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BACKGROUND: Critical COVID-19 survivors are at risk of developing Post-intensive Care Syndrome (PICS) and Chronic ICU-Related Pain (CIRP). We determined whether a specific care program improves the quality of life (QoL) of patients at risk of developing PICS and CIRP after COVID-19. METHODS: The PAIN-COVID trial was a parallel-group, single-centre, single-blinded, randomized controlled trial. The intervention consisted of a follow up program, patient education on PICS and pain, and a psychological intervention based on Rehm's self-control model in patients with abnormal depression scores (≥8) in the Hospital Anxiety and Depression Scale (HADS) at the baseline visit. QoL was evaluated with the 5-level EQ 5D (EQ 5D 5 L), mood disorders with the HADS, post-traumatic stress disorder (PTSD) with the PCL-5 checklist, and pain with the Brief Pain Inventory short form, the Douleur Neuropathique 4 questionnaire, and the Pain Catastrophizing Scale. The primary outcome was to determine if the program was superior to standard-of-care on the EQ visual analogue scale (VAS) at 6 months after the baseline visit. The secondary outcomes were EQ VAS at 3 months, and EQ index, CIRP incidence and characteristics, and anxiety, depression, and PTSD at 3 and 6 months after baseline visits. CONCLUSIONS: This program was not superior to standard care in improving QoL in critical COVID-19 survivors as measured by the EQ VAS. However, our data can help establish better strategies for the study and management of PICS and CIRP in this population. TRIAL REGISTRATION: # NCT04394169, registered on 5/19/2020.

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Objetivo: Evaluación de la factibilidad de un programa de prehabilitación multimodal y su efecto sobre la capacidad funcional en pacientes candidatos a cirugía cardiaca electiva. Métodos: Estudio piloto realizado desde julio de 2017 hasta junio de 2018 en pacientes candidatos a revascularización miocárdica y/o recambio valvular. El programa consistió en: 1) programa de entrenamiento físico supervisado, 2) incentivación respiratoria, 3) soporte nutricional y 4) entrenamiento en mindfulness. Se realizó una evaluación previa al inicio del programa y al finalizar el mismo (preoperatoriamente). Resultados: Todos los pacientes, excepto uno que rechazó la cirugía, completaron el programa, que tuvo una duración media de 45 días. Ningún paciente presentó complicaciones relacionadas con el programa. El programa indujo un aumento significativo de la capacidad funcional medido por el test de la marcha de seis minutos (510,7+62m vs. 534,3+71m; p=0,007) y el test de la silla (13,2+4,7 vs. 16,4+7 repeticiones; p=0,02), así como un aumento del nivel de actividad física medido mediante el cuestionario de actividad física de Yale (37,6+20 vs. 54,2+27; p=00029). Conclusiones: La prehabilitación multimodal en pacientes candidatos a cirugía cardiaca electiva es factible y aumenta la capacidad funcional preoperatoriamente sin asociarse a complicaciones. El presumible impacto beneficioso de esta mejora sobre la incidencia de complicaciones postoperatorias y estancia hospitalaria requiere ser investigado.(AU)

Objective: Evaluation of the feasibility of a multimodal prehabilitation program and its effect on functional capacity in patients candidates for elective cardiac surgery. Methods: Pilot study conducted from July 2017 to June 2018 in patients candidates to myocardial revascularization and/or valve replacement. The program consisted of: 1) supervised exercise training program, 2) breathing incentive exercises, 3) nutritional support, and 4) mindfulness training. An evaluation was carried out prior to the start of the program and at the end of it (preoperatively). Results: All patients except one who refused surgery, completed the program, which lasted an average of 45 days. No patients presented complications related to the program. The program induced a significantly increase in functional capacity measured by the six-minute walking test (510.7+62m vs 534.3+71m, P=.007) and the chair test (13.2+4, 7 vs 16.4+7 repetitions, P=.02), as well as an increase in the level of physical activity measured by the Yale physical activity questionnaire (37.6+20 vs 54.2+27; P=00029). Conclusions: Multimodal prehabilitation in patients candidates for elective cardiac surgery is feasible and it increases functional capacity preoperatively without being associated with complications. The presumed beneficial impact of this improvement on the incidence of postoperative complications and hospital stay, requires further investigation.(AU)

