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Perioperative Goal-Directed Therapy (PGDT) has significantly showed to decrease complications and risk of death in high-risk patients according to numerous meta-analyses. The main goal of PGDT is to individualize the therapy with fluids, inotropes, and vasopressors, during and after surgery, according to patients' needs in order to prevent organic dysfunction development. In this opinion paper we aimed to focus a discussion on possible alternatives to invasive hemodynamic monitoring in low resource settings.

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Abstract Perioperative Goal-Directed Therapy (PGDT) has significantly showed to decrease complications and risk of death in high-risk patients according to numerous meta-analyses. The main goal of PGDT is to individualize the therapy with fluids, inotropes, and vasopressors, during and after surgery, according to patients' needs in order to prevent organic dysfunction development. In this opinion paper we aimed to focus a discussion on possible alternatives to invasive hemodynamic monitoring in low resource settings.

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Resumen: El fenómeno de la deuda de oxígeno (dO2) descrito hace varias décadas en el contexto del ejercicio físico se ha incorporado progresivamente al terreno de la medicina. En particular se ha utilizado durante los cambios hemodinámicos producidos por la cirugía y la anestesia en los pacientes de alto riesgo. La dO2 se definió como el aumento en la cantidad de oxígeno consumida por el organismo inmediatamente después de realizar un ejercicio físico hasta que el consumo se normaliza nuevamente. En el perioperatorio se llega a producir cuando se presenta un desbalance entre la oferta (DO2) y la demanda de oxígeno (VO2) que lleva a hipoxia tisular. El grado de la dO2 tisular se ha relacionado directamente con la falla de órganos múltiples y morbimortalidad perioperatoria. A pesar de los avances en la medicina, aún no es posible prevenir o disminuir la dO2 con la administración de líquidos o con el uso de agentes vasoactivos. Por lo que un retardo o manejo inadecuado de la hemodinámica perioperatoria producirá hipoperfusión e hipoxia tisular afectando los resultados de la cirugía. El conocimiento y la valoración de la dO2 es esencial durante la anestesia del paciente de alto riesgo. Para lograr este objetivo se requiere del uso de índices adecuados que permitan detectar y cuantificar la hipoperfusión tisular y el desbalance entre la DO2 y la VO2. En esta revisión se presentan los conceptos fundamentales de la dO2, su mecanismo, detección y cuantificación; además de las intervenciones para evitarla o disminuirla y las recomendaciones para los anestesiólogos con el fin de asegurar mejores resultados en los pacientes quirúrgicos de alto riesgo.

Abstract: The phenomenon of oxygen debt (dO2) described several decades ago in the context of physical exercise has been incorporated into medicine, particularly during the hemodynamic changes produced by surgery and anesthesia in high-risk patients. dO2 is defined as the increase in the amount of oxygen consumed by the body immediately after physical exercise until O2 consumption returns to normal. In the perioperative period, an imbalance between oxygen supply (DO2) and demand (VO2) could generate dO2. The degree of tissue dO2 has been directly related to multiple organ failure and perioperative morbimortality. Despite advances in medicine, it is not yet possible to prevent or lower the dO2 with fluid administration or vasoactive agents. Delay or inadequate management of hemodynamics could produce tissue hypoperfusion and hypoxia, affecting surgery outcomes. Knowledge and assessing dO2 during perioperative are essential during anesthesia for high-risk patients. Adequate indices are required to detect and quantify tissue hypoperfusion and the imbalance between DO2 and VO2 during anesthesia. This review presents the mechanism, detection, and quantification of dO2. In addition to interventions to avoid or reduce dO2 and recommendations for anesthesiologists to ensure better results in high-risk surgical patients.

