Clinical guide to perioperative management for videothoracoscopy lung resection (Section of Cardiac, Vascular and Thoracic Anesthesia, SEDAR; Spanish Society of Thoracic Surgery, SECT; Spanish Society of Physiotherapy).

The introduction of video-assisted thoracoscopic (VATS) techniques has led to a new approach in thoracic surgery. VATS is performed by inserting a thoracoscope through a small incisions in the chest wall, thus maximizing the preservation of muscle and tissue. Because of its low rate of morbidity and mortality, VATS is currently the technique of choice in most thoracic procedures. Lung resection by VATS reduces prolonged air leaks, arrhythmia, pneumonia, postoperative pain and inflammatory markers. This reduction in postoperative complications shortens hospital length of stay, and is particularly beneficial in high-risk patients with low tolerance to thoracotomy. Compared with conventional thoracotomy, the oncological results of VATS surgery are similar or even superior to those of open surgery. This aim of this multidisciplinary position statement produced by the thoracic surgery working group of the Spanish Society of Anesthesiology and Reanimation (SEDAR), the Spanish Society of Thoracic Surgery (SECT), and the Spanish Association of Physiotherapy (AEF) is to standardize and disseminate a series of perioperative anaesthesia management guidelines for patients undergoing VATS lung resection surgery. Each recommendation is based on an in-depth review of the available literature by the authors. In this document, the care of patients undergoing VATS surgery is organized in sections, starting with the surgical approach, and followed by the three pillars of anaesthesia management: preoperative, intraoperative, and postoperative anaesthesia.

Guía clínica en el manejo perioperatorio para la cirugía de resección pulmonar por videotoracoscopia (Sección de Anestesia Cardiaca, Vascular y Torácica, SEDAR; Sociedad Española de Cirugía Torácica, SECT; Asociación Española de Fisioterapia, AEF) / Clinical guide to perioperative management for videothoracoscopy lung resection (Section of Cardiac, Vascular and Thoracic Anesthesia, SEDAR; Spanish Society of Thoracic Surgery, SECT; Spanish Society of Physiotherapy)

La introducción de técnicas toracoscópicas asistidas por video en cirugía torácica (VATS) ha permitido realizar un nuevo enfoque en la cirugía torácica. El acceso videotoracoscópico se realiza con pequeñas incisiones, preservando al máximo los músculos y los tejidos. En la actualidad, la VATS se considera de elección en la mayoría de los procedimientos torácicos, principalmente debido a la menor morbimortalidad asociada. La resección pulmonar por VATS presenta reducción de las fugas de aire prolongadas, arritmias, neumonía, dolor postoperatorio y una disminución de los marcadores inflamatorios. Esta reducción de las complicaciones postoperatorias está vinculada a una reducción de la estancia hospitalaria, siendo los pacientes de alto riesgo y con poca tolerancia a la toracotomía los principales beneficiarios de esta técnica.En comparación con la toracotomía convencional, los?resultados?oncológicos de la cirugía VATS son similares o incluso superiores a los de la cirugía abierta.Este documento, de redacción multidisciplinar, consensuado por el grupo de trabajo de cirugía torácica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), de la Sociedad Española de Cirugía Torácica (SECT) y la Asociación Española de Fisioterapia (AEF), pretende estandarizar y difundir, con base en la bibliografía más actual, las mejores pautas de manejo clínico perioperatorio de los pacientes que se someten a una cirugía de resección pulmonar por VATS. Cada recomendación parte de una revisión de la literatura disponible y analizada en profundidad por los autores.Con el objetivo de dirigir el curso asistencial que seguirá el paciente que se somete a una cirugía pulmonar por VATS, esta guía se organiza inicialmente en el enfoque quirúrgico, seguido de los tres puntos clásicos del proceso anestésico. Estos puntos son preoperatorio, intraoperatorio y postoperatorio.(AU)

