Pre-anaesthesia assessment in cataract surgery: Recommendations from the SEDAR Working Group.

INTRODUCTION AND OBJECTIVES: Cataract surgery is one of the most common procedures in outpatient surgery units. The use of information and communication technologies (ICT) in clinical practice and the advent of new health scenarios, such as the Covid pandemic, have driven the development of pre-anaesthesia assessment models that free up resources to improve access to cataract surgery without sacrificing patient safety. The approach to cataract surgery varies considerably among public, subsidised and private hospitals. This raises the need for guidelines to standardise patient assessment, pre-operative tests, management of background medication, patient information and informed consent. RESULTS: In this document, the SEDAR Clinical Management Division together with the Major Outpatient Surgery Division SEDAR Working Group put forward a series of consensus recommendations on pre-anaesthesia testing based on the use of ITCs, health questionnaires, patient information and informed consent supervised and evaluated by an anaesthesiologist. CONCLUSIONS: This consensus document will effectivise pre-anaesthesia assessment in cataract surgery while maintaining the highest standards of quality, safety and legality.

Método de suma acumulada (CUSUM) para evaluar las curvas de aprendizaje del bloqueo femoral continuo guiado por ecografía / Use of the cumulative sum method (CUSUM) to assess the learning curves of ultrasound-guided continuous femoral nerve block

Introducción. Aunque la ecografía es una competencia básica de los residentes de anestesia (RA) hay pocos datos disponibles sobre su proceso de aprendizaje. Este estudio prospectivo observacional tiene como objetivo evaluar el proceso de aprendizaje del bloqueo del nervio femoral continuo guiado por ecografía y determinar el número de procedimientos necesarios que un RA debe realizar para ser exitoso, utilizando el método de suma acumulada (CUSUM). Método. Reclutamos 19 RA sin experiencia previa. Construimos las curvas de aprendizaje utilizando la metodología CUSUM para el bloqueo del nervio femoral continuo guiado por ecografía considerando 2 criterios de éxito: disminución del dolor>2 puntos en una escala numérica [0-10] tras 15min y el tiempo necesario para realizar la técnica. Resultados. Analizamos los datos de 17 RA, que realizaron un total de 237 bloqueos del nervio femoral continuo guiados por ecografía. Ocho de 17 RA tuvieron éxito en cuanto a la disminución del dolor, y asimismo aquellos RA que realizaron>12 bloqueos (8/8) lo consiguieron. En cuanto al tiempo de realización, 5/17 RA alcanzaron el objetivo en 12min; y todos los RA que realizaron>20 procedimientos (4/4) lo alcanzaron. Conclusiones. El número de procedimientos necesarios para alcanzar el éxito parece ser 12, sin embargo es necesario realizar un número mayor para reducir el tiempo de realización del mismo. La metodología CUSUM podría ser útil en programas de formación, permitiendo intervenciones precoces en casos de fallos repetidos, y realizar un currículo basado principalmente en las competencias (AU)

Background. Although ultrasound is a basic competence for anaesthesia residents (AR) there is few data available on the learning process. This prospective observational study aims to assess the learning process of ultrasound-guided continuous femoral nerve block and to determine the number of procedures that a resident would need to perform in order to reach proficiency using the cumulative sum (CUSUM) method. Methods. We recruited 19 AR without previous experience. Learning curves were constructed using the CUSUM method for ultrasound-guided continuous femoral nerve block considering 2 success criteria: a decrease of pain score>2 in a [0-10] scale after 15minutes, and time required to perform it. Results. We analyse data from 17 AR for a total of 237 ultrasound-guided continuous femoral nerve blocks. 8/17 AR became proficient for pain relief, however all the AR who did more than 12 blocks (8/8) became proficient. As for time of performance 5/17 of AR achieved the objective of 12minutes, however all the AR who did more than 20 blocks (4/4) achieved it. Conclusions. The number of procedures needed to achieve proficiency seems to be 12, however it takes more procedures to reduce performance time. The CUSUM methodology could be useful in training programs to allow early interventions in case of repeated failures, and develop competence-based curriculum (AU)

Use of the cumulative sum method (CUSUM) to assess the learning curves of ultrasound-guided continuous femoral nerve block. / Método de suma acumulada (CUSUM) para evaluar las curvas de aprendizaje del bloqueo femoral continuo guiado por ecografía.

