The mtND4 Working Group of the Spanish Society of Anesthesiology and Resuscitation (SEDAR) has issued clinical practice recommendations. This article stems from reports of neurological injury and death following general in adult and patients of maternal Venezuelan ancestry, in whom a possible mitochondrial susceptibility associated with the mtND4 m.11232T>C variant of respiratory chain complex I has been identified. This document is for informational and guidance purposes only. The final clinical decision should be individualized for each patient, taking into account the urgency of the procedure, therapeutic alternatives, and the resources available at each center.
We report the case of a 20-year-old woman who developed acute encephalopathy after uneventful general anaesthesia with sevoflurane, propofol, and opioids. The patient presented neurological impairment followed by metabolic acidosis and hyperlactatemia and neuroimaging findings involving the basal ganglia, brainstem, and cerebellum. Genetic testing confirmed the mitochondrial variant m.11232T > C in the MT-ND4 gene, previously described only in paediatric patients. This case could be one of the first cases described in the literature of acute encephalopathy associated with this mutation in an adult patient, possibly precipitated by exposure to volatile anesthetics. The patient's favorable clinical and radiological evolution after intensive neuroprotective management and suboccipital decompressive craniectomy highlights the importance of early diagnosis and individualized treatment. Mitochondrial dysfunction should be considered in atypical neurological presentations following general anesthesia, especially when accompanied by lactic acidosis and unusual neuroimaging findings.
This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/policies/article-withdrawal).This article has been retracted due to non-compliance with the journal's clinical trial registration policy. In accordance with international editorial standards, clinical trials must be prospectively registered in a public database before enrollment of the first participant. Although the study received Ethics Committee approval, the trial registration was completed after data collection had finished. This retraction is based solely on regulatory and editorial policy requirements and does not reflect concerns regarding the scientific or ethical quality of the research.
BACKGROUND:Acute herpes zoster is associated with severe neuropathic pain and a high risk of developing postherpetic neuralgia (PHN), which significantly impairs quality of life and functional status. Ultrasound-guided thoracic paravertebral block (TPVB) has emerged as a promising regional analgesic technique for managing acute herpes zoster pain and potentially preventing PHN. This study aimed to evaluate the efficacy of ultrasound-guided TPVB with local anaesthetic and corticosteroid in reducing pain intensity, improving functional and quality-of-life outcomes, and decreasing the incidence of PHN. METHODS:In this prospective, randomized, controlled clinical trial, 100 patients with acute thoracic herpes zoster (rash duration ≤14 days, Numerical Rating Scale [NRS] ≥4) were randomly assigned to either a control group receiving standard medical therapy or an intervention group receiving standard therapy plus ultrasound-guided TPVB using 0.25% bupivacaine and 40 mg methylprednisolone. The block was performed at 48 -h intervals for three sessions. The primary outcome was PHN at 90 days (3 meses). Six-month incidence was evaluated as a secondary outcome. Secondary outcomes included pain intensity (NRS), quality of life assessed by the Short Form-36 (SF-36), sleep quality assessed by the Pittsburgh Sleep Quality Index (PSQI), functional disability assessed by the Pain Disability Index (PDI), neuropathic pain assessed by the Douleur Neuropathique 4 (DN4) questionnaire, rescue analgesic consumption, sensory examination findings, patient satisfaction, and adverse events. RESULTS:Patients in the TPVB group demonstrated significantly lower pain scores compared with the control group at all follow-up time points from 48 horas to 6 meses (P < 0.05). The incidence of PHN at 90 days was significantly reduced in the TPVB group compared with the control group (16% vs. 34%, P = 0.037). The TPVB group also showed significant improvements in quality of life (SF-36), sleep quality (PSQI), and functional disability (PDI) at 3 and 6 meses (P < 0.05). Neuropathic pain scores (DN4) were significantly lower at 1, 3, and 6 meses, and rescue analgesic consumption was significantly reduced during the first month of follow-up (P < 0.05). Patient satisfaction scores were significantly higher in the TPVB group (P = 0.033). No serious block-related complications were observed. CONCLUSIONS:Early ultrasound-guided thoracic paravertebral block using local anaesthetic and corticosteroid is an effective and safe adjunctive therapy for acute thoracic herpes zoster. This intervention provides superior pain control, significantly reduces the incidence of postherpetic neuralgia, and improves functional status, sleep quality, and overall quality of life. These findings support the use of early TPVB as part of multimodal pain management strategies aimed at preventing chronic neuropathic pain following herpes zoster.