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Introdução: A fisioterapia na unidade de terapia intensiva (UTI) apresenta como objetivo utilizar estratégias de mobilização precoce a fim de reduzir o impacto da fraqueza muscular adquirida na UTI. Logo, este estudo apresenta como objetivo avaliar a efetividade de um plano de metas fisioterapêuticas para pacientes internados em uma Unidade de Terapia Intensiva.Métodos: Estudo de coorte retrospectivo e prospectivo comparativo realizado em uma UTI de um hospital público de Porto Alegre. Foram incluídos pacientes internados entre os meses de janeiro e junho de 2019, maiores de 18 anos e que tiveram alta da UTI. A coleta de dados foi realizada através de informações e relatório que constam no prontuário eletrônico utilizado na Instituição. Foi analisado o desfecho das metas estabelecidas na admissão para sentar fora do leito e deambular.Resultados: A maioria dos pacientes foi do sexo masculino (57,5%). A média de idade foi de 60,52 ± 17,64 anos. A maioria das metas estabelecidas, tanto para sentar fora do leito como para deambular, foram atingidas (89% e 86,9%, respectivamente). Houve correlação significativa entre o alcance de meta para deambulação e ganho de força muscular pelo escore MRC (p = 0,041) e ganho de força muscular quando comparada admissão e alta da UTI (p = 0,004).Conclusão: Este estudo observou que estabelecer metas para sentar fora do leito e deambular para pacientes internados em UTI é efetivo.

Introduction: Physiotherapy in the intensive care unit (ICU) aims to use early mobilization strategies in order to reduce the impact of muscle acquired weakness in the ICU. Therefore, this study aims to evaluate the effectiveness of a physiotherapeutic goal plan for patients admitted to an Intensive Care Unit. Methods: Retrospective and comparative prospective cohort study carried out in an ICU of a public hospital in Porto Alegre. Patients hospitalized between January and June 2019, over 18 years old and discharged from the ICU were included. Data collection was carried out through information and report contained in the electronic medical record used in the Institution. The outcome of goals established at admission for sitting out of bed and walking was analyzed. Results: Most patients were male (57.5%). The mean age was 63.2 ± 16.2 years. Most established goals, both for sitting out of bed and walking, were achieved (89% and 86.9%, respectively). There was a significant correlation between reaching the ambulation goal and muscle strength gain by the MRC score (p= 0.041) and muscle strength gain when comparing admission and discharge from the ICU (p = 0.004). Conclusion: This study observed that establishing goals for sitting out of bed and walking for ICU patients is effective.

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INTRODUCTION: Sepsis is a disease that is still associated with high mortality, in which timely interventions are related to better results. OBJECTIVE: To determine if there is a difference in in-hospital mortality, fluid balances, norepinephrine initiation and recovery time of blood pressure, when comparing the resuscitation of the patient who is admitted to the emergency room in septic shock by applying the ultrasound protocol (USER) versus the standard of care. PATIENTS AND METHODS: This is a prospective, cohort study conducted in the emergency room of a highly complex hospital of patients with septic shock. RESULTS: 83 patients recruited in total. The groups were comparable in demographics, mean baseline blood pressure, disease severity given by the SOFA value, and arterial lactate. A statistically significant difference was documented in the fluid balances at 4 hours, median 1325mL (IQR:451-2455mL) in Group C versus 900mL (IQR:440-1292) in Group U (p=0.048) and at 6 hours, median 1658mL (IQR:610-2925mL) versus 1107mL (IQR:600-1500mL), p=0.026, as well as in the total fluid balance of hospital stay, median 14,564mL (IQR:8660-18,705mL) versus 8660mL (IQR:5309-16,974mL), p=0.049. On the other hand, in the USER Group, the mean blood pressure ≥ 65mmHg was achieved in 97.4% of the patients 4 hours after the start of the protocol versus 50% in Group C (p=<0.001). Mortality with the use of the protocol compared with conventional therapy was (56.4% vs 61.36%, p=0.647). CONCLUSION: The use of the USER protocol in patients with septic shock in the emergency room showed lower fluid balances at 4 and 6 hours, and of the total hospital stay, as well as earlier initiation of norepinephrine and statistically significant faster improvement in blood pressure. Although a statistically significant difference was not found in the days of ICU stay, hospitalization and in-hospital mortality, a trend was observed in the reduction of these parameters.

