C. Gomar

Prediction of Postoperative Pulmonary Complications in a Population-based Surgical Cohort

Background:Current knowledge of the risk for postoperative pulmonary complications (PPCs) rests on studies that narrowly selected patients and procedures. Hypothesizing that PPC occurrence could be predicted from a reduced set of perioperative variables, we aimed to develop a predictive index for a broad surgical population. Methods:Patients undergoing surgical procedures given general, neuraxial, or regional anesthesia in 59 hospitals were randomly selected for this prospective, multicenter study. The main outcome was the development of at least one of the following: respiratory infection, respiratory failure, bronchospasm, atelectasis, pleural effusion, pneumothorax, or aspiration pneumonitis. The cohort was randomly divided into a development subsample to construct a logistic regression model and a validation subsample. A PPC predictive index was constructed. Results:Of 2,464 patients studied, 252 events were observed in 123 (5%). Thirty-day mortality was higher in patients with a PPC (19.5%; 95% [CI], 12.5–26.5%) than in those without a PPC (0.5%; 95% CI, 0.2–0.8%). Regression modeling identified seven independent risk factors: low preoperative arterial oxygen saturation, acute respiratory infection during the previous month, age, preoperative anemia, upper abdominal or intrathoracic surgery, surgical duration of at least 2 h, and emergency surgery. The area under the receiver operating characteristic curve was 90% (95% CI, 85–94%) for the development subsample and 88% (95% CI, 84–93%) for the validation subsample. Conclusion:The risk index based on seven objective, easily assessed factors has excellent discriminative ability. The index can be used to assess individual risk of PPC and focus further research on measures to improve patient care.

Documento «Sevilla» de Consenso sobre Alternativas a la Transfusión de Sangre Alogénica

El Documento de Consenso sobre Alternativas a la Transfusion de Sangre Alogenica (ATSA) ha sido elaborado por un panel de expertos pertenecientes a 5 sociedades cientificas. Han participado y patrocinado las sociedades espanolas de Anestesiologia (SEDAR), Medicina Intensiva (SEMICYUC), Hematologia y Hemoterapia (AEHH), Transfusion sanguinea (SETS) y Trombosis y Hemostasia (SETH). Las alternativas a la transfusion se han clasificado en farmacologicas y no farmacologicas, con un total de 4 modulos y 12 topicos. La disminucion de las transfusiones de sangre alogenica y/o el numero de pacientes transfundidos fue la principal variable objetivo. El grado de cumplimiento de este objetivo, para cada ATSA, se llevo a cabo siguiendo la metodologia Delphi, que clasifica el grado de recomendacion desde «A» (apoyado por estudios controlados) hasta «E» (estudios no controlados y opinion de expertos). Los expertos concluyeron que la mayor parte de las indicaciones de las ATSA se sustentan en grados de recomendacion medios y bajos, «C», «D» o «E», precisandose nuevos estudios controlados.

The perioperative management of new direct oral anticoagulants: a question without answers

New direct oral anticoagulant agents (DOAC) are currently licensed for thromboprophylaxis after hip and knee arthroplasty and for long-term prevention of thromboembolic events in non-valvular atrial fibrillation as well as treatment and secondary prophylaxis of venous thromboembolism. Some other medical indications are emerging. Thus, anaesthesiologists are increasingly likely to encounter patients on these drugs who need elective or emergency surgery. Due to the lack of experience and data, the management of DOAC in the perioperative period is controversial. In this article, we review available information and recommendations regarding the periprocedural management of the currently most clinically developed DOAC, apixaban, dabigatran, and rivaroxaban. We discuss two trends of managing patients on DOAC for elective surgery. The first is stopping the DOAC 1-5 days before surgery (depending on the drug, patient and bleeding risk) without bridging. The second is stopping the DOAC 5 days preoperatively and bridging with low-molecular-weight heparin. The management of patients on DOAC needing emergency surgery is also reviewed. As no data exist for the use of haemostatic products for the reversal of the anticoagulant effect in these cases, rescue treatment recommendations are proposed.

