Calidad del registro escrito del médico anestesiólogo durante la transferencia de pacientes postoperados: influencia de la aplicación de una herramienta de comunicación estructurada / Quality of the anesthesiologist written record during the transfer of postoperative patients: Influence of implementing a structured communication tool

Objetivo. La falta de comunicación es una de las principales causas de errores asistenciales, especialmente durante la transferencia de pacientes entre profesionales y/o unidades asistenciales; la normalización de la comunicación es una práctica recomendada. En nuestro estudio hemos querido valorar si la aplicación de la herramienta estructurada de comunicación SBAR podría influir sobre la calidad de la información escrita en la hoja de evolución por el anestesiólogo implicado en la transferencia del paciente posquirúrgico. Material y métodos. Se trata de un estudio observacional, retrospectivo, aleatorizado, de revisión de la calidad del registro escrito realizado por el médico anestesiólogo durante la transferencia de pacientes desde el área quirúrgica a la unidad de reanimación postoperatoria, mediante la aplicación de un listado validado. Se evaluaron 3 periodos de observación: un periodo control de 2 meses del año 2011 (preSBAR) y un segundo periodo de 2 meses en 2012 (postSBAR), en este último con 2 grupos de pacientes transferidos con (postSBAR+) o sin SBAR (postSBAR−). Resultados. La fuerza de concordancia entre los evaluadores obtuvo un coeficiente de correlación interclase de 0,8459 (p < 0,001). Existían diferencias significativas en función del grupo estudiado, con mayor puntuación media en el grupo con SBAR (grupo postSBAR+: media ± DE 7,56 ± 1,20 frente a grupo postSBAR−: 5,41 ± 2,98; p < 0,001) y en función de que el anestesiólogo responsable de la intervención participara en el estudio (media ± DE: 7,00 ± 1,99; frente a 4,81 ± 3,24 en los no participantes; p < 0,001) (AU)

Objective. The lack of communication is a major cause of health care errors, especially during patient transfer between practitioners and/or healthcare units, when standardization of communication is a recommended practice. In our study we wanted to assess whether the application of the structured communication SBAR tool could influence the quality of the information written on the progress sheet by the anesthesiologist involved in the transfer of the patient after surgery. Material and methods. This is an observational, retrospective, randomized, quality review of the written record made by the anesthesiologist during the transfer of patients from the surgical area to the postoperative recovery unit, by applying a validated list. We evaluated three observation periods: a control period of two months in 2011 (preSBAR) and a second period of two months in 2012 (postSBAR); in the latter two groups of patients were transferred (postSBAR +) or without SBAR (postSBAR−). Results. The strength of agreement between raters obtained an intraclass correlation coefficient of 0.8459 (p <0.001). There were significant differences in the study group, with highest average score in the group with SBAR (postSBAR + group: mean ± SD 7.56 ± 1.20 versus postSBAR-group: 5.41 ± 2.98, p <0.001) and depending on the anesthesiologist responsible for the intervention participated in the study (mean ± SD: 7.00 ± 1.99, compared to 4.81 ± 3.24 in the non-participants, p <0.001). Conclusions. There was an improvement in the quality of written records made in 2012 during the implementation of the SBAR, without the actual application of this instrument appearing to influence it. The anesthesiologists that were involved in new forms of patient safety were also those who made written records of highest quality (AU)

[Quality of the anesthesiologist written record during the transfer of postoperative patients: Influence of implementing a structured communication tool]. / Calidad del registro escrito del médico anestesiólogo durante la transferencia de pacientes postoperados: influencia de la aplicación de una herramienta de comunicación estructurada.

