sábado, 11 de julio de 2015

Hipotermia perioperatoria/Perioperative hypothermia

Prevención de hipotermia perioperatoria inadvertida
Preventing inadvertent perioperative hypothermia.
Torossian A1, Bräuer A, Höcker J, Bein B, Wulf H, Horn EP.
Dtsch Arztebl Int. 2015 Mar 6;112(10):166-72. doi: 10.3238/arztebl.2015.0166.
Abstract
BACKGROUND: 25-90% of all patients undergoing elective surgery suffer from inadvertent postoperative hypothermia, i.e., a core body temperature below 36°C. Compared to normothermic patients, these patients have more frequent wound infections (relative risk [RR] 3.25, 95% confidence interval [CI] 1.35-7.84), cardiac complications (RR 4.49, 95% CI 1.00-20.16), and blood transfusions (RR 1.33, 95% CI 1.06-1.66). Hypothermic patients feel uncomfortable, and shivering raises oxygen consumption by about 40%. METHODS: This guideline is based on a systematic review of the literature up to and including October 2012 and a further one from November 2012 to August 2014. The recommendations were developed and agreed upon by representatives of five medical specialty societies in a structured consensus process. RESULTS: The patient's core temperature should be measured 1-2 hours before the start of anesthesia, and either continuously or every 15 minutes during surgery. Depending on the nature of the operation, the site of temperature measurement should be oral, naso-/oropharyngeal, esophageal, vesical, or tympanic (direct). The patient should be actively prewarmed 20-30 minutes before surgery to counteract the decline in temperature. Prewarmed patients must be actively warmed intraoperatively as well if the planned duration of anesthesia is longer than 60 minutes (without prewarming, 30 minutes). The ambient temperature in the operating room should be at least 21°C for adult patients and at least 24°C for children. Infusions and blood transfusions that are given at rates of >500 mL/h should be warmed first. Perioperatively, the largest possible area of the body surface should be thermally insulated. Emergence from general anesthesia should take place at normal body temperature. Postoperativehypothermia, if present, should be treated by the administration of convective or conductive heat until normothermia is achieved. Shivering can be treated with medications.
CONCLUSION: Inadvertent perioperative hypothermia can adversely affect the outcome of surgery and the patient's postoperative course. It should be actively prevented.
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Medición de temperatura perioperatoria y manejo: ir más allá del proyecto de mejoramiento de cuidado quirúrgico
Perioperative temperature measurement and management: moving beyond the Surgical Care Improvement Project. Joshua W, Sappenfield, Caron M. Hong and Samuel M.
Journal of Anesthesiology & Clinical Science 2012
Abstract
Intraoperative management of patient body temperature is a standard of care for practicing anesthesiologists. Merely complying with the Surgical Care Improvement Project (SCIP) measurement is inadequate for optimizing perioperative outcomes. Clinicians should have a sound understanding of available temperature monitoring sites, deleterious effects of hypothermia, and indications for therapeutic hypothermia. This foundation will help physicians use indicated modalities to improve patient outcomes throughout the perioperative period. The purpose of this paper is to review appropriate intraoperative temperature monitoring, the importance of maintaining normothermia, and indications for intraoperative hypothermia.
Hipotermia perioperatoria en pacientes pediátricos. Diagnóstico, prevención y manejo
Perioperative hypothermia in pediatric patients: diagnosis, prevention and management
Bajwa SJS and Swati.
Anaesth Pain & Intensive Care 2014;18(1):97-100
ABSTRACT
Hipothermia is the most common perioperative disturbance in pediatric patients. Pediatric patients are highly vulnerable to hypothermia and its associated complications, e.g. respiratory embarrassment, metabolic acidosis, hypoglycemia, hypoxemia, cardiac disturbances, coagulopathy, and a higher incidence of wound infection etc. This higher vulnerability is mainly due to increased heat loss from larger head size, thin skin, lack of subcutaneous pad of fat and limited ability of compensatory thermogenesis from brown fat. As such it is mandatory to design appropriate diagnostic, preventive and therapeutic strategies which can effectively protect pediatric population from the potential catastrophic complications associated with hypothermia during perioperative period. The current review aims to refresh the basic mechanism of hypothermia and discussion of evidence based management strategies to minimize the incidence of hypothermia in pediatric patients. Key words: Perioperative, Hypothermia, Thermoregulation, Thermogenesis
PDF
Atentamente
Anestesia y Medicina del Dolor

