La anestesia subaracnoidea no produce disfunción ventricular izquierda transitoria en pacientes mayores de 60 años sin enfermedad cardiovascular / Spinal anesthesia does not cause left ventricular dysfunction in patients older than 60 years without cardiovascular disease

Objetivos: Evaluar la función sistólica ventricular izquierda por ecocardiograma transtorácico en pacientes mayores de 60 años, sin enfermedad cardiovascular, bajo anestesia subaracnoidea instaurada. Pacientes y métodos: Estudio observacional prospectivo con un total de 54 pacientes mayores de 60 años sin enfermedad cardiovascular, a quienes, tras la instauración de una anestesia subaracnoidea con bupivacaína hiperbárica al 0,5% con bloqueo sensitivoT10 o mayor, se les midió la función sistólica ventricular izquierda a partir del movimiento sistólico del anillo mitral (mitral anular plane systolic excursion [MAPSE].) Además, se midió el índice de colapsabilidad de vena cava inferior (ICVCI), la integral velocidad tiempo del tracto de salida del ventrículo izquierdo (ITTSVI) y del gasto cardiaco (GC). Los valores a los 5min del bloqueo se compararon con los obtenidos previamente al mismo. Resultados: Se evidenció una disminución del 3,3% del MAPSE y una ligera disminución del IVTTSVI y GC, en ningún caso con significación estadística ni clínica. El 14,8% de los pacientes presentó presión arterial media (PAM) igual o inferior a 60mmHg. La comparación de los cambios ecocardiográficos entre estos pacientes y los que no presentaron hipotensión no fueron estadísticamente significativos ni clínicamente relevantes. Discusión: Se demuestra que la anestesia subaracnoidea con nivel anestésico T10 o superior en pacientes mayores de 60 años sin enfermedad cardiovascular, es una técnica segura ya que no altera de forma significativa parámetros ecocardiográficos de medición de la función sistólica ventricular izquierda.(AU)

Background: Elderly patients are undergoing surgery more frequently than ever. In this population, spinal anesthesia, which is known to cause sympathetic blockade associated with arterial vasodilation, is proposed as an excellent option. However, its effects on left ventricular systolic function have not been studied. Objectives: To evaluate left ventricular systolic function by transthoracic echocardiography in patients older than 60 years, without prior cardiovascular disease, under spinal anesthesia. Patients and methods: Prospective observational study with a total of 54 patients older than 60 years without prior cardiovascular disease, in whom, after the completion of subarachnoid anesthesia with hyperbaric 0.5% bupivacaine with sensory block equal to or greater than T10, left ventricular systolic function was measured using MAPSE. In addition, CI-IVC, LVOT-VTI and CO were measured. Values at 5 minutes after the blockade were compared with those obtained previously. Results: A 3.3% decrease in MAPSE and a slight decrease in LVOT-VTI and CO were found, with no statistical or clinical significance. The 14.8% of the patients presented MAP equal to or less than 60mmHg. Comparison of echocardiographic changes between hypotensive and non-hypotensive patients was not statistically significant or clinically relevant. Discussion: Our study shows that spinal anesthesia with anesthetic level T10 or higher in patients older than 60 years without cardiovascular disease is a safe technique since it does not significantly alter echocardiographic parameters measuring left ventricular systolic function.(AU)

Spinal anesthesia does not cause left ventricular dysfunction in patients older than 60 years without cardiovascular disease.

