Hiperglicemia en neurocirugía

Control perioperatorio de la glicemia en neurocirugía


Perioperative glucose control in neurosurgical patients.
Godoy DA, Di Napoli M, Biestro A, Lenhardt R.
Neurocritical Care Unit, Sanatorio Pasteur, Catamarca, Argentina.
Anesthesiol Res Pract. 2012;2012:690362. Epub 2012 Feb 13.
Abstract
Many neurosurgery patients may have unrecognized diabetes or may develop stress-related hyperglycemia in the perioperative period. Diabetes patients have a higher perioperative risk of complications and have longer hospital stays than individuals without diabetes. Maintenance of euglycemia using intensive insulin therapy (IIT) continues to be investigated as a therapeutic tool to decrease morbidity and mortality associated with derangements in glucose metabolism due to surgery. Suboptimal perioperative glucose control may contribute to increased morbidity, mortality, and aggravate concomitant illnesses. The challenge is to minimize the effects of metabolic derangements on surgical outcomes, reduce blood glucose excursions, and prevent hypoglycemia. Differences in cerebral versus systemic glucose metabolism, time course of cerebral response to injury, and heterogeneity of pathophysiology in the neurosurgical patient populations are important to consider in evaluating the risks and benefits of IIT. While extremes of glucose levels are to be avoided, there are little data to support an optimal blood glucose level or recommend a specific use of IIT for euglycemia maintenance in the perioperative management of neurosurgical patients. Individualized treatment should be based on the local level of blood glucose control, outpatient treatment regimen, presence of complications, nature of the surgical procedure, and type of anesthesia administered
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3286889/pdf/ARP2012-690362.pdf


http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3286889/

Una revisión del control glicémico perioperatorio en la población neuroquirúrgica


A review of perioperative glucose control in the neurosurgical population.
Atkins JH, Smith DS.
Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA. atkinsj@uphs.upenn.edu
J Diabetes Sci Technol. 2009 Nov 1;3(6):1352-64.
Abstract
Significant fluctuations in serum glucose levels accompany the stress response of surgery or acute injury and may be associated with vascular or neurologic morbidity. Maintenance of euglycemia with intensive insulin therapy (IIT) continues to be investigated as a therapeutic intervention to decrease morbidity associated with derangements in glucose metabolism. Hypoglycemia is a common side effect of IIT with potential for significant morbidity, especially in the neurologically injured patient. Differences in cerebral versus systemic glucose metabolism, the time course of cerebral response to injury, and heterogeneity of pathophysiology in neurosurgical patient populations are important to consider in evaluating the risks and benefits of IIT. While extremes of glucose levels are to be avoided, there are little data to support specific use of IIT for maintenance of euglycemia in the perioperative management of neurosurgical patients. Existing data are summarized and reviewed in this context.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2787035/pdf/dst-03-1352.pdf

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2787035/

Control de la glicemia en el periodo perioperatorio


Blood glucose control in the perioperative period.
Kadoi Y.
Department of Anesthesiology, Gunma University Hospital, Japan. kadoi@med.gunma-u.ac.jp
Minerva Anestesiol. 2012 May;78(5):574-95. Epub 2012 Feb 10.
Abstract
Extensive data have shown that acute hyperglycemia is commonly present in the perioperative period among patients undergoing surgery or with critical illness, and a direct relationship between perioperative hyperglycemia and mortality has been established. An outstanding trial by Van den Berghe showed that intensive insulin therapy (IIT) (target blood glucose, 80-110 mg/dL) reduced in-hospital mortality. However, recent large trials have questioned the efficacy and safety of IIT and raised concerns about increased mortality rates due to hypoglycemia. This review focused on how anesthetic agents and techniques, fluid management and preoperative oral intake would affect glucose metabolism and insulin resistance, in addition to recent controversial effects of IIT on improved mortality rate. Anesthesiologists should pay attention not only to the efficacy and risks of IIT during the perioperative period, but also to effects of fluid management, anesthetic agents and techniques during anesthesia on glucose homeostasis.
http://www.minervamedica.it/en/journals/minerva-anestesiologica/article.php?cod=R02Y2012N05A0574
http://www.minervamedica.it/en/getfreepdf/dtCF%252Bp%252BS9HFmEiXyJJ7%252F7Z%252B2x5wzoQVc61Tb%252BD%252FuCao6iK0CjGHl%252FEcAvMzQ0TkOE3q%252BwakrlnsgDxt41SOlDQ%253D%253D/R02Y2012N05A0574.pdf




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Anestesiología y Medicina del Dolor
www.anestesia-dolor.org

Tumescencia en quemaduras

Infiltración tumescente de lidocaína y adrenalina para cirugía de quemaduras


Tumescent infiltration of lidocaine and adrenaline for burn surgery.
Gümüs N.
Plastic, Reconstructive and Aesthetic Surgery Department, Cumhuriyet University Medical Faculty, Sivas, Turkeya.
Ann Burns Fire Disasters. 2011 Sep 30;24(3):144-8.



Abstract
Tumescent infiltration is a widely used type of regional anaesthesia for cutaneous surgery. This technique makes it possible to administer high doses of lidocaine and adrenaline within the safety limits, leading to reduction in pain and bleeding during the operation. In this study, tumescent infiltration of lidocaine and adrenaline was used in routine procedures of burn surgery such as escharectomy, debridement, tangential excision, and skin grafting. In 17 patients with scald and flame burns, tumescent infiltration was performed prior to surgical procedures under either general anaesthesia or intravenous sedation. After 15 minutes, escharectomy, debridement of necrotic tissues, tangential excision of the burned skin, removal of the granulation tissue, and harvesting of the skin graft were performed. No complications occurred. All vital signs remained within safety limits during the operations. Haemorrhage was minimal and the operations were thus performed easily and rapidly. During removal of granulation tissue, very little blood loss occurred so that both the excision of granulation tissue and skin grafting were accomplished rapidly because of the minimal need of severe haemostasis. The duration of surgery was considerably reduced. No haematoma or bruising developed after surgery. No blood transfusions were required as the decline in haematocrit levels was not more than 3%. Postoperative analgesia was excellent for the first 8 h, eliminating the need of additional measures. Tumescent infiltration of adrenaline and lidocaine is a simple, effective and safe technique which facilitates anaesthesia in large areas of the burned body surface and leads to less bleeding and easy surgical dissection and hydrodissection, allowing fast, easy and painless burn surgery.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3293232/pdf/Ann-Burns-and-Fire-Disasters-24-144.pdf





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Anestesiología y Medicina del Dolor
www.anestesia-dolor.org

