Prevención, diagnóstico y tratamiento de la hemorragia en cirugía cardiaca / Prevention, diagnosis and treatment of bleeding in cardiac surgery

Los pacientes operados de cirugía cardiaca tienen un riesgo elevado de hemorragia y transfusión. Este riesgo ha ido aumentando en las últimas décadas y, pese a ser una de las complicaciones más frecuentes y con mayor morbimortalidad asociadas a esta cirugía, sigue existiendo una gran variabilidad en cuanto a su manejo entre las instituciones. El uso de algoritmos de manejo de la hemorragia ha demostrado que disminuye los requerimientos de transfusión y por tanto parece imprescindible establecer protocolos que incluyan medidas preventivas, mecanismos eficaces de diagnóstico y algoritmos de tratamiento. Por otra parte, la aparición de nuevos fármacos procoagulantes y de nuevos sistemas de monitorización de la hemostasia están cambiando nuestras posibilidades diagnósticas y terapéuticas. En este trabajo se revisan varios aspectos relacionados con las causas, la prevención, el diagnóstico y el tratamiento de la hemorragia asociada a la cirugía cardiaca y se presenta una propuesta de algoritmo para su manejo(AU)

Patients undergoing cardiac surgery are at high risk of bleeding and transfusion. This risk has increased in recent years and is associated with increased morbidity and mortality. Moreover, despite being one of the most common complications associated with this surgery, there remains a large variability in its management between institutions. Implementation of algorithms for coagulation management has been shown to reduce transfusion requirements and therefore it seems essential to establish protocols that include preventive measures, effective mechanisms for diagnosis and treatment algorithms. On the other hand, the emergence of new drugs and the use of point of care coagulation monitoring systems, is changing our diagnostic and therapeutic options. This paper reviews several aspects related to the causes, diagnosis and treatment of bleeding associated with cardiac surgery and presents an algorithm for its management(AU)

[Prevention, diagnosis and treatment of bleeding in cardiac surgery]. / Prevención, diagnóstico y tratamiento de la hemorragia en cirugía cardiaca.

Patients undergoing cardiac surgery are at high risk of bleeding and transfusion. This risk has increased in recent years and is associated with increased morbidity and mortality. Moreover, despite being one of the most common complications associated with this surgery, there remains a large variability in its management between institutions. Implementation of algorithms for coagulation management has been shown to reduce transfusion requirements and therefore it seems essential to establish protocols that include preventive measures, effective mechanisms for diagnosis and treatment algorithms. On the other hand, the emergence of new drugs and the use of point of care coagulation monitoring systems, is changing our diagnostic and therapeutic options. This paper reviews several aspects related to the causes, diagnosis and treatment of bleeding associated with cardiac surgery and presents an algorithm for its management.

Experiencia con el uso de la mascarilla laríngea Proseal en pacientes sometidos a cirugía de derivación ventrículo peritoneal / Experience with the Proseal laryngeal mask in ventriculoperitoneal shunting

Objetivo: Transmitir la experiencia con el uso de la mascarilla laríngea Proseal (MLP) en el manejo de la vía aérea de los pacientes sometidos a cirugía de derivación ventrículo peritoneal, en cuanto a su utilidad, eficacia y seguridad. Pacientes y métodos: Revisamos retrospectivamente las historias de todos los pacientes sometidos a derivación ventrículo peritoneal y ventilados con MLP entre enero del 2006 y octubre del 2009. Registramos las características demográficas de los pacientes, valoración de la vía aérea, tipo de anestesia, calidad de ventilación y complicaciones perioperatorias. Resultados: Se incluyeron 43 pacientes, 8 (18,6%) cumplían algún criterio de vía aérea difícil (VAD). La inserción de la MLP fue posible en todos los pacientes. La ventilación fue óptima en 39 pacientes (91%), manteniendo valores entre 35-40 mmHg de CO2 telespiratorio y presiones de vía aérea por debajo de 25 cmH2O durante todo el procedimiento. Tres pacientes (7%) presentaron fugas en la vía aérea al ser colocados en la posición quirúrgica cervical lateral forzada y precisaron intubación orotraqueal para iniciar la cirugía. El tiempo quirúrgico promedio fue de 53 minutos. La educción ocurrió sin incidentes en todos los casos. Conclusiones: La MLP es útil en el manejo de la vía aérea de los pacientes intervenidos de derivación ventriculoperitoneal, aunque debido a la posición forzada del cuello, puede ser necesario ajustar la colocación de la mascarilla, y en algunos casos la intubación orotraqueal. Como en otros usos avanzados se requiere experiencia en su uso y tener disponible el material de VAD(AU)

