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Resumen El uso de la ecografia como herramienta de diagnostico clinico y guia de procedimientos a pie de cama se ha convertido en un examen indispensable en los cuidados del paciente agudo. La capacitacion de los profesionales en unas competencias minimas de conocimiento, manejo e indicaciones de uso requieren de una formacion reglada definida por las Sociedades Cientificas. El grupo de trabajo de Ecografia en Cuidados Intensivos de la Sociedad Espanola de Anestesiologia y Reanimacion (SEDAR), de la Sociedad Espanola de Medicina Interna (SEMI) y la Sociedad Espanola de Medicina de Urgencias y Emergencias (SEMES) ha desarrollado este documento de consenso en el que se define el programa de formacion y las competencias minimas recomendadas a adquirir con relacion al uso de la Ecografia en Cuidados Intensivos, Anestesia, Urgencias y Emergencias. En este documento se definen el programa de formacion y las competencias a adquirir para alcanzar el diploma acreditativo en ecografia toraco-pulmonar, ecografia abdominal y ecografia vascular. Este documento puede servir de guia para definir las competencias a adquirir en los programas de formacion de medicos internos residentes (MIR) de los especialistas que trabajen en cuidados intensivos, anestesia, urgencias y emergencias.

The use of ultrasound as a clinical diagnostic tool and guide of bedside procedures has become an indispensable examination in the acute critically ill patient. The training of professionals in minimum skills of knowledge, management and indications of use of ultrasound required to be defined by the Scientific Societies. The Intensive Care Ultrasound Working Group of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), of the Spanish Society of Internal Medicine (SEMI) and the Spanish Society of Emergency Medicine (SEMES) has developed this consensus document in which the recommended training program and the minimum competencies to be achieved with regard to the use of Ultrasound in Intensive Care, Anesthesia and Emergency medicine are defined. This document defines the training program and the skills to acquire in order to achieve the diploma in lung, abdominal and vascular ultrasound. This document can serve as a guide to define the skills to be acquired in the training programs of residents (MIRs) of specialists working in intensive care, anesthesia, and emergency medicine.

This document outlines aspects of innovation considered relevant for HS and proposes general actions for an Exploitation plan. Innovation is an essential component of the strategic objectives of E-RIHS. It encompasses novel research actions, offer of unique access services and provision of smart tools. Exploiting innovation, for the benefit of the E-RIHS ecosystem and the society, requires a number of actions along the innovation chain, including the presence of an efficient monitoring and evaluation system, appropriate knowledge and technology transfer channels, proper IPR protection and efficient communication with key stakeholders both in the public and the private sectors. An overall systematic approach to the above will ensure success and sustainability of ERIHS as an innovator and as a leader in the global HS landscape. This document is Deliverable 6.2, elaborated in the context of project IPERION HS, WP-06: Innovation and Exploitation, Task 6.4: Exploitation Plan. The analysis for the work presented herein was based on extensive interactions between the co-authors and builds upon a number of documents produced in the context of IPERION HS and E-RIHS PP (in particular Deliverable 9.4: Innovation Agenda).