BACKGROUND: Although ultrasound is a basic competence for anaesthesia residents (AR) there is few data available on the learning process. This prospective observational study aims to assess the learning process of ultrasound-guided continuous femoral nerve block and to determine the number of procedures that a resident would need to perform in order to reach proficiency using the cumulative sum (CUSUM) method. METHODS: We recruited 19 AR without previous experience. Learning curves were constructed using the CUSUM method for ultrasound-guided continuous femoral nerve block considering 2 success criteria: a decrease of pain score>2 in a [0-10] scale after 15minutes, and time required to perform it. RESULTS: We analyse data from 17 AR for a total of 237 ultrasound-guided continuous femoral nerve blocks. 8/17 AR became proficient for pain relief, however all the AR who did more than 12 blocks (8/8) became proficient. As for time of performance 5/17 of AR achieved the objective of 12minutes, however all the AR who did more than 20 blocks (4/4) achieved it. CONCLUSIONS: The number of procedures needed to achieve proficiency seems to be 12, however it takes more procedures to reduce performance time. The CUSUM methodology could be useful in training programs to allow early interventions in case of repeated failures, and develop competence-based curriculum.

Protocolo clínico asistencial de manejo de la hipertermia maligna / Clinical protocol for the management of malignant hyperthermia

La hipertermia maligna es un síndrome hipermetabólico que ocurre en pacientes susceptibles, tras la exposición a un fármaco anestésico desencadenante (succinilcolina, anestésicos inhalatorios). En España, se presenta en uno de cada 40.000 en adultos, con una mortalidad estimada del 10%. Está inducido por una regulación anormal de los receptores de rianodina, que produce una liberación masiva del calcio del retículo sarcoplasmático del músculo. Las manifestaciones clínicas son variadas y consisten en: elevación del CO2, taquicardia e inestabilidad hemodinámica, acidosis metabólica y respiratoria, sudoración profusa, hiperpirexia, elevación de CPK, mioglobinuria, fallo renal, CID y finalmente parada cardiorrespiratoria. El tratamiento con dantroleno sódico inhibe la liberación de calcio al antagonizar los receptores de rianodina. El diagnóstico definitivo se realiza con el test de contracción de fibra muscular expuesta a cafeína y halotano. Ante este grave evento la protocolización del manejo ayuda a garantizar que el paciente reciba una atención fiable y segura (AU)

Malignant hyperthermia is a hypermetabolic syndrome that appears in susceptible patients after exposure to certain anaesthetic drugs (succinylcholine, inhalation anaesthetics). Its incidence in Spain is 1 in 40,000 adults, with a 10% mortality rate. It is induced by an abnormal regulation of the ryanodine receptors, producing a massive release of calcium from the sarcoplasmic reticulum in the striate muscle. Clinical manifestations include: CO2 increase, tachycardia, haemodynamic instability, metabolic and respiratory acidosis, profuse sweating, hyperpyrexia, CPK increase, myoglobinuria, kidney failure, disseminated intravascular coagulation (DIC), and ending in cardiac arrest. Dantrolene sodium is a ryanodine receptor antagonist, and inhibits the release of intracellular calcium. Definitive diagnosis is achieved by the exposure of muscle fibres to caffeine and halothane. Protocols can help guarantee a reliable and secure management when this severe event occurs (AU)

Clinical protocol for the management of malignant hyperthermia. / Protocolo clínico asistencial de manejo de la hipertermia maligna.

Malignant hyperthermia is a hypermetabolic syndrome that appears in susceptible patients after exposure to certain anaesthetic drugs (succinylcholine, inhalation anaesthetics). Its incidence in Spain is 1 in 40,000 adults, with a 10% mortality rate. It is induced by an abnormal regulation of the ryanodine receptors, producing a massive release of calcium from the sarcoplasmic reticulum in the striate muscle. Clinical manifestations include: CO2 increase, tachycardia, haemodynamic instability, metabolic and respiratory acidosis, profuse sweating, hyperpyrexia, CPK increase, myoglobinuria, kidney failure, disseminated intravascular coagulation (DIC), and ending in cardiac arrest. Dantrolene sodium is a ryanodine receptor antagonist, and inhibits the release of intracellular calcium. Definitive diagnosis is achieved by the exposure of muscle fibres to caffeine and halothane. Protocols can help guarantee a reliable and secure management when this severe event occurs.

Control de la temperatura perioperatoria: encuesta sobre las prácticas actuales / Perioperative temperature control: survey on current practices

