Práctica actual de la anestesia regional en América del Sur: encuesta en línea / Current practice in regional anaesthesia in South America: an online survey

Objetivo. El objetivo de este estudio fue describir el perfil de utilización y las limitaciones del uso de la anestesia regional en países de América del Sur. Métodos. Tras la aprobación del comité de ética institucional, se envió un enlace a una encuesta en línea por e-mail a anestesiólogos de Argentina, Bolivia, Chile, Colombia, Panamá, Paraguay, Perú y Uruguay. La encuesta se procesó de forma anónima. Resultados. Se recibieron un total de 1.260 cuestionarios completos. El 97,6% de los anestesiólogos encuestados refiere utilizar anestesia regional en su práctica clínica habitual, el 66,9% realiza bloqueos de nervio periférico (BNP) con regularidad, el 21,6% usa técnicas de BNP continuo y un 4,6% usa catéteres estimulantes. La principal fuente de formación fueron los programas de residencia. En cuanto a los BNP más usados, los más comunes son el interescalénico (52,3%), el axilar (45,1%), el femoral (43,2%) y el de tobillo (43%). En cuanto a la técnica de neurolocalización, el 16% utiliza parestesia, el 44,2% estimulador de nervio periférico y un 18,1% ultrasonografía. Conclusiones. La anestesia regional y los BNP son de uso común entre los anestesiólogos de América del Sur. Cada país tiene su propio perfil de utilización y sus propias limitaciones para su uso. Dicho perfil debe ser tomado en cuenta a la hora de planificar las distintas formas de entrenamiento, en especial los programas de residencia (AU)

Objective. A survey was conducted in order to obtain a profile of the practice of regional anesthesia in South America, and determine the limitations of its use. Methods. After institutional ethics committee approval, a link to an online questionnaire was sent by e-mail to anaesthesiologists in Argentina, Bolivia, Chile, Colombia, Panamá, Paraguay, Perú, and Uruguay. The questionnaire was processed anonymously. Results. A total of 1,260 completed questionnaires were received. The results showed that 97.6% of the anaesthesiologists that responded used regional anaesthesia in clinical practice, 66.9% performed peripheral nerve block (PNB) regularly, 21.6% used continuous PNB techniques, and 4.6% used stimulating catheters. The primary source of training was residency programs. As regards PNB, the most common performed were interscalene (52.3%), axillary (45.1%), femoral (43.2%), and ankle block (43%). As regards the localisation technique employed, 16% used paraesthesia, 44.2% used a peripheral nerve stimulator, and 18.1% ultrasound guidance. Conclusions. Regional anaesthesia and PNB are commonly used among South American anaesthesiologists. Considering that each country has its own profile for use, this profile should guide training in clinical practice, especially in residency programs (AU)

Current practice in regional anaesthesia in South America: An online survey. / Práctica actual de la anestesia regional en América del Sur: encuesta en línea.

OBJECTIVE: A survey was conducted in order to obtain a profile of the practice of regional anesthesia in South America, and determine the limitations of its use. METHODS: After institutional ethics committee approval, a link to an online questionnaire was sent by e-mail to anaesthesiologists in Argentina, Bolivia, Chile, Colombia, Panamá, Paraguay, Perú, and Uruguay. The questionnaire was processed anonymously. RESULTS: A total of 1,260 completed questionnaires were received. The results showed that 97.6% of the anaesthesiologists that responded used regional anaesthesia in clinical practice, 66.9% performed peripheral nerve block (PNB) regularly, 21.6% used continuous PNB techniques, and 4.6% used stimulating catheters. The primary source of training was residency programs. As regards PNB, the most common performed were interscalene (52.3%), axillary (45.1%), femoral (43.2%), and ankle block (43%). As regards the localisation technique employed, 16% used paraesthesia, 44.2% used a peripheral nerve stimulator, and 18.1% ultrasound guidance. CONCLUSIONS: Regional anaesthesia and PNB are commonly used among South American anaesthesiologists. Considering that each country has its own profile for use, this profile should guide training in clinical practice, especially in residency programs.

