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lunes, 27 de marzo de 2017

Bloqueo neuromuscular en ancianos / Neuromuscular blockade in geriatris

Marzo 27, 2017. No. 2641

Bloqueo neuromuscular en el paciente anciano

Neuromuscular blockade in the elderly patient.

Lee LA1, Athanassoglou V1, Pandit JJ1.

J Pain Res. 2016 Jun 17;9:437-44. doi: 10.2147/JPR.S85183. eCollection 2016.Abstract

Neuromuscular blockade is a desirable or even essential component of general anesthesia for major surgical operations. As the population continues to age, and more operations are conducted in the elderly, due consideration must be given to neuromuscular blockade in these patients to avoid possible complications. This review considers the pharmacokinetics and pharmacodynamics of neuromuscular blockade that may be altered in the elderly. Compartment distribution, metabolism, and excretion of drugs may vary due to age-related changes in physiology, altering the duration of action with a need for reduced dosage (eg, aminosteroids). Other drugs (atracurium, cisatracurium) have more reliable duration of action and should perhaps be considered for use in the elderly. The range of interpatient variability that neuromuscular blocking drugs may exhibit is then considered and drugs with a narrower range, such as cisatracurium, may produce more predictable, and inherently safer, outcomes. Ultimately, appropriate neuromuscular monitoring should be used to guide the administration of muscle relaxants so that the risk of residual neuromuscular blockade postoperatively can be minimized. The reliability of various monitoring is considered. This paper concludes with a review of the various reversal agents, namely, anticholinesterase drugs and sugammadex, and the alterations in dosing of these that should be considered for the elderly patient.

KEYWORDS: anesthesia; drugs; elderly; pharmacodynamics; pharmacokinetics

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Relajantes neuromusculares en el anciano

Neuromuscular blockade in the elderly.

Stankiewicz-Rudnicki M1.

Anaesthesiol Intensive Ther. 2016;48(4):257-260. doi: 10.5603/AIT.2016.0045.

Abstract

The aim of the presented review is to highlight the clinical problem of postoperative residual curarization (PORC) following general anaesthesia in the elderly. Possible complications of PORC are described along with age-induced changes in pharmacokinetics of long and intermediate-acting neuromuscular blocking agents. This is intended to facilitate the selection and to promote appropriate intraoperative use of muscle relaxants in patients over the age of 65 years.

KEYWORDS: elderly patients; muscle relaxants; neuromuscular block; postoperative residual curarization; reversal

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Relación entre la concentración efectiva el sitio diana de rocuronio y el grado de recuperación del bloqueo neuromuscular en pacientes de edad avanzada.

The relationship between the target effective site concentration of rocuronium and the degree of recovery from neuromuscular blockade in elderly patients.

Fan X1, Ma M1, Li Z1, Gong S1, Zhang W1, Wen Y1.

Int J Clin Exp Med. 2015 Sep 15;8(9):16369-73. eCollection 2015.

Abstract

OBJECTIVE: To study the relationship between the target effective site concentration (Ce) of rocuronium and the degree of recovery from neuromuscular blockade in elderly patients. METHODS: 50 elderly patients (ASA grade II) scheduled for selective surgical procedure under general anaesthesia were randomly divided into two groups, A and B, with 25 cases in each group. The Ce of rocuronium for intubation was 3 μg·ml(-1) in both groups, and the Ce during operation were 0.8 and 1.0 μg·ml(-1) in group A and B, respectively. When target controlled infusion of rocuronium was stopped, without the administration of reversal agents for neuromuscular blockade, the relationship between Ce and the first twitch height (T1) was studied by regression analysis. RESULTS: There was a significant linear relationship between Ce and T1, and there was no statistical difference in regression coefficient and interception between group A and B (P>0.05). CONCLUSION: The degree of recovery from neuromuscular blockade could be judged by the target effective site concentration of rocuronium at the time of reversal from neuromuscular blockade in the elderly patients.

KEYWORDS: Rocuronium; geriatrics; neuromuscular blockade; pharmacodynamics

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Curso sobre Anestesia en Trasplantes, Cirugía abdominal, Plástica, Oftalmología y Otorrinolaringología.