Introducción. La prevención de la hipotermia perioperatoria disminuye la morbimortalidad y el coste hospitalario. Este estudio evaluó su nivel de aplicación en 3 hospitales universitarios españoles de tercer nivel. Material y métodos. Una encuesta entre anestesiólogos evaluó la importancia estimada y la práctica clínica en materias de prevención de la hipotermia perioperatoria. Los resultados se compararon en función de la experiencia. Una p < 0,05 fue considerada significativa. Resultados. Ciento dieciséis anestesiólogos contestaron a la encuesta, 48 (41,3%) residentes, 32 (27,6%) adjuntos de menos de 10 años de experiencia, y 36 (31,1%) adjuntos de 10 o más años de experiencia. La prevención de la hipotermia fue evaluada con 7,49 ± 1,79 puntos en una escala de importancia de 0 a 10, sin diferencias entre grupos (p = 0,58). Los adjuntos recién graduados valoraban la temperatura al final de la intervención más que el resto de anestesiólogos (p = 0,02). El calentador de sueros, junto con una manta convectiva fue la medida de prevención más habitual (47%). Solo un 20% de los encuestados monitorizaban la temperatura intra-operatoria, aunque un 75% lo consideraban un parámetro importante. Ninguna unidad disponía de un protocolo de prevención de hipotermia. Discusión y conclusión. A pesar de no existir protocolos de prevención, los anestesiólogos son conscientes de la importancia de la normotermia perioperatoria, pero aún no influye suficiente en su manejo peri-operatorio para diagnosticar y prevenir la hipotermia. Una armonización a nivel local, regional y nacional podría mejorar estas prácticas en el futuro (AU)

Introduction. Prevention of perioperative hypothermia decreases morbidity and mortality, as well as hospital costs. This study was conducted to evaluate the level of implementation of protocols in 3 tertiary Spanish University Hospitals. Material and methods. A survey among anaesthesiologists assessed estimated importance and clinical practice in terms of prevention of perioperative hypothermia. Results were compared depending on their experience. P<.05 was considered significant. Results. A total of 116 anaesthesiologists answered the survey, of whom 48 (41.3%) were residents, 32 (27.6%) were staff with less than 10 years of experience, and 36 (31.1%) staff with 10 years or more of experience, In a 0-10 importance scale, prevention of hypothermia was scored 7.49±1,79, with no difference between groups (P=.58). Younger staff were more concerned of the end surgery temperature than other colleagues (P=.02). The most usual practice was a combination warming the intravenous fluids and an electric blanket (55%). Only 20% of the anaesthesiologists monitored temperature intra-operatively, even though 75% considered it an important parameter. No unit had a written protocol for prevention of perioperative hypothermia. Discussion and conclusion. Despite the absence of prevention protocols, the anaesthesiologists were aware of the importance maintaining a normal peri-operative temperature, but this awareness is still not enough to influence their perioperative management to diagnose and prevent hypothermia. A harmonisation of practice at local, regional and national level could improve this practice in the future (AU)

Perioperative temperature control: Survey on current practices.

INTRODUCTION: Prevention of perioperative hypothermia decreases morbidity and mortality, as well as hospital costs. This study was conducted to evaluate the level of implementation of protocols in 3 tertiary Spanish University Hospitals. MATERIAL AND METHODS: A survey among anaesthesiologists assessed estimated importance and clinical practice in terms of prevention of perioperative hypothermia. Results were compared depending on their experience. P<.05 was considered significant. RESULTS: A total of 116 anaesthesiologists answered the survey, of whom 48 (41.3%) were residents, 32 (27.6%) were staff with less than 10 years of experience, and 36 (31.1%) staff with 10 years or more of experience, In a 0-10 importance scale, prevention of hypothermia was scored 7.49±1,79, with no difference between groups (P=.58). Younger staff were more concerned of the end surgery temperature than other colleagues (P=.02). The most usual practice was a combination warming the intravenous fluids and an electric blanket (55%). Only 20% of the anaesthesiologists monitored temperature intra-operatively, even though 75% considered it an important parameter. No unit had a written protocol for prevention of perioperative hypothermia. DISCUSSION AND CONCLUSION: Despite the absence of prevention protocols, the anaesthesiologists were aware of the importance maintaining a normal peri-operative temperature, but this awareness is still not enough to influence their perioperative management to diagnose and prevent hypothermia. A harmonisation of practice at local, regional and national level could improve this practice in the future.

Pharmaceutical consumption and cost in patients with dementia: A longitudinal study by the Registry of Dementias of Girona (ReDeGi) in Catalonia (Spain).

OBJECTIVE: Drug spending increases exponentially from the age of 65-70 years, and dementia is one of the diseases significantly contributing to this increase. Our aim was to describe pharmaceutical consumption and cost in patients with dementia, using the Anatomical Therapeutic Chemical (ATC) classification system. We also assessed the evolution of costs and consumption, and the variables associated to this evolution during three years. METHODS: Three years prospective cohort study using data from the ReDeGi and the Health Region of Girona (HRG) Pharmacy Unit database from the Public Catalan Healthcare Service (PCHS). Frequency of consumption and costs of ATC categories of drugs were calculated. RESULTS: Sample of 869 patients with dementia, most of them with a diagnosis of degenerative dementia (72.6%), and in a mild stage of the disease (68.2%). Central nervous system (CNS) drugs had the highest consumption rate (97.2%), followed by metabolic system drugs (80.1%), and cardiovascular system drugs (75.4%). Total pharmaceutical cost was of 2124.8 € per patient/year (standard deviation (SD)=1018.5 €), and spending on CNS drugs was 55.5% of the total cost. After 36 months, pharmaceutical cost increased in 694.9 € (SD=1741.9), which was associated with dementia severity and institutionalization at baseline. CONCLUSIONS: Pharmaceutical consumption and costs are high in patients with dementia, and they increase with time, showing an association with baseline dementia severity and institutionalization. CNS drugs are the pharmaceuticals with highest prescription rates and associated costs.

