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ObjetiveTo analyze the effects of the implementation of an ERAS program in patients undergoing pulmonary resection in a tertiary university hospital on the rates of complications and readmission and the length of stay.Methodsambispective cohort study, with a prospective arm of patients undergoing thoracic surgery within an ERAS program versus a retrospective arm of patients before the implementation of the protocol. We recluited 50 patients per arm. The primary outcome was the number of patients with 30-day surgical complications. Secondary outcome included ERAS adherence, no-surgical complications, mortality, readmission, reintervention rates, pain and hospital lenght of stay. We performed a multivariate logistic analysis to study the association of coutcomes with ERAS adherence.ResultsWe found no difference between the two groups in surgical complications [Standard 18 (36%) vs 12 (24%], p =0.19]. ERAS group was significantly lower only in its readmission rate [Standard 15 (30%) vs 6 (12%], p =0.03]. In multivariate analyses, ERAS adherence was the only factor associated with a reduction in surgical complications [OR (95%CI) = 0.02 (0.00, 0.59), p = 0.03] and length of stay [HR (95%CI) = 18.5 (4.39, 78.4), p < 0.001].ConclusionsERAS program was able to decrease the readmission rate at our centre significantly. The adherence to the ERAS protocol influenced the reduction of surgical complications and length of stay.

Some patients still report moderate-to-severe postoperative pain after cesarean delivery. Local anesthetic wound infusion improves acute pain and might act on peripheral and central sensitization mechanisms; however, no studies have proved this hypothesis. We evaluated the potential benefits of continuous wound infusion of levobupivacaine after cesarean delivery on secondary hyperalgesia (primary end point) and primary hyperalgesia, pain relief, persistent pain, and inflammatory and metabolic stress response.Healthy women scheduled for elective cesarean delivery participated in this prospective, randomized, triple-blind, placebo-controlled trial (NCT01458431). All patients received spinal anesthesia with 0.5% hyperbaric bupivacaine with fentanyl and a multiholed wound catheter placed under the fascia. Women were randomized to receive continuous wound infusion (0.35% levobupivacaine 7 mL/h for 48 hours; group L) or an equal volume of saline (group S). Secondary hyperalgesia to punctate mechanical stimuli was evaluated using dynamic tests, and primary hyperalgesia was evaluated using an electronic von Frey anesthesiometer; both were assessed at 24, 48, and 72 hours. The following variables were collected: intensity of postoperative parietal and visceral pain at rest and on movement rated on a visual analog scale72 hours, time to first bolus of patient-controlled analgesia (PCA), cumulative dose of rescue morphine (PCA) and acetaminophen, ability to sleep and sleep quality, and patient satisfaction. Persistent postoperative pain was evaluated during a telephone interview at 1, 3, 6, and 12 months after surgery. C-reactive protein, acid glycoprotein, preprandial glucose, insulin, cortisol, prolactin, growth hormone, and interleukin-6 were measured before cesarean delivery and at 8, 24, and 48 hours. Adverse events and patient outcomes were recorded.Seventy women were included. In group L, the area of secondary hyperalgesia was significantly reduced (43.4 [18.5-80] vs 68.4 [39.0-136] cm2 and 45.1 [0.9-89.8] vs 67.3 [31.3-175] cm2 at 24 and 48 hours, respectively; group:time interaction P value.001), the mechanical pain threshold was significantly higher at 24 hours (633 [441-802] vs 417 [300-572] g.mm-2; P = .001), and morphine consumption was significantly lower at 24 hours (4 [2-11] vs 11[6-23]; P = .003) compared with group S. Levobupivacaine had no effect on persistent postoperative pain at 1, 3, 6, and 12 months. Plasma insulin levels in the immediate postoperative period and at 8, 24, and 48 hours were significantly lower in group L (P.001). There were no significant differences in other biochemical parameters of inflammatory and endocrine-metabolic response.Levobupivacaine wound infusion provides adequate analgesia and might be an effective antihyperalgesic adjunct.

