Hemorragia obstétrica / Obstetric hemorrhage

Abril 21, 2017. No. 2666

Manejo del sangrado masivo en pacientes obstétricas Testigos de Jehova. La abrumadora importancia de un protocolo multidisciplinario preestablecido. Management of massive bleeding in a Jehovah's Witness obstetric patient: the overwhelming importance of a pre-established multidisciplinary protocol. Belaouchi M1, Romero E1, Mazzinari G1, Esparza M1, García-Cebrían C1, Gil F2, Muñoz M3. Blood Transfus. 2016 Jul 12;14(6):541-544. doi: 10.2450/2016.0229-15. [Epub ahead of print] Introduction Life-threatening massive bleeding is doubtlessly one of the biggest challenges in health care, especially in patients who reject allogeneic transfusion, such as Jehovah's Witnesses. However, according to the principle of patients' autonomy, our job is to accept their decision and provide them with the best possible assistance. We present a protocol for the management of massive post-operative bleeding successfully applied in a Jehovah's Witness after a Caesarean section (CS). PDF Listas de verificación y desempeño multidisciplinario del equipo durante la hemorragia obstétrica simulada. Checklists and multidisciplinary team performance during simulated obstetric hemorrhage. Hilton G1, Daniels K2, Goldhaber-Fiebert SN3, Lipman S3, Carvalho B3, Butwick A3. Int J Obstet Anesth. 2016 Feb;25:9-16. doi: 10.1016/j.ijoa.2015.08.011. Epub 2015 Aug 21. Abstract BACKGROUND: Checklists can optimize team performance during medical crises. However, there has been limited examination of checklist use during obstetric crises. In this simulation study we exposed multidisciplinary teams to checklist training to evaluate checklist use and team performance during a severe postpartum hemorrhage. METHODS: Fourteen multidisciplinary teams participated in a postpartum hemorrhage simulation occurring after vaginal delivery. Before participating, each team received checklist training. The primary study outcome was whether each team used the checklist during the simulation. Secondary outcomes were the times taken to activate our institution-specific massive transfusion protocol and commence red blood cell transfusion, and whether a designated checklist reader was used. RESULTS: The majority of teams (12/14 (86%)) used the checklist. Red blood cell transfusion was administered by all teams. The median [IQR] times taken to activate the massive transfusion protocol and transfuse red blood cells were 5min 14s [3:23-6:43] and 14min 40s [12:56-17:28], respectively. A designated checklist reader was used by 7/12 (58%) teams that used the checklist. Among teams that used a checklist with versus without a designated reader, we observed no differences in the times to activate the massive transfusion protocol or to commence red blood cell transfusion (P>0.05). CONCLUSIONS: Although checklist training was effective in promoting checklist use, multidisciplinary teams varied in their scope of checklist use during a postpartum hemorrhage simulation. Future studies are required to determine whether structured checklist training can result in more standardized checklist use during a postpartum hemorrhage. KEYWORDS: Checklist; Multidisciplinary; Obstetrics; Postpartum hemorrhage; Simulation PDF  Manejo transfusional y de la coagulación en hemorragia obstétrica severa Transfusion and coagulation management in major obstetric hemorrhage. Butwick AJ1, Goodnough LT. Curr Opin Anaesthesiol. 2015 Jun;28(3):275-84. doi: 10.1097/ACO.0000000000000180. Abstract PURPOSE OF REVIEW: Major obstetric hemorrhage is a leading cause of maternal morbidity and mortality. We will review transfusion strategies and the value of monitoring the maternal coagulation profile during severe obstetric hemorrhage. RECENT FINDINGS: Epidemiologic studies indicate that rates of severe postpartum hemorrhage (PPH) in well resourced countries are increasing. Despite these increases, rates of transfusion in obstetrics are low (0.9-2.3%), and investigators have questioned whether a predelivery 'type and screen' is cost-effective for all obstetric patients. Instead, blood ordering protocols specific to obstetric patients can reduce unnecessary antibody testing. When severe PPH occurs, a massive transfusion protocol has attracted interest as a key therapeutic resource by ensuring sustained availability of blood products to the labor and delivery unit. During early postpartum bleeding, recent studies have shown that hypofibrinogenemia is an important predictor for the later development of severe PPH. Point-of-care technologies, such as thromboelastography and rotational thromboelastometry, can identify decreased fibrin clot quality during PPH, which correlate with low fibrinogen levels. SUMMARY: A massive transfusion protocol provides a key resource in the management of severe PPH. However, future studies are needed to assess whether formula-driven vs. goal-directed transfusion therapy improves maternal outcomes in women with severe PPH. PDF Foro Internacional de Medicina Crítica Ciudad de México, Julio 13-15, 2017 Información / Information

