Obstetric anaesthesia manpower and service provision issues (introduction and European perspective).

Global health is an important and far-reaching concept in which health and access to surgical and anaesthetic care is crucial. Universal access to anaesthesia is a challenge in many countries. Manpower shortages are an important cause of difficulties and each European country has found different ways of facing a lack of healthcare professionals. In obstetric anaesthesia, the availability of competent anaesthesiologists has been related to the morbidity and mortality outcomes of patients. In this narrative review, authors from different European countries explain how manpower is managed in obstetric anaesthesia in delivery suites and obstetric operating rooms in different settings. To address manpower difficulties and issues, the goals are to achieve a minimum standard of care and at the same time, to promote clinical excellence through training, delegation to younger or less experienced colleagues, direct or at-a-distance supervision, or other means. The experience of sharing knowledge about the way in which manpower and service provision are organised in other healthcare settings is a significant opportunity to develop strategies for advancing tomorrow's obstetric anaesthesia in the world. While taking into account the level of socio-economic development in different countries, the aim is to standardise practice and workload organisation. Co-operative international projects in training and education in obstetric anaesthesia are ways in which better obstetric patient care can be achieved in the future.

Edgar Alexander Pask (1912-1966). Sus contribuciones científicas durante la segunda guerra mundial y en la Universidad De Newcastle Upon Tyne / Edgar Alexander Pask (1912-1966). His Scientific Contributions During The Second World War And In Newcastle Upon Tyne University

Edgar Alexander Pask Catedrático de Anestesiología de la Universidad de Newcastle upon Tyne realizó importantes auto-experimentos durante la Segunda Guerra Mundial. Aportamos datos biográficos y su currículo científico. Trabajó en el Departamento Nuffield de Anestesia de Oxford con el Profesor Sir Robert Macintosh. Permitió ser anestesiado en múltiples ocasiones con éter durantela realización de estas investigaciones en el Centro de Fisiología de la RAF en Farnborough. Estudio de los efectos de la hipoxia endescensos en paracaídas, estudio de la eficacia de las distintas técnica de ventilación artificial, estudio de la eficacia de los distintossalvavidas. Después de la Segunda Guerra Mundial sus contribuciones científicas estuvieron relacionadas con la fisiología respiratoria, la monitorización, mortalidad e infecciones. Desarrolló aparatos de ventilación artificial, monitores de determinación de gasesarteriales y anestésicos. En su honor, la Asociación de Anestesistas de Gran Bretaña e Irlanda creó la Medalla Pask. (AU)

Edgar Alexander Pask Professor of Anaesthesia at the University of Newcastle upon Tyne performed self-experiments during the Second World War. We describe his scientific curriculum vitae and biographical data. He worked in the Nuffield Department of Anaesthesia in Oxford with Professor sir Robert Macintosh. He allowed himself to be anaesthetized with ether on many occasions duringthese experiments in the Physiological Laboratory, RAF Research Station in Farnborough. His research was: Studies of breathingin high altitude descend with a parachute in hypoxemia, study of the efficacy of different methods of artificial respiration, testingof life jackets. After the Second World War his scientific reports were related with respiratory physiology, monitoring, mortality andinfections. He developed ventilators, monitoring equipment of arterial blood gases and anaesthetic drugs. In his honour Pask Medalof the Association of Anaesthetists of Great Britain and Ireland was established. (AU)

Diferencias de género en Anestesiología. ¿En qué punto nos encontramos en España? Resultados de una encuesta nacional / Gender differences in Anaesthesiology. At what point do we find ourselves in Spain? Results from a Spanish survey