OBJECTIVE: The lack of communication is a major cause of health care errors, especially during patient transfer between practitioners and/or healthcare units, when standardization of communication is a recommended practice. In our study we wanted to assess whether the application of the structured communication SBAR tool could influence the quality of the information written on the progress sheet by the anesthesiologist involved in the transfer of the patient after surgery. MATERIAL AND METHODS: This is an observational, retrospective, randomized, quality review of the written record made by the anesthesiologist during the transfer of patients from the surgical area to the postoperative recovery unit, by applying a validated list. We evaluated three observation periods: a control period of two months in 2011 (preSBAR) and a second period of two months in 2012 (postSBAR); in the latter two groups of patients were transferred (postSBAR +) or without SBAR (postSBAR-). RESULTS: The strength of agreement between raters obtained an intraclass correlation coefficient of 0.8459 (p <0.001). There were significant differences in the study group, with highest average score in the group with SBAR (postSBAR + group: mean ± SD 7.56 ± 1.20 versus postSBAR-group: 5.41 ± 2.98, p <0.001) and depending on the anesthesiologist responsible for the intervention participated in the study (mean ± SD: 7.00 ± 1.99, compared to 4.81 ± 3.24 in the non-participants, p <0.001). CONCLUSIONS: There was an improvement in the quality of written records made in 2012 during the implementation of the SBAR, without the actual application of this instrument appearing to influence it. The anesthesiologists that were involved in new forms of patient safety were also those who made written records of highest quality.

Furosemida nebulizada como tratamiento en urgencias de la disnea en pacientes con cáncer terminal / Nebulized furosemide to treat breathlessness in emergency patients with advanced cancer

Tres pacientes con cáncer avanzado y crisis de disnea por diferentes causas fueron tratados con furosemida nebulizada en un servicio de urgencias hospitalario. Cuarenta miligramos de furosemida fueron nebulizados e inhalados en una sola administración. La disnea mejoró de forma importante en los dos pacientes con una funcionalidad del 50% o más medida con el Palliative Performance Status (PPS), que controló el episodio. No fue así en el tercer paciente con disnea en fase final de la vida. No se observaron efectos adversos en ninguno de los casos. La inhalación de furosemida nebulizada parece ser efectiva en el tratamiento de la disnea en pacientes con cáncer terminal y un PPS igual o mayor al 50%, pero esta observación requiere ser confirmada con estudios randomizados controlados (AU)

Three patients with advanced cancer and acute dyspnea for different reasons were treated with furosemide spray in a hospital emergency department. A single dose of 40 mg of nebulized furosemide was sprayed and inhaled in a single dose. Breathlessness improved significantly, bringing the episode under control, in patients with at least 50% of function according to the Palliative Performance Status (PPS) scale. However, furosemide did not improve the condition of apatient with end-stage dyspnea. No adverse effects were observed. Inhaling nebulized furosemide seems to be an effective treatment for breathlessness in patients with terminal cancer and a 50% PPS function assessment, although randomized controlled trials are needed to confirm this hypothesis (AU)

[Endotracheal tube fire during laryngeal surgery: analysis of the root cause of a sentinel event]. / Ignición del tubo endotraqueal durante cirugía laríngea. análisis causa-raíz de un suceso centinela.

Endotracheal tube fire during laryngeal surgery is a rare complication but one that has serious consequences. Surgeons, anesthesiologists and others involved with this type of surgery should become familiar with how to manage this difficult situation, which should be considered a sentinel event requiring prompt analysis of the root cause and surrounding circumstances. Measures to improve management should be implemented and training provided in order to prevent the recurrence of a similar unfortunate event. We report a case in which a patient's airway caught fire during use of an electrocautery device. The patient died as a result of the lesions sustained. We report the results of the investigation and the protocols for prevention and response implemented in our surgical department, in the hope that the experience will be of interest to others working in similar settings.