Prolonged mechanical ventilation (MV) is a major complication following cardiac surgery. We conducted a secondary analysis of the Transfusion Requirements in Cardiac Surgery (TRICTS) III trial to describe MV duration, identify factors associated with prolonged MV, and examine associations of prolonged MV with mortality and complications.Four thousand, eight hundred and nine participants undergoing cardiac surgery at 71 hospitals worldwide were included. Prolonged MV was defined based on the Society of Thoracic Surgeons definition as MV lasting 24 hr or longer. Adjusted associations of patient and surgical factors with prolonged MV were examined using multivariable logistic regression. Associations of prolonged MV with complications were assessed using odds ratios, and adjusted associations between prolonged MV and mortality were evaluated using multinomial regression. Associations of shorter durations of MV with survival and complications were explored.Prolonged MV occurred in 15% (725/4,809) of participants. Prolonged MV was associated with surgical factors indicative of complexity, such as previous cardiac surgery, cardiopulmonary bypass duration, and separation attempts; and patient factors such as critical preoperative state, left ventricular impairment, renal failure, and pulmonary hypertension. Prolonged MV was associated with perioperative but not long-term complications. After risk adjustment, prolonged MV was associated with perioperative mortality; its association with long-term mortality among survivors was weaker. Shorter durations of MV were not associated with increased risk of mortality or complications.In this substudy of the TRICS III trial, prolonged MV was common after cardiac surgery and was associated with patient and surgical risk factors. Although prolonged MV showed strong associations with perioperative complications and mortality, it was not associated with long-term complications and had weaker association with long-term mortality among survivors.www.gov (NCT02042898); registered 23 January 2014. This is a substudy of the Transfusion Requirements in Cardiac Surgery (TRICS) III trial.RéSUMé: OBJET: La ventilation mécanique (VM) prolongée est une complication majeure après chirurgie cardiaque. Nous avons effectué une analyze secondaire de l’étude TRICS III sur les besoins de transfusion au cours de la chirurgie cardiaque pour décrire la durée de la VM, identifier les facteurs associés à une VM prolongée et examiner les associations de la VM prolongée avec la mortalité et les complications. MéTHODES: Quatre mille huit cent neuf participants subissant une chirurgie cardiaque dans 71 hôpitaux à travers le monde ont été inclus. La VM prolongée a été définie à partir de la définition de la Society of Thoracic Surgeons comme un événement durant 24 heures ou plus. Des associations ajustées de facteurs liés aux patients et à la chirurgie avec la VM prolongée ont été examinées en utilisant une régression logistique multifactorielle. Des associations de la VM prolongée avec des complications ont été évaluées en utilisant des rapports de cotes; les associations ajustées entre VM prolongée et mortalité ont été évaluées au moyen d’une régression multinominale. Les associations d’une VM de plus courte durée avec la survie et des complications ont été explorées. RéSULTATS: La VM prolongée est survenue chez 15 % (725/4 809) des participants. Une VM prolongée a été associée à des facteurs chirurgicaux indicateurs de complexité (comme une chirurgie cardiaque antérieure, la durée de la circulation extracorporelle et les tentatives de débranchement) et à des facteurs liés au patient (comme un état préopératoire critique, une défaillance ventriculaire gauche, une insuffisance rénale et une hypertension pulmonaire). La VM prolongée a été associée à des complications périopératoires, mais pas à des complications à long terme. Après ajustement pour le risque, la VM prolongée a été associée à la mortalité périopératoire; son association avec la mortalité à long terme des survivants a été plus faible. Les durées plus courtes de VM n’ont pas été associées à une augmentation du risque de mortalité ou à des complications. CONCLUSION: Dans cette étude auxiliaire de l’essai TRICS III, la VM prolongée a été fréquente après chirurgie cardiaque et a été associée à des facteurs de risque liés au patient et à la chirurgie. Bien que la VM prolongée ait présenté de fortes associations avec les complications périopératoires et la mortalité, elle n’a pas été associée avec des complications à long terme et était plus faiblement associée à la mortalité à long terme parmi les survivants. ENREGISTREMENT DE L’éTUDE: www.ClinicalTrials.gov (NCT02042898); enregistrée le 23 janvier 2014. Il s’agit d’une étude auxiliaire de l’étude TRICS III sur les besoins de transfusion en chirurgie cardiaque.

AIM To characterize the association between diabetes and transfusion and clinical outcomes in cardiac surgery, and to evaluate whether restrictive transfusion thresholds are harmful in these patients. MATERIALS AND METHODS The multinational, open-label, randomized controlled TRICS-III trial assessed a restrictive transfusion strategy (haemoglobin [Hb] transfusion threshold

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.

Background Hydroxyethyl starch (HES) solutions increase the risk of acute kidney injury (AKI) in critically ill patients admitted to intensive care unit (ICU) for medical indications. We conducted a cohort study to evaluate the renal safety of modern 6% HES solutions in high-risk patients having cardiac surgery. Method In this multicentre prospective cohort study, we recruited 261 consecutive patients at high-risk for developing cardiac surgery-associated AKI, based on a Cleveland score ≥ 4 points, from July to December 2017th in 14 hospitals in Spain and the United Kingdom. Multivariable logistic regression modeling and propensity-score matched-pairs analysis were used to determine the adjusted association between administration of HES and AKI. Results Of the cohort, 95 patients (36.4%) received 6% HES 130/0.4 either intraoperatively or postoperatively. Postoperative AKI occurred in 145 patients (55.5%). The unadjusted odds of AKI was significantly higher in the HES group, when compared to those not receiving HES (OR 2.22, 95% CI 1.30–3.80, p = 0.003). In multivariable logistic regression models, modern HES was not associated with significantly increased risk of AKI (adjusted OR 0.84, 95% CI 0.41–1.71, p = 0.63). In propensity score match-pairs analysis of 188 patients, the HES group experienced similar adjusted odds of AKI (OR 1.05, CI 95% 0.87–1.27, p = 0.57) and RRT (OR 1.06, CI 95% 0.92–1.22, p = 0.36). Conclusions The use of modern hydroxyethyl starch 6% HES 130/0.4 was not associated with an increased risk of AKI nor dialysis in this cohort of patients at elevated risk for developing AKI after cardiac surgery.