Anafilaxia perioperatoria

Anafilaxia perioperatoria

Peri-operative anaphylaxis.
Nel L, Eren E.
Department of Anaesthetics, Southampton University Hospitals NHS Trust, Tremona Road, Southampton, United Kingdom.
Br J Clin Pharmacol. 2011 May;71(5):647-58. doi: 10.1111/j.1365-2125.2011.03913.x.
Abstract
Peri-operative anaphylaxis is an important cause for mortality and morbidity associated with anaesthesia. The true incidence is unknown and is most likely under reported. Diagnosis can be difficult, particularly as a number of drugs are given simultaneously and any of these agents can potentially cause anaphylaxis. This review covers the clinical features, differential diagnosis and management of anaphylaxis associated with anaesthesia. The investigations to confirm the clinical suspicion of anaphylaxis and further tests to identify the likely drug(s) are examined. Finally the salient features of common and rare causes including non-drug substances are described.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3093071/pdf/bcp0071-0647.pdf


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Anestesiología y Medicina del Dolor
www.anestesia-dolor.org

Revisión de drogas: Dolor neuropático: Actualización final

Revisión de drogas: Dolor neuropático: Actualización final


Drug Class Review: Neuropathic Pain: Final Update 1 Report [Internet].
Editors
Selph S, Carson S, Fu R, Thakurta S, Low A, McDonagh M.
Portland (OR): Oregon Health & Science University; 2011 Jun.
Drug Class Reviews.
Excerpt
PURPOSE: We compared the effectiveness and harms of anticonvulsants, tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors (SNRIs), and the lidocaine patchin adults with neuropathic pain. DATA SOURCES: To identify published studies, we searched MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, and reference lists of included studies. We also searched the US Food and Drug Administration Center for Drug Evaluation and Research website for additional unpublished data and dossiers of information submitted by 5 pharmaceutical manufacturers. REVIEW METHODS: Study selection, data abstraction, validity assessment, grading the strength of the evidence, and data synthesis were all carried out according to standard Drug Effectiveness Review Project review methods. RESULTS AND CONCLUSIONS: Overall, the strength of evidence evaluating the comparative benefits or harms of these drugs to treat neuropathic pain was low to moderate. Based on a small number of short-term trials directly comparing the drugs in patients with painful diabetic neuropathy and postherpetic neuralgia, the evidence did not support a statistically significant difference in response (50% reduction in pain) or withdrawal due to adverse events with gabapentin, pregabalin, and lamotrigine compared with tricyclic antidepressants. Oralpregabalin was similar to lidocaine 5% medicated patchin rate of response, but resulted in more patients withdrawing due to an adverse event. Adjusted indirect comparisons of placebo-controlled trials suggested that duloxetine, pregabalin, and gabapentin were superior to lacosamide and lamotrigine, but no difference in withdrawal from study due to adverse events was found. In these analyses, differences were not found between pregabalin, duloxetine, and gabapentin or comparisons of 5% lidocaine patch and amitriptyline or gabapentin. Tricyclic antidepressants caused more dry mouth than pregabalin or gabapentin while gabapentin and pregabalin resulted in higher rates of ataxia. In patients with cancer-related neuropathic pain who were taking opioids, there was no difference in pain relief with low-dose gabapentin compared with low-dose imipramine. Monotherapy with either drug was insufficient for pain relief. In patients with spinal cord injury, gabapentin was more effective for pain relief than amitriptyline. The difference was significant only in the subgroup of patients with the highest levels of depression. In patients with central poststroke pain, there was no difference between amitriptyline and carbamazepine. There was no direct evidence in patients with HIV-associated neuropathic pain, multiple sclerosis, complex regional pain syndrome, postmastectomy pain syndrome, phantom limb pain, or traumatic nerve injury pain. Evidence for comparative effectiveness in patients with types of neuropathic pain other than diabetic or postherpetic was insufficient to assess comparative safety. Post hoc analyses have not found older age to have an impact on response or treatment-emergent adverse events with duloxetine. Combination therapy with duloxetine and pregabalin; lidocaine patch and pregabalin; or gabapentin with imipramine, nortriptyline, or venlafaxine may have had a potential benefit compared with monotherapy, but there was an increased risk of adverse events.


http://www.ncbi.nlm.nih.gov/books/NBK61823/pdf/TOC.pdf



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Anestesiología y Medicina del Dolor
www.anestesia-dolor.org

Tratamiento de dolor agudo en niños

Tratamiento de dolor agudo en niños
Acute pain management in children.
Verghese ST, Hannallah RS.
The George Washington University Medical Center, Division of Anesthesiology, Children's National Medical Center, Washington, DC, USA.
J Pain Res. 2010 Jul 15;3:105-23.
Abstract
The greatest advance in pediatric pain medicine is the recognition that untreated pain is a significant cause of morbidity and even mortality after surgical trauma. Accurate assessment of pain in different age groups and the effective treatment of postoperative pain is constantly being refined; with newer drugs being used alone or in combination with other drugs continues to be explored. Several advances in developmental neurobiology and pharmacology, knowledge of new analgesics and newer applications of old analgesics in the last two decades have helped the pediatric anesthesiologist in managing pain in children more efficiently. The latter include administering opioids via the skin and nasal mucosa and their addition into the neuraxial local anesthetics. Systemic opioids, nonsteroidal anti-inflammatory agents and regional analgesics alone or combined with additives are currently used to provide effective postoperative analgesia. These modalities are best utilized when combined as a multimodal approach to treat acute pain in the perioperative setting. The development of receptor specific drugs that can produce pain relief without the untoward side effects of respiratory depression will hasten the recovery and discharge of children after surgery. This review focuses on the overview of acute pain management in children, with an emphasis on pharmacological and regional anesthesia in achieving this goal
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3004641/pdf/jpr-3-105.pdf


Atentamente
Dr. Enrique Hernández-Cortez
Anestesiología y Medicina del Dolor
www.anestesia-dolor.org

Evaluación médica preoperatoria: parte 1; principios generales y consideraciones cardiovasculares

Evaluación médica preoperatoria: parte 1; principios generales y consideraciones cardiovasculares


Preoperative medical evaluation: part 1: general principles and cardiovascular considerations.
Becker DE.
Sinclair Community College, Dayton, OH 45402, USA.Dan.Becker@sinclair.edu
Anesth Prog. 2009 Autumn;56(3):92-102.
Abstract
A thorough assessment of a patient's medical status is standard practice when dental care is provided. Although this is true for procedures performed under local anesthesia alone, the information gathered may be viewed somewhat differently if the dentist is planning to use sedation or general anesthesia as an adjunct to dental treatment. This article is the first of a 2-part sequence and will address general principles and cardiovascular considerations. A second article will address pulmonary, metabolic, and miscellaneous disorders.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2749585/pdf/i0003-3006-56-3-92.pdf





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Anestesiología y Medicina del Dolor
www.anestesia-dolor.org

Analgesia preventiva

Analgesia preventiva. Efecto de dosis pequeña de ketamina sobre los requerimientos de morfina después de cirugía renal