The TotaltrackTM is a new video laryngeal mask, which combines a supraglottic airway with a videolaryngoscope. We evaluated the performance of this device in an observational study in 300 adult patients. The Totaltrack was inserted at the first attempt and the glottis seen in all cases. In 249 patients (83%; 95%CI 78.7-87.3%) the glottis was seen at the first attempt. Adequate ventilation and tracheal intubation were achieved in all patients. The median time to visualisation of vocal cords, to confirmation of ventilation and to successful tracheal intubation was 5 s, 13 s and 24 s, respectively. Nineteen patients (6.3%; 95%CI 3.55-9.05%) suffered minor complications, such as mucosal lesion or blood staining. The Totaltrack appears effective for airway management.

Adherence to Enhanced Recovery Protocols (ERPs) is associated with faster functional recovery, better patient satisfaction, lower complication rates and reduced length of hospital stay. Understanding institutional barriers and facilitators is essential for improving adherence to ERPs. The purpose of this study was to identify institutional factors associated with adherence to an ERP for colorectal surgery.A secondary analysis of a nationwide study was conducted including 686 patients who underwent colorectal surgery across twenty-one institutions in Spain. Adherence to ERPs was calculated based upon the components recommended by the Enhanced Recovery After Surgery (ERAS®) Society. Institutional characteristics (i.e., case volume, ERP duration, anesthesia staff size, multidisciplinary meetings, leadership discipline) were captured from each participating program. Multivariable regression was performed to determine characteristics associated with adherence.The median adherence to ERAS was 68.2% (IQR 59.1%-81.8%). Multivariable linear regression revealed that anesthesiologist leadership (+5.49%, 95%CI +2.81% to +8.18%, P 0.01), duration of ERAS implementation (+0.46% per year, 95%CI +0.06% to +0.86%, P 0.01) and the use of regular multidisciplinary meetings (+4.66%, 95%CI +0.06 to +7.74%, P 0.01) were independently associated with greater adherence. Case volume (-2.38% per 4 cases weekly, 95%CI -3.03 to -1.74, P 0.01) and number of anesthesia providers (-1.19% per 10 providers, 95%CI +2.23 to -8.18%, P 0.01) were negatively associated with adherence.Adherence to ERPs is strongly associated with anesthesiology leadership, regular multidisciplinary meetings, and program duration, whereas case volume and the size of the anesthesia staff were potential barriers. These findings highlight the importance of strong leadership, experience and establishing a multidisciplinary team when developing an ERP for colorectal surgery.

Objective To evaluate the implementation of a maternal early warning system (MEWS) for monitoring patients during the first two hours after delivery in a tertiary level hospital. Methods Implementation of the criteria between 15 March and 15 September 2018 was evaluated in 1166 patients. The parameters collected were systolic and diastolic blood pressure, heart rate, oxygen saturation, urine output, uterine involution, and bleeding. Out-of-range values of any of these parameters triggered a warning, and an obstetrician was called to examine the patient. The obstetrician then decided whether to call the anesthesiologist. We carried out a sensitivity-specificity study of triggers and a multivariate analysis of the factors involved in developing potentially fatal disorders (PFD), reintervention, critical care admission, and stay. Results The MEWS was triggered in 75 patients (6.43%). Leading trigger was altered systolic blood pressure in 32 patients (42.7%), and 11 patients had a PFD. Twenty-eight triggers were false-negatives. Sensitivity and specificity of the system was 0.28 (0.15, 0.45) and 0.94 (0.93, 0.96), respectively. The multivariate analysis showed a correlation between trigger activation and PFD. Conclusion Our MEWS presented low sensitivity and high specificity, with a significant number of false-negatives.

Healthcare is in constant transformation. Health systems should focus on improving efficiency to meet a growing demand for high-quality, low-cost health care. The operating room is one of the biggest sources of revenue and one of the largest areas of expense. Therefore, operating room management is a critical key to success. The aim of this article is to analyse the current principles of organisation, optimisation and clinical management of the operating room and its impact on the quality and safety of care.

Healthcare is in constant transformation. Health systems should focus on improving efficiency to meet a growing demand for high-quality, low-cost health care. The operating room is one of the biggest sources of revenue and one of the largest areas of expense. Therefore, operating room management is a critical key to success. The aim of this article is to analyze the current principles of organization, optimization and clinical management of the operating room and its impact on the quality and safety of care.

