Medwave

Cupos disponibles para curso Formulación y evaluación de proyectos en salud que se inicia el 02 de septiembre.

Mayor información en http://ecampus.medwave.cl/?page_id=761


Los últimos artículos publicados en Medwave son:


EDITORIAL

Resúmenes Epistemonikos en Medwave: evidencia confiable y amigable que llegó para quedarse
Gabriel Rada, Vivienne C. Bachelet (Chile)

Medwave 2015 Ago;15(7):e6232
http://dx.doi.org/10.5867/medwave.2015.6232


DEL EDITOR

Cuatro estados de ánimo del clínico basado en evidencia: lo que nos dejó el primer suplemento de resúmenes Epistemonikos
Gabriel Rada

Medwave 2015 Ago;15(7):e6237
http://www.medwave.cl/link.cgi/Medwave/Perspectivas/DelEditor/6237


RESÚMENES EPISTEMONIKOS


¿Noradrenalina o terlipresina para el síndrome hepatorrenal?
Pilar Celis, Gabriel Rada (Chile)

Medwave 2015 Ago;15(Suppl 2):e6232
http://dx.doi.org/10.5867/medwave.2015.6235


¿Cuál es el efecto de la combinación de suero hipertónico y furosemida en la insuficiencia cardiaca aguda?
Patricio Zepeda, Carmen Rain, Paola Sepúlveda (Chile)

Medwave 2015;15(Suppl 2):e6233
http://dx.doi.org/10.5867/medwave.2015.6233


¿Es útil agregar antivirales a los corticoides en la parálisis de Bell en adultos?
Benjamín Walbaum, Gabriel Rada (Chile)

Medwave 2015;15(Suppl 2):e6226
http://dx.doi.org/10.5867/medwave.2015.6226


Nuevo curso “Estadística descriptiva e introducción a la estadística inferencial aplicada a las ciencias de la salud” a realizarse entre el 14 de octubre y el 22 de enero de 2016.

Información detallada en http://ecampus.medwave.cl/?page_id=1288


Inscripciones abiertas para nuevo ciclo del curso de Prevención y control de infecciones asociadas a la atención en salud.

Información e inscripciones en http://ecampus.medwave.cl/?page_id=764


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Enfermedades autoinmunes y embarazo/Autoimmune diseases and pregnancy

Agosto 29, 2015. No. 2069

Enfermedades autoinmunes y embarazo. Análisis de una serie de casos Autoimmune diseases and pregnancy: analysis of a series of cases. Gomes V, Mesquita A, Capela C. BMC Res Notes. 2015 Jun 4;8:216. doi: 10.1186/s13104-015-1177-x. Abstract BACKGROUND: An autoimmune disease is characterized by tissue damage, caused by self-reactivity of different effector mechanisms of the immune system, namely antibodies and T cells. All autoimmune diseases, to some extent, have implications for fertility and obstetrics. Currently, due to available treatments and specialised care for pregnant women with autoimmune disease, the prognosis for both mother and child has improved significantly. However these pregnancies are always high risk. The purpose of this study is to analyse the fertility/pregnancy process of women with systemic and organ-specific autoimmune diseases and assess pathological and treatment implications. METHODS: The authors performed an analysis of the clinical records and relevant obstetric history of five patients representing five distinct autoimmune pathological scenarios, selected from Autoimmune Disease Consultation at the Hospital of Braga, and reviewed the literature. RESULTS: The five clinical cases are the following: Case 1-28 years old with systemic lupus erythematosus, and clinical remission of the disease, under medication with hydroxychloroquine, prednisolone and acetylsalicylic acid, with incomplete miscarriage at 7 weeks of gestation without signs of thrombosis. Case 2-44 years old with history of two late miscarriages, a single preterm delivery (33 weeks) and multiple thrombotic events over the years, was diagnosed with antiphospholipid syndrome after acute myocardial infarction. Case 3-31 years old with polymyositis, treated with azathioprine for 3 years with complete remission of the disease, took the informed decision to get pregnant after medical consultation and full weaning from azathioprine, and gave birth to a healthy term new-born. Case 4-38 years old pregnant woman developed Behcet's syndrome during the final 15 weeks of gestation and with disease exacerbation after delivery. Case 5-36 years old with autoimmune thyroiditis diagnosed during her first pregnancy, with difficult control over the thyroid function over the years and first trimester miscarriage, suffered a second miscarriage despite clinical stability and antibody regression. CONCLUSIONS: As described in literature, the authors found a strong association between autoimmune disease and obstetric complications, especially with systemic lupus erythematosus, antiphospholipid syndrome and autoimmune thyroiditis. PDF  Anticuerpos antifosfolípidos y syndrome antifosfolípido en el embarazo. Conceptos diagnósticos Antiphospholipid Antibodies and Antiphospholipid Syndrome during Pregnancy: Diagnostic Concepts. Levy RA, Dos Santos FC, de Jesús GR, de Jesús NR. Front Immunol. 2015 May 7;6:205. doi: 10.3389/fimmu.2015.00205. eCollection 2015. Abstract Antiphospholipid syndrome (APS) comprises of a wide spectrum of clinical and obstetric manifestations linked to the presence of antiphospholipid antibodies (aPL). APS was described in the context of lupus, and later as an isolated syndrome or primary APS. The presence of aPL, especially the lupus anticoagulant test, is associated with adverse pregnancy outcomes, such as fetal death, recurrent early miscarriages, pre-eclampsia, and placental insufficiency, but does not seem to influence infertility. High quality scientific data to support these associations, however, are lacking, and controversies arise about the definition of positive aPL (low vs medium-high titers) or even the definition of the adverse events. This review discusses APS classification criteria and the current debate about it. KEYWORDS: antiphospholipid antibodies; antiphospholipid syndrome; fetal death; recurrent early miscarriage PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015