Preventive analgesia: Effect of small dose of ketamine on morphine requirement after renal surgery.
Parikh B, Maliwad J, Shah VR.
Department of Anaesthesia and Critical Care, Institute of Kidney Diseases and Research Centre, Ahmedabad, Gujarat, India.
J Anaesthesiol Clin Pharmacol. 2011 Oct;27(4):485-8.
Abstract
BACKGROUND: N-methyl D-Aspartate (NMDA) receptors seem to be responsible for pain memory and their blockade can contribute significantly in prevention of pain. This study was conducted to evaluate the preventive effect of small dose of ketamine, a NMDA receptor blocker, given before skin incision in renal surgery, with the aim to compare analgesic efficacy, intra operative and post-operative side effects.MATERIALS AND METHODS: In a prospective double-blind study, 60 American Society of Anesthesiologists (ASA) risk I and II adult patients scheduled for elective open renal surgeries by flank incision were randomly divided in two groups. Ketamine group (group K) received ketamine 0.15 mg/kg intravenously, 30 minute before start of surgery followed by infusion of ketamine 2 mcg/kg/min till start of skin closure. Control group (group C) received normal saline in place of ketamine. Both groups received morphine 0.15 mg/ kg i.v. at the time of skin closure. The analgesic efficacy was judged by visual analogue scale (VAS) at rest and on movement, time to first analgesic and morphine consumption in 24 hours. Opioid or ketamine related side effects were also recorded. RESULTS: Patients in ketamine group had significantly lower VAS score, longer time to first analgesic (21.6 ± 0.12 Vs 3.8 ± 0.7 hrs), and lower morphine consumption (5.8 ± 1.48 Vs 18.1 ± 1.6 mg) in 24 hours. There were no demonstrable side effects related to ketamine in group K whereas incidence of nausea and vomiting was higher in group C. CONCLUSION: Our results demonstrate that small dose of ketamine decreases post-operative pain, reduces morphine consumption, and delays patients request for analgesia beyond the clinical duration of action of ketamine after open renal surgery.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3214553/?tool=pubmed


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Anestesiología y Medicina del Dolor
www.anestesia-dolor.org

Analgesia preventiva en niños

Comparación del efecto de analgesia preventiva con ketamina rectal y acetaminofen rectal después de amigdalectomía pediátrica


Comparison of the Preventive Analgesic Effect of Rectal Ketamine and Rectal Acetaminophen after Pediatric Tonsillectomy.
Heidari SM, Mirlohi SZ, Hashemi SJ.
Department of Anesthesiology and Intensive Care, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
Int J Prev Med. 2012 Mar;3(Suppl1):S150-S155.
Abstract
OBJECTIVES: There is a little data about rectal administration of Ketamine as a postoperative analgesic, so we compared the efficacy of rectal ketamine with rectal acetaminophen, which is applied routinely for analgesia after painful surgeries like tonsillectomy.METHODS: In this single-blinded comparative trial, we enrolled 70 children undergoing elective tonsillectomy, and divided them randomly in two groups. Patients received rectal ketamine (2 mg / kg) or rectal acetaminophen (20 mg / kg) at the end of surgery. The children's Hospital of Eastern Ontario Pain scale was used to estimate pain in children. Also the vital signs, Wilson sedation scale, and side effects in each group were noted and compared for 24 hours. RESULTS: The ketamine group had a lower pain score at 15 minutes and 60 minutes after surgery in Recovery (6.4 ± 0.8, 7.4 ± 1 vs. 7.1 ± 1.2, 7.8 ± 1.2 in the acetaminophen group, P < 0.05) and one hour and two hours in the ward (7.2 ± 0.7, 7 ± 0.5 vs. 7.9 ± 1.2, 7.5 ± 1.2 in the acetaminophen group, P < 0.05), with no significant differences till 24 hours. Dreams and hallucinations were not reported in the ketamine group. Systolic blood pressure was seen to be higher in the ketamine group (104.4 ± 7.9 vs. 99.8 ± 7.7 in the acetaminophen group) and nystagmus was reported only in the ketamine group (14.2%). Other side effects were equivalent in both the groups. CONCLUSIONS: With low complications, rectal ketamine has analgesic effects, especially in the first hours after surgery in comparison with acetaminophen, and it can be an alternative analgesic with easy administration in children after tonsillectomy.


http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3399302/?tool=pubmed



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Dr. Enrique Hernández-Cortez
Anestesiología y Medicina del Dolor
www.anestesia-dolor.org

Mas sobre aminas y shock séptico

Estudio comparativo entre dopamina y norepinefrina en el manejo del shock séptico

Comparative study of dopamine and norepinephrine in the management of septic shock.
Agrawal A, Gupta A, Consul S, Shastri P.
Department of Internal Medicine, Chattrapati Shahuji Maharaj Medical University, Lucknow, Uttar Pradesh, India.
Saudi J Anaesth. 2011 Apr;5(2):162-6.
Abstract
The objective was to compare the ability of norepinephrine and dopamine in reversing the hemodynamic and metabolic abnormalities of septic shock using Edwards Vigileo Monitor with Flotrac Sensor. DESIGN: Prospective randomized control study.METHODS: Fifty consecutive patients presenting with hyperdynamic septic shock who fulfilled the inclusion criteria were randomly allocated to either group I or group II. The goal of therapy was to achieve and maintain for 6 hours, all of the following - systolic blood pressure (SBP) >90 mmHg, systemic vascular resistance index (SVRI) >1800 dynes.s/cm(5)m(2), cardiac index (CI) >4.0 lt/min/m(2), index of oxygen delivery >550 ml/min/m(2), index of oxygen uptake >150 ml/min/m(2). The patients in group I were started on dopamine infusion at 10 μg/kg/min which was increased by 2.5 μg/kg/min, every 15 minutes till the goals were achieved. The patients in group II received norepinephrine infusion started at a dose of 0.5 μg/kg/min with a dose increment of 0.25 μg/kg/min, every 15 minutes till the goals were achieved. RESULTS: Post-treatment heart rate showed an increase in the mean value in group I patients and a decrease in group II patients. The post-treatment mean SBP and SVRI in group II was significantly higher than that in group I. Patients in group I showed a significantly higher increase in post-treatment CI and index of oxygen delivery compared to patients in group II. Nineteen out of 25 patients responded to the treatment in group II while only 10 out of 25 responded in group I. CONCLUSION: Norepinephrine was more useful in reversing the hemodynamic and metabolic abnormalities of hyperdynamic septic shock compared to dopamine.
http://www.saudija.org/temp/SaudiJAnaesh52162-4405277_121412.pdf


http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3139308/


Comparación entre fenilefrina y norepinefrina en el tratamiento de shock séptico resistente a dopamina
Comparison of phenylephrine and norepinephrine in the management of dopamine-resistant septic shock.
Jain G, Singh DK.
Department of Anesthesia, Banaras Hindi University, Varanasi, U.P., India.
Indian J Crit Care Med. 2010 Jan;14(1):29-34.

