Vía aérea difícil / The dificult airway

Vía aérea difícil The dificult airway The airway is the portal of entry for oxygen into the human body. Establishing an airway is the first priority of resuscitation because, without an adequate airway, all other medical treatments are futile. All airways established in the out-of hospital setting must be considered difficult airways; the importance of knowing when to intubate and what to do in the case of a technically challenging airway is not often appreciated. Several recent studies have highlighted the high failure rate for prehospital intubations as well as significant complications with this procedure. The most devastating is unrecognized esophageal intubation. In this chapter, we will briefly review some basic principles of airway assessment and the approach to tracheal intubation. Capítulo/Chapter

Atentamente Anestesia y Medicina del Dolor anestesia-dolor.org

“Eutanasia en pediatría

Estimado Pediatra te invito al Seminario de Pediatría, Cirugía Pediátrica y Lactancia Materna. El día 22 de Julio 2015 las 21hrs (Centro, México DF, Guadalajara y Lima Perú) a la Conferencia: “Eutanasia en pediatría” por el “Dr. Jorge Chuck Sepúlveda”, Pediatra Bioeticista de la Cd. de Guadalajara, Jal. La sesión inicia puntualmente las 21 hrs.
Para entrar a la Sala de Conferencia:
1.- hacer click en la siguiente liga, o cópiala y escríbela en tu buscador http://connectpro60196372.adobeconnect.com/eutanasia_pediatria/
2.- “Entra como Invitado” Escribes tu nombre y apellido en el espacio en blanco
3.- Hacer click en el espacio que dice “Entrar en la Sala”

5.- A disfrutar la conferencia
6.- Recomendamos que dejes tu Nombre Completo, Correo electrónico y que participes.


Henrys


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

Medwave edición de julio 2015

A continuación le informamos los artículos recientemente publicados en Medwave.


REVISIÓN CLÍNICA

Factores maternos y perinatales influyentes en la morbilidad neonatal: revisión narrativa de la literatura
Jónathan Hernández Núñez, Magel Valdés Yong, Yoanca de la Caridad Suñol Vázquez, Marelene de la Caridad López Quintana (Cuba)

Medwave 2015 Jul;15(6):e6182
http://dx.doi.org/10.5867/medwave.2015.06.6182


RESUMENES EPISTEMONIKOS

¿Sirve agregar azatioprina a los corticoides en pacientes con polimiositis?
Cristina Meneses, Gabriel Rada (Chile)

Medwave 2015 Jul;15(suppl 1):e6179
http://dx.doi.org/10.5867/medwave.2015.6179


¿Existe alguna diferencia entre los inhibidores de la enzima convertidora y los antagonistas del receptor de angiotensina para la insuficiencia cardiaca?
Carmen Rain, Gabriel Rada (Chile)

Medwave 2015 Jul;15(suppl 1):e6177
http://dx.doi.org/10.5867/medwave.2015.6177


CARTA A LA EDITORA

Diplomas adicionales y proyectos de investigación: construyendo bases académicas
Dipesh Pravin Gopal, Pieter Mackeith (Reino Unido)

Medwave 2015 Jul;15(6):e6175
http://dx.doi.org/10.5867/medwave.2015.06.6175


EDITORIAL
Queremos publicar más estudios cualitativos en salud
Vivienne C. Bachelet, Bernardita Baeza (Chile)

Medwave 2015 Jul;15(5):e6167
http://dx.doi.org/10.5867/medwave.2015.05.6167


Se encuentran abiertas las inscripciones para ciclo especial del curso Economía de la salud. Inicio 29 de julio.

Para información más detallada: http://www.medwave.cl/link.cgi/eCampus/ges02/

Y para el curso Prevención y Control de Infecciones Asociadas a la Atención de Salud

Mas información en: http://www.medwave.cl/link.cgi/eCampus/IAAS

Toda nuestra oferta de cursos y diplomados e-learning en http://www.medwave.cl/link.cgi/eCampus/Capacitacion


