Revista Espanola de Anestesiologia y Reanimacion最新文献

Tubeless anaesthesia has become widespread in videothoracoscopic surgery, even in major procedures such as lobectomies. There are several advantages in avoiding general anaesthesia and one-lung mechanical ventilation, such as faster recovery and shorter hospital stays. However, hypoxaemia and hypercapnia are the most reported causes of conversion to general anaesthesia. High Flow Oxygen Therapy (HFOT) generates flow-dependent positive end-expiratory pressure, improves oxygenation and also carbon dioxide washout by flow-dependent dead space flushing. For this reason, intraoperative HFOT may reduce the rate of conversion to general anaesthesia. We report our experience with intraoperative HFOT in a 71-year-old female with lung adenocarcinoma undergoing VATS upper left lobectomy.

Background and objectives

Percutaneous implantation of an aortic valve prosthesis is a therapeutic alternative for patients with severe aortic stenosis. The procedure is traditionally performed under general anaesthesia; however, sedation is now gaining in popularity because it reduces the need for vasoactive drugs and shortens the patient's stay in the critical care unit and on the ward. The aim of this study is to evaluate the clinical efficacy, safety and potential benefits of sedation with dexmedetomidine in patients undergoing percutaneous implantation of an aortic valve prosthesis in terms of haemodynamic and respiratory complications.

Materials and methods

We performed a retrospective study of 222 patients that had undergone percutaneous implantation of an aortic valve prosthesis between 2012 and 2019 under sedation with either dexmedetomidine plus remifentanil (DEX-RMF) or propofol plus remifentanil (PROPO-RMF). We collected data on complications, mainly haemodynamic and respiratory, during and after the procedure.

Results

No significant differences were found between sedation with dexmedetomidine and propofol (in combination with remifentanil) in terms of haemodynamic stability and intraprocedural cerebral blood oxygen. In the DEX-RMF group, however, mean blood pressure, midazolam dose, and duration of anaesthesia were lower compared with the PROPO-RMF group, but the incidence of haemodynamic and respiratory complications did not differ significantly between groups.

Conclusions

Our results show that sedation, particularly with adjuvant dexmedetomidine, is a valid anaesthetic techniques in percutaneous aortic valve prosthesis implantation.

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. Nerve injury incidence was low (.8%), and not associated with nerve blocks. The incidence of prolonged quadricipital paralysis was also low (1.3%), and was mainly associated with femoral nerve block (75% of cases).

Conclusions

This retrospective study supports the use of regional blocks as opioid- sparing techniques, highlighting their role in rapid functional recovery with no motor impairment.

Objective

To improve knowledge about routine clinical practice in the management of paediatric acute pain in Spain.

Methods

A telematic survey was conducted via the Internet on a representative sample of healthcare professionals involved in the management of paediatric acute pain (specifically anaesthesiologists) in Spain. The survey included 28 questions about their usual clinical practice in the assessment and treatment of acute pain, and also training and organisational aspects in paediatric acute pain.

Results

The survey was completed during March 2021 by 150 specialists in anaesthesiology. The respondents widely experienced in the management of acute paediatric pain (mean years of experience: 14.3: SD: 7.8), essentially in acute postoperative pain (97% of cases). Although 80% routinely used validated paediatric acute pain assessment scales, only 2.6% used specific scales adapted for patients with cognitive impairment. Most of the respondents routinely used analgesic drugs such as paracetamol (99%) or metamizole (92%), but only 84% complemented these drugs with a loco-regional blocking technique or other non-steroidal anti-inflammatory drugs (62%). Furthermore, only 62.7% acknowledged having received specific training in paediatric acute pain, only 45% followed hospital institutional protocols, and a scant 28% did so through paediatric pain units.

Conclusions

The survey identified important points for improvement in the training and organisation of acute pain management in Spanish paediatric patients.

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.

