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BACKGROUND: Laryngeal mask airway (LMA) is commonly used for airway management. A cuff hyperinflation was associated with complications, poor ventilation and increased risk of gastric insufflation. This study was designed to determine the best cuff inflation method of AuraOnceÔ LMA during bronchoscopy and EBUS (Endobronquial Ultrasound Bronchoscopy) procedure. We designed a Randomized controlled, doble-blind, clinical trial to compare the efficacy and safety of three cuff inflation methods of AuraOnceÔ LMA. METHODS: 210 consenting patients scheduled for EBUS procedure under general anesthesia, using AuraOnceâ LMA were randomized into three groups depending on cuff insufflation: residual volume (RV), half of the maximum volume (MV), unchanged volume (NV). Parameters regarding intracuff pressure (IP), airway leak pressure (OLP), leakage volume (LV) were assessed, as well as postoperative complications (PC). RESULTS: 201 (95.7%) patients completed the study. Mean IP differed between groups (MV: 59.4±32.4 cm H2O; RV: 75.1±21.1 cm H2O; NV: 83.1±25.5 cmH20; P 60 cmH2O was lower in the MV group compared to the other two (MV: 20/65(30.8%); RV:47/69 (68.1%); NV 48/67 (71.6%); pCONCLUSION: When a cuff manometer is not available, a partial inflation of AuraOnceÔ LMA cuff using MV method allows to control intracuff pressure, with no significant changes of OLP and LV compared to RV and NV insufflation method. Registration Clinical Trial: NCT04769791

BACKGROUND: High intraoperative PEEP with recruitment manoeuvres may improve perioperative outcomes. We re-examined this question by conducting a patient-level meta-analysis of three clinical trials in adult patients at increased risk for postoperative pulmonary complications who underwent non-cardiothoracic and non-neurological surgery. METHODS: The three trials enrolled patients at 128 hospitals in 24 countries from February 2011 to February 2018. All patients received volume-controlled ventilation with low tidal volume. Analyses were performed using one-stage, two-level, mixed modelling (site as a random effect; trial as a fixed effect). The primary outcome was a composite of postoperative pulmonary complications within the first week, analysed using mixed-effect logistic regression. Pre-specified subgroup analyses of nine patient characteristics and seven procedure and care-delivery characteristics were also performed. RESULTS: Complete datasets were available for 1913 participants ventilated with high PEEP and recruitment manoeuvres, compared with 1924 participants who received low PEEP. The primary outcome occurred in 562/1913 (29.4%) participants randomised to high PEEP, compared with 620/1924 (32.2%) participants randomised to low PEEP (unadjusted odds ratio [OR]=0.87; 95% confidence interval [95% CI], 0.75-1.01; P=0.06). Higher PEEP resulted in 87/1913 (4.5%) participants requiring interventions for desaturation, compared with 216/1924 (11.2%) participants randomised to low PEEP (OR=0.34; 95% CI, 0.26-0.45). Intraoperative hypotension was associated more frequently (784/1913 [41.0%]) with high PEEP, compared with low PEEP (579/1924 [30.1%]; OR=1.87; 95% CI, 1.60-2.17). CONCLUSIONS: High PEEP combined with recruitment manoeuvres during low tidal volume ventilation in patients undergoing major surgery did not reduce postoperative pulmonary complications. CLINICAL TRIAL REGISTRATION: NCT03937375 (Clinicaltrials.gov).

Purpose of review This review is based on the latest evidence to provide a good standard of care for COVID-19 parturients and protection to healthcare givers. Recent findings COVID-19 by itself is not an indication for cesarean section. Different publications demonstrated the efficacy of neuraxial analgesia/anesthesia for delivery. Although SARS-CoV-2 was associated with a certain neurotropism, neuraxial block was not associated with neurological damage in COVID-19 parturients, and seems as safe and effective as in normal situations. It permits to avoid a general anesthesia in case of intrapartum cesarean section. Epidural failure is a concern: it may lead to a general anesthesia in case of emergency cesarean section. Local protocols and well-trained anesthesiologists will be helpful. COVID-19 patients require special circuits and every step (transfer to and from theatre, recovery, analgesia, and so on) should be planned in advance. For cesarean section under general anesthesia, personal protection equipment must be enhanced. Postoperative analgesia with neuraxial opioids, NSAIDs, or regional blocks are recommended. COVID-19 and pregnancy increase the risk of thrombosis, so thromboprophylaxis has to be considered and protocolized. Summary Anesthetic care for delivery in COVID-19 parturients should include neuraxial blocks. Special attention should be paid on the risk of thrombosis.

Objective Publications of diverse medical specialties confirm that gender differences still exist in the medical field. This particular study aims to investigate whether this problem exists in the specialty of Anaesthesiology in Spain. Methods An anonymous survey was distributed among anaesthesiologists in Spain. It had 39 questions and was designed to investigate professional position, work conditions, personal situation, and individual perceptions. The goal was to target the majority of anaesthesiologists working in Spain. Results Completed surveys were received from 1619 respondents which represents 17.6% of the total number of anaesthesiologists in Spain; 654 respondents were male (40.4%) and 965 were female (59.6%). The greater differences were found in the following areas: 70.0% of the respondents advised that their head of department is male. When asked about management and leadership positions, 25.2% of female respondents had ever had any management role in contrast to 46.1 % of men (p Conclusion The results of the survey show the existence of a gender gap among Spanish anaesthesiologists. Of particular note, women are under-represented in academic and leadership positions. Additionally, a considerable percentage of respondents perceive gender-based discrimination to be active in their workplaces. This study could serve as a template for future research in other neighbouring countries and as a means to monitor any changes in coming years.