Levofloxacino y fibrilación auricular / Levofloxacin and atrial fibrillation

El levofloxacino es una quinolona de tercera generación con actividad frente a patógenos atípicos y gramnegativos, incluida la Pseudomona aeruginosa. Se considera superior a otras de su misma clase frente a gramnegativos, lo que permite su uso en gran variedad de infecciones sistémicas. Se conocen numerosos efectos adversos relacionados con las quinolonas, tales como alteraciones en el cartílago de conjunción, fototoxicidad, rotura tendinosa, cuadros neurológicos, gastrointestinales, arritmias, etc. Se expone el caso de una mujer sana de 53 años, que tras la ingesta de 500 mg de levofloxacino cada 6 horas durante dos días, presentó una hepatitis medicamentosa y una fibrilación auricular que remitieron tras abandonar la administración de dicho fármaco. La génesis de arritmias con la ingesta de quinolonas es bien conocida, en particular la prolongación del intervalo QT, que puede derivar en arritmias ventriculares. Por este motivo diversos autores desaconsejan esta familia de antibióticos en pacientes de riesgo

Levofloxacin is a third generation quinolone that acts against Gram-negative pathogens and atypical bacteria, including Pseudomona aeruginosa. Since levofloxacin is more powerful against Gram-negative bacteria than similar drugs it is recommended for a large variety of systemic infections. Numerous side effects of the quinolones are known. They include cartilage alterations, phototoxicity, tendinous rupture, neurologic dysfunction, gastrointestinal symptoms and arrhythmia. The case of a 53 year-old woman who developed drug-induced hepatitis and atrial fibrillation after the administration of levofloxacin 500 mg every 6 hours is presented. All side effects disappeared upon withdrawal of the drug. The development of arrhythmias associated with the administration of quinolones is well documented, especially the enlargement of the QT interval, which may result in ventricular arrhythmia. For this reason many authors advise against the use of quinolones in risk patients

Hematoma epidural dorsal tras implante de neuroestimulador dorsal / Dorsal epidural hematoma after implantation of a dorsal nerve simulation

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Physiological evidence for a sodium-dependent high-affinity phosphate and nitrate transport at the plasma membrane of leaf and root cells of Zostera marina L.

Zostera marina L. is an angiosperm that grows in a medium in which inorganic phosphate (P(i)) and nitrate (NO(3)(-)) are present in micromolar concentrations and must be absorbed against a steep electrochemical potential gradient. The operation of a Na(+)-dependent NO(3)(-) transport was previously demonstrated in leaf cells of this plant, suggesting that other Na(+)-coupled systems could mediate the uptake of anions. To address this question, P(i) transport was studied in leaves and roots of Z. marina, as well as NO(3)(-) uptake in roots. Electrophysiological studies demonstrated that micromolar concentrations of P(i) induced depolarizations of the plasma membrane of root cells. However, this effect was not observed in leaf cells. P(i)-induced depolarizations showed Michaelis-Menten kinetics (K(m)=1.5+/-0.6 microM P(i); D(max)=7.8+/-0.8 mV), and were not observed in the absence of Na(+). However, depolarizations were restored when Na(+) was resupplied. NO(3)(-) additions also evoked depolarizations of the plasma membrane of root cells only in the presence of Na(+). Both NO(3)(-)- and P(i)-induced depolarizations were accompanied by an increase in cytoplasmic Na(+) activity, detected by Na(+)-sensitive microelectrodes. P(i) net uptake (measured in depletion experiments) was stimulated by Na(+). These results strongly suggest that P(i) uptake in roots of Z. marina is mediated by a high-affinity Na(+)-dependent transport system. Both NO(3)(-) and P(i) transport systems exploit the steep inwardly directed electrochemical potential gradient for Na(+), considering the low cytoplasmic Na(+) activity (10.7+/-3.3 mM Na(+)) and the high external Na(+) concentration (500 mM Na(+)).

[Infraclavicular brachial plexus block using a multiple injection technique and an approach in the cranial direction in a patient with anticipated difficulties in tracheal intubation]. / Bloqueo infraclavicular del plexo braquial con técnica de inyección múltiple y abordaje en sentido craneal en paciente con dificultad prevista de intubación traqueal.

