Analgesia controlada por paciente con remifentanil vs bloqueo peridural en analgesia obstétrica. Estudio multicéntrico randomizado
Patient controlled analgesia with remifentanil versus epidural analgesia in labour: randomised multicentre equivalence trial. Freeman LM, Bloemenkamp KW, Franssen MT, Papatsonis DN, Hajenius PJ, Hollmann MW, Woiski MD, Porath M, van den Berg HJ, van Beek E,Borchert OW, Schuitemaker N, Sikkema JM, Kuipers AH, Logtenberg SL, van der Salm PC, Oude Rengerink K, Lopriore E, van den Akker-van Marle ME, le Cessie S, van Lith JM, Struys MM, Mol BW, Dahan A, Middeldorp JM. BMJ. 2015 Feb 23;350:h846. doi: 10.1136/bmj.h846. Abstract OBJECTIVE: To determine women's satisfaction with pain relief using patient controlled analgesia with remifentanil compared with epidural analgesia during labour. DESIGN: Multicentre randomised controlled equivalence trial. SETTING: 15 hospitals in the Netherlands. PARTICIPANTS: Women with an intermediate to high obstetric risk with an intention to deliver vaginally. To exclude a clinically relevant difference in satisfaction with pain relief of more than 10%, we needed to include 1136 women. Because of missing values for satisfaction this number was increased to 1400 before any analysis. We used multiple imputation to correct for missing data. INTERVENTION: Before the onset of active labour consenting women were randomised to a pain relief strategy with patient controlled remifentanil or epidural analgesia if they requested pain relief during labour. MAIN OUTCOME MEASURES: Primary outcome was satisfaction with pain relief, measured hourly on a visual analogue scale and expressed as area under the curve (AUC), thus providing a time weighted measure of total satisfaction with pain relief. A higher AUC represents higher satisfaction with pain relief. Secondary outcomes were pain intensity scores, mode of delivery, and maternal and neonatal outcomes. Analysis was done by intention to treat. The study was defined as an equivalence study for the primary outcome. RESULTS: 1414 women were randomised, of whom 709 were allocated to patient controlled remifentanil and 705 to epidural analgesia. Baseline characteristics were comparable. Pain relief was ultimately used in 65% (447/687) in the remifentanil group and 52% (347/671) in the epidural analgesia group (relative risk 1.32, 95% confidence interval 1.18 to 1.48). Cross over occurred in 7% (45/687) and 8% (51/671) of women, respectively. Of women primarily treated with remifentanil, 13% (53/402) converted to epidural analgesia, while in women primarily treated with epidural analgesia 1% (3/296) converted to remifentanil. The area under the curve for total satisfaction with pain relief was 30.9 in the remifentanilgroup versus 33.7 in the epidural analgesia group (mean difference -2.8, 95% confidence interval -6.9 to 1.3). For who actually received pain relief the area under the curve for satisfaction with pain relief after the start of pain relief was 25.6 in the remifentanil group versus 36.1 in the epidural analgesia group (mean difference -10.4, -13.9 to -7.0). The rate of caesarean section was 15% in both groups. Oxygen saturation was significantly lower (SpO2 <92%) in women who used remifentanil (relative risk 1.5, 1.4 to 1.7). Maternal and neonatal outcomes were comparable between both groups. CONCLUSION: In women in labour, patient controlled analgesia with remifentanil is not equivalent to epidural analgesia with respect to scores on satisfaction with pain relief. Satisfaction with pain relief was significantly higher in women who were allocated to and received epidural analgesia. PDF
Remifentanil intravenoso vs ropivacaína epidural con sufentanil para analgesia de parto. Estudio retrospectivo
Intravenous remifentanil versus epidural ropivacaine with sufentanil for labour analgesia: a retrospective study.