OBJETIVO: En la última década se han publicado numerosos trabajos en los que se pone de manifiesto la persistencia de diferencias de género en medicina. La finalidad de este estudio fue investigar si este problema existe en la especialidad de Anestesiología en España. MÉTODOS: El estudio se llevó a cabo mediante una encuesta anónima que se distribuyó entre los especialistas en Anestesiología. El cuestionario estaba formado por 39 preguntas diseñadas para investigar la situación profesional, laboral y personal, así como las percepciones individuales en relación con la discriminación de género en el trabajo. RESULTADOS: Se incluyeron 1.619 encuestas, lo que representa el 17,6% del total de anestesiólogos de España; 654 participantes fueron hombres (40,4%) y 965 mujeres (59,6%). Las mayores diferencias fueron observadas en las siguientes áreas: el 70,0% de participantes informaron de que su jefe de servicio es un hombre. En relación con los puestos de liderazgo, el 25,2% de las mujeres que respondieron a la encuesta habían desempeñado algún puesto de confianza frente al 46,1% de los hombres (p < 0,001). En cuanto a la posición académica, el 10,3% de los hombres respondieron ser profesores de universidad en contraste con el 4,8% de mujeres (p < 0,001). El 46,0% de las mujeres que participaron en la encuesta piensan que existe discriminación de género en su profesión, mientras que solo el 12,6% de los hombres lo reconocieron. Un tercio de las mujeres (36,6%) consideran su condición de género una barrera para promocionar y tienen miedo de perder su trabajo por quedarse embarazadas. Además, tanto hombres como mujeres han presenciado un trato diferente por parte de pacientes y personal sanitario hacia sus compañeras anestesiólogas. CONCLUSIÓN: Los resultados de esta encuesta demuestran que existe una brecha de género en Anestesiología en España. En concreto, las mujeres están poco representadas en puestos académicos y de liderazgo, y un porcentaje considerable de encuestados perciben diferencias de género en el trabajo. Este estudio puede servir para monitorizar futuros cambios en nuestro país y como ejemplo para investigaciones en otros países vecinos

OBJECTIVE: Publications of diverse medical specialties confirm that gender differences still exist in the medical field. This particular study aims to investigate whether this problem exists in the specialty of Anaesthesiology in Spain. METHODS: An anonymous survey was distributed among anaesthesiologists in Spain. It had 39 questions and was designed to investigate professional position, work conditions, personal situation, and individual perceptions. The goal was to target the majority of anaesthesiologists working in Spain. RESULTS: Completed surveys were received from 1,619 respondents which represents 17.6% of the total number of anaesthesiologists in Spain; 654 respondents were male (40.4%) and 965 were female (59.6%). The greater differences were found in the following areas: 70.0% of the respondents advised that their head of department is male. When asked about management and leadership positions, 25.2% of female respondents had ever had any management role in contrast to 46.1% of men (p < 0.001). Regarding academic positions, 10.3% of male respondents are university professors in contrast to only 4.8% of women (p < 0.001). 46.0% of the women surveyed believe that gender discrimination exists in the workplace whereas only 12.6% of men reported the same. A third of women (36.6%) consider their gender a barrier to promotion and fear losing their job due to pregnancy. Furthermore, both genders have witnessed patients and colleagues treating staff differently according to gender. CONCLUSION: The results of the survey show the existence of a gender gap among Spanish anaesthesiologists. Of particular note, women are under-represented in academic and leadership positions. Additionally, a considerable percentage of respondents perceive gender-based discrimination to be active in their workplaces. This study could serve as a template for future research in other neighbouring countries and as a means to monitor any changes in coming years

Gender differences in Anaesthesiology. At what point do we find ourselves in Spain? Results from a Spanish survey. / Diferencias de género en Anestesiología. ¿En qué punto nos encontramos en España? Resultados de una encuesta nacional.

