Análisis de coste-eficacia del recuperador postoperatorio de sangre de drenajes en cirugía protésica primaria de rodilla. ¿Debemos seguir recomendando su empleo en la actualidad? / Cost-effectiveness of post-operative cell salvage in total knee arthroplasty. Should we continue to recommend its use today?

Objetivos. La artroplastia total de rodilla (ATR) presenta una elevada tasa transfusional. En nuestro protocolo, indicamos el empleo del recuperador de drenajes postoperatorios (RDPO) en los pacientes con contraindicación al ácido tranexámico. Analizamos el efecto de los RDPO respecto la tasa transfusional y sus costes en pacientes intervenidos de ATR. Material y métodos. Se incluyeron prospectivamente 518 pacientes. De ellos, 434 recibieron ácido tranexámico y en 84 se contraindicó. Calculamos la masa eritrocitaria, el volumen sanguíneo y el porcentaje de volumen sanguíneo perdido. Controlamos las incidencias asociadas al uso del recuperador y la tasa de transfusión. Realizamos un análisis de costes asociados a los métodos de prevención de transfusión alogénica. Resultados. En 10 de los 84 pacientes no candidatos a ácido tranexámico no colocamos el RDPO. En los 74 en los que colocamos un RDPO, reinfundimos 158 ± 72 ml de masa eritrocitaria. La tasa de transfusión alogénica fue del 36%, y en los que no se colocó, del 52%. Con el empleo de RDPO el riesgo relativo de transfusión se situó en el 0,69 (0,41-1,16), con una reducción de riesgo absoluto del 16% (-8,-40%). El número de pacientes a tratar para evitar una transfusión alogénica fue de 7. Los costes tangibles directos para evitar una transfusión alogénica se situó en 1.610€. No observamos complicaciones asociadas a la reinfusión de la sangre recuperada. Conclusiones. El empleo de RDPO tras ATR precisa de su empleo en 7 pacientes para evitar una transfusión alogénica, con un coste más de 10 veces superior al del concentrado alogénico

Objectives. Total knee arthroplasty (TKA) has a high transfusion rate. In our protocol, the use of postoperative cell salvage is indicated in patients with contraindications to tranexamic acid (TA). An analysis was performed on the effect of post-operative cell salvage (POCS) regarding transfusion rate and costs in patients undergoing TKA. Material and methods. A prospective analysis was conducted on 518 patients, of whom 434 received TA, and 84 were contraindicated. The red cell mass, blood volume, and the percentage of lost blood volume were calculated. Incidents associated with the use of post-operative re-perfusion of drained blood and the rate of transfusion were recorded. An analysis was performed on the costs associated with allogeneic transfusion prevention methods. Results. A POCS drain was not inserted in 10 out of the 84 patients not candidates for TA. In the 74 in which it was placed, 158 ± 72 ml of red cell mass was reinfused. The allogeneic transfusion rate was 36%, and was 52% in those with no drain inserted. Relative risk of transfusion using POCS was 0.69 (0.41 to 1.16) with an absolute risk reduction of 16% (-8 to 40%). The number needed to treat to avoid allogeneic transfusion was 7. The direct costs to avoid allogeneic transfusion were €1,610. No complications associated with blood re-infusion were observed. Conclusions. The use of POCS would be required in 7 patients after TKA to avoid one allogeneic transfusion with a cost over 10 times that of a transfusion of red cell concentrates

Cost-effectiveness of post-operative cell salvage in total knee arthroplasty. Should we continue to recommend its use today? / Análisis de coste-eficacia del recuperador postoperatorio de sangre de drenajes en cirugía protésica primaria de rodilla. ¿Debemos seguir recomendando su empleo en la actualidad?

