el embarazo debe ser liderada por un profesional que conozca las particularidades del manejo. El bienestar materno es el mejor predictor de bienestar fetal. Una cesárea puede ser necesaria.

Acceso venoso difícil en pediatría / Difficult venous access in pediatrics

BACKGROUND: Cannulation of a peripheral venous access is a routine procedure in pediatric patients admitted to the hospital. 50% of the time cannulation on the first attempt is not feasible, so it is necessary to repeat the puncture, resulting in a complex and frustrating procedure. Half of the children admitted to the hospital have a difficult venous access (DIVA). OBJECTIVE: To carry out a review, which provides information about DIVA in pediatrics, how to evaluate and proceed in these patients. DESIGN: DIVA Score considers vein palpability, vein visibility, age and history of prematurity. The score ranges from 0 to 10 points. Values greater than 4 are associated with difficult venous access. There are associated risk factors: obesity, musculoskeletal malformations, chemotherapy treatment, diabetes mellitus, patients on dialysis, limb edema, moderate to severe dehydration, history of difficult venous access, anxiety of the patient and/or parents report that the child is less likely to cooperate. When making the decision to establish a venous access, it should be evaluated whether it is an emergency or not, the characteristics of the medications and infusions, the time of therapy and the anatomical sites for puncture. Ultrasound and transillumination techniques decrease the time to obtain a venous access and increase the success rate on the first attempt. CONCLUSION: The decision to obtain a venous access must take into account the criteria and risk factors for DIVA. The most recognized scale is the DIVA Score.

INTRODUCCIÓN: La canulación de un acceso venoso periférico es un procedimiento rutinario en los pacientes pediátricos que ingresan al hospital. 50% de las veces la canulación al primer intento es frustra, por lo que es necesario repetir la punción resultando el procedimiento complejo y frustrante. La mitad de los niños que ingresa al hospital presentan un acceso venoso difícil (DIVA, sigla derivada de "difficult intravenous access"). OBJETIVO: Realizar una revisión, que entrega información acerca de DIVA en pediatría, cómo evaluar y proceder en estos pacientes. DESARROLLO: DIVA Score considera palpabilidad y visibilidad venosa, edad y antecedente de prematurez. El puntaje va desde 0 a 10 puntos. Valores mayores a 4 se asocian a acceso venoso difícil. Existen factores de riesgo asociados: obesidad, malformaciones osteomusculares, tratamiento con quimioterapia, diabetes mellitus, pacientes en diálisis, edema de extremidades, deshidratación moderada a severa, historia de acceso venoso difícil, ansiedad del paciente y/o padres que refieren que el niño es poco probable que coopere. Al tomar la decisión de establecer un acceso venoso se debe evaluar si es urgencia o no, las características de los medicamentos e infusiones, tiempo de terapia y los sitios anatómicos para punción. La ultrasonografía y las técnicas de transiluminación disminuyen el tiempo de obtención del acceso venoso e incrementan la tasa de éxito en el primer intento. CONCLUSIÓN: En la decisión de obtener un acceso venoso se deben tener en cuenta los criterios y factores de riesgo de acceso venoso difícil. La escala más reconocida es el DIVA Score.

Revisión de evidencia del impacto de la anestesia obstétrica en los desenlaces maternos y neonatales. Un análisis de la literatura / Review of evidence of the impact of obstetric anesthesia on maternal and neonatal outcomes. An analysis of the literature

We present the analysis and comments of a review of evidence of the impact of obstetric anesthesia on maternal and neonatal outcomes, based on an article previously published by Lim et al.[1]. The advances in obstetric anesthesia on analgesia and anesthesia for labor and delivery, anesthesia for cesarean section and outcomes in obstetric anesthesia.

Se presenta el análisis y comentarios de una revisión de evidencia del impacto de la anestesia obstétrica en los desenlaces maternos y neonatales, basado en un artículo previamente publicado por Lim y cols.[1]. Se analizan los avances en la anestesiología obstétrica sobre analgesia y anestesia para el parto, anestesia para cesárea y desenlaces en anestesia obstétrica.

Implementación del Primer Examen Clínico Objetivo Estructurado (ECOE) para la Certificación de la Especialidad en Anestesiología en Chile

Anesthesiology became the first Chilean medical specialty certification board to incorporate an objective structured clinical examination (OSCE) into its certification system. The main reason for the introduction of an OSCE is to include an evaluation that allow candidates to demonstrate what they really "do" in clinical practice domains. Inherent in this justification is that the OSCE detects competences that are not well evaluated in current written and oral exams. This article describes the process of implementing an OSCE in Anesthesiology certification and a description of its application after one year of operation.

[Implementation of an Objective Structured Clinical Examination (OSCE) for Anesthesiology Certification in Chile]. / Implementación del Primer Examen Clínico Objetivo Estructurado (ECOE) para la Certificación de la Especialidad en Anestesiología en Chile.

