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Resumen: La oxigenación por membrana extracorpórea (extracorporeal membrane oxygenation, ECMO) es un sistema extracorpóreo de asistencia cardiorrespiratoria cuya utilización se ha visto incrementada en la última década. La insuficiencia respiratoria, el shock postcardiotomía y el fallo primario del injerto cardíaco o pulmonar son complicaciones que pueden requerir la utilización de asistencia mecánica cardiorrespiratoria y, en este escenario, el conocimiento de las peculiaridades perioperatorias médicas y quirúrgicas es fundamental.A pesar de la evolución tecnológica en el área de la asistencia extracorpórea, la morbimortalidad de estos pacientes continúa siendo elevada, por lo tanto, la decisión del implante de la ECMO como la de su retirada debe establecerse dentro de un equipo multidisciplinar experto en el área.El presente documento de consenso pretende unificar conocimientos y aportar recomendaciones basadas tanto en la bibliografía reciente como en la experiencia de los principales centros nacionales implantadores de ECMO con el objetivo final de mejorar la atención integral al paciente. Abstract: ECMO is an extracorporeal cardiorespiratory support system whose use has been increased in the last decade. Respiratory failure, postcardiotomy shock, and lung or heart primary graft failure may require the use of cardiorespiratory mechanical assistance. In this scenario perioperative medical and surgical management is crucial.Despite the evolution of technology in the area of extracorporeal support, morbidity and mortality of these patients continues to be high, and therefore the indication as well as the ECMO removal should be established within a multidisciplinary team with expertise in the area.This consensus document aims to unify medical knowledge and provides recommendations based on both the recent bibliography and the main national ECMO implantation centers experience with the goal of improving comprehensive patient care.

Background: 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., Methods: 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., Results: 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., Conclusions: 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., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Aortic pathology is always a challenge for the clinician, and must be diagnosed and treated by a multidisciplinary team due to the technical and technological complexity of the resources used. Ongoing efforts to implement a systematic, protocolized approach involving "Aortic teams" made up of cardiologists, cardiac surgeons, vascular surgeons, anaesthesiologists and radiologists, among others are now leading to improved outcomes. The aim of this consensus document drawn up by the Aortic working groups of the Spanish Society of Anaesthesiology, Resuscitation and Pain Therapy (SEDAR) and the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) is to disseminate a set of working protocols. The latest consensus document of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society for Vascular Surgery (ESVS) define the concept of "AORTIC TEAM"(1). The aortic team should be closely involved from diagnosis to treatment and finally follow-up, and should be formed of cardiac and vascular surgeons working together with anaesthesiologists, cardiologists, radiologists and geneticists. Treatment of aortic pathologies should be centralised in large centres, because this is the only way to effectively understand the natural course of the disease, provide the entire range of treatment options under one umbrella and treat potential complications. A streamlined emergent care pathway (24/7 availability), adequate transportation and transfer capabilities, as well as rapid activation of the multidisciplinary team must be available. In light of the complexity and constant evolution of therapeutic options, we present this first version of the Anaesthesiology and surgical guidelines for surgery of the ascending aorta and aortic arch. Some questions will no doubt remain unanswered, and future versions will include new techniques that, though implemented in some centres, are still not widely recommended., (Copyright © 2021 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.)

ECMO is an extracorporeal cardiorespiratory support system whose use has been increased in the last decade. Respiratory failure, postcardiotomy shock, and lung or heart primary graft failure may require the use of cardiorespiratory mechanical assistance. In this scenario perioperative medical and surgical management is crucial. Despite the evolution of technology in the area of extracorporeal support, morbidity and mortality of these patients continues to be high, and therefore the indication as well as the ECMO removal should be established within a multidisciplinary team with expertise in the area. This consensus document aims to unify medical knowledge and provides recommendations based on both the recent bibliography and the main national ECMO implantation centres experience with the goal of improving comprehensive patient care., (Copyright © 2021 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.)

