Multidisciplinary consensus document on the management of massive haemorrhage (HEMOMAS document).

Massive haemorrhage is common and often associated with high morbidity and mortality. We perform a systematic review of the literature, with extraction of the recommendations from the existing evidences because of the need for its improvement and the management standardization. From the results we found, we wrote a multidisciplinary consensus document. We begin with the agreement in the definitions of massive haemorrhage and massive transfusion, and we do structured recommendations on their general management (clinical assessment of bleeding, hypothermia management, fluid therapy, hypotensive resuscitation and damage control surgery), blood volume monitoring, blood products transfusion (red blood cells, fresh frozen plasma, platelets and their best transfusion ratio), and administration of hemostatic components (prothrombin complex, fibrinogen, factor VIIa, antifibrinolytic agents).

[Prevention, diagnosis and treatment of bleeding in cardiac surgery]. / Prevención, diagnóstico y tratamiento de la hemorragia en cirugía cardiaca.

Patients undergoing cardiac surgery are at high risk of bleeding and transfusion. This risk has increased in recent years and is associated with increased morbidity and mortality. Moreover, despite being one of the most common complications associated with this surgery, there remains a large variability in its management between institutions. Implementation of algorithms for coagulation management has been shown to reduce transfusion requirements and therefore it seems essential to establish protocols that include preventive measures, effective mechanisms for diagnosis and treatment algorithms. On the other hand, the emergence of new drugs and the use of point of care coagulation monitoring systems, is changing our diagnostic and therapeutic options. This paper reviews several aspects related to the causes, diagnosis and treatment of bleeding associated with cardiac surgery and presents an algorithm for its management.

Incidence and predictors of major perioperative adverse cardiac and cerebrovascular events in non-cardiac surgery.

BACKGROUND: Major adverse cardiac and cerebrovascular events (MACCE) represent the most common cause of serious perioperative morbidity and mortality. Our aim was to identify risk factors for MACCE in a broad surgical population with intermediate-to-high surgery-specific risk and to build and validate a model to predict the risk of MACCE. METHODS: A prospective, multicentre study of patients undergoing surgical procedures under general or regional anaesthesia in 23 hospitals. The main outcome was the occurrence of at least one perioperative MACCE, defined as any of the following complications from admittance to discharge: cardiac death, cerebrovascular death, non-fatal cardiac arrest, acute myocardial infarction, congestive heart failure, new cardiac arrhythmia, angina, or stroke. The MACCE predictive index was based on ß-coefficients and validated in an external data set. RESULTS: Of 3387 patients recruited, 146 (4.3%) developed at least one MACCE. The regression model identified seven independent risk factors for MACCE: history of coronary artery disease, history of chronic congestive heart failure, chronic kidney disease, history of cerebrovascular disease, preoperative abnormal ECG, intraoperative hypotension, and blood transfusion. The area under the receiver-operating characteristic curve was 75.9% (95% confidence interval, 71.2-80.6%). CONCLUSIONS: The risk score based on seven objective and easily assessed factors can accurately predict MACCE occurrence after non-cardiac surgery in a population at intermediate-to-high surgery-specific risk.

[Repercussions and management of perioperative hyperglycemia in cardiac surgery]. / Repercusiones y manejo de la hiperglucemia peroperatoria en cirugía cardiaca.

Surgery produces a neuroendocrine stress response that affects resistance to insulin, reduces insulin secretion, and increases the release of glucose from the liver. This situation can trigger hyperglycemia in both diabetics and nondiabetics. Hyperglycemia has been linked to an increase in the morbidity and mortality among patients who undergo cardiac surgery, and the benefits of correcting hyperglycemia in this setting by means of intensive insulin therapy are well documented. This review discusses various aspects of hyperglycemia, particularly the evidence supporting stricter control of this condition in patients undergoing cardiac surgery. Furthermore, based on the available data and recommendations, and our clinical experience, we suggest therapeutic strategies to improve the control of hyperglycemia in these patients.

Validation of the index of consciousness during sevoflurane and remifentanil anaesthesia: a comparison with the bispectral index and the cerebral state index.