Lin R, Tao Y, Yu Y, Xu Z, Su J, Liu Z. PLoS One. 2014 Nov 11;9(11):e112283. doi: 10.1371/journal.pone.0112283. eCollection 2014. Abstract Remifentanil with appropriate pharmacological properties seems to be an ideal alternative to epidural analgesia during labour. A retrospective cohort study was undertaken to assess the efficacy and safety of remifentanil intravenous patient-controlled analgesia (IVPCA) compared with epidural analgesia. Medical records of 370 primiparas who received remifentanil IVPCA or epidural analgesia were reviewed. Pain and sedation scores, overall satisfaction, the extent of pain control, maternal side effects and neonatal outcome as primary observational indicators were collected. There was a significant decline of pain scores in both groups. Pain reduction was greater in the epidural group throughout the whole study period (0 ∼ 180 min) (P < 0.0001), and pain scores in the remifentanil group showed an increasing trend one hour later. The remifentanil group had a lower SpO2 (P < 0.0001) and a higher sedation score (P < 0.0001) within 30 min after treatment. The epidural group had a higher overall satisfaction score (3.8 ± 0.4 vs. 3.7 ± 0.6, P = 0.007) and pain relief score (2.9 ± 0.3 vs. 2.8 ± 0.4, P < 0.0001) compared with the remifentanil group. There was no significant difference on side effects between the two groups, except that a higher rate of dizziness (1% vs. 21.8%, P < 0.0001) was observed duringremifentanil analgesia. And logistic regression analysis demonstrated that nausea, vomiting were associated with oxytocin usage and instrumental delivery, and dizziness was associated to the type and duration of analgesia. Neonatal outcomes such as Apgar scores and umbilical-cord blood gas analysis were within the normal range, but umbilical pH and base excess of neonatus in the remifentanil group were significantly lower. RemifentanilIVPCA provides poorer efficacy on labor analgesia than epidural analgesia, with more sedation on parturients and a trend of newborn acidosis. Despite these adverse effects, remifentanil IVPCA can still be an alternative option for labor analgesia under the condition of one-to-one bedside care, continuous monitoring, oxygen supply and preparation for neonatal resuscitation. PDF
Comparación de remifentanil-etonox vs etononox en analgesia de parto
Comparison of remifentanil: Entonox with Entonox alone in labor analgesia. Varposhti MR, Ahmadi N, Masoodifar M, Shahshahan Z, Tabatabaie MH. Adv Biomed Res. 2013 Nov 30;2:87. doi: 10.4103/2277-9175.122511. eCollection 2013. Abstract BACKGROUND: We designed a study to evaluate the effectiveness of continuous low dose infusion of remifentanil adding to self-administration of entonox administered for pain relief during the active phase of first stage of labor. MATERIALS AND METHODS: Thirty healthy term pregnant women recruited in our randomized double-blind, cross over study. They received the study medicines during two 30-min periods with a 15-min wash-out sequence after each period. Fifteen parturient used remifentanil as a single bolus dose followed by constant low dose infusion and self-administration of entonox (group R) during the first period and entonox and saline (group P) during the second period, while the remainder of the parturient used the drugs in a reverse order. Pain and Ramsay score, maternal and fetal hemodynamic, and ventilation were assessed during each intervention. RESULTS: In this study, mean pain severity scores were 8 ± 0.9 before and 5.4 ± 1.7 after intervention in group P, and 7.8 ± 0.1, 3.5 ± 1.3 in group R, respectively. Mean pain severity difference was 2.6 ± 1.5 in group P, while 4.3 ± 1.5 in group R; so, use of entonox and remifentanil can decreaselabor pain two times more in comparison with entonox/placebo (normal saline). However, hemodynamic and ventilation parameter inremifentanil/entonox period were same as in entonox/placebo period. No statistical differences were seen in mean Ramsay score between group R and P. There was no episode of maternal bradycardia, hypotension, or hypoxemia. CONCLUSION: Not only adding low dose infusion of remifentanil to self-administration of entonox was notable in labor pain reduction, it did n't make more parturient and neonatal side-effects. KEYWORDS: Entonox; labor pain; remifentanil PDF
