Management of antiplatelet therapy in patients with coronary stents undergoing noncardiac surgery: association with adverse events.

BACKGROUND: Perioperative discontinuation of antiplatelet therapy (APT) in patients with coronary stents has been associated with major adverse cardiac events. Our aim was to analyse the perioperative management of APT in such patients and its relationship to the incidence of major adverse cardiac and cerebrovascular events (MACCE) and major bleeding events (MBE) in noncardiac surgery. METHODS: We completed a prospective multicentre observational study of patients with coronary stents undergoing noncardiac surgery in 11 hospitals in Spain. The main objectives were to record perioperative events and prospectively analyse the management of APT, and to assess whether the different preoperative APT regimens were associated with MACCE and MBE. RESULTS: Of 432 surgical procedures studied, 15% experienced a perioperative MACCE and 37% a MBE. Overall mortality was 3.0%. Presurgical APT was prescribed in 95% of procedures, and was preoperatively discontinued in 15%. Surgery was urgent or emergent in 22% of patients, 31% were ASA IV, and 38% had a Revised Cardiac Risk Index of IV. MACCE were related to recent myocardial infarction (P=0.038), chronic kidney disease (P<0.001), insulin-dependent diabetes (P=0.006) and no preoperative APT (P=0.018). MBE also increased MACCE risk (P<0.001). We found statin therapy (P=0.049) and obesity (P=0.016) to be protective factors for MACCE. CONCLUSIONS: Patients with coronary stents undergoing noncardiac surgery suffer a high incidence of perioperative adverse events, even with perioperative APT. Major adverse cardiac and cerebrovascular events are mainly related to previous medical conditions and perioperative major bleeingn events. Our findings should be treated with caution when applied to an elective surgery population. CLINICAL TRIAL REGISTRATION: NCT01171612.

Un año de registro de traumatismos graves en Cataluña. Análisis de los primeros resultados / TraumCat: preliminary analysis of a year of severe trauma registry in Catalonia

Objetivo: Evaluar los resultados del primer año de implantación de un registro poblacional hospitalario de traumatismos graves en Cataluña (TraumCat). Método: Un total de 15 hospitales han recogido de forma prospectiva información sobre pacientes traumáticos graves, adultos y pediátricos (menores de 16 años), durante un periodo de un año (del 1 julio 2012 al 1 julio 2013) y la han introducido en un registro informatizado accesible en red. Resultados: Se han registrado 1.106 casos de pacientes con traumatismos de alta energía(12,2% en menores de 16 años). Un 84% de los traumatismos fueron no intencionales en adultos jóvenes. El 54,4% de los traumatismos se originaron en accidentes de circulación y el26,9% en precipitaciones. Un 5,4% correspondían a agresiones. Un 46% de pacientes presentaban un ISS mayor a 15, mientras que el NISS era mayor a 15 en un 51%. La tasa media de mortalidad fue del 10%. Sin embargo, en mayores de 60 años la tasa alcanzó el 25,2%.Conclusiones: TraumCat permite conocer la dimensión y evaluar el proceso asistencial en torno al traumatismo grave en Cataluña. Es preciso avanzar en la consolidación y mejora de esta herramienta como estrategia de monitorización del proceso asistencial y análisis de resultados (AU)

Objective: To analyze results of the first year’s use of the Hospital Population-Based Registry of Severe Trauma in Catalonia (TraumCat).Methods: Fifteen hospitals prospectively collected information on adults and children (< 16 years of age) with severetrauma for 1 year (July 1, 2012 to July 1, 2013). The information was stored in an online database. Results: The registry received 1106 cases of high-energy trauma (12.2% under the age of 16 years) were registered. Eight-four percent of the injuries in young adults were accidental; in the full cohort, 54.4% of the patients were injured in traffic accidents and 26.9% in falls. Personal violence accounted for 5.4%. The Injury Severity Score was over 15 in46% of the patients, and the New Injury Severity Score was over 15 in 51%. Mortality was 10% overall, but in patients aged over 60 years, mortality was 25.2%.Conclusions: TraumCat reveals the scope of severe trauma in Catalonia and facilitates analysis of the process of treatment of these injuries. This tool should be more firmly established and improved as a strategy for monitoring trauma care and outcomes (AU)

[Effectiveness of topical anesthesia enhanced by sedation and analgesia for cataract surgery]. / Eficacia de la anestesia tópica potenciada con sedación y analgesia en la operación de cataratas.

OBJECTIVES: To compare the efficacy of topical anesthesia and retrobulbar anesthesia for cataract surgery by lens emulsification. PATIENTS AND METHODS: Two hundred sixty patients were randomized to two groups in this open clinical trial. Patients with cataracts that could not be treated by lens emulsification were excluded. Group I patients (n = 129) received 0.5% tetracaine drops and intravenous fentanyl and propofol, along with continuous sedation. Group II patients (n = 131) received 2% lidocaine in the retrobulbar space and hypnotic doses of intravenous propofol before retrobulbar injection. The anesthesiologist evaluated anesthesia negatively if SpO2 was 90% and either heart rate or blood pressure varied more than 20%. The ophthalmologist evaluated anesthesia negatively if the eye did not remain fixed in the center, if blepharospasm appeared or if the anterior chamber of the eye collapsed. The patient reported the intensity of any discomfort experienced on a six-point scale. Anesthesia was determined to be effective when favorable evaluations were given by both the anesthesiologist and the ophthalmologist and when no significant discomfort (first three points on the scale) was reported by the patient. The two treatment groups were compared using a single and multiple factor analysis. RESULTS: Group II experienced significantly fewer instances of ineffective anesthesia than did group I (8 versus 22) and fewer negative evaluations by the ophthalmologists (7 versus 18). More patients in group I reported discomfort than in group II (46 versus 9), although most complaints were of slight discomfort. Multiple factor analysis showed that a patient in group I had 4.64 more chances of experiencing ineffective anesthesia. CONCLUSIONS: Topical anesthesia is less effective than retrobulbar anesthesia for cataract surgery by lens emulsification.

[Paradoxical bradycardia and hemorrhagic shock]. / Bradicardia paradójica y shock hemorrágico.

We report two cases of paradoxical bradycardia associated with acute hemorrhage and hypotension in conscious patients who had no antecedents of myocardial disease. In some cases of massive and rapid hypovolemia the occurrence of bradycardia may constitute a protective reflex directed to improve ventricular filling. This reflex is probably mediated by a vagal mechanism which acts on a previously increased sympathetic nerve tone and tends to maintain systemic vascular resistances and keep a cerebral blood flow high enough to preserve conscience level. We discuss the differential diagnosis with vasovagal syncope which can also occur during the initial phases of acute hemorrhage and during the preterminal bradycardia that develops during the so called "irreversible phase" of shock. Paradoxical bradycardia during hemorrhagic shock is always a sign of important bleeding that requires a rapid reposition of volemia. Administration of vagolytic agents is contraindicated since they can favour the occurrence of severe cardiac arrhythmias.