A man with a pathologic diaphysial fracture of the middle third of the left humerus underwent emergency surgery for osteosynthesis of the fracture. Preoperative examination revealed that intubation would be difficult due to a history of radical surgery for epidermoid carcinoma of the oropharynx, and local-regional anesthesia was therefore considered. An interscalene approach was contraindicated because of the presence of an ulcerated metastatic cutaneous lesion in the area of puncture; and axillary block was also ruled out given that the fracture made movement painful. However, a satisfactory block and optimal conditions for surgery were achieved through an infraclavicular block using a cephalad multiple injection technique. Among the various levels of brachial plexus blockade, the infraclavicular option is little known and the least utilized, considering that one of its advantages is that the upper limb does not need to be moved for referencing (giving it an advantage over the axillary block) and that it has a lower incidence of pneumothorax (in comparison with a supraclavicular approach). Combined with a multiple injection technique and puncture in a cephalad direction, this solution allowed proximal surgery to be performed on the arm of a patient in whom intubation would have been difficult.

Bloqueo infraclavicular del plexo braquial con técnica de inyección múltiple y abordaje en sentido craneal en paciente con dificultad prevista de intubación traqueal / Infraclavicular block of the brachial plexus with a cephalad multiple injection technique in a patient with difficult tracheal intubation

A un paciente con fractura patológica diafisaria de tercio medio de la diáfisis humeral izquierda al que se le indicó tratamiento quirúrgico urgente para osteosíntesis de dicha fractura, la exploración clínica preoperatoria evidenció una dificultad de intubación debido a sus antecedentes de cirugía radical de carcinoma epidermoide de orofaringe, por lo que se consideró de elección una técnica locorregional. El abordaje interescalénico se contraindicó por la existencia de una lesión metastásica cutánea ulcerada en la zona de punción; el bloqueo axilar se descartó igualmente ante la presencia de la fractura que hacía muy dolorosa la movilización. Sin embargo se consiguió un bloqueo satisfactorio y unas condiciones óptimas para la intervención quirúrgica mediante un bloqueo infraclavicular con técnica de inyección múltiple y abordaje en sentido craneal. De los diferentes niveles de bloqueo del plexo braquial, el infraclavicular es poco conocido y menos utilizado, teniendo en cuenta que presenta como ventajas el no necesitar la movilización del miembro superior para sus referencias de punción (ventaja frente al bloqueo axilar) y una menor incidencia de neumotórax (frente al abordaje supraclavicular); combinado con una técnica de inyección múltiple y con una punción en sentido craneal nos permitió una cirugía proximal de miembro superior en un paciente con dificultad de intubación prevista (AU)

Consideraciones anestésicas en el síndrome de prader-willi para cirugía mayor de cifoscoliosis / On anesthesia for major scoliosis surgery in Prader-Willi syndrome

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Covariate effects on the apparent clearance of tacrolimus in paediatric liver transplant patients undergoing conversion therapy.

OBJECTIVE: To analyse the influence of covariates on the apparent clearance (CL) of tacrolimus in paediatric liver transplant recipients being converted from cyclosporin to tacrolimus. DESIGN: Retrospective modelling study. PATIENTS AND PARTICIPANTS: 18 children, 13 girls and 5 boys, aged 4 months to 16 years (median 9.1 years) who required conversion to tacrolimus because of acute or chronic rejection or cyclosporin toxicity. METHODS: 287 whole-blood tacrolimus concentrations from therapeutic drug monitoring were used to build a nonlinear mixed-effects population model (NONMEM program) for the apparent clearance of tacrolimus. Variables considered were age, total bodyweight (TBW), body surface area (BSA), time after initiation of treatment (T), gender, haematocrit (Hct), albumin (Alb), aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma-glutamyl transpeptidase (gammaGT), alkaline phosphatase (ALP), bilirubin (BIL), creatinine clearance (CL(CR)) and dosage of concomitant corticosteroids (EST). RESULTS: TBW, T, BIL and ALT were the covariates that displayed a significant influence on CL according to the final regression model: CL (L/h) = 10.4(TBW/70)3/4 x e(-0.00032 T) x e(-0.057 BIL) x (1 - 0.079 ALT). With this model, the estimates of the coefficients of variation were 24.3% and 29.5% for interpatient variability in CL and residual variability, respectively. CONCLUSIONS: The proposed model for tacrolimus CL can be applied for a priori dosage calculations, although the results should be used with caution because of the unexplained variability in the CL. We therefore recommended close monitoring of tacrolimus whole blood concentrations, especially within the first months of treatment. The best use of the model would be its application in dosage adjustment based on therapeutic drug monitoring and the Bayesian approach.