Resumo Justificativa O protocolo ERAS – do Ingles Enhanced Recovery After Surgery – consiste em um conjunto de medidas perioperatorias destinadas a melhorar a recuperacao do paciente e diminuir o tempo de internacao e as complicacoes pos‐operatorias. Avaliamos a implantacao e os resultados de um protocolo ERAS para cirurgia colorretal. Metodos Estudo observacional em centro unico. Os dados foram coletados de pacientes consecutivos submetidos a cirurgia colorretal aberta ou laparoscopica durante dois periodos: tres anos antes (pre‐ERAS) e dois anos apos (pos‐ERAS) a implantacao de um protocolo ERAS. As caracteristicas basais de ambos os grupos foram comparadas. O desfecho primario foi o numero de pacientes com 180 dias de acompanhamento com complicacoes moderadas ou graves. Os desfechos secundarios foram tempo de internacao pos‐cirurgia e complicacoes especificas. Os dados foram extraidos de prontuarios dos pacientes. Resultados O grupo pre‐ERAS foi composto por 360 pacientes e o grupo pos‐ERAS por 319. No grupo pre ERAS, 214 pacientes (59,8%) desenvolveram pelo menos uma complicacao versus 163 (51,10%) no grupo pos‐ERAS. Um numero maior de pacientes do grupo pre‐ERAS desenvolveu complicacoes moderadas ou graves (31,9% vs. 22,26%, p = 0,009); e complicacoes graves (15,5% vs. 5,3%; p Conclusoes A implantacao do protocolo ERAS para cirurgia colorretal foi associada a uma reducao significativa das complicacoes pos‐operatorias e do tempo de internacao.

There are currently various projects underway that attempt to monitor the nociceptive responses caused by surgical stress and ensure patients the best analgesic conditions. The systemic response to surgical stress has repercussions in the postoperative period, such as worse pain control, delayed recovery, greater complications, longer stay in resuscitation and hospital units, and increased healthcare costs. However, treatment with higher doses of opioids than necessary may lead to slower awakening, increased drowsiness and adverse effects, as well as situations of postoperative opioid-induced hyperalgesia. There are 2 large groups of nociceptive monitoring according to the origin of the theoretical objective of monitoring response to the stimulus, that may derive from changes in the electroencephalogram or the response of the autonomic nervous system.

Resumen En la actualidad han aparecido diferentes proyectos para intentar monitorizar las respuestas nociceptivas provocadas por el estres quirurgico y para mantener a los pacientes en las mejores condiciones analgesicas. La respuesta sistemica al estres quirurgico tiene repercusiones en el postoperatorio, como son el peor control del dolor, una recuperacion mas tardia, mayores complicaciones, mayor tiempo de estancia en unidades de reanimacion y hospitalaria, e incremento del coste de los servicios sanitarios. Sin embargo, el tratamiento con mayores dosis de opiaceos de las necesarias puede suponer situaciones de despertar mas lento, mayor somnolencia y efectos adversos, pero tambien situaciones de hiperalgesia postoperatoria por opiaceos. Existen 2 grandes grupos de monitorizacion nociceptiva segun el origen del objetivo teorico de vigilancia de la respuesta al estimulo, pudiendo ser derivados de cambios en el electroencefalograma o de la respuesta del sistema nervioso autonomo.

ResumoJustificativaA terapia hemodinâmica alvo‐dirigida (THAD) é uma abordagem focada no uso do débito cardíaco (DC) e parâmetros relacionados, como desfechos para fluidos e medicamentos para aprimorar a perfusão tecidual e o fornecimento de oxigênio. Objetivo primário: determinar os efeitos da THAD sobre as taxas de complicações no pós‐operatório.MétodosMetanálise dos efeitos da THAD em cirurgias não cardíacas de adultos sobre as complicações pós‐operatórias e mortalidade, com a metodologia PRISMA. Uma busca sistemática foi feita no Medline PubMed, Embase e Biblioteca Cochrane (última atualização, outubro de 2014). Os critérios de inclusão foram estudos clínicos randômicos (ECRs) nos quais a THAD no intraoperatório foi comparada com a terapia convencional de reposição de líquidos em cirurgia não cardíaca. Os critérios de exclusão foram traumatismo e estudos de cirurgia pediátrica e aqueles que usaram cateter de artéria pulmonar. Os desfechos, primário e secundário, foram complicações pós‐operatórias e mortalidade, respectivamente. Os estudos que atenderam aos critérios de inclusão foram examinados na íntegra e submetidos à análise quantitativa, análise de subgrupo pré‐definido (estratificada por tipo de monitor, terapia e objetivo hemodinâmico) e análise de sensibilidade pré‐definida.Resultados51 ECRs foram identificados inicialmente, 24 atenderam aos critérios de inclusão. Cinco ECRs foram adicionados por busca manual, resultando em 29 ECRs para análise final, incluindo 2.654 pacientes. Uma redução significativa das complicações para a THAD (RR: 0,70, IC de 95%: 0,62‐0,79, p

