Challenges for Nurse Anesthetists Reentering Practice Following Substance Use Disorder Treatment.

Substance use disorder (SUD) is a persistent, relapsing condition that is present in approximately 10% of anesthesia providers, who, compared with other healthcare providers, face a greater risk of developing an SUD by virtue of constant access to medications. The ability of certified registered nurse anesthesiologists (CRNAs) to obtain or maintain employment after treatment for SUD treatment is not well documented. The purpose of this qualitative study was to explore challenges encountered by CRNAs in recovery as they attempt to reenter practice following SUD treatment. The phenomenon was explored through multiple-case study, using qualitative semistructured interviews with participants in four cases: CRNAs in recovery, CRNA colleagues, CRNA employers, and professional health program employees. Thirty-six participants conveyed their perspectives about challenges that CRNAs in recovery face upon reentry into practice following SUD treatment. The Worker Well-Being conceptual model was used to guide this study. The study revealed that more SUD education is a key facilitator for reentry, risk of relapse was a major concern, and stigma was the most significant barrier for CRNAs in recovery. Stigma persists as a considerable barrier in many facets of SUD, contributing to an increase in shame associated with having the disease.

Anesthesia Medication Safety in Relation to Pharmacopeia Medication Use Best Practice Initiatives.

Improvement to anesthesia medication safety is a useful and worthwhile area of research. Anesthesia is one of the few healthcare professions to have immediate access to compounding and label high-hazard medications at the bedside. There is a need to assess the perceptions of anesthesia medication safety and this relationship with pharmacopeia's updated recommendations for anesthesia to improve medication safety and prevent adverse drug events. Certified registered nurse anesthetist (CRNA) perceptions of medication safety climate in Florida were measured utilizing a validated Likert-scale that merged the Attitudes Questionnaire themes of teamwork, climate, safety climate, job satisfaction, stress recognition, perceptions of management, and working. The Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture themes utilized were organizational learning, error communication, and support for patient safety. The overall email invitations delivered 5,890, 524 participants voluntarily started, and 401 completed the questionnaire resulting in a 77% completion rate. The overall response rate was 8.896% and 6.8% overall completion rate. The findings demonstrate a correlation between themes related to supportive organizational learning, stress reduction, positive changes, and creating anesthesia medication quality improvements. CRNAs' openness in adopting new pharmacopeia best practice recommendations can improve anesthesia medication safety delivery. The survey indicated clinical noteworthiness that supports the importance of additional examination of frontline providers' perceptions regarding anesthesia medication safety, buy-in, and adoption of updated pharmacopeia recommendations.

A New Distal Pharyngeal Airway Device Associated with a Reduced Need for Chin-Lift and Jaw-Thrust Maneuvers in Sedated Patients.

Oropharyngeal airways (OPA) or nasopharyngeal airways (NPA) sometimes require chin-lift or jaw-thrust (CLJT) maneuvers to relieve airway obstruction which creates the burden of continuous hands-on care by the anesthesia provider. A new distal pharyngeal airway device (DPA) was used on 63 successive ambulatory surgery patients to assess the frequency of patients requiring manual CLJT maneuvers to prevent airway obstruction. Results were then compared with a contemporaneous group of patients who had used OPA or NPA devices for similar procedures. Patients using the DPA had a 38.5% lower rate of CLJT maneuvers compared with the combined OPA/NPA groups (22.2% of 63 vs. 60.7% of 163, P ≤ .001). Moreover, the results for the DPA group were close to those of the natural airway group (22.2% of 62 vs. 24.8% of 233, P = .66) Results were similar for a sub-set of the above groups who required deep sedation or deep extubation. CLJT maneuvers were common in this ambulatory surgery setting. The new DPA device was associated with a reduced need for such manual maneuvers when compared with similar patients who received OPA or NPA devices and is comparable with the rate for natural airways.

[Peripheral Regional Anesthesia Techniques - Standards in Flux?!] / Periphere Regionalanästhesieverfahren ­ Standards im Wandel?!