A comparison between the HeRO graft and conventional arteriovenous grafts in hemodialysis patients.

Venous stenosis and occlusion are a major cause of vascular access dysfunction and failure. The HeRO Graft bypasses occlusion and traverses stenosis with outflow directly into the central venous circulation. A randomized, multicenter study was conducted to evaluate the efficacy and safety of the HeRO Graft relative to conventional AV grafts. The design was to enroll 143 patients in a 2:1 randomization ratio between HeRO and conventional AV control groups. Data on 72 subjects (52 HeRO Graft and 20 AV graft controls) were obtained. The HeRO Graft and control cohorts were comparable in baseline characteristics. Adequacy of dialysis, bacteremia rates, and adverse events were consistent between groups. Twelve month Kaplan-Meier estimates for primary and secondary patency rates were 34.8% and 67.6% in the HeRO Graft cohort, and 30.6% and 58.4% in the control cohort. There was no statistical difference in terms of patency between groups. The rates of intervention were 2.2/year for HeRO Graft and 1.6/year for the control (p = 0.100). Median days to loss of secondary patency was 238 for HeRO Graft versus 102 for the control (p = 0.032). The HeRO Graft appears to provide similar patency, adequacy of dialysis, and bacteremia rates to those of conventional AV grafts.

Repair of high-risk incisional hernias and traumatic abdominal wall defects with porcine mesh.

Complex ventral hernias represent a significant challenge to surgeons. We hypothesized that a wide underlay technique in combination with a novel biologic mesh would result in repair with a low recurrence rate. Medical records of patients undergoing ventral herniorrhaphy with XenMatrix biologic mesh were evaluated. All patients were evaluated for hernia recurrence both immediately and after 2 to 3 years. There were 57 patients included in the study. The overall recurrence rate was 7.2 per cent; however, all recurrences were early and were likely technical failures. The average duration of follow-up was 30.6 months with no further recurrences after the early technical failures. The average number of previous recurrences was 1.5. Fascial closure was obtained over the mesh in 84 per cent of patients, with component separation being necessary in 36 per cent of patients. Lack of fascial reapproximation over the mesh was associated with early recurrence (0 vs 55%, P < 0.0001). Complex ventral hernias can be repaired with a low recurrence rate. Our technique in combination with the XenMatrix biologic mesh provides for durable repair. Whenever possible, the fascia should be closed above the underlay mesh, because this technique provides a more durable repair than using the mesh as a "fascial bridge".

A systematic method for follow-up improves removal rates for retrievable inferior vena cava filters in a trauma patient population.

BACKGROUND: Retrievable inferior vena cava filters (rIVCF) reduce the short-term risk of pulmonary embolism without the filter and inferior vena cava (IVC) thrombosis that have been reported with the use of permanent filters. Studies have shown that most rIVCFs are not removed, leaving patients at risk for thrombotic complications of rIVCF retention. We hypothesize that the application of a systematic follow-up for rIVCF will improve filter removal rates, providing patients short-term prophylaxis from pulmonary embolism whereas avoiding complications of permanent filter retention. METHODS: The trauma registry of a Level I trauma center was queried to identify patients who underwent placement of IVCFs between January 1, 2003, and June 30, 2008. The medical records were reviewed and details of the patient's injuries, indications for filter placement, repositioning, and retrieval were collected. Radiographic images were reviewed to confirm ultimate filter retention or removal. RESULTS: Between January 1, 2003, and June 30, 2008, rIVCFs were placed in 118 patients, 44% had known venous thromboembolic event. Three patients died before rIVCFs could be considered for extraction, leaving 115 patients for evaluation. Filters were removed in 80 patients (70%) overall. Of the 35 patients in whom filters were not removed, 11 were lost to follow-up, 4 failed removal attempts, and 20 had indications for filter retention. The rIVCFs were retrieved in 75% of patients not lost to follow-up and 92% of patients who did not have contraindications for filter removal. CONCLUSION: A dedicated system for following-up patients with rIVCFs markedly improves removal rates of retrievable filters.