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BACKGROUND: The detrimental effects of inotropes are well-known, and in many fields they are only used within a goal-directed therapy approach. Nevertheless, standard management in many centers includes administering inotropes to all patients undergoing cardiac surgery to prevent low cardiac output syndrome and its implications. Randomized evidence in favor of a patient-tailored, inotrope-sparing approach is still lacking. We designed a randomized controlled noninferiority trial in patients undergoing cardiac surgery with normal ejection fraction to assess whether an dobutamine-sparing strategy (in which the use of dobutamine was guided by hemodynamic evidence of low cardiac output associated with signs of inadequate tissue perfusion) was noninferior to an inotrope-to-all strategy (in which all patients received dobutamine). RESULTS: A total of 160 patients were randomized to the dobutamine-sparing strategy (80 patients) or to the dobutamine-to-all approach (80 patients). The primary composite endpoint of 30-day mortality or occurrence of major cardiovascular complications (arrhythmias, acute myocardial infarction, low cardiac output syndrome and stroke or transient ischemic attack) occurred in 25/80 (31%) patients of the dobutamine-sparing group (p = 0.74) and 27/80 (34%) of the dobutamine-to-all group. There were no significant differences between groups regarding the incidence of acute kidney injury, prolonged mechanical ventilation, intensive care unit or hospital length of stay. DISCUSSION: Although it is common practice in many centers to administer inotropes to all patients undergoing cardiac surgery, a dobutamine-sparing strategy did not result in an increase of mortality or occurrence of major cardiovascular events when compared to a dobutamine-to-all strategy. Further research is needed to assess if reducing the administration of inotropes can improve outcomes in cardiac surgery. Trial registration ClinicalTrials.gov, NCT02361801. Registered Feb 2nd, 2015. https://clinicaltrials.gov/ct2/show/NCT02361801.

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BACKGORUND: Current evidence suggests that intraoperative goal-directed haemodynamic therapy (GDT) should be considered for high-risk patients undergoing major gastrointestinal surgery. We aimed to evaluate if an algorithm using venoarterial carbon dioxide difference (CO2 gap) and pulse pressure variation (PPV) as therapeutic targets during GDT would decrease the major complications after gastrointestinal surgery. METHODS: This was a before-and-after study (n = 204) performed in a tertiary hospital on patients who underwent elective open major gastrointestinal surgeries. The inclusion criteria were surgeries expected to last more than two hours, family and physician's agreement on total postoperative support, and survival expectancy of at least three months. The exclusion criteria were previous haemodynamic instability, presence of infection, cardiac arrhythmias, and emergency surgery. In the intervention group (IG), an algorithm was applied using fluids, dobutamine, and noradrenaline during the intraoperative period aiming at MAP > 65 mm Hg, SpO2 > 95%, CO2 gap < 6 mm Hg, and PPV < 13%. The control group (CG) comprised consecutive eligible patients who were operated by the same team before the institution of the algorithm. RESULTS: The rates of moderate and severe postoperative complications were lower in the IG (11% vs. 23%; IC: RR = 0.47, 95% CI: 0.246-0.929; P = 0.025). The respective 90- and 180-day mortality rates in the IG and CG were 9.8% vs. 22.5% (P = 0.014) and 12.6% vs. 25.5% (P = 0.020). CONCLUSIONS: An algorithm aiming to minimise the CO2 gap and normalise PPV was feasible and effective in decreasing rates of moderate and severe complications after surgery in high-risk patients.

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OBJECTIVE: Severe sepsis and Septic Shock may progress in the first hours after presentation and has been associated with an increased mortality. Prompt recognition and treatment of early septic shock (ESS) may improve survival. The purpose of our study was to describe the monitoring and management strategies of ESS, within Intensive Care Units (ICU) in Puerto Rico (PR). METHODS: In order to achieve our objective, a self-administered survey, previously validated by the Canadian Critical Care Trials Group, was administered to 25 physicians during a Critical Care Medicine (CCM) Meeting. Questions about usual monitoring and resuscitation end-points were administered. RESULTS: Most of the participants were affiliated to community hospitals (84%) and 92% were pulmonary or CCM specialists, with more than 15 years of working experience (80%). Monitoring devices and parameters mostly used by at least 85% of the respondents were: Oxygen Saturation, Foley catheters, Telemetry, Heart Rate, Blood Pressure, and Urinary Output. Intra-arterial lines and Central Venous Pressure were less used. Most use normal saline (96%), as the initial fluid of resuscitation. Only 24% would use inotropes to improve perfusion. CONCLUSION: Significant variability exists in the management of ESS among physicians in the ICU in PR. Compared to other studies, fewer physicians in PR use invasive monitoring techniques. These results highlight the need for quality education and training in CCM as well as continuing education in the field.