INTRODUCTION AND ENDPOINTS:Preoperative anaemia is a common finding in patients with colorectal cancer (CRC) and is significantly associated with morbidity and mortality. Patient Blood Management Programs (PBM), have been developed to improve patient outcomes. This study aimed to evaluate the effectiveness of the Outpatient Blood Management Program (OBMP) in a tertiary hospital in Spain. The primary endpoint was to determine the percentage of patients who recover from anaemia after treatment at the OBMP. Additionally, correlations between preoperative anaemia, administered treatments, and surgical waiting times were analyzed. METHODS:A retrospective observational study was conducted including 537 patients who underwent surgical intervention for CRC. Demographic data, haemoglobin values at three time points (inclusion on the surgical waiting list, preoperative, and postoperative), as well as the time intervals between inclusion on the waiting list and the performance of surgery, were collected. RESULTS:The prevalence of anaemia was 43.3% at the time of inclusion on the surgical waiting list. Of the total anaemic patients, 42% received specific treatment. Treatment at the OBMP was associated with a higher recovery rate (37%) and a more significant increase in haemoglobin (1.35 g/dl IC95% (0.7-2.1) vs 0.4 IC95% (0-1.6) g/dl )). Preoperative anaemia was associated with longer surgical waiting times, higher incidence of transfusions, higher prevalence of postoperative anaemia, and prolonged hospital stays. CONCLUSION:The OBMP offers an opportunity to improve the management of anaemia in patients undergoing surgery for colorectal cancer (CRC); however, it requires interdisciplinary coordination to minimize its impact on surgical waiting times.
The objective of the Continuous Update Project of the RICA Pathway (Enhanced Recovery After Surgery in Adults) is to maintain updated and consensual recommendations based on scientific evidence, facilitating their implementation and evaluation. The project was developed between November 2021 and October 2025, focusing on elective major surgery in adults. Evidence was evaluated using the GRADE methodology, with reviews in PubMed, Embase, and the Cochrane Library, including systematic reviews, meta-analyses, randomised clinical trials, consensus guidelines, and multicenter studies. The project was structured into a coordinating group, a consulting group, and various reviewing groups, and the recommendations were evaluated and accepted by consensus. 103 recommendations were approved, compared to 135 in the 2021 edition. 83% of these presented high or moderate evidence, and 76% had a strong grade of recommendation in favor. The recommendations were grouped into sets of measures ("bundles") to improve their applicability.
INTRODUCTION:The intensity of intraoperative hemodynamic support may reflect perioperative physiological complexity and be associated with increased hospital resource utilization. OBJECTIVE:To evaluate the use of intraoperative hemodynamic support and the intensity of such support as markers of perioperative complexity and hospital resource utilization. MATERIALS AND METHODS:Analytical study using a secondary database with perioperative information from patients undergoing noncardiac surgery (n = 6246). The main exposure was intraoperative hemodynamic support, analysed both dichotomously and through a continuous index of intraoperative hemodynamic support intensity. Outcomes included admission to the intensive care unit (ICU) and hospital length of stay. Multivariable logistic and negative binomial regression models were used, adjusted for relevant clinical and surgical variables, including interaction analyses. RESULTS:Intraoperative hemodynamic support was not independently associated with ICU admission (OR 1.09; 95% CI: 0.93-1.28). In contrast, ASA score (OR 2.89 per point), surgical duration, age, and emergency surgery showed significant associations. Intraoperative hemodynamic support was associated with a longer hospital length of stay (IRR 1.06; 95% CI: 1.02-1.09), an effect that was more pronounced in prolonged procedures. The continuous index of intraoperative hemodynamic support intensity showed a strong association with longer hospital stays (IRR 1.37; 95% CI: 1.34-1.40). CONCLUSIONS:Greater intraoperative hemodynamic support intensity was associated with longer hospital length of stay, particularly in prolonged surgeries, serving as a marker of perioperative complexity and hospital resource utilization.