Resumen Objetivo En la ultima decada se han publicado numerosos trabajos en los que se pone de manifiesto la persistencia de diferencias de genero en medicina. La finalidad de este estudio fue investigar si este problema existe en la especialidad de Anestesiologia en Espana. Metodos El estudio se llevo a cabo mediante una encuesta anonima que se distribuyo entre los especialistas en Anestesiologia. El cuestionario estaba formado por 39 preguntas disenadas para investigar la situacion profesional, laboral y personal, asi como las percepciones individuales en relacion con la discriminacion de genero en el trabajo. Resultados Se incluyeron 1.619 encuestas, lo que representa el 17,6% del total de anestesiologos de Espana; 654 participantes fueron hombres (40,4%) y 965 mujeres (59,6%). Las mayores diferencias fueron observadas en las siguientes areas: el 70,0% de participantes informaron de que su jefe de servicio es un hombre. En relacion con los puestos de liderazgo, el 25,2% de las mujeres que respondieron a la encuesta habian desempenado algun puesto de confianza frente al 46,1% de los hombres (p Conclusion Los resultados de esta encuesta demuestran que existe una brecha de genero en Anestesiologia en Espana. En concreto, las mujeres estan poco representadas en puestos academicos y de liderazgo, y un porcentaje considerable de encuestados perciben diferencias de genero en el trabajo. Este estudio puede servir para monitorizar futuros cambios en nuestro pais y como ejemplo para investigaciones en otros paises vecinos.

Purpose of review Even if its use is scarce in most countries, many articles concerning combined spinal epidural (CSE) were published. In this review, we present the latest advances concerning CSE in obstetrics. Recent findings During labour, CSE improves epidural analgesia quality. Epidural with intradural opioids can produce maternal hypotension and foetal heart rate abnormalities (FHR-Ab), without increasing the caesarean section rate. For caesarean section, CSE decreases the neuraxial block failure rate, with no significant increase of complications. Epidural volume extension (EVE) after CSE for caesarean section could be an interesting option even though more evidence is needed. Summary For labour analgesia, CSE has the fastest onset time of analgesia. Its side effects have no consequences on maternal, labour or foetal outcomes. It provides better analgesia than epidural analgesia and can be used for external cephalic version and high-risk patients. For caesarean section, CSE has become the reference neuraxial technique for low-dose spinal anaesthesia, with higher success rate compared with regular spinal anaesthesia. Recent systematic revisions did not confirm this superiority. CSE offers the advantage of EVE, intraoperative top-ups, postoperative administration of neuraxial opioids and local anaesthetics. The risk of complications is balanced by the benefits of the technique.

BACKGROUND Recent investigations have showed that caesarean section (CS) might be a cause of chronic pain, with a consequent decrease in quality of life. METHODS Prospective observational study in a Spanish tertiary hospital. Main Outcome measure was to assess early neuropathic characteristics of pain (DN2 score ≥ 3) one week after CS as a potential risk factor for post-caesarean section chronic pain (PCSCP) at three months. Secondary outcome was to identify other risk factors. 610 consecutive consenting patients undergoing CS were interviewed preoperatively, at discharge from recovery room and 24h postoperatively. Telephone follow-up interviews were conducted one week, three months and twelve months following surgery. RESULTS We analysed 597 consecutive patients. The incidence of PCSCP at three and twelve postoperative months were 6.2% and 1% respectively. Subjects with NRS score superior to five on movement one week after CS presented higher incidence of PCSCP (NRS superior to five: 19 (52,2%); NRS equal or lower to five: 172 (30,9%); p=0,009). On multivariate analysis neuropathic pain one week after CS was associated with a higher risk of PCSCP (AOR: 1.63 (95% CI: 1.26-2.11; p

PURPOSE OF REVIEW The objective of this review is to analyze and summarize the current anesthetic methods used to alleviate pain and discomfort during transvaginal oocyte retrieval procedures (TORP), to try to reach practical recommendations, based on the evidence, which will translate into daily practice, the knowledge on the anesthetic management of patients scheduled for TORP. RECENT FINDINGS There is no strong evidence to recommend the avoidance of any technique or drug for TORP, including nitrous oxide or halogenated agents. Women should be offered any available technique. The evidence available up to date is not convincing enough to recommend avoiding any anesthetic technique in terms of pregnancy and birth rates. SUMMARY TORP is painful for women and different techniques may be used for pain relief in day case surgery. The other important outcome to consider is the pregnancy rate, and any anesthetic technique or drug which would improve this pregnancy rate should be recommended. Conscious sedation and general anesthesia proved to be well tolerated for woman and the oocytes, despite the use of propofol, opioids, benzodiacepines, nitrous oxide, or other drugs. Spinal anesthesia and paracervical block are also acceptable options, and can be combined with conscious sedation. Nevertheless, more studies are needed to find out the ideal drug or technique combination for the woman and the oocyte.

Low back pain is currently one of the main public health problems. Among the multiple causes, pain in the zygapophysial joints, also called facets or posterior vertebral joints, are an important cause, usually secondary to osteoarthritis. The source of low back pain is often difficult to find, making the therapeutic approach to the patient sub-optimal. Diagnostic blocks are a very important tool in establishing an adequate treatment for patients with low back pain, as long as they are performed accurately, with an adequate local anaesthetic volume, with a suitable image and fluoroscopic projection and its result are precisely interpreted. In this article a review is presented on the importance of diagnostic blocks, as well as how they should be performed in order to obtain the maximum information and the greatest therapeutic benefit.