Resumen Introduccion El objetivo de este estudio fue examinar el interes, el conocimiento y el cumplimiento de los protocolos ERA en cuidados perioperatorios. Materiales y metodos Entre septiembre y diciembre de 2014 se realizo una encuesta de libre acceso desde las webs de la Sociedad Espanola de Anestesiologia y Reanimacion, la Asociacion Espanola de Cirujanos, la Sociedad Espanola de Nutricion Enteral y Parenteral, y ERAS Espana (GERM). Resultados Respondieron 272 profesionales (44,5% anestesiologos, 45,2% cirujanos) de 110 hospitales, el 73,1% con experiencia en protocolos ERAS. Conocia especificamente los protocolos ERAS un 86,1%, aunque solo el 50,9% conocia las recomendaciones ERAS y el 42,4% las espanolas (GERM). Ademas, el 73,1% de sus hospitales realizaban protocolos ERAS, principalmente en colorrectal (93%), segun recomendaciones GERM/ERAS (52,2%). Un 95,5% mostro interes en desarrollar guias nacionales. El 46,6% realizaron evaluacion nutricional preoperatoria, aunque no existiera un metodo de cribado universal de desnutricion (56,8%). La carga preoperatoria con bebidas carbohidratadas se realizo en el 51,4%; se evitaron sonda nasogastrica y drenajes (79,3%), profilaxis de nauseas y vomitos postoperatorios (73,4%), terapia dirigida por objetivos de liquidos (73,3%), mantenimiento de normotermia activa (87,4%). La mayoria realizo movilizacion (90,1%) y alimentacion temprana (87,9%). Las principales causas de fracaso del protocolo fueron las nauseas y vomitos postoperatorios (46,5%) y el ileo (58,9%). Conclusion La realizacion de protocolos de recuperacion intensificada seria conocida en Espana, aunque no parece existir un consenso ni se realizan segun las guias. El cumplimiento general de los elementos del protocolo seria adecuado, aunque exista un deficit en el manejo nutricional perioperatorio.

Resumen Introduccion Numerosos estudios han comparado la monitorizacion perioperatoria guiada por Doppler esofagico (ODM) para establecer estrategias de reemplazo de volumen intravascular. El uso del ODM con algoritmos hemodinamicos se denomina terapia hemodinamica guiada por objetivos (THGO). Metodos Metaanalisis de los efectos del ODM en THGO para cirugia no cardiaca de adultos, las complicaciones postoperatorias y la mortalidad, acorde a PRISMA. Se practico busqueda sistematica en Medline, PubMed, EMBASE y la Cochrane Library (ultima actualizacion, marzo de 2015). Criterios de inclusion: ensayos clinicos aleatorizados (ECA) que comparan THGO con otra alternativa de manejo de fluidos. Desenlaces primarios: complicaciones generales. Desenlaces secundarios: mortalidad; numero de pacientes con complicaciones; complicaciones especificas. Se realizo analisis cuantificable, analisis predefinido de subgrupos y sensibilidad, y analisis secuencial de estudios. Resultados Se identificaron inicialmente 56 ECA, siendo finalmente admitidos para el estudio 15 (1.368 pacientes). Se observo una reduccion significativa global, con THGO, de las complicaciones asociadas comparada con fluidoterapia convencional (RR = 0,75; IC 95%: 0,63-0,89; p = 0,0009), en cirugia colorrectal, urologica y de alto riesgo No se encontraron diferencias en los resultados secundarios, ni en otros subgrupos. El impacto en la prevencion de complicaciones en pacientes con ODM es alto, con una reduccion del riesgo relativo (RRR) del 50% y un numero necesario a tratar (NNT) = 6. Conclusiones La THGO guiada por ODM disminuye las complicaciones postoperatorias, principalmente en pacientes sometidos a cirugia colorrectal y de alto riesgo. No se encontraron diferencias con respecto a la fluidoterapia restrictiva y en pacientes de riesgo intermedio.