Abstract
INTRODUCTION: THIS STUDY AIMS TO COMPARE TWO VASOCONSTRICTORS: - norepinephrine and phenylephrine - in the management of dopamine-resistant septic shock. MATERIALS AND METHODS: We performed a randomized, prospective, controlled trial in 54 septic shock patients, with persistent hypotension despite adequate volume resuscitation and continued dopamine infusion ~25mug/kg/h. Patients were randomly allocated into two groups to receive either norepinephrine or phenylephrine infusion (n = 27 each) titrated to achieve a target of SBP > 90mm Hg, MAP > 75 mm Hg, SVRI > 1100 dynes.s/cm5m2, CI > 2.8 L/min/m2, DO2I > 550 ml/min/m2, and VO2I > 150 ml/min/m2 for continuous 6 h. All the parameters were recorded every 30 min and increment in dose of studied drug was done in the specified dose range if targets were not achieved. Data from pulmonary arterial and hepatic vein catheterization, thermodilution catheter, blood gas analysis, blood lactate levels, invasive blood pressure, and oxygen transport variables were compared with baseline values after achieving the targets of therapy. Differences within and between groups were analyzed using a one-way analysis of variance test and Fischer's exact test. RESULTS: No difference was observed in any of the investigated parameters except for statistically significant reduction of heart rate (HR) (P<0.001) and increase in stroke volume index (SVI) (P<0.001) in phenylephrine group as compared to nonsignificant change in norepinephrine group. CONCLUSIONS: Phenylephrine infusion is comparable to norepinephrine in reversing hemodynamic and metabolic abnormalities of sepsis patients, with an additional benefit of decrease in HR and improvement in SVI.

http://www.ijccm.org/article.asp?issn=0972-5229;year=2010;volume=14;issue=1;spage=29;epage=34;aulast=Jain


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Dr. Juan Carlos Flores-Carrillo
Anestesiología y Medicina del Dolor
www.anestesia-dolor.org

Anestesia materna, procedimientos y dolor fetal

Anestesia/analgesia fetal y materna para procedimientos fetales


Fetal and maternal analgesia/anesthesia for fetal procedures.
Van de Velde M, De Buck F.
Department of Anesthesiology, University Hospitals Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium.
Fetal Diagn Ther. 2012;31(4):201-9. Epub 2012 Apr 25.

Abstract
For many prenatally diagnosed conditions, treatment is possible before birth. These fetal procedures can range from minimal invasive punctions to full open fetal surgery. Providing anesthesia for these procedures is a challenge, where care has to be taken for both mother and fetus. There are specific physiologic changes that occur with pregnancy that have an impact on the anesthetic management of the mother. When providing maternal anesthesia, there is also an impact on the fetus, with concerns for potential negative side effects of the anesthetic regimen used. The question whether the fetus is capable of feeling pain is difficult to answer, but there are indications that nociceptive stimuli have a physiologic reaction. This nociceptive stimulation of the fetus also has the potential for longer-term effects, so there is a need for fetal analgesic treatment. The extent to which a fetus is influenced by the maternal anesthesia depends on the type of anesthesia, with different needs for extra fetal anesthesia or analgesia. When providing fetal anesthesia, the potential negative consequences have to be balanced against the intended benefits of blocking the physiologic fetal responses to nociceptive stimulation
http://content.karger.com/produktedb/produkte.asp?DOI=000338146&typ=pdf


Dolor fetal: revisión sistemática multidisciplinaria de las evidencias


Fetal pain: a systematic multidisciplinary review of the evidence.
Lee SJ, Ralston HJ, Drey EA, Partridge JC, Rosen MA.
School of Medicine, Department of Anatomy, University of California, San Francisco, CA 94143-0648, USA.
JAMA. 2005 Aug 24;294(8):947-54.
Abstract
CONTEXT: Proposed federal legislation would require physicians to inform women seeking abortions at 20 or more weeks after fertilization that the fetus feels pain and to offer anesthesia administered directly to the fetus. This article examines whether a fetus feels pain and if so, whether safe and effective techniques exist for providing direct fetal anesthesia or analgesia in the context of therapeutic procedures or abortion. EVIDENCE ACQUISITION: Systematic search of PubMed for English-language articles focusing on human studies related to fetal pain, anesthesia, and analgesia. Included articles studied fetuses of less than 30 weeks' gestational age or specifically addressed fetal pain perception or nociception. Articles were reviewed for additional references. The search was performed without date limitations and was current as of June 6, 2005. EVIDENCE SYNTHESIS: Pain perception requires conscious recognition or awareness of a noxious stimulus. Neither withdrawal reflexes nor hormonal stress responses to invasive procedures prove the existence of fetal pain, because they can be elicited by nonpainful stimuli and occur without conscious cortical processing. Fetal awareness of noxious stimuli requires functional thalamocortical connections. Thalamocortical fibers begin appearing between 23 to 30 weeks' gestational age, while electroencephalography suggests the capacity for functional pain perception in preterm neonates probably does not exist before 29 or 30 weeks. For fetal surgery, women may receive general anesthesia and/or analgesics intended for placental transfer, and parenteral opioids may be administered to the fetus under direct or sonographic visualization. In these circumstances, administration of anesthesia and analgesia serves purposes unrelated to reduction of fetal pain, including inhibition of fetal movement, prevention of fetal hormonal stress responses, and induction of uterine atony. CONCLUSIONS: Evidence regarding the capacity for fetal pain is limited but indicates that fetal perception of pain is unlikely before the third trimester. Little or no evidence addresses the effectiveness of direct fetal anesthetic or analgesic techniques. Similarly, limited or no data exist on the safety of such techniques for pregnant women in the context of abortion. Anesthetic techniques currently used during fetal surgery are not directly applicable to abortion procedures
http://jama.jamanetwork.com/article.aspx?articleid=201429


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Anestesiología y Medicina del Dolor
www.anestesia-dolor.org

Pregabalina en dolor agudo y crónico

Pregabalina en dolor agudo y crónico
Pregabalin in acute and chronic pain.

Baidya DK, Agarwal A, Khanna P, Arora MK.

Department of Anaesthesia and Intensive Care, All India Institute of Medical Sciences, New Delhi, India.

Baidya DK, Agarwal A, Khanna P, Arora MK. Pregabalin in acute and chronic pain.


J J Anaesthesiol Clin Pharmacol. 2011 Jul;27(3):307-14.