BACKGROUND: Elderly patients are undergoing surgery more frequently than ever. In this population, spinal anesthesia, which is known to cause sympathetic blockade associated with arterial vasodilation, is proposed as an excellent option. However, its effects on left ventricular systolic function have not been studied. OBJECTIVES: To evaluate left ventricular systolic function by transthoracic echocardiography in patients older than 60 years, without prior cardiovascular disease, under spinal anesthesia. PATIENTS AND METHODS: Prospective observational study with a total of 54 patients older than 60 years without prior cardiovascular disease, in whom, after the completion of subarachnoid anesthesia with hyperbaric 0.5% bupivacaine with sensory block equal to or greater than T10, left ventricular systolic function was measured using MAPSE. In addition, CI-IVC, LVOT-VTI and CO were measured. Values at 5 min after the blockade were compared with those obtained previously. RESULTS: A 3.3% decrease in MAPSE and a slight decrease in LVOT-VTI and CO were found, with no statistical or clinical significance. 14.8% of the patients presented MAP equal to or less than 60 mmHg. Comparison of echocardiographic changes between hypotensive and non-hypotensive patients was not statistically significant or clinically relevant. DISCUSSION: Our study shows that spinal anesthesia with anesthetic level T10 or higher in patients older than 60 years without cardiovascular disease is a safe technique since it does not significantly alter echocardiographic parameters measuring left ventricular systolic function.

Rotura de aneurisma iliaco durante el preacondicionamiento con levosimendán previo a cirugía de revascularización coronaria, ¿fue levosimendán el factor más influyente? / Iliac aneurysm rupture during preconditioning with levosimendan for coronary artery graft, it was levosimendan the most influencing factor?

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Factores implicados en el desarrollo de vasoplejía tras cirugía cardiaca con circulación extracorpórea. Estudio prospectivo observacional / Factors involved in the development of vasoplegia after cardiac surgery with extracorporeal circulation. A prospective observational study

Objetivo. Investigamos la incidencia y los factores de riesgo asociados al desarrollo de vasoplejía en el postoperatorio inmediato y a las 24 h en pacientes sometidos a cardiocirugía con circulación extracorpórea. La mayoría de los factores de riesgo evidenciados provienen de estudios retrospectivos. Métodos. Entre noviembre de 2011 y mayo de 2012 estudiamos prospectivamente 188 pacientes consecutivos operados de cardiocirugía con circulación extracorpórea. Excluimos intervenciones quirúrgicas de urgencia y de alta complejidad. Evaluamos la vasoplejía en el postoperatorio inmediato y a las 24 h, definida como presiones arteriales medias inferiores a 50 mmHg y perfusión de noradrenalina superior a 0,08 μg/kg/min, monitorizadas con gasto cardiaco y resistencias vasculares sistémicas. Todos se sometieron al mismo protocolo anestésico, tratamiento hemodinámico y de circulación extracorpórea. Resultados. El 48% presentaron vasoplejía en el postoperatorio inmediato y un 34% a las 24 h. Los factores de riesgo para el desarrollo de vasoplejía fueron el uso de inhibidores de la enzima convertidora de la angiotensina, presentar una presión arterial media < 50 mmHg a la entrada en circulación extracorpórea, el tiempo de pinzamiento aórtico y la temperatura mínima durante la circulación extracorpórea. Y 24 h se correlacionó con el uso de inhibidores de la enzima convertidora de la angiotensina y el tiempo de circulación extracorpórea. Conclusión. La incidencia de vasoplejía en estos pacientes es elevada. El uso preoperatorio de inhibidores de la enzima convertidora de la angiotensina y la presión arterial media a la entrada de circulación extracorpórea son factores de riesgo potencialmente controlables, o si el paciente se presenta con ellos, prever el tratamiento o la prevención de la vasoplejía (AU)

