Sistema de monitorización de Temperatura 3MTM Bair HuggerTM / 3MTM Bair HuggerTM Temperature Monitoring System

La hipotermia perioperatoria inadvertida sigue siendo un problema clínico de alta incidencia asociado a graves complicaciones. La monitorización de la temperatura central en el proceso perioperatorio es recomendada por las guías clínicas nacionales e internacionales con un nivel de evidencia elevado. El sistema de monitorización de temperatura 3M™ Bair Hugger™ surge como respuesta a una necesidad clínica, innovando al medir de manera directa, precisa y no invasiva la evolución de la temperatura central del paciente. Las características de este dispositivo lo sitúan como una gran opción para monitorizar la hipotermia perioperatoria de una manera sencilla y cómoda para el paciente, evitando las complicaciones y sus costes hospitalarios derivados. (AU)

Inadvertent perioperative hypothermia remains a clinical problem of high incidence associated with serious complications. The core temperature monitoring in the perioperative process is recommended by national and international clinical guidelines with a high level of evidence. The 3M™ Bair Hugger™ Temperature Monitoring System arises in response to a clinical need, innovating by measuring in a direct, precise and non-invasive way the evolution of the patient’s core temperature. This device characteristics place it as a great option to control perioperative hypothermia in a simple and comfortable way for the patient, avoiding complications and it´s hospital costs. (AU)

Critical Care Management of Surgical Patients with Heart Failure or Left Ventricular Assist Devices: A Brief Overview.

Patients with heart failure, including those with implanted left ventricular assist devices, continue to increase in number. When they require noncardiac surgery, cardiac critical care expertise may not be immediately available to assist. This review serves to provide surgeons and surgical intensivists with a brief overview of the management of this patient population and common clinical scenarios and complications.

Perioperative changes of response to antiplatelet medication in vascular surgery patients.

INTRODUCTION: Reduced antiplatelet activity of aspirin (ALR) or clopidogrel (CLR) is associated with an increased risk of thromboembolic events. The reported prevalence data for low-responders vary widely and there have been few investigations in vascular surgery patients even though they are at high risk for thromb-embolic complications. The aim of this prospective observational monocentric study was to elucidate possible changes in ALR or CLR after common vascular procedures. METHODS: Activity of aspirin and clopidogrel was measured by impedance aggregometry using a multiple electrode aggregometer (Multiplate®). Possible risk factors for ALR or CLR were identified by demographical, clinical data and laboratory parameters. In addition, a follow-up aggregometry was performed after completion of the vascular procedure to identify changes in antiplatelet response. RESULTS: A total of 176 patients taking antiplatelet medications aspirin and/or clopidogrel with peripheral artery disease (PAD) and/or carotid stenosis (CS) were included in the study. The prevalence of ALR was 13.1% and the prevalence of CLR was 32% in the aggregometry before vascular treatment. Potential risk factors identified in the aspirin group were concomitant insulin medication (p = 0.0006) and elevated C-reactive protein (CRP) (p = 0.0021). The overall ALR increased significantly postoperatively to 27.5% (p = 0.0006); however, there was no significant change in CLR that was detected. In a subgroup analysis elevation of the platelet count was associated with a post-procedure increase of ALR incidence. CONCLUSION: The incidence of ALR in vascular surgery patients increases after vascular procedures. An elevated platelet count was detected as a risk factor. Further studies are necessary to analyse this potential influence on patency rates of vascular reconstructions.

Intraoperative Electronic Alerts Improve Compliance With National Quality Program Measure for Perioperative Temperature Management.

