Introduction: Emergence delirium is a state of mental dissociation which occurs in children as they emerge from anesthesia. Its incidence ranges between 10% and 80% and is associated with neurotoxicity, prolonged hospital stay, self-harm and heteroaggressiveness. To date, the Pediatric Anesthesia Emergence Delirium (PAED) scale is the best studied tool for diagnosing this condition. Objective: Given the lack of a similar tool for the Colombian context, the aim of this study was to translate and culturally adapt the PAED scale in Spanish. Methods: Prospective study with a mixed (quantitative and qualitative) methodology approach consisting of three phases. Phase 1 comprised the translation into Spanish of the PAED tool and its cultural adaptation to the Colombian context. Phase 2 consisted of expert validations. Phase 3 consisted of a pilot test using the final version of the scale, during which two trained observers used the tools during the consecutive assessment of 49 pediatric patients in a hospital post-anesthetic care unit. Parametric statistics were used to analyze the information. Results: With moderate to near-perfect agreement, the translation and cultural adaptation process was validated by expert judgement in order to obtain the final Spanish version of the PAED scale. In the pilot test, inter-observer agreement ranged from acceptable to near-perfect (Cohen’s k 0.29-0.95; p: 0.001) for the tool’s assessment categories. Absolute agreement obtained for the diagnosis of emergence delirium based on the adapted PAED scale was excellent, with an ICCA (absolute agreement) of 0.82 (0.69–0.90) to 0.92 (0.846–0.96). Conclusion: A Spanish version of the PAED scale culturally adapted to the Colombian context was validated by expert judgement and shown to be useful in the clinical setting.

Editorial

Introduction: Device-associated infections (DAIs) are preventable adverse events that represent a critical issue for patient safety. These infections, including central line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), and ventilator-associated pneumonia (VAP), can be influenced by geographic factors, insurance schemes, sex, and age, leading to differential risks and creating another form of health inequity. Objective: To explore and measure inequities in patient safety associated with DAIs in Colombia, using data from the SIVIGILA system (2012–2022). Methods: This observational, analytical study analyzed data on CLABSI, CAUTI, and VAP reported in SIVIGILA. Incidence rates were estimated using random-effects metamodels adjusted for region, year, and device-days. Inequities were formally assessed using coefficients of variation, group deviations, risk differences, and relative risks across comparison groups (region, age group, municipalities). Results: A total of 750 aggregate reports covering over 49,101 DAI events from 2012 to 2022 were analyzed. CLABSI accounted for 44.4% of events. DAIs were more frequent among men (55.2%), in the contributory insurance scheme (49.3%), followed by the subsidized scheme (42.1%), with only 3% occurring in individuals without affiliation to the general social security system (SGSSS). Mortality associated with these events was 19.9%. Bivariate analyses and metamodels revealed inequities in DAI occurrence, particularly in areas with lower access and resources. DAIs showed disparities across departments, regions, sexes, and age groups. Most municipalities and departments reported rates below 3 cases per 1,000 device-days for CLABSI and VAP, but some departments exhibited risks up to four times higher. CAUTI showed a more homogeneous risk distribution. Conclusions: The study highlights significant inequities in the occurrence of DAIs in Colombia. These findings underscore the need for regional and targeted strategies to enhance patient safety and reduce disparities in healthcare.

This article describes the establishment of the first anesthesiology department of a hospital of a health maintenance organization (HMO) in Colombia. It was founded by a heterogeneous group of anesthesiologists, several of them with formal subspecialty training abroad, who designed its administrative, academic and clinical strategies. This led to innovative approaches of perioperative medicine including preanesthetic assessment, deep venous thrombosis prophylaxis, optimization of preoperative testing, massive transfusion protocols, patient blood management (PBM) protocols, enhanced recovery after surgery (ERAS), intensive care unit bypass for neurosurgical procedures, and perioperative outcome analysis, all which were novel in the country. Moreover, for over three decades it hosted an annual anesthesia course to address original topics, hosting global opinion leaders in anesthesia and reinvesting the profits in continuous medical education, more than 20 anesthesia journal subscriptions and simulation equipment as well as physiological data acquisition software and equipment. Lastly, it established the first four-year residency program in Colombia, focusing on perioperative medicine based on interventions for improving patient outcomes.