OBJECTIVE: Publications of diverse medical specialties confirm that gender differences still exist in the medical field. This particular study aims to investigate whether this problem exists in the specialty of Anaesthesiology in Spain. METHODS: An anonymous survey was distributed among anaesthesiologists in Spain. It had 39 questions and was designed to investigate professional position, work conditions, personal situation, and individual perceptions. The goal was to target the majority of anaesthesiologists working in Spain. RESULTS: Completed surveys were received from 1,619 respondents which represents 17.6% of the total number of anaesthesiologists in Spain; 654 respondents were male (40.4%) and 965 were female (59.6%). The greater differences were found in the following areas: 70.0% of the respondents advised that their head of department is male. When asked about management and leadership positions, 25.2% of female respondents had ever had any management role in contrast to 46.1% of men (p<0.001). Regarding academic positions, 10.3% of male respondents are university professors in contrast to only 4.8% of women (p<0.001). 46.0% of the women surveyed believe that gender discrimination exists in the workplace whereas only 12.6% of men reported the same. A third of women (36.6%) consider their gender a barrier to promotion and fear losing their job due to pregnancy. Furthermore, both genders have witnessed patients and colleagues treating staff differently according to gender. CONCLUSION: The results of the survey show the existence of a gender gap among Spanish anaesthesiologists. Of particular note, women are under-represented in academic and leadership positions. Additionally, a considerable percentage of respondents perceive gender-based discrimination to be active in their workplaces. This study could serve as a template for future research in other neighbouring countries and as a means to monitor any changes in coming years.

Bloqueos diagnósticos en el manejo del paciente con lumbalgia secundaria a síndrome facetario / Diagnostic nerve blocks in the management of low back pain secondary to facet joint syndrome

El dolor lumbar o lumbalgia es uno de los principales problemas de salud pública de la sociedad actual. De entre las múltiples causas de la misma las articulaciones zigoapofisarias, también denominadas facetas o articulaciones vertebrales posteriores, son una causa importante, generalmente secundaria a artrosis. El diagnóstico de la causa de la lumbalgia suele ser en muchas ocasiones difícil, haciendo que el enfoque terapéutico del paciente no sea el óptimo. Los bloqueos diagnósticos constituyen una herramienta de suma importancia para establecer un tratamiento adecuado del paciente con lumbalgia, siempre y cuando sean realizados de manera precisa, con un volumen adecuado de anestésico local, con una imagen y proyección fluoroscópica idónea y el resultado sea interpretado de manera exacta. En el siguiente artículo revisaremos la importancia de los bloqueos diagnósticos, así como el modo en que deben ser realizados, para obtener la máxima información de los mismos y el mayor beneficio terapéutico

Low back pain is currently one of the main public health problems. Among the multiple causes, pain in the zygapophysial joints, also called facets or posterior vertebral joints, are an important cause, usually secondary to osteoarthritis. The source of low back pain is often difficult to find, making the therapeutic approach to the patient sub-optimal. Diagnostic blocks are a very important tool in establishing an adequate treatment for patients with low back pain, as long as they are performed accurately, with an adequate local anaesthetic volume, with a suitable image and fluoroscopic projection and its result are precisely interpreted. In this article a review is presented on the importance of diagnostic blocks, as well as how they should be performed in order to obtain the maximum information and the greatest therapeutic benefit

Diagnostic nerve blocks in the management of low back pain secondary to facet joint syndrome. / Bloqueos diagnósticos en el manejo del paciente con lumbalgia secundaria a síndrome facetario.

Low back pain is currently one of the main public health problems. Among the multiple causes, pain in the zygapophysial joints, also called facets or posterior vertebral joints, are an important cause, usually secondary to osteoarthritis. The source of low back pain is often difficult to find, making the therapeutic approach to the patient sub-optimal. Diagnostic blocks are a very important tool in establishing an adequate treatment for patients with low back pain, as long as they are performed accurately, with an adequate local anaesthetic volume, with a suitable image and fluoroscopic projection and its result are precisely interpreted. In this article a review is presented on the importance of diagnostic blocks, as well as how they should be performed in order to obtain the maximum information and the greatest therapeutic benefit.

Pronóstico y predictores de mortalidad de los pacientes ancianos críticos / Prognosis and predictors of mortality in critically ill elderly patients

