Falla renal aguda perioperatoria/Perioperative acute kidney injury

Diciembre 30, 2015. No. 2191

Falla renal aguda perioperatoria Perioperative acute kidney injury. Goren O, Matot I. Br J Anaesth. 2015 Dec;115 Suppl 2:ii3-ii14. doi: 10.1093/bja/aev380. Abstract Perioperative acute kidney injury (AKI) is not uncommon and is associated with considerable morbidity and mortality. Recently, several definition systems for AKI were proposed, incorporating both small changes of serum creatinine and urinary output reduction as diagnostic criteria. Novel biomarkers are under investigation as fast and accurate predictors of AKI. Several special considerations regarding the risk of AKI are of note in the surgical patient. Co-morbidities are important risk factors for AKI. The surgery in itself, especially emergency and major surgery in the critically ill, is associated with a high incidence of AKI. Certain types of surgeries, such as cardiac and transplantation surgeries, require special attention because they carry higher risk of AKI. Nephrotoxic drugs, contrast dye, and diuretics are commonly used in the perioperative period and are responsible for a significant amount of in-hospital AKI. Before surgery, the anaesthetist is required to identify patients at risk of AKI, optimize anaemia, and treat hypovolaemia. During surgery, normovolaemia is of utmost importance. Additionally, the surgical and anaesthesia team is advised to use measures to reduce blood loss and avoid unnecessary blood transfusion. Hypotension should be avoided because even short periods of mean arterial pressure <55-60 mm Hg carry a risk of postoperative AKI. Higher blood pressures are probably required for hypertensive patients. Urine output can be reduced significantly during surgery and is unrelated to perioperative renal function. Thus, fluids should not be given in excess for the sole purpose of avoiding or treating oliguria. Use of hydroxyethyl starch needs to be reconsidered. Recent evidence indicates a beneficial effect of administering low-chloride solutions. KEYWORDS: acute kidney injury; perioperative complications; perioperative management; surgery PDF Comparación de biomarcadores plasmáticos y urinarios en falla renal aguda Comparison of Plasma and Urine Biomarker Performance in Acute Kidney Injury. Schley G, Köberle C, Manuilova E, Rutz S, Forster C, Weyand M, Formentini I, Kientsch-Engel R, Eckardt KU, Willam C. PLoS One. 2015 Dec 15;10(12):e0145042. doi: 10.1371/journal.pone.0145042. eCollection 2015. Abstract BACKGROUND: New renal biomarkers measured in urine promise to increase specificity for risk stratification and early diagnosis of acute kidney injury (AKI) but concomitantly may be altered by urine concentration effects and chronic renal insufficiency. This study therefore directly compared the performance of AKI biomarkers in urine and plasma.METHODS:This single-center, prospective cohort study included 110 unselected adults undergoing cardiac surgery with cardiopulmonary bypass between 2009 and 2010. Plasma and/or urine concentrations of creatinine, cystatin C, neutrophil gelatinase-associated lipocalin (NGAL), liver fatty acid-binding protein (L-FABP), kidney injury molecule 1 (KIM1), and albumin as well as 15 additional biomarkers in plasma and urine were measured during the perioperative period. The primary outcome was AKI defined by AKIN serum creatinine criteria within 72 hours after surgery.RESULTS:Biomarkers in plasma showed markedly better discriminative performance for preoperative risk stratification and early postoperative (within 24h after surgery) detection of AKI than urine biomarkers. Discriminative power of urine biomarkers improved when concentrations were normalized to urinary creatinine, but urine biomarkers had still lower AUC values than plasma biomarkers. Best diagnostic performance 4h after surgery had plasma NGAL (AUC 0.83), cystatin C (0.76), MIG (0.74), and L-FAPB (0.73). Combinations of multiple biomarkers did not improve their diagnostic power. Preoperative clinical scoring systems (EuroSCORE and Cleveland Clinic Foundation Score) predicted the risk for AKI (AUC 0.76 and 0.71) and were not inferior to biomarkers. Preexisting chronic kidney disease limited the diagnostic performance of both plasma and urine biomarkers.CONCLUSIONS:In our cohort plasma biomarkers had higher discriminative power for risk stratification and early diagnosis of AKI than urine biomarkers. For preoperative risk stratification of AKI clinical models showed similar discriminative performance to biomarkers. The discriminative performance of both plasma and urine biomarkers was reduced by preexisting chronic kidney disease. PDF Amplias fluctuaciones perioperatorias de glicemia aumentan el riesgo de lesión renalpostoperatoria aguda: estudio prospectivo de cohortes. Wider Perioperative Glycemic Fluctuations Increase Risk of Postoperative Acute Kidney Injury: A Prospective Cohort Study. Sim MA, Liu W, Ng RR, Ti LK, Chew ST. Medicine (Baltimore). 2015 Nov;94(44):e1953. doi: 10.1097/MD.0000000000001953. Conclusions. Wide acute perioperative glycemic fluctuations should be avoided as they are associated with a significantly increased risk of AKI and ICU length of stay in both the diabetics and the nondiabetics. PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015