Etiología y uso de la técnica de la "gota colgante". Una revisión
Etiology and use of the "hanging drop" technique: a review. Todorov L, VadeBoncouer T. Pain Res Treat. 2014;2014:146750. doi: 10.1155/2014/146750. Epub 2014 Apr 15. Abstract Background. The hanging drop (HD) technique presumably relies on the presence of subatmospheric epidural pressure. It is not clear whether this negative pressure is intrinsic or an artifact and how it is affected by body position. There are few data to indicate how often HD is currently being used. Methods. We identified studies that measured subatmospheric pressures and looked at the effect of the sitting position. We also looked at the technique used for cervical and thoracic epidural anesthesia in the last 10 years. Results. Intrinsic subatmospheric pressures were measured in the thoracic and cervical spine. Three trials studied the effect of body position, indicating a higher incidence of subatmospheric pressures when sitting. The results show lower epidural pressure with the sitting position. 28.8% of trials of cervical and thoracic epidural anesthesia that documented the technique used, utilized the HD technique. When adjusting for possible bias, the rate of HD use can be as low as 11.7%. Conclusions. Intrinsic negative pressure might be present in the cervical and thoracic epidural space. This effect is more pronounced when sitting. This position might be preferable when using HD. Future studies are needed to compare it with the loss of resistance technique. PDF
Localización del Espacio Epidural mediante una variante del Signo de Gutiérrez.
DRA. LILIAN ELANIA OLEAS VIVAR Tesis de Anestesiología PDF
Técnicas de identificación del espacio epidural
E. Figueredo Rev. Esp. Anestesiol. Reanim. 2005; 52: 401-412 PDF
La Gota de Lambertus para localizar el espacio epidural
El uso temprano de ketamina antagonista del receptor NMDA en estado epiléptico refractario y súper refractario.
Early Use of the NMDA Receptor Antagonist Ketamine in Refractory and Super refractory Status Epilepticus. Zeiler FA. Crit Care Res Pract. 2015;2015:831260. doi: 10.1155/2015/831260. Epub 2015 Jan 12. Abstract Refractory status epilepticus (RSE) and superrefractory status epilepticus (SRSE) pose a difficult clinical challenge. Multiple cerebral receptor and transporter changes occur with prolonged status epilepticus leading to pharmacoresistance patterns unfavorable for conventional antiepileptics. In particular, n-methyl-d-aspartate (NMDA) receptor upregulation leads to glutamate mediated excitotoxicity. Targeting these NMDA receptors may provide a novel approach to otherwise refractory seizures. Ketamine has been utilized in RSE. Recent systematic review indicates 56.5% and 63.5% cessation in seizures in adults and pediatrics, respectively. No complications were described. We should consider earlier implementation of ketamine or other NMDA receptor antagonists, for RSE. Prospective study of early implementation of ketamine should shed light on the role of such medications in RSE. PDF
Ketamina como un potencial manejo de ideación suicida. Revisión sistemática de la literatura
Ketamine as a potential treatment for suicidal ideation: a systematic review of the literature. Reinstatler L, Youssef NA. Drugs R D. 2015 Mar;15(1):37-43. doi: 10.1007/s40268-015-0081-0. Abstract OBJECTIVE: To review the published literature on the efficacy of ketamine for the treatment of suicidal ideation (SI). METHODS: The PubMed and Cochrane databases were searched up to January 2015 for clinical trials and case reports describing therapeuticketamine administration to patients presenting with SI/suicidality. Searches were also conducted for relevant background material regarding the pharmacological function of ketamine. RESULTS: Nine publications (six studies and three case