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BACKGROUND: Cytoreductive surgery (CRS) with Hyperthermic Intraperitoneal Chemotherapy (HIPEC) in peritoneal carcinomatosis treatment causes significant hemodynamic, metabolic, and hematological alterations. Studies on the anesthetic intraoperative management are heterogeneous and scarce. There is a great heterogeneity in the anesthetic management of CRS and HIPEC. The aim of this study is to analyze perioperative hemodynamic goal-directed management and to evaluate the complications arisen until the seventh postoperative day. METHODS: Prospective, observational study of all CRS and HIPEC patients from March 2014 to May 2017. Hemodynamic and clinical parameters were registered during surgery and the first 3 postoperative days. We correlated intraoperative data with the postoperative course until the seventh day. RESULTS: A total of 92 patients were included in the study (age 58.5 ± 10.9 years, 47% colorectal carcinoma, and 38% ovarian carcinoma). Peritoneal Carcinomatosis Index (PCI) (median and ranges) was 10 [0-39]. Cardiac Index (CI) 3.15 l/min-1/m-2 [1.79-5.60]) and Systolic Volume Variation (SVV) (10% [3%-17%]) remained within the values of normality in all surgery phases. A large difference was observed between the minimum and maximum ranges of fluid therapy administered (median 9.8 ml/kg/h [5.3-24.3]), showing a great interindividual variation in the fluids requirement. A direct relationship was observed between PCI and surgery duration, fluid therapy, and intraoperative transfusion percentage (p < 0.02). CONCLUSIONS: There is a great variability in the intraoperative fluid therapy needs of the patients. SVV monitoring makes it possible to adjust the fluid therapy needs in each surgery phase. The use of a hemodynamic goal-directed anesthetic protocol in CRS and HIPEC enables to individually adjust the fluid therapy, avoiding over-hydration and ensuring hemodynamic stability in all surgery phases.

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Abstract Introduction: In last few years, emphasis was placed in goal-directed therapy in order to optimize patient's hemodynamic status and improve their prognosis. Parameters based on the interaction between heart and lungs have been questioned in situations like low tidal volume and open chest surgery. The goal of the study was to analyze the changes that one-lung ventilation can produce over stroke volume variation and to assess the possible impact of airway pressures and lung compliance over stroke volume variation. Methods: Prospective observational study, 112 patients undergoing lung resection surgery with one-lung ventilation periods were included. Intravenous fluid therapy with crystalloids was set at 2 mL.g-1. Hypotension episodes were treated with vasoconstrictive drugs. Two-lung Ventilation was implemented with a TV of 8 mL.g-1 and one-lung ventilation was managed with a TV of 6 mL.g-1. Invasive blood pressure was monitored. We recorded the following cardiorespiratory values: heart rate, mean arterial pressure, cardiac index, stroke volume index, airway peak pressure, airway plateau pressure and static lung compliance at 3 different times during surgery: immediately after lung collapse, 30 min after initiating one-lung ventilation and after restoration of two-lung ventilation. Results: Stroke volume variation values were influenced by lung collapse (before lung collapse 14.6 (DS) vs. OLV 9.9% (DS), p < 0.0001); or after restoring two-lung ventilation (11.01 (DS), p < 0.0001). During two-lung Ventilation there was a significant correlation between airway pressures and stroke volume variation, however this correlation lacks during one-lung ventilation. Conclusion: The decrease of stroke volume variation values during one-lung ventilation with protective ventilatory strategies advices not to use the same threshold values to determine fluid responsiveness.

