Monitorización de la nocicepción mediante el índice NoL y estudio de las complicaciones por opioides en cirugía abdominal laparoscópica

INTRODUCCIÓN: El dispositivo NoL de monitorización de la nocicepción cuenta con un sistema multiparamétrico; recoge información sobre la frecuencia cardiaca, la fotopletismografía, la conductancia cutánea y la temperatura del paciente.OBJETIVO: Determinar si la monitorización de la nocicepción intraoperatoria mediante el dispositivo NoL permite una mejor titulación de los fármacos opioides, así como una disminución de las complicaciones postoperatorias típicas asociadas a los mismos.MATERIAL Y MÉTODOS: Se trata de un estudio analítico observacional de cohortes. La muestra se basó en aquellos pacientes sometidos a cirugía abdominal laparoscópica. Los pacientes se dividieron en dos grupos: NoL visible y NoL no visible. En primer lugar, se recogieron una serie de datos demográficos básicos, así como los antecedentes y los tratamientos crónicos de los pacientes. Luego, durante el intraoperatorio se recogieron datos sobre la cantidad de opioides administrada. Posteriormente, se reunieron datos sobre las complicaciones postoperatorias ocurridas para cada uno de los pacientes en los primeros 30 días post-intervención quirúrgica.RESULTADOS: Existe una diferencia estadísticamente significativa sobre la administración de fármacos opioides durante el intraoperatorio entre ambos grupos comparativos, con un valor de p = 0,033 para el fentanilo y un valor de p = 0,015 para la morfina. Así mismo, también existen diferencias en la cantidad de opioide utilizada durante el postoperatorio con una p = 0,019. En cuanto a las complicaciones postoperatorias, en el grupo de NoL no visible, existe una mayor incidencia, con una diferencia estadísticamente significativa, de dolor (p CONCLUSIONES: La monitorización intraoperatoria de la nocicepción permite una reducción en la cantidad de fármacos opioides administrada, no sólo durante el período intraoperatorio, sino también en el postoperatorio. Así mismo, esto favorece una disminución de la incidencia de complicaciones típicamente asociadas al uso de fármacos opioides como son el dolor, el íleo paralítico o las náuseas y vómitos postoperatorios.<br /

Estudio del manejo anestésico perioperatorio de los pacientes receptores de trasplante renal de donante cadáver en un hospital de tercer nivel.

El trasplante renal es la terapia de elección para la mayoría de las causas de insuficiencia renal crónica terminal ya que mejora la calidad de vida y la supervivencia frente a la hemodiálisis y a la diálisis peritoneal. El manejo anestésico del trasplante renal requiere un profundo conocimiento de las alteraciones metabólicas y sistémicas de la enfermedad renal en su fase terminal así como de la comprensión de la fisiopatología, la bioquímica de la uremia, su efecto sobre la farmacocinética y el metabolismo de los fármacos utilizados. Las recientes mejoras en el tratamiento inmunosupresor combinado así como el mantenimiento óptimo de la volemia intraoperatoria han mejorado el resultado global en los receptores de trasplante. Sin embargo a medida que se van ampliando los criterios de inclusión de los pacientes en los programas de trasplante, el anestesiólogo se enfrenta a un aumento en las comorbilidades lo que implica un incremento en la complejidad de la anestesia, así como del tratamiento del dolor y de las posibles complicaciones perioperatorias. Por todo ello la optimización de la salud del receptor antes del trasplante renal y de todos estos factores perioperatorios asociados es crucial para conseguir el mejor resultado posible. La tasa de trasplante renal de cadáver por millón de población se sitúa en 48,3 lo que sitúa a España entre los países con una mayor tasa en este tipo de trasplantes. Durante el 2015 se han realizado en toda España 2.905 trasplantes renales lo que supone un aumento del 8,5% con respecto al año 2014. Mientras que la actividad de trasplante renal realizada en España ha sido prioritariamente de donante cadáver, durante el 2014 se realizaron 423 trasplantes renales de donante vivo, lo que supone casi el 16% del total de la actividad renal. En la actualidad se dispone en España de 46 centros de trasplante renal autorizados, 39 de adultos y 7 de trasplante infantil. El Hospital Universitario Miguel Servet de Zaragoza es el centro hospitalario de referencia de tercer nivel que cubre la totalidad de los trasplantes renales de la comunidad autónoma de Aragón. Aunque hoy en día la mortalidad del receptor es cercana al 0.03%, el trasplante renal sigue siendo un procedimiento con un alto riesgo perioperatorio, fundamentalmente desde el punto de vista de las complicaciones cardiovasculares. Desde el punto de vista preanestésico es importante que el paciente se encuentre en una situación óptima con respecto a los efectos de la uremia sobre los diferentes órganos y sistemas así como desde el punto de vista del medio interno. La disfunción y complicaciones postoperatorias del injerto a corto y largo plazo se correlaciona directamente con un tiempo de isquemia fría prolongado y de un inadecuado control de la volemia que mantenga una presión de perfusión del riñón trasplantado. Las diferentes medidas de manejo de la fluidoterapia con cristaloides y coloides sigue siendo controvertido hoy en día especialmente en estos pacientes con disfunción renal crónica. Aunque las técnicas quirúrgicas y anestésicas han mejorado en los últimos años, son muchos los aspectos, con respecto al manejo del paciente de trasplante renal, optimización de la volemia y uso de agentes anestésicos ideales, en los que existe controversia en la bibliografía médica y que es preciso definir. Por tanto, en el trasplante renal es clave ampliar los conocimientos de las implicaciones anestésico-quirúrgicas que pueden afectar a los resultados a corto y largo plazo, revisando los estudios con la evidencia más actual

