Search

Resumen Introducción El tumor retroperitoneal con extensión a la vena cava inferior (VCI) más frecuente es el carcinoma de células renales. Tiene una supervivencia a 5 años de hasta un 32% cuando se realiza nefrectomía radical y trombectomía. El tratamiento quirúrgico es complejo y puede necesitar el soporte de circulación extracorpórea y parada circulatoria e hipotermia. Métodos Estudio descriptivo, retrospectivo, mediante análisis de datos de pacientes intervenidos de tumores con invasión de la VCI entre 1992 y 2015. Se recogieron datos demográficos, tumorales, de técnica quirúrgica, intraoperatorios, posquirúrgicos y de mortalidad. Las variables cuantitativas se presentan como media±desviación estándar y las cualitativas como número de casos. La supervivencia se registró por curvas de Kaplan-Meier. Resultados Se presentan 18 pacientes con tumores retroperitoneales (carcinoma de células renales 66%) con extensión a VCI. Se utilizó circulación extracorpórea en 13casos y paro circulatorio en 5. Doce pacientes tuvieron un aumento de creatinina >0,3mg/dl sin precisar terapias de sustitución renal. La estancia en la Unidad de Cuidados Críticos fue de 2,8±2 días. La supervivencia media fue de 791±633 días, con una mortalidad a los 30 días del 11% y a los 5 años del 72%. Conclusiones El tumor con extensión a VCI presenta un desafío quirúrgico. La supervivencia a corto plazo es elevada; a largo plazo es limitada por el proceso neoplásico. Introduction The most frequent tumor located at the inferior vena cava (IVC) is renal cell carcinoma. When radical nephrectomy and thrombectomy is performed, survival is 32%. It is a complex surgery that may require extracorporeal circulation support and hypothermic circulatory arrest. Methods Retrospective descriptive study via data analysis of patients operated on tumors with IVC invasion within 1992 and 2015. The data collected included demographic, tumor, surgical technique, intraoperative, post-surgical and mortality date. The quantitative variables are presented as mean±standard desviation, and the qualitative variables as number of cases. Survival has been registred by means of the Kaplan-Meier curves. Results We present 18 patients with IVC tumor extension (renal cell carcinoma 66%). The extracorporeal circulation was used in 13 of the cases and circulatory arrest in 5. Twelve patients showed an increase in creatinine>0.3mg/dl without requiring renal replacement therapy. The stay in Intensive Care Unit was 2.8±2 days. The mean survival rate was 791±633 days, with a 30-day mortality rate of 11% and a 5-year mortality rate of 72%. Conclusions Tumors with IVC extension are a rare pathology that poses a surgical challenge and requires a multidisciplinary team for its management. Short-term survival is high, being limited by the neoplastic process in the long term.

Resumen La ecocardiografía transesofágica en la cirugía mínimamente invasiva mitral es una técnica imprescindible en la actualidad. La diversa información que nos ofrece durante todo el proceso quirúrgico implementa la monitorización continua intraoperatoria, ayuda al cirujano a guiar su actuación ante campos quirúrgicos de escasa visualización, permite valorar exhaustivamente la enfermedad valvular y diagnosticar potenciales complicaciones derivadas de la cirugía. En este trabajo se revisan y concretan los aspectos principales y específicos de esta técnica como soporte a la cirugía mini-invasiva mitral. Transoesophageal echocardiography is an essential technique in minimally invasive mitral surgery. It provides continuous haemodynamic monitoring for the anaesthetic management and provides assistance to the surgeons during the different stages of the procedure when visibility can be limited. This paper reviews the value and role of transoesophageal echocardiography during minimally invasive mitral valve surgery.