Background Numerous studies have compared perioperative esophageal Doppler monitoring (EDM) guided intravascular volume replacement strategies with conventional clinical volume replacement in surgical patients. The use of the EDM within hemodynamic algorithms is called ‘goal directed hemodynamic therapy’ (GDHT). Methods Meta-analysis of the effects of EDM guided GDHT in adult non-cardiac surgery on postoperative complications and mortality using PRISMA methodology. A systematic search was performed in Medline, PubMed, EMBASE, and the Cochrane Library (last update, March 2015). Inclusion criteria: Randomized clinical trials (RCTs) in which perioperative GDHT was compared to other fluid management. Primary outcomes: Overall complications. Secondary outcomes: Mortality; number of patients with complications; cardiac, renal and infectious complications; incidence of ileus. Studies were subjected to quantifiable analysis, pre-defined subgroup analysis (stratified by surgery, type of comparator and risk); pre-defined sensitivity analysis and trial sequential analysis (TSA). Results Fifty six RCTs were initially identified, 15 fulfilling the inclusion criteria, including 1368 patients. A significant reduction was observed in overall complications associated with GDHT compared to other fluid therapy (RR = 0.75; 95% CI: 0.63–0.89; p = 0.0009) in colorectal, urological and high-risk surgery compared to conventional fluid therapy. No differences were found in secondary outcomes, neither in other subgroups. The impact on preventing the development of complications in patients using EDM is high, causing a relative risk reduction (RRR) of 50% for a number needed to treat (NNT) = 6. Conclusions GDHT guided by EDM decreases postoperative complications, especially in patients undergoing colorectal surgery and high-risk surgery. However, no differences versus restrictive fluid therapy and in intermediate-risk patients were found.

Introduction The aim of this study was to determine the interest in ERAS protocols, and the extent to which clinicians are familiar with and apply these protocols during perioperative care. Materials and methods Free access survey hosted on the Spanish Society of Anesthesiology and Critical Care; Spanish Association of Surgeons and Spanish Society of Enteral and Parenteral nutrition and ERAS Spain (GERM) websites conducted between September and December 2014. Results The survey was answered by 272 professionals (44.5% anaesthetists, 45.2% general surgeons) from 110 hospitals, 73% of whom had experience in ERAS protocols. Most (86.1%) had specific knowledge of ERAS protocols, whereas only 50.9% were familiar with ERAS recommendations and 42.4% with GERM recommendations. Most (73.1%) respondents reported that ERAS protocols are performed in their hospitals, mainly in colorectal surgery (93%), and 52.2% reported that GERM/ERAS recommendations are followed. Nearly all (95.5%) would be interested in the development of multidisciplinary national guidelines. Less than half (46.6%) perform preoperative nutritional assessment, albeit without a universal malnutrition screening method (56.8%). Preoperative loading with carbohydrate drinks is carried out in only 51.4% of cases; nasogastric tube and drainage are avoided (79.3%), prophylaxis for postoperative nausea and vomiting (73.4%), goal directed fluid therapy (73.3%), and active normothermia maintenance (87.4%) are performed. In most cases, mobilization (90.1%) and early feeding (87.9%) are performed. The leading causes of protocol failure are postoperative nausea and vomiting (46.5%) and ileus (58.9%). Conclusion Clinicians in Spain are familiar with fast track protocols, although there is no overall consensus, and hospitals do not adhere to existing guidelines. Overall compliance with the items of the protocol is adequate, although perioperative nutritional management is poor.