Model for predicting early and late-onset postoperative pulmonary complications in perioperative patients receiving neuromuscular blockade: a secondary analysis

Pulmonary complications continue to be the most common adverse event after surgery. The main objective was to carry out two independent predictive models, both for early pulmonary complications in the Post-Anesthesia Care Unit and late-onset pulmonary complications after 30 postoperative days. The secondary objective was to determine whether presenting early complications subsequently causes patients to have other late-onset events. This is a secondary analysis of a cohort study. 714 patients were divided into four groups depending on the neuromuscular blocking agent, and spontaneous or pharmacological reversal. Incidence of late-onset complications if we have not previously had any early complications was 4.96%. If the patient has previously had early complications the incidence of late-onset complications was 22.02%. If airway obstruction occurs, the risk of atelectasis increased from 6.88 to 22.58% (p = 0.002). If hypoxemia occurs, the incidence increased from 5.82 to 21.79% (p < 0.001). Based on our predictive models, we conclude that diabetes mellitus and preoperative anemia are two risk factors for early and late-onset postoperative pulmonary complications, respectively. Hypoxemia and airway obstruction in Post-Anesthesia Care Unit increased four times the risk of the development of pneumonia and atelectasis at 30 postoperative days

Neuromonitoring depth of anesthesia and its association with postoperative delirium

Delirium after surgery or Postoperative delirium (POD) is an underdiagnosed entity, despite its severity and high incidence. Patients with delirium require a longer hospital stay and present more postoperative complications, which also increases hospital costs. Given its importance and the lack of specific treatment, multifactorial preventive strategies are evidenced based. Our hypothesis is that using general anaesthesia and avoiding the maximum time in excessively deep anaesthetic planes through BIS neuromonitoring device will reduce the incidence of postoperative delirium in patients over the age of 65 and their hospitalization stay. Patients were randomly assigned to two groups: The visible BIS group and the hidden BIS neuromonitoring group. In the visible BIS group, the depth of anaesthesia was sustained between 40 and 60, while in the other group the depth of anaesthesia was guided by hemodynamic parameters and the Minimum Alveolar Concentration value. Patients were assessed three times a day by research staff fully trained during the 72 h after the surgery to determine the presence of POD, and there was follow-up at 30 days. Patients who developed delirium (n = 69) was significantly lower in the visible BIS group (n = 27; 39.1%) than in the hidden BIS group (n = 42, 60.9%; p = 0.043). There were no differences between the subtypes of delirium in the two groups. Patients in the hidden BIS group were kept for 26.6 ± 14.0 min in BIS values &lt; 40 versus 11.6 ± 10.9 min (p &lt; 0.001) for the patients in the visible BIS group. The hospital stay was lower in the visible BIS group 6.56 ± 6.14 days versus the 9.30 ± 7.11 days (p &lt; 0.001) for the hidden BIS group, as well as mortality; hidden BIS 5.80% versus visible BIS 0% (p = 0.01). A BIS-guided depth of anaesthesia is associated with a lower incidence of delirium. Patients with intraoperative neuromonitoring stayed for a shorter time in excessively deep anaesthetic planes and presented a reduction in hospital stay and mortality

Laparoscopic surgery in 3D improves results and surgeon convenience in sleeve gastrectomy for morbid obesity

Purpose Advanced laparoscopic procedures are still challenging. One critical issue is the lack of stereoscopic vision. The aim of this surgical study is to evaluate whether 3D vision offers any advantages for surgical performance over 2D vision during sleeve gastrectomy for morbid obesity using a laparoscopic system that allows changing between 2D and 3D optics. Methods A total of 78 patients were analyzed, with 37 in the 2D group and 41 in the 3D group. Performance time, hospital stay, complications, and early outcomes were collected. To assess the quality of the 2D and 3D techniques, visual analog scales from 0 to 10 were designed, and image quality, depth of field, precision in performing tasks, and general ergonomics were measured. Results According to the vision system used, the mean duration of surgery was 85 ± 16.8 min for patients operated on with the 2D system and 69 ± 16.9 min for those operated on with the 3D system. There were no significant differences between the overall percentages of complications according to the type of vision used. However, postoperative complications were more severe in the 2D laparoscopy group. The average length of stay was shorter for patients in the 3D group. Regarding the differences perceived by the surgeon, the depth of field and the precision of tasks were better in the 3D vision group. Conclusion The 3D system provided greater depth perception and precision in more complex tasks, enabling safer surgery. This led to a reduction in the operative time and hospital stay. Moreover, the severity of complications was less

Correction: Is the heart rate variability monitoring using the analgesia nociception index a predictor of illness severity and mortality in critically ill patients with COVID-19? A pilot study.

