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The outcomes of heart-lung transplant (HLT) are worse than those of heart transplant (HT) and lung transplant alone; this and the availability of mechanical assistance have meant that the indications for HLT have been changing. This study aims to analyze the evolution of indications for HLT in a country of 47 million inhabitants.We performed a retrospective observational study of all HLTs performed in Spain (performed in 2 centers) from 1990 to 2020. The total number of patients included was 1751 (HT 1673 and HLT 78). After clinical adjustment, overall survival was compared between the 2 groups. Seven etiological subgroups were considered within the HLT group: (1) cardiomyopathy with pulmonary hypertension (CM + PH);, (2) Eisenmenger syndrome, (3) congenital heart disease without Eisenmenger syndrome, (4) idiopathic pulmonary arterial hypertension (IPAH), (5) cystic fibrosis, (6) chronic obstructive pulmonary disease (COPD) and/or emphysema), and (7) diffuse interstitial lung disease.There were a large number of differences between patients with HLT vs HT. HLT had a 2.69-fold increased probability of death in the first year compared with HT. The indications for HLT have changed over the years. In the recent period the indications are mainly congenital heart disease and Eisenmenger syndrome, with some cases of CM + PH. Other indications for HLT have virtually disappeared, mainly lung diseases (IPAH, COPD, cystic fibrosis). Median survival was low in CM + PH (18 days), diffuse interstitial lung disease (29 days), and ischemic heart disease (114 days); intermediate in Eisenmenger syndrome (600 days); and longer in IPAH, COPD and/or emphysema, and cystic fibrosis.HLT is a procedure with high mortality. This and mechanical assists mean that the indications have changed over the years. Etiological analysis is of utmost interest to take advantage of organs and improve survival.

Resumen La introduccion de tecnicas toracoscopicas asistidas por video en cirugia toracica (VATS) ha permitido realizar un nuevo enfoque en la cirugia toracica. El acceso videotoracoscopico se realiza con pequenas incisiones, preservando al maximo los musculos y los tejidos. En la actualidad, la VATS se considera de eleccion en la mayoria de los procedimientos toracicos, principalmente debido a la menor morbimortalidad asociada. La reseccion pulmonar por VATS presenta reduccion de las fugas de aire prolongadas, arritmias, neumonia, dolor postoperatorio y una disminucion de los marcadores inflamatorios. Esta reduccion de las complicaciones postoperatorias esta vinculada a una reduccion de la estancia hospitalaria, siendo los pacientes de alto riesgo y con poca tolerancia a la toracotomia los principales beneficiarios de esta tecnica. En comparacion con la toracotomia convencional, los?resultados?oncologicos de la cirugia VATS son similares o incluso superiores a los de la cirugia abierta. Este documento, de redaccion multidisciplinar, consensuado por el grupo de trabajo de cirugia toracica de la Sociedad Espanola de Anestesiologia y Reanimacion (SEDAR), de la Sociedad Espanola de Cirugia Toracica (SECT) y la Asociacion Espanola de Fisioterapia (AEF), pretende estandarizar y difundir, con base en la bibliografia mas actual, las mejores pautas de manejo clinico perioperatorio de los pacientes que se someten a una cirugia de reseccion pulmonar por VATS. Cada recomendacion parte de una revision de la literatura disponible y analizada en profundidad por los autores. Con el objetivo de dirigir el curso asistencial que seguira el paciente que se somete a una cirugia pulmonar por VATS, esta guia se organiza inicialmente en el enfoque quirurgico, seguido de los tres puntos clasicos del proceso anestesico. Estos puntos son preoperatorio, intraoperatorio y postoperatorio.

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyses, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

Resumen: La patología de la aorta supone un reto para la medicina. Tanto a nivel diagnóstico, como terapéutico, el volumen de variables implicado ha hecho que dicha patología sea abordada por una ingente cantidad de especialistas. El manejo quirúrgico de dichas patologías implica un esfuerzo extraordinario por parte de muchos profesionales, dada la complejidad técnica y tecnológica empleada. A lo largo de estos años, dichos esfuerzos están dando sus frutos en forma de mejoras de resultados, gracias a un abordaje sistemático y protocolizado en el seno de un grupo de expertos (Comités de aorta o «Aortic team») en el que se han de implicar cardiólogos, cirujanos cardiacos, cirujanos vasculares, anestesiólogos y radiólogos, principalmente.En este documento, consensuado entre los grupos de trabajo de aorta de las sociedades españolas de Anestesiología y Cirugía Torácica-Cardiovascular se busca difundir los modos de trabajo más consensuados entre los centros de mayor actividad del país por parte de ambas especialidades, en lo que al tratamiento quirúrgico se refiere de la patología crónica de aorta descendente.Somos conscientes de la evolución constante de la terapéutica, lo cual sin duda puede hacer cuestionables algunas opiniones aquí expresadas y que sin duda irán modificándose en futuras ediciones.Este documento aspira a ser una herramienta de trabajo para los diferentes profesionales implicados en el tratamiento de la patología aórtica. Abstract: The pathology of the aorta is a challenge for medicine. Diagnostic and therapeutics move a huge volume of variables. This has let this pathology to be addressed by a big number of specialists. The surgical management of these pathologies implies an extraordinary effort on the part of many professionals, given the technical and technological complexity employed. Throughout these years, these efforts are paying off in the form of improved results, thanks to a systematic and protocolized approach within a group of experts (Aortic Committees or “Aortic team”) in which they have to involve cardiologists, cardiac surgeons, vascular surgeons, anesthesiologists and radiologists, mainly.In this document, agreed between the Aorta working groups of the Spanish societies of Anesthesiology and Thoracic-Cardiovascular Surgery, it is sought to disseminate the most agreed working modes among the centers of greatest activity in the country by both specialties, as far as surgical treatment is concerned in descending chronical aortic pathology.We are aware of the constant evolution of therapeutics, which can undoubtedly make some of the opinions expressed here questionable and that will undoubtedly be modified in future editions.This document aims to be a working tool for the different professionals involved in the treatment of aorticpathology.

The coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV 2), is usually associated with a wide variety of clinical presentations from asymptomatic to severe cases. The use of saliva as a diagnostic and monitoring fluid has gained importance since it can be used to investigate the immune response and to direct quantification of antibodies against COVID-19. Additionally, the use of proteomics in saliva has allowed to increase our understanding of the underlying pathophysiology of diseases, bringing new perspectives on diagnostics, monitoring, and treatment. In this work, we compared the salivary proteome of 10 patients with COVID-19, (five patients with mild and five patients with severe COVID-19) and ten control healthy patients. Through the application of proteomics, we have identified 30 proteins whose abundance levels differed between the COVID-19 groups and the control group. Two of these proteins (TGM3 and carbonic anhydrase-CA6) were validated by the measurement of gGT and TEA respectively, in 98 additional saliva samples separated into two groups: (1) COVID-19 group, integrated by 66 patients who tested positive for COVID-19 (2) control group, composed of 32 healthy individuals who did not show any sign of disease for at least four weeks and were negative for COVID-19 in RT-PCR. In the proteomic study there were observed upregulations in CAZA1, ACTN4, and ANXA4, which are proteins related to the protective response against the virus disturbance, and the upregulation of TGM3, that is correlated to the oxidative damage in pulmonary tissue. We also showed the downregulation in cystatins and CA6 that can be involved in the sensory response to stimulus and possibly related to the presence of anosmia and dysgeusia during the COVID-19. Additionally, the presence of FGB in patients with severe COVID-19 but not in mild COVID-19 patients could indicate a higher viral aggregation and activation in these cases. In conclusion, the salivary proteome in patients with COVID-19 showed changes in proteins related to the protective response to viral infection, and the altered sensory taste perception that occur during the disease. Moreover, gGT and TEA could be potential biomarkers of respiratory complications that can occurs during COVID 19 although further larger studies should be made to corroborate this.

RESUMO Objetivo: Determinar os niveis plasmaticos e o comportamento farmacocinetico da micafungina em pacientes tratados com oxigenacao por membrana extracorporea. Metodos: As amostras foram colhidas por meio de pontos de acesso antes e depois da membrana, em dois hospitais espanhois de nivel terciario. Os momentos para o calculo das curvas farmacocineticas foram antes da administracao do farmaco, e 1, 3, 5, 8, 18 e 24 horas apos o inicio da infusao nos dias 1 e 4 de tratamento. Calcularam-se a area sob a curva, a depuracao do farmaco, o volume de distribuicao e a meia-vida plasmatica por meio de analise farmacocinetica nao compartimental. Resultados: Os valores farmacocineticos analisados no primeiro e quarto dias de tratamento nao mostram qualquer diferenca de concentracao entre amostras colhidas antes da membrana e apos a membrana, e o comportamento farmacocinetico foi similar na vigencia de diferentes falencias de orgaos. A area sob a curva antes da membrana no dia 1 foi de 62,1 (IC95% 52,8 - 73,4) e a area sob a curva apos a membrana nesse mesmo dia foi de 63,4 (IC95% 52,4 - 76,7), com p = 0,625. A area sob a curva antes da membrana no dia 4 foi de 102,4 (IC95% 84,7 - 142,8), enquanto a area sob a curva apos a membrana nesse mesmo dia foi de 100,9 (IC95% 78,2 - 138,8), com p = 0,843. Conclusao: Os parâmetros farmacocineticos da micafungina nao foram alterados significantemente.

