martes, 23 de agosto de 2011

Biblioteca médica


BIBLIOTECA MEDICA



Posted: 22 Aug 2011 01:21 PM PDT
En una enfermedad autoinmune, el sistema inmunológico ataca a las células sanas del organismo, en vez de defenderlo de afecciones externas. La ciencia quiere vencer esta batalla y propone a las células madre como “escudo”. ¿Podrá ganar la guerra? Aún no se sabe, pero cada avance médico es un nuevo paso hacia la victoria. Agencia CTyS (Nadia Luna) - El doctor en Ciencias Biológicas, Alejandro
Posted: 22 Aug 2011 01:21 PM PDT
Investigadores del nordeste argentino aplicaron una técnica novedosa en la detección de una bacteria, que se creía no tenía relación directa con el cáncer de útero. Agencia CTyS (Leandro Lacoa) El interés primordial del estudio estuvo en la bacteria Chlamydia trachomatis que provoca 89 millones de casos de infecciones genitales por año a nivel mundial, según datos de la OMS. El Dr. del Área de
Posted: 22 Aug 2011 01:21 PM PDT
El Instituto de Biología y Medicina Experimental (Ibyme-CONICET) desarrolla compuestos a base de uva y té verde para combatir la endometriosis, una enfermedad que afecta a un millón de argentinas y puede provocar dolores pélvicos agudos y esterilidad. Los resultados de los experimentos son muy alentadores Agencia CTyS (Emanuel Pujol) - La efectividad de estos compuestos naturales fue
Posted: 22 Aug 2011 01:21 PM PDT
Científicos presentaron un kit de análisis de laboratorio del tamaño de una tarjeta de crédito, capaz de analizar sangre de forma barata y sencilla. El invento se dio a conocer en la revista Nature Medicine. El llamado mChip es una tarjeta de plástico con diez detectores sobre los que se deposita una gota de sangre. De este desarrollo se espera que pueda detectar en cuestión de minutos y a un
Posted: 22 Aug 2011 01:21 PM PDT
Chocolate para el corazónEl chocolate puede ser un recurso para la conquista, pero ese no sería el único beneficio que aporta a los corazones; en efecto, investigadores de la UBA analizan su capacidad para prevenir enfermedades cardiovasculares. La Facultad de Farmacia y Bioquímica indaga las cualidades del cacao para regular la presión arterial, a través del análisis de sus mecanismos

lunes, 22 de agosto de 2011

IX curso taller de patología quirúrgica del pie

Buenas noches, nos quedan solo 15 días para el inicio del IX curso taller de patología quirúrgica del pie, este curso taller se llevará a cabo del 6 al 9 de septiembre del 2011, hay BECAS disponibles para asistir, solo tienen que solicitarla a bibliomanazteca@yahoo.com.mx para que les envié el pre registro lo llenen y yo los pueda inscribir al curso con beca, así que los conmino a venir al curso, así que todavía espero muchas solicitudes!!!!!!, les anexo programa del curso.




Escalosfríos en anestesia


Meperidina intratecal reduce el escalofrío intraoperatoria durante prostatectomía transuretral en pacientes ancianos
Intrathecal meperidine reduces intraoperative shivering during transurethral prostatectomy in elderly patients.
Chun DH, Kil HK, Kim HJ, Park C, Chung KH.
Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea.
Korean J Anesthesiol. 2010 Dec;59(6):389-93. Epub 2010 Dec 31.
Abstract
BACKGROUND: Shivering is a frequent event during the perioperative period. We performed a prospective, randomized, double-blind study to determine whether intrathecal meperidine (0.2 mg/kg) decreases the incidence and intensity of shivering after spinal anesthesia for transurethral operations. METHODS: Fifty patients scheduled for elective transurethral resection operations under spinal anesthesia were randomly allocated to two groups. Spinal anesthesia consisted of 0.5% hyperbaric bupivacaine 8 mg and, mperidine (0.2 mg/kg) (meperidine group) or, normal saline (saline group). Data collection, including sensory block level (by pinprick), blood pressure, heart rate, sublingual temperature, incidence and intensity of shivering, pruritus, nausea, and vomiting was performed at 10 minute intervals. RESULTS: The incidence and intensity of shivering was significantly less in the meperidine group than saline group (P = 0.012 and P = 0.008, for incidence and intensity, respectively). However, pruritus was more common in the meperidine group compared with the saline group (16% vs. 0%, P < 0.05). CONCLUSIONS: The addition of meperidine 0.2 mg/kg to intrathecal bupivacaine lowers the incidence and severity of shivering during transurethral prostatectomy in elderly patients