PLOS ONE 17(1), e0262110 (2022). doi:10.1371/journal.pone.0262110, Published by PLOS, San Francisco, California, US

(1) Background: Surgical outcomes in free flap reconstruction of head and neck defects in cancer patients have improved steadily in recent years, however, correct anaesthesia management is also important. The aim of this study has been to show whether goal directed therapy can improve flap viability and morbidity and mortality in surgical patients. (2) Methods: we performed an observational case control study to analyse the impact of introducing a semi invasive device (Flo Trac®) during anaesthesia management to optimize fluid management. Patients were divided into two groups: one received goal directed therapy (GDT group) and the other conventional fluid management (CFM group). Our objective was to compare surgical outcomes, complications, fluid management, and length of stay between groups. (3) Results: We recruited 140 patients. There were no differences between groups in terms of demographic data. Statistically significant differences were observed in colloid infusion (GDT 53.1% vs. CFM 74.1%, p = 0.023) and also in intraoperative and postoperative infusion of crystalloids (CFM 5.72 (4.2, 6.98) vs. GDT 3.04 (2.29, 4.11), p &lt, 0.001), which reached statistical significance. Vasopressor infusion in the operating room (CFM 25.5% vs. GDT 74.5%, p &lt, 0.001) and during the first postoperative 24h (CFM 40.6% vs. GDT 75%, p &gt, 0.001) also differed. Differences were also found in length of stay in the intensive care unit (hours: CFM 58.5 (40, 110) vs. GDT 40.5 (36, 64.5), p = 0.005) and in the hospital (days: CFM 15.5 (12, 26) vs. GDT 12 (10, 19), p = 0.009). We found differences in free flap necrosis rate (CMF 37.1% vs. GDT 13.6%, p = 0.003). One-year survival did not differ between groups (CFM 95.6% vs. GDT 86.8%, p = 0.08). (4) Conclusions: Goal directed therapy in oncological head and neck surgery improves outcomes in free flap reconstruction and also reduces length of stay in the hospital and intensive care unit, with their corresponding costs. It also appears to reduce morbidity, although these differences were not significant. Our results have shown that optimizing intraoperative fluid therapy improves postoperative morbidity and mortality.

Tuberous sclerosis (TSC) is a rare disease with multi-systemic involvement, predominantly neurological. Little evidence exists about the anesthetic management of patients with this disorder, particularly in pregnant women. This article discusses a case of a patient with TSC admitted to our hospital for the delivery of a twin gestation. Twenty-four hours after surgery, the patient presented left-side facial-brachial hypoesthesia and headache. A brain CT revealed a right frontal cortical bleeding tumor, which was diagnosed as glioblastoma multiforme. The patient was discharged 15 days after admission and a neurosurgical approach was suggested.

Free flap surgery is the gold standard surgical treatment for head and neck defects in cancer patients. Outcomes have improved considerably, probably due to recent advances in surgical techniques. In this article, we review improvements in the parameters traditionally used to optimise haematocrit levels and body temperature and to prevent vasoconstriction, and describe the use of cardiac output-guided fluid management, a technique that has proved useful in other procedures. Finally, we review other parameters used in free flap surgery, such as clotting / platelet management and nutritional optimisation.

to evaluate mortality of patients≥80 years admitted to the Surgical Intensive Care Unit (SICU), global hospital mortality and factors related to it.observational retrospective study of patients≥80 years admitted to SICU between June 2012 and June 2015.a total of 299 patients were included, 54 of them died in the SICU (18.1%) and 80 patients (26.8%) died during their hospital stay. SICU mortality was independently related to age (OR=1.125; 95%CI: 1.042-1.215; P=.003), SAPS II (OR=1.026; 95% CI: 1.008-1.044; P=.004), need for renal replacement therapy (RRT) (OR=1.960; 95%CI: 1.046-3.671; P=.036) and need for mechanical ventilation for more than 24hours (OR=2.834; 95%CI: 1.244-6.456; P=.013). Factors independently related to hospital mortality were age (OR=1.125; 95%CI: 1.054-1.192; P.001), SOFA score (OR=1.154; 95% CI: 1.079-1.235; P.001), need for RRT (OR=1.924; 95%CI: 1.121-3.302; p=0.018) and need for mechanical ventilation for more than 24hours (OR=3.144; 95% CI: 1.771-5.584; P.001).In critically ill patients over 80 years hospital mortality was independently related to age, SOFA score, RRT need and need for mechanical ventilation for more than 24hours. Our results raise important issues about end-of-life care and life-sustaining interventions in elderly, critically ill patients.

Background Although ultrasound is a basic competence for anaesthesia residents (AR) there is few data available on the learning process. This prospective observational study aims to assess the learning process of ultrasound-guided continuous femoral nerve block and to determine the number of procedures that a resident would need to perform in order to reach proficiency using the cumulative sum (CUSUM) method. Methods We recruited 19 AR without previous experience. Learning curves were constructed using the CUSUM method for ultrasound-guided continuous femoral nerve block considering 2 success criteria: a decrease of pain score > 2 in a [0–10] scale after 15 min, and time required to perform it. Results We analyze data from 17 AR for a total of 237 ultrasound-guided continuous femoral nerve blocks. 8/17 AR became proficient for pain relief, however all the AR who did more than 12 blocks (8/8) became proficient. As for time of performance 5/17 of AR achieved the objective of 12 min, however all the AR who did more than 20 blocks (4/4) achieved it. Conclusions The number of procedures needed to achieve proficiency seems to be 12, however it takes more procedures to reduce performance time. The CUSUM methodology could be useful in training programmes to allow early interventions in case of repeated failures, and develop competence-based curriculum.