We present the case of a 44-year-old male, without a relevant medical history, admitted to the ICU after a multiple trauma caused by a high-energy traffic accident. The patient was initially conscious and oriented with Glasgow 14 and without neurological symptoms.

To quantify the acute effects of dobutamine in postoperative low cardiac output syndrome (LCOS) using transthoracic echocardiographic, hemodynamic, and blood biomarker monitoring and to assess its association with clinical outcomes.Observational prospective study.Single university hospital.Patients undergoing elective cardiac surgery.None.Echocardiographic parameters, hemodynamic data, and plasma biomarkers were obtained before and early after inotrope initiation. The diagnostic value of transthoracic echocardiographic parameters and their association with clinical outcome were evaluated. Thirty-eight LCOS patients and 12 control patients were included. The left ventricular outflow tract velocity time integral was significantly lower in LCOS patients (11.75 v 19.08 cm; p0.001) and showed a marked improvement after dobutamine administration (∼37% increase). Dobutamine improved left and right ventricular function, increased mean arterial pressure and urine output, and lowered lactate levels. The duration of dobutamine support, but not in-hospital mortality, was associated with echocardiographic estimates of cardiac performance early after dobutamine initiation.Early transthoracic echocardiographic assessment and the acute response to inotropic therapy may provide rapid and highly valuable information in the diagnostic workup and risk evaluation of patients with suspected LCOS after cardiac surgery.

ResumenIntroducciónLa cirugía cardiaca mínimamente invasiva sobre la válvula mitral ha crecido en popularidad. El objetivo del estudio es valorar la morbilidad y eficacia de la técnica a medio plazo en una serie inicial.Material y métodos212 pacientes fueron sometidos a cirugía sobre la válvula mitral entre los años 2009 y 2013; 44 mediante cirugía mínimamente invasiva por toracotomía y 168 por esternotomía media. Se realizó un emparejamiento estadístico para la obtención del grupo control por regresión logística y nivelación del grado de propensión considerando las principales variables de riesgo. Se registró la morbilidad y calidad de la reparación o sustitución. Se realizó un análisis univariante y multivariante para un evento compuesto de morbimortalidad, eficacia y requerimientos de hemoderivados.ResultadosFueron incluidos 44 pacientes por grupo. La media de seguimiento fue de 26,6 (14,6) y 28,4 (1,1) meses en el grupo de estudio y control, respectivamente. Se realizó reparación de la válvula mitral en el 70,5% en el grupo estudio y en el 68,2% en el grupo control. No se encontraron diferencias en la morbimortalidad perioperatoria. El número de pacientes que desarrollaron insuficiencia mitral moderada o severa durante el seguimiento fue del 9,1% en el grupo estudio y 11,4% en el control (p=1,0). Tanto en el análisis univariante como multivariante la cirugía mínimamente invasiva fue un predictor independiente de menor transfusión.ConclusiónLa cirugía mínimamente invasiva no es inferior a la esternotomía en morbilidad hospitalaria, ni en la calidad de la técnica quirúrgica en un programa de iniciación.AbstractIntroductionMinimally-invasive mitral valve cardiac surgery has become increasingly popular. The objective of this study is to assess morbidity and efficiency of the technique in the medium run in an initial series.Material and methods212 patients underwent mitral valve surgery between 2009 and 2013; 44 with minimally-invasive thoracotomy and 168 via median sternotomy. Statistical pairing was conducted to obtain the control group by means of logistic regression and propensity score matching considering the main risk variables. Morbidity and repair or replacement quality were registered. A univariate and multivariate analysis was carried out for an event comprising morbidity and mortality, efficiency and blood component requirements.ResultsEach group included 44 patients. Average follow-up time was 26.6 (14.6) and 28.4 (1.1) months in the study group and control group respectively. Mitral valve repair was performed in 70.5% of patients in the study group and in 68.2% of patients in the control group. No differences were found in perioperative morbidity and mortality. The number of patients who developed moderate or severe mitral insufficiency during follow-up was 9.1% in the study group and 11.4% in the control group (p=1.0). Minimally-invasive surgery was an independent predictor for lower transfusion in both the univariate and multivariate analyses.ConclusionMinimally-invasive surgery is not inferior to sternotomy in hospital morbidity or in the quality of surgical technique in an initial program.