Response entropy changes after noxius stimulus.

Small changes in the frequency of the electromyography could reflect an inadequate anesthetic or analgesic level, and it could be more specific than the hemodynamic monitors. The Datex-Ohmeda S/5 Entropy Module includes information about the electromyographic activity of the face muscles (response entropy--RE). The aim of our study is compare entropy and BIS ability to detect a nociceptive stimulus during a sevoflurane anesthesia. We designed an observational, prospective and descriptive study that included 20 patients. We performed sevoflurane anaesthesia induction, the end-tidal was kept at 3 and 4 %, during 15 min at each concentration, with no analgesic drug and no neuromuscular blocking agent, and we applied a nociceptive stimulus: tetanus 100 Hz, during 5 s. We set the standard monitorization, BIS, RE, and state entropy (SE) along the study. There was a significant difference between RE and SE post-noxious stimulus values at 3 and 4 % end-tidal sevoflurane (p < 0.05). Only RE changed significantly at the moment of the noxious stimulation at both sevoflurane concentrations studied (p < 0.05). In patients under general anesthesia only carried out with sevoflurane at concentrations that inhibit the movement to painful stimuli, the RE is a single parameter able to detect variations after the nociceptive stimulation.

[Acute early postpartum cardiac failure associated with dilated cardiomyopathy: successful treatment with intra-aortic balloon counter-pulsation and levosimendan]. / Défaillance cardiaque aiguë associée à une cardiomyopathie dilatée en post-partum précoce: traitement par ballon de contrepulsion aortique et lévosimendan.

The use of levosimendan (Simdax(®)) was described in cases of acute cardiac failure in patients with peripartum cardiopmyopathy. We report the case of a 36 years old Philippine woman with an undiagnosed dilated myocardiopathy. She developed an acute severe left ventricular dysfunction in the early postpartum period after a cesarean section, possibly related to the recurrence of an unknown peripartum myocardiopathy. Due to failure of the conventional treatment with diuretics and inotropic support, an intra-aortic balloon with counter-pulsation was inserted. In rescue, treatment with levosimendan permitted to wean the patient from haemodynamic support, and a heart transplant was probably avoided. Three months later, a new echocardiography showed a persistent left ventricular dilation and a still marked alteration of left ventricular ejection fraction (28%).

[Maternal hypotension with low doses of spinal bupivacaine or levobupivacaine and epidural volume expansion with saline for cesarean section]. / Hipotensión arterial materna con dosis bajas de bupi y levo- bupivacaína intradural para cesárea más extensión epidural con salino.

BACKGROUND AND OBJECTIVE: Epidural volume extension (EVE) with saline solution can contribute to greater cephalad spread of drugs injected into the subarachnoid space during cesarean section. We studied the incidence of material hypotension with spinal bupivacaine or levobupivacaine (L-bupivacaine) and the spread after epidural saline injection. MATERIAL AND METHODS: After ethics committee approval, we randomized women scheduled for cesarean section to 4 groups to receive 5 mg of 0.25% bupivacaine with (n=51) or without (n=6) saline EVE; 5 mg of 025% L-bupivacaine (n=50); or 6 mg of 03% L-bupivacaine (n=50). All patients also received 25 microg of fentanyl per 2 mL of local hyperbaric spinal anesthetic. In all except the non-EVE group, 10 mL of saline was infused through an epidural catheter 5 minutes after anesthetic infusion. We recorded patient demographic data, procedural and anesthetic times, incision-clamping times, occurrence of hypotension, ephedrine dose required, motor and sensory blockade, requirement for rescue analgesics, and neonatal outcome. RESULTS: After 6 patients had been randomized to the non-EVE group, no further patients were assigned because all the women required rescue analgesics. Demographic data, duration of procedure, time between. incision and delivery, and Apgar scores were similar in all the groups. The incidence of hypotension was lower in the group receiving 5 mg of L-bupivacaine (26% vs. 52.9% in the bupivacaine 5-mg group, and 56% in the 6-mg L-bupivacaine group, P = .04). More women given 5 mg of L-bupivacaine required rescue analgesia (46%) than did those receiving 5 mg of bupivacaine (235%) or 6 mg of L-bupivacaine (28%) (P = .039). Hypotension was associated with a lower umbilical cord pH (P = .001). Ephedrine doses over 20 mg were also associated with a lower umbilical cord pH (P = .031). CONCLUSIONS: The incidence of hypotension was lowest in the group anesthetized with 5 mg of L-bupivacaine, but the need for rescue analgesia was greater in this group. Doses of 5 mg and 6 mg may be sufficient for cesarean section, as they provide a good level of sensory blockade.