OBJECTIVES: Total knee arthroplasty (TKA) has a high transfusion rate. In our protocol, the use of postoperative cell salvage is indicated in patients with contraindications to tranexamic acid (TA). An analysis was performed on the effect of post-operative cell salvage (POCS) regarding transfusion rate and costs in patients undergoing TKA. MATERIAL AND METHODS: A prospective analysis was conducted on 518 patients, of whom 434 received TA, and 84 were contraindicated. The red cell mass, blood volume, and the percentage of lost blood volume were calculated. Incidents associated with the use of post-operative re-perfusion of drained blood and the rate of transfusion were recorded. An analysis was performed on the costs associated with allogeneic transfusion prevention methods. RESULTS: A POCS drain was not inserted in 10 out of the 84 patients not candidates for TA. In the 74 in which it was placed, 158±72ml of red cell mass was reinfused. The allogeneic transfusion rate was 36%, and was 52% in those with no drain inserted. Relative risk of transfusion using POCS was 0.69 (0.41 to 1.16) with an absolute risk reduction of 16% (-8 to 40%). The number needed to treat to avoid allogeneic transfusion was 7. The direct costs to avoid allogeneic transfusion were €1,610. No complications associated with blood re-infusion were observed. CONCLUSIONS: The use of POCS would be required in 7 patients after TKA to avoid one allogeneic transfusion with a cost over 10 times that of a transfusion of red cell concentrates.

Optimización de la hemoglobina preoperatoria en cirugía ortopédica mayor utilizando hierro intravenoso con o sin eritropoyetina. Estudio epidemiológico / Optimizing preoperative haemoglobin in major orthopaedic surgery using intravenous iron with or without erythropoietin. An epidemiologic study

Objetivo: Evaluar la efectividad del tratamiento con hierro intravenoso, solo o asociado a eritropoyetina (rHuEPO), mediante el incremento de hemoglobina (Hb). Como objetivo secundario se analizó la relación del incremento de Hb con los parámetros utilizados para evaluar la anemia. Material y método: Estudio observacional retrospectivo realizado en 2 centros entre enero de 2005 y diciembre de 2009. Se incluyeron pacientes sometidos a cirugía ortopédica electiva con déficit de hierro y que fueron tratados con hierro sacarosa intravenosos solo o asociado a rHuEPO. Se analizó la efectividad del tratamiento mediante la diferencia entre la Hb basal y la Hb previa a la cirugía y se valoró la relación entre los parámetros hematimétricos y del metabolismo del hierro con la efectividad del tratamiento. Resultados: Se incluyeron 412 pacientes que recibieron una mediana de 800 mg de hierro sacarosa. A 125 pacientes (30,4%) se les asoció 2,4 viales de rHuEPO. El incremento de Hb fue de 0,8 (1,1) g/dL en los pacientes tratados con hierro intravenoso y de 1,5 (1,3) g/dL en los que se asoció rHuEPO (p < 0,01). El incremento de Hb en los pacientes tratados con hierro se correlacionó con el porcentaje de hematíes hipocromos (r = 0,52) y el valor del receptor soluble de la transferrina (r = 0,59). Conclusiones: La efectividad del tratamiento con hierro sacarosa en pacientes con déficit de hierro para la optimización de la Hb preoperatoria fue moderada, siendo mayor con la administración adyuvante de eritropoyetina. La determinación de los parámetros funcionales del estado del hierro nos podría guiar para mejorar la efectividad del tratamiento (AU)

Aim: To evaluate the effectiveness of intravenous iron treatment, with or without associated erythropoietin (rHuEPO), measured as haemoglobin (Hb) increase. The relationships between the Hb increase and parameters used to evaluate anaemia were analysed. Material and method: Retrospective observational study carried out in two third-level hospitals between January 2005 and December 2009. The study included patients with iron deficiency anaemia scheduled for elective orthopaedic surgery and treated with intravenous iron sucrose alone or associated with rHuEPO. Treatment efficacy was analysed based on the Hb increase from baseline to just before surgery. Results: A total of 412 patients who received a median of 800 mg of iron sucrose were included; 125 of them (30.4%) additionally received 2.4 vials of rHuEPO. The Hb increase was 0.8 (1.1) g/dL in patients treated with intravenous iron and 1.5 (1.3) g/dL in those additionally given rHuEPO (P < .01). The percentage of hypochromic red blood cells (r = 0.52) and soluble transferrin receptor (r = 0.59) value were significantly correlated to the Hb increase in patients receiving iron. Conclusions: In patients with iron deficiency anaemia, the effectiveness of iron sucrose treatment to optimize Hb before surgery was moderate; adjuvant administration of erythropoietin improved the results. Determination of functional iron status parameters may improve the treatment effectiveness (AU)

Optimizing preoperative haemoglobin in major orthopaedic surgery using intravenous iron with or without erythropoietin. An epidemiologic study.

