lunes, 27 de abril de 2015

Ketamina en Cesárea/Ketamine in C-section

No.1952                                                                                   Abril 25, 2015
Efecto de dosis bajas de ketamina sobre el dolor postoperatorio después de cesárea con raquia. Estudio clínico randomizado
The effect of low-dose intravenous ketamine on postoperative pain following cesarean section with spinal anesthesia: a randomized clinical trial.
Rahmanian M1, Leysi M1, Hemmati AA2, Mirmohammadkhani M3.
Oman Med J. 2015 Jan;30(1):11-6. doi: 10.5001/omj.2015.03.
Abstract
OBJECTIVES: Low-dose ketamine has been considered a good substitute for opioids for controlling postoperative pain. The purpose of this study was to determine the effect of low-dose intravenous ketamine following cesarean section with spinal anesthesia on postoperative pain and its potential complications. METHODS: One hundred and sixty pregnant women volunteered to participate in this randomized controlled trial. Participants were randomly divided into two groups (n=80 for each group). Five minutes after delivery, the experimental group received 0.25mg/kg ketamine while the control group received the same amount of normal saline. RESULTS: There was a significant difference between the two groups in the severity of pain at one, two, six, and 12 hours following surgery. Postoperative pain was significantly less severe in the experimental group. Compared to the control group, the experimental group felt pain less frequently and therefore asked for analgesics less often. On average, the number of doses of analgesics used for the participants in the experimental group was significantly less than the number of doses used for the control group. Analgesic side effects (including nausea, itching, and headache) were not significantly different between the two groups. However, vomiting was significantly more prevalent in the control group and hallucination was more common in the experimental group. CONCLUSION: We conclude that administration of low doses of ketamine after spinal anesthesia reduces the need for analgesics and has fewer side effects than using opioids. Further studies are required to determine the proper dose of ketamine which offers maximum analgesic effect. Furthermore, administration of low-dose ketamine in combination with other medications in order to minimize its side effects warrants further investigation.
KEYWORDS: Anesthesia, Spinal; Cesarean Section; Ketamine; Pain, Postoperative
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Efectos analgésicos de ketamina intravenosa durante raquia en embarazadas programadas para cesárea. Estudio clínico randomizado
Analgesic Effects of Intravenous Ketamine during Spinal Anesthesia in Pregnant Women Undergone Caesarean Section; A Randomized Clinical Trial.
Behdad S1, Hajiesmaeili MR, Abbasi HR, Ayatollahi V, Khadiv Z, Sedaghat A.
Anesth Pain Med. 2013 Sep;3(2):230-3. doi: 10.5812/aapm.7034. Epub 2013 Sep 1.
Abstract
BACKGROUND: Suitable analgesia after cesarean section helps mothers to be more comfortable and increases their mobility and ability to take better care of their infants.
OBJECTIVES: Pain relief properties of ketamine prescription were assessed in women with elective cesarean section who underwent spinal anesthesia with low dose intravenous ketamine and midazolam and intravenous midazolam alone. PATIENTS AND METHODS:Sixty pregnant women scheduled for spinal anesthesia for cesarean section were randomized into two study groups.Ketamine (30 mg) + midazolam (1 mg = 2CC) or 1mg midazolam (2CC) alone, was given immediately after spinal anesthesia. Pain scores at first, second and third hours after CS operation, analgesic requirement and drug adverse effects were recorded in all patients. RESULTS: Ketamine group had significant pain relief properties in compare with control group in first hours after cesarean section (0.78 ± 1.09 vs. 1.72 ± 1.22, VAS score, P = 0.00). Total dose of meperidine consumption in women of ketamine group was significantly lower than women of control group (54.17 ± 12.86 vs. 74.44 ± 33.82 mg, P = 0.02). There were no significant drug side effects in participated patients. CONCLUSIONS: Intravenous low-dose ketamine combined with midazolam for sedation during spinal anesthesia for elective Caesarean sectionprovides more effective and long lasting pain relief than control group.
KEYWORDS: Analgesia; Anesthesia, Spinal; Cesarean Section; Ketamine; Pain Clinics
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Efectos de dosis bajas de ketamina en la analgesia post cesárea con anestesia subaracnoidea
The Effect of Low-dose Ketamine on Post-caesarean Delivery Analgesia after Spinal Anesthesia.
Han SY1, Jin HC, Yang WD, Lee JH, Cho SH, Chae WS, Lee JS, Kim YI.
Korean J Pain. 2013 Jul;26(3):270-6. doi: 10.3344/kjp.2013.26.3.270. Epub 2013 Jul 1.
Abstract
BACKGROUND: Ketamine, an N-methyl-D-aspartate receptor antagonist, might play a role in postoperative analgesia, but its effect on postoperative pain after caesarean section varies with study design. We investigated whether the preemptive administration of low-dose intravenous ketamine decreases postoperative opioid requirement and postoperative pain in parturients receiving intravenous fentanyl with patient-controlled analgesia (PCA) following caesarean section. METHODS: Spinal anesthesia was performed in 40 parturients scheduled for elective caesarean section. Patients in the ketamine group received a 0.5 mg/kg ketamine bolus intravenously followed by 0.25 mg/kg/h continuous infusion during the operation. The control group received the same volume of normal saline. Immediately after surgery, the patients were connected to a PCA device set to deliver 25-µg fentanyl as an intravenousbolus with a 15-min lockout interval and no continuous dose. Postoperative pain was assessed using the cumulative dose of fentanyl and visual analog scale (VAS) scores at 2, 6, 24, and 48 h postoperatively. RESULTS: Significantly less fentanyl was used in the ketamine group 2 h after surgery (P = 0.033), but the difference was not significant at 6, 12, and 24 h postoperatively. No significant differences were observed between the VAS scores of the two groups at 2, 6, 12, and 24 h postoperatively. CONCLUSIONS: Intraoperative low-dose ketamine did not have a preemptive analgesic effect and was not effective as an adjuvant to decrease opioid requirement or postoperative pain score in parturients receiving intravenous PCA with fentanyl after caesarean section.
KEYWORDS: caesarean delivery; ketamine; patient-controlled analgesia; preemptive analgesia; spinal anesthesia
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Anestesia y Medicina del Dolor