Vía aérea difícil/Difficult airway

Agosto 27, 2015. No. 2067

La vía aérea difícil con recomendaciones para su manejo. Parte 1. Intubación traqueal difícil en el paciente inconsciente/inducido. The difficult airway with recommendations for management--part 1--difficult tracheal intubation encountered in an unconscious/induced patient. Law JA1, Broemling N, Cooper RM, Drolet P, Duggan LV, Griesdale DE, Hung OR, Jones PM, Kovacs G, Massey S, Morris IR, Mullen T, Murphy MF, Preston R, Naik VN, Scott J, Stacey S, Turkstra TP,Wong DT; Canadian Airway Focus Group. Can J Anaesth. 2013 Nov;60(11):1089-118. doi: 10.1007/s12630-013-0019-3. Epub 2013 Oct 17. Abstract BACKGROUND: Previously active in the mid-1990s, the Canadian Airway Focus Group (CAFG) studied the unanticipated difficult airway and made recommendations on management in a 1998 publication. The CAFG has since reconvened to examine more recent scientific literature on airway management. The Focus Group's mandate for this article was to arrive at updated practice recommendations for management of the unconscious/induced patient in whom difficult or failed tracheal intubation is encountered. METHODS: Nineteen clinicians with backgrounds in anesthesia, emergency medicine, and intensive care joined this iteration of the CAFG. Each member was assigned topics and conducted reviews of Medline, EMBASE, and Cochrane databases. Results were presented and discussed during multiple teleconferences and two face-to-face meetings. When appropriate, evidence- or consensus-based recommendations were made together with assigned levels of evidence modelled after previously published criteria. CONCLUSIONS: The clinician must be aware of the potential for harm to the patient that can occur with multiple attempts at tracheal intubation. This likelihood can be minimized by moving early from an unsuccessful primary intubation technique to an alternative "Plan B" technique if oxygenation by face mask or ventilation using a supraglottic device is non-problematic. Irrespective of the technique(s) used, failure to achieve successful tracheal intubation in a maximum of three attempts defines failed tracheal intubation and signals the need to engage an exit strategy. Failure to oxygenate by face mask or supraglottic device ventilation occurring in conjunction with failed tracheal intubation defines a failed oxygenation, "cannot intubate, cannot oxygenate" situation. Cricothyrotomy must then be undertaken without delay, although if not already tried, an expedited and concurrent attempt can be made to place a supraglottic device. PDF La vía aérea difícil con recomendaciones para su manejo. Parte 2. La VAD anticipada The difficult airway with recommendations for management--part 2--the anticipated difficult airway. Law JA, Broemling N, Cooper RM, Drolet P, Duggan LV, Griesdale DE, Hung OR, Jones PM, Kovacs G,Massey S, Morris IR, Mullen T, Murphy MF, Preston R, Naik VN, Scott J, Stacey S, Turkstra TP, Wong DT; Canadian Airway Focus Group. Can J Anaesth. 2013 Nov;60(11):1119-38. doi: 10.1007/s12630-013-0020-x. Epub 2013 Oct 17. Abstract BACKGROUND: Appropriate planning is crucial to avoid morbidity and mortality when difficulty is anticipated with airway management. Many guidelines developed by national societies have focused on management of difficulty encountered in the unconscious patient; however, little guidance appears in the literature on how best to approach the patient with an anticipated difficult airway. METHODS: To review this and other subjects, the Canadian Airway Focus Group (CAFG) was re-formed. With representation from anesthesiology, emergency medicine, and critical care, CAFG members were assigned topics for review. As literature reviews were completed, results were presented and discussed during teleconferences and two face-to-face meetings. When appropriate, evidence- or consensus-based recommendations were made, and levels of evidence were assigned. PRINCIPAL FINDINGS: Previously published predictors of difficult direct laryngoscopy are widely known. More recent studies report predictors of difficult face mask ventilation, video laryngoscopy, use of a supraglottic device, and cricothyrotomy. All are important facets of a complete airway evaluation and must be considered when difficulty is anticipated with airway management. Many studies now document the increasing patient morbidity that occurs with multiple attempts at tracheal intubation. Therefore, when difficulty is anticipated, tracheal intubation after induction of general anesthesia should be considered only when success with the chosen device(s) can be predicted in a maximum of three attempts. Concomitant predicted difficulty using oxygenation by face mask or supraglottic device ventilation as a fallback makes an awake approach advisable. Contextual issues, such as patient cooperation, availability of additional skilled help, and the clinician's experience, must also be considered in deciding the appropriate strategy. CONCLUSIONS: With an appropriate airway evaluation and consideration of relevant contextual issues, a rational decision can be made on whether an awake approach to tracheal intubation will maximize patient safety or if airway management can safely proceed after induction of general anesthesia. With predicted difficulty, close attention should be paid to details of implementing the chosen approach. This should include having a plan in case of the failure of tracheal intubation or patient oxygenation. PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015

