Patient Blood Management en artroplastia primaria de cadera y rodilla. Encuesta entre los investigadores del estudio POWER.2 / Patient Blood Management for primary hip and knee replacement. A survey among POWER.2 study researchers

ANTECEDENTES: La implementación de los programas Patient Blood Management (PBM) es variable en Europa, incluso en centros en los que estos programas están bien establecidos, donde existe variabilidad en cuanto a prácticas transfusionales. OBJETIVOS Y MÉTODOS: Realizamos una encuesta para valorar la práctica actual sobre PBM perioperatoria en pacientes programados para artroplastia total de cadera y rodilla, entre los investigadores involucrados en el Estudio POWER.2 en España (estudio observacional prospectivo que evaluaba las vías de recuperación intensificada en cirugía ortopédica). RESULTADOS: Se obtuvo un total de 322 respuestas (37,8%). El 50% de los respondedores revisaban los niveles de hemoglobina, al menos 4 semanas antes de la cirugía; el 35% trataba a todos los pacientes anémicos, aunque el 99,7% consideraba que la detección y tratamiento de la anemia preoperatoria podrían influir en los resultados postoperatorios. La falta de infraestructuras (76%) y la falta de tiempo (51%) fueron los principales motivos para no tratar a los pacientes anémicos. El estatus del hierro es revisado antes de la cirugía por el 19% de manera rutinaria, y el 36% lo evalúa únicamente en pacientes anémicos. Hb<9,9g/dl es el valor umbral para demorar la cirugía para el 61% de los clínicos, y el 22% consideraría transfundir preoperatoriamente a los pacientes clínicamente estables sin sangrado activo. El valor umbral para transfundir a los pacientes sin enfermedad cardiovascular es 8g/dl para el 43% y 7g/dl para el 34% de los respondedores; el 75% de los facultativos considera que utiliza «umbrales restrictivos», y el 90% sigue la política transfusional uno a uno (single unit). CONCLUSIONES: Los resultados de nuestra encuesta muestran la variabilidad en la práctica clínica en PBM en cirugía ortopédica mayor, a pesar de ser el tipo de cirugía con más tradición en estos programas

BACKGROUND: Implementation of Patient Blood Management programs remain variable in Europe, and even in centres with well-established PBM programs variability exists in transfusion practices. OBJECTIBES AND METHODS: We conducted a survey in order to assess current practice in perioperative Patient Blood Management in patients undergoing total hip and knee replacement among researchers involved in POWER.2 Study in Spain (an observational prospective study evaluating enhanced recovery pathways in orthopaedic surgery). RESULTS: A total of 322 responses were obtained (37.8%). Half of responders check Haemoglobin levels in patients at least 4 weeks before surgery; 35% treat all anaemic patients, although 99.7% consider detection and treatment of preoperative anaemia could influence the postoperative outcomes. Lack of infrastructure (76%) and lack of time (51%) are the main stated reasons not to treat anaemic patients. Iron status is routinely checked by 19% before surgery, and 36% evaluate it solely in the anaemic patient. Hb<9.9 g/dl is the threshold to delay surgery for 61% of clinicians, and 22% would consider transfusing preoperatively clinically stable patients without active bleeding. The threshold to transfuse patients without cardiovascular disease is 8 g/dl for 43%, and 7 g/dl for 34% of the responders; 75% of clinicians consider they use "restrictive thresholds", and 90% follow the single unit transfusion policy. CONCLUSIONS: The results of our survey show variability in clinical practice in Patient Blood Management in major orthopaedic surgery, despite being the surgery with the greatest tradition in these programs

Patient Blood Management for primary hip and knee replacement. A survey among POWER.2 study researchers. / Patient Blood Management en artroplastia primaria de cadera y rodilla. Encuesta entre los investigadores del estudio POWER.2.

BACKGROUND: Implementation of Patient Blood Management programs remain variable in Europe, and even in centres with well-established PBM programs variability exists in transfusion practices. OBJECTIVES AND METHODS: We conducted a survey in order to assess current practice in perioperative Patient Blood Management in patients undergoing total hip and knee replacement among researchers involved in POWER.2 Study in Spain (an observational prospective study evaluating enhanced recovery pathways in orthopaedic surgery). RESULTS: A total of 322 responses were obtained (37.8%). Half of responders check Haemoglobin levels in patients at least 4 weeks before surgery; 35% treat all anaemic patients, although 99.7% consider detection and treatment of preoperative anaemia could influence the postoperative outcomes. Lack of infrastructure (76%) and lack of time (51%) are the main stated reasons not to treat anaemic patients. Iron status is routinely checked by 19% before surgery, and 36% evaluate it solely in the anaemic patient. Hb<9.9 g/dl is the threshold to delay surgery for 61% of clinicians, and 22% would consider transfusing preoperatively clinically stable patients without active bleeding. The threshold to transfuse patients without cardiovascular disease is 8 g/dl for 43%, and 7 g/dl for 34% of the responders; 75% of clinicians consider they use "restrictive thresholds", and 90% follow the single unit transfusion policy. CONCLUSIONS: The results of our survey show variability in clinical practice in Patient Blood Management in major orthopaedic surgery, despite being the surgery with the greatest tradition in these programs.

