Encuesta sobre la anestesiología en cirugía vascular e impacto de la pandemia por la COVID-19

Los pacientes sometidos a cirugía vascular son pluripatológicos y complejos. En los últimos años ha habido un incremento importante en el número de pacientes intervenidos por vía endovascular. La Sección de Anestesiología Cardíaca, Vascular y Torácica de la Sociedad Española de Anestesiología y Reanimación (SEDAR) diseñó una encuesta telemática basada en 29 preguntas mediante Google Forms® que envió a todos sus miembros. Un total de 204 anestesiólogos contestaron una serie de preguntas estructuradas en bloques: 1. Cirugía de la endarterectomía carotídea; 2. Reparación de aneurisma de aorta abdominal y torácica; 3. Cirugía arterial y venosa de miembros inferiores; 4. Impacto de la pandemia por la COVID-19 sobre la programación quirúrgica en cirugía vascular; 5. Programas de recuperación intensificada en cirugía vascular, y 6. Otras preguntas. A pesar de determinadas diferencias en cuanto al manejo anestésico, la anestesia locorregional es una técnica ampliamente utilizada. Los tres determinantes para la actuación del anestesiólogo son el paciente, su patología y la idiosincrasia de cada centro. Actualmente, los programas de recuperación acelerada en cirugía vascular no están ampliamente implementados en España. Finalmente, los resultados ponen de manifiesto que, durante la primera ola de la pandemia por la COVID-19, la cirugía vascular quedó prácticamente reducida a la cirugía urgente y emergente, según las recomendaciones anestésicas y quirúrgicas de las diferentes sociedades científicas, incluidas la SEDAR y la SEACV

Impact of surgical technique and analgesia on clinical outcomes after lung transplantation A STROBE-compliant cohort study

There is paucity of data on the impact of surgical incision and analgesia on relevant outcomes. A retrospective STROBE-compliant cohort study was performed between July 2007 and August 2017 of patients undergoing lung transplantation. Gender, age, indication for lung transplantation, and the 3 types of surgical access (Thoracotomy (T), Sternotomy (S), and Clamshell (C)) were used, as well as 2 analgesic techniques: epidural and intravenous opioids. Outcome variables were: pain scores; postoperative hemorrhage in the first 24 hours, duration of mechanical ventilation, and length of stay at intensive care unit (ICU). Three hundred forty-one patients were identified. Thoracotomy was associated with higher pain scores than Sternotomy (OR 1.66, 95% CI: 1.01; 2.74, P: .045) and no differences were found between Clamshell and Sternotomy incision. The median blood loss was 800 mL [interquartile range (IQR): 500; 1238], thoracotomy patients had 500 mL [325; 818] (P < .001). Median durations of mechanical ventilation in Thoracotomy, Sternotomy, and Clamshell groups were 19 [11; 37] hours, 34 [IQR 16; 57.5] hours, and 27 [IQR 15; 50.5] hours respectively. Thoracotomy group were discharged earlier from ICU (P < .001). Thoracotomy access produces less postoperative hemorrhage, duration of mechanical ventilation, and lower length of stay in ICU, but higher pain scores and need for epidural analgesia

The Effects of Escalation of Respiratory Support and Prolonged Invasive Ventilation on Outcomes of Cardiac Surgical Patients: A Retrospective Cohort Study