BACKGROUND: The purpose of this study was to validate a new level of consciousness monitor derived from the EEG, called the index of consciousness (IoC), by comparing it with the bispectral index (BIS) and the cerebral state index (CSI) during general anaesthesia for cardiac surgery using sevoflurane, remifentanil, and atracurium. METHODS: After ethical committee approval and written patient consent, data from 35 patients [31 males, four females, age 55 (10) yr] were recorded during general anaesthesia for elective cardiac bypass surgery. All patients were induced with sevoflurane 8%, until the Observer's Assessment of Alertness and Sedation (OAAS) scale level 1 was reached, and then was set at a 1% end-tidal sevoflurane concentration. Subsequently, remifentanil and atracurium were administered, the trachea was intubated, and the procedure continued as usual. To assess accuracy, the prediction probability (Pk) was calculated both during induction and during maintenance. RESULTS: The Pk values [mean (se)] for IoC, BIS, and CSI during induction were 0.90 (0.01), 0.90 (0.01), and 0.88 (0.01), respectively, whereas the corresponding Pk values during maintenance were 0.95 (0.01), 0.94 (0.01), and 0.60 (0.01). CONCLUSIONS: The three indices performed equally well during the induction phase and were able to predict the level of consciousness of the patients satisfactorily. During maintenance, the IoC and the BIS showed good agreement with the clinical signs. The CSI was significantly influenced by the administration of atracurium; therefore, the agreement with the OAAS scale during the maintenance phase was significantly less for CSI than for IoC and BIS.

[Multidisciplinary consensus document on the management of massive haemorrhage (HEMOMAS document)]. / Documento multidisciplinar de consenso sobre elmanejo de la hemorragia masiva (document HEMOMAS)

Massive haemorrhage is common and often associated with high morbidity and mortality. We perform a systematic review of the literature, with extraction of the recommendations from the existing evidences because of the need for its improvement and the management standardization. From the results we found, we wrote a multidisciplinary consensus document. We begin with the agreement in the definitions of massive haemorrhage and massive transfusion, and we do structured recommendations on their general management (clinical assessment of bleeding, hypothermia management, fluid therapy, hypotensive resuscitation and damage control surgery), blood volume monitoring, blood products transfusion (red blood cells, fresh frozen plasma, platelets and their best transfusion ratio), and administration of hemostatic components (prothrombin complex, fibrinogen, factor VIIa, antifibrinolytic agents).

Impaired executive functioning influences verbal memory in anorexia nervosa.

BACKGROUND: How executive functioning affects delayed verbal recall in AN has never been tested. We investigated the influence of speed of information processing (SIP) and inhibition on delayed verbal recall in females with AN. METHODS: Measures of SIP and inhibition from 35 females with AN were analyzed using hierarchical multiple regression after controlling for age, depressive symptomatology and body mass index. Each predictor was evaluated using structure coefficients, common variance and dominance weights. RESULTS: The combination of measures of SIP and inhibition accounted for almost 80% of the variance on the delayed recall of the story recall task. When the rest of the variables were partialled out, SIP and inhibition accounted for more than 50% of the variance. CONCLUSIONS: As it occurs with visuospatial abilities in AN, basic cognitive abilities such as speed of information processing and cognitive inhibition may affect other cognitive functions such as delayed verbal memory regardless of immediate recall. These findings may help interpret performance on cognitive tests in future research.

Successful management of pleuritic pain with thoracic paravertebral block.

BACKGROUND AND OBJECTIVES: Thoracic paravertebral block (TPVB) is a unilateral analgesic technique that has been advocated in both acute and chronic thoracic and abdominal pain. Other blocks such as interpleural and epidural can be effectively used in pleuritic pain. This report illustrates that TPVB could also be effective for this kind of pain. METHODS: A 45-year-old man with acute pancreatitis was referred to the critical care unit 11 days after emergency admission with severe left pleural effusion and acute respiratory failure. His medical history revealed hypertension and chronic obstructive pulmonary disease (COPD); in addition, he was a heavy drinker and smoker. A pleuritic pain that only slightly improved with nonopioid analgesics and opioids resulted in the patient's increasing inability to eliminate bronchial secretions. In an attempt to avoid endotracheal intubation, the pain unit recommended a continuous paravertebral block. The block was performed at T9 on the left side. An initial bolus of 15 mL bupivacaine 0.25% was administered and a continuous infusion, initially at 5 mL/h, was increased up to 10 mL/h to achieve the desired analgesic effect. RESULTS: After the block the verbal analogue scale decreased from 9 to 3, and this level of pain relief was maintained until the end of the treatment 48 hours after the block. The patient improved and was discharged to the ward without the need for endotracheal intubation. CONCLUSIONS: This case report supports the notion that, in practice, the paravertebral block could be an effective and safe alternative to relief of pleuritic pain.