Anticlotting drugs and regional anaesthetic and analgesic techniques: comparative update of the safety recommendations

&NA; The wide use of anticlotting drugs by patients scheduled for surgery is a challenge for the anaesthesiologist when considering a regional anaesthesia technique. This practice seems safe if there is an appropriate management based on safety intervals established according to the pharmacology of the drug and the regional technique. Some anaesthesiology societies have published recommendations for the safe practice of regional anaesthesia with the simultaneous use of anticoagulants (heparin, low molecular weight heparins, oral anticoagulants (OA), fondaparinux and others) and antiplatelet agents (aspirin, clopidogrel, ticlopidine, argatroban and others). One of the most recent guidelines has been published by the Spanish Society of Anaesthesia and Critical Care. This article reviews these recommendations and compares them with others published in the last years. The recommendations are similar, but some interesting differences can be observed and need to be considered. A European consensus in this setting would probably be necessary.

Carbon dioxide embolism during laparoscopy and hysteroscopy

Venous carbon dioxide embolism is a rare but potentially lethal complication of laparoscopy. The risk is increased when it is associated with hysteroscopy. A case is presented of a young women undergoing laparoscopy and hysteroscopy for infertility. Cardiovascular collapse and cardiac arrest, associated with a mill-wheel murmur, occurred during hysteroscopy at the time of a change of position. The patient had irreversible brain damage and died a week later. Early diagnosis and prevention of this serious complication are discussed.

Contralateral Neuropathic Pain Following a Surgical Model of Unilateral Nerve Injury in Rats

Background and Objectives: Damage to peripheral nerves provokes chronic neuropathic pain that lasts beyond the duration of the nerve injury. The presence of pain signs have been reported in areas other than those attributed to the injured nerve, i.e., in contralateral regions. We evaluated the presence, magnitude, and chronology of mechanical and cold allodynia in the contralateral paw of rats undergoing unilateral ligation of the L5 and L6 spinal nerves. Methods: Twenty‐three male Sprague‐Dawley rats underwent spinal nerve ligation of the left L5 and L6 spinal nerves (SNL group) and 7 rats received a sham surgery without nerve ligation (sham group). Signs of mechanical allodynia as assessed with von Frey filaments, and cold allodynia as assessed with the acetone drop test, were studied before surgery and throughout 21 postoperative days. Responses of ipsilateral and contralateral paws of the SNL group were compared between themselves and with those in the sham group. Results: Rats in the SNL group developed mechanical and cold allodynia responses in the ipsilateral paw, and also in the contralateral paw. Allodynia in the contralateral paw appeared later, becoming statistically significant on day 10 after surgery for mechanical allodynia and on day 21 for cold allodynia as compared with the sham group. Contralateral pain was of a lower intensity than on the ipsilateral side. Conclusions: After L5 and L6 spinal nerve ligation, rats developed mechanical and cold allodynia in the contralateral paw, suggesting extraterritorial development of neuropathic signs. This finding has implications for future study design and therapeutic approaches.

Antecedentes, objetivos y método de la encuesta de actividad anestésica en Cataluña (ANESCAT 2003)

Fundamento y objetivo En todo el mundo el incremento de la actividad anestesica y la falta de anestesiologos suscitan preocupacion. En 2003 la Societat Catalana d’Anestesiologia, Reanimacio i Terapeutica del Dolor llevo a cabo un estudio para cuantificar la actividad anestesiologica en Cataluna (Espana) (ANESCAT 2003). Pacientes y metodo ANESCAT es un conjunto de 3 encuestas para cuantificar la actividad anestesiologica y los recursos. Se estimo que la muestra necesaria para la representacion de las anestesias anuales en Cataluna era de 12.228 casos. Se llevo a cabo un estudio prospective transversal en forma de encuesta realizada en 14 dias aleatorios del ano 2003. Cada centro designo un coordinador responsible de que se cumplimentara un cuestionario para cada anestesia, el cual recogia informacion de las caracteristicas del paciente, tecnica anestesica y procedimiento para el que se realizaba. Resultados En ANESCAT participaron 131 centros sanitarios publicos y privados, el 100% de los que practicaron anestesias en el ano 2003. La distribucion geografica de estos fue: Barcelona ciudad, 54 (41,2%); resto de la provincia, 39 (29,8%); Tarragona, 15 (11,5%);Girona, 14 (10,7%), y Lleida 9, (6,9%). Se recogieron 23.136 cuestionarios de anestesias; la variacion del numero de cuestionarios recogidos los dias laborables de corte fue de un 1,85% y el porcentaje de datos incompletos fue inferior al 5%. Ademas, se recibieron 765 cuestionarios unipersonales de actividad individualizada. Conclusiones Con una organizacion y metodo sencillos, y una elevada motivacion de un colectivo de anestesiologos, fue posible conducir un estudio extenso que permitio conocer con una gran precision la actividad que realiza dentro de un territorio. Este tipo de estudios es necesario para introducir cambios en la organizacion y los requerimientos de recursos.