The introduction of video-assisted thoracoscopic (VATS) techniques has led to a new approach in thoracic surgery. VATS is performed by inserting a thoracoscope through a small incisions in the chest wall, thus maximizing the preservation of muscle and tissue. Because of its low rate of morbidity and mortality, VATS is currently the technique of choice in most thoracic procedures. Lung resection by VATS reduces prolonged air leaks, arrhythmia, pneumonia, postoperative pain and inflammatory markers. This reduction in postoperative complications shortens hospital length of stay, and is particularly beneficial in high-risk patients with low tolerance to thoracotomy.Compared with conventional thoracotomy, the oncological results of VATS surgery are similar or even superior to those of open surgery.This aim of this multidisciplinary position statement produced by the thoracic surgery working group of the Spanish Society of Anesthesiology and Reanimation (SEDAR), the Spanish Society of Thoracic Surgery (SECT), and the Spanish Association of Physiotherapy (AEF) is to standardize and disseminate a series of perioperative anaesthesia management guidelines for patients undergoing VATS lung resection surgery. Each recommendation is based on an in-depth review of the available literature by the authors.In this document, the care of patients undergoing VATS surgery is organized in sections, starting with the surgical approach, and followed by the three pillars of anaesthesia management: preoperative, intraoperative, and postoperative anaesthesia.(AU)

Clinical guide to perioperative management for videothoracoscopy lung resection (Section of Cardiac, Vascular and Thoracic Anesthesia, SEDAR; Spanish Society of Thoracic Surgery, SECT; Spanish Society of Physiotherapy). / Guía clínica en el manejo perioperatorio para la cirugía de resección pulmonar por videotoracoscopia (Sección de Anestesia Cardiaca, Vascular y Torácica, SEDAR; Sociedad Española de Cirugía Torácica, SECT; Asociación Española de Fisioterapia, AEF).

The introduction of video-assisted thoracoscopic (VATS) techniques has led to a new approach in thoracic surgery. VATS is performed by inserting a thoracoscope through a small incisions in the chest wall, thus maximizing the preservation of muscle and tissue. Because of its low rate of morbidity and mortality, VATS is currently the technique of choice in most thoracic procedures. Lung resection by VATS reduces prolonged air leaks, arrhythmia, pneumonia, postoperative pain and inflammatory markers. This reduction in postoperative complications shortens hospital length of stay, and is particularly beneficial in high-risk patients with low tolerance to thoracotomy. Compared with conventional thoracotomy, the oncological results of VATS surgery are similar or even superior to those of open surgery. This aim of this multidisciplinary position statement produced by the thoracic surgery working group of the Spanish Society of Anesthesiology and Reanimation (SEDAR), the Spanish Society of Thoracic Surgery (SECT), and the Spanish Association of Physiotherapy (AEF) is to standardize and disseminate a series of perioperative anaesthesia management guidelines for patients undergoing VATS lung resection surgery. Each recommendation is based on an in-depth review of the available literature by the authors. In this document, the care of patients undergoing VATS surgery is organized in sections, starting with the surgical approach, and followed by the three pillars of anaesthesia management: preoperative, intraoperative, and postoperative anaesthesia.

Ensayo clínico sobre el efecto del ácido tranexámico en el sangrado y la fibrinólisis durante la artroplastia simple de cadera y rodilla / Clinical trial on the effect of tranexamic acid on bleeding and fibrinolysis in primary hip and knee replacement

Objetivo: La isquemia derivada de la aplicación del torniquete es un factor fibrinolítico que podría potenciar la eficacia del ácido tranexámico (ATx) en artroplastia total de rodilla (ATR) frente a la artroplastia total de cadera (ATC). Nuestro objetivo es comparar el efecto del ATx sobre sangrado y fibrinólisis en estas 2 artroplastias, valorando la incidencia de complicaciones. Método: Ensayo clínico prospectivo, aleatorizado y doble ciego. Los pacientes programados para ATR o ATC recibían ATx (2 infusiones 10mg/kg) o placebo. Se cuantificó sangrado y parámetros de fibrinólisis, y se detectaron complicaciones tromboembólicas con ecografía doppler y tomografía computarizada. Resultados: Fueron incluidos 44 pacientes (11 ATC y 11 ATR tratados con ATx; 11 ATC y 11 ATR fueron controles). El sangrado fue significativamente menor en el grupo tratado con ATx (promedio 921mL vs. 1383mL en ATC y 969mL vs. 1223mL en ATR) y se necesitaron menos transfusiones (ninguna frente a 5 unidades en grupo control). El ATx fue igualmente eficaz en la reducción del sangrado en ambas cirugías (reducción del 33% en ATC y del 21% en ATR). El gran incremento medio de dímero D entre el periodo basal y las 6h (1.004 a 10.284μg /L en ATC y 571 a 6.480μg /L en ATR) es atenuado por el uso de ATx (1.077 a 2.590μg/L en ATC y 655 a 2.535μg/L en ATR). No hubo diferencias significativas en eventos tromboembólicos. Conclusiones: El ATx profiláctico es igualmente efectivo en ATR y ATC para reducir sangrado. Ambas cirugías tienen efecto similar sobre la fibrinólisis