BACKGROUND:Sepsis is a leading cause of morbidity and mortality among hospitalized patients and is associated with intensive use of β-lactam antibiotics. These drugs show time-dependent pharmacodynamics and high pharmacokinetic variability in this population, making it difficult to achieve therapeutic levels. Therapeutic drug monitoring (TDM) may optimise dosing, but its routine clinical implementation remains limited. OBJECTIVE:To evaluate whether individualized β-lactam dosing guided by TDM reduces time to full clinical recovery compared with standard dosing in hospitalized patients with sepsis (ICU and ward). METHODS:OPTIBETA is a pragmatic, randomized, controlled, open-label clinical trial with blinded outcome assessment to be conducted at a tertiary hospital in Spain. Adult patients (≥18 years) admitted to the intensive care unit or infectious diseases ward with sepsis will be included. Participants will be randomized 1:1 to either a TDM-guided dosing arm (dose adjustments according to PK/PD targets) or a standard dosing arm. Clinical, microbiological, and pharmacological outcomes will be collected. The primary endpoint is time to complete clinical cure. Secondary outcomes include overall survival, microbiological cure, ICU and hospital length of stay, adverse events, and achievement of PK/PD targets. The estimated sample size is 198 patients. EXPECTED RESULTS:We hypothesize that TDM-guided dosing will reduce time to clinical cure, improve overall outcomes, and decrease adverse events compared with standard dosing. CONCLUSIONS:OPTIBETA will provide high-quality evidence on the role of β-lactam TDM in hospitalized patients with sepsis and may support its inclusion in antimicrobial stewardship programs.
BACKGROUND:Total knee arthroplasty (TKA) is associated with significant postoperative pain. Regional analgesic techniques targeting femoral nerve (FN) and adductor canal (AC) are commonly employed; however, uncertainty persists regarding optimal injection site within the AC. Cadaveric investigations provide anatomical insights into injectate spread patterns, but their interpretation requires caution when extrapolating to clinical practice. METHODS:Twelve thighs from six embalmed human cadavers underwent ultrasound-guided injections of different-colored dyes, with equal volumes administered at three predefined locations: FN, proximal AC, and distal AC. Subsequent anatomical dissections were performed to assess nerve staining patterns. Injection sites and volumes were standardized to allow for comparative anatomical evaluation. RESULTS:Femoral-level injections stained the femoral nerve and its major branches. Proximal AC injections consistently stained both the saphenous nerve and nerve to vastus medialis, whereas distal canal injections predominantly stained the saphenous nerve with only variable distal obturator involvement. The vaso-adductor membrane stained consistently after proximal canal injection. No sciatic nerve staining was observed. CONCLUSION:Equal-volume dye injections at the FN, proximal AC, and distal AC demonstrate distinct patterns of neural staining. Proximal AC injections resulted in consistent staining of both SN and NVM, whereas distal injections predominantly involved SN. These findings provide anatomical relevance regarding adductor canal block techniques but do not imply clinical superiority of any technique. Clinical correlation is required before extrapolating these observations to clinical practice.
Tracheoesophageal fistula (TEF) is a life-threatening complication that may develop following prolonged intubation. Consequently, the importance of early diagnosis and intervention cannot be overstated. In the presence of TEF, orotracheal intubation (OTI) must be performed with the utmost caution. In patients with post-intubation respiratory failure or gastric distension, it is important to consider the risk of the endotracheal tube (ETT) penetrating the esophagus through the TEF. We describe the case of a 57-year-old female patient with a history of prolonged intubation. The ETT entered the esophagus through the TEF and abutted an esophageal stent that had been placed after the TEF diagnosis, resulting in respiratory failure. The patient improved following endoscopic evaluation and intervention. This case illustrates a rare complication that can occur during intubation in patients with TEF.