Resumen Introduccion Aunque la ecografia es una competencia basica de los residentes de anestesia (RA) hay pocos datos disponibles sobre su proceso de aprendizaje. Este estudio prospectivo observacional tiene como objetivo evaluar el proceso de aprendizaje del bloqueo del nervio femoral continuo guiado por ecografia y determinar el numero de procedimientos necesarios que un RA debe realizar para ser exitoso, utilizando el metodo de suma acumulada (CUSUM). Metodo Reclutamos 19 RA sin experiencia previa. Construimos las curvas de aprendizaje utilizando la metodologia CUSUM para el bloqueo del nervio femoral continuo guiado por ecografia considerando 2 criterios de exito: disminucion del dolor > 2 puntos en una escala numerica [0-10] tras 15 min y el tiempo necesario para realizar la tecnica. Resultados Analizamos los datos de 17 RA, que realizaron un total de 237 bloqueos del nervio femoral continuo guiados por ecografia. Ocho de 17 RA tuvieron exito en cuanto a la disminucion del dolor, y asimismo aquellos RA que realizaron > 12 bloqueos (8/8) lo consiguieron. En cuanto al tiempo de realizacion, 5/17 RA alcanzaron el objetivo en 12 min; y todos los RA que realizaron > 20 procedimientos (4/4) lo alcanzaron. Conclusiones El numero de procedimientos necesarios para alcanzar el exito parece ser 12, sin embargo es necesario realizar un numero mayor para reducir el tiempo de realizacion del mismo. La metodologia CUSUM podria ser util en programas de formacion, permitiendo intervenciones precoces en casos de fallos repetidos, y realizar un curriculo basado principalmente en las competencias.

Chest pain during labor can have many etiologies, one of which is myocardial ischemia. We report a 38-year-old woman with American Society of Anesthesiology physical status I scheduled for elective cesarean delivery who experienced chest pain and electrocardiographic signs of myocardial ischemia immediately after carbetocin administration. Subsequent investigations revealed an aberrant right coronary artery originating from the left coronary sinus coursing between the aorta and the pulmonary artery. This was considered the likely cause of the patient's chest pain. The patient gave written permission for the authors to publish this report.

Introduction In 2011, a hospital-wide outbreak of OXA-48 producing Klebsiella pneumoniae occurred in our hospital, an epidemiological setting of high ESBL-producing K. pneumoniae rates. This study identifies risk factors for colonization with carbapenemase-producing enterobacteria (CPE) at Surgical Intensive Care Unit (SICU) admission. Methods A 2-year retrospective study was performed in all patients admitted to the SICU that following routine had a rectal swab collected upon admission. Results Of 254 patients admitted, 41 (16.1%) harbored CPE (five showing two carbapenemase-producing isolates). Most frequent carbapenemase-producing isolates and carbapenemases were K. pneumoniae (39/46, 84.8%) and OXA-48 (31/46; 76.1%), respectively. Carriers significantly had higher rates of chronic renal disease, previous digestive/biliary endoscopy, hospitalization, ICU/SICU admission, intraabdominal surgery, and antibiotic intake, as well as higher median values of clinical scores (SOFA, SAPS II and APACHE II). In the multivariate analysis (R2 = 0.309, p Conclusions A strong association between production of ESBLs and carriage of CPE (mainly OXA-48 producing K. pneumoniae) was found. According to the model, the co-selection of β-lactamases by previous exposure to broad-spectrum cephalosporins and β-lactam/β-lactamase inhibitors (with lower relative risk), abdominal surgery and prior digestive/biliary endoscopy were factors associated with CPE carriage.

BACKGROUND Breakthrough pain (BTP) is a common problem during labor analgesia. Programmed intermittent epidural bolus (PIEB) has demonstrated superior to background epidural infusion (BEI) concerning BTP, but the effect of combining both modes remains unknown. We hypothesized that this combination could reduce BTP incidence. METHODS Nulliparous parturients with early cervical dilation were randomized to receive 5 mL/h BEI of levobupivacaine 0.125% plus fentanyl 1.45 µg/mL (standard group) or 5 mL/h BEI + 10 mL/h PIEB (PIEB group). In case of BTP, patient-controlled epidural analgesia (PCEA) boluses of 10 mL (20-min lockout interval) were administered. If PCEA was insufficient, a 10-mL clinician bolus was delivered. The primary endpoint was the percentage of parturients who required supplementary epidural boluses. RESULTS One hundred and twenty women were recruited. Eighty-nine percent of parturients required supplementary boluses in standard group versus 30% in PIEB group (RR=3.07; 95% CI: 1.99-4.76; P

Resumen La hemorragia masiva obstetrica es una de las causas principales de morbimortalidad materna en el mundo. Entre otras definiciones, se conoce como la perdida > 2.500 ml de sangre y se asocia a ingreso en unidades de pacientes criticos y a histerectomia. Los cambios fisiologicos del embarazo permiten una hemorragia cuantiosa antes de objetivar una caida de la hemoglobina y/o el hematocrito. Dentro de los cambios fisiologicos del embarazo, existe una hipercoagulabilidad asociada a la gestante. Algunas comorbilidades asociadas al embarazo pueden contribuir a la aparicion de una hemorragia catastrofica con una coagulopatia de consumo, que hace la situacion aun mas grave. La optimizacion, la preparacion, el uso racional de recursos y la protocolizacion de actuaciones son utiles para mejorar los resultados en estas pacientes. El uso de protocolos basados en point of care con test viscoelasticos esta demostrando utilidad. Si se produce una hipofibrinogenemia durante la hemorragia, la administracion precoz de fibrinogeno puede ser muy util. Para corregir eficazmente la coagulopatia pueden ser necesarios otros factores de la coagulacion, ademas de fibrinogeno, durante la reposicion en la hemorragia posparto. Se recomienda la realizacion de una histerectomia si las medidas medicas y quirurgicas se han mostrado ineficaces.