Background: Tourniquet-induced ischaemia could increase fibrinolysis and enhance tranexamic acid (TXA) efficacy in total knee arthroplasty (TKA) compared to total hip arthroplasty (THA). The aims of this study are to compare the effect of TXA on bleeding and fibrinolysis in both types of surgery, and to record thromboembolic complications. Methods: A prospective double-blind study was conducted on patients scheduled for TKA or THA who received TXA (2 bolus of 10mg/kg) or placebo. Bleeding and fibrinolysis were evaluated. Doppler-ultrasound and computed tomography were performed in order to assess any thromboembolic complications. Results: A total of 44 patients were included (11 THA and 11 TKA treated with TXA; 11 THA and 11 TKA as controls). Blood losses were significantly lower in the TXA group (mean 921mL vs 1,383mL in THA and 969mL vs 1,223mL in TKA), and no transfusions were needed with TXA, whereas 5 blood units were transfused in controls. TXA was equally effecting in reducing bleeding in both surgeries (33% in THA and 21% in TKA). The significant mean increase in D-dimers from baseline to 6 hours after surgery (1,004 ug/L to 10,284 ug/L in THA and 571 ug/L to 6,480 ug/L in TKA) was attenuated by TXA (1,077 ug/L to 2,590 ug/L in THA and 655 ug/L to 2,535 ug/L in TKA). There were no differences in thromboembolic episodes. Conclusions: Prophylactic use of tranexamic acid is equally effective in reducing bleeding in TKA and THA. Both surgeries have a similar effect on fibrinolysis

Clinical trial on the effect of tranexamic acid on bleeding and fibrinolysis in primary hip and knee replacement. / Ensayo clínico sobre el efecto del ácido tranexámico en el sangrado y la fibrinólisis durante la artroplastia simple de cadera y rodilla.

BACKGROUND: Tourniquet-induced ischaemia could increase fibrinolysis and enhance tranexamic acid (TXA) efficacy in total knee arthroplasty (TKA) compared to total hip arthroplasty (THA). The aims of this study are to compare the effect of TXA on bleeding and fibrinolysis in both types of surgery, and to record thromboembolic complications. METHODS: A prospective double-blind study was conducted on patients scheduled for TKA or THA who received TXA (2 bolus of 10mg/kg) or placebo. Bleeding and fibrinolysis were evaluated. Doppler-ultrasound and computed tomography were performed in order to assess any thromboembolic complications. RESULTS: A total of 44 patients were included (11 THA and 11 TKA treated with TXA; 11 THA and 11 TKA as controls). Blood losses were significantly lower in the TXA group (mean 921mL vs 1,383mL in THA and 969mL vs 1,223mL in TKA), and no transfusions were needed with TXA, whereas 5 blood units were transfused in controls. TXA was equally effecting in reducing bleeding in both surgeries (33% in THA and 21% in TKA). The significant mean increase in D-dimers from baseline to 6 hours after surgery (1,004 ug/L to 10,284 ug/L in THA and 571 ug/L to 6,480 ug/L in TKA) was attenuated by TXA (1,077 ug/L to 2,590 ug/L in THA and 655 ug/L to 2,535 ug/L in TKA). There were no differences in thromboembolic episodes. CONCLUSIONS: Prophylactic use of tranexamic acid is equally effective in reducing bleeding in TKA and THA. Both surgeries have a similar effect on fibrinolysis.