http://ekja.org/Synapse/Data/PDFData/0011KJAE/kjae-59-389.pdf  
 
Estudio comparativo del efecto de clonidina y tramadol sobre el escalofrío post anestesia espinal
A comparative study of the effect of clonidine and tramadol on post-spinal anaesthesia shivering.
Shukla U, Malhotra K, Prabhakar T.
Department of Anaesthesiology and Critical Care, UP Rural Institute of Medical Sciences & Research, Saifai, Etawah, Uttar Pradesh, India.
Indian J Anaesth. 2011 May;55(3):242-6.
Abstract
The aim of this study was to evaluate the efficacy, potency and side effects of clonidine as compared to tramadol in post-spinal anaesthesia shivering. In this prospective double-blind randomized controlled clinical trial, 80 American Society of Anaesthesiologists grade-l (ASAI) patients aged between 18 and 45 years scheduled for various surgical procedures under spinal anaesthesia, who developed shivering were selected.The patients were divided into two groups: Group C (n=40) comprised of patients who received clonidine 0.5mg/kg intravenously (IV) and group patients who received tramadol 0.5 mg/kg IV. Grade of shivering, disappearance of shivering, haemodynamics and side effects were observed at scheduled intervals. Disappearance of shivering was significantly earlier in group C (2.54±0.76) than in group T (5.01±1.02) (P=.0000001). Response rate to treatment in group C was higher (97.5%) than in group T (92.5%), but the difference was not significant. Nausea, vomiting and dizziness were found to be higher in group T (P=0.001, 0.005, 0.001, respectively), while the patients in group C were comparatively more sedated (sedation level, 2; group C, 25%). We conclude that clonidine gives better thermodynamics than tramadol, with fewer side effects

http://www.ijaweb.org/temp/IndianJAnaesth553242-7646208_020726.pdf  

Dosis bajas de ketamina y ondansetron profilácticos para prevenir escalosfrío durante anestesia espinal 
Prophylactic low dose ketamine and ondansetron for prevention of shivering during spinal anaesthesia.
Shakya S, Chaturvedi A, Sah BP.
Department of Anaesthesiology, Manipal College of Medical Sciences, Pokhara, Nepal.
J Anaesthesiol Clin Pharmacol. 2010 Oct;26(4):465-9
Abstract
BACKGROUND:
Perioperative shivering is a common problem during anaesthesia. Apart from physical warming many drugs have also been used for prevention of shivering. Ketamine has been used for preventing shivering during anaesthesia in doses of 0.5 to 0.75mg kg(-1), but even these doses causes too much sedation and hallucination. Ondansetron (8 mg) has been recently evaluated for its perioperative antishivering effect in patients under anaethesia. Present study was conducted to evaluate the efficacy and safety of low dose Ketamine (0.25mg kg(-1)) and Ondansetron (4 mg) for prevention of shivering during spinal anaesthesia. PATIENTS #ENTITYSTARTX00026;METHODS: Total 120 patients undergoing lower abdominal surgery under spinal anaesthesia were included. 3ml of hyperbaric bupivacaine 0.5% was used for spinal anaesthesia. After intrathecal injection, the patients were randomly divided in 3 groups of 40 each who received Ketamine 0.25mg kg(-1)or Ondansetron 4mg IV or Saline. Vitals, temperature and shivering scores were recorded every 5 minutes. Side effects i.e. hypotension, nausea and vomiting, sedation and hallucinations were also recorded. RESULTS: Fall in temperature was more significant in saline and ondansetron group (gp) than in ketamine group at all time interval. Out of 40 patients, shivering was maximum & seen in 17 patients (42.50%) in saline gp, 4 patients (10%) in ondansetron gp and in only 1patient (2.5%) in ketamine gp. Odd ratio of ketamine, ondansetron and saline are 1, 4.33 and 28.33 respectively which means that shivering in saline gp was 28.83 times higher than ketamine gp and 6.65 times higher than in ondansetron .Shivering rate was 4.33 times higher in ondansetron gp than in ketamine gp. Hypotension was lowest in ketamine gp (10%) in comparison to ondansetron gp (22.5%) and saline gp. (20%). Mild sedation was seen in almost all (95%) patients in ketamine gp. CONCLUSION: Prophylactic low dose ketamine (0.25mg kg(-1)) and Ondansetron (4mg) significantly decreased shivering in patients undergoing spinal anaesthesia without significant side effects