Conoce las 5 enfermedades que se pueden mejorar con una cirugía bariátrica

Fuente
Este artículo es originalmente publicado en:
http://www.entornointeligente.com/articulo/6784812/CHILE-Conoce-las-5-enfermedades-que-se-pueden-mejorar-con-una-cirugiacute;a-bariaacute;trica-24082015

Conoce las 5 enfermedades que se pueden mejorar con una cirugía bariátrica


CHILE: Conoce las 5 enfermedades que se pueden mejorar con una cirugía bariátrica / Emol / La obesidad -que en Chile afecta a siete de cada diez mayores de 15 años, y a cuatro de cada diez niños- es una enfermedad que suele asociarse a un tema estético y de imagen. Sin embargo, quizás más importante aún es que se trata de un mal que puede afectar fuertemente la calidad y la esperanza de vida, ya que impacta en el funcionamiento del cuerpo, dando origen a una serie de problemas de salud.

Concretamente, cinco son las enfermedades que puede presentar una persona obesa:

1.- Diabetes tipo 2: mal crónico que se caracteriza por altos niveles de azúcar en sangre. Es de lento desarrollo y aunque afecta a personas con obesidad o sobrepeso, también puede presentarse en personas delgadas.

2.- Hígado graso: consiste en la acumulación excesiva de grasa en las células del hígado. No produce síntomas, de ahí que sea considerada una enfermedad "silenciosa". Por esta razón, muchos pacientes que la padecen pueden llegar a presentar hepatitis, fibrosis y hasta cirrosis.

3.- Síndrome de apnea del sueño: es un trastorno común, en el que la persona hace una o más pausas en la respiración durante el dormir. Sus consecuencias son diversas y van desde tener un sueño de mala calidad, hasta aumentar el riesgo de sufrir hipertensión arterial, infarto cardíaco, accidente cerebrovascular, etc.