Hipotensión arterial materna con dosis bajas de bupi y levobupivacaína intradural para cesárea más extensión epidural con salino / Maternal hypotension with low doses of spinal bupivacaine or levobupivacaine and epidural volume extension with saline for cesarean section

INTRODUCCIÓN: La extensión epidural con suero salino(EVE), puede contribuir a una mayor extensión cefálica delos fármacos inyectados en el espacio subaracnoideo en lacesárea. Hemos estudiado la incidencia de hipotensiónmaternal con bupivacaína subaracnoidea o l-bupivacaína yla extensión después de la inyección de suelo salino epidural.MATERIAL Y MÉTODOS: Tras la aprobación del comitéde ética, realizamos un estudio prospectivo aleatorizadoen mujeres programadas para cesárea. Estas fueronasignadas a uno de los siguientes cuatro grupos: B-5 noEVE, bupivacaína 5 mg 0,25% (n=6) sin inyección desalino epidural; B-5, bupivacaína 5 mg 0,25% (n=51),LB-5: l-bupivacaína 5 mg 0,25% (n=50) y LB-6: l-bupivacaína6 mg 0,3% (n=50). En todos los grupos, se añadiófentanilo 25 μg a la mezcla de 2 ml de anestésicolocal hiperbárico subaracnoideo. En los primeros 5minutos tras la inyección, se administraron 10 ml de suerosalino por el catéter epidural, excepto en el grupocontrol (B-5 no EVE). Se recogieron datos demográficosy tiempos de cirugía, anestesia, incisión-clampaje, incidenciade hipotensión, la dosis de efedrina necesaria, elbloqueo motor y sensitivo, la necesidad de analgesia derescate y los resultados neonatales.RESULTADOS: En el grupo B-5 no EVE no se incluyeronmás pacientes tras incluir 6 pacientes debido a que entodos los casos precisaron suplemento analgésico. Losdatos demográficos, duración del procedimiento, intervaloincisión-nacimiento y test de Apgar fueron comparables.La incidencia de hipotensión arterial fue menor en elgrupo LB-5, 26% frente a 52,9% en B-5 y 56% en el grupoLB-6 (p=0,04). Las necesidades de analgesia de rescatefueron mayores en el grupo LB-5 (46%) frente a B-5(23,5%) y LB-6 (28%) (p=0,039). La hipotensión se relacionócon un pH de cordón umbilical más bajo (p=0,001).Las dosis de efedrina superiores a 20 mg, se asociaron conun pH de cordón umbilical más bajo (p=0,031)...(AU)

BACKGROUND AND OBJETIVE: Epidural volumeextension (EVE) with saline solution can contribute togreater cephalad spread of drugs injected into thesubarachnoid space during cesarean section. We studiedthe incidence of material hypotension with spinalbupivacaine or levobupivacaine (L-bupivacaine) and thespread after epidural saline injection.MATERIAL AND METHODS: After ethics committeeapproval, we randomized women scheduled for cesareansection to 4 groups to receive 5 mg of 0.25% bupivacainewith (n=51) or without (n=6) saline EVE; 5 mg of 0.25% Lbupivacaine(n=50); or 6 mg of 0.3% L-bupivacaine (n=50).All patients also received 25 μg of fentanyl per 2 mL of localhyperbaric spinal anesthetic. In all except the non-EVEgroup, 10 mL of saline was infused through an epiduralcatheter 5 minutes after anesthetic infusion. We recordedpatient demographic data, procedural and anesthetic times,incision-clamping times, occurrence of hypotension,ephedrine dose required, motor and sensory blockade,requirement for rescue analgesics, and neonatal outcome.RESULTS: After 6 patients had been randomized to thenon-EVE group, no further patients were assignedbecause all the women required rescue analgesics.Demographic data, duration of procedure, time betweenincision and delivery, and Apgar scores were similar inall the groups. The incidence of hypotension was lowerin the group receiving 5 mg of L-bupivacaine (26% vs52.9% in the bupivacaine 5-mg group, and 56% in the6-mg L-bupivacaine group, P=.04). More women given5 mg of L-bupivacaine required rescue analgesia (46%)than did those receiving 5 mg of bupivacaine (23.5%) or6 mg of L-bupivacaine (28%) (P=.039). Hypotension wasassociated with a lower umbilical cord pH (P=.001).Ephedrine doses over 20 mg were also associated with alower umbilical cord pH (P=.031)...(AU)