This review article provides an overview of current developments in peripheral regional anaesthesia (RA). The authors present a subjective compilation based on discussions at professional events and inquiries to the Working Group on Regional Anaesthesia of the German Society for Anaesthesiology and Intensive Care Medicine (DGAI). The article addresses several relevant topics, including the handling of antithrombotic medication in peripheral blockades with reference to European guidelines, the debate on the discharge timing after plexus anaesthesia, and the consideration of rebound pain as an independent pain entity following RA.Furthermore, the contentious discussion regarding the administration of peripheral nerve blockades under general anaesthesia is illuminated. The authors express no fundamental concerns in this regard but emphasize the importance of preoperative evaluation and individual patient needs. The question of mixing local anaesthetics is also addressed, with the authors critically questioning this tradition and recommending the use of individual, long-acting substances.Another focal point is the application of peripheral nerve blockades in emergency medicine, both in preclinical and emergency room settings. The authors highlight the necessity for high-quality studies and discuss the complex organizational issues associated with the preclinical application of RA techniques.

Uso del contenido de fluido torácico para la predicción del balance hídrico y las complicaciones pulmonares postoperatorias tras cirugía abdominal mayor / Use of thoracic fluid content for prediction of fluid balance and postoperative pulmonary complications after major abdominal surgery: An observational study

Antecedentes y objetivos: Los efectos nocivos del exceso de líquidos se manifiestan frecuentemente en los pulmones. El contenido de fluido torácico (thoracic fluid content [TFC]) es una variable que proporciona el monitor por biorreactancia STARLING™, que representa el volumen total de líquido en el tórax. El objetivo es analizar la asociación entre la variación de los valores del TFC (TFCd0%) a las 24horas postoperatorias, el balance hídrico postoperatorio y las complicaciones pulmonares postoperatorias. Material y métodos: Estudio observacional prospectivo y analítico. Se incluyeron pacientes programados para cirugía abdominal mayor en un hospital universitario de tercer nivel. Fueron monitorizados durante la intervención y las 24 primeras horas postoperatorias con el monitor STARLING™, midiendo el TFC y su variación en distintas etapas del perioperatorio. Se realizaron ecografías pulmonares seriadas y se recogieron las complicaciones pulmonares postoperatorias. Se realizó una regresión logística para predecir la aparición de atelectasias y congestión pulmonar. Se calculó el coeficiente de correlación de Pearson para comprobar la asociación entre TFC y balance hídrico. Resultados: Se analizaron 50 pacientes. El TFCd0% medido en la mañana del primer día postoperatorio aumentó una mediana del 27,1% [IQR: 20,3-37,5] y se correlacionó con una r=0,44 con el balance postoperatorio de 677ml [IQR: 125,5-1.412]. El aumento del TFC se relacionó con un mayor riesgo de sufrir atelectasias (OR=1,24) y congestión pulmonar (OR=1,3). Conclusiones: El TFCd0% medido a las 24horas de la cirugía presenta una correlación moderada con el balance hídrico postoperatorio. Su incremento es un factor de riesgo para la aparición de complicaciones pulmonares postoperatorias.(AU)

Background and objectives: The harmful effects of excess fluids frequently manifest in the lungs. Thoracic fluid content (TFC) is a variable provided by the STARLINGTM bioreactance monitor, which represents the total volume of fluid in the chest. The objective is to analyze the association between the variation in TFC values (TFCd0%) at 24 hours postoperatively, postoperative fluid balance, and postoperative pulmonary complications. Material and methods: Prospective and analytical observational study. Patients scheduled for major abdominal surgery at a tertiary teaching hospital were included. They were monitored during the intervention and the first 24 postoperative hours with the monitor. STARLINGTM, measuring TFC and its variation in different stages of the perioperative period. Serial lung ultrasounds were performed and postoperative pulmonary complications were recorded. Logistic regression was performed to predict the occurrence of atelectasis and pulmonary congestion. The Pearson correlation coefficient was calculated to verify the association between TFC and water balance. Results: 50 patients were analyzed. TFCd0% measured on the morning of the first postoperative day increased by a median of 27.1% [IQR: 20.3-37.5] and was correlated at r=0.44 with the postoperative balance of 677 ml [IQR: 125.5-1,412]. Increased TFC was related to a higher risk of atelectasis (OR=1.24) and pulmonary congestion (OR=1.3). Conclusions: TFCd0% measured 24 hours after surgery presents a moderate correlation with postoperative fluid balance. Its increase is a risk factor for the appearance of postoperative pulmonary complications.(AU)

Efectos intraoperatorios de una maniobra de reclutamiento alveolar en pacientes sometidos a cirugía laparoscópica de colon / Intraoperative effects of an alveolar recruitment manoeuvre in patients undergoing laparoscopic colon surgery