Predicting trauma admissions: the effect of weather, weekday, and other variables.

One of the challenges all hospitals, especially designated trauma centers, face is how to make sure they have adequate staffing on various days of the week and at various times of the year. A number of studies have explored whether factors such as weather, temporal variation, holidays, and events that draw mass gatherings may be useful for predicting patient volume. This article looks at the effects of weather, mass gatherings, and calendar variables on daily trauma admissions at the three Level I trauma hospitals in the Minneapolis-St. Paul metropolitan area. Using ARIMA statistical modeling, we found that weekends, summer, lack of rain, and snowfall were all predictive of daily trauma admissions; holidays and mass gatherings such as sporting events were not. The forecasting model was successful in reflecting the pattern of trauma admissions; however, it's usefulness was limited in that the predicted range of daily trauma admissions was much narrower than the observed number of admissions. Nonetheless, the observed pattern of increased admission in the summer months and year-round on Saturdays should be helpful in resource planning.

Risk factors and patterns of injury in snowmobile crashes.

OBJECTIVE: To evaluate risk factors for snowmobile injury and patterns of injury. METHODS: We performed a retrospective analysis of patients with snowmobile injury at three trauma centers. Data were collected from trauma databases and patients charts from January 1988 through April 1996; we obtained statistics from the Minnesota Department of Natural Resources for comparison purposes. RESULTS: There were 274 patients identified. The average age was 29 years (SD 12, range 1.6-77). The male:female ratio was 6.6:1. Helmets were used in 35%, not used in 10%, and not reported in 55%. Ethanol consumption was reported in 44% of patients. The average speed of the snowmobile at the time of the accident, when reported, was 47 mph/75 kph (n = 103, range 10-100 mph/16-166 kph). Of these patients, 26% (n = 27) reported a speed in excess of the legal limit (55 mph/88 kph). Accidents were more common in the afternoon and evening hours, and most accidents were caused by the snowmobile striking terrain or man-made objects. Mortality rate was 3.6% for this patient group (10 of 274). The average injury severity score (ISS) was 15 (SD 11). The average Glasgow Coma Score (GCS) was 14. The average number of patients who went to the intensive care unit and the total lengths of stay were 2 +/- 5 and 8 +/- 9 days, respectively. Neither GCS nor ISS correlated with reported speed. The frequencies of different types of injuries are as follows: fractures of upper and lower extremities (n = 184), serious head injury (n = 92), facial fractures or soft tissue injury to head or neck (n = 88), thoracic injury (n = 80), spine injuries (n = 50), intraabdominal injuries (n = 41), and pelvic fractures (n = 31). CONCLUSIONS: Snowmobile injuries are related to ethanol use and the high speed attained by the newer generation of snowmobiles. Extremity fractures were a common component of snowmobile injury in this series, and rates of such injuries are similar to rates injuries in motorcycle accidents in states with helmet laws. Efforts at prevention of snowmobile injuries should be targeted at rider education and enforcement of alcohol restrictions.

[Myocardial revascularization surgery without extracorporeal circulation. (Preliminary experience)]. / Cirugía de revascularización del miocardio sin la asistencia de circulación extracorpórea. (Experiencia preliminar).

Two hundred and three (203) open heart surgical procedures have been performed at the Complejo Hospitalario Metropolitano, from January 1997 to august 1998; Hundred and twenty-three (123) were of myocardial revascularization and twenty-four (24) of these patients were selected for revascularization without the assistance of the extracorporeal circulation machine. They were patients with chronic stable angina and had lesions of more than 95% in the descending anterior artery, high ventriculo-lateral branch and right coronary artery up to the crux cordis. In nineteen (19) patients the surgical approach was though a medical sternotomy; in four (4) through a left anterolateral thoracostomy and in three (3) of these patients a transverse sternotomy was added. There were no deaths perioperatively and at thirty (30) days there were no evidences of new Q waves or residual angina. With this technique, the time in the Intensive Care Unit and in the hospital has diminished; the patients also required less time in mechanical ventilation; less vasoactive amines are needed. In the operating room less equipment is necessary and the costs are significantly lower.