Committee for European Education in Anaesthesiology (CEEA)

y el Colegio de Anestesiólogos de León A.C.

Abril 7-9, 2017, León Guanajuato, México

Informes (477) 716 06 16, kikinhedz@gmail.com

Anestesiología y Medicina del Dolor

52 664 6848905

vwhizar@anestesia-dolor.org

anestesia-dolor.org

Comparación de los resultados de la artroplastia total del hombro reversa, con y sin reparación subscapular

Comparison of reverse total shoulder arthroplasty outcomes with and without subscapularis repair

Fuente
Este artículo es originalmente publicado en:

https://www.ncbi.nlm.nih.gov/pubmed/28277259

http://www.jshoulderelbow.org/article/S1058-2746(16)30448-7/fulltext

De:

Friedman RJ¹, Flurin PH², Wright TW³, Zuckerman JD⁴, Roche CP⁵.

J Shoulder Elbow Surg. 2017 Apr;26(4):662-668. doi: 10.1016/j.jse.2016.09.027. Epub 2016 Oct 27.

Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

Abstract

BACKGROUND:

Repair of the subscapularis with reverse total shoulder arthroplasty (rTSA) is controversial. The purpose of this study is to quantify rTSA outcomes in patients with and without subscapularis repair to determine if there is any impact on clinical outcomes.

CONCLUSIONS:

Significant clinical improvements were observed for both the subscapularis-repaired and non-repaired cohorts, with some statistical differences observed using a variety of outcome measures. Repair of the subscapularis did not lead to inferior clinical outcomes as predicted by biomechanical models. No difference was noted in the complication or scapular notching rates between cohorts. These clinical results show that rTSA using a lateralized humeral prosthesis delivers reliable clinical improvements with a low risk of instability, regardless of subscapularis repair.

KEYWORDS:

Shoulder; arthroplasty; complications; dislocation; reverse; subscapularis

Resumen

ANTECEDENTES:

La reparación del subescapular con artroplastia total reversa del hombro (rTSA) es controvertida. El propósito de este estudio es cuantificar los resultados de rTSA en pacientes con y sin subscapularis reparación para determinar si hay algún impacto en los resultados clínicos.
CONCLUSIONES:Se observaron mejoras clínicas significativas para las cohortes reparadas y no reparadas, con algunas diferencias estadísticas observadas utilizando una variedad de medidas de resultado. La reparación de la subescapularis no condujo a resultados clínicos inferiores como se predice por los modelos biomecánicos. No se observó ninguna diferencia en la complicación o las tasas de muescas escapulares entre cohortes. Estos resultados clínicos muestran que rTSA usando una prótesis humeral lateralizada proporciona mejoras clínicas confiables con un bajo riesgo de inestabilidad, independientemente de la reparación subscapular.

PALABRAS CLAVE:Hombro; Artroplastia; Complicaciones; dislocación; reversa; Subescapular

PMID: 28277259 DOI: 10.1016/j.jse.2016.09.027

Con Técnica de Yesos Seriados y Cirugía de Mínima Invasión, el IMSS Atiende a Bebés con Pie Zambo No.081/2017

http://www.ortopediainfantil.com.mx/academia/con-tecnica-de-yesos-seriados-y-cirugia-de-minima-invasion-el-imss-atiende-a-bebes-con-pie-zambo-no-0812017/

El tratamiento inicia en las primeras semanas de vida y continúa hasta los 5 años de edad, cuando el pie está estable.

Los pequeños se benefician con la alineación de los pies y recuperan flexibilidad para realizar sus actividades.

El Servicio de Ortopedia Pediátrica del Hospital “Dr. Victorio de la Fuente Narváez” del IMSS brinda un tratamiento eficaz a bebés que nacen con pie equinovaro aducto congénito (PEVAC), también conocido en Latinoamérica como pie Bott o pie Zambo, mediante la colocación de yesos seriados y una cirugía de mínima invasión, para alinear los pies y recuperar su flexibilidad.