Objective. The incidence and risk factors for vasoplegia in the early postoperative period and at 24 h are investigated in patients subjected to cardiopulmonary bypass surgery. Vasoplegia following cardiac surgery with cardiopulmonary bypass is associated with a high morbimortality. The risk factors described emerged from retrospective, non-controlled studies. Methods. Observational prospective study of 188 consecutive patients subjected to cardiac surgery with cardiopulmonary bypass in a single hospital between November 2011 and May 2012. Emergency surgery or complex procedures were excluded. Vasoplegia was assessed during the immediate postoperative period, and at 24 h after surgery, and was defined as a mean arterial pressure below 50 mmHg, and the need for a noradrenaline perfusion of more than 0.08 μg/kg/min, monitored by cardiac output and systemic vascular resistances. The anaesthetic and cardiopulmonary bypass protocols, as well as haemodynamic management, were the same in all patients. Results. Almost half (48%) of patients had vasoplegia in the immediate postoperative period, and 34% at 24 h. Risk factors for immediate vasoplegia development were preoperative use of angiotensin converting enzyme inhibitor drugs, a mean arterial pressure < 50 mmHg immediately after beginning cardiopulmonary bypass, duration of aortic clamping as well as the cardiopulmonary bypass, and minimum temperature in cardiopulmonary bypass. Vasoplegia at 24 h after surgery was correlated to preoperative angiotensin converting enzyme inhibitor drug treatment and cardiopulmonary bypass duration. Conclusion. The incidence of vasoplegia after cardiac surgery with cardiopulmonary bypass is high during the first 24 postoperative hours. Preoperative treatment with angiotensin converting enzyme inhibitor and the mean arterial pressure at the beginning of cardiopulmonary bypass are the more easily controllable risk factors. In patients arriving to surgery with those drugs, treatment or prevention of vasoplejia should be planned (AU)

[Factors involved in the development of vasoplegia after cardiac surgery with extracorporeal circulation. A prospective observational study]. / Factores implicados en el desarrollo de vasoplejía tras cirugía cardiaca con circulación extracorpórea. Estudio prospectivo observacional.

OBJECTIVE: The incidence and risk factors for vasoplegia in the early postoperative period and at 24h are investigated in patients subjected to cardiopulmonary bypass surgery. Vasoplegia following cardiac surgery with cardiopulmonary bypass is associated with a high morbimortality. The risk factors described emerged from retrospective, non-controlled studies. METHODS: Observational prospective study of 188 consecutive patients subjected to cardiac surgery with cardiopulmonary bypass in a single hospital between November 2011 and May 2012. Emergency surgery or complex procedures were excluded. Vasoplegia was assessed during the immediate postoperative period, and at 24h after surgery, and was defined as a mean arterial pressure below 50mmHg, and the need for a noradrenaline perfusion of more than 0.08µg/kg/min, monitored by cardiac output and systemic vascular resistances. The anaesthetic and cardiopulmonary bypass protocols, as well as haemodynamic management, were the same in all patients. RESULTS: Almost half (48%) of patients had vasoplegia in the immediate postoperative period, and 34% at 24h. Risk factors for immediate vasoplegia development were preoperative use of angiotensin converting enzyme inhibitor drugs, a mean arterial pressure<50mmHg immediately after beginning cardiopulmonary bypass, duration of aortic clamping as well as the cardiopulmonary bypass, and minimum temperature in cardiopulmonary bypass. Vasoplegia at 24h after surgery was correlated to preoperative angiotensin converting enzyme inhibitor drug treatment and cardiopulmonary bypass duration. CONCLUSION: The incidence of vasoplegia after cardiac surgery with cardiopulmonary bypass is high during the first 24 postoperative hours. Preoperative treatment with angiotensin converting enzyme inhibitor and the mean arterial pressure at the beginning of cardiopulmonary bypass are the more easily controllable risk factors. In patients arriving to surgery with those drugs, treatment or prevention of vasoplejia should be planned.

Bloqueo paravertebral continuo para analgesia en cirugía cardiaca mínimamente invasiva / Continuous paravertebral block for analgesia in minimally invasive cardiac surgery

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Proyecto Redesra / No disponible

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Corrección de ductus arterioso pesistente no diagnosticado durante el tratamiento endovascular de coartación de aorta / No disponible

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[First-year medical residents' self-assessment of skill in basic life support and automatic external defibrillation]. / Percepción de los residentes de primer año de sus competencias en soporte vital básico y desfibrilación automática externa.