Revisión del manejo de la vía aérea díficil en cirugía torácica / Review of difficult airway management in thoracic surgery

El manejo de la vía aérea difícil (VAD) en cirugía torácica es muy específico y más complejo que en otras especialidades debido a la exigencia de separación o aislamiento pulmonar y a una mayor presencia de anormalidades asociadas a la vía aérea superior e inferior. Basándonos en el análisis de las evidencias clínicas de 818 artículos indexados en PubMed, presentamos una revisión actualizada y un algoritmo específico del manejo de la VAD en cirugía torácica. Recomendamos para la VAD prevista la intubación traqueal con fibroncoscopio en ventilación espontánea y el uso de bloqueador bronquial. Para la VAD imprevista, el uso inicial de videolaringoscopios y un adecuado nivel de relajación neuromuscular (rocuronio/sugammadex). Solo se recomienda el uso de tubos de doble luz si hay indicación absoluta de aislamiento pulmonar. Finalmente, la extubación en este contexto debe ejecutarse con la máxima atención y realizarse según las normas de la Difficult Arway Society (AU)

The management of difficult airway (DA) in thoracic surgery is more difficult due to the need for lung separation or isolation and frequent presence of associated upper and lower airway problems. We performed an article review analysing 818 papers published with clinical evidence indexed in Pubmed that allowed us to develop an algorithm. The best airway management in predicted DA is tracheal intubation and independent bronchial blockers guided by fibroscopy maintaining spontaneous ventilation. For unpredicted DA, the use of videolaryngoscopes is recommended initially, and adequate neuromuscular relaxation (rocuronium/sugammadex), among other maneuvers. In both cases, double lumen tubes should be reserved for when lung separation is absolutely indicated. Finally, extubation should be a time of maximum care and be performed according to the safety measures of the Difficult Arway Society (AU)

Review of difficult airway management in thoracic surgery. / Revisión del manejo de la vía aérea díficil en cirugía torácica.

The management of difficult airway (DA) in thoracic surgery is more difficult due to the need for lung separation or isolation and frequent presence of associated upper and lower airway problems. We performed an article review analysing 818 papers published with clinical evidence indexed in Pubmed that allowed us to develop an algorithm. The best airway management in predicted DA is tracheal intubation and independent bronchial blockers guided by fibroscopy maintaining spontaneous ventilation. For unpredicted DA, the use of videolaryngoscopes is recommended initially, and adequate neuromuscular relaxation (rocuronium/sugammadex), among other maneuvers. In both cases, double lumen tubes should be reserved for when lung separation is absolutely indicated. Finally, extubation should be a time of maximum care and be performed according to the safety measures of the Difficult Arway Society.

Fasting plasma peptide YY concentrations are increased in patients with major depression who associate weight loss.

BACKGROUND: Many patients with major depression refer a decreased appetite and weight loss among their symptoms. Peptide YY (PYY) and ghrelin belong to the family of peptides of the gut-brain axis implicated in the regulation of appetite and energy metabolism. PYY stimulates a powerful central satiety response and ghrelin increases food intake and weight gain. Brain-derived neurotrophic factor (BDNF) also contributes to the central control of food intake as an anorexigenic factor. AIM: To study fasting plasma total and acylated ghrelin, plasma PYY and serum BDNF levels in patients with major depression with weight loss as one of their symptoms and compare them with matched healthy controls. SUBJECTS AND METHODS: Fifteen adult patients, 9 male and 6 female, with recent diagnosis of major depression, and 16 healthy adult subjects, matched by age and anthropometric parameters were studied. All depressed patients referred weight loss and were not under antidepressant therapy. Fasting total PYY, total ghrelin and acylated ghrelin and BDNF were determined. RESULTS: Fasting total PYY was higher in patients than controls (2.01±0.09 vs 1.29±0.16 pmol/l). There were no differences in fasting total ghrelin, acylated ghrelin or BDNF levels. CONCLUSIONS: Major depressed patients, with weight loss at diagnosis, showed higher fasting plasma PYY levels that could contribute to their reduced appetite.

Insulin resistance, low-grade inflammation and type 1 diabetes mellitus.