Aortic pathology is always a challenge for the clinician, and must be diagnosed and treated by a multidisciplinary team due to the technical and technological complexity of the resources used. Ongoing efforts to implement a systematic, protocolized approach involving "Aortic teams" made up of cardiologists, cardiac surgeons, vascular surgeons, anaesthesiologists and radiologists, among others are now leading to improved outcomes. The aim of this consensus document drawn up by the Aortic working groups of the Spanish Society of Anaesthesiology, Resuscitation and Pain Therapy (SEDAR) and the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) is to disseminate a set of working protocols. The latest consensus document of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society for Vascular Surgery (ESVS) define the concept of "AORTIC TEAM"(1). The aortic team should be closely involved from diagnosis to treatment and finally follow-up, and should be formed of cardiac and vascular surgeons working together with anaesthesiologists, cardiologists, radiologists and geneticists. Treatment of aortic pathologies should be centralised in large centres, because this is the only way to effectively understand the natural course of the disease, provide the entire range of treatment options under one umbrella and treat potential complications. A streamlined emergent care pathway (24/7 availability), adequate transportation and transfer capabilities, as well as rapid activation of the multidisciplinary team must be available. In light of the complexity and constant evolution of therapeutic options, we present this first version of the Anaesthesiology and surgical guidelines for surgery of the ascending aorta and aortic arch. Some questions will no doubt remain unanswered, and future versions will include new techniques that, though implemented in some centres, are still not widely recommended., (Copyright © 2021 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objective: To determine micafungin plasma levels and pharmacokinetic behavior in patients treated with extracorporeal membrane oxygenation., Methods: The samples were taken through an access point before and after the membrane in two tertiary hospitals in Spain. The times for the calculation of pharmacokinetic curves were before the administration of the drug and 1, 3, 5, 8, 18 and 24 hours after the beginning of the infusion on days one and four. The area under the curve, drug clearance, volume of distribution and plasma half-life time with a noncompartmental pharmacokinetic data analysis were calculated., Results: The pharmacokinetics of the values analyzed on the first and fourth day of treatment did not show any concentration difference between the samples taken before the membrane (Cin) and those taken after the membrane (Cout), and the pharmacokinetic behavior was similar with different organ failures. The area under the curve (AUC) before the membrane on day 1 was 62.1 (95%CI 52.8 - 73.4) and the AUC after the membrane on this day was 63.4 (95%CI 52.4 - 76.7), p = 0.625. The AUC before the membrane on day 4 was 102.4 (95%CI 84.7 - 142.8) and the AUC was 100.9 (95%CI 78.2 - 138.8), p = 0.843., Conclusion: The pharmacokinetic parameters of micafungin were not significantly altered.

Pulmonary arterial hypertension (PAH), defined by a mean pulmonary arterial pressure greater than 25 mm Hg at rest or greater than 30 mm Hg with exercise, poses a challenge to anesthesiologists during perioperative management. The pathogenesis of PAH is multifactorial and includes genetic factors that explain individual susceptibility and external trigger or risk factors. We report the case of a woman with severe pulmonary hypertension who was waiting for a lung transplant when she was scheduled for laparoscopic cholecystectomy. We discuss the clinical course and monitoring of hemodynamic and respiratory parameters at the different stages of laparoscopic surgery.

Pulmonary artery hypertension is a rare entity but one that presents genuine challenges during anesthesia mainly because of the high risk of exacerbation and right heart failure during and after surgery. This review covers currently available treatments, the battery of diagnostic procedures at our disposal, and the basic precepts for the perioperative management of patients with this condition. Adequate hemodynamic control and the early use of selective pulmonary vasodilators are absolutely essential.