AIM: To evaluate the effectiveness of intravenous iron treatment, with or without associated erythropoietin (rHuEPO), measured as haemoglobin (Hb) increase. The relationships between the Hb increase and parameters used to evaluate anaemia were analysed. MATERIAL AND METHOD: Retrospective observational study carried out in two third-level hospitals between January 2005 and December 2009. The study included patients with iron deficiency anaemia scheduled for elective orthopaedic surgery and treated with intravenous iron sucrose alone or associated with rHuEPO. Treatment efficacy was analysed based on the Hb increase from baseline to just before surgery. RESULTS: A total of 412 patients who received a median of 800mg of iron sucrose were included; 125 of them (30.4%) additionally received 2.4 vials of rHuEPO. The Hb increase was 0.8 (1.1) g/dL in patients treated with intravenous iron and 1.5 (1.3) g/dL in those additionally given rHuEPO(P<.01). The percentage of hypochromic red blood cells (r=0.52) and soluble transferrin receptor (r=0.59) value were significantly correlated to the Hb increase in patients receiving iron. CONCLUSIONS: In patients with iron deficiency anaemia, the effectiveness of iron sucrose treatment to optimize Hb before surgery was moderate; adjuvant administration of erythropoietin improved the results. Determination of functional iron status parameters may improve the treatment effectiveness.

Afección laríngea obstructiva y síndrome de apnea obstructiva del sueño, una asociación con severo riesgo perioperatorio / Obstructive laryngeal disease and obstructive sleep apnoea syndrome, a combination with serious peri-operative risk

Presentamos el caso de una paciente con diagnósticos de bronquitis crónica, síndrome de apnea obstructiva del sueño y edemas laríngeos de gran tamaño que se intervino para resección mediante microcirugía transoral láser. En el postoperatorio inmediato desarrolló una insuficiencia respiratoria aguda por colapso faríngeo que requirió reintubación en condiciones de urgencia y traslado a UCI no prevista, en la que se mantuvo la ventilación mecánica durante 18 h, procediendo a continuación a la extubación. La evolución posterior fue normal. Se describe la asociación de varios factores de riesgo para el tratamiento anestésico y la importancia de detectar en el preoperatorio la gravedad de cada una de las alteraciones, especialmente la severidad del síndrome de apnea obstructiva del sueño (AU)

We present the case of a patient who was diagnosed with chronic bronchitis, obstructive sleep apnoea syndrome, and large Reinke laryngeal oedemas that were removed by transoral laser microsurgery. In the immediate post-operative period acute respiratory insufficiency occurred due to pharyngeal collapse that required emergency re-intubation, after which the patient was transferred to the ICU where mechanical ventilation was given for18 h. Subsequent progress was normal. We describe the combination of various risk-factors related to anaesthetic management and the importance of considering each one of them, especially the preoperative detection of the severity of obstructive sleep apnoea syndrome (AU)

Should all patients be optimized to the same preoperative hemoglobin level to avoid transfusion in primary knee arthroplasty?