BACKGROUND: Reimbursement for anesthesia services has been shifting from a fee-for-service model to a value-based model that ties payment to quality metrics. The Centers for Medicare & Medicaid Service's (CMS) value-based payment program includes a quality measure for perioperative temperature management (Measure #424, Perioperative Temperature Management). Compliance may impose new challenges in clinical practice, data collection, and reporting. We investigated the impact of an electronic decision-support tool on adherence to this emerging standard. METHODS: In this retrospective observational study, perioperative temperature data were collected from cases eligible for reporting this measure to CMS from a single academic medical center before and after the implementation of an electronic decision-support tool that prompted temperature measurement and maintenance of normothermia. Proportions of measure compliance were assessed using segmented regression analysis. Proportions of intraoperative temperature measurement were also assessed, and multivariable logistic regression was performed to assess the association between patient and surgical factors and measure compliance. RESULTS: A total of 24,755 cases eligible for reporting in 2017 were assessed, and 25,274 cases from 2016 were included as an extended baseline. Segmented time-series regression did not show a significant baseline trend in measure compliance. Introduction of the alerts was associated with an increase in overall compliance from 84.4% (95% confidence interval [CI], 83.6%-85.2%) to 92.4% (91.4%-93.4%), and an increase in intraoperative compliance from 26.8% (25.8%-27.8%) to 71.0% (69.6%-72.4%). The association between the alerts and overall compliance was also present on multivariable analysis. CONCLUSIONS: Implementation of an intraoperative decision-support tool was associated with statistically significant improvement in the maintenance of normothermia in cases eligible for reporting to CMS. This led to improved compliance with Measure #424 and suggests that electronic alerts can help practices improve their performance and payment bonus eligibility.

Perioperative Point of Care Ultrasound (POCUS) for Anesthesiologists: an Overview.

PURPOSE OF REVIEW: Point of care ultrasound (POCUS) has played a role across almost every medical specialty. Although anesthesiologists have been using bedside ultrasound for nerve blocks and vascular access for many years now, there has been a recent push to incorporate whole-body POCUS into anesthesiologists' training and daily practice. This article provides a brief overview of the indications, techniques for image acquisition, and general principles in interpreting basic images. RECENT FINDINGS: Whole-body POCUS can provide quick diagnoses and impact clinical management across relevant pre-, intra-, and post-operative settings. Anesthesia providers need to understand different applications for POCUS, including focused cardiac ultrasound (FoCUS), lung ultrasound (LUS), gastric ultrasound, abdominopelvic ultrasound, and the use of ultrasound for airway management. Currently, there is no standard ultrasound curriculum for anesthesiology residents, and teaching methods include informal bedside teaching, structured expert demonstration, didactic lectures, and simulations. Model/simulation-based lecture series may be effective in teaching ultrasound to anesthesiology residents, and e-learning and traditional didactics are both equally effective in teaching POCUS applications such as LUS and focused assessment with sonography in trauma (FAST). Creating protocol-guided frameworks for POCUS, such as I-AIM (indication, acquisition, interpretation, medical decision making), can also ensure more consistent and reliable diagnoses and interpretations of findings. Applications of POCUS should be focused, goal-oriented, easily learned, rapidly performable at bedside, accurate, and reliable. A variety of studies have shown this potential for POCUS in assessing cardiac, pulmonary, and intraabdominal pathologies, making it an emerging area of interest in medicine. The incorporation of POCUS into perioperative medicine provides an important tool to ensure continued improvement in coordinating care for patients in the perioperative period.

The initial U.S. experience with the Tempo active fixation temporary pacing lead in structural heart interventions.

