La anemia como factor de riesgo quirúrgico en cirugía vascular. Algoritmos de diagnóstico y tratamiento / Anaemia as surgical risk factor in vascular surgery. Diagnostic and treatment algorithms

La anemia es una entidad clínica que se detecta frecuentemente en la evaluación preoperatoria, especialmente en pacientes de edad avanzada. Se asocia a un aumento de la morbimortalidad perioperatoria, así como a una mayor probabilidad de transfusión de sangre alogénica (TSA), con los riesgos que ello implica. Aunque la anemia puede ser multifactorial y difícil de tipificar en algunos casos, sus causas más frecuentes son las deficiencias nutricionales (hierro, ácido fólico y vitamina B12) y la anemia por enfermedad crónica o anemia inflamatoria. En el paciente candidato a cirugía vascular arterial la prevalencia de anemia preoperatoria se sitúa alrededor del 50%. Además, uno de cada 3 pacientes presenta anemia en los 3 meses previos a la cirugía. El estado inflamatorio, inherente al proceso crónico vascular, y las pérdidas sanguíneas quirúrgicas favorecen la predisposición a padecer anemia. La anemia, como factor de mal pronóstico perioperatorio, exige su diagnóstico y tratamiento. Se proponen algoritmos para el manejo de la anemia, diferenciando la cirugía programada de la urgente. Se destaca la administración preferente de hierro por vía intravenosa en los períodos preoperatorio y postoperatorio precoz (AU)

Anaemia is a clinical condition that is frequently detected in the pre-operative evaluation, particularly in elderly patients. Anaemia is associated with increased peri-operative morbidity and mortality, as well as a greater likelihood of allogeneic blood transfusion, along with the risks involved. Although anaemia can be due to many factors and difficult to establish in some cases, its most common causes are nutritional deficiencies (iron, folic acid, and vitamin B12) and anaemia of chronic inflammatory disease. In patient candidates for arterial vascular surgery, preoperative anaemia prevalence is around 50%. In addition, one out of three patients has anaemia in the 3 months prior to surgery. The inflammatory condition, inherent to chronic vascular processes, and surgical blood loss favours the predisposition to anaemia. Anaemia, as factor of poor peri-operative prognosis, requires diagnosis and treatment. Algorithms are proposed for managing the anaemia, differentiating scheduled from urgent surgery. The administration of IV iron should be in the preoperative and early postoperative periods (AU)

Prevalencia de anemia en pacientes sometidos a cirugía vascular electiva y su influencia en el postoperatorio / Prevalence of anaemia in patients undergoing elective vascular surgery and its influence in the postoperative period

INTRODUCCIÓN: La anemia es muy frecuente en los pacientes sometidos a cirugía vascular y puede influir en los resultados postoperatorios. OBJETIVOS: Evaluar la prevalencia de anemia en los pacientes intervenidos de cirugía arterial aortoilíaca e infrainguinal. Analizar la influencia de la anemia en la aparición de complicaciones postoperatorias. MATERIAL Y MÉTODOS: Se ha realizado un estudio retrospectivo, transversal y multicéntrico en 12 unidades de cirugía vascular. Se han registrado las cifras de hemoglobina de todos los pacientes que han sido intervenidos de forma consecutiva durante 2 meses. Además se han registrado los factores de riesgo de arteriosclerosis habituales y las complicaciones postoperatorias hasta 30 días de la cirugía. RESULTADOS: Se han registrado 530 pacientes. La tasa global de anemia ha sido del 53,8%, siendo del 50,8% en hombres y del 62,2% en mujeres. El 66,9% de los pacientes con isquemia crónica crítica tiene anemia. Los anémicos son mayores que los no anémicos y son más frecuentemente hipertensos, diabéticos, tienen más insuficiencia cardiaca y renal, y presentan unas cifras más elevadas de proteína C reactiva. Además también presentan anemia previa (hasta 3 meses) con más frecuencia, tienen una mayor estancia hospitalaria (10,4 vs. 7,0) y reciben más transfusiones. Los anémicos no presentan más complicaciones ostoperatorias pero en el análisis multivariante la enfermedad pulmonar obstructiva crónica y la anemia en los 3 meses anteriores son factores predictores de complicaciones. CONCLUSIONES: La prevalencia de anemia en los pacientes con arteriopatía periférica severa es muy elevada. Los pacientes anémicos en el preoperatorio se transfunden 3 veces más y tiene una estancia hospitalaria más larga que los no anémicos. La anemia en los 3 meses anteriores a la cirugía es un factor predictor de complicaciones postoperatorias

INTRODUCTION: Anaemia is very common in patients subjected to vascular surgery and can influence the post-operative outcome. OBJECTIVES: To evaluate the prevalence of anaemia in patients undergoing aortoiliac and infra-inguinal vascular surgery. To analyse the influence of the anaemia on the presentation of post-operative complications. MATERIAL AND METHODS: A retrospective, cross-sectional, multicentre study was conducted in 12 vascular surgery units. The haemoglobin levels were recorded on all patients that had been consecutively intervened over a period of 2 months. The usual arteriosclerosis risk factors were recorded, as well as the post-operative complications up to 30 days from the surgery. RESULTS: A total of 530 patients were included. The overall rate of anaemia was 53.8%, with 50.8% in males and 62.2% in females. More than two-thirds (66.9%) of patients with chronic critical ischaemia had anaemia. There were more anaemic patients than non-anaemic ones, and they more frequently have hypertension and diabetes. They also present with more cardiac and renal failure, and have a more elevated C-reactive protein levels. They also have previous anaemia (up to 3 months) more often, have a longer hospital stay (10.4 vs. 7.0), and receive more transfusions. They do not have more post-operative complications, but chronic obstructive pulmonary disease and anaemia in the previous 3 months are predictive factors of complications. CONCLUSIONS: Anaemia prevalence id very high in patients with severe peripheral arterial disease. Patients that are anaemic in the pre-operative period are transfused three times more and have a longer hospital stay than non-anaemic patients. Anaemia in the 3 months before the surgery is a predictive factor for post-operative complications