http://www.joacp.org/temp/JAnaesthClinPharmacol264465-5565468_152734.pdf 
 
Atentamente
Anestesiología y Medicina del Dolor

Ventilación en pediatría


Práctica clínica: ventilación no invasiva en recién nacidos
Clinical practice : noninvasive respiratory support in newborns.
de Winter JP, de Vries MA, Zimmermann LJ.
Department of Pediatrics, Spaarne Hospital, Hoofddorp, The Netherlands.pdewinter@spaarneziekenhuis.nl
Eur J Pediatr. 2010 Jul;169(7):777-82. Epub 2010 Feb 24.
Abstract
The most important goal of introducing noninvasive ventilation (NIV) has been to decrease the need for intubation and, therefore, mechanical ventilation in newborns. As a result, this technique may reduce the incidence of bronchopulmonary dysplasia (BPD). In addition to nasal CPAP, improvements in sensors and flow delivery systems have resulted in the introduction of a variety of other types of NIV. For the optimal application of these novelties, a thorough physiological knowledge of mechanics of the respiratory system is necessary. In this overview, the modern insights of noninvasive respiratory therapy in newborns are discussed. These aspects include respiratory support in the delivery room; conventional and modern nCPAP; humidified, heated, and high-flow nasal cannula ventilation; and nasal intermittent positive pressure ventilation. Finally, an algorithm is presented describing common practice in taking care of respiratory distress in prematurely born infants

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2876262/pdf/431_2010_Article_1159.pdf 
 
Presión positiva continua no invasiva en falla respiratoria aguda: Casco versus mascarilla facial
Noninvasive continuous positive airway pressure in acute respiratory failure: helmet versus facial mask.
Chidini G, Calderini E, Cesana BM, Gandini C, Prandi E, Pelosi P.
Pediatric Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy. giovannachid@libero.it
Pediatrics. 2010 Aug;126(2):e330-6. Epub 2010 Jul 26.
Abstract
OBJECTIVE:
Noninvasive continuous positive airway pressure (nCPAP) is applied through different interfaces to treat mild acute respiratory failure (ARF) in infants. Recently a new pediatric helmet was introduced in clinical practice to deliver nCPAP. The objective of this study was to compare the feasibility of the delivery of nCPAP by the pediatric helmet with delivery by a conventional facial mask in infants with ARF. PATIENTS AND METHODS: We conducted a single-center physiologic, randomized, controlled study with a crossover design on 20 consecutive infants with ARF. All patients received nCPAP by helmet and facial mask in random order for 90 minutes. In infants in both trials, nCPAP treatment was preceded by periods of unassisted spontaneous breathing through a Venturi mask. The primary end point was the feasibility of nCPAP administered with the 2 interfaces (helmet and facial mask). Feasibility was evaluated by the number of trial failures defined as the occurrence of 1 of the following: intolerance to the interface; persistent air leak; gas-exchange derangement; or major adverse events. nCPAP application time, number of patients who required sedation, and the type of complications with each interface were also recorded. The secondary end point was gas-exchange improvement.
RESULTS: Feasibility of nCPAP delivery was enhanced by the helmet compared with the mask, as indicated by a lower number of trial failures (P < .001), less patient intolerance (P < .001), longer application time (P < .001), and reduced need for patient sedation (P < .001). For both delivery methods, no major patient complications occurred. CONCLUSIONS: The results of this current study revealed that the helmet is a feasible alternative to the facial mask for delivery of nCPAP to infants with mild ARF.