Abstract

Pregabalin is a gamma-amino-butyric acid analog shown to be effective in several models of neuropathic pain, incisional injury, and inflammatory injury. In this review, the role of pregabalin in acute postoperative pain and in chronic pain syndromes has been discussed. Multimodal perioperative analgesia with the use of gabapentinoids has become common. Based on available evidence from randomized controlled trials and meta-analysis, the perioperative administration of pregabalin reduces opioid consumption and opioid-related adverse effects in the first 24 h following surgery. Postoperative pain intensity is however not consistently reduced by pregabalin. Adverse effects like visual disturbance, sedation, dizziness, and headache are associated with higher doses. The advantage of the perioperative use of pregabalin is so far limited to laparoscopic, gynecological, and daycare surgeries which are not very painful. The role of the perioperative administration of pregabalin in preventing chronic pain following surgery, its efficacy in more painful surgeries and surgeries done under regional anesthesia, and the optimal dosage and duration of perioperative pregabalin need to be studied. The efficacy of pregabalin in chronic pain conditions like painful diabetic neuropathy, postherpetic neuralgia, central neuropathic pain, and fibromyalgia has been demonstrated.


http://www.joacp.org/text.asp?2011/27/3/307/83672


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Anestesiología y Medicina del Dolor


www.anestesia-dolor.org

Dolor y cerebro: especificidad y plasticidad del cerebro en dolor crónico clínico

Dolor y cerebro: especificidad y plasticidad del cerebro en dolor crónico clínico


Pain and the brain: Specificity and plasticity of the brain in clinical chronic pain
A.V. Apkarian, J.A. Hashmi, and M.N. Baliki
Department of Physiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, 60611. Departments of Anesthesia, Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, 60611
Pain. 2011 March ; 152(3 Suppl): S49-S64. doi:10.1016/j.pain.2010.11.010.


We review recent advances in brain imaging in humans, concentrating on advances in our understanding of the human brain in clinical chronic pain. Understanding regarding anatomical and functional reorganization of the brain in chronic pain is emphasized. We conclude by proposing a brain model for the transition of the human from acute to chronic pain.
Keywords: fMRI, VBM, brain activity, brain reorganization, acute pain, chronic pain


http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3045648/pdf/nihms259049.pdf

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3045648/?tool=pubmed



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Anestesiología y Medicina del Dolor
www.anestesia-dolor.org

El síndrome metabólico, el estrés oxidativo, el medio ambiente, y la enfermedad cardiovascular: la gran exploración

El síndrome metabólico, el estrés oxidativo, el medio ambiente, y la enfermedad cardiovascular: la gran exploración


The Metabolic Syndrome, Oxidative Stress, Environment, and Cardiovascular Disease: The Great Exploration
Rebecca Hutcheson and Petra Rocic
Department of Biochemistry and Molecular Biology, College of Medicine, University of South Alabama, 307 North University Boulevard, Mobile, AL 36688, USA
Experimental Diabetes Research Volume 2012 (2012),

Article ID 271028, 13 pages
doi:10.1155/2012/271028


The metabolic syndrome affects 30% of the US population with increasing prevalence. In this paper, we explore the relationship between the metabolic syndrome and the incidence and severity of cardiovascular disease in general and coronary artery disease (CAD) in particular. Furthermore, we look at the impact of metabolic syndrome on outcomes of coronary revascularization therapies including CABG, PTCA, and coronary collateral development. We also examine the association between the metabolic syndrome and its individual component pathologies and oxidative stress. Related, we explore the interaction between the main external sources of oxidative stress, cigarette smoke and air pollution, and metabolic syndrome and the effect of this interaction on CAD. We discuss the apparent lack of positive effect of antioxidants on cardiovascular outcomes in large clinical trials with emphasis on some of the limitations of these trials. Finally, we present evidence for successful use of antioxidant properties of pharmacological agents, including metformin, statins, angiotensin II type I receptor blockers (ARBs), and angiotensin II converting enzyme (ACE) inhibitors, for prevention and treatment of the cardiovascular complications of the metabolic syndrome.
http://www.hindawi.com/journals/edr/2012/271028/





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Cardiomiopatía periparto. Revisión de la literatura

Cardiomiopatía periparto. Revisión de la literatura  Peripartum cardiomyopathy: review of the literature. Bhakta P, Biswas BK, Banerjee B. Department of Anesthesiology, Barnes-Jewish Hospital South, Washington University School of Medicine, 660 S Euclid Avenue, St. Louis, MO, USA. Yonsei Med J. 2007 Oct 31;48(5):731-47. Abstract Peripartum cardiomyopathy (PPCM) is a rare but serious form of cardiac failure affecting women in the last months of pregnancy or early puerperium. Clinical presentation of PPCM is similar to that of systolic heart failure from any cause, and it can sometimes be complicated by a high incidence of thromboembolism. Prior to the availability of echocardiography, diagnosis was based only on clinical findings. Recently, inclusion of echocardiography has made diagnosis of PPCM easier and more accurate. Its etiopathogenesis is still poorly understood, but recent evidence supports inflammation, viral infection and autoimmunity as the leading causative hypotheses. Prompt recognition with institution of intensive treatment by a multidisciplinary team is a prerequisite for improved outcome. Conventional treatment consists of diuretics, beta blockers, vasodilators, and sometimes digoxin and anticoagulants, usually in combination. In resistant cases, newer therapeutic modalities such as immunomodulation, immunoglobulin and immunosuppression may be considered. Cardiac transplantation may be necessary in patients not responding to conventional and newer therapeutic strategies. The role of the anesthesiologist is important in perioperative and intensive care management. Prognosis is highly related to reversal of ventricular dysfunction. Compared to historically higher mortality rates, recent reports describe better outcome, probably because of advances in medical care. Based on current information, future pregnancy is usually not recommended in patients who fail to recover heart function. This article aims to provide a comprehensive updated review of PPCM covering etiopathogeneses, clinical presentation and diagnosis, as well as pharmacological, perioperative and intensive care management and prognosis, while stressing areas that require further research http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2628138/pdf/ymj-48-731.pdf

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Trombosis venosa profunda, TEP en viajeros