4.- Hipertensión arterial: patología crónica que consiste en el aumento de la presión arterial. Su síntoma principal es la cefalea, aunque no siempre se da en todas las personas. Es una enfermedad controlable, pero si no es tratada a tiempo puede derivar en complicaciones graves.

5.- Problemas osteoarticulares: involucran el deterioro y disfunción del sistema óseo y articular del cuerpo. Tiene dos síntomas principales: dolor y dificultad para el funcionamiento de alguna articulación. Es importante tratarlos, ya que de lo contrario acarrean disfuncionalidad en la vida del paciente.

Cirugía bariátrica, la solución

"Es importante que el paciente con obesidad sea evaluado por un profesional, para definir si algunas de estas enfermedades ya están presentes; de ser así, es fundamental realizar un tratamiento", explica Jorge León, médico del Programa de Obesidad y Diabetes de la Clínica de la Universidad de Los Andes.

En este sentido, la mejor opción la tiene la denominada cirugía bariátrica, la cual mejora y puede llegar a eliminar estas patologías, transformando considerablemente la calidad de vida de quienes las sufren.

La cirugía bariátrica contempla varias técnicas, de las cuales las de mayor uso actualmente son la gastrectomía vertical, conocida como manga gástrica, y el bypass gástrico. Ambos procedimientos se hacen por vía laparoscópica, es decir pequeñas incisiones en la pared abdominal que permite una rápida recuperación general del paciente.

Cada técnica tiene que indicarse de acuerdo a las características del paciente y deben ser discutidas en un grupo multidisciplinario dedicado a la obesidad.

Después de una cirugía bariátrica, los cuidados más importantes son:

1.- Seguir la pauta de alimentación entregada.

2.- Hacer la vida en pie, no mantenerse en cama, pero sin realizar actividad física ni levantar pesos.

3.- Tomar los medicamentos prescritos por el médico.

4.- Realizar los controles indicados.

5.- Mantener contacto con el médico ante cualquier problema en su evolución.

Con Información de Emol

www.entornointeligente.com

Medwave. Agosto 2015

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Puede ver aquí la Guía de Orientación para Autores en el Envío de su Manuscrito: http://www.medwave.cl/link.cgi/FAQ-autores.act y las Normas de Publicación Medwave aquí:http://www.medwave.cl/medios/Editorial/DocsPolsEdit/Normas%20de%20Publicacion%20Medwave.pdf


Ultimos días para inscripción en el Diplomado en gestión y protocolización de los cuidados. Inicio 26 de agosto. Información en http://ecampus.medwave.cl/?page_id=770


Los últimos artículos publicados en Medwave son:

RESÚMENES EPISTEMONIKOS

¿Es útil agregar antivirales a los corticoides en la parálisis de Bell en adultos?
Benjamín Walbaum, Gabriel Rada (Chile)

Medwave 2015;15(Suppl 2):e6226
http://dx.doi.org/10.5867/medwave.2015.6226


¿Uso de dosis altas de corticoides inhalados o adicionar teofilina en pacientes con asma no controlada?
Pilar Celis, Gabriel Rada (Chile)

Medwave2015;15(Suppl 2):e6224
http://dx.doi.org/10.5867/medwave.2015.6224


¿Es el cierre percutáneo de la orejuela de la aurícula izquierda comparable al tratamiento anticoagulante en fibrilación auricular?
Thomas Uslar, Jaime Anabalón (Chile)

Medwave 2015;15(Suppl 2):e6218
http://dx.doi.org/10.5867/medwave.2015.6218


¿Es efectivo el rituximab para inducir remisión en las vasculitis asociadas a ANCA?
Carmen Rain, Tatiana Yañez, Gabriel Rada (Chile)

Medwave 2015;15(Suppl 2):e6209
http://dx.doi.org/10.5867/medwave.2015.6209


¿Debemos agregar vancomicina en polvo a la profilaxis antibiótica en cirugía de columna? - Primera actualización
Mario López, Marcelo Molina (Chile)

Medwave 2015; 15(Suppl 2):e6202
http://dx.doi.org/10.5867/medwave.2015.6202


Curso próximo a iniciarse 02 de septiembre: Formulación y evaluación de proyectos en salud. Mayor información en http://ecampus.medwave.cl/?page_id=761


