A. Abad-Gurumeta

A systematic review of sugammadex vs neostigmine for reversal of neuromuscular blockade.

We reviewed systematically sugammadex vs neostigmine for reversing neuromuscular blockade. We included 17 randomised controlled trials with 1553 participants. Sugammadex reduced all signs of residual postoperative paralysis, relative risk (95% CI) 0.46 (0.29–0.71), p = 0.0004 and minor respiratory events, relative risk (95% CI) 0.51 (0.32–0.80), p = 0.0034. There was no difference in critical respiratory events, relative risk (95% CI) 0.13 (0.02–1.06), p = 0.06. Sugammadex reduced drug‐related side‐effects, relative risk (95% CI) 0.72 (0.54–0.95), p = 0.02. There was no difference in the rate of postoperative nausea or the rate of postoperative vomiting, relative risk (95% CI) 0.94 (0.79–1.13), p = 0.53, and 0.87 (0.65–1.17), p = 0.36 respectively.

Perioperative goal-directed hemodynamic therapy in noncardiac surgery: a systematic review and meta-analysis

STUDY OBJECTIVE Goal-directed fluid therapy (GDHT) has been proposed as a method to reduce complications and mortality. DESIGN Meta-analysis of the effects of perioperative GDHT in adult noncardiac surgery on mortality and postoperative complications was performed using the PRISMA methodology. A systematic search was performed in MEDLINE, PubMed, EMBASE, and the Cochrane Library (last update, October 2014). Inclusion criteria were as follows: randomized clinical trials (RCTs) in which perioperative GDHT was compared with conventional fluid management in noncardiac surgery. Exclusion criteria were as follows: trauma and pediatric surgery studies. End points were mortality and number of patients with complications. SETTING District general hospital. PATIENTS Thirty-nine RCTs were initially identified, with 8 fulfilling the inclusion criteria. Two RCTs were added by manual search, resulting in 10 RCTs in the final analysis, including 1527 patients. MEASUREMENTS Those studies that fulfilled the entry criteria were examined in full and subjected to quantifiable analysis, predefined subgroup analysis (stratified by supraphysiological or physiological hemodynamic goal and by time the intervention was carried out, perioperative or postoperative), and predefined sensitivity analysis. MAIN RESULTS A significant reduction was observed in mortality associated with GDHT compared with conventional fluid therapy (risk ratio, 0.63; 95% confidence interval, 0.42-0.94; P = .02). However, no differences were found in the number of patients with complications (risk ratio, 0.75; 95% confidence interval, 0.50-1.17; P = .21), and the sensitivity analysis did not confirm the results. CONCLUSIONS This meta-analysis, with its limitations, shows that the use of perioperative GDHT may reduce postoperative mortality, but it is unable to show a reduction in the number of patients with complications.

Perioperative Use of Clevidipine: A Systematic Review and Meta-Analysis

Background Clevidipine is an ultrashort-acting drug for rapid reduction of blood pressure by selectively acting on the L-type Ca2+ channels on arteriolar smooth muscle. The drug’s ultrashort action in reducing the blood pressure is due to its rapid hydrolysis by blood and extravascular tissue esterases, which does not depend on hepato-renal metabolism and excretion. An analysis of the perioperative management of blood pressure should be considered to compare with other intravenous antihypertensive agents. Methods Analyses of the available evidence in randomized clinical trials following the PRISMA methodology as well as clinical significance according to the GRADE system were conducted. Placebo versus other antihypertensive drugs studies were included. Statistical assessments were done using the X2 and I2 tests. Results Clevidipine was more effective in maintaining the blood pressure within pre-specified ranges compared with other antihypertensive drugs (MD, -17.87 CI 95%: -29.02 to -6.72; p = 0.02). The use of Clevidipine versus placebo and rescue antihypertensive intravenous drug showed a clear reduction in rates of treatment failure (RR 0.10; IC 95%; 0.05–0.18; p <0.0001). There was no difference in the incidence of adverse events compared with placebo (RR 1.47; 95% CI 0.89 to 2.43, p = 0.14) and with other antihypertensive drugs (RR 0.78, 95% CI 0.45 to 1.35; p = 0.37). In addition, there was no difference in the incidence of atrial fibrillation (AF) between clevidipine and control groups (RR 1.09, IC del 95%: 0.65 a 1.83; p = 0.73). Conclusions Clevidipine is an ultrafast-acting drug that is highly effective for management of perioperative arterial hypertension. It is devoid of adverse effects associated with the use of other IV antihypertensives. Its favorable pharmacodynamic and pharmacokinetic properties make clevidipine the drug of choice for the management of acute perioperative hypertension. It is important to emphasize the need for further studies with a larger number of patients to confirm these findings and increase the degree of evidence.

[Intraoperative goal directed hemodynamic therapy in noncardiac surgery: a systematic review and meta-analysis].