Anesthesiology became the first Chilean medical specialty certification board to incorporate an objective structured clinical examination (OSCE) into its certification system. The main reason for the introduction of an OSCE is to include an evaluation that allow candidates to demonstrate what they really "do" in clinical practice domains. Inherent in this justification is that the OSCE detects competences that are not well evaluated in current written and oral exams. This article describes the process of implementing an OSCE in Anesthesiology certification and a description of its application after one year of operation.

Asociación entre meningitis y punción dural en ratas bacterémicas. Un análisis crítico / The Association between meningitis and dural puncture in bacteremic rats. A critical análisis

INTRODUCTION: The presence of an active bacteremia has been considered a relative contraindication to perform an intrathecal puncture due to the risk of causing meningitis or epidural abscess. However, a clear and definite causal relationship has not yet been demonstrated. OBJECTIVES: To determine the relationship between intrathecal puncture and the development of meningitis in sub-jects with bacteremia. MATERIALS AND METHODS: Experimental study in rats with chronic bacteremia to which dural puncture was performed. Meningitis was then evaluated by direct drainage of the cisterna magna and histopathological studies of brain tissue. RESULTS AND CONCLUSION: 12 of 40 bacteremic rats that underwent intrathecal puncture developed meningitis. Previous administration of antibiotics seems to reduce this risk.

INTRODUCCIÓN: Se ha considerado la presencia de una bacteremia activa como contraindicación relativa para realizar una punción intratecal por el riesgo de provocar meningitis o absceso peridural. Sin embargo, aún no se ha podido demostrar una relación causal clara y definida. OBJETIVOS: Determinar la relación entre punción intratecal y el desarrollo de meningitis en sujetos con bacteremia. MATERIALES Y MÉTODOS: Estudio experimental en ratas con bacteremia crónica a las que se les realizó punción dural, luego se evaluó la presencia o no de meningitis mediante drenaje directo de la cisterna magna y estudios histopatológicos de tejido cerebral. RESULTADOS Y CONCLUSIÓN: 12 de 40 ratas bacterémicas a las que se le realizó punción intratecal desarrollaron meningitis. La adminis-tración previa de antibiótico parece disminuir este riesgo.

Cell Saver en Obstetricia. Primer caso reportado en Chile / Cell Saver in Obstetrics. First case reported in Chile

La hemorragia obstétrica representa un desafío para el equipo médico, aportando con importante morbilidad y mortalidad a las pacientes embarazadas.El manejo adecuado, precoz y expedito beneficia el logro de resultados favorables para la madre e hijo; es por esto que debemos reconocer activamente aquellas pacientes en riesgo de presentar un sangrado obstétrico significativo.Presentamos el primer caso reportado en Chile de una paciente embarazada con mala inserción placentaria, sometida a cesárea y decómo se realizó el manejo del sangrado intraoperatorio, con énfasis en el uso de Cell Saver como técnica ahorradora de sangre.(AU)

Obstetric hemorrhage is a challenge for the medical team, contributing with significant morbidity and mortality to the pregnant patient.An appropriate, early, and expeditious management eases the achievement of favourable results for mother and son. We must recognizeactively those patients at risk of a significant obstetric bleeding.We present the first case report in Chile of a pregnant patient with abnormal placentation, undergoing a caesarean section and howbleeding was handled during the surgery, with emphasis on the use of a Cell Saver device as a blood-saving technique.(AU)

[Analysis of incident reports in an anesthesiology unit of a university hospital]. / De la anestesia a la seguridad de la atención: experiencia de 6 años en el análisis de reportes de incidentes en un hospital universitario.

BACKGROUND: Incident reporting is an effective strategy used to enhance patient safety. An incident is an event that could eventually result in harm to a patient. AIM: To classify and analyze incidents reported by an Anesthesiology division at a University hospital in Chile. MATERIAL AND METHODS: A retrospective analysis of the reported incidents registered in our institutional database from January 2008 to January 2014. They were classified according to three variables proposed by the World Health Organization system to determine the type of incident and patients’ potential harm. RESULTS: There were 297 reports registered. Etiologic classification according to the WHO system showed that 29% (n = 85) were related with management, 20% (59) with drugs, 20% (59) with medical devices, 16% (48) with procedures and 15% (46) with human factors. Seventy two percent (58) of incidents caused low or moderate harm and 28% (22) resulted in a severe adverse event or death. CONCLUSIONS: Our analysis highlights that a high rate of incidents are associated with management, the leading cause of reports in our center. Due to the low incident report rate in our country, it is difficult to perform appropriate comparisons with other centers. In the future, local incident reporting systems should be improved.