http://pediatrics.aappublications.org/content/126/2/e330.full.pdf+html 
 
Presión positiva nasal continua (CPAP) para el cuidado respiratorio en el recién nacido
Nasal continuous positive airway pressure (CPAP) for the respiratory care of the newborn infant.
Diblasi RM.
Center for Developmental Therapeutics, Seattle Children's Research Institute, 1900 Ninth Avenue, Seattle WA 98101, USA. robert.diblasi@seattlechildrens.org
Respir Care. 2009 Sep;54(9):1209-35.
Abstract
Nasal continuous positive airway pressure (CPAP) is a noninvasive form of respiratory assistance that has been used to support spontaneously breathing infants with lung disease for nearly 40 years. Following reports that mechanical ventilation contributes to pulmonary growth arrest and the development of chronic lung disease, there is a renewed interest in using CPAP as the prevailing method for supporting newborn infants. Animal and human research has shown that CPAP is less injurious to the lungs than is mechanical ventilation. The major concepts that embrace lung protection during CPAP are the application of spontaneous breathing at a constant distending pressure and avoidance of intubation and positive-pressure inflations. A major topic for current research focuses on whether premature infants should be supported initially with CPAP following delivery, or after the infant has been extubated following prophylactic surfactant administration. Clinical trials have shown that CPAP reduces the need for intubation/mechanical ventilation and surfactant administration, but it is still unclear whether CPAP reduces chronic lung disease and mortality, compared to modern lung-protective ventilation techniques. Despite the successes, little is known about how best to manage patients using CPAP. It is also unclear whether different strategies or devices used to maintain CPAP play a role in improving outcomes in infants. Nasal CPAP technology has evolved over the last 10 years, and bench and clinical research has evaluated differences in physiologic effects related to these new devices. Ultimately, clinicians' abilities to perceive changes in the pathophysiologic conditions of infants receiving CPAP and the quality of airway care provided are likely to be the most influential factors in determining patient outcomes.

http://www.rcjournal.com/contents/09.09/09.09.1209.pdf 
 
Atentamente
Dr. Enrique Hernández-Cortez
Anestesiología y Medicina del Dolor

2 nuevos artículos en "Evidencias enPediatría" (avance del nº de septiembre)

Hola a tod@s

Ayer se publicaron en la web de la revista "Evidencias en Pediatría" http://www.evidenciasenpediatria.es 2 nuevos artículos valorados críticamente correspondientes al próximo nº de septiembre.

Sus títulos son:

Vacunas antirotavirus e invaginación intestinal: ¿Podemos seguir tranquilos? http://goo.gl/TxURR 

Una solución de rehidratación oral hipotónica con zinc y prebióticos podría acortar la duración de la diarrea aguda  http://goo.gl/rtgoH 


Como en anteriores ocasiones os recordamos que, quien desee suscribirse al boletín de noticias de la revista puede hacerlo desde su página principal, desde el enlace "Suscripción gratuita al boletín de novedades", a la derecha de vuestra pantalla.

Atentamente:

Cristóbal Buñuel, en nombre del equipo editorial de "Evidencias en Pediatría"
http://www.evidenciasenpediatria.es

En twitter: http://twitter.com/#!/evidpediatria
En facebook: https://www.facebook.com/pages/Evidencias-en-Pediatr%C3%ADa/396993320672

Carta de un abogado a los médicos


Para meditar, cuidarse y actuar !
saludos
Carta de un abogado a los médicos 
Por suerte, esto esta escrito por un abogado. Seria bueno que los responsables de las Sociedades Científicas se pusieran en contacto con él. Nos parece oportuno transcribir parte de este artículo publicado en el Diario El Cronista, hace aproximadamente dos años, por el Dr. Marcos R. Llambias. "Ha tomado estado público la pesadilla que causa desvelos, cuando no INFARTOS, a muchos miembros de la comunidad médica. Los juicios por mala praxis se han convertido en un provechoso recurso de subsistencia para muchos abogados ávidos de litigio, conocedores de las falencias del sistema.

Los títeres del arte de curar, marionetas de obras sociales, hospitales y sistemas prepagos de atención médica trabajan donde y como pueden. Su responsabilidad social hace funcionar las instituciones y su irresponsabilidad personal los lleva a exponerse inútilmente.

El día en que ellos, verdaderos médicos por vocación, dejen de pensar tanto en el paciente, en su capacitación profesional a cualquier costo, en las instituciones para las que trabajan, y tomen conciencia de lo mucho que arriesgan en cada acto médico, ese día la atención del país se paralizara. Porque solo un demente alguien que ha perdido la facultad de discernir entre la bondad y la estupidez, puede aceptar la responsabilidad de barajar una vida humana cuando un sistema perverso y carente en todo sentido no le brinda la seguridad y tranquilidad necesarias para trabajar como corresponde.