Colloids versus crystalloids in the prevention of hypotension induced by spinal anesthesia in elective cesarean section. A systematic review and meta-analysis.

The incidence of hypotension associated to spinal anesthesia in elective cesarean section is high. To determine the effects of colloids and crystalloids in the incidence of hypotension induced by spinal anesthesia in elective cesarean section, an attempt was made to define which type of fluid and what total volume should be administered. Following the PRISMA methodology a systematic review and meta-analysis were carried out. A systematic Medline/PubMed, EMBASE and Cochrane Library search was made to identify trials where women were scheduled for elective cesarean section with spinal anesthesia and volume loading (preload or co-load). The primary outcome was the incidence of hypotension. Stratification into subgroups was made for the primary outcome according to the type of colloid administered, differentiating those studies employing new generation colloids (HES 6% 130/0.4) from those not using such colloids, based on the volume of colloid administered and the combination of a vasopressor. The secondary outcome was the incidence of intraoperative nausea and vomiting. Two-hundred and twenty-seven controlled clinical trials were analyzed; eleven randomized clinical trials including 990 patients were included. A significative decrease of incidence of hypotension associated to spinal anesthesia was observed with the use of colloids compared to crystalloids (RR [95% CI] 0.70 [0.53-0.92], P=0.01). However, there was no difference between crystalloid and colloid in the risk of intraoperative nausea and vomiting (RR [95% CI] 0.75 [0.41-1.38]; P=0.33). This meta-analysis shows colloid administration to significantly reduce the incidence of hypotension associated to spinal anesthesia in elective cesarean section compared with of crystalloid use.

[Monitoring oxygen consumption in energy metabolism in pediatric anesthesia: clinical utility]. / Monitorización del consumo metabólico de oxígeno en anestesia pediátrica. Utilidad clínica.

OBJECTIVES: To determine changes in oxygen consumption as a marker of energy metabolism during general inhaled anesthesia in pediatric patients and to identify factors that might influence consumption. MATERIAL AND METHODS: Prospective, observational, double-blind study in children under inhaled anesthesia in spontaneous ventilation. We monitored heart rate electrocardiogram, noninvasive blood pressure, respiratory frequency, carbon dioxide (CO2) end-expiratory pressure, oxygen saturation by pulse oximetry, state entropy, response entropy, esophageal temperature, and (by indirect calorimetry) oxygen consumption and the respiratory quotient. Capillary blood was extracted every 5 minutes to determine lactate concentration. RESULTS: Thirty-six patients (ASA 1-2) between 5 and 11 years old were included. Mean (SD) oxygen consumption was 0.6 (0.12) mL x kg(-1)min(-1) at baseline, 5.3 (03) mL x kg(-1) min(-1) during maintenance of anesthesia, and 8.1 (1.1) mL x kg(-1) min(-1) on awakening. A progressive increase was detected in lactic acid concentration, from a baseline mean of 0.8 (0.1) mmol/L to 2.2 (0.9) mmol/L half an hour later; the change was unrelated to oxygen consumption. After correcting the flow of normal saline solution to 0.9%, a significant increase in oxygen consumption (P < .05) was detected. Factors that were significantly correlated (P < 0.1 and r of +/- 0.95) were temperature (oxygen consumption decreased > 10% for each degree centigrade decrease), inspired oxygen fraction > 0.8; sharp changes in the expired CO2 fraction exceeding 2 standard deviations (+/- 6), use of nitrous oxide in the gas mix (inspired nitrous oxide fraction > 20%), the length of the sampling line, and increased respiratory frequency. A model with 3 factors was constructed to explain the kinetics of oxygen consumption during anesthesia. CONCLUSIONS: Oxygen consumption monitoring may provide an indirect indicator of homeostatic changes during surgery. The ideal system for carrying out such monitoring during anesthesia remains to be found, and the values to guide the anesthesiologist in deciding whether or not to intervene immediately still need to be determined.