Neurotoxicity caused by cefepime may occur predominantly in patients with impaired renal function. A case of a cefepime-induced non-convulsive status epilepticus (NCSE) is presented. A 65-year-old woman suffered a severe NCSE due to cefepime in the presence of acute renal failure, requiring coma induction with sodium thiopental. A serious interaction between valproic acid (VPA) and meropenem was also produced after changing cefepime to meropenem. Continuous veno-venous haemofiltration was employed to improve cefepime clearance, and the patient progressively regained her previous mental condition. In conclusion, the cefepime dose must be adjusted according to renal function in order to avoid toxicity in patients with renal failure. Electroencephalogram should be considered in cases of acute confusional state in patients receiving cefepime, to achieve early detection of NCSE. Continuous renal replacement therapy may be successfully employed in severe cases in order to accelerate cefepime removal. Likewise, meropenem should not be used concomitantly with VPA.

ResumoJustificativaO parto em pacientes cardíacas é um desafio para o anestesiologista, para o qual o bem‐estar tanto da mãe quanto do feto é a questão principal. Em caso de cesariana, o monitoramento avançado permite melhorar a condição hemodinâmica e diminuir a morbidade e mortalidade.ObjetivoDescrever o uso da análise do contorno do pulso calibrado por termodiluição transpulmonar (Picco Plus®) para o manejo perioperatório de cesariana em paciente com miocardiopatia grave.Relato de casoDescrevemos o caso de uma paciente de 28 anos com uma doença cardíaca congênita, submetida a uma cesariana sob anestesia geral devido a afecção materna e apresentação fetal pélvica. O manejo nos períodos intraoperatório e pós‐operatório foi aprimorado por monitoração hemodinâmica avançada obtida pela análise do contorno da onda de pulso e calibração por termodiluição (monitor Picco Plus®). As informações sobre pré‐carga, pós‐carga e contratilidade miocárdica foram úteis para orientar a reposição hídrica e o uso de medicamentos vasoativos.ConclusãoEste relato de caso ilustra a importância da monitoração hemodinâmica avançada com dispositivo aceitavelmente invasivo em pacientes obstétricas com alto risco cardíaco. O aumento do conhecimento no manejo hemodinâmico avançado provavelmente possibilitará a redução da morbidade e mortalidade de pacientes obstétricas no futuro.AbstractBackgroundThe delivery of cardiac patients is a challenge for the anaesthesiologist, to whom the welfare of both the mother and the foetus is a main issue. In case of caesarean section, advanced monitoring allows to optimize haemodynamic condition and to improve morbidity and mortality.ObjectiveTo describe the use of pulse contour analysis calibrated by Trans‐pulmonar thermodilution (Picco Plus®) for the perioperative management of a caesarean section in a patient with severe cardiomyopathy.Case reportWe describe the case of a 28‐year‐old woman with a congenital heart disease who was submitted to a caesarean section under general anaesthesia for maternal pathology and foetal breech presentation. Intra‐ and post‐operative management was optimized by advanced haemodynamic monitorization obtained by pulse contour wave analysis and thermodilution calibration (Picco Plus® monitor). The information about preload, myocardial contractility and postcharge was useful in guiding the fluid therapy and the use of vasoactive drugs.ConclusionThis case report illustrates the importance of advanced haemodynamic monitoring with an acceptably invasive device in obstetric patients with high cardiac risk. The increasing experience in advanced haemodynamic management will probably permit to decrease morbidity and mortality of obstetric patients in the future.

Introduction Prevention of perioperative hypothermia decreases morbidity and mortality, as well as hospital costs. This study was conducted to evaluate the level of implementation of protocols in 3 tertiary Spanish University Hospitals. Material and methods A survey among anaesthesiologists assessed estimated importance and clinical practice in terms of prevention of perioperative hypothermia. Results were compared depending on their experience. p Results A total of 116 anaesthesiologists answered the survey, of whom 48 (41.3%) were residents, 32 (27.6%) were staff with less than 10 years of experience, and 36 (31.1%) staff with 10 years or more of experience, In a 0–10 importance scale, prevention of hypothermia was scored 7.49 ± 1.79, with no difference between groups (p = 0.58). Younger staff were more concerned of the end surgery temperature than other colleagues (p = 0.02). The most usual practice was a combination warming the intravenous fluids and an electric blanket (55%). Only 20% of the anaesthesiologists monitored temperature intra-operatively, even though 75% considered it an important parameter. No unit had a written protocol for prevention of perioperative hypothermia. Discussion and conclusion Despite the absence of prevention protocols, the anaesthesiologists were aware of the importance maintaining a normal peri-operative temperature, but this awareness is still not enough to influence their perioperative management to diagnose and prevent hypothermia. A harmonisation of practice at local, regional and national level could improve this practice in the future.