OBJECTIVE: To determine first-year medical residents' perception of their competence in basic life support (BLS) and the use of automatic external defibrillation (AED). MATERIAL AND METHODS: Course in BLS and AED accredited by the European Resuscitation Council with pre- and post-course self-assessment. The post-training questionnaire was administered immediately after the course and 8 months later. The data recorded covered (a) prior training and experience, (b) self-assessment of BLS and AED skills (9 items, scored 1-5), (c) the skill considered most difficult, and (d) satisfaction (13 items, scored 0-10). RESULTS: The questionnaire was initially completed by 71 residents; 31 also responded 8 months later. Self-assessment scores improved immediately after the course (P = .0001). Scores had fallen 8 months later (P = .0001) but were still significantly higher than pre-course perception of skill (P = .017). More than 95% of the residents considered themselves to be competent after the course and more than 80% felt competent 8 months later, with the exception of skills in bag-mask ventilation (74.2%) and removal of a foreign body (61.3%). The skill considered most difficult was bag-mask ventilation. Mean (SD) BLS and AED scores for real-life situations were 8.48 (1.33) and 9.19 (0.94), respectively, after the course and 7.32 (1.4) and 7.29 (1.32) at 8 months (P = .0001). Overall satisfaction was high. CONCLUSIONS: The residents perceived themselves as competent to give BLS and AED immediately after the course and 8 months after training, although fewer felt as competent at the second assessment. Bag-mask ventilation was considered the most difficult skill.

Percepción de los residentes de primer año de sus competencias en soporte vital básico y desfibrilación automática externa / First-year medical residents’ self-assessment of skill in basic life support and automatic external defibrillation

OBJETIVOS: Evaluar la opinión de residentes de primeraño sobre sus competencias en soporte vital básico(SVB) y desfibrilación automática externa (DAE).MATERIAL Y MÉTODOS: Curso acreditado de SVB yDAE según el European Resuscitation Council. Encuestaantes, inmediatamente después del curso y a los 8 meses.Datos registrados: a) formación y experiencia previas; b)autoevaluación de habilidades para SVB y DAE (9ítems; puntuación: 1-5); c) habilidad considerada másdifícil; d) encuesta de satisfacción (13 ítems; puntuación:0-10).RESULTADOS: El estudio inicial incluyó 71 residentesde los cuales 31 cumplimentaron también la encuesta alos 8 meses. La autoevaluación mejoró después del curso(p = 0,0001). A los 8 meses las puntuaciones empeoraron(p = 0,0001) pero se mantuvieron significativamentesuperiores a las iniciales (p < 0,017). Más del 95% de losresidentes se consideraron competentes después del cursoy más del 80% a los 8 meses, excepto para la ventilacióncon bolsa-mascarilla (74,2%) y la liberación decuerpo extraño (61,3%). La habilidad considerada másdifícil fue la ventilación con bolsa-mascarilla. La valoraciónde las competencias para SVB y DAE en situaciónreal fue 8,48 (±1,33) y 9,19 (±0,94) después del curso y7,32 (±1,4) y 7,29 (±1,32) a los 8 meses (p = 0,0001). Lasatisfacción global fue alta.CONCLUSIONES: Los residentes consideraron que erancompetentes para aplicar SVB y DAE inmediatamentedespués del curso y a los 8 meses de su formación, aunqueen menor grado. La habilidad considerada más difícilfue la ventilación con bolsa-mascarilla(AU)

OBJECTIVE: To determine first-year medical residents’perception of their competence in basic life support (BLS)and the use of automatic external defibrillation (AED).MATERIAL AND METHODS: Course in BLS and AEDaccredited by the European Resuscitation Council withpre- and post-course self-assessment. The post-trainingquestionnaire was administered immediately after thecourse and 8 months later. The data recorded covered a)prior training and experience, b) self-assessment of BLSand AED skills (9 items, scored 1-5), c) the skill consideredmost difficult, and d) satisfaction (13 items, scored 0-10).RESULTS: The questionnaire was initially completed by71 residents;, 31 also responded 8 months later. Selfassessmentscores improved immediately after the course(P=.0001). Scores had fallen 8 months later (P=.0001) butwere still significantly higher than pre-course perceptionof skill (P=.017). More than 95% of the residentsconsidered themselves to be competent after the courseand more than 80% felt competent 8 months later, withthe exception of skills in bag-mask ventilation (74.2%)and removal of a foreign body (61.3%). The skillconsidered most difficult was bag-mask ventilation.Mean (SD) BLS and AED scores for real-life situationswere 8.48 (1.33) and 9.19 (0.94), respectively, after thecourse and 7.32 (1.4) and 7.29 (1.32) at 8 months(P=.0001). Overall satisfaction was high.CONCLUSIONS: The residents perceived themselves ascompetent to give BLS and AED immediately after thecourse and 8 months after training, although fewer feltas competent at the second assessment. Bag-maskventilation was considered the most difficult skill(AU)