Abstract Objectives: The aim of this study was to determine the effects of escalation of respiratory support and prolonged postoperative invasive ventilation on patient–centered outcomes, and identify perioperative factors associated with these two respiratory complications. Design: A retrospective cohort analysis of cardiac surgical patients admitted to cardiothoracic intensive care unit (ICU) between August 2015 and January 2018. Escalation of respiratory support was defined as ‘unplanned continuous positive airway pressure’, ‘non-invasive ventilation’ or ‘reintubation’ following surgery; prolonged invasive ventilation was defined as ‘invasive ventilation beyond the first 12 hours following surgery’. The primary endpoint was the composite of escalation of respiratory support and prolonged ventilation. Setting: Tertiary cardiothoracic ICU. Participants: A total of 2,098 patients were included and analyzed. Interventions: None. Measurements and Main Results: The composite of escalation of support or prolonged ventilation occurred in 509 patients (24.3%). Patients who met the composite had higher mortality (2.9% vs 0.1%; P<0.001) and longer median [interquartile range] length of ICU (2.1 [1.0–4.9] vs 0.9 [0.8–1.0] days; P<0.0001) and hospital (10.6 [8.0–16.0] vs 7.2 [6.2–10.0] days; P<0.0001) stay. Hypoxemia and anemia on admission to ICU were the only two factors independently associated with need for escalation of respiratory support or prolonged invasive ventilation. Conclusions: Escalation of respiratory support or prolonged invasive ventilation are frequently seen in cardiac surgery patients, and are highly associated with increased mortality and morbidity. Hypoxemia and anemia on admission to ICU are potentially modifiable factors associated with escalation of respiratory support or prolonged invasive ventilation.ACM is supported by a Clinical Research Career Development Fellowship from the Wellcome Trust (WT 2055214/Z/16/Z). VZ is supported by an Academic Clinical Fellowship from the National Institute for Health Research (ACF-2016-09-011)

Dolor agudo en procedimientos de cirugía cardiotorácica: tromboendarterectomía pulmonar y trasplante de pulmón