Introducción: Las atelectasias pulmonares son habituales en pacientes sometidos a cirugía abdominal laparoscópica bajo anestesia general, aumentando el riesgo de complicaciones respiratorias perioperatorias. Las maniobras de reclutamiento alveolar (MRA) permiten la reexpansión del parénquima atelectasiado, aunque no está claramente establecida la duración de su beneficio. El objetivo de este estudio fue determinar la efectividad de una MRA en cirugía de colon laparoscópica, la duración de la respuesta en el tiempo y su repercusión hemodinámica. Métodos: Se incluyeron 25 pacientes sometidos a cirugía de colon laparoscópica. Tras la inducción anestésica e inicio de la cirugía con neumoperitoneo, se realizó una MRA y determinación posterior de la PEEP óptima. Se analizaron variables de mecánica respiratoria y de intercambio gaseoso, así como parámetros hemodinámicos, antes de la maniobra y periódicamente durante los 90 min siguientes. Resultados: Tres pacientes fueron excluidos por causas quirúrgicas. El gradiente alveoloarterial de oxígeno pasó de 94,3 (62,3-117,8) mmHg antes a 60,7 (29,6-91,0) mmHg después de la maniobra (p < 0,05). Esta diferencia se mantuvo durante los 90 min del estudio. La compliance dinámica del sistema respiratorio pasó de 31,3 mL/cmH2O (26,1-39,2) antes de la maniobra, a 46,1 mL/cmH2O (37,5-53,5) tras la misma (p < 0,05). Esta diferencia se mantuvo durante 60 min. No se identificaron cambios significativos en ninguna de las variables hemodinámicas estudiadas. Conclusión: En pacientes sometidos a cirugía laparoscópica de colon, la realización de una MRA intraoperatoria mejora la mecánica del sistema respiratorio y la oxigenación, sin apreciarse un compromiso hemodinámico asociado. El beneficio de estas maniobras se extiende al menos durante una hora.(AU)

Introduction: Pulmonary atelectasis is common in patients undergoing laparoscopic abdominal surgery under general anaesthesia, which increases the risk of perioperative respiratory complications. Alveolar recruitment manoeuvres (ARM) are used to open up the lung parenchyma with atelectasis, although the duration of their benefit has not been clearly established. The aim of this study was to determine the effectiveness of an ARM in laparoscopic colon surgery, the duration of response over time, and its haemodynamic impact. Methods: Twenty-five patients undergoing laparoscopic colon surgery were included. After anaesthetic induction and initiation of surgery with pneumoperitoneum, an ARM was performed, and then optimal PEEP determined. Respiratory mechanics and gas exchange variables, and haemodynamic parameters, were analysed before the manoeuvre and periodically over the following 90 minutes. Results: Three patients were excluded for surgical reasons. The alveolar arterial oxygen gradient went from 94.3 (62.3-117.8) mmHg before to 60.7 (29.6-91.0) mmHg after the manoeuvre (P < .05). This difference was maintained during the 90 minutes of the study. Dynamic compliance of the respiratory system went from 31.3 ml/cmH2O (26.1-39.2) before the manoeuvre to 46.1 ml/cmH2O (37.5-53.5) after the manoeuvre (P < .05). This difference was maintained for 60 minutes. No significant changes were identified in any of the haemodynamic variables studied. Conclusion: In patients undergoing laparoscopic colon surgery, performing an intraoperative ARM improves the mechanics of the respiratory system and oxygenation, without associated haemodynamic compromise. The benefit of these manoeuvres lasts for at least one hour.(AU)

Análisis retrospectivo de la anestesia regional en la cirugía de cadera: Auditoría clínica / Retrospective analysis of regional anaesthesia in hip surgery: A clinical audit