La TVP y la TEP son entidades de muy alto riesgo en algunos procedimientos quirúrgicos. Los pacientes que viajan más de 6 horas en avión, en especial si tienen factores de riesgo, pueden ser candidatos para desarrollar esta temida complicación. Este creciente grupo de pacientes-viajeros requiere de una vigilancia especial antes, durante y después de cirugía. Deep vein thrombosis and pulmonary embolism are high-risk conditions in some surgeries. People who travel by plane more than 6 hours, especially if they have risk factors, may be able to develop this feared complication. This growing group of patients-travelers requiring special vigilance before, during, and after surgery. Trombosis relacionada a los viajes. ¿Es un problema? Travel-related thrombosis: is this a problem? Brenner B. Thrombosis and Hemostasis Unit, Department of Hematology and Bone Marrow Transplantation, Rambam Medical Center and Rappaport Faculty of Medicine, Technion-lsrael Institute of Technology, Haifa, Israel. Isr Med Assoc J. 2006 Dec;8(12):859-61. http://www.ima.org.il/imaj/dynamic/web/ArtFromPubmed.asp?year=2006&month=12&page=859   Meta-análisis: viajes y riesgo de tromboembolismo  Meta-analysis: travel and risk for venous thromboembolism. Chandra D, Parisini E, Mozaffarian D. Harvard School of Public Health, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts 02115, USA. Ann Intern Med. 2009 Aug 4;151(3):180-90. Epub 2009 Jul 6. BACKGROUND: Abstract. The potential risk for travel-related venous thromboembolism (VTE) has become an important public health concern because of rapid increases in long-distance travel; however, previous studies on this relationship are surprisingly contradictory. PURPOSE: To estimate the risk for VTE in travelers, determine whether a dose-response relationship exists, and identify reasons for the contradictory results of previous studies. DATA SOURCES: MEDLINE, EMBASE, BIOSIS, CINAHL, grey-literature sources, contact with investigators, and reference lists of studies, without language restrictions. STUDY SELECTION: Reports were selected if they investigated the association between travel and VTE for persons who used any mode of transportation and if nontraveling persons were included for comparison. DATA EXTRACTION:  Data on study and patient characteristics, risk estimates, and quality were independently extracted by 2 investigators. Pooled effect estimates were obtained by using random-effect meta-analysis. DATA SYNTHESIS: Of 1560 identified abstracts, 14 studies (11 case-control, 2 cohort, and 1 case-crossover) met inclusion criteria, including 4055 cases of VTE. Compared with nontravelers, the overall pooled relative risk for VTE in travelers was 2.0 (95% CI, 1.5 to 2.7). Significant heterogeneity was present because of the method for selecting control participants (P = 0.008): whether the studies used control participants who had been referred for VTE evaluation or nonreferred control participants. When the studies that used referred control participants were excluded, the pooled relative risk for VTE in travelers was 2.8 (CI, 2.2 to 3.7), without significant heterogeneity. A dose-response relationship was identified, with an 18% higher risk for VTE for each 2-hour increase in duration of travel by any mode (P = 0.010) and a 26% higher risk for every 2 hours of air travel (P = 0.005). LIMITATION: All available studies were from Western countries; generalizability to non-Western populations is expected but needs confirmation. CONCLUSION: Travel is associated with a nearly 3-fold higher risk for VTE, with a dose-response relationship of 18% higher risk for each 2-hour increase in travel duration. Heterogeneity in results of previous studies was due to selection bias toward the null from use of referred control participants. http://annals.org/article.aspx?volume=151&page=180  Viajes aéreos y tromboembolismo venoso: una revisión sistemática Air travel and venous thromboembolism: a systematic review. Philbrick JT, Shumate R, Siadaty MS, Becker DM. Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, VA 22908, USA. J Gen Intern Med. 2007 Jan;22(1):107-14. Abstract CONTEXT: Despite multiple attempts to document and quantify the danger of venous thromboembolism (VTE) following prolonged travel, there is still uncertainty about the magnitude of risk and what can be done to lower it. OBJECTIVES: To review the methodologic strength of the literature, estimate the risk of travel-related VTE, evaluate the efficacy of preventive treatments, and develop evidence-based recommendations for practice. DATA SOURCES: Studies identified from MEDLINE from 1966 through December 2005, supplemented by a review of the Cochrane Central Registry of Controlled Trials, the Database of Abstracts of Reviews of Effects, and relevant bibliographies. STUDY SELECTION: We included all clinical studies that either reported primary data concerning travel as a risk factor for VTE or tested preventive measures for travel-related VTE. DATA EXTRACTION AND ANALYSIS: Two reviewers reviewed each study independently to assess inclusion criteria, classify research design, and rate methodologic features. The effect of methodologic differences, VTE risk, and travel duration on VTE rate was evaluated using a logistic regression model.  DATA SYNTHESIS: Twenty-four published reports, totaling 25 studies, met inclusion criteria (6 case-control studies, 10 cohort studies, and 9 randomized controlled trials). Method of screening for VTE [screening ultrasound compared to usual clinical care, odds ratio (OR) 390], outcome measure [all VTE compared to pulmonary embolism (PE) only, OR 21], duration of travel (<6 hours compared to 6-8 hours, OR 0.011), and clinical risk ("higher" risk travelers compared to "lower," OR 3.6) were significantly related to VTE rate. Clinical VTE after prolonged travel is rare [27 PE per million flights diagnosed through usual clinical care, 0.05% symptomatic deep venous thrombosis (DVT) diagnosed through screening ultrasounds], but asymptomatic thrombi of uncertain clinical significance are more common. Graduated compression stockings prevented travel-related VTE (P < 0.05 in 4 of 6 studies), aspirin did not, and low-molecular-weight heparin (LMWH) showed a trend toward efficacy in one study. CONCLUSIONS: All travelers, regardless of VTE risk, should avoid dehydration and frequently exercise leg muscles. Travelers on a flight of less than 6 hours and those with no known risk factors for VTE, regardless of the duration of the flight, do not need DVT prophylaxis. Travelers with 1 or more risk factors for VTE should consider graduated compression stockings and/or LMWH for flights longer than 6 hours http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1824715/ pdf/11606_2006_Article_16.pdf

