Efectos del droperidol y el ondansetrón en la dispersión de la repolarización ventricular: un estudio clínico aleatorizado, doble ciego en pacientes adultos anestesiados / Effects of droperidol and ondansetron on dispersion of ventricular repolarization: a randomized double-blind clinical study in anesthetized adult patients

Introducción y objetivo. El droperidol y el ondansetrón prolongan el intervalo QT, lo que ha generado dudas sobre la posibilidad de que pudieran inducir arritmias como la torsades de pointes (TdP). Sin embargo, se ha demostrado que no es la prolongación del QT sino la dispersión espacial de la repolarización ventricular el principal sustrato arritmogénico para el desarrollo de TdP. El objetivo de este estudio es valorar los efectos del droperidol y el ondansetrón en la dispersión de la repolarización a través de la medida del intervalo T-peak-to-end (Tp-e) y los cocientes Tp-e/QT y Tp-e/RR1/2 en pacientes quirúrgicos anestesiados. Métodos. Estudio doble ciego en 63 adultos sin cardiopatía o factores que favorecen la prolongación del intervalo QT, sometidos a cirugía no cardiaca asignados aleatoriamente a 2 grupos: droperidol u ondansetrón. Durante la anestesia con propofol se realizó un ECG de 12 derivaciones, posteriormente se inyectaron 1,25 mg de droperidol o 4 mg de ondansetrón y 5 min después se obtuvo un nuevo ECG. El análisis de los ECG fue realizado independientemente por 2 cardiólogos que desconocían el momento del registro y el fármaco administrado. Los intervalos QT, RR y Tp-e se midieron como promedio de 5 latidos sucesivos en la derivación II (QT) o V5 (Tp-e). Se calculó el valor medio para cada medida en el análisis estadístico. Resultados. Recibieron droperidol 32 pacientes (19 mujeres) y ondansetrón 31 (22 mujeres). Ambos fármacos prolongaron el intervalo QTcF (fórmula Fridericia) un promedio 6,8 y 7,2 ms, respectivamente, pero ninguno aumentó el intervalo Tp-e o los cocientes Tp-e/QT y Tp-e/RR1/2. Conclusión. A dosis antieméticas, ni el ondansetrón ni el droperidol aumentan la dispersión de la repolarización ventricular en pacientes adultos sanos anestesiados con propofol (AU)

Background and objective. Droperidol and ondansetron prolong QT interval, a circumstance that has raised some concerns regarding the possibility of inducing torsades de pointes (TdP). However drug-induced spatial dispersion of ventricular repolarization has been shown to be the principal arrhythmogenic substrate for TdP. The aim of this study is to explore the effects of droperidol and ondansetron on the dispersion of repolarization, measured using the T peak-to-end interval (Tp-e) and Tp-e/QT and Tp-e/RR1/2 ratios in surgical anesthetized patients. Methods. A randomized, double-blind study carried out on sixty-three adult patients without cardiac disease or factors favoring QT prolongation and undergoing non-cardiac surgery were randomly assigned to the droperidol or ondansetron group. Under propofol anesthesia, a 12-lead EKG was obtained, and 1.25 mg droperidol or 4 mg ondansetron was injected. Five minutes later, a new 12-lead EKG was recorded. EKG analyses were independently performed by two cardiologists blinded to the state of the traces or group allocation. QT, RR and Tp-e intervals were measured by averaging five successive beats in lead II (QT) or V5 (Tp-e). The mean value for each measurement was calculated for statistical analysis. Results. Thirty-two patients (19 women) received droperidol, and 31 (22 women) ondansetron. Droperidol and ondansetron prolonged the QTcF interval (Fridericia formula) by 6.8 and 7.2 ms (mean values) respectively, but neither droperidol nor ondansetron increased the Tp-e interval or Tp-e/QT and Tp-e/RR1/2 ratios. Conclusion. At antiemetic doses, neither ondansetron (4 mg) nor droperidol (1.25 mg) increases the dispersion of ventricular repolarization in healthy adult patients anesthetized with propofol (AU)

Effects of droperidol and ondansetron on dispersion of ventricular repolarization: A randomized double-blind clinical study in anesthetized adult patients.