Introducción: La artroplastia total de cadera es una de las intervenciones quirúrgicas más frecuentes en el contexto hospitalario. Sin embargo, sigue desconociéndose el método ideal para manejar el dolor postoperatorio. Las técnicas de analgesia multimodal basadas en la anestesia regional se encuentran entre las soluciones más prometedoras. Objetivos: El objetivo de este estudio fue evaluar el dolor postoperatorio tras la artroplastia total de cadera, de acuerdo con si se realizaron, o no, bloqueos del nervio periférico (bloqueo femoral, bloqueo de la fascia iliaca y bloqueo del grupo de nervios pericapsulares). Se midió el consumo de morfina intravenosa durante la estancia del paciente en la unidad de cuidados posanestésicos, así como el número de rescates con opioides transcurridas 24 y 48 h de la intervención. Como objetivos secundarios, se establecieron la prevalencia de la lesión nerviosa, la prolongación del bloqueo cuadricipital y el consumo de morfina, de acuerdo con otras variables de interés. Materiales y métodos: En este estudio retrospectivo observacional, se recopilaron datos de la historia clínica digital de 656 pacientes de cirugía traumatológica de abril de 2018 a agosto de 2020, con los criterios de inclusión siguientes: mayores de 18 años, ASA I-III, artroplastia total de cadera primaria con anestesia general o anestesia subaracnoidea (solo con bupivacaína hiperbárica) y uso de levobupivacaína para el bloqueo del nervio periférico. Resultados: Se seleccionó un total de 362 pacientes. La indicación quirúrgica principal fue coxartrosis (61,3%), seguida de fractura de cadera (22,6%). Se realizaron bloqueos del nervio periférico en 169 pacientes (66,3% femoral, 27,7% PENG, y 6% de fascia ilíaca). El consumo medio postoperatorio de opioides en la UCPA fue inferior en los pacientes que recibieron bloqueo PENG (2,2 mg) o femoral (3,27 mg), en comparación con los que no recibieron ninguno de los dos (6,69 mg)...(AU)

Introduction: Total hip arthroplasty is one of the most frequent surgical interventions in the hospital setting. Nonetheless, the ideal method to manage post-operative pain is still unknown. Multimodal analgesia techniques based on regional anaesthesia are amongst the most promising solutions. Objectives: The aim of this study was to evaluate postoperative pain after total hip arthroplasty according to whether peripheral nerve block was performed (femoral block, fascia iliaca block and pericapsular nerve group block). Intravenous morphine consumption during the patient's stay in the post-anaesthesia care unit was measured, as well as the number of opioid rescues at 24 and 48h post intervention. As secondary objectives, the prevalence of nerve injury, prolonged quadricipital block, and morphine consumption were established according to other variables of interest. Materials and methods: In this observational retrospective study, data was collected from the electronic medical record of 656 traumatological surgery patients from April 2018 to August 2020, with the following inclusion criteria: over 18 years old, ASA I-III, primary total hip arthroplasty under general anaesthesia or subarachnoid anaesthesia (only with hyperbaric bupivacaine) and use of levobupivacaine for peripheral nerve block. Results: A total of 362 patients were selected. The main surgical indication was coxarthrosis (61.3%), followed by hip fracture (22.6%). Peripheral nerve blocks were performed on 169 patients (66.3% femoral, 27.7% PENG, and 6.0% fascia iliaca). Mean postoperative opioid consumption in PACU was lower in patients in who received a PENG (2.2 mg) or a femoral (3.27 mg) block, compared to those who received neither (6.69 mg). There were no differences in opioid rescues at 24 and 48h after the procedure...(AU)

Guía de la Sociedad Española De Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), Sociedad Española de Medicina de Urgencias y Emergencias (SEMES) y Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello (SEORL-CCC) para el manejo de la vía aérea difícil. Parte I / Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR) Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part I

La sección de Vía Aérea de la Sociedad Española De Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES) y la Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello (SEORL-CCC) presentan la Guía para el manejo integral de la vía aérea difícil en el paciente adulto. Sus principios están focalizados en el factor humano, los procesos cognitivos para la toma de decisiones en situaciones críticas y la optimización en la progresión de la aplicación de estrategias para preservar una adecuada oxigenación alveolar con el objeto de mejorar la seguridad y la calidad asistencial. El documento proporciona recomendaciones basadas en la evidencia científica actual, herramientas teórico/educativas y herramientas de implementación, fundamentalmente ayudas cognitivas, aplicables al tratamiento de la vía aérea en el campo de la anestesiología, cuidados críticos, urgencias y medicina prehospitalaria. Para ello se realizó una amplia búsqueda bibliográfica según las directrices PRISMA-R y se analizó utilizando la metodología GRADE. Las recomendaciones se formularon de acuerdo con esta metodología. Las recomendaciones de aquellas secciones con evidencia de baja calidad se basaron en la opinión de expertos mediante consenso alcanzado a través de un cuestionario Delphi.(AU)

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factor, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.(AU)

Guía de la Sociedad Española De Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), Sociedad Española de Medicina de Urgencias y Emergencias (SEMES) y Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello (SEORL-CCC) para el manejo de la vía aérea difícil. Parte II / Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR) Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part II