Introduction Cardiac surgery (CS) is associated with a significant use of blood products. The aim of this study was to evaluate the effect of red blood cells concentrates (RBC) transfusion on regional cerebral oxygen saturation (SrO2) in patients undergoing CS with additive EuroSCORE I > 6. Material and methods This is a prospective descriptive study. Patients with additive EuroSCORE I > 6 undergoing CS with extracorporeal circulation were included in the study. The demographic values, perioperative complications, hospital/ICU length of stay (LOS), as well as the preinduction baseline SrO2 values, the lowest SrO2 value during surgery, number of blood products transfused, hemoglobin (HB) and pre and postransfusional SrO2 values were recorded, and events of significant decrease in SrO2 below 20% of basal value or decrease below 50%. We considered responders those who had an increase post-transfusion SrO2 at least 20% of pre-transfusion value, an increase of standard deviation (7.9) or an increase up to basal SrO2. Results Data from 57 patients were collected. The average additive EuroSCORE I was 7.4 (SD 2.6) and the EuroSCORE II was 6.1 (SD 7.4). 52% were male. 35.1% of patients received intraoperative transfusion of at least one unit of RBC. The overall mortality was 8.7% (N = 5). During surgery 29.8% of the overall sample presented a decrease of more than 20% of baseline SrO2 or a value lower than 50%. Patients with a significant decrease in SrO2 presented a higher rate of perioperative complications (p = 0.04) and longer ICU-LOS 4.3 (SD 3.6) vs. 6.8 (SD 8.2) days (p = 0.01) and hospital LOS 10.1 (SD 3.1) vs. 14.2 (SD 9.4) days (p = 0.01). Pretransfusional HB was 7.4 (SD 0.8) mg/dl and postransfusional value was 8.4 (SD 0.8) (p = 0.00). Pretransfusional SrO2 was 59 (SD 8.6) and increased non- significantly after RBC transfusion to 61.1 (SD 7.9) (p = 0.1). Only 6 patients out of 21 could be considered responders. There were no significant differences in morbidity, mortality or LOS between responders and non-responders. Discussion In our population a non statistically significant increase in SrO2 was observed after RBC transfusion. When considering responders few patients were identified by SrO2. In conclusion SrO2 might not be reliable triger to decide transfusion.

Resumen Introduccion La cirugia cardiaca se asocia a un uso significativo de hemoderivados. El objetivo de este estudio fue evaluar el efecto de la transfusion sobre la saturacion regional de oxigeno cerebral (SrO2) en pacientes tratados mediante cirugia cardiaca con EuroSCORE I aditivo > 6. Material y metodos Estudio prospectivo observacional. Se incluyo en el estudio a los pacientes con EuroSCORE I aditivo > 6 tratados mediante cirugia cardiaca con circulacion extracorporea. Se recogieron los valores demograficos, complicaciones perioperatorias, estancias hospitalarias, asi como el valor de SrO2 basal preinduccion, el valor mas bajo de hemoglobina (Hb) registrado durante la cirugia, el valor de la Hb y la SrO2 pre y postransfusional, asi como la existencia de una caida significativa de mas del 20% del valor basal de la SrO2 o por debajo del 50%. Consideramos como respondedores a la transfusion aquellos que presentaron un aumento de la SrO2 postransfusion de al menos el 20% del valor previo, un aumento de la desviacion estandar (DE) (7,9) o un aumento hasta el nivel basal. Resultados Se recogieron los datos de 57 pacientes. El EuroSCORE I aditivo medio ± DE fue de 7,4 ± DE 2,6 y el EuroSCORE II fue de 6,1 ± DE 7,4. El 52% fueron varones. Se trasfundio al menos un concentrado de hematies al 35,1% de la muestra (20 pacientes). La SrO2 pretransfusional fue 59 ± DE 8,6 y aumento de forma no significativa tras la transfusion del primer CH (61,19 ± 7,9; p = 0,1). Un 29,8% de los pacientes presentaron durante la cirugia una disminucion de la SrO2 del 20% con respecto a su basal o un valor inferior al 50%. Los pacientes con una disminucion significativa de la SrO2 presentaron un mayor tasa de complicaciones perioperatorias (p = 0,04). La estancia en la Unidad de Cuidados Intensivos (UCI) fue mayor en los pacientes con una disminucion significativa de la SrO2 respecto a los que la no presentaron (6,8 ± 8,2 dias vs. 4,3 ± 3,6; p = 0,01) al igual que la estancia hospitalaria (14,2 ± 9,4 dias vs. 10,1 ± 3,1; p = 0,01). En nuestra muestra, 6 de los 21 pacientes fueron respondedores. No hubo diferencias significativas en la morbilidad o la mortalidad entre los respondedores y los no respondedores. Discusion En nuestra poblacion, se observo un aumento no significativo en la SrO2 tras la transfusion. Cuando se analizaron los respondedores a la transfusion por incrementos de SrO2, pocos pacientes fueron identificados como respondedores. En conclusion, la SrO2 podria no ser una herramienta que guie la transfusion en pacientes tratados mediante cirugia cardiaca con EuroSCORE I aditivo > 6.