BACKGROUND AND OBJECTIVE: Droperidol and ondansetron prolong QT interval, a circumstance that has raised some concerns regarding the possibility of inducing torsades de pointes (TdP). However drug-induced spatial dispersion of ventricular repolarization has been shown to be the principal arrhythmogenic substrate for TdP. The aim of this study is to explore the effects of droperidol and ondansetron on the dispersion of repolarization, measured using the T peak-to-end interval (Tp-e) and Tp-e/QT and Tp-e/RR(1/2) ratios in surgical anesthetized patients. METHODS: A randomized, double-blind study carried out on sixty-three adult patients without cardiac disease or factors favoring QT prolongation and undergoing non-cardiac surgery were randomly assigned to the droperidol or ondansetron group. Under propofol anesthesia, a 12-lead EKG was obtained, and 1.25mg droperidol or 4mg ondansetron was injected. Five minutes later, a new 12-lead EKG was recorded. EKG analyses were independently performed by two cardiologists blinded to the state of the traces or group allocation. QT, RR and Tp-e intervals were measured by averaging five successive beats in leadII (QT) or V5 (Tp-e). The mean value for each measurement was calculated for statistical analysis. RESULTS: Thirty-two patients (19 women) received droperidol, and 31 (22 women) ondansetron. Droperidol and ondansetron prolonged the QTcF interval (Fridericia formula) by 6.8 and 7.2ms (mean values) respectively, but neither droperidol nor ondansetron increased the Tp-e interval or Tp-e/QT and Tp-e/RR(1/2) ratios. CONCLUSION: At antiemetic doses, neither ondansetron (4mg) nor droperidol (1.25mg) increases the dispersion of ventricular repolarization in healthy adult patients anesthetized with propofol.

Shock anafiláctico prolongado de 4 días de duración / Anaphylactic shock lasting 4 days

Se presenta el caso de un varón de 62 años programado para una cistectomía radical que a los 10 min de comenzar la cirugía presentó hipotensión arterial severa, taquicardia sinusal y un aumento de las presiones en la vía aérea. No se obtuvo respuesta a la administración de diversos fármacos vasoactivos (efedrina, fenilefrina, dopamina, noradrenalina). Tras descartar otras posibles etiologías se valoró la posibilidad de que se tratara de una reacción de anafilaxia y se inició la administración de adrenalina, con lo que se consiguió estabilizar hemodinámicamente al paciente. En la unidad de reanimación fue preciso mantener la perfusión de adrenalina y la ventilación mecánica durante 4 días (AU)

We present a case of a 62 year-old male scheduled for radical cystectomy, who, ten minutes into the surgery, presented with severe hypotension, tachycardia and increased airway pressure. There was no response to the administration of vasoactive drugs such as, ephedrine, phenylephrine, dopamine and norepinephrine. After ruling out several causes, we evaluated the possibility of an anaphylactic reaction. Adrenaline was given, and the patient stabilized. An adrenaline infusion and mechanical ventilation was required for four days in the critical care unit (AU)

[Anaphylactic shock lasting 4 days]. / Shock anafiláctico prolongado de 4 días de duración.

We present a case of a 62 year-old male scheduled for radical cystectomy, who, ten minutes into the surgery, presented with severe hypotension, tachycardia and increased airway pressure. There was no response to the administration of vasoactive drugs such as, ephedrine, phenylephrine, dopamine and norepinephrine. After ruling out several causes, we evaluated the possibility of an anaphylactic reaction. Adrenaline was given, and the patient stabilized. An adrenaline infusion and mechanical ventilation was required for four days in the critical care unit.

[Spanish Society of Anaesthesia (SEDAR) guidelines for pre-anaesthesia checking procedures]. / Directrices de procedimientos de comprobación y validación («chequeo¼) previos a la anestesia de la Sociedad Española de Anestesiología.