La sección de Vía Aérea de la Sociedad Española De Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES) y la Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello (SEORL-CCC) presentan la Guía para el manejo integral de la vía aérea difícil en el paciente adulto. Sus principios están focalizados en el factor humano, los procesos cognitivos para la toma de decisiones en situaciones críticas y la optimización en la progresión de la aplicación de estrategias para preservar una adecuada oxigenación alveolar con el objeto de mejorar la seguridad y la calidad asistencial. El documento proporciona recomendaciones basadas en la evidencia científica actual, herramientas teórico/educativas y herramientas de implementación, fundamentalmente ayudas cognitivas, aplicables al tratamiento de la vía aérea en el campo de la anestesiología, cuidados críticos, urgencias y medicina prehospitalaria. Para ello se realizó una amplia búsqueda bibliográfica según las directrices PRISMA-R y se analizó utilizando la metodología GRADE. Las recomendaciones se formularon de acuerdo con esta metodología. Las recomendaciones de aquellas secciones con evidencia de baja calidad se basaron en la opinión de expertos mediante consenso alcanzado a través de un cuestionario Delphi.(AU)

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factor, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.(AU)

La adición de midazolam intratecal al anestésico local mejora los bloqueos sensorial y motor y reduce la puntuación del dolor sin incrementar los efectos secundarios en la cirugía de miembros inferiores. Metaanálisis y revisión sistemática / Adding intrathecal midazolam to local anesthetics improves sensory and motor block and reduces pain score without increasing side effects in lower limb surgeries: A meta-analysis and systematic review

Este metaanálisis investiga el impacto de midazolam intratecal en la anestesia espinal, el control del dolor postoperatorio y los efectos secundarios relacionados con la anestesia en la cirugía de miembros inferiores. Realizamos una búsqueda en Medline, Science Direct, Google Scholar y Cochrane Library de los estudios que reportaron el inicio y la duración de los bloqueos sensorial y motor, el tiempo transcurrido hasta la primera solicitud de analgesia, el consumo de opioides durante 24h, el control del dolor postoperatorio y los efectos secundarios tras la administración de midazolam intratecal en pacientes sometidos a cirugía de miembros inferiores. Se identificaron 10 estudios, que se incluyeron en el metaanálisis. La revisión fue realizada siguiendo las directrices PRISMA, registrándose en la base de datos PROSPERO (ID-CRD42022346361) en agosto de 2022. Nuestros resultados muestran que los pacientes que reciben 1mg de midazolam intratecal reflejaron un tiempo de inicio de bloqueo significativamente más alto (p=0,001 [IC: −0,98, −0,31]), mayor duración de los bloqueos sensorial y motor (p<0,00001 [IC: 18,08, 39,12]; p=0,002 [IC: 0,45, 2]), y mayor tiempo transcurrido hasta la primera solicitud de analgesia de rescate (p=0,0003 [IC: 1,22, 4,14]). Las puntuaciones de dolor a las 4 y 12h postoperatorias fueron significativamente inferiores en los pacientes que recibieron midazolam intratecal (p=0,00001 [: −1,20, −0,47] y p=0,05 [IC: −0,52, −0,01] respectivamente). En conclusión, la adición de midazolam intratecal al anestésico local en la cirugía de miembros inferiores acorta el tiempo de inicio de los bloqueos sensorial y motor, incrementa la duración del bloqueo y prolonga el tiempo transcurrido hasta la primera solicitud de analgesia. Las puntuaciones del dolor a las 4 y 12horas postoperatorias fueron menores, no observándose efectos secundarios adicionales.(AU)

This meta-analysis was done to investigate the role of intrathecal midazolam in lower limb surgeries regarding prolongation of spinal block, postoperative pain control and associated side effects. The included studies reported onset and duration of sensory and motor block, time to first request analgesia, 24hours opioid consumption, postoperative pain control, and associated side effects following use of intrathecal midazolam for lower limb surgeries. This review was performed following the PRISMA guidelines and using the online databases, Medline, Science Direct, Google scholar and Cochrane library. We registered this review with the PROSPERO database (ID-CRD42022346361) in August 2022. A total of 10 randomised controlled trials were included in this meta-analysis. Our results showed patients receiving 1mg intrathecal midazolam showed significantly faster onset of sensory block (P=.001 [CI: −0.98, −0.31]). Duration of sensory and motor block were also significantly prolonged in intrathecal midazolam group (P<.00001 [CI: 18.08, 39.12], P=.002 [CI: 0.45, 2]). Intrathecal midazolam also increased the time to first request analgesia (P=.0003 [CI: 1.22, 4.14]). Pain scores at 4 and 12hours postoperatively were significantly lower in patients receiving intrathecal midazolam (P=.00001[CI: −1.20, −0.47] and P=0.05 [CI: −0.52, −0.01] respectively). In conclusion, the addition of intrathecal midazolam to local anesthetics in lower limb surgeries results in early onset of sensory and motor block. It also increases the duration of sensory and motor block. The time to first request analgesia is increased. VAS pain scores at 4 and 12hours postoperatively were also lower without any increased side effects.(AU)

Trombo en tránsito izquierdo intraoperatorio en trasplante bipulmonar diagnosticado por ecocardiografía transesofágica: ¿qué es lo siguiente? / Left side clot in transit in double-lung transplantation diagnosticated by transesophageal echocardiography: What's next?