The pathology of the aorta is a challenge for medicine. Diagnostic and therapeutics move a huge volume of variables. This has let this pathology to be addressed by a big number of specialists. The surgical management of these pathologies implies an extraordinary effort on the part of many professionals, given the technical and technological complexity employed. Throughout these years, these efforts are paying off in the form of improved results, thanks to a systematic and protocolized approach within a group of experts (Aortic Committees or "Aortic team") in which they have to involve cardiologists, cardiac surgeons, vascular surgeons, anesthesiologists and radiologists, mainly. In this document, agreed between the Aorta working groups of the Spanish societies of Anesthesiology and Thoracic-Cardiovascular Surgery, it is sought to disseminate the most agreed working modes among the centers of greatest activity in the country by both specialties, as far as surgical treatment is concerned in descending chronical aortic pathology. We are aware of the constant evolution of therapeutics, which can undoubtedly make some of the opinions expressed here questionable and that will undoubtedly be modified in future editions. This document aims to be a working tool for the different professionals involved in the treatment of aorticpathology. (C) 2020 Sociedad Espanola de Cirugia Cardiovascular y Endovascular. Published by Elsevier Espana, S.L.U.

The ERAS guidelines are intended to identify, disseminate and promote the implementation of the best, scientific evidence-based actions to decrease variability in clinical practice. The implementation of these practices in the global clinical process will promote better outcomes and the shortening of hospital and critical care unit stays, thereby resulting in a reduction in costs and in greater efficiency. After completing a systematic review at each of the points of the perioperative process in cardiac surgery, recommendations have been developed based on the best scientific evidence currently available with the consensus of the scientific societies involved. (C) 2020 Sociedad Espanola de Cirugia Cardiovascular y Endovascular. Published by Elsevier Espana, S.L.U.

Resumen Debido a la grave situacion de pandemia que vivimos causada por el COVID-19, la Seccion de Anestesia Cardiaca, Vascular y Toracica de la SEDAR pretende dar informacion de los aspectos mas relevantes a considerar en pacientes con sospecha o infeccion confirmada por coronavirus que van a ser sometidos a cirugia toracica. Creemos que es esencial mantener una optima transmision de informacion para llevar a cabo maniobras seguras, tanto para los pacientes como para el personal sanitario. La estrategia de manejo debe basarse en una organizacion exquisita del trabajo, definiendo quien, como y cuando va a realizar cada tarea y procedimiento. Las recomendaciones que se proponen, tras valorar el riesgo-beneficio en el escenario especifico de la cirugia de torax y la experiencia de expertos en toracica obtenida en el estudio COV2-VIAEREA, tratan de asesorar sobre los aspectos anestesicos claves a tener en cuenta ante una eventual necesidad de cirugia toracica en el contexto de la pandemia por COVID-19.

Extracorporeal membrane oxygenation (ECMO) is mechanical circulatory and respiratory assistance and offers an alternative to cardiopulmonary bypass (CPB) for certain thoracic procedures including lung transplantation.

Resumen Objetivo El objetivo principal del estudio fue valorar la repercusion de la implantacion de un programa de ahorro de sangre en pacientes intervenidos mediante cirugia cardiaca programada con el analisis de la tasa transfusional y las complicaciones. Materiales y metodos Estudio unicentrico, observacional, retrospectivo, comparativo que incluyo a 604 pacientes mayores de 15 anos consecutivos intervenidos mediante cirugia cardiaca programada. Se analizaron 2 grupos de pacientes establecidos por la aplicacion o no de un programa de ahorro de sangre entre diciembre de 2012 y julio de 2013 (293 pacientes, grupo prep) y entre abril de 2015 y mayo de 2016 (311 pacientes, grupo posp). Resultados Disminuyo la tasa transfusional global de componentes sanguineos en el grupo posp (89,5 vs. 67,6%; p Conclusiones La implantacion de los programas de ahorro de sangre en el Area de Cirugia Cardiaca tiene consecuencias favorables como el ahorro de componentes sanguineos y la disminucion de complicaciones pulmonares, aunque sin consecuencias en la disminucion de la mortalidad.

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.

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.