Hipotermia perioperatoria/Perioperative hypothermia

Prevención de hipotermia perioperatoria inadvertida
Preventing inadvertent perioperative hypothermia.
Torossian A1, Bräuer A, Höcker J, Bein B, Wulf H, Horn EP.
Dtsch Arztebl Int. 2015 Mar 6;112(10):166-72. doi: 10.3238/arztebl.2015.0166.
Abstract
BACKGROUND: 25-90% of all patients undergoing elective surgery suffer from inadvertent postoperative hypothermia, i.e., a core body temperature below 36°C. Compared to normothermic patients, these patients have more frequent wound infections (relative risk [RR] 3.25, 95% confidence interval [CI] 1.35-7.84), cardiac complications (RR 4.49, 95% CI 1.00-20.16), and blood transfusions (RR 1.33, 95% CI 1.06-1.66). Hypothermic patients feel uncomfortable, and shivering raises oxygen consumption by about 40%. METHODS: This guideline is based on a systematic review of the literature up to and including October 2012 and a further one from November 2012 to August 2014. The recommendations were developed and agreed upon by representatives of five medical specialty societies in a structured consensus process. RESULTS: The patient's core temperature should be measured 1-2 hours before the start of anesthesia, and either continuously or every 15 minutes during surgery. Depending on the nature of the operation, the site of temperature measurement should be oral, naso-/oropharyngeal, esophageal, vesical, or tympanic (direct). The patient should be actively prewarmed 20-30 minutes before surgery to counteract the decline in temperature. Prewarmed patients must be actively warmed intraoperatively as well if the planned duration of anesthesia is longer than 60 minutes (without prewarming, 30 minutes). The ambient temperature in the operating room should be at least 21°C for adult patients and at least 24°C for children. Infusions and blood transfusions that are given at rates of >500 mL/h should be warmed first. Perioperatively, the largest possible area of the body surface should be thermally insulated. Emergence from general anesthesia should take place at normal body temperature. Postoperativehypothermia, if present, should be treated by the administration of convective or conductive heat until normothermia is achieved. Shivering can be treated with medications.
CONCLUSION: Inadvertent perioperative hypothermia can adversely affect the outcome of surgery and the patient's postoperative course. It should be actively prevented.
PDF
Medición de temperatura perioperatoria y manejo: ir más allá del proyecto de mejoramiento de cuidado quirúrgico
Perioperative temperature measurement and management: moving beyond the Surgical Care Improvement Project. Joshua W, Sappenfield, Caron M. Hong and Samuel M.
Journal of Anesthesiology & Clinical Science 2012
Abstract
Intraoperative management of patient body temperature is a standard of care for practicing anesthesiologists. Merely complying with the Surgical Care Improvement Project (SCIP) measurement is inadequate for optimizing perioperative outcomes. Clinicians should have a sound understanding of available temperature monitoring sites, deleterious effects of hypothermia, and indications for therapeutic hypothermia. This foundation will help physicians use indicated modalities to improve patient outcomes throughout the perioperative period. The purpose of this paper is to review appropriate intraoperative temperature monitoring, the importance of maintaining normothermia, and indications for intraoperative hypothermia.
Hipotermia perioperatoria en pacientes pediátricos. Diagnóstico, prevención y manejo
Perioperative hypothermia in pediatric patients: diagnosis, prevention and management
Bajwa SJS and Swati.
Anaesth Pain & Intensive Care 2014;18(1):97-100
ABSTRACT
Hipothermia is the most common perioperative disturbance in pediatric patients. Pediatric patients are highly vulnerable to hypothermia and its associated complications, e.g. respiratory embarrassment, metabolic acidosis, hypoglycemia, hypoxemia, cardiac disturbances, coagulopathy, and a higher incidence of wound infection etc. This higher vulnerability is mainly due to increased heat loss from larger head size, thin skin, lack of subcutaneous pad of fat and limited ability of compensatory thermogenesis from brown fat. As such it is mandatory to design appropriate diagnostic, preventive and therapeutic strategies which can effectively protect pediatric population from the potential catastrophic complications associated with hypothermia during perioperative period. The current review aims to refresh the basic mechanism of hypothermia and discussion of evidence based management strategies to minimize the incidence of hypothermia in pediatric patients. Key words: Perioperative, Hypothermia, Thermoregulation, Thermogenesis
PDF
Atentamente
Anestesia y Medicina del Dolor