Medwave abril 2015

A continuación le informamos los artículos recientemente publicados en Medwave.


RESUMEN EPISTEMONIKOS

¿Es beneficiosa la profilaxis antibiótica en la pancreatitis aguda?: primera actualización
Gabriel Rada, José Peña (Chile)

Medwave 2015 Abr;15(3):e6125
http://dx.doi.org/10.5867/medwave.2015.03.6125


EDITORIAL
La evidencia y la región - ¿conversan o colisionan?
Vivienne C. Bachelet

Medwave 2015 Abr;15(3):e6127
http://dx.doi.org/10.5867/medwave.2015.03.6127


ESTUDIO PRIMARIO

Estudio transversal sobre tabaquismo y su relación con valores espirométricos en estudiantes de tercer año de medicina
Victor Hugo Fernández, Mariela Edith Beligoy, Yessica Vanesa Lima, Pablo Federico Barissi (Argentina)

Medwave 2015 Abr;15(3):e6124
http://dx.doi.org/10.5867/medwave.2015.03.6124


RESUMEN EPISTEMONIKOS

¿Debe indicarse acetilcisteína para prevenir la nefropatía por contraste?
Ariel Izcovich, Gabriel Rada (Argentina, Chile)

Medwave 2015 Abr;15(3):e6122
http://dx.doi.org/10.5867/medwave.2015.03.6122


ARTÍCULO DE REVISIÓN

Plantas latinoamericanas como fuente de nuevos antineoplásicos, situación actual y nuevas oportunidades contra el cáncer
Eduardo Freddy Orrego Escobar (Chile)

Medwave 2015 Abr;15(3):e6121
http://dx.doi.org/10.5867/medwave.2015.03.6121


PORTADA MEDWAVE
www.medwave.cl

Analgesia obstétrica con remifentanil / Labor analgesia with remifentanil

No.1953                                                                                   Abril 26, 2015
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.
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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.
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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
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Anestesia y Medicina del Dolor

Espacio peridural / Epidural space

No.1954                                                                                   Abril 27, 2015
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.
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Localización del Espacio Epidural mediante una variante del Signo de Gutiérrez.
DRA. LILIAN ELANIA OLEAS VIVAR
Tesis de Anestesiología
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Técnicas de identificación del espacio epidural
E. Figueredo
Rev. Esp. Anestesiol. Reanim. 2005; 52: 401-412
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La Gota de Lambertus para localizar el espacio epidural
Videoclip
Video
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Anestesia y Medicina del Dolor