We have prospectively studied the effects of three types of patient controlled anesthesia (PCA) i... more We have prospectively studied the effects of three types of patient controlled anesthesia (PCA) in 30 patients who underwent elective upper abdominal surgery. Patients were allocated into three groups of 10. The first group received postoperative anesthesia by means of intravenous conventional PCA at fixed demand doses (PCADF). A second group was treated with demand doses that were varied in each bolus according to the intensity of pain (PCADV). A third group received continuous infusion with additional demand doses in variable bolus (PCAC + DV). The analgesic agent used in this study was morphine chloride. The total accumulated doses of morphine in PCADV group were lower than those of the other two groups. These differences were statistically significant when they were compared with PCADF group (p less than 0.01 at 2 and 6 hours; p less than 0.05 at 12 and 24 hours) and with PCAC + DV group (p less than 0.01 at 2, 6, 12, and 24 hours). Differences in morphine consumption during the...
Introduction: A semi-upright position in ventilated patients is recommended to prevent ventilator... more Introduction: A semi-upright position in ventilated patients is recommended to prevent ventilator-associated pneumonia (VAP) and is one of the components in the Ventilator Bundle of the Institute for Health Care Improvement. This recommendation, however, is not an evidence-based one.
The use of cardiac output monitoring may improve patient outcomes after major surgery. However, l... more The use of cardiac output monitoring may improve patient outcomes after major surgery. However, little is known about the use of this technology across nations. This is a secondary analysis of a previously published observational study. Patients aged 16 years and over undergoing major non-cardiac surgery in a 7-day period in April 2011 were included into this analysis. The objective is to describe prevalence and type of cardiac output monitoring used in major surgery in Europe. Included in the analysis were 12,170 patients from the surgical services of 426 hospitals in 28 European nations. One thousand four hundred and sixteen patients (11.6 %) were exposed to cardiac output monitoring, and 2343 patients (19.3 %) received a central venous catheter. Patients with higher American Society of Anesthesiologists (ASA) scores were more frequently exposed to cardiac output monitoring (ASA I and II, 643 patients [8.6 %]; ASA III-V, 768 patients [16.2 %]; p < 0.01) and central venous cathe...
Fluid challenges (FCs) are one of the most commonly used therapies in critically ill patients and... more Fluid challenges (FCs) are one of the most commonly used therapies in critically ill patients and represent the cornerstone of hemodynamic management in intensive care units. There are clear benefits and harms from fluid therapy. Limited data on the indication, type, amount and rate of an FC in critically ill patients exist in the literature. The primary aim was to evaluate how physicians conduct FCs in terms of type, volume, and rate of given fluid; the secondary aim was to evaluate variables used to trigger an FC and to compare the proportion of patients receiving further fluid administration based on the response to the FC. This was an observational study conducted in ICUs around the world. Each participating unit entered a maximum of 20 patients with one FC. 2213 patients were enrolled and analyzed in the study. The median [interquartile range] amount of fluid given during an FC was 500 ml (500-1000). The median time was 24 min (40-60 min), and the median rate of FC was 1000 [500-1333] ml/h. The main indication for FC was hypotension in 1211 (59 %, CI 57-61 %). In 43 % (CI 41-45 %) of the cases no hemodynamic variable was used. Static markers of preload were used in 785 of 2213 cases (36 %, CI 34-37 %). Dynamic indices of preload responsiveness were used in 483 of 2213 cases (22 %, CI 20-24 %). No safety variable for the FC was used in 72 % (CI 70-74 %) of the cases. There was no statistically significant difference in the proportion of patients who received further fluids after the FC between those with a positive, with an uncertain or with a negatively judged response. The current practice and evaluation of FC in critically ill patients are highly variable. Prediction of fluid responsiveness is not used routinely, safety limits are rarely used, and information from previous failed FCs is not always taken into account.