Introduction: Hepatopulmonary syndrome (HPS) is a serious, progressive disease. Its pathophysiology resides in a hypoxic intrapulmonary shunt and severe clinical deterioration. Liver transplantation (LT) is the only effective treatment in appropriately selected patients. Objective: To acknowledge the importance of early diagnosis of HPS. Patients and methods: Observational, descriptive, retrospective trial including 8 patients with HPS that received LT between April 2006 and August 2014. The clinical data prior to transplantation and follow-up after the procedure were reviewed. A multivariate analysis (stepwise forward logistic regression analysis) was used to identify the variable that could potentially increase the risk of death. Results: Of the 8 patients, death could only be significantly predicted based on the pre-LT arterial blood partial oxygen pressure (PaO2) (p = 0.002). The average pre-LT PaO2 of the patients that died was 51.5 ±2.49 SD, with a statistically significant difference (p = 0.002). None of the variables was statistically significant for HPS reversibility. The survival rate of patients diagnosed with HPS following the LT was 62.5%. Conclusions: The level of pre-LT hypoxemia is an important predictor for immediate postoperative mortality. Early detection of the condition is critical to reduce the post LT morbidity and mortality so that the indication for transplant is made at the right time, regardless of the stage of liver disease. The most efficient clinical strategy could be the use of appropriate early detection protocols for HPS through screening of hypoxemia in patients with portal hypertension. Introducción: El síndrome hepatopulmonar (SHP) es una enfermedad grave y progresiva cuya fisiopatología reside en un shunt intrapulmonar con hipoxia y deterioro clínico severo. Como único tratamiento efectivo se ha postulado el trasplante hepático (TH), en pacientes adecuadamente seleccionados. Objetivo: Reconocer la importancia del diagnostico temprano del SHP. Pacientes y métodos: Mediante un estudio observacional, descriptivo, con carácter retrospectivo de 8 pacientes con SHP, a los que se les realizó TH en el período entre Abril 2006-Agosto 2014. Se han revisado los datos clínicos previos al trasplante y el seguimiento tras este. Se empleó un estudio multivariante (stepwise forward logistic regression analisis), para determinar cual variable podría incrementar el riesgo de muerte. Resultados: De los 8 pacientes, el resultado de muerte sólo pudo ser predicho significativamente por el factor presión parcial de oxígeno en sangre arterial (PaO2) pre-TH (p=0,002). La PaO2 pre-TH promedio de los pacientes que fallecieron era de 51,5 +/- 2,49 DS, siendo la diferencia estadísticamente significativa (p=0,002). Ninguna variable resultó estadísticamente significativa para reversibilidad del SHP. La supervivencia de los pacientes con criterio de SHP posterior al TH fue de 62,5%. Conclusiones: El grado de hipoxemia pre-TH es un factor predictor importante de mortalidad en el postoperatorio inmediato. La precocidad en la detección de la entidad es fundamental tanto para disminuir la morbimortalidad post TH como para indicar éste en el momento óptimo independientemente del estadío de la enfermedad hepática. Protocolos adecuados de detección precoz del SHP mediante screening de hipoxemias en pacientes con hipertensión portal, puede ser la estrategia clínica más eficiente.

Patients with cystic fibrosis have a higher risk of developing chronic respiratory infectious diseases. The Nocardia farcinica lung infection is rare in this group of patients, and there are limited publications about this topic. Its diagnosis is complex, due to the clinical and the radiology signs being non-specific. Identification of the agent responsible in the sputum culture is occasionally negative. It is a slow growing organism and for this reason treatment is delayed, which can lead to an increase in complications, hospitable stays, and mortality. A case is reported on a 26 year-old woman with cystic fibrosis and chronic lung colonization by Nocardia farcinica and Aspergillus fumigatus, on long-term treatment with ciprofloxacin, trimethoprim-sulfamethoxazole, and posaconazole, who was admitted to ICU after bilateral lung transplantation. The initial post-operative progress was satisfactory. After discharge, the patient showed a gradual respiratory insufficiency with new chest X-ray showing diffuse infiltrates. Initially, the agent was not seen in the sputum culture. Prompt and aggressive measures were taken, due to the high clinical suspicion of a Nocardia farcinica lung infection. Treatment with a combination of amikacin and meropenem, and later combined with linezolid, led to the disappearance of the lung infiltrates and a clinical improvement. In our case, we confirm the rapid introduction of Nocardia farcinica in the new lungs. The complex identification and the delay in treatment increased the morbimortality. There is a special need for its eradication in patients with lung transplant, due to the strong immunosuppressive treatment.

Background Infections and primary graft dysfunction are devastating complications in the immediate postoperative period following lung transplantation. Nowadays, reliable diagnostic tools are not available. Biomarkers could improve early infection diagnosis. Methods Multicentre prospective observational study that included all centres authorized to perform lung transplantation in Spain. Lung infection and/or primary graft dysfunction presentation during study period (first postoperative week) was determined. Biomarkers were measured on ICU admission and daily till ICU discharge or for the following 6 consecutive postoperative days. Results We included 233 patients. Median PCT levels were significantly lower in patients with no infection than in patients with Infection on all follow up days. PCT levels were similar for PGD grades 1 and 2 and increased significantly in grade 3. CRP levels were similar in all groups, and no significant differences were observed at any study time point. In the absence of PGD grade 3, PCT levels above median (0.50 ng/ml on admission or 1.17 ng/ml on day 1) were significantly associated with more than two- and three-fold increase in the risk of infection (adjusted Odds Ratio 2.37, 95% confidence interval 1.06 to 5.30 and 3.44, 95% confidence interval 1.52 to 7.78, respectively). Conclusions In the absence of severe primary graft dysfunction, procalcitonin can be useful in detecting infections during the first postoperative week. PGD grade 3 significantly increases PCT levels and interferes with the capacity of PCT as a marker of infection. PCT was superior to CRP in the diagnosis of infection during the study period.