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Prehabilitation programs that combine exercise training, nutritional support, and emotional reinforcement have demonstrated efficacy as a strategy for preoperative optimization in abdominal surgery. The experience in cardiac surgery, one of those associated with greater morbidity and mortality, is anecdotal. OBJECTIVE: evaluation of the feasibility of a multimodal prehabilitation program and its effect on functional capacity in patients candidates for elective cardiac surgery. METHODS: Pilot study conducted from July 2017 to June 2018 in patients candidates to myocardial revascularization and/or valve replacement. The program consisted of: 1) supervised exercise training program, 2) breathing incentive exercises, 3) nutritional support, and 4) mindfulness training. An evaluation was carried out prior to the start of the program and at the end of it (preoperatively). RESULTS: All patients except one who refused surgery, completed the program, which lasted an average of 45 days. No patients presented complications related to the program. The program induced a significantly increase in functional capacity measured by the six-minute walking test (510.7 + 62 m vs 534.3 + 71 m, p = 0.007) and the chair test (13.2 + 4, 7 vs 16.4 + 7 repetitions, p = 0.02), as well as an increase in the level of physical activity measured by the Yale physical activity questionnaire (37.6 + 20 vs 54.2 + 27; p = 00029). CONCLUSIONS: Multimodal prehabilitation in patients candidates for elective cardiac surgery is feasible and it increases functional capacity preoperatively without being associated with complications. The presumed beneficial impact of this improvement on the incidence of postoperative complications and hospital stay, requires further investigation.

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PURPOSE: The occurrence of adverse events (AE) in hospitalized patients substancially increases the risk of disability or death, having a major negative clinical and economic impact on public health. For early identification of patients at risk and to establish preventive measures, different healthcare systems have implemented rapid response systems (RRS). The aim of this study was to carry out a cost-effectiveness analysis of implementing a RRS in a tertiary-care hospital. METHODS: We included all the patients admitted to Hospital Clínic de Barcelona from 1 to 2016 to 31 December 2016. The cost-effectiveness analysis was summarized as the incremental cost-effectiveness ratio (incremental cost divided by the incremental effectiveness of the two alternatives, RRS versus non-RRS). The effectiveness of the RRS, defined as improvements in health outcomes (AE, cardiopulmonary arrest and mortality), was obtained from the literature and applied to the included patient cohort. A budget impact analysis on the implementation of the RRS from a hospital perspective was performed over a 5-year time horizon. RESULTS: 42,409 patients were included, and 448 (1.05%) had severe AE requiring ICU admission. The cost-effectiveness analysis showed an incremental cost (savings) of EUR - 1,471,101 of RRS versus the non-RRS. The budgetary impact showed a cost reduction of EUR 896,762.00 in the first year and EUR 1,588,579.00 from the second to the fifth year. CONCLUSIONS: The present analysis shows the RRS as a dominant, less costly and more effective structure compared to the non-RRS.

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BACKGROUND: Recipient hepatectomy during liver transplantation can be a challenging operation and can increase cold ischaemic time. The aim of this study is to assess factors associated with prolonged recipient hepatectomy. METHODS: From 2005 to 2015, 930 patients were submitted to liver transplantation in our hospital. Prolonged hepatectomy time was defined as operative time >180 min (from knife on skin to total hepatectomy). Patients undergoing early liver retransplantation and living donation were excluded. RESULTS: A total of 715 patients were included in our study. Median age at transplantation was 53 (18-70) years, and median BMI was 26.2 (16-40). Median hepatectomy time was 131 min. Prolonged hepatectomy time occurred in 89 (12.4%) patients. At univariate analysis, previous decompensated cirrhosis with variceal bleeding and/or ascites, higher BMI and previous abdominal surgery were associated with prolonged operating time. Higher surgeon experience and acute liver failure were associated with shorter hepatectomy time. At multivariate analysis, previous episodes of variceal bleeding (p = 0.027, OR 1.78), BMI > 27 (p = 0.01, OR 1.75), previous abdominal surgery (p = 0.04, OR 1.68) and surgeon experience (p = 0.007, OR 2.04) were independently associated with operating time. Prolonged hepatectomy time was significantly associated with cold and total ischaemic time and intraoperative bleeding (p < 0.001, p = 0.002 and p = 0.002, respectively). CONCLUSIONS: Recipient BMI, previous episodes of variceal bleeding, previous abdominal surgery and surgeon experience are independently associated with hepatectomy duration. These factors can be helpful to identify those patients with potentially prolonged hepatectomy time, and therefore, strategies can be put in place to optimize outcomes in this group of patients.