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Intubacion con paciente despierto/Awake intubation

La anestesia tópica de la vía aérea es mandatoria para realizar la intubación con paciente despierto y por lo general se lleva a cabo con lidocaína tópica en aerosol, sin vasoconstrictores. El propósito principal de esta "topicalización" es tener un paciente que tolere el uso de un dispositivo para la vía oral que facilite la intubación traqueal. La intubación nasal requiere topicalización adicional de las vías nasales en combinación con un vasoconstrictor. La mayoría de los anestesiólogos usan sedación cuidadosa cuando se lleva a cabo intubación con paciente despierto.   Topical anesthesia of the airway is a required to perform awake intubation and is typically accomplished with topical lidocaine in spray, without vasoconstrictors. The main purpose of this "topicalization" is to have a patient accepting the use of an oral airway used to facilitate awake oral intubation. Nasal intubation requires additional topicalization of the nasal ways in combination with a vasoconstrictor. Most anesthesiologist use cautious sedation when awake intubation is carried out. Intubación con paciente despierto usando el laringoscopio (Pentax airway scope) en 30 pacientes. Awake tracheal intubation using Pentax airway scope in 30 patients: A Case series. Kajekar P, Mendonca C, Danha R, Hillermann C. Indian J Anaesth. 2014 Jul;58(4):447-51. doi: 10.4103/0019-5049.138987. Abstract BACKGROUND AND AIMS: Pentax airway scope (AWS) has been successfully used for managing difficult intubations. In this case series, we aimed to evaluate the success rate and time taken to complete intubation, when AWS was used for awake tracheal intubation. METHODS: We prospectively evaluated the use of AWS for awake tracheal intubation in 30 patients. Indication for awake intubation, intubation time, total time to complete tracheal intubation, laryngoscopic view (Cormack and Lehane grade), total dose of local anaesthetic used, anaesthetists rating and patient's tolerance of the procedure were recorded. RESULTS: The procedure was successful in 25 out of the 30 patients (83%). The mean (standard deviation) intubation time and total time to complete the tracheal intubation was 5.4 (2.4) and 13.9 (3.7) min, respectively in successful cases. The laryngeal view was grade 1 in 24 and grade 2 in one of 25 successful intubations. In three out of the five patients where the AWS failed, awake tracheal intubation was successfully completed with the assistance of flexible fibre optic scope (FOS). CONCLUSION: Awake tracheal intubation using AWS was successful in 83% of patients. Success rate can be further improved using a combination of AWS and FOS. Anaesthesiologists who do not routinely use FOS may find AWS easier to use for awake tracheal intubation using an oral route. KEYWORDS: Awake fibreoptic intubation; awake intubation; pentax airway scope; video laryngoscope PDF Preparación para realizar intubación fibroscópica con paciente despierto Preparing to perform an awake fiberoptic intubation. Walsh ME, Shorten GD. Yale J Biol Med. 1998 Nov-Dec;71(6):537-49. Abstract Fiberoptically guided tracheal intubation represents one of the most important advances in airway management to occur in the past thirty years. Perhaps its most important role is in management of the anticipated difficult airway. This is a situation in which the dangers of encountering the life-threatening "can't intubate, can't ventilate" situation can be avoided by placement of an endotracheal tube while the patient is awake. Although skill at the procedure of endoscopy is obviously necessary in this setting, these authors hold that success or failure of the technique frequently depends on the adequacy of preparation. These measures include 1) pre-operative assessment of the patient; 2) careful explanation of what lies in store; 3) "setting the stage"; 4) preparing the equipment to be used; and 5) preparing the patient (antisialogue, sedation, application of topical anesthesia to the upper airway). If these preparatory measures are carried out meticulously, the likelihood of performing a successful and comfortable awake fiberoptic tracheal intubation is greatly increased. PDF  Inserción con paciente despierto  del fibroscopio Bonfil retromolar en 5 pacientes con vía aérea difícil Awake insertion of the Bonfils Retromolar Intubation Fiberscope in five patients with anticipated difficult airways. Abramson S, Holmes AA, Hagberg CA. Anesth Analg. 