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.

Resumen Presentamos el caso de una mujer de 60 anos de edad con fibrilacion auricular, programada para el reemplazo quirurgico de valvula aortica y mitral. La ecocardiografia transesofagica (ETE) intraoperatoria revelo una masa pedunculada de 20 × 30 mm anclada y movil en la orejuela izquierda que sobresalia hacia la auricula izquierda. Dos meses antes, como valoracion preoperatoria, se habia realizado una ecocardiografia transtoracica, la cual no habia mostrado ninguna masa en AI. De acuerdo con las ultimas guias, la ETE debe ser utilizada en todos los procedimientos a corazon abierto para: 1) confirmar y redefinir el diagnostico preoperatorio; 2) detectar patologia nueva o insospechada; 3) ajustar el plan anestesico y quirurgico, y 4) evaluar los resultados de la intervencion quirurgica. Nuestro caso confirma la importancia de la deteccion intraoperatoria de nuevos hallazgos que puedan condicionar el procedimiento y la planificacion quirurgica.

Background:Transthoracic echocardiography (TTE) cannot reliably exclude left atrial (LA) thrombi prior cardiac surgery. LA trombi have been shown to be associated with an increased stroke rate. TEE has a sensitive and specificity of 100% in detection of LA and left atrial appendage (LAA) thrombi in contrast to TTE which has limitations when assessing the presence of masses or thrombi in the left atrium.Case report:We report the case of a 60-year-old woman scheduled for aortic and mitral replacement. Her history includes atrial fibrillation and ischemic stroke. Chronic anticoagulation was suspended five days before surgery and low molecular weight heparin began. The intraoperative TEE revealed a new 20x30 mm diameter pedunculated mass in LAA protruding to LA. Preoperative TTE had been performed 2 months before, showing any mass inside. This made the surgeon was very cautious in the left atrial opening because the possibility of thrombus embolization.Discussion:According to the latest guidelines, TEE should be used in all open heart procedures in order to: (1) confirm and refine the preoperative diagnosis, (2) detect new or unsuspected pathology, (3) adjust the anesthetic and surgical plan accordingly, and (4) assess the results of surgical intervention. Our case confirms the importance of detection of new findings prior the operation which changes the surgical procedure and planning.Thrombi appear as echogenic mass protruding into the main cavity, and are generally broad and pedunculated base, they mostly are stationary. It should make us suspect its presence whenever there are stasis phenomena such as atrial fibrillation and mitral stenosis. Thrombogenic risk increases with decreasing LAA velocities: 40 cm/s (1%). The flow velocities in LAA as may incur indication surgery ligation.The withdrawal of the anticoagulation, can cause thrombosis in this area and therefore its substitution for HLMW is necessary although not always prevent from a new thrombus.Conclusions:TEE should be used in all open heart procedures.Intraoperative TEE gives the possibility to detect new pathologies that changes the surgical procedure.

Resumen Introduccion La elevacion del lactato serico en el posoperatorio de la cirugia cardiaca es frecuente y su etiopatogenia, multifactorial. Esta elevacion se asocia a hipoxia tisular (hiperlactatemia tipo A) y a alteraciones metabolicas no hipoxicas (hiperlactatemia tipo B). El objetivo de este estudio fue evaluar la evolucion del lactato en el posoperatorio de la ablacion de la fibrilacion auricular durante la cirugia valvular cardiaca y analizar si los niveles de lactato pudieran ser predictores de morbimortalidad. Material y metodos Estudio de casos y controles. Se estudiaron 32 pacientes intervenidos entre 2011 y 2012 de ablacion de la fibrilacion auricular realizada junto a la cirugia de recambio valvular (grupo Maze), y 32 pacientes pareados (grupo Control). Se analizaron los niveles posoperatorios seriados de lactato, la morbimortalidad perioperatoria y la estancia hospitalaria. Se realizo un estudio univariante y multivariante para estancias prolongadas y un suceso compuesto de morbimortalidad con el fin de detectar predictores independientes. Resultados El lactato estuvo mas elevado a las 6, 12 y 24 h en el grupo Maze. En el analisis univariante resultaron significativos como predictores de complicaciones, mortalidad y estancias prolongadas el hecho de pertenecer al grupo Maze (OR 3,88; IC 95% 1,3-11,1; p = 0,01) y la elevacion de lactato a las 12 h (OR 1,33; IC 95% 1,01-1,7; p = 0,04). En el analisis multivariante la pertenencia al grupo Maze fue predictor independiente de complicaciones mayores (OR 4,13; IC 95% 1,3-12,9; p = 0,015), para el suceso compuesto de morbimortalidad (OR 3,9; IC 95% 1,3-11,6; p = 0,01) y para estancia prolongada en la Unidad de Cuidados Criticos (OR 5,7; IC 95% 2,01-15,7; p = 0,01). Conclusiones La cirugia de ablacion de la fibrilacion auricular podria ser una causa no descrita previamente de hiperlactatemia tipo B con picos entre las 4-24 h tras cirugia cardiaca. El valor predictivo de esta elevacion, su correlacion con la morbimortalidad, su sensibilidad y su especificidad para discriminar los umbrales significativos estan aun por definir.