[Transitional carcinomas of the urinary tract: synchronous and metachronous lesions]. / Carcinomas transicionales del tracto urinario: lesiones sincrónicas y metacrónicas.

OBJECTIVE: The urothelium is a pseudostratified cylindrical epithelium that lines the calices, renal pelvis, urethers, bladder, part of the urethra and part of the prostate ducts. Transitional cell carcinoma (TCC) is a malignant neoplasia that can appear in any site where urothelium is present, being the bladder the most frequently affected organ. We performed an analysis of our experience and conducted a literature-based metanalysis to evaluate the coexistence of tumoral lesions at different locations in the urinary tract. MATERIAL AND METHODS: Between 1983 and 1993, 397 patients with TCC lesions involving the upper urinary tract (UUT), bladder, urethra or prostate, were diagnosed and treated. Coexistence, either synchronic or metachronic, of several lesions in different sites of the urinary tract was considered as a multiple tumor. RESULTS: Overall, 440 tumors were diagnosed in 397 patients. A single lesion appeared in 360 patients, while 37 presented multiple locations with a total of 79 tumors. The lesions were located at the following levels: 17 renal, 21 uretheral, 372 vesical, 13 in the urethra and 17 in the prostate ducts. According to the location, the frequency of single lesions was: UUT 58%, bladder 91%, urethra 8% and prostate ducts 35%. Synchronic UUT and intravesical tract tumors develops in 1% and 4% of patients with bladder TCC, respectively. Two percent of vesical tumors showed metachronic relationship with UUT tumors and the same rate was seen for intravesical lesions. CONCLUSIONS: Urothelial UUT tumors have a typical nosologic entity with specific features. Their coexistence with vesical tumors is frequent. When tumors of the bladder occur after a UUT tumor the interval of highest incidence between diagnoses is 2-3 years, and there are no histological risk factors among them for prognosis. Transitional cell prostatic urethral tumors are most often secondary to histologically similar, poor prognosis, bladder tumors, and usually synchronic.

[Pseudosarcomatous tumor of the bladder]. / Tumor seudosarcomatoso de vejiga.

Pseudosarcomatous tumour of the bladder is a benign neoforming process of uncommon occurrence, consisting in a fibroblastic proliferation originated in the vesical wall and the perivesical fat, with unknown etiology, that given its cellular pleomorphism and the infiltrative nature of the injury can be incorrectly diagnosed as a sarcoma. This paper presents one case of pseudosarcomatous tumour of the bladder in a 9 year-old child, with no history of local traumatism or previous surgery, consisting in a tumoration affecting the vesical wall associated with a significant perivesical fibrosis with extension towards the area of the iliac veasels. Microscopically, the injury shows proliferation of spindle cells, arranged in a myxoid stroma with a prominent vascular net. No cytologic atypia is demonstrated or increase in the number of mitosis. The immunohistochemical study shows features of myofibroblasts in the proliferant cell. A review of the literature is made on 40 cases of inflammatory pseudosarcoma, evaluating the clinical characteristics, morphologic findings and treatment involved, as well as the postoperative evolution of the patient.

[Descriptive epidemiology of bladder cancer in the health area 8 in Madrid. Retrospective study on 315 patients]. / Epidemiología descriptiva del cáncer vesical en el area sanitaria 8 de Madrid. Estudio retrospectivo sobre 315 pacientes.

The Madrid Health Care District No. 8 includes 19 town councils located in the South and West of the Autonomous Community. The actual population is 381,052 inhabitants with a floating population of 50,000 people. Currently, Mostoles Hospital is the Referral Health Centre of this district. Between 1983 and 1992, 315 patients received treatment for vesical cancer. Of them, 77% were primarily superficial and 23% infiltrant. 98% were transitional carcinomas. Patient's mean age was 65.9 years, with 83.5% men and 15.5% women. Incidence obtained was 14 x 10(5) inhabitants (23.5 men and 4.6 women). Smoking was the only risk factor statistically significant. Prevalence was 39.3 x 10(5). Actual mortality rate obtained for vesical cancer was 1.3 x 10(5). Comparison of our overall data with national and international statistics show extended consistence except for the mortality rate which was lower than the data consulted.

[Epithelial tumors of the upper urinary tract]. / Tumores epiteliales del tracto urinario superior.