Resumen Introduccion La prevencion de la hipotermia perioperatoria disminuye la morbimortalidad y el coste hospitalario. Este estudio evaluo su nivel de aplicacion en 3 hospitales universitarios espanoles de tercer nivel. Material y metodos Una encuesta entre anestesiologos evaluo la importancia estimada y la practica clinica en materias de prevencion de la hipotermia perioperatoria. Los resultados se compararon en funcion de la experiencia. Una p Resultados Ciento dieciseis anestesiologos contestaron a la encuesta, 48 (41,3%) residentes, 32 (27,6%) adjuntos de menos de 10 anos de experiencia, y 36 (31,1%) adjuntos de 10 o mas anos de experiencia. La prevencion de la hipotermia fue evaluada con 7,49 ± 1,79 puntos en una escala de importancia de 0 a 10, sin diferencias entre grupos (p = 0,58). Los adjuntos recien graduados valoraban la temperatura al final de la intervencion mas que el resto de anestesiologos (p = 0,02). El calentador de sueros, junto con una manta convectiva fue la medida de prevencion mas habitual (47%). Solo un 20% de los encuestados monitorizaban la temperatura intra-operatoria, aunque un 75% lo consideraban un parametro importante. Ninguna unidad disponia de un protocolo de prevencion de hipotermia. Discusion y conclusion A pesar de no existir protocolos de prevencion, los anestesiologos son conscientes de la importancia de la normotermia perioperatoria, pero aun no influye suficiente en su manejo peri-operatorio para diagnosticar y prevenir la hipotermia. Una armonizacion a nivel local, regional y nacional podria mejorar estas practicas en el futuro.

Introduction Even though foreign body aspiration (FBA) is rare in adult patients, they sometimes require the performance of rigid bronchoscopy for its extraction. Ventilation for this procedure is challenging, especially in patients with pulmonary disease. Clinical, diagnostic evaluation and interventions We described the case of a 71-year old man who presented with a FBA in the left upper lobe associated with a controlateral pneumothorax. After the placement of a pleural drainage, the foreign body was extracted, using rigid bronchoscopy under general anaesthesia and high flow jet ventilation with no further haemodynamic or pulmonary complications, suggesting that this technique is safe in patients with pulmonary leaks. Conclusions In the case described, rigid bronchoscopy minimized the risk of aspiration of blood and detritus due to continuous flow of gas upward, and avoided the increase of the air leak through the pneumothorax thank to limited airway pressures, making it a clear indication., Introducción: Aunque la aspiración de cuerpos extraños es rara en adultos, requiere en algunas ocasiones la realización de una broncoscopia rígida para su extracción. El modo ventilatorio para este procedimiento es un reto, especialmente en pacientes con enfermedad pulmonar. Clínica, evaluación diagnóstica e intervenciones: Describimos aquí el caso de un paciente de 71 años con aspiración de un cuerpo extraño enclavado a nivel del lóbulo superior izquierdo asociado a un neumotórax contralateral. Después de insertar un tubo de tórax se extrajo el cuerpo extraño utilizando broncoscopia rígida bajo anestesia general y ventilación jet de alto flujo sin complicaciones hemodinámicas o pulmonares adicionales, sugiriendo que esta técnica es segura en pacientes con fugas pulmonares. Conclusiones: En el presente caso clínico, la broncoscopia rígida minimizó el riesgo de aspiración de sangre y detritus gracias a la inyección de un flujo continuo de gas ascendente, y evitó así el incremento de la fuga a través del neumotórax por las presiones limitadas en la vía aérea, constituyendo una indicación clara de esta técnica

BACKGROUND The Zero-Heat-Flux technology of the SpotOn® sensor to measure core temperature has been validated in vascular and cardiac surgery. Our aim was to assess its validity in gynecological surgery in terms of time of measurement, thermic status (hypo-, normo-, or hyperthermia) and the use of different warming devices. METHODS Prospective study in patients scheduled for major gynecological surgery using three warming systems (Snuggle Warm®, Lithotomy Underbody Blanket® and Warmtac Pad®). Intraoperative temperature was simultaneously monitored using the SpotOn® sensor and a Drager® esophageal probe; measurements were taken after induction (T0), between 0 and 60 min (T1), between 60 and 120 minutes (T2) and after 120 minutes (T3). We calculated the level of correlation between pairs of measurements both overall and in subgroups with an acceptable difference of less than 0.5 °C. We built Bland-Altman plots, and calculated the Pearson correlation (PC) and intraclass correlation coefficient (ICC) to test our data. RESULTS We recruited 70 patients and included 66 for analysis, giving a total of 401 paired measurements. Overall, the PC and ICC for paired temperature readings were 0.82 and 0.90, respectively. The lowest levels of correlation were observed after intubation, when a convective blanket was placed under the patient, and in hypothermic patients. The highest correlations were observed at T2, and in normothermic patients. CONCLUSIONS We found a high overall correlation between the SpotOn® and the esophageal probe, with negligible differences and almost perfect agreement. The warming system used, time of measurement, and thermic status appear to influence the level of correlation, but these differences were not clinically significant.

Postdural puncture headache (PDPH) is the most common serious complication in obstetric anesthesia. We show the incidence of accidental dural puncture (ADP), PDPH, epidural blood patch (EBP) and associated morbidity following a protocol established in an obstetric anesthesia department.An observational, prospective, analytical study performed in 66,540 epidural labor analgesia procedures. The objective is to describe the incidence of ADP, PDPH and EBP in a large obstetric anesthesia population, as well as morbidity associated with ADP and EBP.Incidence of ADP and PDPH was 0.76% and 59%, respectively, and the global incidence of EBP was 0.2%. Experience of the anesthetist performing the epidural (1st or 2nd year resident) and night shift were correlated with ADP. Low back pain was more frequent in patients undergoing EBP.We found an incidence of ADP and PDPH of 0.76% and 59%, respectively. Experience of the anesthetist performing the epidural (1st or 2nd year resident) and night shift were correlated with ADP. EBP is a safe, easy and acceptable treatment for PDPH, despite a higher risk of low back pain.

