Preoperative coagulation screening tests in pediatric patients: Clinical relevance and hemorrhagic outcomes of abnormal results.

PURPOSE: Coagulation screening tests in children are still frequently performed in many countries to evaluate bleeding risk. The aim of this study was to assess the management of unexpected prolongations of the activated partial thromboplastin time (APTT) and prothrombine time (PT) in children prior to elective surgery, and the perioperative hemorrhagic outcomes. METHODS: Children with prolonged APTT and/or PT who attended a preoperative anesthesia consultation from January 2013 to December 2018 were included. Patients were grouped according to whether they were referred to a Hematologist or were scheduled to undergo surgery without further investigation. The primary endpoint was to compare perioperative bleeding complications. RESULTS: 1835 children were screened for eligibility. 102 presented abnormal results (5.6%). Of them, 45% were referred to a Hematologist. Significant bleeding disorders were associated with a positive bleeding history, odds ratio of 51 (95% CI 4.8-538.5, P=.0011). No difference in perioperative hemorrhagic outcomes were found between the groups. An additional cost of 181 euros per patient and a preoperative median delay of 43 days was observed in patients referred to Hematology. CONCLUSIONS: Our results suggest that hematology referral has limited value in asymptomatic children with a prolonged APTT and/or PT. Hemorrhagic complications were similar among patients referred and not referred to Hematology. A positive personal or family bleeding history can help identify patients with a higher bleeding risk, thus it should guide the need for coagulation testing and hematology referral. Further efforts should be made to standardize preoperative bleeding assessments tools in children.

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)

Ácido acetilsalicílico y clonidina en el perioperatorio de pacientes intervenidos de cirugía no cardíaca (estudio POISE-2) / Perioperative acetylsalicylic acid and clonidine in noncardiac surgery patients (POISE-2 trial)

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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.

Errores de medicación y etiquetado de las jeringas / Medication errors and syringe labeling

Los problemas asociados con el tratamiento farmacológico en el entorno hospitalario son frecuentes y se asocian, en ocasiones, a daño para el paciente y mayores costes. La Declaración de Helsinki sobre seguridad del paciente en anestesiología incluye, entre otras recomendaciones, que todos los servicios de anestesia tengan protocolos para el adecuado etiquetado de las jeringas que contienen la medicación necesaria durante la anestesia. Recientemente, el Sistema Español de Notificación de Seguridad en Anestesia y Reanimación y la Sociedad Española de Anestesiología y Reanimación, junto al Instituto para el Uso Seguro de los Medicamentos-España, han publicado las recomendaciones de etiquetado de jeringas, líneas y envases de acuerdo a dichas normas. En este trabajo se revisan brevemente los errores de medicación en anestesia y el papel del etiquetado de la medicación en la seguridad del paciente (AU)

Drug-related problems are frequent in the hospital setting and sometimes lead to patient harm and increased costs. The “Helsinki Declaration on Patient Safety in Anesthesiology” includes, among other recommendations, that all anesthesia departments have protocols for the correct labelling of syringes containing the medication required for anesthesia. In accordance with this document, the Spanish System of Safety Reporting in Anesthesia and Resuscitation and the Spanish Society of Anesthesiology and Resuscitation, together with the Institute for Safe Medication Practices in Spain have recently published their recommendations on the labelling of syringes, lines and bags. The present article briefly reviews medication errors in anesthesia and the role of medication labelling in patient safety (AU)

Validation of a novel respiratory rate monitor based on exhaled humidity.

BACKGROUND: Postoperative monitoring of ventilation is largely restricted to the measurement of haemoglobin-oxygen saturation and respiratory rate (RR) derived from the ECG. measurement is inadequate when used with supplemental oxygen and ECG-derived RR is subject to artifacts. A new monitor measures RR by quantifying the humidity of exhaled air (respiR8(®)). METHODS: The accuracy of the system was tested using a breathing simulator. In healthy volunteers, the respiR8(®) monitor was compared with two other methods of measuring RR: capnometry and counting of thoracic breathing movements. The ability of the monitor to track changes in RR resulting from the infusion of 2.5 µg kg(-1) fentanyl was assessed and compared with RR measured from a validated flow measurement system. The RR in 50 postoperative patients measured with the respiR8(®) was compared with that derived from the ECG. RR values were compared by population-based Bland-Altman analyses. RESULTS: The respiR8(®) monitor was accurate in the range required in clinical practice. There was a close agreement between RR from respiR8(®), capnometry, and manual counting of respiratory movements without bias (limits of agreement ±1 bpm). The respiR8(®) monitor was well able to accurately track RR changes from fentanyl. In postoperative patients, RR from respiR8(®) and ECG had a bias of 1.7 (5.7) bpm due to greater RR values observed from the ECG due to artifacts. CONCLUSIONS: The respiR8(®) gives an accurate measurement of RR and is useful in postoperative care.

[Serious complications after pulmonary radiofrequency ablation: report of 2 cases]. / Dos casos de complicaciones graves tras radiofrecuencia pulmonar.

Radiofrequency ablation can be used to treat primary or metastatic pulmonary tumors when surgery is not indicated or involves high risk. Although this technique is less invasive than surgical resection, it is not free of risk for complications and adverse events, especially when it is used in patients with serious respiratory disease in whom comorbidity is common. We report 2 cases of serious complications. One was an intractable air leak that led to death. The other was a large hemothorax that was brought under control in the radiology procedure room. We review the literature on this technique as well as recommendations that contribute to making it as safe as possible.