OBJECTIVES: This multicenter retrospective study of the initial U.S. experience evaluated the safety and efficacy of temporary cardiac pacing with the Tempo® Temporary Pacing Lead. BACKGROUND: Despite increasing use of temporary cardiac pacing with the rapid growth of structural heart procedures, temporary pacing leads have not significantly improved. The Tempo lead is a new temporary pacing lead with a soft tip intended to minimize the risk of perforation and a novel active fixation mechanism designed to enhance lead stability. METHODS: Data from 269 consecutive structural heart procedures were collected. Outcomes included device safety (absence of clinically significant cardiac perforation, new pericardial effusion, or sustained ventricular arrhythmia) and efficacy (clinically acceptable pacing thresholds with successful pace capture throughout the index procedure). Postprocedure practices and sustained lead performance were also analyzed. RESULTS: The Tempo lead was successfully positioned in the right ventricle and achieved pacing in 264 of 269 patients (98.1%). Two patients (0.8%) experienced loss of pace capture. Procedural mean pace capture threshold (PCT) was 0.7 ± 0.8 mA. There were no clinically significant perforations, pericardial effusions, or sustained device-related arrhythmias. The Tempo lead was left in place postprocedure in 189 patients (71.6%) for mean duration of 43.3 ± 0.7 hr (range 2.5-221.3 hr) with final PCT of 0.84 ± 1.04 mA (n = 80). Of these patients, 84.1% mobilized out of bed with no lead dislodgment. CONCLUSION: The Tempo lead is safe and effective for temporary cardiac pacing for structural heart procedures, provides stable peri and postprocedural pacing and allows mobilization of patients who require temporary pacing leads.

Comparison of two point of care whole blood coagulation analysis devices and conventional coagulation tests as a predicting tool of perioperative bleeding in adult cardiac surgery-a pilot prospective observational study in Japan.

BACKGROUND: It is widely accepted that Point-of Care Test (PoCT) devices are useful in the detection of coagulopathies in situations of massive bleeding such as major cardiac surgery. These devices contribute to the reduction of blood transfusion. However, their implementation remains limited in Japan because of their cost and lack of health insurance support. STUDY DESIGN AND METHODS: Conventional coagulation tests and thromboelastography (TEG)/Sonoclot values were measured in 50 consecutive cardiac surgery cases. Clinical background information such as operative procedures was obtained from electronic medical records, and the theoretical perioperative total blood loss was calculated by measuring the hemoglobin content and total red blood cell transfusion volume. The correlation between perioperative total blood loss and the measured laboratory values or clinical parameters was evaluated by a multivariate linear regression analysis. The risk factors of the total amount of platelet transfusion and postoperative drain bleeding volume were similarly evaluated. RESULTS: No significant association between the estimated perioperative total blood loss (eTBL) and the laboratory measurements including conventional coagulation tests, TEG and Sonoclot was observed. On the other hand, postoperative drain bleeding volume was significantly associated with postoperative Sonoclot CR (p = 0.039) as well as preoperative use of oral anticoagulants and cell saver treated blood volume. Platelet transfusion amount was significantly associated with post-CBP PF and time to peak value of Sonoclot (p = 0.014 and 0.001, respectively). CONCLUSION: Sonoclot measurements may be useful to estimate the risks of postoperative bleeding and platelet transfusion in cardiac surgeries in Japan.

Perioperative blood pressure monitoring.

Arterial blood pressure monitoring is a major part of the decision-making process for every anesthetic. It is important to recognize the advantages, disadvantages, and limitations of available measurement modalities as well as have some understanding of the engineering principles on which these measurements are based. Oscillometry is by far the most common modality used but is limited by its intermittent nature and inaccuracy during hypotension and hypertension. Arterial catheterization is the gold standard for measuring blood pressure but is an invasive procedure that is expensive and not without risk of harm to the patient. Volume clamp and tonometric technologies are relatively new and allow for continuous noninvasive monitoring of the blood arterial waveform, but their accuracy when compared with oscillometry is not well described, and they have not been widely incorporated into standard practice. Additional research is needed to determine whether continuous noninvasive blood pressure monitors can improve outcomes.

Periprocedural Considerations for Patients with Gastric Electrical Stimulators.