INTRODUCTION:Safety rounds (SR) have become an effective strategy to enhance safety culture across various healthcare settings. Surgical critical care units (SCCUs) and postanesthesia care units (PACUs) are high-risk environments where active surveillance and early risk identification are essential to ensure safe care. This study aims to evaluate the applicability and effectiveness of SR in SCCUs and PACUs, providing evidence of their impact on quality and patient safety improvement. METHODS:A quasi-experimental study was conducted in a tertiary-level Spanish hospital with multidisciplinary participation. A structured four-phase procedure was designed for SR implementation in SCCUs and PACUs. Twelve key safety indicators were assessed through direct observation and document review using lot quality assurance sampling. RESULTS:Six SRs were conducted between 2022 and 2024. A progressive improvement in indicator compliance was observed, with non-compliance decreasing from 45% in the first round to 0% in the fourth. Indicators such as "Zero Pneumonia" and "Zero Resistance" showed recurrent difficulties, highlighting critical areas requiring targeted interventions. CONCLUSIONS:SRs are an effective and adaptable tool to improve safety in SCCUs and PACUs. Their success relies on a structured approach, visible leadership, and active staff engagement, establishing them as a sustainable strategy for continuous improvement.
INTRODUCTION:Chronic musculoskeletal pain in older adults is associated with unhealthy lifestyles, possibly influenced by social determinants of health (SDH). OBJECTIVE:To identify the association between SDH and unhealthy lifestyles in older adults with chronic musculoskeletal pain. MATERIAL AND METHODS:A cross-sectional study was conducted. A structured survey was administered to assess SDH (gender, educational level, income, availability of green spaces, rurality, multimorbidity, and cohabitation) and lifestyles (physical activity: IPAQ; sleep quality: abbreviated PSQI; perceived stress: PSS-4; adherence to the Mediterranean diet: MedDiet Score). Mann-Whitney U tests and multivariate logistic regression models were applied. RESULTS:One hundred people were included (mean age 69.0 ± 9.8; 83% women). Forty percent were physically inactive, 71% had poor sleep quality, 36% had high perceived stress, and 76% had low adherence to the Mediterranean diet. Female sex was associated with poorer sleep quality (p = 0.023), absence of green areas with less weekly walking time (p = 0.042), multimorbidity with higher perceived stress (p = 0.039), and low educational level with lower adherence to the Mediterranean diet (p = 0.022). These findings were maintained in logistic regression models adjusted for age, body mass index, and pain intensity. CONCLUSIONS:Being female, having lower educational attainment, living without access to green areas, and presenting multimorbidity were associated with poorer sleep, decreased dietary adherence, lower physical activity, and higher stress, respectively. These findings correspond to associations observed in a cross-sectional design and do not allow causal relationships to be established.
BACKGROUND:Lumbar plexus block (LPB) can be used with different techniques for anaesthesia and postoperative analgesia during femoral surgery. This study aimed to compare in-plane and out-of-plane methods using the Shamrock technique. METHODS:Forty-two patients scheduled for surgery due to femoral neck fractures were included in this randomized controlled study. The Shamrock technique was used to visualise the lumbar plexus. Patients were randomized to 2 groups: one group received LPB using the in-plane technique (IP group, n = 20), and the other received LPB using the out-of-plane technique (OOP group, n = 20). The primary outcome measure was block procedure time. Secondary outcomes included the number of needle insertions and redirections, needle depth (cm), minimal nerve stimulation (mA), sensory and motor block levels, and epidural spread. RESULTS:No statistically significant difference was found between the groups in block procedure times (p > 0.05).The number of insertions and the number of needle redirections were significantly lower in the OOP group compared to the IP group (p = 0.005). The needle depth was significantly greater in the IP group compared to the OOP group (6.5 ± 1.1 cm vs 5.1 ± 0.8 cm, p = 0.001). No difference was found in sensory and motor block times (p > 0.05). No differences were observed in the number of patients with epidural spread or in the incidence of complications (p > 0.05). CONCLUSION:The OOP technique demonstrated similar efficacy to the IP method using the Shamrock technique. The OOP technique can be used as an alternative for elderly patients in whom the IP technique can be difficult.