Un varón de 61 años sin predisposición trombótica es sometido a trasplante bipulmonar como último tratamiento para su EPOC terminal sin soporte de ECMO. Tras el implante y la reperfusión de ambos pulmones, se realizó un examen ecocardiográfico transesofágico completo para comprobar principalmente las anastomosis de las venas pulmonares. En este estudio se identificó una gran masa móvil, hiperecogénica, densa y heterogénea en la aurícula izquierda, compatible con un trombo en tránsito desde la circulación venosa pulmonar. Este hallazgo fue comunicado al equipo quirúrgico inmediatamente para reabrir la anastomosis y retirar el coágulo antes de mayores consecuencias. No hubo manifestaciones clínicas cuando se despertó al paciente.(AU)

61-year-old man without any thrombotic predisposition was undergone double sequential lung transplantation due to terminal stage of COPD without extracorporeal membrane oxygenation (ECMO) support. After implantation and reperfusion of both lungs, a complete transoesophageal echocardiography exam was performed to check especially the pulmonary venous anastomosis. In this exam, a large heterogenous, dense, hyperechoic mobile mass was identified in the LA, which was compatible with a thrombus in transit from pulmonary veins circulation. This finding was communicated to the surgical team to reopen the anastomosis and remove the clot before further consequences. There were no clinical manifestations when the patient was awakened.(AU)

Edema agudo de pulmón secundario a síndrome de absorción intravascular durante histeroscopia: a propósito de un caso / Acute pulmonary edema secondary to intravascular absorption syndrome during hysteroscopy: A case report

La histeroscopia es un procedimiento endoscópico que estudia el interior de la cavidad uterina y del canal endocervical con objetivo diagnóstico-terapéutico. Para obtener una visualización óptima de las estructuras se utilizan diversos fluidos como el suero salino fisiológico. Una complicación poco frecuente es la sobredosificación de volumen, lo cual puede asociarse a un síndrome de absorción intravascular tras histeroscopia, normalmente tras procedimientos largos o disección de tejidos. Respecto de este síndrome, no se disponen datos de incidencia y prevalencia, existiendo pocos casos reportados en relación a solución salina fisiológica. Se presenta el caso de una paciente sometida a resección miomatosa, que, como consecuencia del síndrome de absorción vascular, dio lugar a edema agudo de pulmón que requirió ingreso en la Unidad de Cuidados Intensivos.(AU)

Hysteroscopy is an exploratory endoscopic technique that studies the interior of the uterine cavity and the endocervical canal. Various fluids, such as physiological saline, are used to optimise visualisation of the internal structures during this procedure. A rare complication of hysteroscopy is fluid overload, which can be associated with intravascular absorption syndrome, usually after lengthy procedures or tissue dissection. There are no data on the incidence and prevalence of this syndrome, and few cases involving physiological saline solution have been reported. We present a case of hysteroscopic myomectomy complicated by vascular absorption syndrome, which gave rise to acute pulmonary oedema that required admission to the intensive care unit.(AU)

Anesthesia decision analysis using a cloud-based big data platform.

Big data technologies have proliferated since the dawn of the cloud-computing era. Traditional data storage, extraction, transformation, and analysis technologies have thus become unsuitable for the large volume, diversity, high processing speed, and low value density of big data in medical strategies, which require the development of novel big data application technologies. In this regard, we investigated the most recent big data platform breakthroughs in anesthesiology and designed an anesthesia decision model based on a cloud system for storing and analyzing massive amounts of data from anesthetic records. The presented Anesthesia Decision Analysis Platform performs distributed computing on medical records via several programming tools, and provides services such as keyword search, data filtering, and basic statistics to reduce inaccurate and subjective judgments by decision-makers. Importantly, it can potentially to improve anesthetic strategy and create individualized anesthesia decisions, lowering the likelihood of perioperative complications.