2008 Apr;106(4):1215-7, table of contents. doi: 10.1213/ane.0b013e318167cc7c. Abstract Traditionally, an awake intubation is performed by flexible fiberoptic laryngoscopy. However, many new devices have been developed to assist anesthesiologists with both routine and difficult airway management, one of which is the Bonfils Retromolar Intubation Fiberscope. This device may be more beneficial than the flexible fiberoptic laryngoscope since it can readily navigate through soft tissue and physically lift airway structures, is more affordable, durable, and easier to clean. This case series demonstrates successful use of the Bonfils Scope in five patients for awake orotracheal intubation with anticipated difficult airways. PDF   Manejo urgente de la vía aérea en un caso con fibrodisplasia osificante progresiva Emergent airway management in a case of fibrodysplasia ossificans progressiva. Parekh UR1, Read S1, Desai V2, Budde AO1. J Anaesthesiol Clin Pharmacol. 2014 Oct;30(4):565-7. doi: 10.4103/0970-9185.142865. Abstract Fibrodysplasia ossificans progressiva (FOP), or Stone man syndrome, is rare and one of the most disabling genetic conditions of the connective tissue due to progressive extraskeletal ossification. It usually presents in the first decade of life as painful inflammatory swellings, either spontaneously or in response to trauma, which later ossify and lead to severe disability. Progressive spinal deformity including thoracolumbar kyphoscoliosis leads to thoracic insufficiency syndrome, increasing the risk for pneumonia and right sided heart failure. We present the airway management in a 22-year-old male, diagnosed with FOP with severe disability, who required urgent airway intervention as a result of respiratory failure from pnuemonia. Tracheostomy triggers ossification and consequent airway obstruction at the tracheostomy site and laryngoscopy triggers temporomandibular joint ankylosis. Therefore, awake fiber-optic endotracheal intubation is recommended in these patients. Use of an airway endoscopy mask enabled us to simultaneously maintain non-invasive ventilation and intubate the patient in a situation where tracheostomy needed to be avoided. KEYWORDS: Airway endoscopy mask; airway management; fibrodysplasia ossificans progressiva PDF Dexmedetomidina para intubación con paciente despierto en una parturienta con síndrome de Klippel-Feil y malformación de Arnold Chiari tipo I Dexmedetomidine for an awake fiber-optic intubation of a parturient with Klippel-Feil syndrome, Type I Arnold Chiari malformation and status post released tethered spinal cord presenting for repeat cesarean section. Shah TH, Badve MS, Olajide KO, Skorupan HM, Waters JH, Vallejo MC. Clin Pract. 2011 Jul 1;1(3):e57. doi: 10.4081/cp.2011.e57. eCollection 2011. Abstract Patients with Klippel-Feil Syndrome (KFS) have congenital fusion of their cervical vertebrae due to a failure in the normal segmentation of the cervical vertebrae during the early weeks of gestation and also have myriad of other associated anomalies. Because of limited neck mobility, airway management in these patients can be a challenge for the anesthesiologist. We describe a unique case in which a dexmedetomidine infusion was used as sedation for an awake fiber-optic intubation in a parturient with Klippel-Feil Syndrome, who presented for elective cesarean delivery. A 36-year-old female, G2P1A0 with KFS (fusion of cervical vertebrae) who had prior cesarean section for breech presentation with difficult airway management was scheduled for repeat cesarean delivery. After obtaining an informed consent, patient was taken in the operating room and non-invasive monitors were applied. Dexmedetomidine infusion was started and after adequate sedation, an awake fiber-optic intubation was performed. General anesthetic was administered after intubation and dexmedetomidine infusion was continued on maintenance dose until extubation. Klippel-Feil Syndrome (KFS) is a rare congenital disorder for which the true incidence is unknown, which makes it even rare to see a parturient with this disease. Patients with KFS usually have other congenital abnormalities as well, sometimes including the whole thoraco-lumbar spine (Type III) precluding the use of neuraxial anesthesia for these patients. Obstetric patients with KFS can present unique challenges in administering anesthesia and analgesia, primarily as it relates to the airway and dexmedetomidine infusion has shown promising result to manage the airway through awake fiberoptic intubation without any adverse effects on mother and fetus. KEYWORDS: Klippel-Feil syndrome; awake fiberoptic intubation; cesarean section.; dexmedetomidine PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015