Etiquetado de los medicamentos inyectables que se administran en anestesia. Recomendaciones de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), Sistema Español de Notificación en Seguridad en Anestesia y Reanimación (SENSAR) e Instituto para el Uso Seguro de los Medicamentos (ISMP-España) / No disponible

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Dos casos de complicaciones graves tras radiofrecuencia pulmonar / Serious complications after pulmonary radiofrequency ablation: report of 2 cases

La radiofrecuencia es una técnica alternativa para el tratamiento de tumores pulmonares, primarios o metastásicos, aplicable cuando la cirugía no está indicada o implica un elevado riesgo. Aunque menos agresiva que la resección quirúrgica, la técnica no está desprovista de posibles complicaciones y efectos secundarios, máxime cuando se aplica sobre pacientes con una patología respiratoria grave y frecuente comorbilidad. Presentamos dos complicaciones graves, una fuga aérea intratable que causó el fallecimiento del paciente y un hemotórax de gran cuantía que pudo ser controlado en la propia sala de radiología. Se revisa la literatura sobre el tema y las recomendaciones para hacer la técnica lo más segura posible(AU)

Radiofrequency ablation can be used to treat primary or metastatic pulmonary tumors when surgery is not indicated or involves high risk. Although this technique is less invasive than surgical resection, it is not free of risk for complications and adverse events, especially when it is used in patients with serious respiratory disease in whom comorbidity is common. We report 2 cases of serious complications. One was an intractable air leak that led to death. The other was a large hemothorax that was brought under control in the radiology procedure room. We review the literature on this technique as well as recommendations that contribute to making it as safe as possible(AU)

Fuego en el quirófano: ¿mito o realidad?, y... ¿qué podemos aprender? / No disponible

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[Intravenous remifentanyl for labor analgesia]. / Remifentanilo intravenoso para analgesia del trabajo del parto.

BACKGROUND: Intravenous remifentanil may be the preferred analgesic when regional techniques are contraindicated. OBJECTIVE: To perform a systematic review on the use of remifentanil for analgesia in labor. METHODS: We searched MEDLINE (January 1995-August 2007) for studies on obstetric analgesia with remifentanil. RESULTS: We found 32 references representing the use of remifentanil in 257 women in labor. In most cases, patients reported relief of pain and a high level of satisfaction, with no severe side effects in mothers or neonates. When compared with meperidine and nitrous oxide in clinical trials, remifentanil provided better analgesia with fewer adverse effects. CONCLUSION: Analgesia with intravenous remifentanil is more effective and safer than other alternatives to regional analgesic techniques in obstetrics. Nevertheless, the optimum system for infusing the drug must b e established and further studies of maternal and fetal safety should be carried out.

[Removal of an epidural catheter from a patient receiving anticoagulant and antiplatelet therapy]. / Retirada de catéter epidural en un paciente con doble antiagregación.

We describe the management of anticoagulant and antiplatelet therapy to reduce the risk of hematoma on removal of an epidural catheter. The situation arose following major vascular surgery complicated by an acute myocardial infarction that required anticoagulant and antiplatelet therapy following implantation of a coronary stent.

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.

Remifentanilo intravenoso para analgesia del trabajo del parto / Intravenous remifentanyl for labor analgesia

La analgesia con remifentanilo intravenoso podría serla primera alternativa a las técnicas regionales cuandoéstas se encuentran contraindicadas.OBJETIVO: Revisión sistemática de la bibliografía disponiblesobre el uso de remifentanilo como analgesia delparto. Método: Búsqueda en MEDLINE (enero 1995-marzo 2009) y revisión de bibliografía de las publicacionessobre la analgesia obstétrica con remifentanilo.RESULTADOS: Se encontraron 37 referencias con untotal de 281 embarazadas tratadas con remifentanilo. Enla mayoría de los casos las pacientes mostraron descensoen el dolor referido y alto grado de satisfacción, sinefectos secundarios graves en las madres o neonatos.Comparándolo en ensayos clínicos con meperidina y óxidonitroso, el remifentanilo obtuvo mejores resultados enanalgesia y menores efectos secundarios.CONCLUSIÓN: La analgesia con remifentanilo intravenosoes una alternativa más eficaz y segura que otras técnicasno regionales en la analgesia obstétrica. Aún debeestablecerse el sistema óptimo de administración y se precisanestudios más amplios de seguridad materno-fetal(AU)

BACKGROUND: Intravenous remifentanil may be the preferredanalgesic when regional techniques are contraindicated.OBJETIVE: To perform a systematic review on the use ofremifentanil for analgesia in labor.METHODS: We searched MEDLINE (January 1995-August 2007) for studies on obstetric analgesia withremifentanil.RESULTS: We found 32 references representing the use ofremifentanil in 257 women in labor. In most cases, patientsreported relief of pain and a high level of satisfaction, with nosevere side effects in mothers or neonates. When compared withmeperidine and nitrous oxide in clinical trials, remifentanilprovided better analgesia with fewer adverse effects.CONCLUSION: Analgesia with intravenous remifentanil ismore effective and safer than other alternatives to regionalanalgesic techniques in obstetrics. Nevertheless, the optimumsystem for infusing the drug must be established and furtherstudies of maternal and fetal safety should be carried out(AU)