Objective The number of indications for total hip replacement (THR) and total knee replacement (TKR) surgery is increasing. Enhanced recovery after surgery (ERAS) represents the next step in the evolution of standardised care. The primary aim of this study is to measure the in-hospital 30-day medical and surgical postoperative complications rate. The study's secondary aims are to determine the length of stay, 30-day mortality rate, 30-day reoperation and readmission rates, the ERAS overall compliance and predefined ERAS individual items compliance. Methods This multicentre, prospective, observational study will include adult patients (aged >18 years) undergoing elective THR and TKR surgery. Consecutive patients undergoing surgery within the 2-month data collection period will be included. Centres that offer the THR and/or TKR surgery will be eligible to participate. The data collection will be done through an online data collection form via a secure, password-protected platform at each centre with predefined data fields. Results Ethical approval for this study has been obtained from the Comite de Etica de la Investigacion de la Comunidad Autonoma de Aragon (C.P.-C.I. PI18/135; on 23 May 2018). It was prospectively registered on 27 June 2018, at www.clinicaltrials.gov with identification no. NCT03570944. Conclusion The study will be disseminated through the SPARN-RedGERM, SEDAR, GERM and through social media. Peer-reviewed publications will be published under corporate authorship, including POWER.2 Study Group and SPARN-RedGERM.

BACKGROUND Our objective was to evaluate and compare the visualization of different types of needles with or without ultrasound image enhancement software, both in biological tissues and artificial models. METHODS This is an observational study on fresh porcine tissue and gelatin models. Six types of plexus needles were studied. The same anesthesiologist performed in-plane punctures with each needle at 30°, 40° and 50° in both 2D mode and using software-based enhanced mode without changing position, generating 72 images. The images were evaluated blind by 38 anesthesiologists with at least two years of experience in ultrasound and rated from 0 to 10. A univariate and multivariate analysis was performed to identify differences between the images according to needle, mode, angle and experimental model. We described the results as mean (standard deviation). RESULTS The Echoplex needle, 8.31 (1.94), was significantly better than the Sonoplex needle, 7.53 (2.16), P=0.0003, and both were significantly better than the other needles (P

We reviewed systematically sugammadex vs neostigmine for reversing neuromuscular blockade. We included 17 randomised controlled trials with 1553 participants. Sugammadex reduced all signs of residual postoperative paralysis, relative risk (95% CI) 0.46 (0.29-0.71), p = 0.0004 and minor respiratory events, relative risk (95% CI) 0.51 (0.32-0.80), p = 0.0034. There was no difference in critical respiratory events, relative risk (95% CI) 0.13 (0.02-1.06), p = 0.06. Sugammadex reduced drug-related side-effects, relative risk (95% CI) 0.72 (0.54-0.95), p = 0.02. There was no difference in the rate of postoperative nausea or the rate of postoperative vomiting, relative risk (95% CI) 0.94 (0.79-1.13), p = 0.53, and 0.87 (0.65-1.17), p = 0.36 respectively.

Background: The ERAS (enhanced recovery after surgery) care has been shown to improve outcome after colorectal surgery compared to traditional care. Audit of process compliance and patient outcomes are important features to assess the impact of a predefined protocol. We did a study to determine the influence of the ERAS protocols in patients undergoing elective colorectal surgery Methods: We did a multicenter, prospective cohort study at 80 Spanish hospitals. We recruited adults scheduled for elective colorectal surgery and deemed to have an ERAS protocol. 22 individual ERAS items were assessed in all included patients. The primary outcome was moderate to severe postoperative complications within 30 days after surgery. Secondary outcomes included ERAS compliance, readmissions, reinterventions, length of stay and mortality. Findings: Between September 15, 2017, and December 15, 2017, 2084 patients were included. 879 (42·1%) presented postoperative complications; 566 (27·1%) presented moderate-severe complications. The number of patients with moderate or severe complication was lower in the ERAS group, 25·2% vs. 30·3%, p=0·011, but not in terms of overall complications, readmission, reintervention or mortality rate. The overall compliance rate with the ERAS protocol was 63·6% [54·5%-77·3%], with the rate for patients declared as ERAS being 72·7% [59·1%-81·8%] vs Non-ERAS 59·1% [50%-63·6%], p