Monitorización del dióxido de carbono, anestésicos inhalatorios y óxido nitroso / No disponible

Los analizadores de gases se fundamentan en principios físicos. Estos mejoran su exactitud y permiten la monitorización respiración a respiración. Describimos los fundamentos de la absorción con infrarrojos, la absorción de luz ultravioleta, la conductividad térmica, los electrodos de dióxido de carbono, los electrodos transcutáneos, las sondas intravasculares y la monitorización del CO2 al final de la espiración (AU)

Gas analysers are based on physical principles. They improve accuracy; they can provide continuous breath-to-breath measurement. We describe infrared absorption, ultraviolet absorption, thermal conductivity, electrode of CO2, electrodes transcutaneous, intravascular probes and end tidal CO2 measurement (AU)

Renal AA amyloidosis secondary to morbid obesity?

Systemic amyloidosis is characterized by extracellular deposits on different organs of insoluble fibrils compounded of low molecular weight subunits coming from a great diversity of serum proteins. Secondary amyloidosis AA is due to fibril deposition composed of fragments of the acute phase reactant serum amyloid A. We report a case of a young patient with morbid obesity and hypertension who was admitted to our hospital for acute renal insufficiency associated with nephrotic range proteinuria which developed while on antibiotic treatment for a respiratory infection. AA Amyloidosis was diagnosed by renal biopsy. Based on recent evidence we hypothesize that morbid obesity could be the underlying cause of the deposit disease.

Monitorización de la concentración de oxígeno / No disponible

La monitorización de los gases respiratorios, (oxígeno, dióxido de carbono, óxido nitroso, agentes inhalatorios) es muy importante en la práctica anestésica y un estándar de monitorización. La fracción inspirada de oxígeno se puede medir con analizadores paramagnéticos, métodos polarográficos, células galvánicas y espectrometría de masas. Los analizadores paramagnéticos de oxígeno son los dispositivos más usados para la monitorización de la fracción inspirada de oxígeno. La espectrometría de masas es una técnica muy exacta (AU)

Monitoring of respiratory gases (oxygen, carbon dioxide, nitrous oxide, volatile agents), is considered highly important for the practice of anaesthesia and also a standard monitoring technique during anaesthesia. Paramagnetic oxygen analyser are the most common form of oxygen analyser used for monitoring inspired oxygen levels. Paramagnetic and mass spectrometer methods are suitable for analysis of respiratory gas mixtures. Fuel cell and polarographic methods are suitable for blood gas analysis. Mass spectrometry isa very accurate technique (AU)

Técnicas analgésicas no neuroaxiales en el parto: recomendaciones, eficacia y efectos adversos / No disponible

El dolor del trabajo del parto es vivido de forma muy diversa por cada mujer y puede llegar a ser la experiencia más dolorosa de su vida. Por ello, la oferta analgésica ante un parto, debe ser amplia y adaptada a las necesidades de la parturienta y al medio en el que se trabaja. La técnica más eficaz para el tratamiento de este dolor es la analgesia epidural, aunque no se aplica a todas las mujeres por diversas razones (contraindicación, falta de disponibilidad o rechazo de la mujer). Se pueden ofrecer métodos analgésicos no farmacológicos, de eficacia variable, que van desde el apoyo emocional, a la acupuntura, masaje, etc. Además, se pueden administrar fármacos sistémicos, entre los que destacamos el uso de opiáceos, especialmente la meperidina como fármaco más usado y el remifentanilo como una opción reciente. Los fármacos inhalatorios autoadministrados, son de uso común en el Reino Unido desde hace un siglo, si bien su uso en España es excepcional hasta ahora. Tanto la administración de opiáceos como de fármacos inhalatorios, requieren un medio hospitalario y unas precauciones que hacen necesaria la colaboración y presencia de un anestesiólogo (AU)

Labour pain is individually felt by women and it can be the most painful experience that a woman can feel in all the life. That is the reason because the analgesic offer for labour pain should be wide and adapted to individual needs and adapted too to the environmental conditions (hospital and not hospital labour). The most effective technique for labour pain is epidural or neuraxial analgesia. This technique is sometimes unavailable for different reasons, such as: contraindication, not available in hospital, and woman’s refusal. Non pharmacological techniquesc an be offered to laboring women, as example: acupuncture, massage, emotional support, etc. Its efficacy is variable and not completely studied. Systemic analgesia is another analgesic option and we remark the use of pethidine, as the most popular opioid for labour pain, and remifentanil, as a recently developed analgesic option. Self-administered inhalatory drugs have been commonly used in United Kingdom in the last century, although its use in Spain is nowadays unusual. Opioids and inhalatory drugs must be delivered in a hospital, with protocols and specialist medical care, what means the anesthesiologist guard duty (AU)