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Anticoagulantes

Inicio preoperatorio versus postoperatorio de tromboprofilaxis después de cirugía ortopédica mayor: seguridad y eficacia de la administración postoperatoria avalada por estudios recientes de nuevos anticoagulantes orales  Preoperative versus postoperative initiation of thromboprophylaxis following major orthopedic surgery: safety and efficacy of postoperative administration supported by recent trials of new oral anticoagulants. Perka C. Orthopaedic Department, Charité, University Medicine Berlin, Free and Humboldt-University of Berlin, Berlin, Germany. carsten.perka@charite.de. Thromb J. 2011 Nov 16;9:17. Abstract ABSTRACT: In European countries, low-molecular-weight heparin is generally initiated preoperatively for thromboprophylaxis in hip or knee replacement surgery. The objective of this review is to compare pre- and postoperative thromboprophylaxis strategies using available evidence, and discuss the challenges and issues that arise. Surgery is the first step in the process of thrombus formation, but thrombosis is not an instant process and the formation and growth of the thrombus can take several days or weeks. Hence, it may be possible to stop this process if thromboprophylaxis is initiated after surgery. Meta-analyses or systematic reviews comparing pre- and postoperative initiation of therapy have found no consistent differences in efficacy and similar safety (bleeding rates) between the two strategies. The recently available oral anticoagulant dabigatran etexilate provides thromboprophylaxis when administered postoperatively and is as safe as preoperative enoxaparin. Further support for the use of postoperative oral thromboprophylaxis in hip or knee replacement surgery has been provided by the phase III clinical trials of rivaroxaban and apixaban versus preoperative enoxaparin. Postoperative thromboprophylaxis offers the opportunity to change management practices in Europe. As postoperative initiation may have a clinical benefit in some settings (e.g. for neuraxial anesthesia) and practical advantages (e.g. allowing same-day admission), it is a worthwhile thromboprophylactic strategy for hip or knee replacement surgery. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3228673/pdf/1477-9560-9-17.pdf   La prueba para nuevos anticoagulantes orales: estudios de evidencia clínica  The proof for new oral anticoagulants: clinical trial evidence. Huisman MV. Section of Vascular Medicine, Department of General Internal Medicine, Room CI R-43, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands. Eur Orthop Traumatol. 2011 Jul;2(1-2):7-14. Epub 2011 May 19. Abstract INTRODUCTION: Patients undergoing elective total hip or total knee replacement surgery are at increased risk of venous thromboembolism in the post-operative period and are recommended to receive thromboprophylaxis for 10-35 days. Although several thromboprophylactic agents are available, these are associated with well-recognized limitations. For the low molecular weight heparins (LMWHs) such as enoxaparin, these limitations include parenteral administration, indirect mode of action, inability to inhibit clot-bound thrombin and association with complications such as heparin-induced thrombocytopenia. These limitations make post-operative thromboprophylaxis challenging. Several new oral anticoagulants are in the advanced stages of clinical development. These agents have been designed to target either thrombin (dabigatran etexilate) or factor Xa (rivaroxaban and apixaban), which are key coagulation cascade enzymes. METHODS AND RESULTS: This review will present the published phase III clinical trial evidence of the efficacy and safety of dabigatran etexilate, rivaroxaban and apixaban, compared with the LMWH enoxaparin for the prevention of venous thromboembolism in patients who have undergone elective total hip or total knee replacement surgery. All three agents have shown comparable or superior efficacy compared with the European dose regimen of enoxaparin (40 mg once daily), and comparable rates of major bleeding events. Dabigatran etexilate and rivaroxaban are currently licensed for use following elective hip and knee replacement surgery in many countries, but no direct comparative data exist upon which to base the choice of agent. CONCLUSION: A thorough assessment of each individual patient's thromboembolic and bleeding risks should be the basis of selecting the agent in order to balance efficacy and safety http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3150805/pdf/ 12570_2011_Article_63.pdf Anticoagulantes potentes se asocian con mortalidad elevada de todas las causas después de artroplastia de cadera y rodilla  Potent anticoagulants are associated with a higher all-cause mortality rate after hip and knee arthroplasty. Sharrock NE, Gonzalez Della Valle A, Go G, Lyman S, Salvati EA. Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA. sharrockn@hss.edu Clin Orthop Relat Res. 2008 Mar;466(3):714-21. Epub 2008 Feb 10. Abstract Anticoagulation for thromboprophylaxis after THA and TKA has not been confirmed to diminish all-cause mortality. We determined whether the incidence of all-cause mortality and pulmonary embolism in patients undergoing total joint arthroplasty differs with currently used thromboprophylaxis protocols. We reviewed articles published from 1998 to 2007 that included 6-week or 3-month incidence of all-cause mortality and symptomatic, nonfatal pulmonary embolism. Twenty studies included reported 15,839 patients receiving low-molecular-weight heparin, ximelagatran, fondaparinux, or rivaroxaban (Group A); 7193 receiving regional anesthesia, pneumatic compression, and aspirin (Group B); and 5006 receiving warfarin (Group C). All-cause mortality was higher in Group A than in Group B (0.41% versus 0.19%) and the incidence of clinical nonfatal pulmonary embolus was higher in Group A than in Group B (0.60% versus 0.35%). The incidences of all-cause mortality and nonfatal pulmonary embolism in Group C were similar to those in Group A (0.4 and 0.52, respectively). Clinical pulmonary embolus occurs despite the use of anticoagulants. Group A anticoagulants were associated with the highest all-cause mortality of the three modalities studied. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2505231/ pdf/11999_2007_Article_92.pdf   Heparina de bajo peso molecular en la profilaxis de trombosis venosa profunda en pacientes quirúrgicos asiáticos. Experiencia en Kashmir  Low molecular weight heparin in prophylaxis of deep vein thrombosis in Asian general surgical patients: A Kashmir experience. Dar TI, Wani KA, Ashraf M, Malik A, Ahmad S, Gojwari TA, Iqbal A. Indian J Crit Care Med [serial online] 2012 [cited 2012 Jul 28];16:71-4.   Background and Objectives: Deep vein thrombosis (DVT) occurs at a lower rate in Asia than in the rest of the world. We wanted to study the significance and efficacy of low molecular weight heparin (LMWH) in prophylaxis of DVT in major general surgical patients in the Kashmir Valley (India, Asia) so as to make it a routine in our patients. Patients and Methods: This was a prospective study in which the effect of LMWH was compared with no prophylaxis. Results: LMWHs are more effective than no prophylaxis in the prevention of DVT and pulmonary thromboembolism in highest-risk general surgical patients (odds ratio = 16.64; 95% confidence interval = 3.63-1130.03; P-value = 0.014). Conclusion: LMWHs have a significant prophylactic effect on DVT in general surgical patients, with a higher benefit to risk ratio, and, in spite of the low incidence of DVT in Asia, its prophylaxis should routinely be considered in this part of the world as well, preferably in the form of LMWHs. http://www.ijccm.org/text.asp?2012/16/2/71/99107  http://www.ijccm.org/temp/IJCCM16271-6463211_175712.pdf

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Indices de riesgo de trombosis venosa y tromboembolia pulmonar