BACKGROUND AND OBJECTIVE: Optimization of the preoperative hemoglobin (Hb) level is an effective way to reduce allogeneic transfusion in total knee arthroplasty (TKA) though the procedure is expensive, requires close monitoring and is often inconvenient for patients with reduced mobility. Our aim was to investigate the value of preoperative Hb levels to predict transfusion and thereby tailoring Hb optimization to patient characteristics. MATERIALS AND METHODS: All consecutive patients who undergone primary TKA in our center over 2 years, and received tranexamic acid intraoperatively, were reviewed. The adjusted association between preoperative Hb levels and transfusion was assessed by multivariate logistic regression, and the estimated probability of transfusion for individual patients was derived from the logistic model. RESULTS: Out of the 784 patients who meet the inclusion criteria, risk of transfusion was associated with poorer performance status, as measured by the America Association of Anestesiology (ASA) score III/IV (OR: 3·3, P < 0·001) and lower preoperative Hb level (OR 3·8 for each g/dl below 13 g/dl; P < 0·001). According to the Hb level, the estimated probability of transfusion was 0·03 (range: 0·03-0·64) for ASA I/II patients and 0·10 (range: 0·10-0·84) for ASA III/IV. CONCLUSION: Not all the patients undergoing TKA who receive tranexamic acid need the same preoperative Hb optimization target. Two easily available factors, such as the ASA score and the Hb level, can help individualize the Hb optimization target.

Incidence of intraneural needle insertion in ultrasound-guided femoral nerve block: A comparison between the out-of-plane versus the in-plane approaches / Incidencia de inserción intraneural en bloqueo femoral guiado por ecografía: comparación entre los enfoques en plano y fuera de plano

BACKGROUND: The optimal method of ultrasound-guided femoral nerve block (in-plane vs. out-of-plane) has not been established. We tested the hypothesis that the incidence of needle-nerve contact may be higher with out-of-plane than with in-plane needle insertion. METHODS: Forty-four patients with hip fracture (American Society of Anaesthesiologists physical status I-III) were randomized to receive the femoral block with an out-of-plane approach (needle inserted at a 45-60° angle 1 cm caudal to the midpoint of the ultrasound probe just above the femoral nerve) or with an in-plane technique (needle inserted 0.2-0.4 cm from the side of the probe lateral to the femoral nerve). Data collected included depth of needle insertion, response to nerve electric stimulation, and distribution of the injected volume in relation to the nerve (anterior vs. posterior, the latter assuming needle-nerve contact). The sensory block onset was tested at 20 min and block recovery and any neurologic symptoms were evaluated at 24 h. RESULTS: The incidence of needle-nerve contact was significantly higher with the out-of-plane approach (14/22 patients [64%]) than with the in-plane approach (2/22 patients [9%]) (p < 0.001) (OR = 17.5, 95% CI: 4-79). The rate of paraesthesia on crossing the fascia iliaca was similar in the two groups. All blocks uneventfully regressed; and no patient developed neurologic symptoms. CONCLUSIONS: Under the conditions of our study, needle-nerve contact during femoral nerve block occurs frequently with the out-of-plane approach. An in-plane approach results in an equally effective femoral block and less incidence of needle-nerve contact

ANTECEDENTES. No ha quedado establecido un método adecuado para el bloqueo femoral guiado por ecografía (en plano frente a fuera de plano). Probamos la hipótesis de que la incidencia del contacto entre la aguja y un nervio puede ser mayor en la inserción fuera de plano que en el abordaje en plano. MÉTODOS: Cuarenta y cuatro pacientes con fractura de cadera (estadio i-iii según la Sociedad Americana de Anestesiólogos) recibieron de manera aleatorizada un bloqueo femoral con un enfoque fuera de plano (inserción de la aguja en ángulo de 45-60° y 1 cm caudal a la sonda de ecografía sobre el nervio femoral) o con una técnica en plano (inserción de la aguja 0,2-0,4 cm desde el lado de la sonda lateral al nervio femoral). Entre los datos recopilados se incluían la profundidad de inserción de la aguja, la reacción a la estimulación nerviosa y la distribución del volumen inyectado en función del nervio (anterior comparado con posterior, este último con contacto entre la aguja y un nervio). Se analizó el inicio del bloqueo a los 20 min y se evaluaron la recuperación del bloqueo y los síntomas neurológicos después de 24 h. RESULTADOS: La incidencia del contacto entre la aguja y los nervios fue significativamente mayor con el enfoque fuera de plano (14/22 pacientes [64%]) que con el abordaje en plano (2/22 pacientes [9%]) (p < 0,001) (OR = 17,5 [95%]; IC: 4-79). El grado de parestesia en aponeurosis fue similar en ambos grupos. Se revirtieron todos los bloqueos sin incidentes; ningún paciente desarrolló síntomas neurológicos. CONCLUSIONES: En las condiciones de nuestro estudio, el contacto entre la aguja y un nervio durante el bloqueo femoral sucede a menudo con el enfoque fuera de plano. Un abordaje en plano tiene como resultado un bloqueo femoral igualmente efectivo, y una incidencia menor del contacto entre la aguja y un nervio

Incidence of intraneural needle insertion in ultrasound-guided femoral nerve block: a comparison between the out-of-plane versus the in-plane approaches.