Objetivos. Evaluar la mortalidad de los pacientes de edad≥80 años ingresados en la unidad de cuidados intensivos quirúrgica (UCIQ), la mortalidad global hospitalaria y los factores asociados a la misma. Material y métodos. Estudio observacional retrospectivo de los pacientes con edad≥80 años ingresados en UCIQ entre junio de 2012 y junio de 2015. Resultados. Se incluyeron 299 pacientes, de los cuales 54 fallecieron en la UCIQ (18,1%) y 80 pacientes (26,8%) durante su ingreso hospitalario. La mortalidad en la UCIQ se relacionó de forma independiente con la edad (OR=1,125; IC 95%: 1,042-1,215; p=0,003), SAPS II (OR=1,026; IC 95%: 1,008-1,044; p=0,004), la necesidad de técnicas de reemplazo renal (TRR) (OR=1,960; IC 95%: 1,046-3,671; p=0,036) y la necesidad de ventilación mecánica invasiva más de 24h (OR=2,834; IC 95%: 1,244-6,456; p=0,013). Se relacionaron de forma independiente con la mortalidad hospitalaria la edad (OR=1,125; IC 95%: 1,054-1,192; p<0,001), la escala SOFA (OR=1,154; IC 95%: 1,079-1,235; p<0,001), la necesidad de TRR (OR=1,924; IC 95%: 1,121-3,302; p=0,018) y la necesidad de ventilación mecánica invasiva más de 24horas (OR=3,144; IC 95%: 1,771-5,584; p<0,001). Conclusiones. la mortalidad hospitalaria en pacientes críticos de edad≥80 años se relacionó de forma independiente con la edad, la escala SOFA, la necesidad de TRR y la necesidad de ventilación mecánica invasiva más de 24h. Nuestros hallazgos plantean importantes cuestiones acerca de los cuidados al final de la vida en los pacientes ancianos críticos quirúrgicos y de la utilización de medidas de soporte vital (AU)

Objectives. to evaluate mortality of patients≥80 years admitted to the Surgical Intensive Care Unit (SICU), global hospital mortality and factors related to it. Material and methods. observational retrospective study of patients≥80 years admitted to SICU between June 2012 and June 2015. Results. a total of 299 patients were included, 54 of them died in the SICU (18.1%) and 80 patients (26.8%) died during their hospital stay. SICU mortality was independently related to age (OR=1.125; 95%CI: 1.042-1.215; P=.003), SAPS II (OR=1.026; 95% CI: 1.008-1.044; P=.004), need for renal replacement therapy (RRT) (OR=1.960; 95%CI: 1.046-3.671; P=.036) and need for mechanical ventilation for more than 24hours (OR=2.834; 95%CI: 1.244-6.456; P=.013). Factors independently related to hospital mortality were age (OR=1.125; 95%CI: 1.054-1.192; P<.001), SOFA score (OR=1.154; 95% CI: 1.079-1.235; P<.001), need for RRT (OR=1.924; 95%CI: 1.121-3.302; p=0.018) and need for mechanical ventilation for more than 24hours (OR=3.144; 95% CI: 1.771-5.584; P<.001). Conclusions. In critically ill patients over 80 years hospital mortality was independently related to age, SOFA score, RRT need and need for mechanical ventilation for more than 24hours. Our results raise important issues about end-of-life care and life-sustaining interventions in elderly, critically ill patients (AU)

Prognosis and predictors of mortality in critically ill elderly patients. / Pronóstico y predictores de mortalidad de los pacientes ancianos críticos.

OBJECTIVES: to evaluate mortality of patients≥80 years admitted to the Surgical Intensive Care Unit (SICU), global hospital mortality and factors related to it. MATERIAL AND METHODS: observational retrospective study of patients≥80 years admitted to SICU between June 2012 and June 2015. RESULTS: a total of 299 patients were included, 54 of them died in the SICU (18.1%) and 80 patients (26.8%) died during their hospital stay. SICU mortality was independently related to age (OR=1.125; 95%CI: 1.042-1.215; P=.003), SAPS II (OR=1.026; 95% CI: 1.008-1.044; P=.004), need for renal replacement therapy (RRT) (OR=1.960; 95%CI: 1.046-3.671; P=.036) and need for mechanical ventilation for more than 24hours (OR=2.834; 95%CI: 1.244-6.456; P=.013). Factors independently related to hospital mortality were age (OR=1.125; 95%CI: 1.054-1.192; P<.001), SOFA score (OR=1.154; 95% CI: 1.079-1.235; P<.001), need for RRT (OR=1.924; 95%CI: 1.121-3.302; p=0.018) and need for mechanical ventilation for more than 24hours (OR=3.144; 95% CI: 1.771-5.584; P<.001). CONCLUSIONS: In critically ill patients over 80 years hospital mortality was independently related to age, SOFA score, RRT need and need for mechanical ventilation for more than 24hours. Our results raise important issues about end-of-life care and life-sustaining interventions in elderly, critically ill patients.