[This corrects the article DOI: 10.1371/journal.pone.0249128.]

Is the heart rate variability monitoring using the analgesia nociception index a predictor of illness severity and mortality in critically ill patients with COVID-19? A pilot study.

IntroductionThe analysis of heart rate variability (HRV) has proven to be an important tool for the management of autonomous nerve system in both surgical and critically ill patients. We conducted this study to show the different spectral frequency and time domain parameters of HRV as a prospective predictor for critically ill patients, and in particular for COVID-19 patients who are on mechanical ventilation. The hypothesis is that most severely ill COVID-19 patients have a depletion of the sympathetic nervous system and a predominance of parasympathetic activity reflecting the remaining compensatory anti-inflammatory response.Materials and methodsA single-center, prospective, observational pilot study which included COVID-19 patients admitted to the Surgical Intensive Care Unit was conducted. The normalized high-frequency component (HFnu), i.e. ANIm, and the standard deviation of RR intervals (SDNN), i.e. Energy, were recorded using the analgesia nociception index monitor (ANI). To estimate the severity and mortality we used the SOFA score and the date of discharge or date of death.ResultsA total of fourteen patients were finally included in the study. ANIm were higher in the non-survivor group (p = 0.003) and were correlated with higher IL-6 levels (p = 0.020). Energy was inversely correlated with SOFA (p = 0.039) and fewer survival days (p = 0.046). A limit value at 80 of ANIm, predicted mortalities with a sensitivity of 100% and specificity of 85.7%. In the case of Energy, a limit value of 0.41 ms predicted mortality with all predictive values of 71.4%.ConclusionA low autonomic nervous system activity, i.e. low SDNN or Energy, and a predominance of the parasympathetic system, i.e. low HFnu or ANIm, due to the sympathetic depletion in COVID-19 patients are associated with a worse prognosis, higher mortality, and higher IL-6 levels

Model for predicting early and late-onset postoperative pulmonary complications in perioperative patients receiving neuromuscular blockade: a secondary analysis

Abstract Pulmonary complications continue to be the most common adverse event after surgery. The main objective was to carry out two independent predictive models, both for early pulmonary complications in the Post-Anesthesia Care Unit and late-onset pulmonary complications after 30 postoperative days. The secondary objective was to determine whether presenting early complications subsequently causes patients to have other late-onset events. This is a secondary analysis of a cohort study. 714 patients were divided into four groups depending on the neuromuscular blocking agent, and spontaneous or pharmacological reversal. Incidence of late-onset complications if we have not previously had any early complications was 4.96%. If the patient has previously had early complications the incidence of late-onset complications was 22.02%. If airway obstruction occurs, the risk of atelectasis increased from 6.88 to 22.58% (p = 0.002). If hypoxemia occurs, the incidence increased from 5.82 to 21.79% (p < 0.001). Based on our predictive models, we conclude that diabetes mellitus and preoperative anemia are two risk factors for early and late-onset postoperative pulmonary complications, respectively. Hypoxemia and airway obstruction in Post-Anesthesia Care Unit increased four times the risk of the development of pneumonia and atelectasis at 30 postoperative days

Predictive study of pharmacological reversal for residual neuromuscular blockade and postoperative pulmonary complications: a prospective, observational, cohort study

In recent years, some studies have generated controversy since they conclude that intraoperatively pharmacological reversal of neuromuscular blockade does not contribute to the reduction of postoperative residual neuromuscular blockade or pulmonary complications. Therefore, the main objective of this study was to assess the incidence of residual neuromuscular blockade and postoperative pulmonary complications according to spontaneous or pharmacological neuromuscular reversal. The secondary aim was to present a prognostic model to predict the probability of having postoperative residual neuromuscular blockade depending on a patient's comorbidities and intraoperative neuromuscular blocking agents management. A single-center, prospective, observational cohort study including patients undergoing surgical procedures with general anesthesia was designed. A total of 714 patients were analyzed. Patients were divided into four groups: cisatracurium with spontaneous reversal, cisatracurium with neostigmine antagonism, rocuronium with spontaneous reversal, and rocuronium with sugammadex antagonism. According to our binomial generalized linear model, none of the studied comorbidities was a predisposing factor for an increase in the residual neuromuscular blockade. However, in our study, pharmacological reversal of rocuronium with sugammadex and, particularly, neuromuscular monitoring during surgery were the factors that most effectively reduced the risk of residual neuromuscular blockade as well as early and late postoperative pulmonary complications