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BACKGROUND: Prehabilitation may reduce postoperative complications, but sustainability of its health benefits and impact on costs needs further evaluation. Our aim was to assess the midterm clinical impact and costs from a hospital perspective of an endurance-exercise-training-based prehabilitation programme in high-risk patients undergoing major digestive surgery. METHODS: A cost-consequence analysis was performed using secondary data from a randomised, blinded clinical trial. The main outcomes assessed were (i) 30-day hospital readmissions, (ii) endurance time (ET) during an exercise testing, and (iii) physical activity by the Yale Physical Activity Survey (YPAS). Healthcare use for the cost analysis included costs of the prehabilitation programme, hospitalisation, and 30-day emergency room visits and hospital readmissions. RESULTS: We included 125 patients in an intention-to-treat analysis. Prehabilitation showed a protective effect for 30-day hospital readmissions (relative risk: 6.4; 95% confidence interval [CI]: 1.4-30.0). Prehabilitation-induced enhancement of ET and YPAS remained statistically significant between groups at the end of the 3 and 6 month follow-up periods, respectively (ΔET 205 [151] s; P=0.048) (ΔYPAS 7 [2]; P=0.016). The mean cost of the programme was €389 per patient and did not increment the total costs of the surgical process (€812; CI: 95% -878 - 2642; P=0.365). CONCLUSIONS: Prehabilitation may result in health value generation. Moreover, it appears to be a protective intervention for 30-day hospital readmissions, and its effects on aerobic capacity and physical activity may show sustainability at midterm. CLINICAL TRIAL REGISTRATION: NCT02024776.

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Introducción. Una baja reserva cardiorrespiratoria, un bajo nivel de actividad física y la fragilidad se relacionan con una mayor morbimortalidad perioperatoria. Implementar medidas para optimizar estos aspectos es clave para mejorar el pronóstico. Es fundamental conocer la magnitud del problema para dimensionar los programas de optimización preoperatoria. Objetivo. Caracterizar la población quirúrgica de un hospital universitario de nivel terciario. Métodos. Se incluyeron prospectivamente todos los pacientes sometidos a evaluación preoperatoria para cirugía digestiva con ingreso durante 3 meses. Se evaluó el nivel de actividad física, la capacidad funcional, la fragilidad y el estado emocional, y se realizó un test de medición del estado físico (5 Times Sit-to-Stand Test). Se recogieron datos demográficos, clínicos y relacionados con la cirugía. Resultados. Se incluyeron 140 pacientes (60±15 años, 56% varones, 25% ASA III o IV). El 49% estaban propuestos para cirugía oncológica y un 13% había recibido neoadyuvancia. El 70% de los pacientes presentaban una capacidad funcional reducida y eran sedentarios. Un 18% fueron considerados frágiles y más de un 50% completaron el 5 Times Sit-to-Stand Test en un tiempo superior a los valores de referencia. La edad avanzada, el ASA III/IV, el sedentarismo, la fragilidad y un nivel de ansiedad/depresión elevado se relacionaron con una menor capacidad funcional. Conclusiones. La población quirúrgica de nuestro entorno tiene una baja reserva funcional y un elevado índice de sedentarismo y fragilidad, factores asociados a un peor pronóstico quirúrgico. Urge implementar medidas preoperatorias para identificar la población de riesgo y programas de prehabilitación considerados estrategias de optimización preoperatoria con gran potencial (AU)