We present this document as a guide to preparing a specific institutional pre-anaesthesia checklist, as recommended in the Helsinki declaration on patient safety in anaesthesiology. Also, the recently recommended WHO "safe surgery check-list" includes a check-list for anaesthesia. A working group was established in accordance with the charter of the Spanish Society of Anaesthesiology and Resuscitation (Sociedad Española de Anestesiología y Reanimación [SEDAR]). The new patient safety culture introduced into medicine, and the recommendations of European anaesthesia societies has led us to design and update protocols in order to improve results in this important part of our speciality. We have prepared these recommendations or guidelines using, as examples, updates of pre-anaesthesia check-lists by other American (ASA), British, or Canadian societies of anaesthesia. With that aim, we enlisted the help of anaesthesia ventilator experts and the participation and advice of experienced anaesthesiologists from all parts of Spain. After various corrections and modifications, the document was available at www.sedar.es, so that any anaesthesiologist could propose any correction, or give their opinion. Finally, these guidelines have been approved by the SEDAR Board of Directors, before it was sent for publication in this journal. The aims of this document are to provide: a guideline applicable to all anaesthesia machines, a descriptive pre-anaesthesia check-list that include everything necessary for the anaesthesia procedure, and a resumed check-list to be available in all the anaesthesia machines or other equivalent, but prepared for each institution, which should include anaesthetic equipment and drugs. So, in order to ensure the aims and requirements of the European Board of Anaesthesiology, the European Society of Anaesthesiology, and the WHO are met, each institution should have a protocol for checking equipment and drugs. These guidelines are applicable to any anaesthesia equipment, enabling every institution to develop their own checking protocols, adapted to their anaesthesia machines and their procedures. With the consent of the SEDAR, this group will collaborate with anaesthesia machines providers in order to develop specific checklists for each of their models that will be available at www.sedar.es.

Directrices de procedimientos de comprobación y validación («chequeo») previos a la anestesia de la Sociedad Española de Anestesiología / Spanish Society of Anaesthesia (SEDAR) guidelines for pre-anaesthesia checking procedures

Este documento que presentamos pretende servir de guía para la elaboración por cada centro de una lista de chequeo previo a la anestesia o pre-anestesia, tal y como recomienda la reciente declaración de Helsinki sobre seguridad del paciente en anestesia. Además, la reciente implantación del «check-list quirúrgico de la OMS» (safe surgery check-list) incluye un epígrafe de chequeo de anestesia. El grupo de trabajo se constituyó con este fin según los estatutos de la Sociedad Española de Anestesiología, Reanimación y Tratamiento del Dolor (SEDAR). La nueva cultura de seguridad del paciente que se está implantando en la práctica médica y las recomendaciones de las sociedades europeas de anestesia nos obligan a actualizar y realizar protocolos que mejoren los resultados en este aspecto fundamental de nuestra especialidad. Tomando como ejemplo las actualizaciones de las listas de comprobación de diferentes asociaciones de anestesiólogos como la americana, británica o canadiense, hemos elaborado esta propuesta. Para ello hemos contado con la ayuda de expertos en respiradores y la colaboración y consejos de anestesiólogos expertos de todas las comunidades autónomas. Después de sucesivas correcciones, fue publicada en la página web de la SEDAR para que cualquier anestesiólogo pudiera aportar sus correcciones o su opinión. Finamente el documento ha sido aprobado por la junta directiva de la SEDAR, antes de ser enviado para su publicación en esta revista. Los objetivos de este documento son: proporcionar unas directrices o recomendaciones de comprobación aplicables a todos los sistemas de anestesia, realizar un listado descriptivo de comprobación que incluya todos los elementos necesarios para el procedimiento anestésico y aportar un listado con los elementos del chequeo en forma de esquema para disponer de él en cada equipo de anestesia o de otro similar realizado por cada centro, que incluya respirador, monitores, material auxiliar y fármacos. Por tanto, para cumplir con las recomendaciones de seguridad del paciente del European Board of Anaesthesiology (EBA), European Society of Anaesthesiology (ESA) y de la OMS, cada centro debe elaborar una lista de comprobación y verificación (en adelante «chequeo») previo a la anestesia. Este documento proporciona unas directrices aplicables a todos los sistemas de anestesia de tal manera que cada departamento pueda desarrollar sus propios protocolos de comprobación, adaptados a sus equipos de anestesia y a sus procedimientos de trabajo. De acuerdo con la directiva de la SEDAR, este grupo de trabajo colaborará con los fabricantes de equipos de anestesia para desarrollar listas de comprobación específicas de cada uno de sus modelos para que estén disponibles en www.sedar.es(AU)

