Description of Intensive Care and Intermediate Care resources managed by Anaesthesiology Departments in Spain and their adaptation capacity during the COVID-19 pandemic.

INTRODUCTION: It is essential to understand the strategic importance of intensive care resources in the sustainable organisation of healthcare systems. Our objective has been to identify the intensive and intermediate care beds managed by Anaesthesiology and Resuscitation Services (A-ICU and A-IMCU) in Spain, their human and technical resources, and the changes made to these resources during the COVID-19 pandemic. MATERIAL AND METHODS: Prospective observational study performed between December 2020 and July 2021 to register the number and characteristics of A-ICU and A-IMCU beds in hospitals listed in the catalogue published by the Spanish Ministry of Health. RESULTS: Data were obtained from 313 hospitals (98% of all hospitals with more than 500 beds, 70% of all hospitals with more than 100 beds). One hundred and forty seven of these hospitals had an A-ICU with a total of 1702 beds. This capacity increased to 2107 (124%) during the COVID-19 pandemic. Three hundred and eight hospitals had an A-IMCU with a total of 3470 beds, 52.9% (2089) of which provided long-term care. The hospitals had 1900 ventilators, at a ratio of 1.07 respirators per A-ICU; 1559 anaesthesiologists dedicated more than 40% of their working time to intensive care. The nurse-to-bed ratio in A-ICUs was 2.8. DISCUSSION: A large proportion of fully-equipped ICU and IMCU beds in Spanish hospitals are managed by the anaesthesiology service. A-ICU and A-IMCUs have shown an extraordinary capacity to adapt their resources to meet the increased demand for intensive care during the COVID-19 pandemic.

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.

Coloides perioperatorios: de la teoría a la práctica / Perioperative colloids: From theory to practice

Introducción: La administración intravenosa de fluidos constituye un elemento fundamental en la reanimación de pacientes con hipovolemia. Las guías clínicas restringen el uso de coloides en favor de los cristaloides. Actualmente, no conocemos con exactitud cuál es la práctica clínica habitual al respecto durante el periodo perioperatorio. El objetivo del presente estudio es describir el uso perioperatorio de coloides y analizar las posibles causas que motivan su utilización. Material y métodos: Estudio observacional, transversal, multicéntrico. Subanálisis del estudio Fluid Day. Se incluyeron todos los pacientes mayores de 18 años sometidos a cirugía durante las 24h de los 2 días del estudio (18 y 20 de febrero de 2019). Se registraron datos demográficos, comorbilidades, datos referentes al acto anestésico y el procedimiento quirúrgico, fluidos administrados, sangrado perioperatorio y tipo de monitorización utilizado durante el periodo perioperatorio. Resultados: Se analizaron 5.928 casos. Un total de 542 pacientes (9,1%) recibieron algún tipo de coloides, siendo el hidroxietilalmidón el más utilizado (5,1%). Los pacientes que recibieron coloides tuvieron intervenciones más prolongadas (150 [90-255] vs. 75 [45-120] min), fueron intervenidos de urgencia (13,7 vs. 7,5%) y se clasificaron como de alto riesgo (22 vs. 4,8%) más frecuentemente. Su recuperación inmediata mayoritariamente transcurrió en unidades de críticos (45,1 vs.15,8%). Los pacientes que presentaron una hemorragia menor de 500ml recibieron coloides en un 5,9% frente al 45,9% cuando se superó esta cifra. Los pacientes que recibieron coloides presentaban anemia más frecuentemente: 29,4 vs. 16,3%. La administración de coloides supuso un mayor riesgo de transfusión (OR 15,7). La monitorización avanzada también aumentó la probabilidad de administrar coloides (OR 9,43). Conclusiones: En nuestro medio y en condiciones de práctica clínica habitual, la utilización de los coloides es escasa...(AU)

Introduction: Fluid administration is the cornerstone in hypovolemic patient's reanimation. Clinical guidelines restrict colloid administration favouring crystalloids. Currently, we don’t know exactly which is the daily clinical practice during the perioperative period. The objective of this study is to describe perioperative use of colloids analysing possible reasons aiming to use them. Material and Methods: Prospective, cross-section, national, multicentre observational study. Fluid Day sub-study. We enrolled all patient's older than 18 years old who underwent surgery during the 24h of the 2-days study (February, 2019, 18th and 20th). We registered demographic data, comorbidities, anaesthetic and surgical procedure data, fluids administered, perioperative bleeding and monitoring type used during the perioperative period. Results: A total of 5928 cases were analysed and 542 patients (9.1%) received any type of colloids, being hydroxiethyl-starch the most frequently used (5.1%). Patients receiving colloids suffered more longing surgery (150 [90-255] vs. 75 [45-120] min), were urgently operated (13.7 vs. 7.5%) and were more frequent classified as high risk (22 vs. 4.8%). Their recovery was mostly in critical care units (45.1 vs.15.8%). Patients with bleeding less than 500mL received colloids in a percentage of 5.9 versus 45.9% when this figure was overcome. Patients who received colloids were anaemic more frequently: 29.4 vs. 16.3%. Colloids administration had a higher risk for transfusion (OR 15.7). Advanced monitoring also increased the risk for receiving colloids (OR 9.43). Conclusions: In our environment with routine clinical practice, colloids administration is limited and close linked to perioperative bleeding.(AU)

Perioperative colloids: From theory to practice.