Sodium-dependent nitrate transport at the plasma membrane of leaf cells of the marine higher plant Zostera marina L.

NO(3)(-) is present at micromolar concentrations in seawater and must be absorbed by marine plants against a steep electrochemical potential difference across the plasma membrane. We studied NO(3)(-) transport in the marine angiosperm Zostera marina L. to address the question of how NO(3)(-) uptake is energized. Electrophysiological studies demonstrated that micromolar concentrations of NO(3)(-) induced depolarizations of the plasma membrane of leaf cells. Depolarizations showed saturation kinetics (K(m) = 2.31 +/- 0.78 microM NO(3)(-)) and were enhanced in alkaline conditions. The addition of NO(3)(-) did not affect the membrane potential in the absence of Na(+), but depolarizations were restored when Na(+) was resupplied. NO(3)(-)-induced depolarizations at increasing Na(+) concentrations showed saturation kinetics (K(m) = 0.72 +/- 0.18 mM Na(+)). Monensin, an ionophore that dissipates the Na(+) electrochemical potential, inhibited NO(3)(-)-evoked depolarizations by 85%, and NO(3)(-) uptake (measured by depletion from the external medium) was stimulated by Na(+) ions and by light. Our results strongly suggest that NO(3)(-) uptake in Z. marina is mediated by a high-affinity Na(+)-symport system, which is described here (for the first time to our knowledge) in an angiosperm. Coupling the uptake of NO(3)(-) to that of Na(+) enables the steep inwardly-directed electrochemical potential for Na(+) to drive net accumulation of NO(3)(-) within leaf cells.

Population estimation of valproic acid clearance in adult patients using routine clinical pharmacokinetic data.

The aim of the present study was to estimate valproic acid (VPA) clearance values for adult patients with epilepsy, using serum concentrations gathered during their routine clinical care. Retrospective steady state serum concentrations data (n=534) collected from 208 adult patients receiving VPA were studied. Data were analysed according to a one-compartment model using the NONMEM program. The influence of VPA daily dose (Dose), gender, age, total body weight (TBW), and comedication with carbamazepine (CBZ), phenytoin (PHT) and phenobarbital (PB) were investigated. The results of the population pharmacokinetics analysis were validated in a group of 30 epileptic patients. The final regression model for VPA clearance (Cl) was: $¿rm Cl¿left (¿rm L/h ¿right )=0¿rm. 004¿times TBW¿times Dose ¿0.304¿¿rm ¿times 1.363¿,¿rm CBZ¿times 1. 541¿,¿rm PHT¿times 1.397¿,¿rm PB.$ The inter-individual variability in VPA clearance, described by a proportional error model, had a variation coefficient (CV) of 23.4% and the residual variability, described using an additive model, was 11.4 mg/L. These results show that VPA clearance increased linearly with TBW, but increases nonlinearly with increasing VPA daily dose. Concomitant administration of CBZ, PHT and PB led to a significant increase in VPA clearance. The model predictions in the validation group were found to have satisfactory precision and bias. In conclusion, inter-individual variability in VPA clearance can be partly explained by TBW, daily dose and bitherapy with CBZ, DPH or PB. Inclusion of these factors allows this variability to be reduced by 37.23% which may be very useful for clinicians when establishing the initial VPA dosage regimen. However, the magnitude of inter-individual plus residual variabilities, remaining in the final model, render these dosage predictions imprecise and justify the need for VPA serum level monitoring in order to individualize dosage regimens more accurately.