[Changes in the pain produced by the peripheral venous injection of propofol when it is combined with lidocaine or fentanyl]. / Modificación del dolor producido con la inyección venosa periférica de Propofol al combinarlo con Lidocaína o Fentanyl.

The author studied the use of intravenous Propofol for the relief of pain. He demonstrated that Propofol and 10 mg of Lidocaine intravenously decreased moderate or severe pain from 31.6% to 9% and that increasing the dose of Lidocaine did not significantly decrease the pain further. Fentanyl did not produce a statistically significant further diminution of the pain from the level of relief obtained with Propofol.

[New dosage of heparin during cardiac surgery with extracorporeal circulation]. / Nueva dosis de heparina durante cirugía cardíaca con circulación extracorpórea.

We studied the effect of 4 mg/kg of heparine, measured with the activity cosgulation time (hemocron), in cardiac surgical patients operated with extracorporeal circulation. The basal TCA was 118 +/- 13 seg with this doses of heparine. The majority of the patients (83.33%) with 4 mg/kg of heparine had more than 450 seg in comparison with the number of patients (30%) who had more than 450 seg with 3 mg/kg of heparine.

[Hypoxemia after general anesthesia in healthy adults]. / Hipoxemia después de anestesia general en adultos sanos.

It has been shown that a variable percentage of patients who receive a general anesthetic are significantly hypoxemic when they arrive at the recovery room. Pulse oximetry has proved to be a reliable method to determine arterial oxygen saturation when compared to arterial or mixed venous blood oxygen saturation measurements. The authors determined the incidence and severity of hypoxemia by pulse oximetry in 45 healthy adult patients, (non obese, non smokers) who underwent non thoracic surgery under general anesthesia. Arterial oxygen saturation was measured without premedication before surgery (control), when they arrived at the recovery room, and 5 and 15 minutes later. The axillary temperature was taken at the same times. The results were expressed as the median and standard deviation and were analyzed with Student T Test, and p LO.05 was considered significant. Nine patients (20%) showed unacceptable oxygen saturation when they arrived at the recovery room (88.4 +/- 2.50%, LO.05). All patients showed significant hypothermia (35.3 +/- 0.54 degrees C). The authors conclude that a significant number of healthy adult patients who are given a general anesthetic show severe hypoxemia when they arrive at the recovery room. The severe hypothermia found in these patients can aggravate the hypoxemia. They consider it is mandatory to control the temperature of and to administer oxygen in the recovery room to all patients who receive a general anesthetic.

Experience with the biofragmentable anastomotic ring (BAR) in bowel preoperatively irradiated with 6000 rad.

Previous studies from the authors' laboratory using the biodegradable anastomotic ring (BAR) have demonstrated the safety of this device in animals irradiated preoperatively with the equivalent of 5000 rad; sutured, stapled, and BAR anastomoses all had leak rates of 10 percent or less in this setting. This study was undertaken to assess the safety of the BAR after irradiation with the equivalent of 6000 rad. Thirteen mongrel dogs underwent preoperative irradiation to the rectum and rectosigmoid, receiving 6000 rad according to the nominal standard dose equation. After a three-week rest period, each dog underwent anterior resection of the rectosigmoid and anastomosis with the BAR. The anastomoses were evaluated for early and late healing and anastomotic leaks. The results were compared with previous data from the authors' laboratory using an identical model. Radiographic leaks were found in 7 of 10 sutured anastomoses, 8 of 10 stapled anastomoses, and 3 of 13 BAR anastomoses (P less than 0.01). Comparative clinical leaks were 5 of 10 for sutured, 5 of 10 for stapled, and 3 of 13 for BAR anastomoses. These data suggest that the BAR may offer added safety to an anastomosis after preoperative irradiation. Whether this effect is due to the atraumatic technique of placing the device, improved blood flow to the anastomotic margins, or other factors, is still underdetermined.