INTRODUCTION AND OBJECTIVES:In order to standardise the periprocedural management of antithrombotic drugs, a national and multidisciplinary consensus document was drawn up in 2018. This study analyses the follow-up of this consensus and its outcome in the perioperative setting. METHODS:Sub-analysis of the REQXAA study (observational, prospective, multicentre with 30-day follow-up) in patients scheduled for surgery. Antithrombotic management was considered appropriate according to the consensus document. Logistic regression analysis was used to study the effect of appropriate management and other variables on the incidence of adverse thrombotic and/or haemorrhagic events (odds ratio (OR) and confidence interval (95% CI)). RESULTS:A total of 506 patients were included (57.5% antiplatelet therapy; 38.9% anticoagulant therapy; 3.6% dual therapy), with 50 adverse events recorded (overall incidence 9.9%), 46 of which were haemorrhagic. In 50.2% of patients, management was suboptimal, which was associated with a significant increase in adverse events (OR 2.3, 95% CI 1.2-4.2). The following factors independently increased the risk: inappropriate indication for bridging therapy (OR 3.9, 95% CI 1.9-7.9), chronic kidney disease (OR 2.0, 95% CI 1.1-3.9) and high thrombotic risk (OR 3.7, 95% CI 1.6-8.6). Patients with moderate-to-high bleeding risk and suboptimal management had a higher risk of bleeding (OR 4.4, 95% CI 1.6-11.9). CONCLUSIONS:Failure to follow the consensus document for the perioperative management of antithrombotic drugs is associated with an increase in adverse events. The implementation of multidisciplinary protocols in the perioperative period, following current recommendations, could improve these outcomes.
BACKGROUND AND AIMS:Managing difficult airways in cancer patients remains a significant challenge for anesthetists worldwide due to the risk of serious complications. Therefore, this study aimed to evaluate the feasibility of awake orotracheal intubation using the C-MAC D-Blade in cancer patients with predicted difficult airways undergoing elective surgery under general anesthesia. METHOD:We enrolled 180 cancer patients with difficult airways, as assessed by the El-Ganzouri Risk Index. Awake orotracheal intubation was performed using the C-MAC D-Blade, with topical local anesthesia and sedation. The primary outcome was the first-attempt intubation success rate. Secondary outcomes included the total intubation time, hemodynamic changes, patient responses, complications, and the ease of the procedure, assessed by both anesthesiologists and patients using a visual analog scale (VAS). RESULTS:First-attempt intubation was successful in 89.4% of patients (n = 161), 8.3% (n = 15) required a second attempt, and 2.2% (n = 4) required a third attempt. No failed intubations were recorded. The mean intubation time with its standard deviation was 40.8 ± 9.01 s. At one and two minutes after intubation, heart rate and mean arterial blood pressure increased significantly from baseline values (P < .001). Tooth damage occurred in three patients, bleeding gums in seven patients, and tissue edema in four patients. The median VAS score for both anesthesiologists and patient satisfaction was 9, indicating high procedural feasibility. Additionally, a statistically significant positive correlation was observed between the number of intubation attempts and cough severity (P = .001). CONCLUSION:Awake video-laryngoscopic intubation using the C-MAC D-Blade achieved a high first-attempt success rate (89.4%) with minimal complications in cancer patients with predicted difficult airways. These results suggest it is a safe and effective option when careful assessment, adequate topical anesthesia, and appropriate sedation are ensured, although comparative studies are needed to better define its role. CLINICAL TRIAL REGISTRY:Registered at clinicaltrial.gov registry system (clinical trial identifier: PACTR202408730457046).