To assess the relationships between insulin resistance and low-grade inflammation in subjects with type 1 diabetes mellitus (T1DM) who do not have clinical macrovascular complications. A total of 120 subjects diagnosed with T1DM 14 years before were evaluated for the following: (1) sex, age, body mass index, waist-to-hip ratio (WHR), blood pressure, smoking, alcohol intake, insulin dose, HbA1c and lipid profile; (2) microvascular complications; (3) plasma concentrations of soluble fractions of tumour necrosis factor-α receptors type 1 and 2, interleukin-6, adiponectin, leptin and high-sensitivity C-reactive protein (hs-CRP); and (4) insulin resistance (estimation of the glucose disposal rate-eGDR). Those subjects with an eGDR below the median of the same sex group were classified as insulin resistant and the others as insulin sensitive. Insulin-resistant men, compared to the insulin-sensitive, had higher WHR (0.89 ± 0.08 vs. 0.83 ± 0.05; P < 0.01), higher systolic [121 (118-125) vs. 114 (108-120) mmHg; P = 0.01] and diastolic [73 (66-80) vs. 67 (70-73) mmHg; P = 0.02] blood pressures, higher HbA1c values [8.7 (8.1-9.9) vs. 7.5 (7.2-8.0) %; P < 0.01] and higher hs-CRP concentrations [1.16 (0.61-3.20) vs. 0.49 (0.31-0.82) mg/dl; P = 0.01], but no other significant differences between groups were found. Insulin-resistant women had higher WHR and HbA1c values, compared to the insulin-sensitive, but they did not have any other differences. In men, hs-CRP correlated significantly with WHR and HbA1c (r = 0.363; P = 0.016 and r = 0.317; P = 0.036, respectively), after adjusting for age, alcohol intake, smoking and microvascular complications. Insulin-resistant men with T1DM have an increase in plasma concentrations of hs-CRP. Central obesity and HbA1c are its main determinants.

Hallazgo de un bronquio traqueal derecho durante fibrobroncoscopia intraoperatoria / No disponible

No disponible

Diagnóstico de síndrome de HELLP por visualización hepática intraoperatoria / No disponible

No disponible

Retinol-binding protein 4 levels in obese children and adolescents with glucose intolerance.

BACKGROUND: Retinol-binding protein 4 (RBP4) is known to be involved in obesity-associated insulin resistance. AIMS: To study the relationships between the degree of adiposity, insulin resistance indices, plasma lipids, inflammatory parameters, glucose intolerance (GI) status and plasma RBP4 levels in obese children and adolescents. PATIENTS AND METHODS: Prospective study comprising 199 obese patients (95 boys) aged 8-16 years (11.8 +/- 1.9). Fifty-three subjects (23 boys) of similar mean age, 11.3 +/- 2.1 years, served as controls. BMI, waist and hip circumferences, plasma lipids, and inflammatory parameters were measured and patients underwent an oral glucose tolerance test. Plasma RBP4 levels were determined by nephelometry. RESULTS: Plasma RBP4 levels (pg/ml) in obese patients with GI (n = 15) were higher (45.0 +/- 14.1) compared with those of obese patients without GI (35.9 +/- 11.7, p = 0.02; n = 184) and controls (31.5 +/- 12.3, p = 0.04) in a generalized linear model adjusted for age, sex, BMI and pubertal status. A negative correlation was found between the skeletal muscle insulin resistance index and RBP4; positive correlations were found between the RBP4 and BMI Z-score (r = 0.213, p < 0.001), waist circumferences (r = 0.135, p < 0.05), plasma triglycerides (r = 0.187, p = 0.005) and apolipoprotein B (0.187, p = 0.007). CONCLUSIONS: Our results suggest a direct relationship between circulating insulin and RBP4 levels, which indicates that this protein might contribute to the development of muscle insulin resistance.

Insuflación continua monitorizada para compensar fuga aérea del neumotaponamiento traqueal / No disponible

No disponible

Circulating and adipose tissue gene expression of zinc-alpha2-glycoprotein in obesity: its relationship with adipokine and lipolytic gene markers in subcutaneous and visceral fat.