Background and Objective: Our goal was to analyze the incidence of perioperative complications in patients with pulmonary emphysema who underwent lung transplantation and to identify variables associated with the incidence of morbidity and mortality during the immediate postoperative period., Patients and Method: We undertook a retrospective study of 65 pulmonary emphysema patients who received lung transplants from 1994 through 2002 with the aim of determining the most common intra- and early postoperative complications in the ICU. An univariate analysis was carried out in order to identify variables associated with the incidence of mortality and postoperative complications. Those variables showing statistical significance underwent a multivariate analysis, by means of a pattern of logistic regression, in order to calculate the odds ratio and confidence interval., Results: Seventeen patients received single-lung transplants (SLT) and 48 patients received sequential double-lung transplants (DLT). Intraoperative complications appeared more frequently in the DLT group. Most frequent complications during surgery were reperfusion syndrome (44.6%) and pulmonary hypertension (16.9%). The intraoperative survival was 100%. Fifty-five patients had some type of postoperative complication. Commonest postoperative complications were infection (56.9%) and primary graft failure (36.6%). In the early postoperative period the mortality rate was 16.9%. Main cause of death in the ICU was sepsis (54.5%). A time of mechanical ventilation > 48 hours and postoperative hemorrhage were the variables with a higher predictive value for mortality in the early postoperative period., Conclusions: Patients with SLT had a lower rate of perioperative complications and a higher survival during their stay in the ICU. Time of mechanical ventilation > 48 hours and postoperative hemorrhage were the variables that best predicted death in the early postoperative period following lung transplantation. Despite our experience, however, perioperative mortality in lung transplantation remains high up to this day.

Objective to review the experience of the lung transplantation unit at Hospital La Fe (Valencia). Between February 1990 and March 1996 we performed 40 lung transplants. The following causes were most common: cystic fibrosis (9 cases), emphysema (8), pulmonary fibrosis (8) and bronchiectasis (7). Types of intervention were 27 double lung transplants (25 sequential and 9 blocked), 9 single lung transplants, and 4 heart-lung transplants. We then reviewed the 36 single and double lung transplants. The main exclusion criteria were age over 65 years, malignant disease, kidney or liver disease, severe or non reversible central nervous system disease, and drug addiction. Prior surgery, mechanical ventilation and the presence of Aspergillus were considered lower-order contraindications. Mean patient age was 37.7 years (14-59). Six patients were colonized by Aspergillus before transplantation. Five had undergone earlier surgery and two were mechanically ventilated before the transplant. The most common complication was respiratory infection, which was present in 6 of the 7 patients who died. Other complications in order of frequency were dehiscence and/or bronchial stenosis, corticoid myopathy and postoperative bleeding. The actuarial survival rate of single and double lung transplants was 67.85 after 3 years, and 87.5% in patients with cystic fibrosis. Lung transplantation is a well-established procedure that is gradually being extended to treat more conditions. The main obstacle is the scarcity of donors. The main challenge at present is bronchiolitis obliterans.

Objective: Since 1990 we have performed 40 lung transplants in the Hospital "La Fe" in Valencia. Nine of them have been performed in cystic fibrosis patients, which is the subject of this paper., Patients and Methods: The mean age of the patients was 19.8 years, with the youngest patient being 14 years of age. In regards to patient selection, it is important to mention that one had a previous lobectomy, another one a thoracic deformity due to long term atelectasis and one needed intubation for hemoptysis within the 7 days before the lung transplant. Prophylaxis with imipenem and cyprofloxicin, aerosolized colistin and amphotericin B, prompt weaning and intensive respiratory physiotherapy were important for controlling postoperative infection., Results: With 15.3 months as the mean follow-up (range 36-3), 3 year survival was 87.5%. Pulmonary infection, which was the most frequent complication, had a good response to adequate antibiotic treatment. The main postoperative problem pertained to the bronchial suture with 2 partial dehiscences, 2 stenoses and one bronchopleural fistula by Aspergillus, all of which were resolved with conservative procedures without surgery., Conclusions: Middle and long term evolution in these patients shows an excellent quality of life with spirometric and ergometric tests within the normal range.