We present this document as a guide to preparing a specific institutional pre-anaesthesia checklist, as recommended in the Helsinki declaration on patient safety in anaesthesiology. Also, the recently recommended WHO "safe surgery check-list" includes a check-list for anaesthesia. A working group was established in accordance with the charter of the Spanish Society of Anaesthesiology and Resuscitation (Sociedad Española de Anestesiología y Reanimación [SEDAR]). The new patient safety culture introduced into medicine, and the recommendations of European anaesthesia societies has led us to design and update protocols in order to improve results in this important part of our speciality. We have prepared these recommendations or guidelines using, as examples, updates of pre-anaesthesia check-lists by other American (ASA), British, or Canadian societies of anaesthesia. With that aim, we enlisted the help of anaesthesia ventilator experts and the participation and advice of experienced anaesthesiologists from all parts of Spain. After various corrections and modifications, the document was available at www.sedar.es, so that any anaesthesiologist could propose any correction, or give their opinion. Finally, these guidelines have been approved by the SEDAR Board of Directors, before it was sent for publication in this journal. The aims of this document are to provide: a guideline applicable to all anaesthesia machines, a descriptive pre-anaesthesia check-list that include everything necessary for the anaesthesia procedure, and a resumed check-list to be available in all the anaesthesia machines or other equivalent, but prepared for each institution, which should include anaesthetic equipment and drugs. So, in order to ensure the aims and requirements of the European Board of Anaesthesiology, the European Society of Anaesthesiology, and the WHO are met, each institution should have a protocol for checking equipment and drugs. These guidelines are applicable to any anaesthesia equipment, enabling every institution to develop their own checking protocols, adapted to their anaesthesia machines and their procedures. With the consent of the SEDAR, this group will collaborate with anaesthesia machines providers in order to develop specific checklists for each of their models that will be available at www.sedar.es(AU)

Causes for cancellation of elective surgical procedures in a Spanish general hospital.

Cancellation of scheduled surgery is undesirable for patients and an inefficient use of resources. We prospectively collected data for 52 consecutive months in a public general hospital to estimate the prevalence and causes. The overall cancellation rate was 6.5% (2559 of 39 115 scheduled operations). Cancellation by broad category was for 'medical reasons' in 50%, 'patient-related factors' in 23%, and due to 'administrative/logistic problems' in 25%. The commonest specific causes within these categories were respectively: infections/fever (18%), patient did not attend (20%) and lack of theatre time (23%). This data will help direct resources to target prevention of cancellations as a result of these main problems.

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[Application of a critical incident reporting and analysis system in an anesthesiology department]. / Utilización de un sistema de comunicación y análisis de incidentes críticos en un servicio de anestesia.

OBJECTIVES: To ascertain the changes in anesthesia-related morbidity and mortality after application of a scheme for reporting critical incidents and to assess the effect of implementing preventive measures against the detected errors. PATIENTS AND METHODS: We defined a critical incident to be any situation in which the margin of safety for the patient was reduced or might have been reduced. We analyzed data from the period between January 1999 and December 2004. RESULTS: The number of critical incidents was 547 (0.79% of 68627 anesthetic procedures). Human error was identified in 279 incidents (51%). The most frequent factors underlying errors were wrong diagnosis of the situation, communication problems, and failure to check equipment and drugs. The patient suffered no adverse effect in 81.8% of the incidents; 78.9% were considered preventable. Introducing an equipment checklist before anesthesia reduced the number of incidents from 90 events in 21809 cases in 31 months to 34 events out of 22064 cases in 29 months; chi2 test, P < 0.05; odds ratio (OR), 2.68; 95% confidence interval (CI), 1.80-3.98). Labeling syringes reduced errors in the administration of medications from 45 errors in 21 809 cases in 31 months to 27 in 22064 cases in 29 months; chi2, P < 0.05; OR, 1.68; 95% CI, 1.04-2.72. CONCLUSIONS: Corrective measures were adopted as a result of the incident reporting scheme. Some of the measures led to a statistically significant reduction in equipment and drug administration errors.

[Incident reporting systems and patient safety in anesthesia]. / Sistemas de comunicación de incidentes y seguridad del paciente en anestesia.