The prevalence of use of the World Health Organization surgical checklist is unknown. The clinica... more The prevalence of use of the World Health Organization surgical checklist is unknown. The clinical effectiveness of this intervention in improving postoperative outcomes is debated. We undertook a retrospective analysis of data describing surgical checklist use from a 7 day cohort study of surgical outcomes in 28 European nations (European Surgical Outcomes Study, EuSOS). The analysis included hospitals recruiting >10 patients and excluding outlier hospitals above the 95th centile for mortality. Multivariate logistic regression and three-level hierarchical generalized mixed models were constructed to explore the relationship between surgical checklist use and hospital mortality. Findings are presented as crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs). A total of 45 591 patients from 426 hospitals were included in the analysis. A surgical checklist was used in 67.5% patients, with marked variation across countries (0-99.6% of patients). Surgical checklist...
Revista Española de Anestesiología y Reanimación, 2013
Haemoperfusion is an extracorporeal technique that removes endotoxin and/or inflammatory mediator... more Haemoperfusion is an extracorporeal technique that removes endotoxin and/or inflammatory mediators by means of an adsorptive mechanism during the passage of the blood through a porous filter. Most of the studies in the literature use polymyxin B as the adsorptive agent. This treatment is based on the assumption that the removal of endotoxin and inflammatory mediators from the circulation attenuates the inflammatory response in sepsis. This review summarizes the theoretical basis, and the experimental and clinical results published to date with the use of haemoperfusion. Although most of the studies show positive results, some doubts have arisen about the suitability of the methods described (small number of cases, low quality of the experimental design, and excessive mortality in the control groups). There are also some inconsistencies regarding the theoretical basis of its use (lack of positive effects after the removal of endotoxin from the circulation using alternative mechanisms, discrepancies regarding the best moment to initiate the therapy, unexplained beneficial effects in the absence of increased endotoxin levels). It is the opinion of the authors that haemoperfusion represents a promising therapy for the treatment of sepsis, but consider that its usefulness requires confirmation in well designed studies before being included in protocols.
In this study, our objective was to determine whether a perioperative hemodynamic protocol based ... more In this study, our objective was to determine whether a perioperative hemodynamic protocol based on noninvasive cardiac output monitoring decreases the incidence of postoperative complications and hospital length of stay in major abdominal surgery patients requiring intensive care unit admission. Secondary objectives were the time to peristalsis recovery and the incidence of wound infection, anastomotic leaks, and mortality. A randomized clinical trial was conducted in 6 tertiary hospitals. One hundred forty-two adult patients scheduled for open colorectal surgery, gastrectomy, or small bowel resection were enrolled. A hemodynamic protocol including fluid administration and vasoactive drugs based on arterial blood pressure, cardiac index, and stroke volume response was compared with standard practice. Patients were followed until hospital discharge (determined by a surgeon blinded to the study) or death. In contrast to previous studies, we designed a pragmatic trial (as opposed to e...
ABSTRACT Delirium is defined as a condition of altered consciousness, which develops acutely and ... more ABSTRACT Delirium is defined as a condition of altered consciousness, which develops acutely and shows a fluctuating clinical course. Delirium is the most common manifestation of brain dysfunction in critically ill patients. Delirium is underestimated and its diagnosis is often missed unless specific diagnostic instruments like CAM-ICU are used. The appearance of delirium and its persistence is associated with worse outcomes in the ICU. Although the pathophysiology of delirium remains elusive, identifying its mechanisms will allow for the development of preventive measures and effective treatments. Non-pharmacological approaches decrease the duration of delirium episodes and thus should be encouraged. Pharmacological treatment traditionally includes antipsychotics such as haloperidol or quetiapine; however, their use lacks significant evidence.
Both dopamine and norepinephrine are recommended as first-line vasopressor agents in the treatmen... more Both dopamine and norepinephrine are recommended as first-line vasopressor agents in the treatment of shock. There is a continuing controversy about whether one agent is superior to the other.
Background Clinical outcomes after major surgery are poorly described at the national level. Evid... more Background Clinical outcomes after major surgery are poorly described at the national level. Evidence of heterogeneity between hospitals and health-care systems suggests potential to improve care for patients but this potential remains unconfi rmed. The European Surgical Outcomes Study was an international study designed to assess outcomes after non-cardiac surgery in Europe.