El pie equinovaro es una de las malformaciones congénitas músculo esqueléticas más comunes (torcido hacia adentro, hacia abajo o hacia sí mismo), ocurre en el primer trimestre del desarrollo, se presenta en tres de cada mil nacidos vivos, y afecta a bebés de ambos sexos de manera similar.

El procedimiento médico inicia entre las dos y tres primeras semanas de vida del bebé y se realiza durante las siguientes seis a ocho semanas, con el cambio semanal de yesos para manejar la deformidad que afecta ambos pies.

La técnica de yesos es la opción número uno en el manejo de pie equinovaro con resultados exitosos y se utiliza desde hace más de 50 años a nivel mundial, explicó Juan Agustín Valcarce León, responsable de la Clínica de Yesos del Hospital de Ortopedia de la Unidad Médica de Alta Especialidad “Dr. Victorio de la Fuente Narváez” del Instituto Mexicano del Seguro Social.

Después de la primera fase de tratamiento se evalúa la mejoría de los pies del pequeño para continuar con la cirugía, la cual se aplica en 90 por ciento de los casos. Cosiste en hacer una incisión de dos a tres milímetros en el Tendón de Aquiles, que se regenera y cubre la nueva longitud del pie, agregó el especialista.

En el pasado se hacía una incisión grande en la parte interna del pie, para alargar las estructuras afectadas.

Los beneficios para el paciente son menos tiempo de hospitalización, resultados de buenos a excelentes a largo plazo, en comparación con el método tradicional, en que el paciente sufría más dolor, mayor rigidez y había necesidad de otras cirugías.

El doctor Valcarce León dijo que en la segunda etapa, el niño mantiene la corrección al usar una barra de acero con zapatos unidos a ella durante tres meses, día y noche, y después sólo en las noches, hasta cumplir cinco años de edad, para lograr un pie flexible y no doloroso, que les permite hacer una vida normal, con actividades físicas y deportivas.

Los pacientes continúan en vigilancia médica con una revisión anual hasta los 18 años de edad, generalmente no tienen que usar plantillas ni calzado ortopédico, ya que tienen los pies alineados, flexibles y con fuerza para realizar cualquier actividad.

#pie zambo #pie equinovaro #pie equinovaro congénito #yesos

sábado, 25 de marzo de 2017

Cirugía de ortopedia en el anciano / Orthopedic surgery in the elderly

Marzo 24, 2017. No. 2638

El aumento aislado de troponina cardiaca no modifica el pronóstico de pacientes geriátricos con fractura de cadera

Isolated cardiac troponin rise does not modify the prognosis in elderly patients with hip fracture.

Vallet H1, Breining A, Le Manach Y, Cohen-Bittan J, Mézière A, Raux M, Verny M, Riou B, Khiami F, Boddaert J.

Medicine (Baltimore). 2017 Feb;96(7):e6169. doi: 10.1097/MD.0000000000006169.

Abstract

Perioperative myocardial infarction remains a life-threatening complication in noncardiac surgery and even an isolated troponin rise (ITR) is associated with significant mortality. Our aim was to assess the prognostic value of ITR in elderly patients with hip fracture.... ITR was not associated with a higher risk of new institutionalization or impaired walking ability at 6 months, in contrast to ACS group.In elderly patients with hip fracture, ITR was not associated with a significant increase in death and/or rehospitalization within 6 months.

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Artroplastía total de cadera. Seguimiento a 5 años de la evolución funcional pacientes independientes viejos y muy viejos

Total hip arthroplasty for hip fractures: 5-year follow-up of functional outcomes in the oldest independent old and very old patients.

Godoy Monzón D1, Iserson KV2, Jauregui J3, Musso C3, Piccaluga F1, Buttaro M1.

Geriatr Orthop Surg Rehabil. 2014 Mar;5(1):3-8. doi: 10.1177/2151458514520700.