BACKGROUND The goal directed hemodynamic therapy is an approach focused on the use of cardiac output and related parameters as end-points for fluids and drugs to optimize tissue perfusion and oxygen delivery. Primary aim: To determine the effects of intraoperative goal directed hemodynamic therapy on postoperative complications rates. METHODS A meta-analysis was carried out of the effects of goal directed hemodynamic therapy in adult noncardiac surgery on postoperative complications and mortality using Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. A systematic search was performed in Medline PubMed, Embase, and the Cochrane Library (last update, October 2014). Inclusion criteria were randomized clinical trials in which intraoperative goal directed hemodynamic therapy was compared to conventional fluid management in noncardiac surgery. Exclusion criteria were trauma and pediatric surgery studies and that using pulmonary artery catheter. End-points were postoperative complications (primary) and mortality (secondary). Those studies that fulfilled the entry criteria were examined in full and subjected to quantifiable analysis, predefined subgroup analysis (stratified by type of monitor, therapy, and hemodynamic goal), and predefined sensitivity analysis. RESULTS 51 RCTs were initially identified, 24 fulfilling the inclusion criteria. 5 randomized clinical trials were added by manual search, resulting in 29 randomized clinical trials in the final analysis, including 2654 patients. A significant reduction in complications for goal directed hemodynamic therapy was observed (RR: 0.70, 95% CI: 0.62-0.79, p<0.001). No significant decrease in mortality was achieved (RR: 0.76, 95% CI: 0.45-1.28, p=0.30). Quality sensitive analyses confirmed the main overall results. CONCLUSIONS Intraoperative goal directed hemodynamic therapy with minimally invasive monitoring decreases postoperative complications in noncardiac surgery, although it was not able to show a significant decrease in mortality rate.

Effect of goal-directed haemodynamic therapy on postoperative complications in low–moderate risk surgical patients: a multicentre randomised controlled trial (FEDORA trial)

Background: The aim of this study was to evaluate postoperative complications in patients having major elective surgery using oesophageal Doppler monitor‐guided goal‐directed haemodynamic therapy (GDHT), in which administration of fluids, inotropes, and vasopressors was guided by stroke volume, mean arterial pressure, and cardiac index. Methods: The FEDORA trial was a prospective, multicentre, randomised, parallel‐group, controlled patient‐ and observer‐blind trial conducted in adults scheduled for major elective surgery. Randomization and allocation were carried out by a central computer system. In the control group, intraoperative fluids were given based on traditional principles. In the GDHT group, the intraoperative goals were to maintain a maximal stroke volume, with mean arterial pressure >70 mm Hg, and cardiac index ≥2.5 litres min−1 m−2. The primary outcome was percentage of patients with moderate or severe postoperative complications during the first 180 days after surgery. Results: In total, 450 patients were randomized to the GDHT group (n=224) or control group (n=226). Data from 420 subjects were analysed. There were significantly fewer with complications in the GDHT group (8.6% vs 16.6%, P=0.018). There were also fewer complications (acute kidney disease, pulmonary oedema, respiratory distress syndrome, wound infections, etc.), and length of hospital stay was shorter in the GDHT group. There was no significant difference in mortality between groups. Conclusions: Oesophageal Doppler monitor‐guided GDHT reduced postoperative complications and hospital length of stay in low–moderate risk patients undergoing intermediate risk surgery, with no difference in mortality at 180 days. Clinical trial registration: ISRCTN93543537.

Terapia hemodinâmica alvo‐dirigida no intraoperatório de cirurgia não cardíaca: revisão sistemática e meta‐análise

BACKGROUND The goal directed hemodynamic therapy is an approach focused on the use of cardiac output and related parameters as end-points for fluids and drugs to optimize tissue perfusion and oxygen delivery. Primary aim: To determine the effects of intraoperative goal directed hemodynamic therapy on postoperative complications rates. METHODS A meta-analysis was carried out of the effects of goal directed hemodynamic therapy in adult noncardiac surgery on postoperative complications and mortality using Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. A systematic search was performed in Medline PubMed, Embase, and the Cochrane Library (last update, October 2014). Inclusion criteria were randomized clinical trials in which intraoperative goal directed hemodynamic therapy was compared to conventional fluid management in noncardiac surgery. Exclusion criteria were trauma and pediatric surgery studies and that using pulmonary artery catheter. End-points were postoperative complications (primary) and mortality (secondary). Those studies that fulfilled the entry criteria were examined in full and subjected to quantifiable analysis, predefined subgroup analysis (stratified by type of monitor, therapy, and hemodynamic goal), and predefined sensitivity analysis. RESULTS 51 RCTs were initially identified, 24 fulfilling the inclusion criteria. 5 randomized clinical trials were added by manual search, resulting in 29 randomized clinical trials in the final analysis, including 2654 patients. A significant reduction in complications for goal directed hemodynamic therapy was observed (RR: 0.70, 95% CI: 0.62-0.79, p<0.001). No significant decrease in mortality was achieved (RR: 0.76, 95% CI: 0.45-1.28, p=0.30). Quality sensitive analyses confirmed the main overall results. CONCLUSIONS Intraoperative goal directed hemodynamic therapy with minimally invasive monitoring decreases postoperative complications in noncardiac surgery, although it was not able to show a significant decrease in mortality rate.