Objective: To describe the use, utility, safety, and effectiveness of the Proseal laryngeal mask for airway management in patients undergoing ventriculoperitoneal shunting. Patients and methods: We retrospectively reviewed the records of all patients in whom the Proseal laryngeal mask was used during ventriculoperitoneal shunting between January 2006 and October 2009. Patient demographic characteristics, airway assessments, type of anesthesia, quality of ventilation, and perioperative complications were recorded. Results: Of the 43 patients included, 8 (18.6%) had at least 1 difficult airway criterion. We were able to insert the Proseal laryngeal mask in all patients. Ventilation was optimal in 39 (91%) patients, with maintenance of end-expiratory carbon dioxide pressures between 35 and 40 mm Hg and airway pressures above 25 cm H2O throughout the procedures. Air leaks developed in 3 cases (7%) when the patient was placed in a lateralcervical position for surgery; these patients required orotracheal intubation before surgery could begin. Mean duration of surgery was 53 minutes. Awakening occurred without incident in all cases. Conclusions: The Proseal laryngeal mask is useful for airway management in patients undergoing ventriculoperitoneal shunting. Due to the forced position of the neck, however, it may be necessary to reposition the mask or even proceed to orotracheal intubation in some cases. As is the case for other advanced uses, experience with the device is necessary. Material for managing a difficult airway should be on hand(AU)

[Experience with the proseal laryngeal mask in ventriculoperitoneal shunting]. / Experiencia con el uso de la mascarilla laríngea Proseal en pacientes sometidos a cirugía de derivación ventrículo peritoneal.

OBJECTIVE: To describe the use, utility, safety, and effectiveness of the Proseal laryngeal mask for airway management in patients undergoing ventriculoperitonea shunting. PATIENTS AND METHODS: We retrospectively reviewed the records of all patients in whom the Proseal laryngeal mask was used during ventriculoperitoneal shunting between January 2006 and October 2009. Patient demographic characteristics, airway assessments, type of anesthesia, quality of ventilation, and perioperative complications were recorded. RESULTS: Of the 43 patients included, 8 (18.6%) had at least 1 difficult airway criterion. We were able to insert the Proseal laryngeal mask in all patients. Ventilation was optimal in 39 (91%) patients, with maintenance of end-expiratory carbon dioxide pressures between 35 and 40 mm Hg and airway pressures above 25 cm H2O throughout the procedures. Air leaks developed in 3 cases (7%) when the patient was placed in a lateral-cervical position for surgery; these patients required orotracheal intubation before surgery could begin. Mean duration of surgery was 53 minutes. Awakening occurred without incident in all cases. CONCLUSIONS: The Proseal laryngeal mask is useful for airway management in patients undergoing ventriculoperitoneal shunting. Due to the forced position of the neck, however, it may be necessary to reposition the mask or even proceed to orotracheal intubation in some cases. As is the case for other advanced uses, experience with the device is necessary. Material for managing a difficult airway should be on hand.

[Prognostic factors for cancer patients in the postanesthetic recovery unit]. / Pronóstico de los pacientes oncológicos médicos ingresados en Reanimación.

OBJECTIVE: To assess the prognosis of cancer patients in an intensive care unit (ICU), to compare the capabilities of severity scoring systems to predict hospital death, and to improve prediction by adding new variables. PATIENTS AND METHODS: Cohort study in a medical-surgical ICU of a university hospital. Demographic and oncologic characteristics were collected along with death records for all nonsurgical cancer patients admitted between January 1995 and June 2000. Severity scores and risk of death were calculated. RESULTS: In the cohort of 250 patients studied, the hospital mortality rate was 58% and the ICU mortality rate was 38.8%. The best predictions were made with the third version of the Acute Physiology and Chronic Health Evaluation (APACHE III), the total maximum Sequential Organ Failure Assessment (SOFA) score, and the total maximum Multiple Organ Dysfunction Score (MODS). The APACHE II and the Simplified Acute Physiology Score (SAPS), version II, were good predictors, whereas the systems of the International Council on Mining and Metals overestimated hospital mortality and the Modality Prediction Model at 0 and 24 hours (MPM0 and MPM24) and the Logistic Organ Dysfunction System underestimated it. The total maximum SOFA and MODS scores had the greatest discriminating capability and the SOFA0, the MODS0, MPM0, and MPM24 had the poorest. All assessment systems except the APACHE III improved when we added new mortality-associated variables: prior functional status, diabetes, radiographic lung infiltrates, mechanical ventilation, and vasoactive support. CONCLUSIONS: Medical oncology patients should not all be denied intensive care. None of the systems assessed offer clinically relevant advantages for predicting hospital mortality in nonsurgical oncology patients in the ICU, although we recommend the SAPS II because it includes oncologic variables, is easy to score, and has good prognostic capability.