Malignant hyperthermia is a potentially life-threatening pharmacogenetic disorder characterized by a hypermetabolic response triggered by exposure to halogenated anesthetics, succinylcholine, and other agents. This is a case of a 40-year-old woman who developed masseter muscle spasm, bronchospasm, hypercapnia, muscle stiffness, and hyperthermia upon the administration of general anesthesia at a clinic in the capital of Colombia. This resulted in a high clinical suspicion of malignant hyperthermia and hence the institutional protocol for management of this condition was activated. It should be highlighted however that the drug used to treat this condition—dantrolene—is not readily available at most clinical institutions in Colombia and in this case a special emergency line must be used in order for the drug to be delivered. Once the drug was received and administered, the patient experienced clinical and hemodynamic recovery, with satisfactory postoperative response. She was discharged on day five without any sequelae. This case report reviews the pathophysiology, diagnosis, and treatment for malignant hyperthermia, as well as the challenges in accessing pharmacological treatment in Colombia.

Editorial

Introduction: Continuous monitoring of exhaled concentrations and CO2 levels is often lacking during the administration of inhaled anesthetics in cardiopulmonary bypass (CPB), these levels often being adjusted intermittently based on blood gas values. This approach disregards variations in fresh gas and circulatory flows between blood samples. Objective: To assess gas behavior during bypass circulation, evaluate data reliability, and analyze gradients through the membrane oxygenator. Methods: Real-time monitoring of inhaled and exhaled volatile anesthetics, CO2, and oxygen was conducted at the oxygenator inlet and outlet ports during CPB. Seventy adult patients undergoing cardiac surgery on CPB were included in order to analyze the impact of circulatory flow across different oxygenators. Results: A strong correlation was found between end-tidal CO2 and arterial blood gas CO2 (Spearman’s Rho = 0.74, p = 0.00). Isoflurane gradients differed significantly among the Affinity, Fusion, and Terumo oxygenators (p = 0.015). Equilibrium for Isoflurane was reached in 493.9 ± 164.98 seconds (95% CI: 454–532 seconds). When circulatory flow was reduced to 0.5 L/min, exhaled concentrations increased significantly (Fisher’s T, p = 0.07). Sevoflurane washout varied significantly across oxygenators at CPB initiation (mean: 117.5 s). Conclusion: Continuous monitoring of inhaled and exhaled gases during CPB should be mandatory to optimize anesthetic delivery and achieve targeted plasma concentrations.

Introduction: Butyrophenones are effective prophylactic drugs against postoperative nausea and vomiting (PONV). Our practice used droperidol for PONV prophylaxis until supply chain issues in 2020 required a substitution to haloperidol. Objective: To compare the use of these two butyrophenones and their association with the magnitude of reduction PONV and sedation during admission to postanesthesia care unit (PACU). Methods: Retrospective review of the records of adult surgical patients administered a butyrophenone and admitted to the PACU, from May 2018 through December 2022. PONV was defined as administration of rescue antiemetics during PACU admission. Inverse probability of treatment weighing (IPTW) analysis was performed using generalized estimating equations with robust variance estimates to assess the effects of droperidol and haloperidol on PONV rate. Results: We identified 905 (2018 – 2020) and 651 patients (2020 – 2022) receiving droperidol or haloperidol, respectively. The IPTW PONV rate was 75 (8.3%) for droperidol and 84 (12.9%) haloperidol (odds ratio 0.60; 95% confidence interval 0.41 to 0.87, for the use of droperidol vs haloperidol). Moderate or higher levels of sedation (Richmond Agitation Sedation Scale score ≤ -3) was noted in 163 (18.0) of droperidol and 102 (15.7%) of haloperidol patients, which was nonsignificant, P=0.222, following IPTW adjustment, P=0.269. Median [interquartile range] PACU length of stay was comparable for two butyrophenones, 70 [51, 99] vs. 68 [48, 105] minutes for droperidol vs haloperidol, respectively, P=0.647. Conclusion: Droperidol was associated with lower rates of PONV during PACU admission than haloperidol, but the rate of sedation was higher.