[spa] 1.1 INTRODUCCIÓN: Una parte importante de la práctica diaria de un anestesiólogo incluye la prevención y tratamiento del dolor que acontece durante el acto quirúrgico. Factores moduladores del dolor inherentes en la cirugía cardiotorácica como la hipotermia, la administración de corticoides o el uso de la circulación extracorpórea pueden impactar en los requerimientos analgésicos de nuestros pacientes. Escasas son las evidencias científicas sobre los requerimientos analgésicos para el control del dolor agudo durante el acto quirúrgico y el postoperatorio inmediato en procedimientos de cirugía torácica como la endarterectomía pulmonar y el trasplante de pulmón. 1.2 HIPÓTESIS: 1.-Los pacientes con hipertensión tromboembólica crónica sometidos a endarterectomía pulmonar con parada circulatoria hipotérmica requieren una menor analgesia en el postoperatorio inmediato que los pacientes sometidos a cirugía cardíaca valvular. 2.- El acceso quirúrgico empleado en el trasplante pulmonar impacta en la intensidad del dolor postoperatorio inmediato, y en otras variables clínicas como la hemorragia en el postoperatorio, la duración de ventilación mecánica postoperatoria y la estancia en unidad de cuidados críticos. 1.3 RESULTADOS Y DISCUSIÓN: 1. Los pacientes con hipertensión tromboembólica crónica sometidos a endarterectomía pulmonar con parada circulatoria hipotérmica requieren una menor cantidad de opioides durante el acto quirúrgico y una menor cantidad de analgesia en el postoperatorio inmediato en comparación a los pacientes sometidos a cirugía cardíaca valvular. Ambos grupos de pacientes presentaron un buen control del dolor agudo en el postoperatorio inmediato. 2. Entre las distintas técnicas quirúrgicas estudiadas en el trasplante pulmonar, los pacientes a los que se les practicó una toracotomía presentaron un mayor dolor postoperatorio inmediato, una menor hemorragia postoperatoria, una menor duración de ventilación mecánica y una menor estancia hospitalaria en la unidad de cuidados de críticos en comparación a los pacientes que se les practicó esternotomía o clamshell. 3. Existen aparte de la escala categórica usada en los estudios 1 y 3 otras herramientas de medición de la intensidad de dolor cómo EVA y NPRS útil en otros escenarios clínicos. 1.4 CONCLUSIONES: 1- Los requerimientos analgésicos en pacientes intervenidos de tromboendarterectomía pulmonar con parada circulatoria hipotérmica son menores que en cirugía cardíaca valvular. 2- Los pacientes intervenidos de una tromboendarterectomía pulmonar recibieron corticoides intraoperatorios, cuya influencia pudo ser determinante en la reducción de los requerimientos analgésicos. 3- La vía de acceso quirúrgica en el trasplante de pulmón por toracotomía presenta un mayor dolor agudo en el postoperatorio inmediato. 4- La vía de acceso quirúrgica en el trasplante de pulmón por toracotomía se acompaña de mejores resultados respecto a la hemorragia postoperatoria, la duración de la ventilación mecánica y la estancia hospitalaria en la UCI. 5. El trasplante unipulmonar se asoció con estancias en UCI más cortas. 6. La técnica analgésica no mostró ser un factor relacionado con la estancia en la UCI. 7- La analgesia epidural favorece un control del dolor en casos en que la administración de opioides sea insuficiente, no siendo necesario su colocación sistemática en todos los pacientes sometidos a trasplante de pulmón. 8- La escala categórica verbal de 0 a 3 de medición de la intensidad de dolor, utilizada en las cirugías de tromboendarterectomía pulmonar y trasplante pulmonar, permite una valoración rápida y continua del dolor agudo postoperatorio inmediato en este tipo de cirugías.[eng] An important role of modern anaesthesiologist is to prevent pain that occurs during surgical act. In cardiothoracic surgery, known factors that modify pain are hypothermia, corticosteroids administration and cardiopulmonary bypass. There are scarce evidences regarding analgesic requirements in specific cardiothoracic procedures such as pulmonary thromboendarterectomy and lung transplantation. HYPOTHESIS: Patients with thromboembolic pulmonary hypertension undergoing pulmonary thromboendarterectomy with deep hypothermic circulatory arrest have less analgesic requirements compared with patients undergoing valvular heart surgery The surgical access in lung transplant impact on postoperative pain intensity and other clinical variables such as postoperative haemorrhage, duration of mechanical ventilation and length of stay in intensive care unit. RESULTS AND DISCUSSION: Patients with thromboembolic pulmonary hypertension undergoing pulmonary thromboendarterectomy require less opioids during surgical act and less analgesic drugs during postoperative period compared with patients undergoing valvular heart surgery Among different surgical accesses in lung transplantation, thoracotomy presented with higher postoperative pain scores, less postoperative haemorrhage, less duration of mechanical ventilation and shorter length of stay in critical care unit when compared with patients having sternotomy and clamshell. CONCLUSIONS: Analgesic requirements of patients undergoing pulmonary thromboendarterectomy with deep hypothermic circulatory arrest are less than patients having valvular heart surgery. Patients undergoing pulmonary thromboendarterectomy received corticosteroids intraoperatively which could impact on analgesic requirements. In lung transplantation, thoracotomy is the surgical access that induces more postoperative pain. Thoracotomy is associated with better outcomes in terms of postoperative haemorrhage, duration of mechanical ventilation and length of stay in ICU. Analgesic technique did not influence length of stay in ICU while single lung transplant is associated with shorter length of stay in ICU

The Effects of Escalation of Respiratory Support and Prolonged Invasive Ventilation on Outcomes of Cardiac Surgical Patients: A Retrospective Cohort Study

Objectives: The aim of this study was to determine the effects of escalation of respiratory support and prolonged postoperative invasive ventilation on patient-centered outcomes, and identify perioperative factors associated with these 2 respiratory complications. Design: A retrospective cohort analysis of cardiac surgical patients admitted to the cardiothoracic intensive care unit (ICU) between August 2015 and January 2018. Escalation of respiratory support was defined as “unplanned continuous positive airway pressure,” “non-invasive ventilation,” or “reintubation” after surgery; prolonged invasive ventilation was defined as “invasive ventilation beyond the first 12 hours following surgery.” The primary endpoint was the composite of escalation of respiratory support and prolonged ventilation. Setting: Tertiary cardiothoracic ICU. Participants: A total of 2,098 patients were included and analyzed. Interventions: None. Measurements and Main Results: The composite of escalation of support or prolonged ventilation occurred in 509 patients (24.3%). Patients who met the composite had higher mortality (2.9% v 0.1%; p < 0.001) and longer median [interquartile range] length of ICU (2.1 [1.0-4.9] v 0.9 [0.8-1.0] days; p < 0.0001) and hospital (10.6 [8.0-16.0] v 7.2 [6.2-10.0] days; p < 0.0001) stay. Hypoxemia and anemia on admission to ICU were the only 2 factors independently associated with the need for escalation of respiratory support or prolonged invasive ventilation. Conclusions: Escalation of respiratory support or prolonged invasive ventilation is frequently seen in cardiac surgery patients and is highly associated with increased mortality and morbidity. Hypoxemia and anemia on admission to the ICU are potentially modifiable factors associated with escalation of respiratory support or prolonged invasive ventilation