OBJECTIVES: Gastric electrical stimulation (GES) is a technology that uses neurostimulation for the modulation of gastric activity. In clinical practice, the most commonly encountered form of GES is high frequency GES. GES devices are typically used for the treatment of refractory gastroparesis, although they have also been investigated for obesity management and the treatment of refractory gastroesophageal reflux disease. Just as many patients with chronic diseases require surgery, patients with an implanted GES device may encounter the need for periprocedural care. Therefore, the purpose of this review is to address the special needs of patients with an implanted GES device. MATERIALS AND METHODS: A systematic computerized search of the literature was performed to consolidate existing knowledge on GES management in the periprocedural setting. Duplicate results were eliminated, and results were further narrowed based on title and abstract. All articles with possible relevance were then reviewed in full. Manufacturer information including pamphlets and websites were also reviewed. RESULTS: A total of 1201 articles were identified for initial review, and 33 met inclusion criteria. CONCLUSIONS: Available data suggests GES is a technology with increasing prevalence. When patients with an implanted GES device present for periprocedural care, the anesthesia staff must consider the device when planning for the procedure. Topics addressed include general anesthetic considerations, nerve localization, radiation exposure, electrocautery, diathermy, emergency external defibrillation, and MRI compatibility.

Perioperative comparison of the agreement between a portable fingertip pulse oximeter v. a conventional bedside pulse oximeter in adult patients (COMFORT trial).

BACKGROUND: Low-cost, portable fingertip pulse oximeters are widely available to health professionals and the public. They are often not tested to International Organization for Standardization standards, or only undergo accuracy studies in healthy volunteers under ideal laboratory conditions. OBJECTIVES: To pragmatically evaluate the agreement between one such device and a conventional bedside pulse oximeter in a clinical setting, in patients with varied comorbidities and skin pigmentations. METHODS: A single-centre equipment comparison study was conducted. Simultaneous measurements were obtained in 220 patients with both a Contec CMS50D Fingertip Pulse Oximeter and a Nihon Kohden Life Scope MU-631 RK conventional bedside monitor. Peripheral oxygen saturations (SpO2) and pulse rates were documented, and patients' skin tone was recorded using the Fitzpatrick scale. Data were assessed using a Bland-Altman analysis with bias, precision and limits of agreement (LOA) calculated with 95% confidence intervals (CIs). A priori acceptability for LOA was determined to be 3%, in keeping with international standards. RESULTS: The mean difference (therefore bias) between the conventional and fingertip oximeters for all data was -0.55% (95% CI -0.73 - -0.36). Upper and lower limits of agreement were 2.16% (95% CI 1.84 - 2.47) and -3.25% (95% CI -3.56 - -2.94). Regression analysis demonstrated worsening agreement with decreasing SpO2. When samples were separated into 'normal' (SpO2≥93%) and 'hypoxaemic' (SpO2 <93%) groups, the normal range displayed acceptable agreement between the two oximeters (bias -0.20% with LOA 2.20 - -2.27), while the hypoxaemic group fell outside the study's a priori limits. Heart rate measurements had a mean difference of -0.43 bpm (LOA -5.61 - 4.76). The study was not powered to detect differences among the skin tones, but demonstrated no trend for this parameter to alter the SpO2measurements. CONCLUSIONS: During normoxia, portable fingertip pulse oximeters are reliable indicators of SpO2and pulse rates in patients with various comorbidities in a pragmatic clinical context. However, they display worsening agreement with conventional pulse oximeters during hypoxaemia. Skin tones do not appear to affect measurements adversely.

Efficacy of an artificial pancreas device for achieving tight perioperative glycemic control in living donor liver transplantation.