BACKGROUND: The optimal method of ultrasound-guided femoral nerve block (in-plane vs. out-of-plane) has not been established. We tested the hypothesis that the incidence of needle-nerve contact may be higher with out-of-plane than with in-plane needle insertion. METHODS: Forty-four patients with hip fracture (American Society of Anaesthesiologists physical status I-III) were randomized to receive the femoral block with an out-of-plane approach (needle inserted at a 45-60° angle 1cm caudal to the midpoint of the ultrasound probe just above the femoral nerve) or with an in-plane technique (needle inserted 0.2-0.4 cm from the side of the probe lateral to the femoral nerve). Data collected included depth of needle insertion, response to nerve electric stimulation, and distribution of the injected volume in relation to the nerve (anterior vs. posterior, the latter assuming needle-nerve contact). The sensory block onset was tested at 20 min and block recovery and any neurologic symptoms were evaluated at 24h. RESULTS: The incidence of needle-nerve contact was significantly higher with the out-of-plane approach (14/22 patients [64%]) than with the in-plane approach (2/22 patients [9%]) (p<0.001) (OR=17.5, 95% CI: 4-79). The rate of paraesthesia on crossing the fascia iliaca was similar in the two groups. All blocks uneventfully regressed; and no patient developed neurologic symptoms. CONCLUSIONS: Under the conditions of our study, needle-nerve contact during femoral nerve block occurs frequently with the out-of-plane approach. An in-plane approach results in an equally effective femoral block and less incidence of needle-nerve contact.

[Obstructive laryngeal disease and obstructive sleep apnoea syndrome, a combination with serious peri-operative risk]. / Afección laríngea obstructiva y síndrome de apnea obstructiva del sueño, una asociación con severo riesgo perioperatorio.

We present the case of a patient who was diagnosed with chronic bronchitis, obstructive sleep apnoea syndrome, and large Reinke laryngeal oedemas that were removed by transoral laser microsurgery. In the immediate post-operative period acute respiratory insufficiency occurred due to pharyngeal collapse that required emergency re-intubation, after which the patient was transferred to the ICU where mechanical ventilation was given for 18h. Subsequent progress was normal. We describe the combination of various risk-factors related to anaesthetic management and the importance of considering each one of them, especially the preoperative detection of the severity of obstructive sleep apnoea syndrome.

Allogeneic blood transfusion does not increase the risk of wound infection in total knee arthroplasty.

BACKGROUND AND OBJECTIVE: Allogeneic blood transfusion has been reported to increase the risk of postoperative infection in arthroplasty though the results are inconclusive. Data from a previous clinical trial on antibiotic prophylaxis in knee arthroplasty were analysed to gain further insight into the relationship between wound infection and both blood transfusion and the storage time of transfused RBCs. MATERIALS AND METHODS: A total of 910 consecutive patients undergoing primary knee arthroplasty were prospectively followed for 12 months after surgery. The main outcome was wound infection, either superficial or deep-tissue. Possible predictors for wound infection included the patient's age and sex, preoperative physical status, time under leg ischaemia, postoperative fluid drainage, and the number and length of storage of transfused RBCs. RESULTS: Deep tissue infection was diagnosed in 28 (3%) patients, superficial infection in 25 (2.7%) and cellulitis in eight (0.8%) patients. Transfusion of at least one blood unit had been given to 22 (36%) of the 61 patients who later developed wound infection and 313 (36%) of those who did not (P > 0.05). Patients who developed wound infection had a significantly poorer physical status and longer time of leg ischaemia. There was no significant difference between both groups of patients in either the amount or the length of storage of transfused RBC units. CONCLUSION: This study failed to find any association between the incidence of wound infection after knee arthroplasty and allogeneic transfusion.