Circulatory assist devices such as extracorporeal membrane oxygenation are indicated in cases of cardiogenic shock refractory to optimal conventional treatment. Bleeding is a serious complication of such systems, mainly due to coagulation disorders caused by continuous administration of heparin, as well as platelet dysfunction. Serial coagulation and hemoglobin (Hb) measurements are essential. Hb measurements can be performed through repeated arterial blood gasometry, and more recently with a new spectrophotometric sensor, Masimo Rainbow Radical-7® device, which gives Hb values continuously and non-invasively. We report a case of a patient undergoing cardiac surgery who required extracorporeal membrane oxygenation for severe cardiogenic shock immediately after surgery. We compare the correlation and the level of agreement with Hb levels measured by 2 existing systems in clinical practice. Our results indicate that the Masimo® spectrophotometric monitor showed statistically comparable Hb values, in the correlation (r = .85; P < .01) and in agreement with those obtained by serial blood gas analyzer, ABL800 FLEX® (wavelength). In view of these results we consider the Masimo® device as a valid alternative for the continuous follow-up of the Hb and control of bleeding in these patients.

The objective of the present work is to describe the experience with intravenous (IV) sildenafil in heart transplant (HT) patients with reactive pulmonary hypertension (PH) who developed right ventricular dysfunction (RVD) in the immediate postoperative period. The first 5 patients who received IV sildenafil followinga HT are presented. The HTs took place between March 2011 and September 2012 in patients aged 37 to 64 years; all patients were male. Prior to the HT, mean pulmonary artery pressure (mPAP) was 32-56 mmHg. In all cases, the hemodynamic study demonstrated PH reactivity (positive vasodilator test with nitric oxide). All 5 patients developed RVD with hemodynamic instability immediately after the HT, despite the administration of nitric oxide from the time of intubation prior to the implant, optimal medical treatment in all cases, and a ventricular assist in 2 cases. In all patients, IV sildenafil was initiated at 10 mg/8 h for 48 h and was subsequently increased to 20 mg/8 h. in its oral formulation until discharge from the hospital. The change in pulmonary pressure was assessed using a Swan-Ganz catheter. Ventricular function was assessed using echocardiography. Length of stay in the Resuscitation Unit and mid-term survival were also assessed. Average time of extracorporeal circulation was 200 ± 110 min and organ ischemic time was 210 ± 95 min. All of the patients demonstrated pulmonary and systemic hemodynamic improvement, as well as recovery of right ventricular function after completing the treatment with IV sildenafil. The stay in the Resuscitation Unit lasted 3-25 days. All the patients were discharged from hospital with no mortality to date. Intravenous sildenafil improves right ventricle hemodynamics associated with pulmonary hypertension post-HT. Prophylactic prevention with this drug could be indicated for patients with reactive PH who are about to receive a transplant.

Primary graft dysfunction is a leading cause of morbimortality in the immediate postoperative period of patients undergoing lung transplantation. Among the treatment options are: lung protective ventilatory strategies, nitric oxide, lung surfactant therapy, and supportive treatment with extracorporeal membrane oxygenation (ECMO) as a bridge to recovery of lung function or re-transplant. We report the case of a 9-year-old girl affected by cystic fibrosis who underwent double-lung transplantation complicated with a severe primary graft dysfunction in the immediate postoperative period and refractory to standard therapies. Due to development of multiple organ failure, it was decided to insert arteriovenous ECMO catheters (pulmonary artery-right atrium). The postoperative course was satisfactory, allowing withdrawal of ECMO on the 5th post-surgical day. Currently the patient survives free of rejection and with an excellent quality of life after 600 days of follow up.

The anesthetist has 2 major tools for optimizing haemodynamics in cardiac surgery: Vasoactive drugs and the intravascular volume. It is necessary to identify which patients would benefit from one or the other therapies for a suitable response to treatment. Hemodynamic monitoring with the different existing parameters (pressure, volumetric static, volumetric functional and echocardiography) allows the management of these patients to be optimized. In this article a review is presented on the most recent and relevant publications, and the different tools available to control the management of the fluid therapy in this context, and to suggest a few guidelines for the haemodynamics monitoring of patients submitted to cardiac surgery. A systematic search has been made in PubMed, limiting the results to the publications over the last five years up to February 2012.

Resumen El uso de tecnologias extracorporeas en el soporte cardiopulmonar se ha extendido en los ultimos 20 anos. Los dispositivos oxigenador de membrana extracorporeo (ECMO) son los mas utilizados y se emplean desde hace anos en los programas de trasplante pulmonar. Sin embargo, hay pocos articulos con series amplias de resultados de ECMO. El empleo del ECMO en el fallo respiratorio, ademas de otorgar un soporte inmediato de oxigeno en pacientes severamente hipoxemicos y/o acidoticos, proporciona proteccion pulmonar ya que permite la disminucion instantanea en las necesidades de presiones y FiO 2 en el ventilador. Las complicaciones del uso de ECMO han ido minimizandose con las mejoras tecnicas que presentan los ultimos modelos de las asistencias, pero la insuficiencia renal, las infecciones, hemorragias y las complicaciones vasculares y mecanicas siguen siendo referidas en numerosos trabajos. Existen actualmente menos controversias en el empleo de la asistencia cardiorrespiratoria con ECMO como alternativa para pacientes descompensados que estan en lista de espera, para el intraoperatorio y postoperatorio del trasplante pulmonar.