reports) met the search criteria for assessing SI after administration of subanestheticketamine. There were no studies examining the effect on suicide attempts or death by suicide. Each study demonstrated a rapid and clinically significant reduction in SI, with results similar to previously described data on ketamine and treatment-resistant depression. A total of 137 patients with SI have been reported in the literature as receiving therapeutic ketamine. Seven studies delivered a dose of 0.5 mg/kg intravenously over 40 min, while one study administered a 0.2 mg/kg intravenous bolus and another study administered a liquid suspension. The earliest significant results were seen after 40 min, and the longest results were observed up to 10 days postinfusion. CONCLUSION: Consistent with clinical research on ketamine as a rapid and effective treatment for depression, ketamine has shown early preliminary evidence of a reduction in depressive symptoms, as well as reducing SI, with minimal short-term side effects. Additional studies are needed to further investigate its mechanism of action, long-term outcomes, and long-term adverse effects (including abuse) and benefits. In addition,ketamine could potentially be used as a prototype for further development of rapid-acting antisuicidal medication with a practical route of administration and the most favorable risk/benefit ratio. PDF
Comparación del efecto pre-emptivo de gabapentina y pregabalina orales en dolor agudo postoperatorio después de cirugía con anestesia espinal
A comparison of effect of preemptive use of oral gabapentin and pregabalin for acute post-operative pain after surgery under spinal anesthesia. Bafna U1, Rajarajeshwaran K1, Khandelwal M1, Verma AP1. J Anaesthesiol Clin Pharmacol. 2014 Jul;30(3):373-7. doi: 10.4103/0970-9185.137270. Abstract BACKGROUND AND AIMS: Preemptive analgesia is an antinociceptive treatment that prevents establishment of altered processing of afferent input. Pregabalin has been claimed to be more effective in preventing neuropathic component of acute nociceptive pain of surgery. We conducted a study to compare the effect of oral gabapentin and pregabalin with control group for post-operative analgesia. MATERIALS AND METHODS: A total of 90 ASA grade I and II patients posted for elective gynecological surgeries were randomized into 3 groups (group A, B and C of 30 patients each). One hour before entering into the operation theatre the blinded drug selected for the study was given with a sip of water. Group A- received identical placebo capsule, Group B- received 600mg of gabapentin capsule and Group C - received 150 mg of pregabalin capsule. Spinal anesthesia was performed at L3-L4 interspace and a volume of 3.5 ml of 0.5% bupivacaine heavy injected over 30sec through a 25 G spinal needle. VAS score at first rescue analgesia, mean time of onset of analgesia, level of sensory block at 5min and 10 min interval, onset of motor block, total duration of analgesia and total requirement of rescue analgesia were observed as primary outcome. Hemodynamics and side effects were recorded as secondary outcome in all patients. RESULTS: A significantly longer mean duration of effective analgesia in group C was observed compared with other groups (P < 0.001). The mean duration of effective analgesia in group C was 535.16 ± 32.86 min versus 151.83 ± 16.21 minutes in group A and 302.00 ± 24.26 minutes in group B. The mean numbers of doses of rescue analgesia in the first 24 hours in group A, B and C was 4.7 ± 0.65, 4.1 ±0.66 and 3.9±0.614. (P value <0.001). CONCLUSION: We conclude that preemptive use of gabapentin 600mg and pregabalin 150 mg orally significantly reduces the postoperative rescue analgesic requirement and increases the duration of postoperative analgesia in patients undergoing elective gynecological surgeries under spinal anesthesia. KEYWORDS: Gabapentin; pregabalin; spinal anesthesia PDF
Reanálisis de consumo de morfina a partir de dos ensayos controlados aleatorios de gabapentina utilizando métodos estadísticos longitudinales controlados.