Update on management of invasive candidiasis.

Given the growing incidence of invasive candidiasis in critically ill and haemato-oncological patients and its poor outcomes, an early diagnosis and treatment are need for get a better prognosis. This document reviews the current ap-proaches that help in diagnosis of invasive candidiasis based on culture-independent microbiological tests. The combination of clinical prediction scores with fungal serological markers could facilitate the approach in antifungal therapy, optimiz-ing it. This article also reviews the epidemiology and primary risk factors for invasive candidiasis in these patients, updating the therapeutic approach algorithms in both clinical contexts based on the main evidence and international guidelines.

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)

Antimicrobial management in nosocomial peritonitis: microbiota, drug and time.

Complicated intra-abdominal infection requires surgical treatment and broad-spectrum empiric antibiotic treatment used early. The rapid spread of multidrug-resistant bacteria has become a serious threat, especially in critical care units. The excessive use of carbapenems has led to carbapenemase-producing Enterobacteriaceae, leaving tigecycline and colistin as therapeutical options. The new antimicrobials, ceftazidime-avibactam and ceftolozane-tazobactam open new horizons in the treatment of multi-drug resistant Enterobacteriaceae. Candida peritonitis causes a high mortality in the critical patient. Diagnosis and early treatment are associated with a better prognosis, the administration of an echinocandin being of choice in these patients.

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.

Monitorización, seguridad y eficacia en el uso de los componentes sanguíneos / Monitoring, safety and efficiency in the use of blood components

No disponible

[Resistant gram-negative bacteria. Therapeutic approach and risk factors]. / Aproximación terapéutica empírica a la infección por gramnegativos resistentes. Valor de los factores de riesgo.

The rapid spread of multidrug-resistant bacteria has become a serious threat, especially in critical care units, thereby prolonging the hospital stay. Enterobacteriaceae have a high capacity to adapt to any environment. Plasmids are the reason behind their expansion. The choice of empiric therapy for intra-abdominal or urinary infections requires knowledge of the intrinsic microbiological variability of each hospital or critical care unit, as well as the source of infection, safety or antibiotic toxicity, interaction with other drugs, the dosage regimen and the presence of risk factors. Carbapenems are the drug of choice in the case of suspected infection by ESBL-producing Enterobacteriaceae. The new ceftazidime/avibactam and ceftolozane/tazobactam drugs are opening up promising new horizons in the treatment of multidrug-resistant Enterobacteriaceae.

[Diagnostic and therapeutic approach of intraabdominal candidiasis]. / Aproximación diagnóstica y terapéutica a la candidiasis intraabdominal.

Invasive fungal disease is associated to a high mortality rate on critical ill patients. In the last decades an important epidemiological shift has been described. Early diagnosis and treatment are related with a better prognosis. The key factors lie in a set of predictive scores that allow to identify patients that will benefit of early treatment, as well as using diagnosis techniques that are culture independent. New diagnosis approximations are being developed with promising results: in situ hybridisation using PNA-FISH probes, MALDI-TOF MS and rapid nucleic acids detection assays. The use of echinocandin is recommended as antifungal therapy on critical ill patients with candida peritonitis.