Incident reporting schemes collect information on adverse events, errors, complications, or problems with the aim of analyzing their causes and suggesting changes to prevent recurrence. Such schemes are currently part of clinical safety programs in various countries. Although the ideal form for a reporting system is debated, an essential part of its success will be the establishment of a culture of safety within an organization. The underlying assumption is that even though errors are an inherent part of a process that relies on human beings, they are nearly always favored by a chain of system failures. Therefore, reporting is intended to stimulate a culture of learning rather than assigning blame. The main limitations of such schemes are under reporting, the use of different terms and concepts, the lack of resources for research and development, and the scarcity or lack of legislation to guarantee the proper use of information without legal consequences.

Sistemas de comunicación de incidentes y seguridad del paciente en anestesia / Incident reporting systems and patient safety in anesthesia

Los sistemas de comunicación de incidentes recogeninformación sobre sucesos adversos, errores, complicacioneso problemas con el objetivo de analizar sus causasy sugerir cambios para evitar su repetición. Actualmenteson parte de los programas de seguridad clínica en diversospaíses. Aunque existe controversia acerca de cuálesserían las características del sistema de comunicaciónideal, para que éste tenga éxito se necesita una cultura deseguridad asentada en la organización. El planteamientode base asume que aunque los errores son inherentes alproceso humano casi siempre los propicia una cadena defallos en el sistema, por lo que los sistemas de comunicaciónse diseñan para estimular una cultura de aprendizajey no de culpabilización. Sus principales limitacionesson la posibilidad de infracomunicación, las diferentesterminologías y conceptos utilizados, la falta de recursospara su investigación y desarrollo, y la escasa o nulalegislación que permita su buen uso sin implicacioneslegales

Incident reporting schemes collect information onadverse events, errors, complications, or problems withthe aim of analyzing their causes and suggesting changesto prevent recurrence. Such schemes are currently partof clinical safety programs in various countries. Althoughthe ideal form for a reporting system is debated,an essential part of its success will be the establishmentof a culture of safety within an organization. The underlyingassumption is that even though errors are aninherent part of a process that relies on human beings, theyare nearly always favored by a chain of system failures.Therefore, reporting is intended to stimulate a culture oflearning rather than assigning blame. The main limitationsof such schemes are under reporting, the use of differentterms and concepts, the lack of resources for researchand development, and the scarcity or lack oflegislation to guarantee the proper use of informationwithout legal consequences

Utilización de un sistema de comunicación y análisis de incidentes críticos en un servicio de anestesia / Application of a critical incident reporting and analysis system in an anesthesiology department

OBJETIVOS: Conocer los cambios en la morbi-mortalidad anestésica con la utilización de un sistema de comunicación de incidentes críticos y valorar los efectos de la resolución de los factores de error detectados. PACIENTES Y MÉTODOS: Consideramos incidente crítico toda situación en la que se redujo o pudo haberse reducido el margen de seguridad del paciente. Analizamos el periodo entre enero de 1999 y diciembre de 2004. RESULTADOS: Se realizaron 68.627 procedimientos anestésicos y se comunicaron 547 incidentes críticos (0,79%). En 279 incidentes (51%) se identificó un error activo. Los factores latentes asociados con mayor frecuencia fueron el error de diagnóstico de la situación, los problemas de comunicación y la falta de comprobación del equipamiento y de los fármacos. El 81,8% de los incidentes no tuvieron ningún efecto sobre el paciente. En el 78,9% el incidente se consideró evitable. La introducción de una lista de comprobación del equipamiento antes de la anestesia redujo los incidentes de 90 por 21809 casos en 31 meses a 34 por 22.064 casos en 29 meses; χ, p<0,05; odds ratio [OR]= 2,68; intervalo de confianza [IC] del 95%= 1,80-3,9811. El etiquetado de jeringas redujo los errores en la administración de medicación de 45 por 21.809 casos en 31 meses a 27 por 22.064 casos en 29 meses; χ, p<0,05; OR= 1,68; IC del 95%= 1,04-2,72. CONCLUSIONES: Como consecuencia del análisis sistemático de los incidentes se adoptaron distintas medidas correctoras, algunas de las cuales demostraron una reducción estadísticamente significativa en los incidentes de equipamiento y los incidentes farmacológicos