Introduction: The use of non-depolarizing neuromuscular blockers (ND-NMB) is essential in anesthetic management as it improves ventilation conditions, airway management, and surgical conditions. However, the residual neuromuscular blockade (RNMB) in the immediate postoperative period derived from the use of these agents is associated with complications such as desaturation, pneumonia, and unplanned intensive care unit admission. The incidence varies significantly across different studies, and associated risk factors have not been consistent. Objectives: To estimate the incidence of RNMB and to identify characteristics of intraoperative management and potential risk factors for RNMB. Methods: A prospective observational study was conducted at a university hospital, using convenience sampling. Train-of-four (TOF) measurements were performed in the post-anesthesia care unit. An exploratory multivariate analysis was performed to identify potential risk factors. Results: A total of 300 patients were included. The incidence of residual neuromuscular blockade (RNMB) was 19% (95% CI: 14.9% - 23.8%). Evidence of relaxation monitoring was observed in 21.3% of the patients. Significant associations with RNMB were found for female gender (OR 1.97, 95% CI 1.02 – 3.81), absence of pharmacological reversal (OR 2.31, 95% CI 1.02 – 5.24), abdominal surgery (OR 2.81, 95% CI 1.37 – 5.72), and multiple intraoperative doses of ND-NMBs (OR 2.77, 95% CI 1.48 – 5.18). Conclusions: Residual neuromuscular blockade (RNMB) is common in our setting, with a low frequency of intraoperative monitoring. The associated risk factors identified can point to specific scenarios that require special attention.

Introduction: The neonatal period, encompassing the first 28 days of life, is marked by low functional reserve and adaptation to extrauterine life. Neonates have higher postoperative morbidity and mortality compared to older pediatric patients. The anesthesiologist’s expertise significantly influences neonatal perioperative outcomes. In Colombia, disparities in healthcare access and education impact neonatal anesthesia training. However, there is limited information on neonatal anesthesia practice and training in the country. Objective: To characterize neonatal anesthesia from the perspective of anesthesiologists, pediatric surgeons, neonatologists, and directors of specialization programs in anesthesiology in Colombia. Methods: An observational, cross-sectional study was conducted. A survey was administered among practicing anesthesiologists, pediatric surgeons, neonatologists, and directors of anesthesiology programs in Colombia with regards to several aspects of neonatal anesthesia. An ad hoc questionnaire was designed including 5 domains: perception of professional practice, techniques used, technical and logistical resources of the institutions, training received during the anesthesiology residency, and curricular aspects of the anesthesiology postgraduate program in Colombia. Results: According to the neonatologists, the anesthesia categories with the worst performance were thermoregulation (poorly managed 38.8% and very poorly managed 22.4%) and management of intravenous fluids (poorly managed 34.7% and very poorly managed 6.1%). With regards to the opinion of the pediatric surgeons, the categories with the lowest performance were thermoregulation (poorly managed 12.5%) and the use of vasoactive medications (poorly managed: 6.3% and very poorly managed 3.1%). 77.8% of the country's anesthesiology programs fail to include neonatal anesthesia as part of the syllabus. 61.5% of anesthesiologists considered their training inadequate to manage a surgical neonate and 89.6% believe that pediatric anesthesia should be a subspecialty in Colombia. Conclusions: There is a discrepancy between anesthesiologists' self-perception of neonatal care and the views of neonatologists and pediatric surgeons. In Colombia, academic training in neonatal anesthesiology appears to be limited, reflecting gaps in the curricular content of training programs.