ResumenLa cirugía cardiaca con circulación extracorpórea (CEC) se asocia con un aumento de sangrado postoperatorio, consumo de productos hemáticos y número de reexploraciones quirúrgicas. Actualmente, del 50% de los pacientes de cirugía cardiaca transfundidos, el 20% tiene un sangrado significativo y el 5% requiere reoperación por sangrado postoperatorio. Este aumento de hemoderivados aumenta la morbimortalidad, la estancia hospitalaria y los costes sanitarios. Las causas de la coagulopatía después de la CEC son multifactoriales: la hemodilución, la exposición de la sangre a los circuitos de la CEC, la destrucción de las plaquetas y la activación de la trombina. Las directrices de las sociedades científicas americanas y europeas recomiendan el uso de ácido tranexámico (AT) para reducir la hemorragia perioperatoria en la cirugía cardiaca. El AT ahorra un promedio de 300ml de sangre con una reducción relativa del 32% al recibir una transfusión. Las intervenciones con CEC sin el uso de fármacos antifibrinolíticos se caracteriza por un aumento de la pérdida de sangre, reoperaciones y la transfusión de productos sanguíneos en comparación con otras intervenciones en donde se han utilizado antifibrinolíticos. El principal problema con el uso de AT se encuentra en los muchos patrones y diferentes dosis de administración, que varían de un artículo a otro. El objetivo de este artículo es alertar sobre el uso de altas dosis de AT y sus consecuencias, según las últimas recomendaciones de la literatura al respecto.AbstractCardiac surgery with cardiopulmonary bypass (CPB) is associated with increased postoperative bleeding, blood product consumption, and the number of surgical re-explorations. Currently, of the 50% of transfused patients from cardiac surgery, 20% have significant bleeding, and 5% required reoperation for postoperative bleeding. This increased consumption of blood increases morbidity, mortality, hospital stay, and healthcare costs. The causes of coagulopathy after CPB are multifactorial: hemodilution, blood exposure to CPB circuits, destruction of platelets, and thrombin activation. The guidelines of the American and European scientific societies recommend the use of tranexamic acid (TA) to reduce perioperative bleeding in cardiac surgery. TA saves an average of 300ml of blood, with a relative reduction of 32% receiving transfusion. CS interventions with CPB carried out without using any antifibrinolytic drug is characterized by increased blood loss, increased reoperations for bleeding, and increased transfusion and blood products, when compared to other interventions where antifibrinolytic were used. The main problem with the use of TA lies in the many administration patterns and different doses,, which vary from one article to another. The aim of this article is to alert on the use of high doses of TA and its consequences according to the latest recommendations in the literature.

Background and goal of study Postoperative myocardial infarction is a serious and frequent complication of cardiac surgery. Nonetheless, diagnosis in this context is occasionally challenging. We sought to evaluate the kinetics and diagnostic accuracy of the new biomarker “heart-type fatty acid-binding protein” (h-FABP) in the early detection of myocardial injury in patients undergoing off-pump coronary artery bypass grafting, compared with classical biomarkers. Materials and methods A prospective study was conducted on 17 consecutive patients who underwent off-pump coronary artery bypass grafting during a 2-month period. Blood samples were drawn for measurement of myocardial ischemic injury biomarkers (h-FABP, troponin, creatine kinase [CK] and CK-MB), at baseline (T1), immediate post-coronary artery bypass grafting (T2), on ICU admission (T3), and after 4 (T4), 8 (T5), 24 (T6) and 48 h (T7). Perioperative ischemic complications, defined according to electrocardiographic, echocardiographic and hemodynamic criteria, were recorded. Results Earlier peak biochemical marker plasma values occurred at T4 with troponin (2.9 ± 5.2 ng/mL), and at T5 with h-FABP (37.9 ± 55.5 ng/mL). Maximum values of CK and CK-MB occurred later, both in T6 (741 ± 779 and 37 ± 51 U/L, respectively). The optimized cut-off obtained for h-FABP was 19 ng/mL, providing a sensitivity and specificity of 77 and 75%, respectively, for diagnosis of perioperative ischemic injury, with an area under the ROC curve for h-FABP of 0.83 (95% CI 0.6–1.0) vs. 0.63 (95% CI 0.33–0.83) for troponin. This cut-off value for h-FABP is reached on average at T2 (mean value of h-FABP at T2: 18.9 ± 21.5 ng/mL). Conclusion This is the first study evaluating the kinetics of h-FABP biomarker in perioperative off-pump coronary artery bypass grafting, and the cut-off value established could help to extend earlier detection of myocardial ischemia in this context.