Assessment of the feasibility of high-concentration capsaicin patches in the pain unit of a tertiary hospital for a population of mixed refractory peripheral neuropathic pain syndromes in non-diabetic patients

Background: High-concentration-capsaicin-patches (Qutenza®) have been put on the market as a treatment for peripheral neuropathic pain. A minimum infrastructure and a determinate skill set for its application are required. Our aim was to assess the feasibility of treatment with high-concentration-capsaicin-patches in clinical practice in a variety of refractory peripheral neuropathic pain syndromes in non-diabetic patients. Methods: Observational, prospective, single-center study of patients attended to in the Pain Unit of a tertiary hospital, ≥18 year-old non-responders to multimodal analgesia of both genders. The feasibility for the application of capsaicin patch in clinical practice was evaluated by means of the number of patients controlled per day when this one was applied and by means of the times used for patch application. Results: Between October 2010 and September 2011, 20 consecutive non-diabetic patients (7 males, 13 females) with different diagnoses of refractory peripheral neuropathic pain syndromes, with a median (range) age of 60 (33–88) years-old were treated with a single patch application. The median (range) number of patients monitored per day was not modified when the capsaicin patch was applied [27 (26–29)] in comparison with it was not applied [28 (26–30)]. The median (range) total time to determine and mark the painful area was 9 (6–15) minutes and of patch application was 60 (58–65) minutes. No important adverse reactions were observed. Conclusion: High-concentration-capsaicin-patch treatment was feasible in our unit for the treatment of a population with refractory peripheral neuropathic pain. The routine of our unit was not affected by its use

Assessment of the feasibility of high-concentration capsaicin patches in the pain unit of a tertiary hospital for a population of mixed refractory peripheral neuropathic pain syndromes in non-diabetic patients

Background: High-concentration-capsaicin-patches (Qutenza®) have been put on the market as a treatment for peripheral neuropathic pain. A minimum infrastructure and a determinate skill set for its application are required. Our aim was to assess the feasibility of treatment with high-concentration-capsaicin-patches in clinical practice in a variety of refractory peripheral neuropathic pain syndromes in non-diabetic patients. Methods: Observational, prospective, single-center study of patients attended to in the Pain Unit of a tertiary hospital, ≥18 year-old non-responders to multimodal analgesia of both genders. The feasibility for the application of capsaicin patch in clinical practice was evaluated by means of the number of patients controlled per day when this one was applied and by means of the times used for patch application. Results: Between October 2010 and September 2011, 20 consecutive non-diabetic patients (7 males, 13 females) with different diagnoses of refractory peripheral neuropathic pain syndromes, with a median (range) age of 60 (33–88) years-old were treated with a single patch application. The median (range) number of patients monitored per day was not modified when the capsaicin patch was applied [27 (26–29)] in comparison with it was not applied [28 (26–30)]. The median (range) total time to determine and mark the painful area was 9 (6–15) minutes and of patch application was 60 (58–65) minutes. No important adverse reactions were observed. Conclusion: High-concentration-capsaicin-patch treatment was feasible in our unit for the treatment of a population with refractory peripheral neuropathic pain. The routine of our unit was not affected by its use