Eventos quirúrgicos prevenibles/Surgical never events

Diciembre 29, 2015. No. 2190

Carga de trabajo quirúrgico y el riesgo de eventos quirúrgicos prevenibles en Inglaterra. Surgical caseload and the risk of surgical Never Events in England. Moppett IK, Moppett SH. Anaesthesia. 2016 Jan;71(1):17-30. doi: 10.1111/anae.13290. Epub 2015 Nov 23. Abstract Never Events are medical errors that are believed to be preventable with appropriate measures. We surveyed all English acute NHS trusts to determine the number of surgical Never Events and surgical caseload for 2011-2014. There were 742 surgically related Never Events in three years, with no change in the number annually. The risk of a surgical Never Event was 1 in 16 423 operations (95% CI 1 in 15 283 to 1 in 17 648) or 1 NeverEvent per 12.9 operating theatres per year (95% CI 1 in 12.1 to 1 in 13.9). The risk of severe harm due to a Never Event was approximately 1 in 238 939 operations. There was no meaningful association between number of Never Events and other safety indicators. Surgical Never Events are undoubtedly important to individual patients, but they are not a useful metric to judge quality of care. PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015

Fuego en quirófano / Fire in the surgical room

Diciembre 26, 2015. No. 2187

Fuego en el quirófano Operating room fires: a closed claims analysis. Mehta SP, Bhananker SM, Posner KL, Domino KB. Anesthesiology. 2013 May;118(5):1133-9. doi: 10.1097/ALN.0b013e31828afa7b. Abstract BACKGROUND: To assess patterns of injury and liability associated with operating room (OR) fires, closed malpractice claims in the American Society of Anesthesiologists Closed Claims Database since 1985 were reviewed.METHODS: All claims related to fires in the OR were compared with nonfire-related surgical anesthesia claims. An analysis of fire-related claims was performed to identify causative factors.RESULTS: There were 103 OR fire claims (1.9% of 5,297 surgical claims). Electrocautery was the ignition source in 90% of fire claims. OR fire claims more frequently involved older outpatients compared with other surgical anesthesia claims (P < 0.01). Payments to patients were more often made in fire claims (P < 0.01), but payment amounts were lower (median $120,166) compared to nonfire surgical claims (median $250,000, P < 0.01). Electrocautery-induced fires (n = 93) increased over time (P < 0.01) to 4.4% claims between 2000 and 2009. Most (85%) electrocautery fires occurred during head, neck, or upper chest procedures (high-fire-risk procedures). Oxygen served as the oxidizer in 95% of electrocautery-induced OR fires (84% with open delivery system). Most electrocautery-induced fires (n = 75, 81%) occurred during monitored anesthesia care. Oxygen was administered via an open delivery system in all high-risk procedures during monitored anesthesia care. In contrast, alcohol-containing prep solutions and volatile compounds were present in only 15% of OR fires during monitored anesthesia care.CONCLUSIONS: Electrocautery-induced fires during monitored anesthesia care were the most common cause of OR fires claims. Recognition of the fire triad (oxidizer, fuel, and ignition source), particularly the critical role of supplemental oxygen by an open delivery system during use of the electrocautery, is crucial to prevent OR fires. Continuing education and communication among OR personnel along with fire prevention protocols in high-fire-risk procedures may reduce the occurrence of OR fires. PDF Fuego y quemaduras con electrocauterio después de preparar la piel con alcohol en neurocirugía Fires and Burns Occurring in an Electrocautery after Skin Preparation with Alcohol during a Neurosurgery. Chae SB, Kim WK, Yoo CJ, Park CW. J Korean Neurosurg Soc. 2014 Apr;55(4):230-3. doi: 10.3340/jkns.2014.55.4.230. Epub 2014 Apr 30. Abstract While there are reports regarding burns occurring to patients during the surgery, there are little reports concerning the incidents of the burns related to neurosurgical operations. Moreover, in Korea, even surveys and statistics on the incidents of burns in operating rooms are not known. This report explores burns occurring to a patient in an electrocautery scenario after disinfecting the surgical site with alcohol during the preparation of a neurosurgical operation in an operating room where there is much exposure to oxygen. The authors show a case of a 33-year-old male patient who undergoing evacuation of hematoma on occipital lesion, suffered second degree burns as a result of surgical fires. KEYWORDS: Alcohol; Burns; Electrocautery; Neurosurgery PDF Usos comunes y complicaciones de la energía en cirugía Common uses and cited complications of energy in surgery. Sankaranarayanan G, Resapu RR, Jones DB, Schwaitzberg S, De S. Surg Endosc. 2013 Sep;27(9):3056-72. doi: 10.1007/s00464-013-2823-9. Epub 2013 Apr 23. Abstract BACKGROUND: Instruments that apply energy to cut, coagulate, and dissect tissue with minimal bleeding facilitate surgery. The improper use of energy devices may increase patient morbidity and mortality. The current article reviews various energy sources in terms of their common uses and safe practices.METHODS: For the purpose of this review, a general search was conducted through NCBI, SpringerLink, and Google. Articles describing laparoscopic or minimally invasive surgeries using single or multiple energy sources are considered, as are articles comparing various commercial energy devices in laboratory settings. Keywords, such as laparoscopy, energy, laser, electrosurgery, monopolar, bipolar, harmonic, ultrasonic, cryosurgery, argon beam, laser, complications, and death were used in the search.RESULTS: A review of the literature shows that the performance of the energy devices depends upon the type of procedure. There is no consensus as to which device is optimal for a given procedure. The technical skill level of the surgeon and the knowledge about the devices are both important factors in deciding safe outcomes.CONCLUSIONS: As new energy devices enter the market increases, surgeons should be aware of their indicated use in laparoscopic, endoscopic, and open surgery. PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015