ResumenLa ecocardiografía transesofágica constituye una herramienta diagnóstica esencial en la patología de la aorta, permitiendo un diagnóstico y la instauración de un tratamiento médico o quirúrgico precoz, así como la monitorización durante la cirugía. La ecocardiografía permite un diagnóstico rápido, preciso y aplicable a pacientes inestables hemodinámicamente y con dificultades para ser trasladados para otras pruebas de imagen. El interés en la formación y el reconocimiento de las imágenes ecocardiográficas por parte del cirujano cardiovascular es cada vez mayor. En este artículo revisaremos la identificación de las distintas entidades patológicas aórticas mediante la ecocardiografía transesofágica (disección aórtica aguda, hematoma intramural, úlcera penetrante, aneurismas aórticos, aneurismas de seno de Valsalva, ateroesclerosis aórtica y traumatismos aórticos).AbstractTransesophageal echocardiography is an essential diagnostic tool in the pathology of the aorta allowing early diagnosis and establishment of medical and early surgical treatment and monitoring during surgery. Echocardiography enables fast and accurate diagnoses and it is applicable to haemodynamically unstable patients with difficulties to be transferred for different image test. There is an increasing interest in training and recognition of echocardiographic images by the cardiovascular surgeons. This article will review the identification of aortic pathologies by transesophageal echocardiography (acute aortic dissection, intramural hematoma, penetrating ulcer, aortic aneurysms, aneurysm of sinus of Valsalva, aortic atherosclerosis and aortic trauma).

Study objective: Assessing length of stay in Intensive Care Units (LOSI) after mitral valve surgery is challenging due to wide spectrum of comorbidities and cardiovascular procedures. The study aim was to elaborate a predictive model in order to identify risk factors and predict the expected resources consumption for better monitoring for caregivers and patients. Design: Retrospective study of prospectively collected data during 2009 and 2013. Setting: University teaching hospital. Patients: We studied all consecutive adult patients (≥ 18 years) who underwent elective mitral valve surgery. We enrolled 212 patients. Measurements: Our outcome variable LOSI. Comorbidities, postoperative morbidity and mortality were collected during the perioperative period. Multivariate analysis was used and data was studied as an additive model to assess the associations between the variables and the presence of correlations between them. Generalized additive model was fitted with least squared means estimated by the additive model due the non linearity of Euroscore I. Histograms of the residuals were examined visually to assess the fit of the models above. The model was selected using the statistical software R version 3.0.2 (R Foundation, Vienna, Austria). Results: Median of LOSI was 4 days (Interquantile range 2 to 4 days). The model for LOSI includes: infection post surgery (p

OBJECTIVES: We aim to describe our experience in coronary artery bypass grafting (CABG) with or without cardiopulmonary bypass by comparing intraoperative and postoperative outcomes. METHODS: From January 1993 to June 2013, 3097 patients underwent consecutive emergency and scheduled CABG surgery. A total of 1770 patients underwent on-pump CABG (ONCABG) and 1327 off-pump CABG (OPCABG). A propensity score matching was performed to identify appropriate matched-pair patients; univariable and multivariable logistic regression analyses were performed to assess significant predictors of hospital and 30-day morbidity and mortality composite end-points. Morbidity composite end-point was defined as any renal, pulmonary, cardiovascular and neurological complication that occurred during hospital stay. We collected all-cause mortality data during the study period. RESULTS: We identified 1004 patients in each group. There were no significant differences in thirty day mortality, 2.8 vs 3.8%, in OPCABG and ONCABG, respectively (P = 0.21). Cardiovascular, neurological, respiratory and renal complications were more frequent in the ONCABG group: 13.9 vs 8.7% (P < 0.001), 3.9 vs 2.2% (P = 0.03), 13.5 vs 7.5% (P < 0.001), 7.1 vs 5.3% (P = 0.095), respectively. The long-term all-cause mortality rate was 12.3 vs 12.9% in the OPCABG versus ONCABG group (P = 0.42), respectively. In both uni- and multivariable analysis preoperative renal failure, chronic obstructive pulmonary disease and ONCABG were independent predictors of mortality and morbidity composite end-points. CONCLUSIONS: OPCABG is associated with less postoperative morbimortality and shorter hospital and intensive care unit length of stay. ONCABG resulted as an independent predictor of morbidity and mortality composite end-point. No statistically significant differences were observed in long-term all-cause mortality between groups.

