A critical review of the perioperative fluid therapy and hemodynamic monitoring recommendations of the Enhanced Recovery of the Adult Pathway (RICA): A position statement of the fluid therapy and hemodynamic monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section (SHTF) of the Spanish Society of Anesthesiology and Critical Care (SEDAR).

In an effort to standardize perioperative management and improve postoperative outcomes of adult patients undergoing surgery, the Ministry of Health, through the Spanish Multimodal Rehabilitation Group (GERM), and the Aragonese Institute of Health Sciences, in collaboration with multiple Spanish scientific societies and based on the available evidence, published in 2021 the Spanish Intensified Adult Recovery (RICA) guideline. This document includes 12 perioperative measures related to fluid therapy and hemodynamic monitoring. Fluid administration and hemodynamic monitoring are not straightforward but are directly related to postoperative patient outcomes. The Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section (SHTF) of the Spanish Society of Anesthesiology and Critical Care (SEDAR) has reviewed these recommendations and concluded that they should be revised as they do not follow an adequate methodology.

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

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

Uso de los test viscoelásticos en los principales escenarios clínicos de sangrado en los centros españoles / Use of viscoelastic tests in the principle bleeding scenarios in Spanish hospitals

Los test viscoelásticos son tecnologías diseñadas para estudiar la dinámica de formación del coágulo, identificar coagulopatías en tiempo real, realizar un diagnóstico y guiar el tratamiento hemostático de forma específica. Sus principales aplicaciones son el tratamiento de la hemorragia significativa en cualquier escenario, así como el de otras situaciones que cursen con alteraciones clínicamente relevantes de la hemostasia, como la coagulopatía del paciente crítico. Su uso se establece mediante algoritmos basados en la evidencia científica que están sujetos a variabilidad en función del contexto clínico. Basada en una encuesta distribuida en varios hospitales, esta revisión objetiva el grado de extensión y la homogeneidad en el uso de los test viscoelásticos en nuestro medio en cirugía cardiaca, en el trasplante hepático y en el paciente politraumatizado. Los resultados obtenidos revelan disparidad en aspectos clave que van desde su capacidad diagnóstica propiamente dicha hasta la interpretación de los parámetros básicos. Estos hallazgos permiten plantear potenciales áreas de investigación con el objetivo de mejorar su rendimiento.(AU)

Viscoelastic tests are designed to study the dynamics of clot formation, identify coagulopathies in real time, arrive at a diagnosis, and guide patient-specific administration of haemostatics. They are mainly used to treat clinically significant bleeding in any setting, and are also used in other situations involving clinically relevant alterations in haemostasis, such as coagulopathy in critically ill patients. These tests are administered following evidence-based algorithms that vary depending on the clinical context. This review summarises the results of a survey conducted in several hospitals to determine the prevalence and standardisation of viscoelastic tests in cardiac surgery, liver transplantation, and multiple trauma patients in Spain. The results reveal divergent opinions on key aspects, ranging from the diagnostic capacity of these tests to the interpretation of the basic parameters. On the basis of these findings, we propose a number of potential areas in which further research will improve the performance of these tests.(AU)

Use of viscoelastic tests in the principle bleeding scenarios in Spanish hospitals.

Viscoelastic tests are designed to study the dynamics of clot formation, identify coagulopathies in real time, arrive at a diagnosis, and guide patient-specific administration of haemostatics. They are mainly used to treat clinically significant bleeding in any setting, and are also used in other situations involving clinically relevant alterations in haemostasis, such as coagulopathy in critically ill patients. These tests are administered following evidence-based algorithms that vary depending on the clinical context. This review summarises the results of a survey conducted in several hospitals to determine the prevalence and standardisation of viscoelastic tests in cardiac surgery, liver transplantation, and multiple trauma patients in Spain. The results reveal divergent opinions on key aspects, ranging from the diagnostic capacity of these tests to the interpretation of the basic parameters. On the basis of these findings, we propose a number of potential areas in which further research will improve the performance of these tests.

One-stop stereology: the estimation of 3D parameters using isotropic rulers.

The stereological estimation of second-order descriptors of spatial architecture appears to be inherently more time-consuming and labour-intensive than the estimation of first-order quantities (total quantities or ratios). Therefore, far fewer researchers tend to make use of second-order approaches in their stereological research projects. In this paper, we use a tutorial approach to illustrate how a desire for practical simplicity has provided us with a data collection method that can be used to simultaneously estimate both first-order and second-order properties of the microstructure of a defined anatomical feature of an organ. The approach does not rely on new results from theory, but nevertheless allows either isotropic uniform random or vertical uniform random sections to be used to make estimates of a comprehensive list of 10 microstructural parameters using relationships that are well known in the literature. The probe used in all cases is an isotropically distributed Ruler and the data collection protocol is easy to learn and apply. We illustrate the method on brain tissue but emphasize that the approach can also be applied to non-biological material.