Introduction. Frailty and low physical activity and cardiorespiratory reserve are related to higher perioperative morbimortality. The crucial step in improving the prognosis is to implement specific measures to optimize these aspects. It is critical to know the magnitude of the problem in order to implement preoperative optimization programmes. Objective. To characterize surgical population in a university hospital. Methods. All patients undergoing preoperative evaluation for abdominal surgery with admission were prospectively included during a 3-month period. Level of physical activity, functional capacity, frailty and emotional state were assessed using score tests. Additionally, physical condition was evaluated using 5 Times Sit-to-Stand Test. Demographic, clinical and surgical data were collected. Results. One hundred and forty patients were included (60±15yr-old, 56% male, 25% ASA III or IV). Forty-nine percent of patients were proposed for oncologic surgery and 13% of which had received neoadjuvant treatment. Seventy percent of patients presented a low functional capacity and were sedentary. Eighteen percent of patients were considered frail and more than 50% completed the 5 Times Sit-to-Stand Test at a higher time than the reference values adjusted to age and sex. Advanced age, ASA III/IV, sedentarism, frailty and a high level of anxiety and depression were related to a lower functional capacity. Conclusions. The surgical population of our area has a low functional reserve and a high index of sedentary lifestyle and frailty, predictors of postoperative morbidity. It is mandatory to implement preoperative measures to identify population at risk and prehabilitation programmes, considered highly promising preventive interventions towards improving surgical outcome (AU)

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INTRODUCTION: Frailty and low physical activity and cardiorespiratory reserve are related to higher perioperative morbimortality. The crucial step in improving the prognosis is to implement specific measures to optimize these aspects. It is critical to know the magnitude of the problem in order to implement preoperative optimization programmes. OBJECTIVE: To characterize surgical population in a university hospital. METHODS: All patients undergoing preoperative evaluation for abdominal surgery with admission were prospectively included during a 3-month period. Level of physical activity, functional capacity, frailty and emotional state were assessed using score tests. Additionally, physical condition was evaluated using 5 Times Sit-to-Stand Test. Demographic, clinical and surgical data were collected. RESULTS: One hundred and forty patients were included (60±15yr-old, 56% male, 25% ASA III or IV). Forty-nine percent of patients were proposed for oncologic surgery and 13% of which had received neoadjuvant treatment. Seventy percent of patients presented a low functional capacity and were sedentary. Eighteen percent of patients were considered frail and more than 50% completed the 5 Times Sit-to-Stand Test at a higher time than the reference values adjusted to age and sex. Advanced age, ASA III/IV, sedentarism, frailty and a high level of anxiety and depression were related to a lower functional capacity. CONCLUSIONS: The surgical population of our area has a low functional reserve and a high index of sedentary lifestyle and frailty, predictors of postoperative morbidity. It is mandatory to implement preoperative measures to identify population at risk and prehabilitation programmes, considered highly promising preventive interventions towards improving surgical outcome.

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Introducción. La demanda de administración de sedación para procedimientos en entornos alejados de quirófano ha crecido extraordinariamente y cada vez requiere un abordaje más complejo. Por diferentes motivos, hoy en día la atención para estas sedaciones está sujeta a mucha variabilidad. Creemos que es necesaria una aproximación a ella desde la seguridad del paciente más que desde intereses corporativos o economicistas. Método. Dentro del Sistema de Notificación en Seguridad en Anestesia y Reanimación (SENSAR) se constituyó un grupo de trabajo de expertos para la redacción de una serie de recomendaciones a través de una revisión no sistemática. El resultado de dicho esfuerzo fue validado mediante 2 rondas de encuestas siguiendo una adaptación del método Delphi ante un panel de expertos de 31 anestesiólogos. Resultados. Las recomendaciones resultantes incluyen la valoración previa, los requisitos materiales y de personal para la sedación del procedimiento, las recomendaciones para después del procedimiento, registros de actividad y controles de actividad y calidad. Tras las 2 rondas Delphi, fueron aprobadas por más del 70% de los miembros del panel de expertos. Conclusión. Presentamos unas recomendaciones para la administración segura de sedación en procedimientos fuera de quirófano centradas en el paciente y elaboradas con el criterio de los profesionales con mayor conocimiento en la administración de la misma y que puede servir como base para la reducción de la variabilidad y mejora de la seguridad del paciente en la organización de la atención sanitaria en este ámbito (AU)