The paper refers to thirteen patients with epithelial tumours of the upper urinary tract, diagnosed and treated at our unit during the last five years and emphasizes the need of early diagnosis, custumorized therapy and close follow-up. Evolution is clearly more favourable in well differentiated and low stage tumours, regardless the type of surgery performed, versus the poor results obtained in infiltrative and undifferentiated cases for which there is no effective treatment available. Results are analyzed based on a brief literature review and considering the short number of cases contributed.

[Orchiectomy and buserelin in combination with flutamide: comparative results in metastatic prostatic carcinoma]. / Orquiectomía y buserelin asociados a flutamida: resultados comparativos en el carcinoma prostático metastásico.

In a prospective, non-randomized study in 44 patients with metastatic prostate carcinoma (D2), without previous hormone therapy, two alternative therapeutic courses to achieve complete androgenic blockade were compared. A first group (n = 29) was assigned to received Flutamide plus Buserelin, whereas the second group (n = 15) underwent orchidectomy, also in association to Flutamide. Both regimes were sustained without interruption, except when progression was evident, and both achieved castration levels of testosterone plasma titres. Mean follow-up duration was 13 months and 7 days, ranging between 2 and 36 months. There were no significant differences between both groups with regard to therapy objective responses and survival. Whereas the responses (CR + PR + E) were 93% in the LHRH analogues group and 86% in the orchidectomy group, overall survival was 66% and 67%, respectively. There were no secondary complications related to the surgical procedure nor adverse effects to drug therapy which required its cessation.

[Scrotal suspension with hypogastric suture. Hemostatic technique in intrascrotal surgery]. / Suspensión del escroto con sutura a hipogastrio. Técnica hemostática en la cirugía intraescrotal.

Appearance of haemorrhages and bruises after surgery of scrotal bags contents is one of the most frequent complications in Urology. Presentation of results obtained in a prospective study carried out on 86 patients who had underwent surgery due to intrascrotal disease. In all of them and regardless of the approach used (inguinal or scrotal), suspension of bags to hypogastrium using suture traction was performed by Oesterling technique in combination to Joseph and O'Boyle's technique. Drainage was not used in any case. The article explains the characteristics of undergoing pathologies' surgical indications, describing both the technique used and the results obtained. It concludes by stating this is a useful method to prevent routine complications in scrotal surgery.

[Renal cholesteatoma: keratin accumulation tumor]. / Colesteatoma renal: tumor por acúmulo de queratina.

Presentation of 6 cases of renal cholesteatoma in 4 male and 2 female patients ranging between 30 and 67 years of age. The most consistent clinical data was a history of relapsing nephritic colic of long-evolution. The average time to diagnose was 19 years. In 50% cases an association to malignant neoplastic pathology was found. The clinical diagnosis was based on the urography and the histopathological examination of the material passed with the urine. Renal exeresis was performed in 5 cases. One was treated in a conservative fashion. Also the etiology causes, diagnostic procedure and other therapeutic possibilities were reviewed.

[Diagnosis and treatment with ureterorenoscopy of ureteral obstruction caused by papillary necrosis]. / Diagnóstico y tratamiento mediante ureterorrenoscopia de la obstrucción ureteral por papila necrosada.

Increasing use of endourological procedures to establish a diagnosis of pyeloureteral lesions detected as a repletion deficiency during urographic study, which when they are obstructive, affect the upper urinary tract. The present report describes the use of ureterorenoscopy as a diagnostic and therapeutic procedure for the ureteral obstruction occurring in a patient with papillary necrosis secondary to analgesics abuse. The papilla was indwelt in the right distal ureter causing obstruction and symptoms of renal colic and septicemia.

[Renal fungal infection: presentation forms and therapeutic advances]. / Infeccion fúngica renal: formas de presentación y avances terapéuticos.

Fluconazole is a broad spectrum anti-fungal agent which combines good tolerance, efficacy and low toxicity, and offers useful advantages in the treatment of certain forms of mycosis. Three cases of renal fungal disease treated with surgery (nephrectomy in two cases and pyelolitectomy plus partial nephrectomy in the third one) and fluconazole or amphotericin B are presented. In all three cases there was at least one predisposing factor (diabetes, urolithiasis, urinary catheter, previous therapy with antibiotics, or AIDS), and the causing pathogens were Candida and Mucor. Administration of fluconazole 100 mg b.i.d. for 4 weeks in the two candida infected patients accomplished a complete cure of the disease. Incidence, etiopathology, presentation forms and diagnostic techniques of urinary mycosis are analyzed together with the current therapeutical options, making special reference to fluconazole.