Morfina asociada a bupivacaína intracisternalen el tratamiento del dolor oncológico maxilofacial / Morphine associated to intracisternal bupivacaine for the management of maxillofacial cancer pain

Introducción: Los tumores maxilofaciales representan un reto para los anestesiólogos dada la dificultad de controlar el dolor con terapias farmacológicas convencionales. El componente cervical alto del tracto espinomesencefálico y los pares craneales V, VII, IX y X, están involucrados en la fisiopatología del dolor cervicocefálico crónico refractario. Existen estudios que proponen el uso de bajas dosis de bupivacaína a nivel de la cisterna magna como tratamiento de este tipo de dolor con buenos resultados. Nosotros proponemos la asociación de morfina a este nivel con el fin de obtener resultados similares evitando los efectos indeseables derivados de la administración única del anestésico local. Caso clínico: Se trata de una paciente de 41 años sin antecedentes personales de interés salvo ulcus gástrico, diagnosticada de carcinoma epidermoide de suelo de boca en estadio evolutivo avanzado (invasión de ganglios regionales y metástasis laterocervicales), remitida a nuestra consulta por cervicalgia y cefalea intensas. Había seguido tratamiento durante un mes con fentanilo transdérmico 150 µg-h-1 asociado a paracetamol 3 g-24 h-1, metamizol 6 g-24 h-1 y metilprednisolona v.o., a pesar de lo cual mantenía una puntuación en la EVA de 8. Se decide realizar una prueba intradural cervical con 1 mg de morfina y de bupivacaína con resultados satisfactorios. Posteriormente se colocó un catéter intradural cervical, comprobando radiológicamente la ubicación intracisternal de la punta. Se administraron inicialmente bolos de 0,9 mg de morfina y 1,2 mg de bupivacaína cada 12 horas. Con estas dosis se consiguió una disminuir 3 puntos en la EVA en los primeros días. Las dosis se aumentaron semanalmente hasta 3,2 mg y 6,2 mg de morfina y bupivacaína diaria consiguiendo una analgesia satisfactoria (EVA=3). No se observaron efectos adversos salvo ligero prurito e inicialmente náuseas, controlados farmacológicamente. Conclusiones: La administración intracisternal de bupivacaína y morfina puede ser un método útil para el tratamiento del dolor crónico maligno de cabeza y cuello, aunque se necesitarán estudios más completos para establecer tanto indicaciones como la seguridad de dicho método (AU)

[Single dose intraoperative administration of 5-fluorouracil (5-FU) in trabeculectomy. Long-term results of a pilot study]. / Einmalige intraoperative Gabe von 5-Fluorouracil (5-FU) bei einer Trabekulektomie. Langzeitergebnisse einer Pilotstudie.

5-Fluorouracil (5-FU) improves the success of trabeculectomy. Since in vitro studies showed a prolonged effect of 36 days of growth inhibition with a single dose of 5-FU, 5-FU is applied intraoperatively. To evaluate the effect of intraoperatively applied 5-FU, we compared 13 (low-risk) patients with intraoperative application of 5-FU to a control group matched by age, diagnosis, sex and stage of glaucoma. Postoperatively on day 4 the IOP was significant lower (4.8 mmHg) in the 5-FU-group in comparison to the untreated group (P = 0.005; power 0.80). After 1 week the difference decreased to 2 mmHg and was not significant any more (P = 0.16). After 1 week a lower mean intraocular pressure of 2 mmHg was found with a P-value of 0.16. It may be that these results are not just due to an antiproliferative mechanism; a direct toxic effect of 5-FU should be considered. 5-FU side effects such as corneal complications and inflammatory reaction were not increased in the 5-FU group. However, one case of persistent hypotony was seen in the 5-FU group. This study found intraoperative use of 5-FU to be a safe procedure with a pronounced capacity to lower IOP in the direct postoperative phase. However, this effect may not be based on an antiproliferative effect alone, but might be of toxic origin.

[Trials in ab-interno sclerostomy with a pulsed dye laser using a scleral dye: reactive black 5]. / Versuche zur Ab-interno-Sklerostomie mittels eines gepulsten Dye-Lasers unter Verwendung eines Sklerafärbemittels: Reactive-Black-5 (RB-5).

Several reports have described the successful performance of ab interno sclerostomies using a pulsed dye laser (666 nm) a goniolens and methylene blue as a scleral dye. However, the laser energy was found to have a bleaching effect on the methylene blue; therefore, methylene blue was replaced by reactive black-5 (RB-5), which seemed to be a more stable dye. To assess laser parameters using RB-5 we compared the number of pulses needed to perforate excised human sclera at different pulse durations (4-8 microseconds), energy levels (50, 100, 130-150, 200, 300 mJ) and delivery angles (20 degrees, 30 degrees, 45 degrees, 90 degrees). Fewer pulses were needed at a shorter pulse duration and higher energy levels. Above 200 mJ, 8 pulses for perforation could not be reduced; however, the width of the fistula increased. With a decrease in the delivery angle, the number of pulses for perforation increased non-proportionally above the calculated increase of the length of the fistula. At an angle of 20 degrees no perforation could be achieved even if 200 pulses of the maximal energy of 200 mJ were applied. This indicates that eyes with flat anterior chambers cannot be successfully treated.