Valproate population pharmacokinetics in children.

OBJECTIVE: A population analysis of the kinetics of valproic acid (VPA) in children with epilepsy was performed in order to characterize the covariates which influence VPA clearance (CL). METHODS: A total of 770 steady-state serum concentration samples was analysed. These were collected during VPA therapy from 255 children, aged 0.1-14 years and weighting 4-74 kg. Age, total body weight (TBW), VPA daily dose, sex and comedication with carbamazepine (CBZ) were considered as covariates. Population analysis was made with NONMEM program, assuming a one-compartment model, fixing the VPA absorption rate, bioavailability and distribution volume at values found in the literature. The results of the population pharmacokinetics analysis were validated in a group of 45 epileptic patients. RESULTS: The final regression model for VPA clearance, that included TBW (kg), daily dose (mg/kg) and CBZ comedication as covariates with a significant influence on this parameter, was as follows: CL (L/h) = 0.012 TBW0.715 DOSE0.306(1.359 CBZ). The coefficient of variation for interpatient variability in CL was 21.4% and the residual variability estimated was 23.9% for a concentration of 65 mg/l. In order to estimate the predictive performance of the selected final model, predictions of the VPA serum concentrations were calculated and compared with VPA measured concentrations in the validation group. This assessment revealed an important improvement in the predictive performance of VPA concentrations in comparison with the basic model that did not include any covariates (root squared mean error: 19.50 vs. 39.73 mg/l). CONCLUSION: A population pharmacokinetic model is proposed to estimate the individual CL for paediatric patients receiving VPA in terms of patient's dose, weight and concomitant CBZ, in order to establish a priori dosage regimens.

[Early pressure in pneumocephalus: an perioperative complication in neuroanesthesia]. / Neumoencéfalo a tensión precoz: una complicación perioperatoria en neuroanestesia.

We report two cases of early-onset pressure pneumocephalus, one occurring during supratentorial brain surgery (craniopharyngioma) which was diagnosed at the end of the anesthetic period upon appearance of comatose status leading to the suspicion of surgical complication in the form of a hematoma. The second case of pneumocephalus was detected after posterior fossa surgery performed with the patient in the sitting position. We review the significance of our anesthetic management on the prevention of tension pneumocephalus, and discuss diagnostic and therapeutic measures available for use in the Postoperative Intensive Care Recovery Unit.

[Hormonal response and two special techniques of postoperative analgesia in pediatric surgery]. / Respuesta hormonal con dos técnicas distintas de analgesia postoperatoria en cirugía pediátrica.

AIMS: We studied neuroendocrine response in the postoperative pain relief in pediatric patients treated with two analgesic techniques (conventional intravenous analgesia and patient controlled analgesia). MATERIAL AND METHODS: A double blind study was made in 30 patients, 6-14 year-old children, under total intravenous anesthesia for programmed surgery. An intravenous analgesia dose of 0.5 mg/Kg was given 10 minutes before operation was finished. Postoperative analgesia was achieved by two techniques: A. Patient controlled analgesia (PCA), and B. Conventional intravenous analgesia every 6 hours. Hormones measurements were made (catecholamines, cortisol, ACTH and beta-endorphin), hemodynamic monitoring (blood pressure and heart rate), and pain measurement (Hannallah's score) in both pre and postoperative times (1, 6 and 24 hours after operation). RESULTS: Pain score was low and without significant differences in both groups (p > 0.05). beta-endorphin level decreased in both groups, and a cortisol and catecholamine level increase was noticed at 6 hours after operation; these changes were less significant in PCA group (p < 0.001). ACTH level did not change significantly in both groups. Hemodynamic monitoring measurements were not significantly different. CONCLUSIONS: Both analgesic techniques were appropriate to postoperative pain relief in pediatric patients. Low pain score shows better conditions to attend these patients. We suggest PCA technique is better to treat postoperative stress response following pediatric surgery.