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

Neurotoxicidad por anestesia / Anesthesia neurotoxicity

Mayo 3, 2017. No. 2678

El precondicionamiento isquémico remoto provee neuroprotección. Impacto de la apoptosis inducida por ketamina en el cerebro de ratas en desarrollo Remote ischemic preconditioning provides neuroprotection: impact on ketamine-induced neuroapoptosis in the developing rat brain. Ma W1, Cao YY, Qu S, Ma SS, Wang JZ, Deng LQ, Yuan WJ, Meng JH. Eur Rev Med Pharmacol Sci. 2016 Dec;20(23):4972-4979. Abstract OBJECTIVE: Previous studies have demonstrated that the commonly used anesthetic ketamine can acutely increase apoptosis and have long-lasting detrimental effects on cognitive function as the animal matures. Remote ischemic preconditioning (RIPC) has been confirmed to have a cerebral protective role in animal models of brain damage. The aim of this study was to investigate whether RIPC can protect the developing brain from anesthetic-induced neurotoxicity. MATERIALS AND METHODS: To investigate the protective properties of RIPC, 60 new-born Sprague-Dawley (SD) rats were randomly allocated into four groups: ketamine (20 mg/kg was diluted in saline, six times at an interval of 2 hours); RIPC (left hind row ischemia 5 min, reperfusion 5 min, a total of four cycles); ketamine + RIPC: RIPC was induced at postnatal day 5 and rats underwent the same treatment with the ketamine group after 48 hours; and saline (group vehicle). Neuronal apoptosis in the frontal cortex and hippocampal CA1 region was measured 24 h after treatment using immunohistochemistry of cleaved caspase-3. Learning and memory abilities were tested at the age of 60 days by Morris water maze test. RESULTS: The percentage of cleaved caspase-3 immunohistochemical staining positive cells in the ketamine + RIPC group showed a more marked decline in neuronal apoptosis of the CA1 region than that in the ketamine group (p < 0.05) but not in the CA1 region (p > 0.05). The mice exposed to RIPC alone showed no difference from the saline-treated mice. Moreover, RIPC significantly reversed the learning and memory deficits observed at 60 days of age. CONCLUSIONS: Our data indicate that RIPC treatment provides protection against ketamine-induced neuroapoptosis in the frontal cerebral cortex but not in the hippocampal CA1 region in developing rats and attenuates long-term behavioural deficits as the animals mature, suggesting a new possible strategy for neuroprotection. PDF Monóxido de carbono y neurotoxicidad inducida por anestesia Carbon monoxide and anesthesia-induced neurotoxicity. Levy RJ1. Neurotoxicol Teratol. 2017 Mar - Apr;60:50-58. doi: 10.1016/j.ntt.2016.09.002. Epub 2016 Sep 9. Abstract The majority of commonly used anesthetic agents induce widespread neuronal degeneration in the developing mammalian brain. Downstream, the process appears to involve activation of the oxidative stress-associated mitochondrial apoptosis pathway. Targeting this pathway could result in prevention of anesthetic toxicity in the immature brain. Carbon monoxide (CO) is a gas that exerts biological activity in the developing brain and low dose exposures have the potential to provide neuroprotection. In recent work, low concentration CO exposures limited isoflurane-induced neuronal apoptosis in a dose-dependent manner in newborn mice and modulated oxidative stress within forebrain mitochondria. Because infants and children are routinely exposed to low levels of CO during low-flow general endotracheal anesthesia, such anti-oxidant and pro-survival cellular effects are clinically relevant. Here we provide an overview of anesthesia-related CO exposure, discuss the biological activity of low concentration CO, detail the effects of CO in the brain during development, and provide evidence for CO-mediated inhibition of anesthesia-induced neurotoxicity. KEYWORDS: Anesthesia-induced neurotoxicity; Apoptosis; Carbon monoxide; Cytoprotection; Endogenous; Exogenous; Exposure; General anesthesia; Low-flow anesthesia; Mitochondria; Oxidative stress; Therapy PDF Neurotoxicidad inducida por anestesia en el cerebro en desarrollo. Actualización de la evidencia preclínica Anaesthetics-induced neurotoxicity in developing brain: an update on preclinical evidence. Zhou Z1, Ma D2. Brain Sci. 2014 Mar 14;4(1):136-49. doi: 10.3390/brainsci4010136. Abstract Every year millions of young people are treated with anaesthetic agents for surgery and sedation in a seemingly safe manner. However, growing and convincing preclinical evidence in rodents and nonhuman primates, together with recent epidemiological observations, suggest that exposure to anaesthetics in common clinical use can be neurotoxic to the developing brain and lead to long-term neurological sequelae. These findings have seriously questioned the safe use of general anaesthetics in obstetric and paediatric patients. The mechanisms and human applicability of  anaesthetic neurotoxicity and neuroprotection have remained under intense investigation over the past decade. Ongoing pre-clinical investigation may have significant impact on clinical practice in the near future. This review represents recent developments in this rapidly emerging field. The aim is to summarise recently available laboratory data, especially those being published after 2010, in the field of anaesthetics-induced neurotoxicity and its impact on cognitive function. In addition, we will discuss recent findings in mechanisms of early-life anaesthetics-induced neurotoxicity, the role of human stem cell-derived models in detecting such toxicity, and new potential alleviating strategies. PDF