Resumo Introdução: Nos últimos anos, a importância da terapia alvo-dirigida foi enfatizada para aprimorar o estado hemodinâmico do paciente e melhorar seu prognóstico. Os parâmetros baseados na interação entre o coração e os pulmões foram questionados em situações como baixo volume corrente e cirurgia aberta do tórax. O objetivo do estudo foi analisar as alterações que a ventilação monopulmonar pode produzir na variação do volume sistólico e avaliar o possível impacto das pressões da via aérea e da complacência pulmonar sobre a variação do volume sistólico. Métodos: Estudo observacional prospectivo, no qual 112 pacientes submetidos à cirurgia de ressecção pulmonar com períodos de ventilação monopulmonar foram incluídos. A terapia de fluídos intravenosos com cristaloides foi ajustada a 2 mL.kg-1.h-1. Os episódios de hipotensão foram tratados com vasoconstritores. A ventilação dos dois pulmões (VDP) foi implantada com volume corrente de 8 mL.kg-1 e a ventilação monopulmonar foi controlada com volume corrente de 6 mL.kg-1. Foi monitorada a pressão arterial invasiva. Registramos os seguintes valores cardiorrespiratórios: frequência cardíaca, pressão arterial média, índice cardíaco, índice de volume sistólico, pressão de pico das vias aéreas, pressão de platô das vias aéreas e complacência pulmonar estática em três tempos durante a cirurgia: imediatamente após o colapso do pulmão, 30 minutos após o início da ventilação monopulmonar e após a restauração da ventilação dos dois pulmões. Resultados: Os valores de variação do volume sistólico foram influenciados pelo colapso pulmonar (antes do colapso pulmonar 14,6 [DS] vs. ventilação monopulmonar 9,9% [DS], p < 0,0001), ou após o restabelecimento da ventilação dos dois pulmões (11,01 [DS], p < 0,0001). Durante a ventilação dos dois pulmões houve uma correlação significativa entre as pressões das vias aéreas e a variação do volume sistólico, porém, essa correlação não existe durante a ventilação monopulmonar. Conclusão: A diminuição dos valores da variação do volume sistólico durante a ventilação monopulmonar com estratégias ventilatórias protetoras sugere não usar os mesmos valores de limiar para determinar a responsividade aos fluídos.

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BACKGROUND: Perioperative goal-directed hemodynamic therapy (GDHT) has been advocated in high-risk patients undergoing noncardiac surgery to reduce postoperative morbidity and mortality. We hypothesized that using cardiac index (CI)-guided GDHT in the postoperative period for patients undergoing high-risk surgery for cancer treatment would reduce 30-day mortality and postoperative complications. METHODS: A randomized, parallel-group, superiority trial was performed in a tertiary oncology hospital. All adult patients undergoing high-risk cancer surgery who required intensive care unit admission were randomly allocated to a CI-guided GDHT group or to a usual care group. In the GDHT group, postoperative therapy aimed at CI ≥ 2.5 L/min/m2 using fluids, inotropes and red blood cells during the first 8 postoperative hours. The primary outcome was a composite endpoint of 30-day all-cause mortality and severe postoperative complications during the hospital stay. A meta-analysis was also conducted including all randomized trials of postoperative GDHT published from 1966 to May 2017. RESULTS: A total of 128 patients (64 in each group) were randomized. The primary outcome occurred in 34 patients of the GDHT group and in 28 patients of the usual care group (53.1% vs 43.8%, absolute difference 9.4 (95% CI, - 7.8 to 25.8); p = 0.3). During the 8-h intervention period more patients in the GDHT group received dobutamine when compared to the usual care group (55% vs 16%, p < 0.001). A meta-analysis of nine randomized trials showed no differences in postoperative mortality (risk ratio 0.85, 95% CI 0.59-1.23; p = 0.4; p for heterogeneity = 0.7; I2 = 0%) and in the overall complications rate (risk ratio 0.88, 95% CI 0.71-1.08; p = 0.2; p for heterogeneity = 0.07; I2 = 48%), but a reduced hospital length of stay in the GDHT group (mean difference (MD) - 1.6; 95% CI - 2.75 to - 0.46; p = 0.006; p for heterogeneity = 0.002; I2 = 74%). CONCLUSIONS: CI-guided hemodynamic therapy in the first 8 postoperative hours does not reduce 30-day mortality and severe complications during hospital stay when compared to usual care in cancer patients undergoing high-risk surgery. TRIAL REGISTRATION: www.clinicaltrials.gov , NCT01946269 . Registered on 16 September 2013.