We have prospectively studied the effects of three types of patient controlled anesthesia (PCA) i... more We have prospectively studied the effects of three types of patient controlled anesthesia (PCA) in 30 patients who underwent elective upper abdominal surgery. Patients were allocated into three groups of 10. The first group received postoperative anesthesia by means of intravenous conventional PCA at fixed demand doses (PCADF). A second group was treated with demand doses that were varied in each bolus according to the intensity of pain (PCADV). A third group received continuous infusion with additional demand doses in variable bolus (PCAC + DV). The analgesic agent used in this study was morphine chloride. The total accumulated doses of morphine in PCADV group were lower than those of the other two groups. These differences were statistically significant when they were compared with PCADF group (p less than 0.01 at 2 and 6 hours; p less than 0.05 at 12 and 24 hours) and with PCAC + DV group (p less than 0.01 at 2, 6, 12, and 24 hours). Differences in morphine consumption during the...
Introduction: A semi-upright position in ventilated patients is recommended to prevent ventilator... more Introduction: A semi-upright position in ventilated patients is recommended to prevent ventilator-associated pneumonia (VAP) and is one of the components in the Ventilator Bundle of the Institute for Health Care Improvement. This recommendation, however, is not an evidence-based one.
The use of cardiac output monitoring may improve patient outcomes after major surgery. However, l... more The use of cardiac output monitoring may improve patient outcomes after major surgery. However, little is known about the use of this technology across nations. This is a secondary analysis of a previously published observational study. Patients aged 16 years and over undergoing major non-cardiac surgery in a 7-day period in April 2011 were included into this analysis. The objective is to describe prevalence and type of cardiac output monitoring used in major surgery in Europe. Included in the analysis were 12,170 patients from the surgical services of 426 hospitals in 28 European nations. One thousand four hundred and sixteen patients (11.6 %) were exposed to cardiac output monitoring, and 2343 patients (19.3 %) received a central venous catheter. Patients with higher American Society of Anesthesiologists (ASA) scores were more frequently exposed to cardiac output monitoring (ASA I and II, 643 patients [8.6 %]; ASA III-V, 768 patients [16.2 %]; p < 0.01) and central venous cathe...
Fluid challenges (FCs) are one of the most commonly used therapies in critically ill patients and... more Fluid challenges (FCs) are one of the most commonly used therapies in critically ill patients and represent the cornerstone of hemodynamic management in intensive care units. There are clear benefits and harms from fluid therapy. Limited data on the indication, type, amount and rate of an FC in critically ill patients exist in the literature. The primary aim was to evaluate how physicians conduct FCs in terms of type, volume, and rate of given fluid; the secondary aim was to evaluate variables used to trigger an FC and to compare the proportion of patients receiving further fluid administration based on the response to the FC. This was an observational study conducted in ICUs around the world. Each participating unit entered a maximum of 20 patients with one FC. 2213 patients were enrolled and analyzed in the study. The median [interquartile range] amount of fluid given during an FC was 500 ml (500-1000). The median time was 24 min (40-60 min), and the median rate of FC was 1000 [500-1333] ml/h. The main indication for FC was hypotension in 1211 (59 %, CI 57-61 %). In 43 % (CI 41-45 %) of the cases no hemodynamic variable was used. Static markers of preload were used in 785 of 2213 cases (36 %, CI 34-37 %). Dynamic indices of preload responsiveness were used in 483 of 2213 cases (22 %, CI 20-24 %). No safety variable for the FC was used in 72 % (CI 70-74 %) of the cases. There was no statistically significant difference in the proportion of patients who received further fluids after the FC between those with a positive, with an uncertain or with a negatively judged response. The current practice and evaluation of FC in critically ill patients are highly variable. Prediction of fluid responsiveness is not used routinely, safety limits are rarely used, and information from previous failed FCs is not always taken into account.