Validación del riesgo de Caprini en la evaluación con pacientes de cirugía plástica Validation of the Caprini risk assessment model in plastic and reconstructive surgery patients. Pannucci CJ, Bailey SH, Dreszer G, Fisher Wachtman C, Zumsteg JW, Jaber RM, Hamill JB, Hume KM, Rubin JP, Neligan PC, Kalliainen LK, Hoxworth RE, Pusic AL, Wilkins EG. Department of Surgery, University of Michigan, Ann Arbor, 48105, USA. J Am Coll Surg. 2011 Jan;212(1):105-12. Epub 2010 Nov 18. Abstract BACKGROUND: The Venous Thromboembolism Prevention Study (VTEPS) Network is a consortium of 5 tertiary referral centers established to examine venous thromboembolism (VTE) in plastic surgery patients. We report our midterm analyses of the study's control group to evaluate the incidence of VTE in patients who receive no chemoprophylaxis, and validate the Caprini Risk Assessment Model (RAM) in plastic surgery patients. STUDY DESIGN: Medical record review was performed at VTEPS centers for all eligible plastic surgery patients between March 2006 and June 2009. Inclusion criteria were Caprini score ≥3, surgery under general anesthesia, and postoperative hospital admission. Patients who received chemoprophylaxis were excluded. Dependent variables included symptomatic deep vein thrombosis (DVT) or pulmonary embolism (PE) within the first 60 postoperative days and time to DVT or PE. RESULTS: We identified 1,126 historic control patients. The overall VTE incidence was 1.69%. Approximately 1 in 9 (11.3%) patients with Caprini score >8 had a VTE event. Patients with Caprini score >8 were significantly more likely to develop VTE when compared with patients with Caprini score of 3 to 4 (odds ratio [OR] 20.9, p < 0.001), 5 to 6 (OR 9.9, p < 0.001), or 7 to 8 (OR 4.6, p = 0.015). Among patients with Caprini score 7 to 8 or Caprini score >8, VTE risk was not limited to the immediate postoperative period (postoperative days 1-14). In these high-risk patients, more than 50% of VTE events were diagnosed in the late (days 15-60) postoperative period. CONCLUSIONS: The Caprini RAM effectively risk-stratifies plastic and reconstructive surgery patients for VTE risk. Among patients with Caprini score >8, 11.3% have a postoperative VTE when chemoprophylaxis is not provided. In higher risk patients, there was no evidence that VTE risk is limited to the immediate postoperative period http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3052944/pdf/nihms237229.pdf   Trombosis venosa profunda: validación del índice pierna-informe (DVT-LSI) Deep vein thrombosis: validation of a patient-reported leg symptom index. Hudgens SA, Cella D, Caprini CA, Caprini JA. Center on Outcomes, Research and Education, Evanston Northwestern Healthcare, 1001 University Place, Suite 100, Evanston, Illinois 60201, USA. shudgens@enh.org Health Qual Life Outcomes. 2003 Dec 15;1:76. Abstract INTRODUCTION: Deep vein thrombosis (DVT) is a serious health problem that affects more than 2 million people annually in the United States. Many of these patients develop asymptomatic DVT, but months to years later may experience symptomatic post-thrombotic syndrome (PTS). It is not known how many cases of PTS can be traced to "asymptomatic" DVT because venography is no longer routinely done and ultrasonography (US) may miss some asymptomatic clots. As a result, a clinical tool in addition to US to detect symptom emergence or exacerbation in patients after DVT would be of value. METHODS: Seventy-seven patients hospitalized with an acute DVT interviewed by telephone at 3-7 days, 30-40 days, and 12-months following discharge were included in this report. All were treated with a standard anticoagulation "Clinical Pathway Protocol" between April 1999 and January 2000. Using a 14-item Deep Vein Thrombosis Leg Symptom Index (DVT-LSI), patients were queried regarding leg pain, swelling, skin discoloration, cosmetic appearance, activity tolerance, emotional distress, and leg-related sleep problems. RESULTS: The DVT-LSI for each leg was reliable at all assessments, with instrument reliability (alpha coefficients) greater than 0.70 at all time points (range 0.71-0.87). DVT-LSI scores, and the percentage of patients exhibiting symptoms, were higher in the DVT-affected leg at all time points. Among patients with unilateral disease, symptom severity ratings were significantly worse for patients in the affected leg compared to the normal leg at all time points, with the exception of those with a right-leg DVT at 12 months. Patients with bilateral thrombi did not have different scores on one leg compared to the other. CONCLUSION: The DVT-LSI is useful in assessing symptomatic clinical outcomes in patients after diagnosis of DVT, and may represent a surrogate marker for DVT otherwise presumed to be asymptomatic http://www.ncbi.nlm.nih.gov/pmc/articles/PMC317368/pdf/1477-7525-1-76.pdf   Trombosis venosa profunda y embolismo pulmonar. Prevención, tratamiento y consideraciones anestésicas  Deep vein thrombosis and pulmonary embolism - Prevention, management, and anaesthetic considerations. Narani KK. Department of Anaesthesiology, Pain and Perioperative Medicine, Sir Ganga Ram Hospital, New Delhi - 110 060, India. Indian J Anaesth. 2010 Jan;54(1):8-17. Abstract There is high incidence of venous thromboembolism, comprising of deep vein thrombosis and pulmonary embolism, in hospitalized patients. The need for systemic thromboprophylaxis is essential, especially in patients with inherited or acquired patient-specific risk factors or in patients undergoing surgeries associated with high incidence of postoperative deep vein thrombosis and pulmonary embolism. These patients, on prophylactic or therapeutic doses of anticoagulants, may present for surgery. General or regional anaesthesia may be considered depending on the type and urgency of surgery and degree of anticoagulation as judged by investigations. The dilemma regarding the type of anaesthesia can be solved if the anaesthesiologist is aware of the pharmacokinetics of drugs affecting haemostasis. The anaesthesiologist must keep abreast with the latest developments of methods and drugs used in the prevention and management of venous thromboembolism and their implications in the conduct of anaesthesia. http://www.ijaweb.org/article.asp?issn=0019-5049;year=2010;volume=54;issue=1;spage=8;epage=17;aulast=Narani http://www.ijaweb.org/temp/IndianJAnaesth5418-4798358_131943.pdf

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Estudio clínico de un método para confirmar los efectos de anestesia espinal en pacientes con lesión medular

Estudio clínico de un método para confirmar los efectos de anestesia espinal en pacientes con lesión medular

Clinical trial of a method for confirming the effects of spinal anesthesia in patients with spinal cord injury. Takatsuki A, Ohtsuka M. Department of Anesthesia, Kanagawa Rehabilitation Hospital, 516 Nanasawa, Atsugi, Kanagawa, 254-0121, Japan, takatuki@pp.iij4u.or.jp. J Anesth. 2012 Jun 19. [Epub ahead of print] Abstract In this case series study, we prospectively examined whether it might be possible to check the effect of spinal anesthesia (SA), based on the disappearance of lower extremity reflexes and spasticity, in patients with spinal cord injury (SCI), in whom the effect cannot be confirmed by the pinprick test or by using the Bromage scale. In 40 patients with chronic, clinically complete cervical SCI who were scheduled to receive SA, pre-anesthetic examination revealed that the Babinski sign, patellar tendon reflex, and spasticity (assessed using the Ashworth scale) were all positive in 31 patients, while two of these three pre-anesthetic assessment parameters were positive in eight patients. The effect of SA in these 39 patients (97.5 %) was confirmed by demonstrating the absence of both the Babinski sign and patellar tendon reflex and loss of spasticity after SA. Our results suggested that the effect of SA can be confirmed by the disappearance of the Babinski sign and patellar tendon reflex and loss of spasticity in most patients with complete cervical SCI, although determination of the level of the block is difficult. In conclusion, loss of the Babinski sign, patellar tendon reflex, and spasticity might be useful for checking the effect of SA in cervical SCI patients. http://www.springerlink.com/content/j5m563q758t17v17/fulltext.pdf

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