[Complications during epilepsy surgery. Experience after 102 interventions between 1997 and 2001]. / Complicaciones en la cirugía de la epilepsia. Experiencia tras 102 intervenciones entre 1997 y 2001.

OBJECTIVES: To describe perioperative complications in different approaches to surgery for epilepsy. PATIENTS AND METHODS: All patients undergoing surgery related to epilepsy between January 1997 and December 2001 were studied. We gathered information on patient characteristics, diagnosis, anticonvulsant treatment, surgical procedure, type of anesthesia and perioperative complications. RESULTS: Ninety-eighty patients underwent 90 procedures under general anesthesia and 12 procedures with local anesthesia and sedation. Surgery was for anteromedial temporal resection in 74 patients, electrode implantation through the foramen ovale in 10 patients, extratemporal excisions in 7 patients, callosotomy in 3 patients, functional hemispherectomy in 3 patients, implantation of electrode grids in 2 patients, and craniotomy with an awake patient in 3 cases. Complications related to the surgical procedure were intraoperative bradycardia (5 cases), dural tension at the start of surgery (3), bleeding (2) and seizure (1). Complications related to anesthesia were bronchospasm (2 cases), histamine-releasing reaction upon administration of the muscle relaxant (1), and difficult intubation (1). During recovery we saw 1 case of postoperative aphasia, 1 of polyuria, 1 of pulmonary condensation, and 1 of factor VII deficit requiring plasma transfusion. CONCLUSIONS: The rate of perioperative complications in surgery for drug-resistant epilepsy is low, the most common complication being self-limiting bradycardia related to surgical maneuvers.

Complicaciones en la cirugía de la epilepsia. Experiencia tras 102 intervenciones entre 1997 y 2001 / Complications of surgical treatment in epilepsy: 102 interventions between 1997 and 2001

OBJETIVOS: Describir las complicaciones perioperatorias en los distintos abordajes de la cirugía de la epilepsia. PACIENTES Y MÉTODOS: Se estudiaron todos los pacientes sometidos a cirugía relacionada con la epilepsia entre enero de 1997 y diciembre de 2001. Se recogieron datos demográficos, diagnóstico, tratamiento anticomicial, procedimiento quirúrgico, tipo de anestesia y las complicaciones aparecidas perioperatoriamente. RESULTADOS: 98 pacientes fueron sometidos a 90 procedimientos bajo anestesia general y a 12 procedimientos bajo anestesia local y sedación. Las intervenciones realizadas fueron resección temporal anteromedial en 74 pacientes, implantación de electrodos a través del foramen oval en 10 pacientes, escisiones extratemporales en 7 pacientes, callosotomía en 3 pacientes, hemisferotomía funcional en 3 pacientes, colocación de mantas de electrodos en 2 pacientes, y craneotomía con el paciente despierto en 3 pacientes. Las complicaciones aparecidas en relación al procedimiento quirúrgico fueron 5 casos de bradicardia intraoperatoria, 3 de duramadre a tensión en el inicio de la intervención, 2 de hemorragia y 1 de crisis comicial. En relación al procedimiento anestésico las complicaciones fueron 2 casos de broncoespasmo, 1 de reacción histaminoliberadora en relación a la administración de relajante muscular y 1 de intubación dificultosa. Durante el postoperatorio aparecieron 1 caso de afasia post-quirúrgica, 1 de poliuria, 1 de condensación pulmonar y 1 paciente requirió transfusión de plasma por déficit de factor VII. CONCLUSIONES: La cirugía de la epilepsia farmacorresistente es un procedimiento con un índice bajo de complicaciones perioperatorias; la más frecuentemente descrita es la aparición de bradicardia autolimitada secundaria a la manipulación quirúrgica (AU)

Prevalencia del dolor en el servicio de urgencias de un hospital general / Prevalence of pain in the emergencies department of a general hospital

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