Reanalysis of morphine consumption from two randomized controlled trials of gabapentin using longitudinal statistical methods. Zhang S, Paul J, Nantha-Aree M, Buckley N, Shahzad U, Cheng J, DeBeer J, Winemaker M, Wismer D, Punthakee D, Avram V, Thabane L. J Pain Res. 2015 Feb 9;8:79-85. doi: 10.2147/JPR.S56558. eCollection 2015. Abstract BACKGROUND: Postoperative pain management in total joint replacement surgery remains ineffective in up to 50% of patients and has an overwhelming impact in terms of patient well-being and health care burden. We present here an empirical analysis of two randomized controlled trials assessing whether addition of gabapentin to a multimodal perioperative analgesia regimen can reduce morphine consumption or improve analgesia for patients following total joint arthroplasty (the MOBILE trials). METHODS: Morphine consumption, measured for four time periods in patients undergoing total hip or total knee arthroplasty, was analyzed using a linear mixed-effects model to provide a longitudinal estimate of the treatment effect. Repeated-measures analysis of variance and generalized estimating equations were used in a sensitivity analysis to compare the robustness of the methods. RESULTS: There was no statistically significant difference in morphine consumption between the treatment group and a control group (mean effect size estimate 1.0, 95% confidence interval -4.7, 6.7, P=0.73). The results remained robust across different longitudinal methods. CONCLUSION: The results of the current reanalysis of morphine consumption align with those of the MOBILE trials. Gabapentin did not significantly reduce morphine consumption in patients undergoing major replacement surgeries. The results remain consistent across longitudinal methods. More work in the area of postoperative pain is required to provide adequate management for this patient population. KEYWORDS: gabapentin; postoperative morphine consumption; randomized controlled trials; reanalysis PDF
Durante años, los científicos que estudian el cerebro se han fijado casi exclusivamente en lo que podían ver: lóbulos cerebrales, surcos, pliegues... Ahora, sin embargo, y gracias a un esquema más completo de cómo las neuronas se conectan unas a otras, los investigadores han podido descubrir la existencia de auténticas 'redes de área local' neuronales, anidadas unas dentro de otras como conchas.
"La corteza cerebral es como un Internet en miniatura -afirma Larry Swanson, de la Universidad del Sur de California y uno de los autores del estudio-. Internet tiene innumerables redes de área local que luego se conectan con las redes regionales más grandes y en última instancia con la columna vertebral de Internet. El cerebro funciona de una manera similar".
Hipertension pulmonar y embarazo. Experiencia de 15 años en una institución de tercer nivel.
Pulmonary hypertension and pregnancy: The experience of a tertiary institution over 15 years. Monagle J, Manikappa S, Ingram B, Malkoutzis V. Ann Card Anaesth 2015;18:153-60 Abstract Background: Pulmonary hypertension (PH) in pregnancy is associated with a high maternal mortality and morbidity and has been found to be as high as 30-56%. Aim: To review the management of such patients in a tertiary center over a 15 year period, as the current literature consists of a few case reports, a few small case series and 2 meta-analyses. Materials and Methods: A review of all patients admitted to our institution for management of PH in pregnancy between 1994 and February 2009 was undertaken. Cases were identified from the high-risk pregnancy database within the department of anesthesia and from the hospital medical records. Severity of PH, type of PH, NYHA functional status at presentation and delivery, mode of delivery, peripartum monitoring and APGAR scores were noted. Patients were reviewed by a multidisciplinary team and management planned accordingly. Results: 19 eligible patients were identified. Patients who were significantly sick due to their PH were aggressively managed during pregnancy. Overall there was an improvement in NYHA functional status at the time of delivery. Epidural analgesia and anesthesia for labor and operatively delivery seem to be the ideal choice. Conclusion: Multidisciplinary approach is a key to the successful management of these patients. Secondary PH results in higher morbidity and mortality, in particular, older the age higher the maternal morbidity and mortality. Keywords: Anesthesia; pregnancy; pulmonary hypertension
Dosis elevadas de dexmedetomidina. Efectiva como agente único para sedación en niños programados en RNM
High dose dexmedetomidine: effective as a sole agent sedation for children undergoing MRI. Ahmed SS, Unland T, Slaven JE, Nitu ME. Int J Pediatr. 2015;2015:397372. doi: 10.1155/2015/397372. Epub 2015 Jan 29. PDF
La dexmedetomidina ofrece una opción para la sedación segura y efectiva para imágenes de medicina nuclear en niños.