De la anestesia a la seguridad de la atención: experiencia de 6 años en el análisis de reportes de incidentes en un hospital universitario / Analysis of incident reports in an anesthesiology unit of a university hospital

Background: Incident reporting is an effective strategy used to enhance patient safety. An incident is an event that could eventually result in harm to a patient. Aim: To classify and analyze incidents reported by an Anesthesiology division at a University hospital in Chile. Material and Methods: A retrospective analysis of the reported incidents registered in our institutional database from January 2008 to January 2014. They were classified according to three variables proposed by the World Health Organization system to determine the type of incident and patients’ potential harm. Results: There were 297 reports registered. Etiologic classification according to the WHO system showed that 29% (n = 85) were related with management, 20% (59) with drugs, 20% (59) with medical devices, 16% (48) with procedures and 15% (46) with human factors. Seventy two percent (58) of incidents caused low or moderate harm and 28% (22) resulted in a severe adverse event or death. Conclusions: Our analysis highlights that a high rate of incidents are associated with management, the leading cause of reports in our center. Due to the low incident report rate in our country, it is difficult to perform appropriate comparisons with other centers. In the future, local incident reporting systems should be improved.

Manejo anestesiológico de pacientes con trastorno hipertensivo del embarazo / Anesthesiological management of patients with hypertensive disorder of pregnancy

Los Trastornos hipertensivos del embarazo (THE) contribuyen a la morbimortalidad materna y fetal. En Chile sigue siendo la 2ª causa de muerte materna. Las Sociedades Estadounidense (ACOG) y Canadiense (SOGC) de Ginecología y Obstetricia publicaron una actualización de sus guías de hipertensión en el embarazo, destacando cambios en definiciones y criterios diagnósticos. Se revisan las modificaciones con el objetivo de orientar el manejo anestesiológico de estas pacientes. Los THE se pueden clasificar en múltiples categorías, destacándose la preeclampsia. Ya no es requisito la proteinuria como criterio diagnóstico. Los signos de severidad afectan el pronóstico y deben ser pesquisados. Se recomienda la interrupción del embarazo a las 37 semanas, en ausencia de signos de severidad. La vía del parto es determinada por las condiciones obstétricas de la paciente. El manejo anestésico engloba el cuidado de crisis hipertensivas, convulsiones, analgesia en el trabajo de parto y anestesia para cesárea. Se recomienda la analgesia epidural precoz en el trabajo de parto y anestesia espinal para cesárea. No se recomienda la administración libre de fluidos endovenosos ni la monitorización invasiva, por el riesgo aumentado de complicaciones.

Hypertensive Disorders of Pregnancy (HDP) contribute to maternal and fetal morbidity and mortality. In Chile, it is still the second leading cause of maternal death. The American (ACOG) and Canadian (SOGC) Societies of Obstetrics and Gynecology published an update of their hypertension guidelines in pregnancy, highlighting changes in definitions and diagnostic criteria. Modifications are revised in order to guide the anesthetic management of these patients. HDP can be classified into multiple categories, highlighting preeclampsia. Proteinuria is no longer required as diagnostic criteria. Severity features affect prognosis and should be actively searched. Interruption of pregnancy at 37 weeks is recommended, in the absence of signs of severity. Delivery should be determined by the obstetric conditions. Anesthetic management includes care of hypertensive crises, seizures, analgesia for labor and anesthesia for cesarean section. Early epidural analgesia is recommended in labor and spinal anesthesia for cesarean section. Intravenous fluids and invasive monitoring are not recommended due to increased complications risks.

Dosis efectiva 90 de oxitocina profiláctica en infusión luego del alumbramiento durante operación cesárea en pacientes en trabajo de parto o cesárea primaria: Un estudio dosis-respuesta con distribución secuencial arriba-abajo

Introducción: La administración profiláctica de oxitocina es parte del manejo activo de la tercera etapa del trabajo de parto y reduce el riesgo de hemorragia posparto. Objetivo: estimar con un modelo dosis-respuesta la dosis de oxitocina endovenosa en infusión continua, efectiva en 90% (ED90) para contracción uterina adecuada luego de trabajo de parto fracasado en pacientes que serán sometidas a operación cesárea versus aquellas sometidas a cesárea electiva. Métodos: Estudio dosis-respuesta, ciego único, de dos ramas utilizando la metodología de la moneda sesgada en relación 9:1 para determinar la DE90. El grupo experimental fueron parturientas sometidas a operación cesárea, secundaria a fracaso en la progresión del trabajo de parto y que habían recibido oxitocina. El grupo control, pacientes sometidas a cesárea electiva. Se les administró oxitocina en infusión continua inmediatamente post nacimiento, de acuerdo a la metodología de la moneda sesgada. Posteriormente, a los 4 minutos del nacimiento, el cirujano estimó si el tono uterino era satisfactorio o no. Los desenlaces secundarios incluyeron requerimientos de uterotónicos adicionales y efectos colaterales maternos. Los datos se analizaron por medio de un modelo de regresión logística y la estimación de la DE90 fue derivada del ajuste de curvas. Resultados: Participaron 38 pacientes sometidas a cesárea electiva y 32 que venían de un trabajo de parto. La DE90 de oxitocina estimada fue significativamente mayor para las pacientes en trabajo de parto (44,2 IU/h, iC95% 33,8-55,6), comparadas con las sometidas a cesárea electiva (16,2 IU/h (iC95% 13,1-19,3)). Significativamente más mujeres en el grupo experimental requirieron uterotónicos suplementarios (34% vs/ 8%, p=0,008). La incidencia global de efectos colaterales fue mayor en el grupo experimental (69% vs/ 34%, p=0.004). Conclusión: La mujeres con exposición previa a oxitocina exógena requieren una mayor dosis de infusión inicial de oxitocina para prevenir atonía uterina post operación cesárea que aquellas sin exposición previa.