Background The aim of this study was to evaluate postoperative complications in patients having major elective surgery using oesophageal Doppler monitor-guided goal-directed haemodynamic therapy (GDHT), in which administration of fluids, inotropes, and vasopressors was guided by stroke volume, mean arterial pressure, and cardiac index. Methods The FEDORA trial was a prospective, multicentre, randomised, parallel-group, controlled patient- and observer-blind trial conducted in adults scheduled for major elective surgery. Randomization and allocation were carried out by a central computer system. In the control group, intraoperative fluids were given based on traditional principles. In the GDHT group, the intraoperative goals were to maintain a maximal stroke volume, with mean arterial pressure >70 mm Hg, and cardiac index ≥2.5 litres min−1 m−2. The primary outcome was percentage of patients with moderate or severe postoperative complications during the first 180 days after surgery. Results In total, 450 patients were randomized to the GDHT group (n=224) or control group (n=226). Data from 420 subjects were analysed. There were significantly fewer with complications in the GDHT group (8.6% vs 16.6%, P=0.018). There were also fewer complications (acute kidney disease, pulmonary oedema, respiratory distress syndrome, wound infections, etc.), and length of hospital stay was shorter in the GDHT group. There was no significant difference in mortality between groups. Conclusions Oesophageal Doppler monitor-guided GDHT reduced postoperative complications and hospital length of stay in low–moderate risk patients undergoing intermediate risk surgery, with no difference in mortality at 180 days. Clinical trial registration ISRCTN93543537.

The risks and benefits of transfusing critically ill patients continue to evoke controversy. Specifically, the critically ill patients with active ischemic cardiac disease continue to represent a "gray area" in the literature.Meta-analysis of the effects of lower versus higher hemoglobin thresholds on mortality in critically ill patients was carried out using PRISMA methodology. A systematic research was performed in PubMed, Embase, and the Cochrane Library (last update, December 2014).Anemic critically ill adult patients admitted to intensive care units and/or anemic patients with acute coronary syndrome in which a restrictive vs. liberal transfusion therapy was compared.mortality. Included studies were subjected to quantifiable analysis, predefined subgroup analysis, trial sequential analysis and predefined sensitivity analysis.Thirty RCT's were initially identified; 6 fulfilled the inclusion criteria, including 2156. There were no differences in mortality between the restrictive and liberal groups (RR: 0.86, 95% CI 0.70-1.05 P=0.14), neither in patients with chronic cardiovascular disease subgroup (RR: 1.13, 95% IC 0.88-1.46 P=0.34). However, there is a trend towards decreased mortality in the subgroup critically ill (RR: 0.86, 95% CI 0.73-1.01 P=0.06); while in the subgroup of patients with acute myocardial infarct seems like it might be a non-significant trend towards increased mortality (RR: 3.85, 95% CI 0.82-18.0 P=0.09).Restrictive strategy is at least as effective to liberal strategy in critically ill patients. Nevertheless, there is insufficient evidence to recommend a restrictive strategy for patients with acute coronary syndrome.

Background: The goal directed hemodynamic therapy is an approach focused on the use of cardiac output and related parameters as end-points for fluids and drugs to optimize tissue perfusion and oxygen delivery. Primary aim: To determine the effects of intraoperative goal directed hemodynamic therapy on postoperative complications rates. Methods: A meta-analysis was carried out of the effects of goal directed hemodynamic therapy in adult noncardiac surgery on postoperative complications and mortality using Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. A systematic search was performed in Medline PubMed, Embase, and the Cochrane Library (last update, October 2014). Inclusion criteria were randomized clinical trials in which intraoperative goal directed hemodynamic therapy was compared to conventional fluid management in noncardiac surgery. Exclusion criteria were trauma and pediatric surgery studies and that using pulmonary artery catheter. End-points were postoperative complications (primary) and mortality (secondary). Those studies that fulfilled the entry criteria were examined in full and subjected to quantifiable analysis, predefined subgroup analysis (stratified by type of monitor, therapy, and hemodynamic goal), and predefined sensitivity analysis. Results: 51 RCTs were initially identified, 24 fulfilling the inclusion criteria. 5 randomized clinical trials were added by manual search, resulting in 29 randomized clinical trials in the final analysis, including 2654 patients. A significant reduction in complications for goal directed hemodynamic therapy was observed (RR: 0.70, 95% CI: 0.62–0.79, p