Background and objectives: Aortic stenosis increases perioperative morbidity and mortality, perioperative invasive monitoring is advised for patients with an aortic valve area 30 mm Hg and it is important to avoid hypotension and arrhythmias. We report the anaesthetic management with continuous spinal anaesthesia and minimally invasive haemodynamic monitoring of two patients with severe aortic stenosis undergoing surgical hip repair. Case report: Two women with severe aortic stenosis were scheduled for hip fracture repair. Continuous spinal anaesthesia with minimally invasive haemodynamic monitoring was used for anaesthetic management of both. Surgery was performed successfully after two consecutive doses of 2 mg of isobaric bupivacaine 0.5% in one of them and four consecutive doses in the other. Haemodynamic conditions remained stable throughout the intervention. Vital signs and haemodynamic parameters remained stable throughout the two interventions. Conclusion: Our report illustrates the use of continuous spinal anaesthesia with minimally invasive haemodynamic monitoring as a valid alternative to general or epidural anaesthesia in two patients with severe aortic stenosis who are undergoing lower limb surgery. However, controlled clinical trials would be required to establish that this technique is safe and effective in these type or patients. Resumo: Justificativa e objetivos: A estenose aórtica aumenta a morbidade e mortalidade no período perioperatório. A monitoração invasiva no perioperatório é recomendada para pacientes com área valvar 30 mm Hg, além de ser importante evitar a hipotensão e arritmias. Relatamos o manejo anestésico com o uso de raquianestesia contínua e monitoração hemodinâmica minimamente invasiva em duas pacientes com estenose aórtica grave, submetidas à cirurgia de reparação do quadril. Relato de caso: Duas pacientes com estenose aórtica grave foram programadas para cirurgia de reparação de fratura de quadril. Raquianestesia contínua com monitoração hemodinâmica minimamente invasiva foi usada para o manejo anestésico de ambas as pacientes. A cirurgia foi realizada com sucesso após duas doses consecutivas de 2 mg de bupivacaína isobárica a 0,5% em uma das pacientes e quatro doses consecutivas na outra. As condições hemodinâmicas permaneceram estáveis durante a intervenção. Os sinais vitais e parâmetros hemodinâmicos permaneceram estáveis durante as duas intervenções. Conclusão: Nosso relato descreve o uso da raquianestesia contínua com monitoração hemodinâmica minimamente invasiva como uma alternativa válida para a anestesia geral ou peridural em duas pacientes com estenose aórtica grave, submetidas à cirurgia de membro inferior. Contudo, ensaios clínicos controlados são necessários para estabelecer que a técnica é segura e eficaz nesse tipo de pacientes. Keywords: Anaesthetic techniques – subdural, Measurement techniques – cardiac output, Palavras-chave: Técnicas anestésicas – subdural, Técnicas de mensuração – débito cardíaco

Objective: Regional anesthesia is the preferred technique used in elective cesarean sections. The controversy lies in knowing what dose of local anesthetic allows for the safety of both mother and fetus during the procedure. The combined spinal-epidural technique (CSE) allows the intradural dose to be lowered, ensuring an adequate block through additional epidural doses. Our aim was to study the success of the technique. Method: We carried out a prospective, randomized study of 102 women scheduled for cesarean section. Our objective was to study the incidence of maternal hypotension, the success of the technique, motor block, and repercussions in parameters of fetal well-being after performing a combined technique (CSE) with low and ultra-low doses of hyperbaric levobupivacaine (LB-5mg versus LB-3.75mg) plus epidural extension with 10ml of isobaric levobupivacaine 0.25%. Results: We found no difference in the incidence of maternal hypotension between our groups. The overall success of the technique was 81.4% directly relating to the length of the surgical procedure. 18.6% of the patients required some type of analgesic booster in the course of the study. We found no difference in the type of neonatal resuscitation used, but there was a statistically significant difference in umbilical cord arterial pH. Conclusion: The use of low and ultra-low doses can be an alternative in carefully selected cases. The doses used were sufficient for the cesarean section to be performed in the majority of our study subjects. We did not find evident advantages with regard to the incidence of maternal hypotension and we do not believe that the use of ultra-low doses proves beneficial.

Objective To determine whether the location of the sciatic nerve (SN) at the popliteal fossa is related to anthropometric variables in the adult population, and to identify possible anatomical variations and their possible implications for clinical practice. Materials and methods Prospective observational study in elective ambulatory surgery patients. Patients were examined using ultrasound, looking at depth, laterality and distance at which the SN bifurcates at the level of the popliteal fossa. These measurements were linked to gender and the anthropometric data of the patients. Results A total of 62 patients were included, with 124 measurements. A statistically significant association was found between SN depth and the diameter of the thigh measured at 10 cm from the popliteal crease ( P Conclusions The depth and laterality of SN are independent of gender, weight and height. The depth at which the SN is located at the level of the popliteal fossa is related to the diameter of the thigh. The bifurcation of SN in popliteal fossa is not related to height.