Introduction. There is an increasing and more complex demand for sedation for procedures out of the operating room. For different reasons, nowadays the administration of sedation varies considerably. We believe that a patient safety approach rather an approach out of corporate or economic interests is desirable. Method. We created a working group of experts within the Spanish Anaesthesia and Reanimation Incident Reporting System (SENSAR) to prepare a series of recommendations through a non-systematic review. These recommendations were validated by an expert panel of 31 anaesthesiologists through two rounds of an adaptation of the Delphi Method where more than 70% agreement was required. Results. The resulting recommendations include previous evaluation, material and staffing needs for sedation for procedures, post-sedation recommendations and activity and quality control advice. Conclusion. We present patient centred recommendations for the safe use of sedation for out of the operating room procedures from the point of view of the professionals with the most experience in its administration. We believe that these can be used as a guide to reduce variability and increase patient safety in the organisation of healthcare (AU)

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INTRODUCTION: There is an increasing and more complex demand for sedation for procedures out of the operating room. For different reasons, nowadays the administration of sedation varies considerably. We believe that a patient safety approach rather an approach out of corporate or economic interests is desirable. METHOD: We created a working group of experts within the Spanish Anaesthesia and Reanimation Incident Reporting System (SENSAR) to prepare a series of recommendations through a non-systematic review. These recommendations were validated by an expert panel of 31 anaesthesiologists through two rounds of an adaptation of the Delphi Method where more than 70% agreement was required. RESULTS: The resulting recommendations include previous evaluation, material and staffing needs for sedation for procedures, post-sedation recommendations and activity and quality control advice. CONCLUSION: We present patient centred recommendations for the safe use of sedation for out of the operating room procedures from the point of view of the professionals with the most experience in its administration. We believe that these can be used as a guide to reduce variability and increase patient safety in the organisation of healthcare.

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BACKGROUND: Patients undergoing liver transplantation (LT) have a high risk of bleeding. The goal of this study was to assess whether the first derivative of the velocity waveform (V-curve) generated by whole blood rotation thromboelastometry (ROTEM®) can predict blood loss during LT. METHODS: Preoperative V-curve parameters were retrospectively evaluated in 198 patients. Patients were divided into quartiles based on blood loss: low (LBL) in the first quartile and high (HBL) in the higher quartiles. A subgroup analysis was performed with patients stratified according to cirrhosis aetiology. A logistic regression model and receiver operator characteristics (ROC) curve were used to test the capacity of the V-curve, to discriminate between LBL and HBL. RESULTS: In the HBL group, the V-curve showed a lower maximum velocity of clot generation (MaxVel), a lower area under maximum velocity curve (AUC), and a higher time-to-maximum velocity (t-MaxVel) than in the LBL group. t-MaxVel was the only parameter showing a capacity to discriminate between the two groups, with a ROC area of 0.69 (95% CI; 0.62-0.74). The ROC area was 0.78 (95% CI; 0.75-0.83) for the 148 patients with cirrhosis, 0.73 (0.60-0.82) for patients with viral hepatitis and 0.83 (0.78-0.96) for patients with alcoholic hepatitis, the group that showed the best discriminative capacity. Moderate but significant correlations were found between all parameters of V-curve and BL. CONCLUSIONS: Pre-transplant V-curve obtained from ROTEM is a promising tool for predicting BL risk during LT, particularly in patients with cirrhosis.