Adverse reactions to vancomycin prophylaxis in cardiac surgery

Several adverse effects of vancomycin have been reported. The aim of this study was to assess the incidence of adverse responses to antibiotic prophylaxis with vancomycin in cardiac surgical patients. Prospectively, 116 consecutive patients (106 adults and 10 children) undergoing cardiac surgical procedures in this institution from January to June 1990 were studied. After the anesthetic induction, vancomycin, 1 g in adults and 10 mg/kg in children, was intravenously administered over 30 minutes. The infusion rate was slowed if any adverse effect was observed. As a control group, 10 similar patients were evaluated during the same period of 30 minutes after anesthetic induction but prior to vancomycin administration and surgical stimulation. Thirty-one patients (26.72%) developed an adverse effect, mainly hypotension (29 patients, 25%), which was considered severe in 15 patients (12.93%). Seven patients (6.03%) developed a maculopapular erythema that was associated with hypotension (Red-Mans syndrome) in 5 patients and with bronchospasm in 1 patient. The incidence of adverse reactions in children (20%) was similar to the overall incidence. Only 1 patient in the control group (10%) developed hypotension during the period studied. The incidence of adverse reactions was not related to age, body weight, vancomycin dose administered per kilogram body weight, type of surgical procedure, or associated disease. Mean duration of the infusion was similar in patients with and without adverse responses (34.60 +/- 12.41 minutes and 37.38 +/- 14.55 minutes, respectively). It is concluded that perioperative prophylaxis with vancomycin in cardiac surgery produces a high and unpredictable risk of significant hypotension.

Transoesophageal echocardiography accurately detects cardiac output variation: a prospective comparison with thermodilution in cardiac surgery

Background and objective: Intraoperative Doppler ultrasound can be used to measure cardiac output by transoesophageal echocardiography. Recently, its reliability, when compared to the thermodilution technique, has been questioned. The purpose of this study was to compare intraoperative changes in cardiac output measured by echo‐Doppler and by thermodilution in cardiac surgery. We also assessed the agreement between the techniques. Methods: Fifty cardiac surgical patients (38 male, 12 female, mean age of 63.4 ± 14.3 yr) were prospectively included after approval by the Ethics Committee of the Institution. Cardiac output was assessed by thermodilution, with 10 mL saline at 12°C, and simultaneously and blindly by echo‐Doppler in deep transgastric view with pulsed wave Doppler at the level of the left ventricular outflow tract. Matched thermodilution cardiac output and echo‐Doppler cardiac output measurements were taken three times at the end of expiration, both pre‐ and post‐cardiopulmonary bypass. Results: Echo‐Doppler measurements were obtained in 44 patients (88%). In three patients, Doppler recordings could not be obtained adequately, and three developed left ventricular outflow tract obstruction after bypass. Bland‐Altman analysis revealed a bias of 0.015 L min−1, with narrow limits of agreement (−1.21 to 1.22 L min−1) and 29.1% error. Echo‐Doppler was accurate (92% sensitivity and 71% specificity, P = 0.008 by receiver operating characteristic curves) for detecting more than 10% of change in thermodilution cardiac output. There were no complications related to the study. Conclusions: The agreement between cardiac output by echo‐Doppler and by thermodilution is clinically acceptable and transoesophageal echocardiography is a reliable tool to assess significant cardiac output changes in a population of selected patients.

Defining the learning outcomes of graduates from the medical school at the University of Barcelona (Catalonia, Spain).

It is generally accepted that medical schools must clearly define learning outcomes for their students. During the process of curriculum change initiated in 1990, Spanish medical schools introduced a range of general objectives but no specific outcomes were defined. In 2001, in an effort to improve its curriculum, the Medical School at the University of Barcelona decided to define the specific learning outcomes for its graduates. The process was carried out by a teachers’ group, comprising individuals from different branches of medicine, drawing largely on the Outcome-based Education in Medicine model introduced by the Scottish Deans’ Medical Curriculum Group (2000). Other different stakeholders were asked to give any suggestions for modifications in order to prepare a definitive document to be approved by the medical school. The whole process took two years to complete. The authors discuss the advantages of such a process for students, teachers and the institution.