OBJECTIVES: To ascertain the changes in anesthesiarelated morbidity and mortality after application of a scheme for reporting critical incidents and to assess the effect of implementing preventive measures against the detected errors. PATIENTS AND METHODS: We defined a critical incident to be any situation in which the margin of safety for the patient was reduced or might have been reduced. We analyzed data from the period between January 1999 and December 2004. RESULTS: The number of critical incidents was 547 (0.79% of 68627 anesthetic procedures). Human error was identified in 279 incidents (51%). The most frequent factors underlying errors were wrong diagnosis of the situation, communication problems, and failure to check equipment and drugs. The patient suffered no adverse effect in 81.8% of the incidents; 78.9% were considered preventable. Introducing an equipment checklist before anesthesia reduced the number of incidents from 90 events in 21809 cases in 31 months to 34 events out of 22064 cases in 29 months; χ2 test, P<0.05; odds ratio (OR), 2.68; 95% confidence interval (CI), 1.80-3.98). Labeling syringes reduced errors in the administration of medications from 45 errors in 21 809 cases in 31 months to 27 in 22064 cases in 29 months; χ2, P<0.05; OR, 1.68; 95% CI, 1.04-2.72. CONCLUSIONS: Corrective measures were adopted as a result of the incident reporting scheme. Some of the measures led to a statistically significant reduction in equipment and drug administration errors

[Comparison of the double burst stimulus with the train-of-four stimuli in monitoring muscle relaxation during anesthesia]. / Comparación del estímulo a doble ráfaga frente al tren de cuatro estímulos en la monitorización de la relajación muscular durante la anestesia.

OBJECTIVE: To compare double burst stimulus (DBS) and the train-of-four stimuli (TOF) for monitoring neuromuscular blockade during anesthesia in terms of muscle relaxation requirements, dose of anticholinesterase agents and the possibility of postanesthetic residual relaxation. PATIENTS AND METHODS: Patients were randomly assigned to two groups according to type of monitoring (DBS group, n = 29; and TOF group, n = 28), and were given an adjusted infusion of vecuronium to obtain response to stimulation with both methods of monitoring. When the block was considered to be sufficiently reversed in the operating theater, the patients were transferred to the postanesthesia recovery unit (PARU), where the coefficient between the fourth and first responses to TOF (T4/T1r) was obtained by electromyography and the patients were given the dose of neostigmine needed to obtain a T4/T1r > 70% RESULTS: Vecuronium was infused at a faster rate during anesthesia in the DBS group than in the TOF group (1.0 +/- 0.19 microgram.kg-1.min-1 and 0.8 +/- 0.24 microgram. kg-1.min-1, respectively, p = 0.005). T4/T1r was less than 70% upon arrival at the PARU in 10 DBS patients and in 2 TOF patients (p = 0.02). No differences were found in neostigmine doses given. CONCLUSIONS: The use of DBS increased the vecuronium dose required during anesthesia and risk in those patients who arrived at the PARU with residual muscle block (T4/T1r < 70%).

[Continuous intraoperative arteriovenous hemodiafiltration in liver transplantation]. / Hemodiafiltración arteriovenosa continua intraoperatoria en el trasplante hepático.

This study reports two cases of urgent hepatic retransplantation due to graft failure developing 37 and 10 days after the first transplant in which intraoperative continuous arteriovenous hemodiafiltration (CAH) was performed. They were female patients aged 33 and 58 years respectively who presented oliguric renal insufficiency before surgery (plasmatic creatinine 2.6 and 2.8 mg/dl and urea 77 and 278 mg/dl) and severe electrolytic imbalance (sodium 128 and 135 mmol/l; potassium 8.5 and 3.8 mmol/l; bicarbonate 8.8 and 12.7 mmol/l; pH 7.18 and 7.16). In both cases CAH was used from the beginning of anesthetic induction (Hemofilter Biospal SCU/CAHH- Kit A2-U with reversed infusion of glucose Dianeal 1.5%). An intraoperative ultrafiltered volume of 2200 and 2400 ml was respectively obtained in each patient. The use of intraoperative CAH favoured the correction of the electrolyte imbalance, contributed to maintain the hemodynamic stability, and rendered the administration of fluids more appropriate during the surgical process.