The use of extracorporeal techniques in cardiopulmonary support has spread in the last 20 years. ECMO (extracorporeal membrane oxygenation) devices are the most commonly employed option, and have been used for years in lung transplant programs. Nevertheless, few articles on the results of ECMO involving large numbers of cases have been published to date. The use of ECMO in respiratory failure affords immediate oxygen support in patients with severe hypoxia and/or acidosis, and moreover provides pulmonary protection, since it allows an instantaneous decrease in the ventilator pressure and FiO2 needs. The complications of ECMO have been minimized thanks to the technological improvements found in the latest devices, though renal failure, infections, bleeding, and vascular and mechanical complications are still reported in many studies. At present there is less controversy regarding the use of cardiorespiratory assists with ECMO as an alternative in decompensated patients who are on the waiting list, referred to the intra- and postoperative periods of lung transplantation.

Resumen La funcion del ventriculo derecho tiene un importante papel en la morbilidad y la mortalidad de los pacientes sometidos a cirugia cardiaca. En este articulo se hace una revision de las diferentes herramientas diagnosticas disponibles en quirofano, entre las que destacan la vision directa del corazon, la ecocardiografia en sus distintas modalidades (transesofagica, epicardica), el estudio hemodinamico invasivo con el cateter de Swan-Ganz y, en casos de infarto del ventriculo derecho, el electrocardiograma. Los diferentes metodos diagnosticos disponibles son complementarios y no excluyentes, ya que cada uno de ellos aporta informacion que subsana las limitaciones de los diferentes sistemas de monitorizacion hemodinamica.

One-year survival in lung transplant is around 85%, but this figure has not increased in recent years, in spite of technical improvements.Retrospective, multicenter cohort study. Data from 272 eligible adults with lung transplant were recorded at 7 intensive care units (ICU) in Spain in 2013. The objective was to identify variables that might help to guide future clinical interventions in order to reducethe risk of death in the postoperative period.One patient (0.3%) died in the operating room and 27 (10%) within 90 days. Twenty (7.4%) died within 28 days, after a median of 14 ICU days. Grade 3 pulmonary graft dysfunction was documented in 108 patients, of whom 21 died, compared with 6 out of 163 without pulmonary graft dysfunction (P.001). At ICU admission, non-survivors had significantly lower (P=.03) median PaO2/FiO2 (200mmHg vs 280mmHg), and the difference increased after 24hours (178 vs 297mmHg, P.001). Thirteen required extracorporeal membrane oxygenation, and 7(53.8%) died. A logistic regression model identified pulmonary graft dysfunction (OR: 6.77), donor age60yr (OR: 2.91) and SOFA8 (OR: 2.53) as independent predictors of 90-day mortality. At ICU admission, higher median procalcitonin (1.6 vs 0.6) and lower median PaO2/FiO2 (200 vs 280mmHg) were significantly associated with mortality.Graft dysfunction remains a significant problem in lung transplant. Early ICU interventions in patients with severe hypoxemia or high procalcitonin are crucial in order to lower mortality.

On of the most common, and serious, complications in cardiac surgery is postoperative bleeding. According to the majority of studies, between 10% and 92% of patients subjected to elective surgery require transfusions of blood products and blood derivatives. Transfusions and reinterventions are associated with longer stays in critical care units and a decrease in survival rates. There have been some important changes in the treatment of changes in haemostasis and post-surgical bleeding in the last few years, particularly with the introduction into clinical practice of working procedures backed up by clinical guidelines, as well as the appearance of new drugs. The aim of this work is to describe the main characteristics and update the use of prothrombin complexes that are currently available in Spain, with special emphasis on their use in cardiac surgery.

Objectives: Mortality is high when cardiogenic shock develops after cardiotomy, making it impossible to discontinue extracorporeal circulation and/or leading to low postoperative cardiac output that is refractory to treatment with vasoactive drugs or implantation of an intra-aortic balloon pump. Extracorporeal membrane oxygenation (ECMO) provides temporary assisted circulation, lending hemodynamic and respiratory support to the patient with cardiogenic shock in order to prevent multiple organ failure and death. Material and methods: For this retrospective study of cases in which ECMO was applied in our hospital’s assisted circulation unit, we analyzed demographic data, indication, score on the European system for cardiac operative risk evaluation (Euroscore), duration of assistance, complications, and survival. Results: In the first 3 years after the assisted circulation unit was established, during which 1375 cardiac interventions took place, ECMO was used postoperatively in 12 patients (0.87%). In 8 of the patients, assistance was provided during cardiac surgery following cardiotomy and in 4 transplant patients it was used following primary graft failure. The mean (SD) patient age was 56.8 (9.1) years. The Euroscore predicted 37.3% (16.7%) of the deaths. ECMO was used for a mean of 5.4 (2.5) days. The most frequent complications were bleeding in the surgical area, cardiac tamponade, and acute renal insufficiency. Overall in-hospital mortality was 50%, lower than rates reported in the literature. Conclusions: ECMO provided viable temporary support, maintaining adequate cardiac output while the patient’s condition could be observed and heart function evaluated. Mortality was reduced.