Sepsis in patients with human immunodeficiency virus (HIV) may be associated with the appearance of cardiac dysfunction. This is a challenge, both when making the differential diagnosis and determining the proper treatment, as there are numerous risk factors: Myocarditis due to the HIV itself, the presence or absence of highly active antiretroviral therapy, toxic substances, and cardiomyopathy associated with sepsis. The diagnostic and therapeutic approach to an HIV positive patient with septic shock and cardiac dysfunction is described, as well as a brief review of the different causes of cardiomyopathy which may affect this group of patients is also presented.

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).

Resumen Introduccion Una complicacion frecuente tras cirugia cardiaca con circulacion extracorporea es la hemorragia postoperatoria, llegando al 20% de los pacientes. La fibrinolisis es una de las causas de este sangrado excesivo y, por ello, se recomienda la utilizacion de acido tranexamico. El problema de su utilizacion reside en las numerosas pautas y en las diferentes dosis de administracion. Nuestro objetivo fue evaluar si existen diferencias en la hemorragia postoperatoria y la morbilidad tras cirugia cardiaca, con la administracion de diferentes dosis de acido tranexamico en 3 hospitales universitarios. Material y metodos Estudio retrospectivo multicentrico de cohortes. Se estudiaron 146 pacientes, intervenidos con CEC en cirugia programada segun el protocolo anestesico-quirurgico de cada centro. Se revisaron las historias clinicas y se dividieron en 2 grupos segun las dosis de acido tranexamico: Grupo A (dosis altas): dosis inicial de 20 mg/kg y perfusion continua de 4 mg/kg/h hasta el cierre de la esternotomia. Se anadieron 100 mg al cebado de CEC. Grupo B (dosis bajas): dosis inicial de 10 mg/kg seguido de una perfusion continua de 2 mg/kg/h hasta el cierre de la esternotomia. Se anadieron 50 mg al cebado de CEC. Se recogieron edad, sexo, peso, talla, tipo de procedimiento quirurgico (valvular, coronario o mixto), hematocrito, INR y recuento de plaquetas preoperatorio, tiempo y temperatura de CEC y hematocrito al cierre esternal. Entre las variables postoperatorias: debito por drenajes a las 6, 12 y 24 h postoperatorias, numero y tipo de hemoderivados transfundidos en las primeras 24 h, necesidad de reintervencion por hemorragia, ACV, AIT o un nuevo infarto agudo de miocardio, convulsiones y mortalidad. Resultados La incidencia de sangrado aumentado (pacientes en el percentil 90) fue superior en el grupo B en todas los momentos de evaluacion del estudio (p Conclusiones La dosis elevada de acido tranexamico en cirugia cardiaca con CEC parece reducir de forma significativa la hemorragia en las primeras horas del postoperatorio frente a dosis bajas. Sin embargo, esta disminucion no se traduce en una reduccion de las necesidades de hemoderivados.

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.