Raquia en niños/Spinal anesthesia in pediatrics

Anestesia espinal para infantes y niños. Una auditoría prospectiva de un año.
Spinal anesthesia in infants and children: A one year prospective audit.
Anesth Essays Res. 2014 Sep-Dec;8(3):324-9. doi: 10.4103/0259-1162.143124.
Abstract
CONTEXT AND AIMS: Spinal anesthesia though gaining popularity in children, the misconceptions regarding its safety and feasibility can be better known with greater use and experience. The objective of this study was to evaluate the success rate, complications and hemodynamic stability related to pediatric spinal anesthesia. MATERIALS AND METHODS: In this 1-year prospective study, 102 pediatric patients aged 6 months to 14 years undergoing infraumbilical and lower extremity surgery were included. Spinal anesthesia was administered using hyperbaric bupivacaine 0.5% in a dose of 0.5 mg/kg (for child < 5 kg), 0.4 mg/kg (for 5-15 kg), 0.3 mg/kg (for >15 kg) in L4-L5 space under all aseptic precautions after sedation. Demographic data, vital parameters, supplemental sedation, number of attempts for lumbar puncture, sensory-motor block characteristics, and complications were noted. RESULTS: Spinal anesthesia was successful in 98 (97.1%) patients. Remaining 4 (3.9%) were failures and were given general anesthesia. Lumbar puncture was successful in first attempt (60 [58.82%]) or 2(nd) attempt (42 [41.18%]). There was no significant change in vital parameters. Mean peak sensory level was T 6.35 ± 1.20 (T4-T8). Mean sensory level at the end of surgery was T 8.11 ± 1.42 (T6-T10). Modified Bromage score was 3 in 98 (96.08%) patients. Sensory and motor block recovery was complete in all patients. Mean time to two segment regression was 43.97 ± 10.72 (30-70) min. Mean time to return Bromage score to 0 was 111.95 ± 20.54 (70-160). Mean duration of surgery was 52.5 ± 16.056 (25-95) min. Incidence of complications was minimal with hypotension occurring in 2 (2%) and shivering in 3 (2.9%) patients. CONCLUSION: Pediatric spinal anesthesia is a safe and effective anesthetic technique for lower abdominal and lower limb surgeries of shorter duration (<90 min) with high success rate. Owing to, its early motor recovery, it can be a preferred technique for day case surgeries in the pediatric population.
KEYWORDS: Complications; hemodynamics; infants; infraumbilical; spinal anesthesia; success rate
Atentamente
Anestesia y Medicina del Dolor

viernes, 10 de julio de 2015

Neuropatía dolorosa diabética aguda

Neuropatía dolorosa diabética aguda. Una forma rara, remitente de neuropatía aguda distal de fibras pequeñas
Acute painful diabetic neuropathy: an uncommon, remittent type of acute distal small fibre neuropathy.
Tran C, Philippe J, Ochsner F, Kuntzer T, Truffert A.
Swiss Med Wkly. 2015 May 5;145:w14131. doi: 10.4414/smw.2015.14131. eCollection 2015.
Abstract
INTRODUCTION: Acute painful diabetic neuropathy (APDN) is a distinctive diabetic polyneuropathy and consists of two subtypes: treatment-inducedneuropathy (TIN) and diabetic neuropathic cachexia (DNC). The characteristics of APDN are (1.) the small-fibre involvement, (2.) occurrence paradoxically after short-term achievement of good glycaemia control, (3.) intense pain sensation and (4.) eventual recovery. In the face of current recommendations to achieve quickly glycaemic targets, it appears necessary to recognise and understand this neuropathy. METHODS AND RESULTS: Over 2009 to 2012, we reported four cases of APDN. Four patients (three males and one female) were identified and had a mean age at onset of TIN of 47.7 years (±6.99 years). Mean baseline HbA1c was 14.2% (±1.42) and 7.0% (±3.60) after treatment. Mean estimated time to correct HbA1c was 4.5 months (±3.82 months). Three patients presented with a mean time to symptom resolution of 12.7 months (±1.15 months). One patient had an initial normal electroneuromyogram (ENMG) despite the presence of neuropathic symptoms, and a second abnormal ENMG showing axonal and myelin neuropathy. One patient had a peroneal nerve biopsy showing loss of large myelinated fibres as well as unmyelinated fibres, and signs of microangiopathy. CONCLUSIONS: According to the current recommendations of promptly achieving glycaemic targets, it appears necessary to recognise and understand this neuropathy. Based on our observations and data from the literature we propose an algorithmic approach for differential diagnosis and therapeutic management of APDN patients.
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Anestesia y Medicina del Dolor