Porque el médico que asume la responsabilidad en un acto quirúrgico, que se somete al estrés de desplegar su arte sobre un paciente dormido, que asume la lucha contra la enfermedad ajena, que desafía a la muerte sabiendo que no siempre triunfara y que acepta hacerlo por la vergonzosa remuneración que el sistema le asigna, ese médico no es bueno, es ESTÚPIDO, es alguien que consume toda su inteligencia en el cadalso de su ofrenda personal hacia un prójimo que no le reconoce el esfuerzo. Agotada su paciencia, ya no puede ver que un error, aunque involuntario, le puede costar su patrimonio, su bienestar, su salud. Este suicida altruista figura en todas las cartillas de los sistemas prepagos de atención médica.

Trabaja en los hospitales nacionales, provinciales o municipales, superado por un aluvión de pacientes que envejece haciendo colas y recibe atención francamente deficitaria.

Deambula por clínicas y sanatorios juntando monedas para poder subsistir. Este médico, suicida por vocación, inteligente para el prójimo y descerebrado para si mismo, bueno y estúpido a la vez, responsable ante la sociedad e irresponsable ante su familia, es la carne del cañón, el centro del blanco de la industria de la "mala praxis". Todo abogado sabe que en este sistema perverso, tan carente de recursos, tan manoseado por inescrupulosos enriquecidos a costa de la salud, el médico es el "hilo fino" mas fácil de cortar, el candidato ideal para exprimir, el ingenuo mas liviano de sacudir para rescatar las monedas que llevan en lo bolsillos.

Lo que pocos se han puesto a pensar, es que, en definitiva este ensañamiento médico, que no discrimina entre idóneos e incapaces, entre buenos y malos, decentes y envilecidos comerciantes, es fundamentalmente perjudicial para el paciente. La comunidad toda empieza a sufrir las consecuencias cuando el médico capacitado, con experiencia, con reconocido prestigio entre sus colegas, empieza a "esquivar" la patología difícil, esa donde arriesga mucho y gana poco. El médico que cuida sus espaldas, discrimina por necesidad. La comunidad toda sufre esta realidad, al verse privada de la idoneidad y la experiencia de sus mejores médicos. Porque los mejores, también los mas inteligentes, rápidamente ven la necesidad de dar un paso al costado para no exponerse. Si bien es cierto que algunos médicos  no están acostumbrados a responsabilizarse por sus acciones, también es cierto que la inmensa mayoría, no tendría que trabajar en las actuales circunstancias. Arriesgan mucho sin ganar nada. Porque si un cirujano tiene que afrontar un juicio por mala praxis, la demanda supera en miles de veces la remuneración de su trabajo. Una intervención $1200 puede convertirse en un juicio de $120.000.

Así las cosas, los sistemas prepagos de atención médica, circular mediante, solicitan a sus médicos fotocopia de la póliza de seguro suscrita. Ellos, al mejor estilo de Poncio Pilato, pretenden que el médico, con centavos que le asignan por su trabajo, contrate un seguro de "mala praxis". De esta manera, los líderes de la medicina prepaga se cubren de los errores del servicio que dicen brindar. Logran su cometido sin sacrificar un solo centavo de sus arcas. Con los aranceles vigentes, ningún médico puede asegurarse contra "mala praxis". Con temor a la "mala praxis", ninguno puede trabajar como deberia. 

El auge de este tipo de juicios no es culpa de los abogados. Ellos, que son muchos y deben subsistir, han visto las falencias del sistema que colocan al médico en la primera línea de fuego. Como frágil fusible de una maquina sanitaria en constante corto circuito, el médico salta y se quema. Gane o pierda, con o sin justicia, con razón o sin ella, el médico debe pagar. La sociedad parece ensañada con los encargados de velar por la salud.

Vocación de SUICIDAS para seguir con esta profesión que tiene el índice mas alto de divorcios, alcoholismos, muertes prematuras y el menor en remuneraciones comparados con otras clásicas.
 

¡Suicida altruista! El profesional en una institución desmantelada y desgastada,

¡se desgasta! 
 