The prevalence of use of the World Health Organization surgical checklist is unknown. The clinica... more The prevalence of use of the World Health Organization surgical checklist is unknown. The clinical effectiveness of this intervention in improving postoperative outcomes is debated. We undertook a retrospective analysis of data describing surgical checklist use from a 7 day cohort study of surgical outcomes in 28 European nations (European Surgical Outcomes Study, EuSOS). The analysis included hospitals recruiting >10 patients and excluding outlier hospitals above the 95th centile for mortality. Multivariate logistic regression and three-level hierarchical generalized mixed models were constructed to explore the relationship between surgical checklist use and hospital mortality. Findings are presented as crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs). A total of 45 591 patients from 426 hospitals were included in the analysis. A surgical checklist was used in 67.5% patients, with marked variation across countries (0-99.6% of patients). Surgical checklist...
Revista Española de Anestesiología y Reanimación, 2013
Haemoperfusion is an extracorporeal technique that removes endotoxin and/or inflammatory mediator... more Haemoperfusion is an extracorporeal technique that removes endotoxin and/or inflammatory mediators by means of an adsorptive mechanism during the passage of the blood through a porous filter. Most of the studies in the literature use polymyxin B as the adsorptive agent. This treatment is based on the assumption that the removal of endotoxin and inflammatory mediators from the circulation attenuates the inflammatory response in sepsis. This review summarizes the theoretical basis, and the experimental and clinical results published to date with the use of haemoperfusion. Although most of the studies show positive results, some doubts have arisen about the suitability of the methods described (small number of cases, low quality of the experimental design, and excessive mortality in the control groups). There are also some inconsistencies regarding the theoretical basis of its use (lack of positive effects after the removal of endotoxin from the circulation using alternative mechanisms, discrepancies regarding the best moment to initiate the therapy, unexplained beneficial effects in the absence of increased endotoxin levels). It is the opinion of the authors that haemoperfusion represents a promising therapy for the treatment of sepsis, but consider that its usefulness requires confirmation in well designed studies before being included in protocols.
In this study, our objective was to determine whether a perioperative hemodynamic protocol based ... more In this study, our objective was to determine whether a perioperative hemodynamic protocol based on noninvasive cardiac output monitoring decreases the incidence of postoperative complications and hospital length of stay in major abdominal surgery patients requiring intensive care unit admission. Secondary objectives were the time to peristalsis recovery and the incidence of wound infection, anastomotic leaks, and mortality. A randomized clinical trial was conducted in 6 tertiary hospitals. One hundred forty-two adult patients scheduled for open colorectal surgery, gastrectomy, or small bowel resection were enrolled. A hemodynamic protocol including fluid administration and vasoactive drugs based on arterial blood pressure, cardiac index, and stroke volume response was compared with standard practice. Patients were followed until hospital discharge (determined by a surgeon blinded to the study) or death. In contrast to previous studies, we designed a pragmatic trial (as opposed to e...
ABSTRACT Delirium is defined as a condition of altered consciousness, which develops acutely and ... more ABSTRACT Delirium is defined as a condition of altered consciousness, which develops acutely and shows a fluctuating clinical course. Delirium is the most common manifestation of brain dysfunction in critically ill patients. Delirium is underestimated and its diagnosis is often missed unless specific diagnostic instruments like CAM-ICU are used. The appearance of delirium and its persistence is associated with worse outcomes in the ICU. Although the pathophysiology of delirium remains elusive, identifying its mechanisms will allow for the development of preventive measures and effective treatments. Non-pharmacological approaches decrease the duration of delirium episodes and thus should be encouraged. Pharmacological treatment traditionally includes antipsychotics such as haloperidol or quetiapine; however, their use lacks significant evidence.
Both dopamine and norepinephrine are recommended as first-line vasopressor agents in the treatmen... more Both dopamine and norepinephrine are recommended as first-line vasopressor agents in the treatment of shock. There is a continuing controversy about whether one agent is superior to the other.
Background Clinical outcomes after major surgery are poorly described at the national level. Evid... more Background Clinical outcomes after major surgery are poorly described at the national level. Evidence of heterogeneity between hospitals and health-care systems suggests potential to improve care for patients but this potential remains unconfi rmed. The European Surgical Outcomes Study was an international study designed to assess outcomes after non-cardiac surgery in Europe.
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Papers by Cesar Aldecoa