Crean en México un guante que traduce el lenguaje de los sordomudos

Fuente
Este artículo es originalmente publicado en:
http://www.madrimasd.org/informacionidi/noticias/noticia.asp?id=64171&origen=notiweb&dia_suplemento=martes

Crean en México un guante que traduce el lenguaje de los sordomudos

Investigadores del Instituto Politécnico Nacional (IPN) mexicano desarrollaron un guante que traduce a texto y sonidos el lenguaje de los sordomudos para facilitar que puedan transmitir mensajes a personas que desconocen los signos, informó la institución educativa en un comunicado.

FUENTE | Agencia EFE

Bloqueos nerviosos periféricos/Peripheral nerve blocks

¿Cuáles bloqueos nerviosos periféricos deben de ser incluidos en los programas de residencia?
Which types of peripheral nerve blocks should be included in residency training programs?
BMC Anesthesiol. 2015 Mar 12;15:32. doi: 10.1186/s12871-015-0001-4. eCollection 2015.
Abstract
BACKGROUND: Despite the increasing use of regional anesthesia, specific recommendations regarding the type of procedures to be included in residency training programs are not currently available. We aimed to determine the nerve block techniques that practicing Chilean anesthesiologists perceived as essential to master during residency training. METHODS: After institutional ethics committee approval, an online survey was sent to 154 anesthesiologists that graduated between 2005-2012, from the two largest university residency programs in Chile. Multiple-choice questions elicited responses concerning the use of regional anesthesia. RESULTS: A total of 109 questionnaires were completed, which corresponded to a response rate of 70.8%. Almost all (98.2%) of the respondents used regional anesthesia in their clinical practice, 86.7% regularly performed peripheral nerve blocks (PNBs) and 51% used continuous PNB techniques. Residency programs represented their primary source of training. The most common PNB techniques performed were interscalene (100%), femoral (98%), popliteal sciatic (93%), and Bier block (90%). Respondents indicated that they were most confident performing femoral (98%), Bier block (90%), interscalene (90%), and popliteal sciatic (85%) blocks. The PNBs perceived as essential for their actual clinical practice were femoral (81%), interscalene (80%), popliteal sciatic (76%), and Bier blocks (62%). CONCLUSIONS: Requesting information from former anesthesiology residents may be a source of information, guiding the specific types of PNBs that should be included in residency training. Other groups can easily replicate this methodology to create their own evidence and clinical practice based guidelines for residency training programs.
KEYWORDS: Medical education; Peripheral nerve blocks; Survey

Atentamente
Anestesia y Medicina del Dolor

Un nuevo fármaco activado con luz mata solo las células cancerosas




Fuente
Este artículo es originalmente publicado en:
http://www.madrimasd.org/informacionidi/noticias/noticia.asp?id=64215

Un nuevo fármaco activado con luz mata solo las células cancerosas


Una nueva técnica que emplea la luz para activar fármacos contra el cáncer solo allí donde se necesita muestra un excelente potencial para mejorar la efectividad de la quimioterapia -con la que se trata a millones de personas con tumores- y reducir sus efectos secundarios. La técnica, conocida como optofarmacología, consiste en modificar moléculas anticancerosas de tal manera que solo funcionen cuando reciben un rayo de luz azul, según anuncia un equipo de científicos dirigidos por el bioquímico Oliver Thorn-Seshold, de la Universidad de Múnich (Alemania).