In recent decades great advances have been made in surgical procedures for treating thoracic and thoracoabdominal aorta defects. Associated mortality and morbidity rates have dropped considerably, mainly in major reference centers, but nonetheless continue to be significant. The need for new strategies to reduce mortality and morbidity has made endovascular approaches an attractive alternative for high-risk surgical patients. The most feared complications of these procedures include paraparesis and paraplegia, which have devastating consequences on patients' quality of life. We provide an updated review of the pathophysiology of spinal cord ischemia in open and endovascular surgery, as well as perioperative measures designed to protect the spinal cord in both types of procedure.

Diagnosis of cardiac neoplasm has become more feasible with the use of echocardiography, but imaging is sometimes not enough to establish a diagnosis, and a biopsy is required to determine the diagnosis and treatment. Transesophageal echocardiography-directed biopsies via a minithoracotomy revealed an extremely rare primary cardiac tumor, a poorly differentiated neuroendocrine carcinoma, in the left atrium of a 54-year-old man who presented with syncope and hypotension.

We report a case of late-onset postpartum sepsis from endometritis due to group A streptococci (GAS) in a 37-year-old white woman. The patient developed septic shock, with mitral regurgitation and cardiac dysfunction. Early treatment with broad-spectrum antibiotics and hemodynamic support was essential for a favorable outcome. Because of the resurgence of virulent strains of GAS that can cause fatal infections, these pathogens should be included in the differential diagnosis of postpartum infections in the mother. Although cardiac dysfunction is rare in association with GAS infection, it should be ruled out by echocardiography when the condition of a patient with sepsis does not improve.

Cholecystectomy is a minor surgery that causes one of the most significant occurrences of postoperative pain. Intercostal nerve blockade is a technique relatively easy to perform, whose benefits by itself are limited, but become more significant when it is associated with other anesthesic blockade or general anaesthesia. The preemptive and multimodal analgesic approach in thoracic surgery by means of intercostal blockades has been studied. The outcomes show a significant decrease of postoperative pain and less worsening of the pulmonary function than those that occurred in control groups.We present the case of a patient who underwent an open cholecystectomy, having unilateral intercostal blockades and he suffered from pain in his right hemithorax and shoulder during the early postoperative period. We review the most important characteristics and side effects of the intercostal blockade to make an etiological diagnosis for the thoracic pain related to it.

Background Triple therapy-based treatment with protease inhibitors in infected genotype 1 hepatitis C (HCV) patients improves efficacy measured as sustained virological response (SVR). Purpose To compare the effectiveness and safety of triple therapy-based treatment in mono-infected and co-infected HCV-HIV patients. Material and methods All treatments started between 2012/07/01 and 2013/12/31 were analysed. A retrospective evaluation was made of electronic medical records and outpatient pharmacy records. SVR was defined as undetectable viral load at week 60. Results 83 patients were included, 80 treated with telaprevir and 3 with boceprevir, 58 mono-infected and 25 co-infected patients. Baseline characteristics in mono-infected patients were: 83% male, mean age 54 years; 26 genotype 1a, 30 1b, 2 untypable; 64% F4; 40% were treatment-naive, 14% relapsers, 12% partial responders, 31% null responders and 3% no data. In co-infected patients: 84% male, mean age 50 years; 17 genotype 1a, 71b, 1 untypable; 92% F4; 40% were treatment-naive, 28% relapsers, 12% partial responders, 12% null responders and 8% no data. We were able to assess the effectiveness of treatment in 71 patients, who achieved 60 weeks of treatment: 51 mono-infected and 20 co-infected. In the mono-infected group: 21 (41%) achieved SVR (86% treatment-naive or relapsers), 20 (39%) had a detectable viral load (50% null responders) (3 boceprevir-treated) and 10 (20%) discontinued treatment due to toxicity or disease progression. This compared with 11 (55%) (73% treatment-naive or relapsers), 8 (40%) (38% null responders) and 1 (5%) in the co-infected group. Adverse events were: anaemia 58%, neutropenia 81% and thrombocytopenia 36% in mono-infected vs. 44%, 80% and 52% in co-infected patients. Conclusion The rate of SVR was about 50%, higher in co-infected than in mono-infected HCV patients. However, it may have been affected by a greater proportion of null responders in the mono-infected group (p > 0.05), because as in published trials, the rates of SVR differed among patients with different responses to previous treatments. References and/or Acknowledgements Zeuzem S, Andreone P, Pol S, et al . Telaprevir for retreatment of HCV infection. N Engl J Med 2011;364:2417–28 Jacobson IM, McHutchison JG, Dusheiko G, et al . Telaprevir for previously untreated chronic hepatitis C virus infection. N Engl J Med 2011;364:2405–16 No conflict of interest.