Resumen Objetivo Explorar si la ubicacion del nervio ciatico (NC) a nivel del hueco popliteo se relaciona con variables antropometricas en la poblacion adulta. Identificar posibles variaciones anatomicas y sus posibles implicaciones en la practica clinica. Material y metodo Estudio prospectivo observacional en cirugia ambulatoria programada. Se examinaron por ultrasonografia la profundidad, la lateralidad y la distancia en la que el NC se bifurca a nivel del hueco popliteo. Se relacionaron estas mediciones segun el genero y otros datos antropometricos de los pacientes. Resultados Se incluyeron 62 pacientes, siendo 124 el total de mediciones. Existe una asociacion estadisticamente significativa (p Conclusiones La profundidad y lateralidad del NC son variables independientes del genero, el peso y la talla. La profundidad a la que el NC se localiza a nivel del hueco popliteo esta relacionada con el diametro del muslo. La bifurcacion del NC en el hueco popliteo no esta relacionada con la talla.

ResumoFármacos inotrópicos fazem parte do tratamento de insuficiência cardíaca; no entanto, o tratamento com inotrópicos tem sido amplamente debatido devido ao aumento da incidência de efeitos adversos e da mortalidade. Recentemente, levosimendana, um agente inotrópico positivo, provou ser eficaz na insuficiência cardíaca aguda, reduz a mortalidade e melhora o desempenho cardíaco e renal. Relatamos o caso de uma paciente de 75 anos, com história de insuficiência cardíaca e renal e fratura de quadril. Levosimendana foi usada na preparação do pré‐operatório como terapia adjuvante para melhorar a função cardíaca e renal e permitir a cirurgia.AbstractInotropic drugs are part of the treatment of heart failure; however, inotropic treatment has been largely debated due to the increased incidence of adverse effects and increased mortality. Recently levosimendan, an inotropic positive agent, has been proved to be effective in acute heart failure, reducing the mortality and improving cardiac and renal performance. We report the case of a 75‐year‐old woman with history of heart and renal failure and hip fracture. Levosimendan was used in preoperative preparation as an adjuvant therapy, to improve cardiac and renal function and to allow surgery.

Altres ajuts: This work was supported in part by an unrestricted grant from Astellas Pharma S.A. (Madrid, Spain). The funder had no role in the study design, data collection and interpretation, or the decision to submit the work for publication. JAR is funded by a Career Development Fellowship from the National Health and Medical Research Council of Australia (APP1048652). Dosing in obese critically ill patients is challenging due to pathophysiological changes derived from obesity and/or critical illness, and it remains fully unexplored. This study estimated the micafungin probability of reaching adequate 24-h area under the curve (AUC)/minimum inhibitory concentration (MIC) values against Candida spp. for an obese/nonobese, critically ill/noncritically ill, large population. Blood samples for pharmacokinetic analyses were collected from 10 critically ill nonobese patients, 10 noncritically ill obese patients, and 11 critically ill morbidly obese patients under empirical/directed micafungin treatment. Patients received once daily 100-150 mg micafungin at the discretion of the treating physician following the prescribing information and hospital guidelines. Total micafungin concentrations were determined by high-performance liquid chromatography (HPLC). Monte-Carlo simulations were performed and the probability of target attainment (PTA) was calculated using the AUC/MIC cut-offs 285 (C. parapsilosis), 3000 (all Candida spp.), and 5000 (non parapsilosis Candida spp.). Intravenous once-daily 100-mg, 150-mg, and 200-mg doses were simulated at different body weights (45, 80, 115, 150, and 185 kg) and age (30, 50, 70 and 90 years old). PTAs ≥ 90% were considered optimal. Fractional target attainment (FTA) was calculated using published MIC distributions. A dosing regimen was considered successful if the FTA was ≥ 90%. Overall, 100 mg of micafungin was once-daily administered for nonobese and obese patients with body mass index (BMI) ≤ 45 kg/m 2 and 150 mg for morbidly obese patients with BMI > 45 kg/m 2 (except two noncritically ill obese patients with BMI ~ 35 kg/m 2 receiving 150 mg, and one critically ill patient with BMI > 45 kg/m 2 receiving 100 mg). Micafungin concentrations in plasma were best described using a two-compartment model. Weight and age (but not severity score) were significant covariates and improved the model. FTAs > 90% were obtained against C. albicans with the 200 mg/24 h dose for all body weights (up to 185 kg), and with the 150 mg/24 h for body weights < 115 kg, and against C. glabrata with the 200 mg/24 h dose for body weights < 115 kg. The lack of adequacy for the 100 mg/24 h dose suggested the need to increase the dose to 150 mg/24 h for C. albicans infections. Further pharmacokinetic/pharmacodynamic studies should address optimization of micafungin dosing for nonalbicans Candida infections.

Labor epidural failure is a challenging situation for the obstetric anesthetist, especially when associated to high risk of caesarean delivery, obesity, and difficult airway predictors. Labor epidural failure is still not standardly defined, consequently its incidence is uncertain: improving the knowledge of risk factors related to failure will increase epidural block success rate. Prolonged labors, previous history of epidural failure, and repeated top-ups needed during labor are recognized risk factors for failure. Clinical experience and the use of modern equipment (ultrasound guided blocks), as well as the choice of neuraxial technique (epidural versus combined spinal-epidural) may affect failure rate. Software-controlled infusion pumps seem to increase epidural analgesia success rate. Among non-technical skills, good communication among medical team members and parturient women is another pivotal point to achieve a satisfactory analgesia for labor. Clear algorithms should be promoted where epidural failure during labor or caesarean delivery may occur.