Comentarios al análisis de la relación coste-efectividad de los programas de autotransfusión / On the analysis of the cost-effectiveness ratio for autologous transfusion programs

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[Cost-effectiveness analysis of an autotransfusion program in primary knee and hip replacement surgery]. / Análisis de la relación coste-efectividad de un programa de autotransfusión en cirugía protésica primaria de rodilla y cadera.

OBJECTIVE: To evaluate the cost-effectiveness of a program for autotransfusion in patients undergoing primary prosthetic surgery of the knee and hip (cemented and non-cemented). MATERIAL AND METHODS: A case-control comparison. Retrospective group: review of case histories of patients undergoing surgery in 1993, screened to identify the subpopulation that would be candidates for a program of autotransfusion and to evaluate the blood transfusion policy. Prospective group: patients undergoing surgery between 1995 and 1996 who participated in an autotransfusion program. We studied the following variables in both groups: prevalence of exposure to homologous blood and the amount, perioperative course of hemoglobin/hematocrit, and mean cost of the blood treatment given. In the prospective group we examined agreement between autologous blood extracted before surgery and later reinfused. RESULTS: The prevalence of exposure to homologous blood fell significantly from the retrospective to the prospective phases as follows: knee surgery 43.8% to 11.6%, cemented hip replacement 75% to 17.4%, non-cemented hip replacement 73.5% to 15.2%. The amount of packed red cells from homologous blood also fell: knee surgery 0.9 +/- 1.1 units to 0.2 +/- 0.5 units, cemented hip replacement 1.4 +/- 1 to 0.3 +/- 0.6 units, non-cemented hip surgery 1.8 +/- 1.3 to 0.3 +/- 0.7 units. The most commonly used techniques were preoperative donation and postoperative blood salvage from drains. The mean direct costs of hemotherapy in the prospective phase (homologous + autologous) were greater than in the retrospective phase, with the highest costs incurred in cases using autotransfusion (preoperative donation + blood salvage). The least differences in cost were seen in preoperative donation, which was also associated with the lowest rate of reinfusion in knee surgery. CONCLUSIONS: The autotransfusion program described is effective for lowering and even preventing exposure to homologous blood. The efficacy of the program is adequate, though it could be improved. The costs related to autologous hemotherapy are greater when combined autotransfusion techniques are used. When only one technique is used, the best cost-benefit ratio comes with preoperative donation.

[Anesthesia and lumbar epidural anesthesia in an infant with third-degree burns]. / Anestesia y analgesia epidural lumbar en un lactante afecto de quemaduras de tercer grado.

Epidural route is widely used in adults for injection of drugs, but it is not so often used in pediatric patients. We present the case of a 8 month old burned infant who received anesthesia and analgesia through a lumbar epidural catheter. The insertion of epidural catheter is described. Two surgical procedures were performed under epidural anesthesia with 0.5% bupivacaine an epinephrine 1:200.000 (2.5 mg/kg). 16 hours of postoperative analgesia was obtained with epidural morphine (0.05 mg/kg). No side effects were seen. We analyze the uses of epidural anesthesia in pediatric patients, the catheter care in the burned child, the hemodynamic changes observed during anesthesia and the results of peridural morphine.

[Comparison of venous pressure in the external jugular vein and the superior vena cava during anesthesia]. / Comparación de la presión venosa en vena yugular externa y vena cava superior durante la anestesia.

Venous pressure between the external jugular vein (EJV), and the superior caval vein (SCV) was compared in 15 patients, free of cardiorespiratory disease and undergoing abdominal surgery. In each patient data was taken in four different positions: A) anaesthetized patient in supine position and mechanical ventilation; B) anaesthetized patient in Trendelenburg position and mechanical ventilation; C) anaesthetized patient in anti-Trendelenburg and mechanical ventilation, and D) awake patient in supine position and spontaneous ventilation. A short, thick catheter with unique end lumen was used for EJV, and a long catheter from the basilic vein, to the SCV. Significant differences between mean and standard deviations of EJV and SCV were not founded. Linea correlation for the 4 positions was performed (r = 0.97, 0.91, 0.88 and 0.60 respectively) being significant for A-B y C positions. 4.5 cm H2O was the maximal difference obtained between SCV and EJV for A, B and C positions, and 10 cm H2O the maximal difference for the D position. The mean changes between the positions A-B, A-C and A-D was compared and significant differences (p less than or equal to 0.001) for A-C were seen, whereas A-B did not attain significant differences. We conclude that the EJV cannulation, with a short and thick catheter, allow the central venous pressure control during anaesthesia, in supine position, Trendelenburg and anti-Trendelenburg, but not during the recovery.