Hemorragia obstétrica / Obstetric haemorrhage

La hemorragia masiva obstétrica es una causa muy importante de mortalidad y morbilidad materna en los países industrializados y del tercer mundo. La hemorragia masiva obstétrica tiene un componente vascular y/o quirúrgico y un componente de coagulopatía. Aunque en dos tercios de los casos de hemorragia postparto precoz no se encuentre ningún factor de riesgo asociado, es muy importante la identificación de los mismos. La hemorragia obstétrica puede, en ocasiones, no ser tratada adecuadamente. La apreciación clínica habitualmente infra estimada pérdida hemática. La hemorragia postparto suele ser la responsable del 95% de las hemorragias postparto y la atonía uterina es la causa más frecuente. El objetivo de la reanimación es restaurar el volumen sanguíneo circulante y mantener una presión de perfusión adecuada. Una vez diagnosticada una hemorragia obstétrica es fundamental actuar de manera secuencial y rápida. El uso racional de los derivados sanguíneos y el trabajo en equipo con el banco de sangre, así como la utilización de medidas tanto quirúrgicas como farmacológicas precoces y decididas en las hemorragias graves, son actitudes necesarias, por lo que se recomienda la implicación directa del personal con más experiencia en la resolución de una hemorragia obstétrica grave. Se recomienda que toda maternidad tenga un protocolo consensuado y conocido por todo el personal de la misma. El protocolo de actuación debe estar adaptado a las características de cada unidad obstétrica y debe revisarse periódicamente. Las enfermas con factores de riesgo de presentar una hemorragia obstétrica deben ser trasladas a un centro de asistencia de nivel III (AU)

Massive obstetric haemorrhage is a very important cause of maternal morbidity and mortality in developed countries and in third world countries. Massive obsteric haemorrhage has a coagulopathic component and a vascular or surgical component that are often associated in the same patient. Nearly two thirds of patients cannot be identified with risk factors for obstetric haemorrhage, although a good knowledge and early identification of associated risk factors is helpful for its prevention in many cases. Obstetric haemorrhage is not always adequately identified or treated, because blood loss is underestimated by clinical observation. Postpartum haemorrhage is the cause of 95% of all obstetric haemorrhages. In this group, the main cause is uterine atony. Women’s resuscitation objective is thr intravascular volume restoration, to reach and adequate tissue perfussion pressure. Once an obstetric haemorrhage is diagnosed, it is very important a coordinated, rapid and protocolized treatment. Rational use of blood components, team work with the blood bank, the use of pharmacological and surgical resources readily, are necessary actions in this context. It is highly recommended prompt implication of senior staff in severe obstetric haemorrhage resolution. It is recommended the use of local protocols for each maternity. This protocol must be known by all team members and it must be adapted to local hospital characteristics, and should be periodically revised. High risk patients for obstetric haemorrhage, must be transferred to a level III hospital where all resources can be used if necessary (AU)

[Postpartum hemorrhage: an observational study of 21,726 deliveries in 28 months]. / Hemorragia obstétrica: estudio observacional sobre 21.726 partos en 28 meses.

OBJECTIVE: To describe the management of severe postpartum hemorrhage. MATERIAL AND METHODS: Prospective observational study from July 2005 to November 2007 in women who were admitted to the recovery unit of a tertiary referral hospital due to postpartum hemorrhage. We analyzed incidence, prevalence, morbidity, mortality, and associated risk factors. RESULTS: The study included 21,726 deliveries (124 with severe bleeding). Postpartum hemorrhage was more common after an instrumental delivery (odds ratio [OR], 4.54) and after a cesarean delivery (OR, 2.86). The risk factors identified in the study population were multiple gestation pregnancy and fetal death. One patient died due to disseminated intravascular coagulation. The main causes of bleeding were uterine atony (45.2%) followed by vaginal tearing (26.6%). Treatment was provided using packed red blood cells in 96.8% of the patients, fibrinogen in 49.2%, prothrombin complex in 7.25% and activated factor VII in 3.2%. Selective arterial embolization was performed in 10.5% of the cases (success rate, 84.6%) and hysterectomy was required in 13.7%. The main complications were need for postoperative mechanical ventilation (11.3%), myocardial ischemia (4%), pulmonary edema (4.8%), acute renal failure (8.9%), ventricular fibrillation (0.8%), and death (0.8%). CONCLUSIONS: The incidence of severe postpartum hemorrhage in patients treated at our hospital is low, as is the mortality rate. Use of fibrinogen is common and provides good results. Angiographic embolization is very effective, though the percentage of hysterectomies is still high. Multiple gestation pregnancy and fetal death are associated risk factors.