Dexmedetomidine offers an option for safe and effective sedation for nuclear medicine imaging in children. Mason KP, Robinson F, Fontaine P, Prescilla R. Radiology. 2013 Jun;267(3):911-7. doi: 10.1148/radiol.13121232. Epub 2013 Feb 28. Abstract PURPOSE: To determine the safety, efficacy, and outcomes of bradycardia, hypotension, and hypertension with dexmedetomidine (DEX), a recently approved sedative used for procedural sedation that has not been described previously for pediatric nuclear medicine imaging. MATERIALS AND METHODS: Between March 2005 and August 2011, 669 patients (mean age, 5.7 years ± 4.5 [standard deviation]; median age, 4.5 years; age range, 0.1-22.5 years) received DEX in this HIPAA-compliant study. Sedation was administered with DEX, an α-2 adrenergic agonist, as an intravenous bolus (2 μg per kilogram of body weight) over a 10-minute period; this was followed by continuous infusion at a rate of 1 μg/kg/h until imaging was complete. The bolus could be repeated up to two times, if needed, to achieve the targeted level of a Ramsay sedation score of 4. After institutional review board approval, collected quality assurance data were reviewed. RESULTS: Adequate sedation was achieved within 8.6 minutes ± 4.6 (median, 8.0 minutes; range, 1.0-40.0 minutes) on average in studies that averaged 41.3 minutes ± 25.5 (median, 31.5 minutes; range, 9.0-183.0 minutes). Of 669 studies, 667 (99.7%) were completed successfully. Six children (0.9%) had brief periods of oxygen desaturation below 95%, none of which required airway intervention. Hypotension, hypertension, and bradycardia (all defined as deviations of more than 20% from age-adjusted awake norms), occurred in 58.7% (n = 393), 2.1% (n = 14), and 4.3% (n = 29) of patients, respectively. Both hypotension and bradycardia were related to age (P = .033 and P = .002, respectively); older children tended to experience more of these events. None of these fluctuations required pharmacologic therapy. Discharge criteria (modified Aldrete score ≥ 9) were met, on average, within 41.4 minutes ± 27.9 (median, 36.0 minutes; range, 1.0-220.0 minutes). CONCLUSION: DEX offers advantages for pediatric sedation for nuclear medicine imaging. DEX produces a condition similar to natural sleep, with no detrimental effect on respiration. The hemodynamic variability anticipated with DEX did not require pharmacologic treatment, and the drug was well tolerated. PDF
Sedación pediátrica en un centro de RNM ambulatoria en un hospital de la comunidad
Pediatric sedation in a community hospital-based outpatient MRI center.
Mason KP1, Fontaine PJ, Robinson F, Zgleszewski S. AJR Am J Roentgenol. 2012 Feb;198(2):448-52. doi: 10.2214/AJR.11.7346. Abstract OBJECTIVE: Although the demand for pediatric MRI is increasing, it is uncommon to find sedation being offered at community hospital-based outpatient centers. We present our safety, efficacy, and outcome data at a community hospital-based outpatient imaging center. MATERIALS AND METHODS: I.v. dexmedetomidine sedation was administered as a bolus of 3 μg/kg and maintained with a continuous infusion of 1 μg/kg/hr until imaging was complete. The dexmedetomidine bolus could be repeated up to two times, if needed. Quality assurance data were reviewed. RESULTS: From April 2009 to July 2010, 279 children (mean age, 4.2 years; age range, 0.2-17.2 years) were sedated. All received a first bolus, 46 required a second dose, and two received a third. The average time to achieve sedation was 7.8 minutes (SD, ± 3.8 minutes). Total duration of imaging (82% brain MRI) averaged 38.1 minutes (range, 8.0-126.0 minutes). On average, discharge criteria were met within 21.3 minutes of arrival in recovery room (± 17.8 minutes). The heart rate and blood pressure deviated from baseline by more than 20% in 5% and 33% of the patients, respectively. No pharmacologic therapy was administered to treat the hemodynamic variability. There were no adverse respiratory events. All imaging studies were successfully completed. CONCLUSION: Dexmedetomidine offers an option for pediatric sedation for MRI at community hospital-based outpatient settings. It preserves respiration but elicits deviations in blood pressure and heart rate that have not required pharmacologic intervention. Dexmedetomidine offers a safe, effective, and efficient agent for sedation for children undergoing MRI in an outpatient setting. PDF