Use of Totaltrack VLM as a rescue device after failed ventilation and tracheal intubation with LMA Fastrach in emergent difficult airways

The inability to secure the airway is the leading cause of anesthesiarelated injury [1]. The failure of one technique increases the risk of failure of successive techniques, which raises the number of attempts and the risk of progression to a “cannot intubate, cannot oxygenate” situation (CICO). Therefore, limiting the number of interventions and achieving a timely nontraumatic endotracheal intubation (ETI) are the main goals in airway management [2,3]. Video laryngoscope, extraglottic airway devices and fiberoptic bronchoscopy (FOB) are the principal rescue techniques to secure the airway. However, no single airway instrument is perfect in all circumstances. We present the successful use of the Totaltrack VLM (TT, Medcomflow s.a., Barcelona, Spain) as a rescue device after failed ventilation and ETI with LMA Fastrach (LMA-Fastrach; LMA Nort America, Inc., San Diego, California) in two emergent difficult airways. The patients gave written informed consent for publication of this article. The first patient was a 73-yr-old, 90 kg male with oral anticoagulation required urgent posterior nasopharyngeal tamponade under general anesthesia due to uncontrollable epixtasis. Preoperative airway assessment included a Mallampati class II, a 4.2-cm interincisive distance, a 7.5-cm thyromental distance and Upper Lip Bite Test class II. Inhalational induction with preserved spontaneous ventilation was adopted. A direct laryngoscopy (LD) showed a Cormack-Lehane grade IV glottic view and presence of blood. After failed ETI with airtraq and LMA-Fastrach plus FB, TT allowed satisfactory ventilation (confirmation with capnography within 10 s), sealing off the periglottic área from blood. An adequate glottic view (POGO 100%) facilitated the ETI in 69.4 s. The procedure was carried out without incident resolving the bleeding. The second patient was a 73-yr-old, 101 kg male (Fig. 1, panel B and C). He required emergent ETI due to acute respiratory insufficiency and chronic renal disease reagudized with anasarca. The preinduction evaluation indicated a Mallampati class III, a 5-cm thyromental distance, thick neck and a sentinel tooth. The DL showed a Cormack Lehane 4 and airway edema. The TT allowed to establish a correct oxygenation at 11.3 s and ETI with the combined use of FB (after 67 s) after failed ventilation and ETI with LMA-Fastrach. Mechanical ventilation and renal replacement therapy were initiated with satisfactory results. The risk of airway complications in emergency and intensive care unit settings is increased. When DL fails, an alternative strategy to airway management should be adopted immediately. The intubating laryngeal mask airway (ILMA) plays an indispensable role as primary and rescue device in difficult airway by providing both a patent airway

Fe de errores: “Recomendaciones de fluidoterapia perioperatoria para la cirugía abdominal mayor. Revisión de las recomendaciones de la Vía RICA. Parte II: Terapia hemodinámica guiada por objetivos. Fundamento para la optimización del volumen intravascular” [Rev Esp Anestesiol Reanim. 2017;64(6):339–347]

a Departamento de Anestesia, Hospital Universitario Infanta Leonor, Universidad Complutense de Madrid, Madrid, España b Departamento de Anestesia, Hospital Universitario LMU de Múnich, Múnich, Alemania c Departamento de Cuidados Intensivos, St George’s University Hospitals, NHS Foundation Trust, Londres, Reino Unido d Departamento de Anestesia Cardiovascular y Torácica, y Cuidados Intensivos, Bahrain Defence Force Hospital, Riffa, Reino de Baréin e University College London Hospital, National Institute for Health Research, Biomedical Research Centre, Londres, Reino Unido f Departamento de Anestesia y Neurocirugía, Wexner Medical Center, The Ohio State University, Columbus, OH, Estados Unidos g Departamento de Anestesia, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España h Departamento de Anestesia, Complejo Asistencial Universitario de Salamanca, Universidad de Salamanca (CAUSA), Salamanca, España

Fe de errores: “Recomendaciones de fluidoterapia perioperatoria para la cirugía abdominal mayor. Revisión de las recomendaciones de la Vía RICA. Parte I : Fundamentos fisiológicos” [Rev Esp Anestesiol Reanim. 2017;64(6):328–338]

a Departamento de Anestesia, Hospital Universitario Infanta Leonor, Universidad Complutense de Madrid, Madrid, España b Departamento de Anestesia, Hospital Universitario LMU de Múnich, Múnich, Alemania c Departamento de Anestesia Cardiovascular y Torácica, y Cuidados Intensivos, Bahrain Defence Force Hospital, Riffa, Reino de Baréin d University College London Hospital, National Institute of Health Research, Biomedical Research Centre, Londres, Reino Unido e Departamento de Anestesia y Neurocirugía, Wexner Medical Center, The Ohio State University, Columbus, OH, Estados Unidos f Departamento de Anestesia, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España g Departamento de Anestesia, Complejo Asistencial de Salamanca, Universidad de Salamanca, Salamanca, España