Background Our Hospital Pharmacy Service (HPS) participates in the process of authorising off-label indications (OLIs) of drugs. Immunosuppressants are often used in OLIs. Purpose To analyse prescriptions for oral immunosuppressants dispensed as OLI in our HPS Outpatient Unit (HPSOU) to identify points in the system that could be improved. Material and methods Retrospective study of oral immunosuppressants dispensed at our centre between March 2012 and March 2014. Variables collected were age, sex, drug, prescribing service and indication; obtained from the HPSOU database and the electronic medical history. Results 269 patients (median age 52 years (5–92), 135 women (50%) and 134 men (50%)) were evaluated. 6 drugs were dispensed in 8 different medicinal products: tacrolimus 94 patients (35%), mycophenolate mofetil 78 (29%), mycophenolic acid 56 (21%), ciclosporin 34 (17%), everolimus 6 (2%) and sirolimus 1 (0.3%). 11 services were involved: Haematology (89 patients: 33%), Rheumatology (61: 23%), Nephrology (56: 21%), Ophthalmology (15: 6%), Digestive (14: 5%), Pneumology (10: 4%), Paediatrics (9: 3%), Neurology (8: 3%), Internal Medicine (4: 1%), Dermatology (2: 0.7%) and Oncology (1: 0.3%). Immunosuppressants were dispensed for 35 different indications. Main indications and their treatments were: Allogeneic Hematopoietic Stem Cell Transplantation (allo-HSCT) for 75 patients (28%), with tacrolimus (71%), mycophenolate mofetil (17%) and ciclosporin (12%); Systemic Lupus Erythematosus (SLE) for 46 (17%), with mycophenolate mofetil (62%), mycophenolic acid (30%) and tacrolimus (8%) and Membranous Glomerulonephritis (MGN) for 20 (7%), with mycophenolic acid (50%) and tacrolimus. Conclusion The use of oral immunosuppressants as OLI is an established treatment for various indications, specially, allo-HSCT, SLE and GMN. The creation of multidisciplinary groups to develop protocols for the management of these drugs is required. References and/or Acknowledgements Summaries of product characteristics of the evaluated medicinal products. No conflict of interest.

Background New oral anticoagulants are an alternative to acenocoumarol in the prevention of stroke and systemic embolism in adult patients with non-valvular atrial fibrillation. Purpose To assess the suitability of prescriptions for new oral anticoagulants for those diagnoses, in accordance with criteria established by the health organisation and to analyse pharmaceutical interventions. Material and methods A prospective, observational and cross-sectional study of all patients admitted to our hospital who were prescribed dabigatran, rivaroxaban or apixaban from 01/02/2014 to 31/08/2014. Electronic medical records and electronic medical prescriptions were used as data sources. Demographics (age, gender), reason for admission, indication for anticoagulation, risk factors for complications such as renal and hepatic failure, concomitant drugs that increase the risk of bleeding (NSAIDs, platelet inhibitors, low molecular weight heparins) and adverse events were collected. In addition, adverse drug-related events avoided were also recorded. Results 64 patients (36 men) with mean age of 76 years (range 35–95) were included. 24 patients were treated with dabigatran, 38 with rivaroxaban and 2 with apixaban. 4 of these treatments were used as off-label treatments. 8 patients had renal failure and 23 had a risk of major bleeding due to concomitant treatments, mainly NSAIDs. Pharmaceutical interventions were performed in the 8 cases of renal failure because the doses needed adjustment. 14 patients with concomitant drugs that could increase the risk of bleeding were also monitored. 100% of recommendations were accepted by physicians. 2 severe adverse events were recorded: 2 bleeding episodes. Conclusion 94% of new oral anticoagulant prescriptions met the criteria established by the healthcare organisation. Pharmacists were involved in the optimisation of a third of the treatments, with total acceptance. It would be desirable to extend this activity, individualization of anticoagulant treatment, into primary medical care. Reference Agencia Espanola de Medicamentos y Productos Sanitarios. Informe de posicionamiento Terapeutico UT/V4/23122013 No conflict of interest.