CONTEXT: Zinc-alpha2-glycoprotein (ZAG) is a soluble protein similar to the class I major histocompatibility complex heavy chain, which has been implicated in lipid catabolism. We hypothesized that ZAG mRNA expression in adipose tissue may be linked with lipolytic and adipokine gene expression and have a close relationship with clinical phenotype. OBJECTIVES: The objective of the study was to analyze ZAG gene expression in human adipose tissue from lean and obese subjects. ZAG circulating plasma levels and its relationship with cardiometabolic risk factors were also studied. DESIGN: Seventy-three Caucasian (43 male and 30 female) subjects were included. Plasma and adipose tissue [sc (SAT) and visceral (VAT)] from the same patient were studied. mRNA of PPARgamma, hormone-sensitive lipase (HSL), adipose triglyceride lipase, adiponectin, omentin, visfatin, and ZAG were quantified. Plasma concentrations of ZAG were determined with ELISA. RESULTS: ZAG plasma levels showed a negative correlation with insulin (r = -0.39; P = 0.008) and the homeostasis model assessment for insulin resistance index (r = -0.36; P = 0.016). No differences in ZAG circulating levels according to body mass index classification were observed. ZAG expression in SAT was significantly reduced in overweight and obese individuals compared with lean subjects (P < 0.001 and P = 0.007, respectively). ZAG mRNA expression in both SAT and VAT depots were negatively correlated with many clinical and metabolic cardiovascular risk factors. After multiple linear regression analysis, SAT ZAG was mainly predicted by adiponectin mRNA expression (B = 0.993; P < 0.0001) and plasma triglyceride levels (B = -0.565; P = 0.006). VAT ZAG expression was predicted by adiponectin expression (B = 0.449; P < 0.0001), and HSL VAT expression (B = 0.180; P = 0.023). CONCLUSIONS: The present study provides evidence of a role of ZAG gene in adipose tissue metabolism, with a close association with adiponectin gene expression in sc and visceral fat.

Plasma visfatin concentrations increase in both hyper and hypothyroid subjects after normalization of thyroid function and are not related to insulin resistance, anthropometric or inflammatory parameters.

OBJECTIVE: The objective of this study was to evaluate plasma visfatin levels in thyroid dysfunction and its relationship with inflammatory, anthropometric and insulin resistance parameters. DESIGN AND PATIENTS: Twenty-four hyperthyroid and 27 hypothyroid patients were studied before and after treatment. Forty-five euthyroid subjects were used as control group. MEASUREMENTS: Fasting plasma visfatin, IL-6, C reactive protein, adiponectin, thyroid hormones, waist-to-hip ratio, BMI, percentage of body fat and homeostasis model insulin resistance index (HOMA-IR) were measured. RESULTS: Hyperthyroid patients showed increased insulin resistance, IL-6 and visfatin levels compared with controls (3.21 +/- 3.0 vs. 1.67 +/- 0.75, P = 0.022; 3.35 +/- 0.41 vs. 2.10 +/- 0.25 pg/ml, P = 0.016; and 37.4 +/- 5.81 vs. 23.79 +/- 4.2 ng/ml, P = 0.061 respectively). After normalization of thyroid function, IL-6 levels and HOMA-IR decreased (2.35 +/- 0.37 vs. 2.10 +/- 0.25 pg/ml, P = 0.045 and 3.21 +/- 0.60 vs. 2.28 +/- 0.38, P = 0.032 respectively), while body weight, adiposity and visfatin levels increased (26.1 +/- 1.2 vs. 26.7 +/- 1.2 kg/m(2), P = 0.049; 30.9 +/- 1.6 vs. 32.2 +/- 1.6%, P = 0.007; and 37.4 +/- 5.81 vs. 63.13 +/- 8.72 ng/ml, P = 0.047 respectively). C reactive protein and adiponectin levels were similar to those of the control group. Hypothyroid patients showed high visfatin levels (40.59 +/- 3.07 vs. 29.34 +/- 4.9 ng/ml, P = 0.049) that increased after treatment (81.4 +/- 9.2 ng/ml, P = 0.001) without changes in anthropometric or insulin resistance parameters. C reactive protein, IL-6 and adiponectin levels were similar to those of the control group. No correlations between visfatin and any analysed parameter were found in either hyper- or hypothyroidism. CONCLUSION: Visfatin exhibits a marked increase after normalization of thyroid function in both hyper and hypothyroid patients. We suggest that visfatin may play a role in the hormone stabilization process independent of anthropometric, inflammatory or insulin resistance variables.