Implementación de un laboratorio de habilidadesclínicas centralizado en la Facultad de Medicina dela Universitat de Barcelona. Cuatro años de experiencia / Implementation of a centralized clinical skills laboratory at the Medical School of the University of Barcelona. Four years of experience

Introducción. La Facultad de Medicina de la Universitat de Barcelona definió en su momento las competencias a adquirir por sus estudiantes y evaluó dicha adquisición, apreciándose un déficit en el ámbito de las habilidades clínicas y de los procedimientos técnicos. Para solventar estos déficit, la facultad decidió implementar un laboratorio de habilidades centralizado. Materiales y métodos. Describimos las diferentes fases del proceso de implementación y el desarrollo de un curso optativo sobre habilidades clínicas para adquirir experiencia en la gestión de dicho centro y dar a conocer el recurso entre los profesores de la facultad. Asimismo, hemos investigado el grado de aceptación de este recurso por los alumnos y profesores utilizando diversos cuestionarios. Resultados. En estos cuatro años de experiencia, aproximadamente 1.000 estudiantes cada año, de grado y de posgrado, han recibido docencia en el laboratorio. Los estudiantes consideran el laboratorio como un instrumento excelente para incrementar su competencia individual en habilidades clínicas y que deben extenderse sus prestaciones a todos los estudiantes. Los profesores consideran el laboratorio como un instrumento muy útil para mejorar la enseñanza clínica. Conclusiones. Consideramos que la experiencia ha sido muy positiva y puede ser útil para el proceso de cambio curricular actualmente en curso en la facultad. La experiencia, además, podría servir de modelo para la implementación de laboratorios de habilidades en otras facultades. Finalmente, la Facultad de Medicina debe incrementar su inversión para mejorar los recursos y la accesibilidad del laboratorio a todos los estudiantes y profesores (AU)

Introduction. Medical School at the University of Barcelona defined learning outcomes and evaluated its acquisition by the students. Some lacks in several clinical skills and procedures have been detected. To improve clinical skills learning, medical school decided to implement a centralized skills centre. Materials and methods. We describe the different steps of the process of implementation of this centre and the development of an elective course on clinical skills and procedures, in order to acquire experience in the management of this center and to show to the teachers the usefulness of these facilities. Finally, we investigated the level of acceptance of this tool by teachers and students by using different kinds of questionnaires. Results. In the last four years about 1000 medical students per year (undergraduate and postgraduate) have been trained in the laboratory. Students consider that the center is an excellent tool to increase their individual competence in clinical skills and it is necessary to extend this tool to all students. For teachers, the center is a very useful tool to improve clinical training. Conclusions. Our experience has been positive and very useful in the curriculum change process carried out at present in our medical school. The experience could serve as a model for the implementation of skills centers in other Spanish Medical Schools. Medical School must increase the investment in order to improve the facilities and the accessibility of the center to all students and teachers (AU)

Propuesta sobre las competencias en Anestesiología, Reanimación y Terapéutica del Dolor de un graduado de Medicina. Consenso del profesorado de las universidades de Cataluña / No disponible

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Toxicidad materna por bupivacaína durante fetoscopia para el tratamiento del síndrome de transfusión fetofetal / Toxic maternal dose of bupivacaine during fetoscopic treatment of twin-to-twin transfusion syndrome

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Respuesta a la carta al director “consideraciones sobre la nueva guía de fármacos inhibidores de la hemostasia y anestesia regional neuroaxial” / Author´s reply to "çOn the new guidelines for inhibitors of hemostasis and regional neuraxial anesthesia"

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