Pronóstico de los pacientes oncológicos médicos ingresados en Reanimación / Prognostic factors for cancer patients in the postanesthetic recovery unit

OBJETIVO: Valorar el pronóstico de los pacientes oncológicosmédicos ingresados en Reanimación (UCI); comparardistintos sistemas de medida de gravedad en sucapacidad de predecir la muerte hospitalaria; y mejorarsu capacidad predictiva con nuevas variables.PACIENTES Y MÉTODOS: Estudio de cohorte en una UCImédico-quirúrgica de un hospital universitario. Se recogieronlas características demográficas y oncológicas, junto conla mortalidad de todos los pacientes oncológicos médicosingresados entre enero de 1995 y junio del 2000. Se calcularonlas puntuaciones de gravedad y el riesgo de muerte.RESULTADOS: Se estudiaron 250 pacientes, con una mortalidadhospitalaria del 58% e intra-UCI del 38,8%. Lamejor capacidad predictiva se obtuvo con APACHE III,SOFA total máximo (TMS) y MODS total máximo (TMM).APACHE II y SAPS II predecían bien, mientras que ICMMsobreestimaba y MPM0, MPM24 y LODS infraestimabanla mortalidad hospitalaria. La mejor discriminación seobtuvo con TMS y TMM, y la peor con SOFA0, MODS0,MPM0 y MPM24. Todos los sistemas de medida de gravedad,excepto APACHE III, mejoraron su discriminación alañadir nuevas variables asociadas con la mortalidad: elestado funcional previo, diabetes, infiltrados pulmonaresradiológicos, ventilación mecánica y soporte vasoactivo.CONCLUSIONES: No se debe privar de los cuidadosintensivos a todos los pacientes oncológicos médicos.Ninguno de los sistemas evaluados ofrece ventajas clínicamenterelevantes para la predicción de la mortalidadhospitalaria en pacientes oncológicos médicos en la UCI,aunque recomendamos el uso del SAPS II porque incluyevariables oncológicas, es fácil de calcular y tienecaracterísticas predictivas buenas (AU)

OBJECTIVE: To assess the prognosis of cancer patients in an intensive care unit (ICU), to compare the capabilities of severity scoring systems to predict hospital death, and to improve prediction by adding new variables. PATIENTS AND METHODS: Cohort study in a medical–surgical ICU of a university hospital. Demographic and oncologic characteristics were collected along with death records for all nonsurgical cancer patients admitted between January 1995 and June 2000. Severity scores and risk of death were calculated. RESULTS: In the cohort of 250 patients studied, the hospital mortality rate was 58% and the ICU mortality rate was 38.8%. The best predictions were made with the third version of the Acute Physiology and Chronic Health Evaluation (APACHE III), the total maximum Sequential Organ Failure Assessment (SOFA) score, and the total maximum Multiple Organ Dysfunction Score (MODS). The APACHE II and the Simplified Acute Physiology Score (SAPS), version II, were good predictors, whereas the systems of the International Council on Mining and Metals overestimated hospital mortality and the Modality Prediction Model at 0 and 24 hours (MPM0 and MPM24) and the Logistic Organ Dysfunction System underestimated it. The total maximum SOFA and MODS scores had the greatest discriminating capability and the SOFA0, the MODS0, MPM0, and MPM24 had the poorest. All assessment systems except the APACHE III improved when we added new mortality-associated variables: prior functional status, diabetes, radiographic lung infiltrates, mechanical ventilation, and vasoactive support. CONCLUSIONS: Medical oncology patients should not all be denied intensive care. None of the systems assessed offer clinically relevant advantages for predicting hospital mortality in nonsurgical oncology patients in the ICU, although we recommend the SAPS II because it includes oncologic variables, is easy to score, and has good prognostic capability (AU)