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INTRODUCTION: In last few years, emphasis was placed in goal-directed therapy in order to optimize patient's hemodynamic status and improve their prognosis. Parameters based on the interaction between heart and lungs have been questioned in situations like low tidal volume and open chest surgery. The goal of the study was to analyze the changes that one-lung ventilation can produce over stroke volume variation and to assess the possible impact of airway pressures and lung compliance over stroke volume variation. METHODS: Prospective observational study, 112 patients undergoing lung resection surgery with one-lung ventilation periods were included. Intravenous fluid therapy with crystalloids was set at 2mL.kg-1.h-1. Hypotension episodes were treated with vasoconstrictive drugs. Two-lung ventilation was implemented with a TV of 8mL.kg-1 and one-lung ventilation was managed with a TV of 6mL.kg-1. Invasive blood pressure was monitored. We recorded the following cardiorespiratory values: heart rate, mean arterial pressure, cardiac index, stroke volume index, airway peak pressure, airway plateau pressure and static lung compliance at 3 different times during surgery: immediately after lung collapse, 30minutes after initiating one-lung ventilation and after restoration of two-lung ventilation. RESULTS: Stroke volume variation values were influenced by lung collapse (before lung collapse14.6 (DS) vs. OLV 9.9% (DS), p < 0.0001); or after restoring two-lung ventilation (11.01 (DS), p < 0.0001). During two-lung ventilation there was a significant correlation between airwaypressures and stroke volume variation, however this correlation lacks during one-lung ventilation. CONCLUSION: The decrease of stroke volume variation values during one-lung ventilation with protective ventilatory strategies advices not to use the same threshold values to determine fluid responsiveness.

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ABSTRACT Severe hemorrhage with necessity of allogeneic blood transfusion is common complication in intensive care unit and is associated with increased morbidity and mortality. Prompt recognition and treatment of bleeding causes becomes essential for the effective control of hemorrhage, rationalizing the use of allogeneic blood components, and in this way, preventing an occurrence of their potential adverse effects. Conventional coagulation tests such as prothrombin time and activated partial thromboplastin time present limitations in predicting bleeding and guiding transfusion therapy in critically ill patients. Viscoelastic tests such as thromboelastography and rotational thromboelastometry allow rapid detection of coagulopathy and goal-directed therapy with specific hemostatic drugs. The new era of thromboelastometry relies on its efficacy, practicality, reproducibility and cost-effectiveness to establish itself as the main diagnostic tool and transfusion guide in patients with severe active bleeding.

RESUMO A hemorragia grave com necessidade de transfusão de sangue e componentes é uma complicação frequente na unidade de terapia intensiva e está associada ao aumento da morbidade e da mortalidade. A identificação adequada e o tratamento precoce da causa específica da coagulopatia tornam-se fundamentais para o controle efetivo da hemorragia, racionalizando a utilização de sangue e componentes, e desta forma, prevenindo a ocorrência de efeitos adversos. Testes convencionais da coagulação (tempo de ativação de protrombina e tempo de tromboplastina parcial ativada) apresentam limitações para prever sangramento e guiar a terapia transfusional em pacientes graves. Testes viscoelásticos como a tromboelastografia e tromboelastometria rotacional permitem a rápida detecção da coagulopatia e orientam a terapia de forma individualizada, alvo dirigida com drogas hemostáticas específicas. A nova era da tromboelastometria confia na sua eficácia, praticidade, reprodutibilidade e custo-eficácia para se firmar como a principal ferramenta diagnóstica e guia transfusional em pacientes com sangramento ativo grave.

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CONTEXT: Sepsis is a disease with high incidence and mortality. Among the interventions of the resuscitation bundle, the early goal-directed therapy (EGDT) is recommended. AIMS: The aim was to evaluate outcomes in patients with severe sepsis and septic shock using EGDT in real life compared with patients who did not undergo it in the Intensive Care Unit (ICU) setting. SETTINGS AND DESIGN: retrospective and observational cohort study at tertiary hospital. SUBJECTS AND METHODS: All the patients admitted to ICU were screened for severe sepsis or septic shock and included in a registry and followed. The patients were allocated in two groups according to submission or not to EGDT. RESULTS: A total of 268 adult patients with severe sepsis or septic shock were included. EGDT was employed in 97/268 patients. The general mortality was higher in no early goal-directed therapy (no-EGDT) then in EGDT groups (49.7% vs. 37.1% [P = 0.04] in hospital and 40.4% vs. 29.9% [P = 0.08] in the ICU, respectively. The general length of stay [LOS] in the no-EGDT and EGDT groups was 45.0 ± 59.8 vs. 29.1 ± 30.1 days [P = 0.002] in hospital and 17.4 ± 19.4 vs. 9.1 ± 9.8 days [P < 0.001] in the ICU, respectively). CONCLUSIONS: Our study shows reduced mortality and LOS in patients submitted to EGDT in the ICU setting. A simplified EGDT without central venous oxygen saturation is an important tool for sepsis management.