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

Donación y transplante / Donation and transplantation

Mayo 4, 2017. No. 2679

Donación de órganos y transplantes en México. Perspectiva de los profesionales de la salud sobre los trasplantes Organ donation and transplantation in Mexico. A transplantation health professionals' perspective. Hernández-Ibarra LE1, Mercado-Martínez FJ2, Martínez-Castañeda A2. Salud Publica Mex. 2017 Jan-Feb;59(1):53-58. doi: 10.21149/7755. Abstract OBJECTIVE: We aimed to explore organ donation and transplantation in Mexico from the point of view of transplantation health professionals. MATERIALS AND METHODS: A qualitative study was carried out. Twenty six organ transplantation health professionals from seven states of Mexico participated. Semi-structured face-to-face interviews were conducted mainly in hospital settings. Critical discourse analysis was performed. RESULTS: According to participants, living organ transplantation offers benefits for recipients as well as for donors. Several factors influence the field of transplantation negatively, among them the scarcity of resources that impedes the incorporation of new health personnel, as well as conflicts between transplantation teams with diverse health professionals and authorities. CONCLUSION: Besides increasing economic resources, transplantation health personnel should be sensitized to find solutions in order to avoid conflicts with different health professionals. Studies on organ donation and transplants also should include other social actors' viewpoint. PDF Donación después de la determinación de la circulación cerebral de la muerte. Donation after brain circulation determination of death. Dalle Ave AL1, Bernat JL2. BMC Med Ethics. 2017 Feb 23;18(1):15. doi: 10.1186/s12910-017-0173-1. Abstract BACKGROUND: The fundamental determinant of death in donation after circulatory determination of death is the cessation of brain circulation and function. We therefore propose the term donation after brain circulation determination of death [DBCDD]. RESULTS: In DBCDD, death is determined when the cessation of circulatory function is permanent but before it is irreversible, consistent with medical standards of death determination outside the context of organ donation. Safeguards to prevent error include that: 1] the possibility of auto-resuscitation has elapsed; 2] no brain circulation may resume after the determination of death; 3] complete circulatory cessation is verified; and 4] the cessation of brain function is permanent and complete. Death should be determined by the confirmation of the cessation of systemic circulation; the use of brain death tests is invalid and unnecessary. Because this concept differs from current standards, consensus should be sought among stakeholders. The patient or surrogate should provide informed consent for organ donation by understanding the basis of the declaration of death. CONCLUSION: In cases of circulatory cessation, such as occurs in DBCDD, death can be defined as the permanent cessation of brain functions, determined by the permanent cessation of brain circulation. KEYWORDS: Brain criterion of death; Determination of death; Donation after circulatory determination of death [DCDD]; Ethics; Extracorporeal membrane oxygenation [ECMO]; Transplantation PDF Donación de órganos y ventilación electiva. Una estrategia necesaria Organ Donation and Elective Ventilation: A Necessary Strategy. Escudero D1, Otero J2, Menéndez de León B3, Perez-Basterrechea M2. Biomed Res Int. 2017;2017:7518375. doi: 10.1155/2017/7518375. Epub 2017 Jan 15. Abstract Organ transplantation is the sole treatment to improve or save the life of patients with final-stage organ failure. The shortage of available organs for transplantation constitutes a universal problem, estimating that 10% of patients on waiting lists die. Brain death is an undesirable result; nevertheless, it has beneficial side-effects since it is the most frequent source of organs for transplantation. However, this phenomenon is relatively uncommon and has a limited potential. One of the options that focuses on increasing organ donation is to admit patients with catastrophic brain injuries (with a high probability of brain death and nontreatable) to the Intensive Care Unit, with the only purpose of donation. To perform elective nontherapeutic ventilation (ENTV), a patient's anticipated willingness to donate organs and/or explicit acceptance by his/her relatives is required. This process should focus exclusively on those patients with catastrophic brain injuries and imminent risk of death which, due to its acute damage, are not considered treatable. This article defends ENTV as an effective strategy to improve donation rate, analyzing its ethical and legal basis. PDF

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