Fluidoterapia para la prevención de hipotensión arterial secundaria a anestesia espinal en operación cesárea: ¿Tenemos todas las respuestas? / Fluid therapy preventing arterial hypotension after spinal anesthesia for cesarean section: do we have all the answers?

Spinal anesthesia is the technique of choice for patients undergoing cesarean section. One of the most common adverse effects of this technique is arterial hypotension, which if severe, can result in serious maternal and fetal injury or death. Different alternatives exist to prevent and treat hypotension associated to spinal anesthesia; one of them is fluid therapy. The objective of this review is to evaluate the currently available evidence for different fluid therapy alternatives and assess their effectiveness. Nowadays, it does not seem advisable to use preload with crystalloids as evidence suggests its ineffectiveness. As for the other three alternatives (preload with colloids, coload with crystalloids and coload with colloids) there is no superiority among them and neither of them seems effective enough to be used as monotherapy. Due to its safety and ease of use, coload with crystalloids associated to alpha agonist vasopressor therapy seems to be the best management strategy. Further studies should aim at the best way to administer fluids in order to optimize vasopressor therapy.

La técnica anestésica de elección para operación cesárea es la anestesia subaracnoídea. Uno de los principales efectos adversos de esta técnica es la hipotensión arterial, que puede llegar a ocasionar graves complicaciones. Existen diversas alternativas para la prevención y manejo de la hipotensión arterial; una de ellas la fluidoterapia. El objetivo de esta revisión es evaluar la evidencia reciente disponible para las distintas alternativas de fluidoterapia y evaluar su efectividad. Actualmente no parece recomendable el utilizar precarga con cristaloides para la prevención de hipotensión arterial. En cuanto a las otras tres alternativas(precarga con coloides, cocarga con cristaloides o cocarga coloides) ninguna parece ser más efectiva que las otras previniendo hipotensión arterial y ninguna sería efectiva como monoterapia. Por su disponibilidad y seguridad de uso, al día de hoy la cocarga con cristaloides asociada a terapia vasopresora alfa agonista parece ser la mejor alternativa. Estudios futuros debieran apuntar a encontrar la forma de infusión que optimize la terapia con vasopresores.

World Health Organization (WHO) surgical safety checklist implementation and its impact on perioperative morbidity and mortality in an academic medical center in Chile.

Health care organizations are unsafe. Numerous centers have incorporated the WHO Surgical Safety Checklist in their processes with good results; however, only limited information is available about its effectiveness in Latin America. We aimed to evaluate the impact of the checklist implementation on the in-hospital morbidity and mortality rate in a tertiary health care center. After Institutional review board approval, and using data from our hospital administrative records, we conducted a retrospective analysis of all surgical encounters (n = 70,639) over the period from January 2005 to December 2012. Propensity scoring (PS) methods (matching and inverse weighting) were used to compare the pre and postintervention period, after controlling for selection bias. After PS matching (n = 29,250 matched pairs), the in-hospital mortality rate was 0.82% [95% confidence interval (CI), 0.73-0.92] before and 0.65% (95% CI, 0.57-0.74) after checklist implementation [odds ratio (OR) 0.73; 95% CI, 0.61-0.89]. The median length of stay was 3 days [interquartile range (IQR), 1-5] and 2 days (IQR, 1-4) for the pre and postchecklist period, respectively (P < 0.01).This is the first Latin American study reporting a decrease in mortality after the implementation of the WHO Surgical Checklist in adult surgical patients. This is a strong and simple tool to make health care safer, especially in developing countries.

Comentario sobre "Estudio aleatorio sobre el efecto de la profilaxis antibiótica en la fiebre epidural durante el trabajo de parto" / Comment on "A randomized trial of the effects of antibiotic prophylaxis on epidural-related fever in labor"

This work presents a critical analysis of the article by Sharma et al.