FUENTE | El País Digital

Hospitalización innecesaria, Enfoque Bioético

Estimado Pediatra te invito al Seminario de Pediatría, Cirugía Pediátrica y Lactancia Materna. El día 15 de Julio 2015 las 21hrs (Centro, México DF, Guadalajara y Lima Perú) a la Conferencia: “Hospitalización innecesaria, Enfoque Bioético” por el “Dr. Adalberto Vázquez García”, Pediatra Bioeticista de la Cd de Guadalajara, Jal. La sesión inicia puntualmente las 21 hrs.
Para entrar a la Sala de Conferencia:
1.- hacer click en la siguiente liga, o cópiala y escríbela en tu buscador http://connectpro60196372.adobeconnect.com/hospitalizacion_innecesaria/
2.- “Entra como Invitado” Escribes tu nombre y apellido en el espacio en blanco
3.- Hacer click en el espacio que dice “Entrar en la Sala”
5.- A disfrutar la conferencia
6.- Recomendamos que dejes tu Nombre Completo, Correo electrónico y que participes.

Henrys


Dr. Enrique Mendoza López
Webmaster: CONAPEME
Coordinador Nacional: Seminario Ciberpeds-Conapeme
Av La clinica 2520-310
Colonia Sertoma ,Mty N.L. México
CP 64710
Tel-Fax 52 81 83482940 y 52 81 81146053
Celular 8183094806
www.conapeme.org
www.pediatramendoza.com
enrique@pediatramendoza.com
emendozal@yahoo.com.mx

miércoles, 8 de julio de 2015

Año global contra el dolor neuropático

Año global contra el dolor neuropático
PAIN Global Year Against Neuropathic Pain
Global Year Against Neuropathic Pain: Articles from 2015 on the topic of Neuropathic Pain and the top 50 most cited articles from past issues on the topic
PAIN Journal of IASP
Atentamente
Anestesia y Medicina del Dolor