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Traumatic Brain Injury (TBI) is a complex disease with a high social burden because of its high mortality and high rate of sequelae. Outcome after TBI is related to early management, including anesthetic management. In this article we review up to date concepts for anesthetic management of TBI patients; from pre-anesthetic evaluation to different aspects of surgical management: induction of anesthesia, airway control, mechanical ventilation, intravenous fluid management, maintenance of anesthesia during neurological and nonneurological surgery, and the treatment of brain edema, coagulopathy, electrolyte balance and temperature. We think the treatment must be directed to goals in order to offer the patient the best conditions for recovery and to avoid secondary brain injury.

El Trauma Cráneo Encefálico (TCE) es una enfermedad compleja, con gran repercusión social por su alta mortalidad y alta tasa de secuelas. El desenlace que tenga nuestro enfermo está relacionado con el manejo temprano que reciba, incluido el manejo anestésico. En este escrito se revisan los conceptos actuales de manejo anestésico de enfermos con TCE, desde su evaluación preanestésica hasta los diferentes aspectos del manejo quirúrgico: inducción de anestesia, control de la vía aérea, ventilación mecánica, manejo de líquidos intravenosos, mantenimiento anestésico en cirugía neurológica y no neurológica, manejo del edema cerebral, de la coagulopatía, de los electrolitos y de la temperatura. Nuestro enfoque se basa en el manejo orientado a metas de manera que ofrezcamos al paciente las mejores condiciones de recuperación y evitemos la lesión secundaria.

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Introduction: Educational programs in pediatric life support endorse a capillary refill time > 2 s as an indicator of shock. In the emergency room, a barrier to the implementation of an early goal directed therapy, aiming at central venous oxygen saturation (ScvO2) ≥ 70% is the insertion of central venous catheter (CVC). Objective: To establish the predictive value of capillary refill time > 2 s to detect ScvO2 < 70% in children admitted to Intensive Care Units. Patients and Method: Prospective study. We included 48 children admitted in the first 24 hours in ICU with superior vena cava CVC. Simultaneously, we measured ScvO2 and capillary refill time in the heel of upper extremity or toe. Results: There were 75 paired measurements ScvO2 (75,9 ± 8,4%) and capillary refill capillary (1,9 ± 1,0 s). We found an inverse correlation between capillary refill time and ScvO2 (r - 0,58 ). The ROC curve analysis revealed an excellent ability for the capillary fill time > 2 s to predict ScvO2 < 70% (AUC 0,94) (95% CI 0,87-0,98). Conclusions: A prolonged capillary refill time > 2 s, is a predictor of ScvO2 < 70% in children admitted to ICU, which supports the current recommendations. This finding may be relevant in emergency units where the use of CVC is limited and ScvO2 is not available.

Introducción: Programas educativos de reanimación pediátrica establecen que un tiempo de llene capilar > 2 s es un indicador de shock. En unidades de emergencia, una barrera para la implementación de una reanimación precoz guiada por metas, teniendo como objetivo una saturación venosa central de oxígeno (ScvO2) ≥ 70%, es la inserción de un catéter venoso central (CVC). Objetivo: Determinar el valor predictivo de un tiempo de llene capilar > 2 s en la detección de ScvO2 < 70% en niños ingresados a la Unidad de Cuidados Intensivos. Pacientes y Método: Estudio prospectivo. Se incluyeron 48 niños ingresados en las primeras 24 h en UCI con CVC en la vena cava superior. De manera simultánea se determinaron ScvO2 y tiempo de llene capilar en talón o dedo de extremidad superior. Resultados: Se obtuvieron 75 mediciones pareadas de ScvO2 (75,9 ± 8,4%) y llene capilar (1,9 ± 1,0 s), observándose una correlación inversa entre llene capilar y ScvO2 (r = -0,58). El análisis de la curva ROC reveló una excelente capacidad del tiempo de llene capilar > 2 s para predecir una ScvO2 < 70% (AUC = 0,94, IC 95% = 0,87-0,98). Conclusiones: La prolongación del tiempo de llene capilar > 2 s es predictor de ScvO2 < 70% en niños críticamente enfermos. Este hallazgo apoya las recomendaciones actuales y podría ser relevante en unidades de emergencia donde el uso de CVC es limitado y la ScvO2 no está disponible.

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