Resumen Objetivo Analizar los datos clinicos y tratar de identificar los factores asociados que pudieran haber influido en la mortalidad postoperatoria de los pacientes de cirugia cardiaca durante su permanencia en la Unidad de Cuidados Criticos de los hospitales de la sanidad publica de la Comunidad Valenciana durante el 2007. Metodo Estudio retrospectivo desde 1 enero de 2007 hasta 31 diciembre del 2007. Se revisaron todas las historias clinicas de los pacientes operados de cirugia cardiaca con y sin circulacion extracorporea y se aplico un formulario de recogida de datos que permitio obtener la informacion necesaria para determinar edad, sexo, indice de masa corporal, factores de riesgo prequirurgicos, tipo de intervencion quirurgica realizada, tiempo de circulacion extracorporea, tiempo de isquemia, causa de mortalidad y tiempo de estancia en la Unidad de Cuidados Criticos. Resultados En los 5 centros publicos donde se realiza cirugia cardiaca la poblacion estudiada fue de 2.113 pacientes. El numero de pacientes fallecidos fue de 124, de ellos 70 fueron hombres y 54 mujeres. La media de edad fue 70 anos (DE 9,43) oscilando entre 36 y 91 anos. El valor medio del indice de masa corporal fue de 28,19 kg/m2 con un maximo de 42 kg/m2. El valor medio del Euroscore fue de 21,92 con un maximo de 94,29. Entre los factores de riesgo estudiados la hipertension arterial estaba presente en la mayoria de los pacientes (74,2%), dislipemia en el 51,6% de los casos, diabetes mellitus en el 38,7%, accidentes cerebrovasculares previos en el 7,3% e insuficiencia renal previa a la cirugia en el 2,4%. Destaca que el porcentaje mas alto de mortalidad, proxima al 35% de los 124 pacientes fallecidos, correspondio al grupo de pacientes sometidos a cirugia de revascularizacion coronaria, seguida de la cirugia combinada (reparacion/sustitucion valvular mas revascularizacion coronaria) con un 19,4%. En cirugia de valvula aortica la mortalidad fue del 18,5% y en cirugia de la valvula mitral un 11,3%. Los tiempos medios de circulacion extracorporea fueron de 148,63 minutos y el de isquemia miocardica de 94,91 minutos. Las causas de muerte mas frecuentes fueron shock cardiogenico (54,8%), seguido de shock distributivo (29,8%) y el menor grado shock hemorragico (8,9%). La estancia media de estos pacientes en las unidades de cuidados criticos fue de 13,6 dias. La mortalidad global fue de 5,87%. Conclusion Del grupo de pacientes estudiados que fallecieron en las unidades de Cuidados Criticos de la Comunidad Valenciana durante el ano 2007 tras ser intervenidos de cirugia cardiaca, fue la cirugia de revascularizacion coronaria la que presento mayor mortalidad. La hipertension arterial es el factor de comorbilidad preoperatoria con mayor prevalencia. El shock cardiogenico y el distributivo fueron las principales causas de mortalidad postoperatoria. Es necesario desarrollar un sistema de estratificacion de riesgo para la prediccion de mortalidad en las unidad de Cuidados Criticos y mejorar la calidad en el perioperatorio. Mortality following cardiac surgery in the national health service hospitals of the Community of Valencia in 2007: a descriptive analysis

Resumen El trasplante pulmonar es una opcion valida para pacientes con sarcoidosis en estadios avanzados que son refractarios a la terapia medica. Se trata de una enfermedad de etiologia desconocida y de evolucion y pronostico muy variables. Asi mismo, existe dificultad para definir el momento idoneo para la intervencion y el tipo de trasplante pulmonar a realizar, lo que podria influir sobre la elevada mortalidad perioperatoria de estos pacientes. La morbimortalidad postoperatoria se eleva en caso de hipertension pulmonar pretrasplante y cirugia toracica previa, asi como con la aparicion en el postoperatorio de fallo primario del injerto, rechazo agudo e infecciones entre otros factores. Presentamos dos casos clinicos de pacientes diagnosticados de sarcoidosis en estadio terminal, sometidos a trasplante pulmonar y trasplante cardiopulmonar con diferentes evoluciones, analizando los factores de morbimortalidad que determinaron su resultado final.