Abstract

INTRODUCTION: This study aimed to determine the dislocation and reoperation rate, functional outcomes, and the survival rate of the unique subset of very old but lucid and independent patients with hip fractures following a total hip arthroplasty (THA) and geriatric team-coordinated perioperative care. METHOD: Between 2000 and 2006, previously independent ambulatory patients ≥80 years old presenting with an intracapsular hip fracture were given THAs under the care of an integrated orthopedic surgery-geriatric service. Their fracture-related complications, ambulation, mental status, and survival were followed for 5 to 11 years postinjury. RESULTS: Five years postinjury, 57 (61.3%) patients of the original study group were living. In all, 3 (3.2%) patients had postoperative hip dislocations (and 2 patients had dislocation twice) and 2 reoperations were needed within the first postoperative month. There were no hip dislocations or reoperations after the first year. Radiographs obtained on 88% of the surviving patients at 5 years postoperatively showed that all remained unchanged from their immediate postoperative images. Nearly half of the patients were still able to ambulate as they did preoperatively and their mixed-model equation was statistically unchanged. CONCLUSION: This study of patients >80 years old with previously good functional status demonstrates that with appropriate surgical (best prosthesis, good operating technique, and regional anesthesia) and geriatric (pre- and postoperative assessments, close follow-up, medication adjustments, and fall-prevention instruction) care, they have few hip dislocations and reoperations, survive postfracture at least as long as their noninjured contemporaries, and continue to function and ambulate as they did prior to their injury.

KEYWORDS: geriatrics; hip fractures; orthogeriatric team; perioperative care; total hip arthroplasty

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Mortalidad postoperatoria después de cirugía para fractura de cadera. Seguimiento a tres años

Postoperative Mortality after Hip Fracture Surgery: A 3 Years Follow Up.

Kilci O1, Un C1, Sacan O1, Gamli M1, Baskan S1, Baydar M1, Ozkurt B2.

PLoS One. 2016 Oct 27;11(10):e0162097. doi: 10.1371/journal.pone.0162097. eCollection 2016.

Abstract

BACKGROUND AND AIMS: To determine mortality rates and predisposing factors in patients operated for a hip fracture in a 3-year follow-up period. METHODS: The study included patients who underwent primary surgery for a hip fracture.The inclusion criteria were traumatic, non-traumatic, osteoporotic and pathological hip fractures requiring surgery in all age groups and both genders. Patients with periprosthetic fractures or previous contralateral hip fracture surgery and patients who could not be contacted by telephone were excluded. At 36 months after surgery, evaluation was made using a structured telephone interview and a detailed examination of the hospital medical records, especially the documents written during anesthesia by the anesthesiologists and the documents written at the time of follow-up visits by the orthopaedic surgeons. A total of 124 cases were analyzed and 4 patients were excluded due to exclusion criteria. The collected data included demographics, type of fracture, co-morbidities, American Society of Anesthesiologists (ASA) scores, anesthesia techniques, operation type (intramedullary nailing or arthroplasty; cemented-noncemented), peroperative complications, refracture during the follow-up period, survival period and mortality causes. RESULTS: The total 120 patients evaluated comprised 74 females(61.7%) and 46 males(38.3%) with a mean age of 76.9±12.8 years (range 23-95 years). The ASA scores were ASA I (0.8%), ASA II (21.7%), ASA III (53.3%) and ASA IV (24.2%). Mortality was seen in 44 patients (36.7%) and 76 patients (63.3%) survived during the 36-month follow-up period. Of the surviving patients, 59.1% were female and 40.9% were male.The survival period ranged between 1-1190 days. The cumulative mortality rate in the first, second and third years were 29.17%, 33.33% and 36.67% respectively. The factors associated with mortality were determined as increasing age, high ASA score, coronary artery disease, congestive heart failure, Alzheimer's disease, Parkinson's disease, malignancycementation and peroperative complications such as hypotension (p<0.05). Mortality was highest in the first month after fracture. CONCLUSION: The results of this study showed higher mortality rates in patients with high ASA scores due to associated co-morbidities such as congestive heart failure, malignancy and Alzheimer's disease or Parkinson's disease. The use of cemented prosthesis was also seen to significantly increase mortality whereas no effect was seen from the anesthesia technique used. Treatment of these patients with a multidiciplinary approach in an orthogeriatric ward is essential. There is a need for further studies concerning cemented vs. uncemented implant use and identification of the best anesthesia technique to decrease mortality rates in these patients.

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