Resumen Objetivos La cirugia cardiaca de acceso minimo mediante minitoracotomia tiene como objetivo principal una reincorporacion precoz a la actividad diaria. Para ello, el control del dolor postoperatorio es fundamental. Realizamos un estudio para valorar la calidad de la analgesia postoperatoria tras cirugia cardiaca por minitoracotomia, segun la tecnica analgesica. Material y metodos Estudio descriptivo observacional retrospectivo. Se incluyeron los pacientes intervenidos de cirugia cardiaca de acceso minimo en nuestro centro, desde el ano 2009 hasta 2011. Los pacientes se dividieron en 2 grupos dependiendo del tipo de analgesia recibida: analgesia por cateter paravertebral, mediante la infusion de anestesicos locales (grupo BPV), y analgesia intravenosa con opiaceos (grupo AIO). Los objetivos del estudio fueron la comparacion de la calidad analgesica y las complicaciones asociadas a la tecnica analgesica, tiempo de extubacion, complicaciones posquirurgicas y tiempos de estancia hospitalaria, entre ambas tecnicas. Resultados Treinta y siete pacientes fueron intervenidos mediante cirugia cardiaca de acceso minimo tipo «Heart-Port» modificado. Quince pacientes recibieron analgesia mediante bloqueo paravertebral y 22 mediante analgesia con opiaceos. Los datos se muestran como media y desviacion estandar (DE). Se aprecio un tiempo de extubacion traqueal inferior a 4 h en el 60% de los pacientes en el grupo BPV, frente al 22% del grupo AIO (p 0,05). No se observaron complicaciones asociadas al bloqueo paravertebral continuo. Discusion La analgesia mediante bloqueo paravertebral es una tecnica aceptablemente segura en cirugia cardiaca por toracotomia, que permite una extubacion precoz con un control optimo del dolor cuando se compara con analgesia iv con opiaceos.

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.

El Strongyloides stercoralis (Ss) es un nematodo endémico en países de clima tropical y subtropical, y en España se han descrito casos, sobre todo en la costa mediterránea. La infección por Ss suele ser asintomática o manifestarse por síntomas predominantemente digestivos, y en los casos de hiperinfestación produce una estrongiloidiasis diseminada con sobreinfecciones bacterianas sistémicas que provocan una disfunción multiorgánica con resultado letal. Los factores de riesgo más importantes para que una infección en principio intestinal y en muchas ocasiones asintomática adquiera características de gravedad son la inmunosupresión y la utilización de corticoides, por su capacidad de alterar la función eosinofílica. El caso que presentamos corresponde a la forma de síndrome de hiperinfección por Ss acompañado de neumonía bilateral que ocasionó síndrome de distrés respiratorio agudo, con demostración del parásito en muestras de esputo, jugo gástrico y heces en un paciente con enfermedad de Crohn y tratamiento crónico con corticoides.

Resumen Objetivo Los resultados quirurgicos en las enfermedades de la aorta toracica descendente y toracoabdominal han mejorado significativamente, aunque la morbimortalidad sigue siendo elevada. Como consecuencia de ello las tecnicas terapeuticas endovasculares se presentan como alternativas atractivas. En este trabajo comparamos los resultados de la cirugia abierta sobre ambos segmentos aorticos con el tratamiento endovascular. Material y Metodos Estudio retrospectivo de los pacientes intervenidos de patologia sobre la aorta toracica descendente y toracoabdominal mediante cirugia abierta y tratamiento endovascular en nuestro hospital desde 1995 a 2009. Analizamos las caracteristicas preoperatorias e intraoperatorias y los resultados postoperatorios de ambos grupos. Resultados Se revisaron 22 pacientes, 10 sometidos a cirugia abierta y 12 a tratamiento endovascular. Las etiologias con indicacion quirurgica fueron aneurismas, disecciones y ambos en el 40%, 30% y 30% en el grupo de cirugia abierta y con el 66,7%, 33,3% y 0% en tratamiento endovascular. La patologia de origen traumatico se correspondio con el 20% y 16,7% y la cirugia de urgencia con el 40% y 16,2% en el grupo de cirugia abierta y endovascular respectivamente. No hubo diferencias estadisticamente significativas en las caracteristicas preoperatorios (excepto en la edad de los pacientes) entre ambos grupos. Se observaron diferencias estadisticamente significativas en los tiempos quirurgicos, estancia en unidad de cuidados criticos y estancia hospitalaria, y en el tiempo de intubacion (p Discusion La incidencia de complicaciones postoperatorias en el grupo de cirugia abierta de la aorta toracica descendente es similar a los centros con un volumen reducido de enfermos. Se observa una tendencia hacia una reduccion de la morbimortalidad asi como diferencias estadisticamente significativas en el tiempo de intubacion, la estancia en la unidad de cuidados criticos y hospitalaria en el grupo de tratamiento endovascular.

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.