Hemorragia masiva obstétrica: enfoque terapéutico actual / Massive obstetric hemorrhage: Current approach to management

La hemorragia masiva obstétrica es una de las causas principales de morbimortalidad materna en el mundo. Entre otras definiciones, se conoce como la pérdida > 2.500 ml de sangre y se asocia a ingreso en unidades de pacientes críticos y a histerectomía. Los cambios fisiológicos del embarazo permiten una hemorragia cuantiosa antes de objetivar una caída de la hemoglobina y/o el hematocrito. Dentro de los cambios fisiológicos del embarazo, existe una hipercoagulabilidad asociada a la gestante. Algunas comorbilidades asociadas al embarazo pueden contribuir a la aparición de una hemorragia catastrófica con una coagulopatía de consumo, que hace la situación aún más grave. La optimización, la preparación, el uso racional de recursos y la protocolización de actuaciones son útiles para mejorar los resultados en estas pacientes. El uso de protocolos basados en point of care con test viscoelásticos está demostrando utilidad. Si se produce una hipofibrinogenemia durante la hemorragia, la administración precoz de fibrinógeno puede ser muy útil. Para corregir eficazmente la coagulopatía pueden ser necesarios otros factores de la coagulación, además de fibrinógeno, durante la reposición en la hemorragia posparto. Se recomienda la realización de una histerectomía si las medidas médicas y quirúrgicas se han mostrado ineficaces

Massive obstetric hemorrhage is a major cause of maternal mortality and morbidity worldwide. It is defined (among others) as the loss of > 2,500 ml of blood, and is associated to a need for admission to critical care and/or hysterectomy. The relative hemodilution and high cardiac output found in normal pregnancy allows substantial bleeding before a drop in hemoglobin and/or hematocrit can be identified. Some comorbidities associated with pregnancy can contribute to the occurrence of catastrophic bleeding with consumption coagulopathy, which makes the situation even worse. Optimization, preparation, rational use of resources and protocolization of actions are often useful to improve outcomes in patients with postpartum hemorrhage. Using massive obstetric hemorrhage protocols is useful for facilitating rapid transfusion if needed, and can also be cost-effective. If hypofibrinogenemia during the bleeding episode is identified, early fibrinogen administration can be very useful. Other coagulation factors in addition to fibrinogen may be necessary during postpartum hemorrhage replacement measures in order to effectively correct coagulopathy. A hysterectomy is recommended if the medical and surgical measures prove ineffective

Severe cefepime-induced status epilepticus treated with haemofiltration / Estatus epiléptico grave inducido por cefepime tratado con hemofiltración

Neurotoxicity caused by cefepime may occur predominantly in patients with impaired renal function. A case of a cefepime-induced non-convulsive status epilepticus (NCSE) is presented. A 65-year-old woman suffered a severe NCSE due to cefepime in the presence of acute renal failure, requiring coma induction with sodium thiopental. A serious interaction between valproic acid (VPA) and meropenem was also produced after changing cefepime to meropenem. Continuous veno-venous haemofiltration was employed to improve cefepime clearance, and the patient progressively regained her previous mental condition. In conclusion, the cefepime dose must be adjusted according to renal function in order to avoid toxicity in patients with renal failure. Electroencephalogram should be considered in cases of acute confusional state in patients receiving cefepime, to achieve early detection of NCSE. Continuous renal replacement therapy may be successfully employed in severe cases in order to accelerate cefepime removal. Likewise, meropenem should not be used concomitantly with VPA (AU)

La neurotoxicidad por cefepime puede producirse principalmente en pacientes con insuficiencia renal. Presentamos un caso de status epiléptico no convulsivo producido por cefepime. Una mujer de 65 años con fracaso renal agudo en tratamiento con cefepime sufrió un episodio grave de status epiléptico no convulsivo que requirió inducción de coma barbitúrico con tiopental sódico. Tras el cambio de cefepime a meropenem se produjo también una interacción grave entre meropenem y ácido valproico. Se utilizó hemofiltración venovenosa continua para acelerar el aclaramiento de cefepime y la paciente recuperó progresivamente su situación neurológica previa. En conclusión, la dosis de cefepime debe ser ajustada a la función renal para evitar toxicidad en pacientes con insuficiencia renal. Debería considerarse la utilización del electroencefalograma en casos de estado confusional agudo en pacientes en tratamiento con cefepime para un diagnóstico precoz del status epiléptico no convulsivo. La terapia continua de reemplazo renal puede ser empleada en casos graves para acelerar la eliminación de cefepime. Además el meropenem no debe de utilizarse concomitantemente con el ácido valproico (AU)