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Introducción. La demanda de administración de sedación para procedimientos en entornos alejados de quirófano ha crecido extraordinariamente y cada vez requiere un abordaje más complejo. Por diferentes motivos, hoy en día la atención para estas sedaciones está sujeta a mucha variabilidad. Creemos que es necesaria una aproximación a ella desde la seguridad del paciente más que desde intereses corporativos o economicistas. Método. Dentro del Sistema de Notificación en Seguridad en Anestesia y Reanimación (SENSAR) se constituyó un grupo de trabajo de expertos para la redacción de una serie de recomendaciones a través de una revisión no sistemática. El resultado de dicho esfuerzo fue validado mediante 2 rondas de encuestas siguiendo una adaptación del método Delphi ante un panel de expertos de 31 anestesiólogos. Resultados. Las recomendaciones resultantes incluyen la valoración previa, los requisitos materiales y de personal para la sedación del procedimiento, las recomendaciones para después del procedimiento, registros de actividad y controles de actividad y calidad. Tras las 2 rondas Delphi, fueron aprobadas por más del 70% de los miembros del panel de expertos. Conclusión. Presentamos unas recomendaciones para la administración segura de sedación en procedimientos fuera de quirófano centradas en el paciente y elaboradas con el criterio de los profesionales con mayor conocimiento en la administración de la misma y que puede servir como base para la reducción de la variabilidad y mejora de la seguridad del paciente en la organización de la atención sanitaria en este ámbito (AU)

Introduction. There is an increasing and more complex demand for sedation for procedures out of the operating room. For different reasons, nowadays the administration of sedation varies considerably. We believe that a patient safety approach rather an approach out of corporate or economic interests is desirable. Method. We created a working group of experts within the Spanish Anaesthesia and Reanimation Incident Reporting System (SENSAR) to prepare a series of recommendations through a non-systematic review. These recommendations were validated by an expert panel of 31 anaesthesiologists through two rounds of an adaptation of the Delphi Method where more than 70% agreement was required. Results. The resulting recommendations include previous evaluation, material and staffing needs for sedation for procedures, post-sedation recommendations and activity and quality control advice. Conclusion. We present patient centred recommendations for the safe use of sedation for out of the operating room procedures from the point of view of the professionals with the most experience in its administration. We believe that these can be used as a guide to reduce variability and increase patient safety in the organisation of healthcare (AU)

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Liver transplantation (LT) offers patients with liver disease a real chance for long-term survival. In the past decade, successful survival after LT along with the Model for End-Stage Liver Disease-based allocation policy have increased willingness to accept patients with a higher risk profile and marginal organs and to prioritize the sickest patients on the waiting list. Therefore, the anesthesiologist now deals with very challenging patients. In the present review, we aimed to highlight key aspects of intraoperative LT management in high-risk patients and to place these aspects in the perspective of their impact on perioperative outcomes. Conservative standardized perioperative strategies mandate a switch toward accurate and tailored perioperative anesthetic care to maintain the steady improvement in recipient survival rates after LT. In our opinion, continuous assessment of fluid status and cardiac performance, strategies promoting graft decongestion, rational hemostatic management, and the identification of LT recipients with potential risk of vascular complications should constitute the cornerstone of intraoperative management.

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INTRODUCTION: There is an increasing and more complex demand for sedation for procedures out of the operating room. For different reasons, nowadays the administration of sedation varies considerably. We believe that a patient safety approach rather an approach out of corporate or economic interests is desirable. METHOD: We created a working group of experts within the Spanish Anaesthesia and Reanimation Incident Reporting System (SENSAR) to prepare a series of recommendations through a non-systematic review. These recommendations were validated by an expert panel of 31 anaesthesiologists through two rounds of an adaptation of the Delphi Method where more than 70% agreement was required. RESULTS: The resulting recommendations include previous evaluation, material and staffing needs for sedation for procedures, post-sedation recommendations and activity and quality control advice. CONCLUSION: We present patient centred recommendations for the safe use of sedation for out of the operating room procedures from the point of view of the professionals with the most experience in its administration. We believe that these can be used as a guide to reduce variability and increase patient safety in the organisation of healthcare.

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Unexpected donation after circulatory determination of death (uDCD) liver transplantation is a complex procedure, in particular when it comes to perioperative recipient management. However, very little has been published to date regarding intraoperative and immediate postoperative care in this setting. Herein, we compare perioperative events in uDCD liver recipients with those of a matched group of donation after brain death liver recipients. We demonstrate that the former group of recipients suffers significantly greater hemodynamic instability and derangements in coagulation following graft reperfusion. Based on our experience, we recommend a proactive recipient management strategy in uDCD liver transplantation that involves early use of vasopressor support; maintaining adequate intraoperative levels of red cells, platelets, and fibrinogen; and routinely administering tranexamic acid before graft reperfusion.

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