PORTADA MEDWAVE
www.medwave.cl

Mas de ventilación mecánica/More on mechanical ventilation

En algunos envios podrá notar que se incluye el hiperlik de los PDFs. Esto le facilita ampliar la información sobre los autores y las revistas con tan solo hacer click sobre los datos incluidos. In some e-mails you may notice that the hyperlinks are included. This makes it easy more information about the authors and journals just clicking on the data included. Em alguns e-mails que você perceber que podem os hiperlinks estão incluídos. Isto torna mais fácil obter mais informações sobre os autores e periódicos apenas clicando sobre os dados incluídos. در برخی از ایمیل شما متوجه است که ممکن است لینک گنجانده شده است. این باعث می شود آن را آسان اطلاعات بیشتر در مورد نویسندگان و مجلات تنها با کلیک کردن بر روی داده ها گنجانده شده است. Beneficios de la ventilación protectora. Viendo más allá de UCI Benefits of lung-protective ventilation: looking beyond the ICU. Gupta N, Yende S. Crit Care. 2014 Sep 25;18(5):530. doi: 10.1186/s13054-014-0530-0. PDF Avances recientes en ventilación mecánica en pacientes sin ARDS Recent advances in mechanical ventilation in patients without acute respiratory distress syndrome. Serpa Neto A, Filho RR, Rocha LL, Schultz MJ. F1000Prime Rep. 2014 Dec 1;6:115. doi: 10.12703/P6-115. eCollection 2014. Abstract While being an essential part of general anesthesia for surgery and at times even a life-saving intervention in critically ill patients, mechanical ventilation has a strong potential to cause harm. Certain ventilation strategies could prevent, at least to some extent, the injury caused by this intervention. One essential element of so-called 'lung-protective' ventilation is the use of lower tidal volumes. It is uncertain whether higher levels of positive end-expiratory pressures have lung-protective properties as well. There are indications that too high oxygen fractions of inspired air, or too high blood oxygen targets, are harmful. Circumstantial evidence further suggests that spontaneous modes of ventilation are to be preferred over controlled ventilation to prevent harm to respiratory muscle. Finally, the use of restrictive sedation strategies in critically ill patients indirectly prevents ventilation-induced injury, as daily spontaneous awakening and breathing trials and bolus instead of continuous sedation are associated with shorter duration of ventilation and shorten the exposure to the injurious effects of ventilation. PDF Enfoques para la ventilación en cuidados intensivos. Approaches to ventilation in intensive care. Spieth PM, Koch T, Gama de Abreu M. Dtsch Arztebl Int. 2014 Oct 17;111(42):714-20. doi: 10.3238/arztebl.2014.0714. Abstract BACKGROUND: Mechanical ventilation is a common and often life-saving intervention in intensive care medicine. About 35% of all patients in intensive care are mechanically ventilated; about 15% of these patients develop a ventilation-associated pneumonia. The goal of ventilation therapy is to lessen the work of respiration and pulmonary gas exchange and thereby maintain or restore an adequate oxygen supply to the body's tissues.Mechanical ventilation can be carried out in many different modes; the avoidance of ventilation-induced lung damage through protective ventilationstrategies is currently a major focus of clinical interest. METHOD: This review is based on pertinent articles retrieved by a selective literature search. RESULTS: Compared to conventional lung-protecting modes of mechanical ventilation, the modern modes of ventilation presented here are further developments that optimize lung protection while improving pulmonary function and the synchrony of the patient with the ventilator. In high-frequencyventilation, tidal volumes of 1-2 mL/kgBW (body weight) are given, at a respiratory rate of up to 12 Hz. Assisted forms of spontaneous respiration are also in use, such as proportional assist ventilation (PAV), neurally adjusted ventilatory assist (NAVA), and variable pressure-support ventilation. Computer-guided closed-loop ventilation systems enable automated ventilation; according to a recent meta-analysis, they shorten weaning times by 32% . CONCLUSION: The currently available scientific evidence with respect to clinically relevant endpoints is inadequate for all of these newer modes ofventilation. It appears, however, that they can lower both the invasiveness and the duration of mechanical ventilation, and thus improve the care of patients who need ventilation. Randomized trials with clinically relevant endpoints must be carried out before any final judgments can be made. PDF