Background and objective

The diagnosis of infection, to diagnose septic shock, has been qualified by leukocyte counts and protein biomarkers. Septic shock mortality is persistently high (20%-50%), and rising in the long term. The definition of sepsis does not include leukocyte count, and lymphopenia has been associated with its mortality in the short term. Immunosuppression and increased mortality in the long term due to sepsis have not been demonstrated. The aim is to relate the occurrence of lymphopenia and its lack of recovery during septic shock with mortality at 2 years.

Patients and methods

Cohort of 332 elderly patients diagnosed with septic shock. Mortality at 28 days and 2 years was analysed according to leukocyte, neutrophil, and lymphocyte counts, and the ability to recover from lymphopenia (LRec).

Results

A total of 74.1% of patients showed lymphopenia, and 66.3% did not improve during ICU stay. Mortality was 31.0% and 50.3% at 28 days and 2 years, respectively. A leukocyte count < 12,000 /μL was a predictor of early mortality (OR: 2.96) and LRec of late mortality (OR: 3.98). Long-term mortality was associated with LRec (HR: 1.69).

Conclusions

In elderly patients with septic shock, the absence of leukocytosis and neutrophilia is associated with 28-day mortality, and LRec with 2-year mortality; this may represent two distinct phenotypes of behaviour after septic shock.

Antecedentes

La limitación del tratamiento de soporte vital (LTSV) es el acto médico de retirar o no iniciar medidas que se consideren fútiles en la situación concreta de un paciente. La LTSV en pacientes críticos sigue siendo un tema difícil de estudiar, debido a la multitud de factores que la condicionan.

Objetivo

Determinar los factores relacionados con la LTSV en la Unidad de Cuidados Intensivos (UCI) en casos de mortalidad hospitalaria post-UCI, así como los factores asociados a los días de supervivencia tras el alta de UCI.

Diseño

Estudio longitudinal retrospectivo.

Ámbito

UCI de un hospital terciario.

Pacientes

Personas fallecidas en sala de hospitalización tras tratamiento en UCI entre enero de 2014 y diciembre de 2019.

Intervenciones

No existen. Se trata de un estudio observacional.

Variables de interés

Edad, sexo, probabilidad de muerte, tipo de ingreso, LTSV en UCI, enfermedad oncológica, dependencia, ventilación mecánica invasiva (VMI) y hemodiálisis de urgencia (HDU), transfusión de hemoderivados (TDH), infección nosocomial (IN), estancias pre-UCI, intra-UCI y post-UCI.

Resultados

De 114 pacientes fallecidos fuera de la UCI, 49 tenían registrada LTSV en UCI (42,98%). La edad y la estancia previa al ingreso en UCI se asociaron positivamente a LTSV (OR 1,03 y 1,08, respectivamente) y la IN, negativamente (OR 0,19). Los pacientes sin LTSV presentaron una estancia post-UCI más alta, mientras que en los pacientes varones fue menor.

Conclusiones

Nuestros resultados apoyan que la LTSV instaurada dentro de UCI puede relacionarse con un menor número de complicaciones comúnmente asociadas a la prolongación innecesaria de la estancia, como la IN.

Background

Life-sustaining treatment limitation (LTSV) is the medical act of withdrawing or not initiating measures that are considered futile in a patient's specific situation. LTSV in critically ill patients remains a difficult topic to study, due to the multitude of factors that condition it.

Objective

To determine factors related to LTSV in ICU in cases of post-ICU in-hospital mortality, as well as factors associated with survival after discharge from ICU.

Design

Retrospective longitudinal study.

Ambit

Intensive care unit of a tertiary hospital.

Patients

People who died in the hospitalization ward after ICU treatment between January 2014 and December 2019.

Interventions

None. This is an observational study.

Variables of interest

Age, sex, probability of death, type of admission, LTSV in ICU, oncological disease, dependence, invasive mechanical ventilation, emergency hemodialysis, transfusion of blood products, noso