Background Inhaled colistimethate is a drug dispensed in hospital pharmacy services, commonly used in obstructive lung diseases. Purpose To describe and evaluate the causality of a case of thrombocytopenia after initiating inhaled colistimethate treatment. Materials and methods Thrombocytopenia was reported by a patient in our outpatient hospital pharmacy service when he came to return Promixin (sodium colistimethate) 1 MIU. The clinical record was retrospectively reviewed to evaluate the possible causality by the Karch-Lasagna algorithm. The adverse event (AE) was notified to the regional pharmacovigilance centre, which consulted national and European agencies about more notifications. Results A 79 year-old man with diffuse interstitial lung disease (DILD) began inhaled treatment with sodium colistimethate 0.5 MIU/12 h to prevent Pseudomonas sp colonisation. Initial platelet level was normal (130,000 cell /mcL), but after six months’ treatment, he presented haematomas in mouth, eye, back and leg with a platelet count of 6, 000 cell/mcL, so colistimethate was discontinued. A week later, after receiving immunoglobulins and corticoids, his platelet level recovered (98,000 cell/mcL). After six weeks, the platelet level had normalised (205,000 cell /mcL) and treatment was restarted at the same dose. Thrombocytopenia reappeared (58,000 cell/mcL) after 15 days of treatment, therefore the drug was definitely stopped. The AE was classified as probable, as it appeared with treatment initiation, disappeared when drug was withdrawn and reappeared after readministration without any alternative explanation. There were no notifications of this AE in the Spanish Pharmacovigilance System and four had been described in the European Medicines Agency database. Conclusions Inhaled colistimethate-induced thrombocytopenia is a serious, rare AE we need to look out for as part of the pharmaceutical care in lung disease patients. No conflict of interest.

Objetivos Establecer la calidad de control analgesico de dos esquemas de analgesia: bloqueo paravertebral continuo (grupo BPVC) frente a analgesia endovenosa (grupo IV) tras cirugia cardiaca minimamente invasiva (CCMI) via abordaje de minitoracotomia (Heart-Port® e implante valvular aortico transcateter [TAVI] transapical). Material y metodos Estudio retrospectivo. Protocolo anestesico postoperatorio comun. Protocolos de analgesia mantenidos durante las primeras 48 h: grupo I V, infusion continua de cloruro morfico 0,5%/1-4 ml/h + paracetamol 1 g/6 h; grupo BPVC, infusion continua y dosis autoadministradas de ropivacaina 0,2% por cateter paravertebral introducido preope-ratoriamente (T4-T5) + paracetamol 1 g/6 h endovenoso. Variables postoperatorias: tiempo de ventilacion mecanica, estancia en unidad de cuidados intensivos (UCI) y hospitalaria global, incidencia de complicaciones. Resultados Cuarenta y ocho pacientes fueron incluidos en el estudio, 28 en el grupo IV (20 Heart-Port® y 8 TAVI transapical) y 20 en el grupo BPVC (14 Heart-Port® y 6 TAVI transapical). Ambos grupos resultaron comparables en las variables demograficas y preoperatorias. El tiempo de ventilacion mecanica y la estancia en UCI fueron significativamente menores en el grupo BPVC (Tabla 1). No se registraron eventos adversos en relacion con la aplicacion de cateter paravertebral en el postoperatorio. Conclusiones La analgesia por bloqueo paravertebral continuo es un procedimiento seguro y eficiente para el control analgesico en la CCMI por abordaje de minitoracotomia. Tabla 1. Tiempo de extubacion ≤ Estancia en UCI (dias) Estancia hospitalaria total (dias) 4 h > 4 h Grupo IV 28,6% 71,4% 2,42 ± 0,76 6,00 ± 3,39 Grupo BPVC 69,2% 30,8% 1,69 ± 0,85 5,69 ± 2,59 p