Intraoperative hyperglycemia during liver transplantation can induce infectious bacterial complications after surgery. The aim of this study was to evaluate the efficacy of the artificial endocrine pancreas in achieving perioperative blood glucose control and preventing infection in patients undergoing living donor liver transplantation (LDLT). We compared 14 patients with an artificial endocrine pancreas device to 14 patients who underwent glycemic control using the sliding scale method with respect to perioperative blood glucose level and postoperative infection. In this study, we aimed to control the perioperative glucose levels consecutively for 24 hours from the induction of anesthesia. The average blood glucose level in the artificial pancreas group was significantly lower than that in the sliding scale group (118 vs. 141 mg/dL, P < 0.05). The postoperative bacterial infection rate of the artificial pancreas group was significantly lower than that of the sliding scale group within one month after LDLT (35.7% vs. 78.6%, P < 0.05). Multiple regression analysis showed non-application of artificial endocrine pancreas as a significant risk factor of posttransplant infection. The artificial endocrine pancreas enabled the perioperative glucose level to be stably controlled without hypoglycemia. Artificial pancreas may reduce the incidence of postoperative infection after LDLT.

Extracorporeal Devices.

Extracorporeal liver support (ECLS) emerged from the need stabilize high-acuity liver failure patients with the highest risk of death. The goal is to optimize the hemodynamic, neurologic, and biochemical parameters in preparation for transplantation or to facilitate spontaneous recovery. Patients with acute liver failure and acute-on-chronic liver failure stand to benefit from these devices, especially because they have lost many of the primary functions of the liver, including detoxifying the blood of various endogenous and exogenous substances, manufacturing circulating proteins, secreting bile, and storing energy. Existing ECLS devices are designed to mimic some of these functions.

High flow nasal therapy in perioperative medicine: from operating room to general ward.

BACKGROUND: High flow nasal therapy (HFNT) is a technique in which humidified and heated gas is delivered to the airways through the nose via small nasal prongs at flows that are higher than the rates generally applied during conventional oxygen therapy. The delivered high flow rates combine mixtures of air and oxygen and enable different inspired oxygen fractions ranging from 0.21 to 1. HFNT is increasingly used in critically ill adult patients, especially hypoxemic patients in different clinical settings. MAIN BODY: Noninvasive ventilation delivers positive pressure (end-expiratory and inspiratory pressures or continuous positive airway pressure) via different external interfaces. In contrast, HFNT produces different physiological effects that are only partially linked to the generation of expiratory positive airway pressure. HFNT and noninvasive ventilation (NIV) are interesting non-invasive supports in perioperative medicine. HFNT exhibits some advantages compared to NIV because HFNT is easier to apply and requires a lower nursing workload. Tolerance of HFNT remains a matter of intense debate, and it may be related to selected parameters. Patients receiving HFNT and their respiratory patterns should be closely monitored to avoid delays in intubation despite correct oxygenation parameters. CONCLUSION: HFNT seems to be an interesting noninvasive support in perioperative medicine. The present review provides anesthesiologists with an overview of current evidence and practical advice on the application of HFNT in perioperative medicine in adult patients.

Perioperative management of obese patient.

PURPOSE OF REVIEW: The volume of bariatric and nonbariatric surgical procedures on obese patients is dramatically increasing worldwide over the past years. In this review, we discuss the physiopathlogy of respiratory function during anesthesia in obese patients, the stratification of perioperative risk to develop intraoperative and postoperative pulmonary complications, the optimization of airway management, and perioperative ventilation, including postoperative respiratory assistance. RECENT FINDINGS: Scores have been proposed to stratify the risk of surgical patients, some of which were specifically developed for obese patients. Most scores identify obstructive sleep apnea and elevated BMI as independent risk factors. Obese patients might be at risk of difficult intubation and mask ventilation, and also of developing postoperative pulmonary complications. Intraoperative ventilation settings affect clinical outcome, but the optimal ventilation strategy is still to be determined. Opioid-free regimens are being widely investigated. Postoperative monitoring and respiratory assistance are necessary in selected patients. Early mobilization and physiotherapy are mandatory. SUMMARY: Obese patients are at higher risk of perioperative complications, mainly associated with those related to the respiratory function. An appropriate preoperative evaluation, intraoperative management, and postoperative support and monitoring is essential to improve outcome and increase the safety of the surgical procedure.