Hemorragia obstétrica: estudio observacional sobre 21.726 partos en 28 meses / Postpartum hemorrhage: an observational study of 21726 deliveries in 28 months

OBJETIVO: Describir el manejo de las pacientes quesufrieron una hemorragia obstétrica grave.MATERIAL Y MÉTODOS: Estudio observacional prospectivodesde julio de 2005 a noviembre de 2007 en mujeresque precisaron ingreso en la Unidad de Reanimación deun hospital terciario de referencia, por hemorragia obstétrica.Se analizó la incidencia, prevalencia, morbi-mortalidady factores de riesgo asociados.RESULTADOS: Hubo 21.726 partos (124 de ellos conhemorragia grave). La odds ratio para la aparición dehemorragia obstétrica fue 4,54 para el parto instrumentaly 2,86 para la cesárea. Los factores de riesgo identificadosen la población evaluada fueron embarazo múltipley muerte fetal anteparto. Una paciente falleciódebido a una coagulación intravascular diseminada. Lacausa principal de hemorragia fue la atonía uterina en el45,2%, seguida por los desgarros vaginales (26,6%). Enel tratamiento de 96,8% de pacientes se usó concentradode hematíes, fibrinógeno en el 49,2%, complejo protrombínicoen el 7,25% y factor VII activado en el 3,2%.Se realizó embolización arterial selectiva en el 10,5% delos casos (tasa de éxito del 84,6%). Fue necesaria la histerectomíaen el 13,7% de pacientes. Las principalescomplicaciones fueron: ventilación mecánica postoperatoria(11,3%), isquemia miocárdica (4%), edema pulmonar(4,8%), fallo renal agudo (8,9%), fibrilación ventricular(0,8%) y muerte (0,8%).CONCLUSIÓN: La incidencia de hemorragia grave enlas pacientes atendidas en nuestro hospital es baja, comolo es la tasa de mortalidad. El uso de fibrinógeno es frecuentey dio buenos resultados. La embolización angiográficaes muy efectiva, aunque finalmente el porcentajede histerectomías es elevado aún. Los embarazos múltiplesy los fetos muertos anteparto son factores de riesgoasociados(AU)

OBJECTIVE: To describe the management of severepostpartum hemorrhage.MATERIAL AND METHODS: Prospective observationalstudy from July 2005 to November 2007 in women whowere admitted to the recovery unit of a tertiary referralhospital due to postpartum hemorrhage. We analyzedincidence, prevalence, morbidity, mortality, andassociated risk factors.RESULTS: The study included 21 726 deliveries (124with severe bleeding). Postpartum hemorrhage wasmore common after an instrumental delivery (odds ratio[OR], 4.54) and after a cesarean delivery (OR, 2.86). Therisk factors identified in the study population weremultiple gestation pregnancy and fetal death. Onepatient died due to disseminated intravascularcoagulation. The main causes of bleeding were uterineatony (45.2%) followed by vaginal tearing (26.6%).Treatment was provided using packed red blood cells in96.8% of the patients, fibrinogen in 49.2%, prothrombincomplex in 7.25% and activated factor VII in 3.2%.Selective arterial embolization was performed in 10.5%of the cases (success rate, 84.6%) and hysterectomy wasrequired in 13.7%. The main complications were needfor postoperative mechanical ventilation (11.3%),myocardial ischemia (4%), pulmonary edema (4.8%),acute renal failure (8.9%), ventricular fibrillation(0.8%), and death (0.8%).CONCLUSIONS: The incidence of severe postpartumhemorrhage in patients treated at our hospital is low, asis the mortality rate. Use of fibrinogen is common andprovides good results. Angiographic embolization is veryeffective, though the percentage of hysterectomies is stillhigh. Multiple gestation pregnancy and fetal death areassociated risk factors(AU)

Observational study of continuous spinal anesthesia with the catheter-over-needle technique for cesarean delivery.

BACKGROUND: Few studies have assessed the efficacy and safety of continuous spinal anesthesia in obstetrics, although placement of a catheter in the intrathecal space theoretically offers advantages in these patients. METHODS: Ninety-two women scheduled for elective cesarean delivery using continuous spinal anesthesia with the catheter-over-needle technique (22- or 24-gauge Spinocath) were included in the study. The doses of local anesthetic used, hemodynamic variables, use of ephedrine and other drugs, and incidence of complications such as technical failure and postdural puncture headache (PDPH) were recorded. RESULTS: The mean (+/-SD) dose of hyperbaric bupivacaine used was 8.2+/-1.8 mg. The incidence of hypotension was 30% and the mean total dose of ephedrine was 4+/-7 mg. The continuous spinal anesthetic technique failed in 18 women (20%). The overall incidence of post-dural-puncture headache was 29%; 18% of patients with post-dural-puncture headache required a blood patch. CONCLUSIONS: Compared to previous reports, the incidence of block failure and PDPH in this study was unacceptably high and therefore the risks of the technique appear to outweigh the advantages of continuous spinal anesthesia in obstetric practice.