Atentamente Anestesia y Medicina del Dolor anestesia-dolor.org

Tramadol y piernas inquietas / Tramadol for restless legs syndrome

Revisión de las estrategias de manejo en el síndrome de piernas inquietas o enfermedad de Willis-Ekbon A review of current treatment strategies for restless legs syndrome (Willis-Ekbom disease). Klingelhoefer L, Cova I, Gupta S, Chaudhuri KR. Clin Med. 2014 Oct;14(5):520-4. doi: 10.7861/clinmedicine.14-5-520. Abstract Restless legs syndrome (RLS), recently renamed Willis-Ekbom disease (WED), is a common movement disorder. It is characterised by the need to move mainly the legs due to uncomfortable, sometimes painful sensations in the legs, which have a diurnal variation and a release with movement. Management is complex. First, centres should establish the severity of RLS using a simple 10-item RLS severity rating scale (IRLS). They should also exclude secondary causes, in particular ensuring normal iron levels. Mild cases can be managed by lifestyle changes, but patients with a IRLS score above 15 usually require pharmacological treatment. Dopaminergic therapies remain the mainstay of medical therapies, with recent evidence suggesting opioids may be particularly effective. This article focuses on the different treatment strategies in RLS, their associated complications and ways to manage them. KEYWORDS: RLS; Restless legs syndrome; medical treatment; side effects; therapy PDF Consenso revisado de la Fundación Willis-Ekbom Disease Foundation sobre el tratamiento del síndrome de piernas inquietas. Willis-Ekbom Disease Foundation revised consensus statement on the management of restless legs syndrome. Silber MH1, Becker PM, Earley C, Garcia-Borreguero D, Ondo WG; Medical Advisory Board of the Willis-Ekbom Disease Foundation. Collaborators (12) Mayo Clin Proc. 2013 Sep;88(9):977-86. doi: 10.1016/j.mayocp.2013.06.016. Abstract Restless legs syndrome (RLS)/Willis-Ekbom disease (WED) is a common disorder, occurring at least twice a week and causing at least moderate distress in 1.5% to 2.7% of the population. It is important for primary care physicians to be familiar with this disorder and its management. Much has changed in its management since our previous algorithm was published in 2004, including the availability of several new drugs. This revised algorithm was written by members of the Medical Advisory Board of the Willis-Ekbom Disease Syndrome Foundation based on scientific evidence and expert opinion. It considers the management of RLS/WED under intermittent RLS/WED, chronic persistent RLS/WED, and refractory RLS/WED. Nonpharmacological approaches, including mental alerting activities, avoiding substances or medications that may exacerbate RLS, and the role of iron supplementation, are outlined. Chronic persistent RLS/WED should be treated with either a nonergot dopamine agonist or a calcium channel α-2-δ ligand. We discuss the available drugs, the factors determining which to use, and their adverse effects. We define refractory RLS/WED and describe management approaches, including combination therapy and the use of high-potency opioids. KEYWORDS: MAB; Medical Advisory Board; RLS; WED; Willis-Ekbom disease; restless legs syndrome PDF

Atentamente Anestesia y Medicina del Dolor anestesia-dolor.org

Farmacología clínica neonatal

Farmacología clínica neonatal Neonatal clinical pharmacology. Allegaert K, van de Velde M, van den Anker J. Paediatr Anaesth. 2014 Jan;24(1):30-8. doi: 10.1111/pan.12176. Epub 2013 Apr 26. Abstract Effective and safe drug administration in neonates should be based on integrated knowledge on the evolving physiological characteristics of the infant who will receive the drug and the pharmacokinetics (PK) and pharmacodynamics (PD) of a given drug. Consequently, clinical pharmacology in neonates is as dynamic and diverse as the neonates we admit to our units while covariates explaining the variability are at least as relevant as median estimates. The unique setting of neonatal clinical pharmacology will be highlighted based on the hazards of simple extrapolation of maturational drug clearance when only based on 'adult' metabolism (propofol, paracetamol). Second, maturational trends are not at the same pace for all maturational processes. This will be illustrated based on the differences between hepatic and renal maturation (tramadol, morphine, midazolam). Finally, pharmacogenetics should be tailored to neonates, not just mirror adult concepts. Because of this diversity, clinical research in the field of neonatal clinical pharmacology is urgently needed and facilitated through PK/PD modeling. In addition, irrespective of already available data to guide pharmacotherapy, pharmacovigilance is needed to recognize specific side effects. Consequently, pediatric anesthesiologists should consider to contribute to improved pharmacotherapy through clinical trial design and collaboration, as well as reporting on adverse effects of specific drugs. PDF

Atentamente Anestesia y Medicina del Dolor anestesia-dolor.org

Hipotermia perioperatoria/Perioperative hypothermia

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

Atentamente Anestesia y Medicina del Dolor anestesia-dolor.org

Hipotermia perioperatoria/Perioperative hypothermia

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

Atentamente Anestesia y Medicina del Dolor anestesia-dolor.org

Raquia en niños/Spinal anesthesia in pediatrics

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

Atentamente Anestesia y Medicina del Dolor anestesia-dolor.org

Neuropatía dolorosa diabética aguda

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

Atentamente Anestesia y Medicina del Dolor anestesia-dolor.org