lunes, 6 de julio de 2015

Sepsis

Desarrollo de una fórmula predictiva de mortalidad por sepsis/sepsis severa en la UCI
Development of a mortality prediction formula due to sepsis/severe sepsis in a medical intensive care unit.
Mohan A, Shrestha P, Guleria R, Pandey RM, Wig N.
Lung India 2015;32:313-9
Abstract
Background: Although sepsis is one of the leading causes of mortality in hospitalized patients, information regarding early predictive factors for mortality and morbidity is limited. Materials and Methods: Patients fulfilling the Infectious Disease Society of America criteria of sepsis within the medical intensive care unit (ICU) were included over two years. Apart from baseline hematological, biochemical, and metabolic parameters, Acute Physiology and Chronic Health Evaluation II (APACHE II), Simplified Acute Physiology Score II and III (SAPS II and SAPS III), and Sequential Organ Function Assessment (SOFA) scores were calculated on day 1 of admission. Patients were followed till death or discharge from the ICU. Results: One hundred patients were enrolled over two years (54% males). The overall mortality was 53%, (69.5% in females, 38.8% in males (P < 0.01). Mortality was 65.7%, 55.7%, and 33.3% in patients with septic shock, severe sepsis, and sepsis, respectively. Patients who died were significantly older than the survivors (mean age, 57.37 ± 20.42 years and 44.29 ± 15.53 years respectively, P < 0.01). Nonsurvivors were significantly more anemic and had higher APACHE II, SAPS II, SAPS III, and SOFA scores. The presence of acute respiratory distress syndrome and renal dysfunction were associated with higher mortality (75% and 70.2%, respectively). There was no significant difference in the duration of mechanical ventilation or ICU stay between survivors and nonsurvivors. On multivariate analysis, significant predictors of mortality with odds ratio greater than 2 included the presence of anemia, SAPS II score greater than 35, SAPS III score greater than 47, and SOFA score greater than 6 at day 1 of admission. Conclusion: Several demographic and laboratory parameters as well as composite critical illness scoring systems are reliable early predictors of mortality in sepsis. A sepsis mortality prediction formula (AIIMS Sepsis Score) based on SAPS II, SAPS III, and SOFA scores and hemoglobin has greater predictive power than these scoring methods individually. Routine use of critical illness scoring systems and a composite mortality prediction formula may provide useful early prognostic information in sepsis/severe sepsis.
Keywords: Mortality, scoring, sepsis
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Métodos moleculares convencionales y moléculas biomarcadores en la detección de la septicemia.
Conventional, molecular methods and biomarkers molecules in detection of septicemia.
Arabestani MR, Rastiany S, Kazemi S, Mousavi SM.
Adv Biomed Res 2015;4:120
Abstract
Sepsis is a leading cause of morbidity and mortality in hospitalized patients worldwide and based on studies, 30-40% of all cases of severe sepsis and septic shock results from the blood stream infections (BSIs). Identifying of the disease, performing laboratory tests, and consequently treatment are factors that required for optimum management of BSIs. In addition, applying precise and immediate identification of the etiologic agent is a prerequisite for specific antibiotic therapy of pathogen and thereby decreasing mortality rates. The diagnosis of sepsis is difficult because clinical signs of sepsis often overlap with other noninfectious cases of systemic inflammation. BSIs are usually diagnosed by performing a series of techniques such as blood cultures, polymerase chain reaction-based methods, and biomarkers of sepsis. Extremely time-consuming even to take up to several days is a major limitation of conventional methods. In addition, yielding false-negative results due to fastidious and slow-growing microorganisms and also in case of antibiotic pretreated samples are other limitations. In comparison, molecular methods are capable of examining a blood sample obtained from suspicious patient with BSI and gave the all required information to prescribing antimicrobial therapy for detected bacterial or fungal infections immediately. Because of an emergency of sepsis, new methods are being developed. In this review, we discussed about the most important sepsis diagnostic methods and numbered the advantage and disadvantage of the methods in detail.
Keywords: Biomarkers, blood-culture, molecular methods, sepsis
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Valor pronóstico de la procalcitonina en adultos sépticos. Revisión sistemática y meta-análisis
Prognostic Value of Procalcitonin in Adult Patients with Sepsis: A Systematic Review and Meta-Analysis.
Liu D, Su L, Han G, Yan P, Xie L.
PLoS One. 2015 Jun 15;10(6):e0129450. doi: 10.1371/journal.pone.0129450. eCollection 2015.Abstract
Procalcitonin (PCT) has been widely investigated for its prognostic value in septic patients. However, studies have produced conflicting results. The purpose of the present meta-analysis is to explore the diagnostic accuracy of a single PCT concentration and PCT non-clearance in predicting all-cause sepsis mortality. We searched PubMed, Embase, Web of Knowledge and the Cochrane Library. Articles written in English were included. A 2 × 2 contingency table was constructed based on all-cause mortality and PCT level or PCT non-clearance in septic patients. Two authors independently evaluated study eligibility and extracted data. The diagnostic value of PCT in predicting prognosis was determined using a bivariate meta-analysis model. We used the Q-test and I2 index to test heterogeneity. Twenty-three studies with 3,994 patients were included. An elevated PCT level was associated with a higher risk of death. The pooled relative risk (RR) was 2.60 (95% confidence interval (CI), 2.05-3.30) using a random-effects model (I2 = 63.5%). The overall area under the summary receiver operator characteristic (SROC) curve was 0.77 (95% CI, 0.73-0.80), with a sensitivity and specificity of 0.76 (95% CI, 0.67-0.82) and 0.64 (95% CI, 0.52-0.74), respectively. There was significant evidence of heterogeneity for the PCT testing time (P = 0.020). Initial PCT values were of limited prognostic value in patients with sepsis. PCT non-clearance was a prognostic factor of death in patients with sepsis. The pooled RR was 3.05 (95% CI, 2.35-3.95) using a fixed-effects model (I2 = 37.9%). The overall area under the SROC curve was 0.79 (95% CI, 0.75-0.83), with a sensitivity and specificity of 0.72 (95% CI, 0.58-0.82) and 0.77 (95% CI, 0.55-0.90), respectively. Elevated PCT concentrations and PCT non-clearance are strongly associated with all-cause mortality in septic patients. Further studies are needed to define the optimal cut-off point and the optimal definition of PCT non-clearance for accurate risk assessment.
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Atentamente
Anestesia y Medicina del Dolor

El funcionamiento de la anestesia continúa siendo un misterio

#anestesia

Fuente
Este artículo es originalmente publicado en:
http://www.madrimasd.org/informacionidi/noticias/noticia.asp?id=64157
El funcionamiento de la anestesia continúa siendo un misterio
El origen de la anestesia moderna tuvo lugar hace más de 150 años en un circo de Boston. Hoy, a pesar de emplearse millones de veces cada día, su mecanismo de acción permanece desconocido y las teorías generales que pretendían explicarla han caído recientemente. Los expertos reclaman mayor investigación para mejorar el cuidado de los pacientes.

FUENTE | SINC