INTRODUCTION: Fluid administration is the cornerstone in hypovolemic patient's reanimation. Clinical guidelines restrict colloid administration favouring crystalloids. Currently, we don't know exactly which is the daily clinical practice during the perioperative period. The objective of this study is to describe perioperative use of colloids analysing possible reasons aiming to use them. MATERIAL AND METHODS: Prospective, cross-section, national, multicentre observational study. Fluid Day sub-study. We enrolled all patient's older than 18 years old who underwent surgery during the 24 h of the 2-days study (February, 2019, 18th and 20th). We registered demographic data, comorbidities, anaesthetic and surgical procedure data, fluids administered, perioperative bleeding and monitoring type used during the perioperative period. RESULTS: A total of 5928 cases were analysed and 542 patients (9.1%) received any type of colloids, being hydroxiethyl-starch the most frequently used (5.1%). Patients receiving colloids suffered more longing surgery (150 [90-255] vs. 75 [45-120] min), were urgently operated (13.7 vs. 7.5%) and were more frequent classified as high risk (22 vs. 4.8%). Their recovery was mostly in critical care units (45.1 vs.15.8%). Patients with bleeding less than 500 ml received colloids in a percentage of 5.9 versus 45.9% when this figure was overcome. Patients who received colloids were anaemic more frequently: 29.4 vs. 16.3%. Colloids administration had a higher risk for transfusion (OR 15.7). Advanced monitoring also increased the risk for receiving colloids (OR 9.43). CONCLUSIONS: In our environment with routine clinical practice, colloids administration is limited and close linked to perioperative bleeding.

Manejo perioperatorio y periprocedimiento del tratamiento antitrombótico: documento de consenso multidisciplinar / Perioperative and periprocedural management of antithrombotic therapy: Multidisciplinar consensus document

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[Obstetric bleeding: an update]. / La hemorragia obstétrica. Actualización.

Massive bleeding in obstetrics still ranks among the most frequent causes of maternal morbidity and mortality worldwide. The most frequent type is primary postpartum hemorrhage, which is usually the result of an atonic uterus. The clinical priorities are to assure hemodynamic stability and to correct coagulation abnormalities. If pharmacologic treatment cannot achieve these goals, invasive methods such as interventional vascular radiology or artery ligation must be used. Hysterectomy is the last resort when the previous methods fail. For the best prognosis, in terms of preventing death, maintaining maternal fertility and minimizing morbidity, every maternity ward should have a well-defined multidisciplinary protocol that facilitates diagnosis and immediate treatment.

La hemorragia obstétrica. Actualización / Obstetric bleeding: an update

La hemorragia obstétrica masiva sigue siendo una delas causas más frecuentes de morbi-mortalidad maternaen todo el mundo. La hemorragia postparto primaria esla más frecuente siendo la atonía uterina su etiologíamás común. Es prioritario garantizar la estabilidadhemodinámica de la paciente y corregir las alteracionesde la coagulación. Si el tratamiento farmacológico resultainsuficiente se deben emplear métodos invasivos comola radiología vascular intervensionista o la ligadura delos vasos arteriales. La histerectomía es la última opcióncuando fracasan las medidas anteriores. Para que el pronósticosea favorable, ya no sólo en términos de mortalidadsino en mantener la fertilidad de la madre y minimizarla morbilidad, es fundamental que cada unidadmaternal cuente con un protocolo de actuación bien definidoy multidisciplinar que facilite el diagnóstico y eltratamiento inmediato(AU)

Massive bleeding in obstetrics still ranks among themost frequent causes of maternal morbidity andmortality worldwide. The most frequent type isprimary postpartum hemorrhage, which is usually theresult of an atonic uterus. The clinical priorities are toassure hemodynamic stability and to correctcoagulation abnormalities. If pharmacologictreatment cannot achieve these goals, invasivemethods such as interventional vascular radiology orartery ligation must be used. Hysterectomy is the lastresort when the previous methods fail. For the bestprognosis, in terms of preventing death, maintainingmaternal fertility and minimizing morbidity, everymaternity ward should have a well-definedmultidisciplinary protocol that facilitates diagnosisand immediate treatment(AU)

[Preoxygenation for anesthesia]. / Preoxigenación en anestesia.

Oxygenation, or rather denitrogenation, prior to apnea during anesthetic induction attempts to replace alveolar nitrogen with oxygen to achieve an intrapulmonary oxygen reserve that will allow apnea to be as prolonged as possible with the least possible desaturation. During apnea, the rate of arterial desaturation depends mainly on the volume of oxygen stored in the lung, on mixed venous oxygen saturation, and on the presence of intrapulmonary shunt. Together, these factors account for the higher rate of desaturation during apnea in children, obese individuals, postoperative patients, and pregnant women. Two approaches to preoxygenation have proven effective to date: ventilation with 100% oxygen at tidal volume for 3 minutes using a well-sealed face mask and the performance of 8 vital capacity maneuvers in 1 minute. The efficacy of preoxygenation can be assessed by expired oxygen fraction or by pulse oximetry. In a healthy adult, both methods described ensure sufficient oxygenation (pulse oximetry 90% to 95%) after a period of apnea lasting between 6 and 10 minutes.