“Por el bien de todos, la legislación debe proteger a todos"

Errores en la prescripción pediátrica


Errores en prescripción y transcripción de medicamentos endovenosos en cuatro servicios pediátricos
Frequency of prescription and transcription errors for intravenous medications in four pediatric services.
Rivas E, Rivas A, Bustos L.
Departamentos de Pediatría y Cirugía Infantil, Facultad de Medicina, Universidad de La Frontera, Temuco, Chile. erivas@ufro.cl
Rev Med Chil. 2010 Dec;138(12):1524-9. Epub 2011 Feb 7.
Abstract
BACKGROUND: Errors in the prescription and transcription of medications in pediatric services is a source of adverse events that can be prevented. AIM: To determine and compare the frequency of prescription and transcription errors for intravenous drugs in four pediatric services in a regional general hospital. MATERIAL AND METHODS: Cross sectional analysis of a probabilistic sample of 500 prescriptions of intravenous medications. Information was gathered using an instrument from the American Academy of Pediatrics. RESULTS: The detected prescription errors were illegible indications in 20%, lack of dosing indication in 11%, omission of the administration route in 24% and omission of the frequency of administration in 15%. Transcription errors were illegible transcription in 3%, not transcribing all indicated medications in 4% and transcription of medications that were not prescribed in 3%. Twenty one percent of prescriptions and 6% of transcriptions had at least one incorrect action. In the different services studied there was a significant association between the percentage of incorrect prescriptions and transcriptions and between illegible prescriptions and transcriptions. CONCLUSIONS: A high percentage of errors in prescription of intravenous medications and their transcriptions, was detected in these services. A better quality of care control is required

http://www.scielo.cl/pdf/rmc/v138n12/art08.pdf

 
Una historia de muchas potencias: ¿Podremos minimizar errores de prescripción y administración con tantas formulaciones en el mercado?
A tale of too many strengths: Can we minimize prescribing errors and dispensing errors with so many formulations in the market?
Gitanjali B.
 J Pharmacol Pharmacother 2011;2:147-9
There are reportedly more than 1,00,000 drug formulations in the market in India. I have not seen a complete list of all the formulations nor been able to verify this figure which has remained unchanged since my days as a postgraduate (which was a very long time ago). However, anyone who has had the patience to look at the branded formulations in any one of the indexing drug formularies will be convinced that this figure could be correct. One of the recent issues of Indian Drug Review (IDR) had approximately 1980 medicines listed under the alphabet 'A'. Some other alphabets had much longer lists. So what is wrong with a country having such a large number of medicines, in different dosage formulations of varying strengths?
The case report described in page "189" is one such example of the many dangers of having too many choices. Paracetamol is one of the most commonly used analgesic and antipyretic in children. The oral liquid formulation is used mainly in small children. Leaving aside the fact that the parents could not read the label as it was in Spanish and presumed the strength to be similar to what is commonly prescribed used in the United Kingdom, why should there be a formulation with a dosage strength of 500 mg/5 ml? Any child requiring this dose (500 mg) should, in the normal course of events, be able to swallow a tablet of the same strength. There may be a small group of elderly patients who are not able to swallow tablets who will perhaps need this formulation. But this group will be extremely small, so small that it would not be financially beneficial for these companies to produce this strength solely for this small group of potential users. However, the potential for harm, as illustrated in this report, is much bigger.

http://www.jpharmacol.com/temp/JPharmacolPharmacother23147-4554877_123908.pdf 
Atentamente
Dr. Enrique Hernández-Cortez
Anestesiología y Medicina del Dolor

Midazolam intratecal


Efectos del midazolam intratecal en la anestesia espinal: estudio randomizado, prospectivo, con casos control
Effects of intrathecal midazolam in spinal anaesthesia: a prospective randomised case control study.
Shadangi BK, Garg R, Pandey R, Das T.
Department of Anaesthesiology, All India Institute of Medical Scences, Ansari Nagar, New Delhi 110029, India. drrgarg@hotmail.com.
Singapore Med J. 2011 Jun;52(6):432-5.
Abstract
Introduction: Subarachnoid block with local anaesthetics and adjuvants has been extensively used for surgery. Intrathecal midazolam produces antinociception and potentiates the effect of local anaesthetics. We compared intrathecal bupivacaine with and without midazolam to assess its effect on the duration of sensory block, motor block and pain relief. Methods: A total of 100 patients scheduled for elective lower abdominal, lower limb and gynaecological procedures were selected to participate in this prospective, randomised, double-blind study. Patients were randomly allocated into two groups for intrathecal drug administration. Group B received 3 mL 0.5 percent bupivacaine with 0.4 mL saline, and group BM received 3 mL 0.5 percent bupivacaine and 0.4 mL (2 mg) midazolam mixture. The onset, duration of sensory/motor block, time to first rescue analgesia and side effects were noted. Results: Demographic profile and duration of surgery were comparable between the two groups. The onset of sensory (4.8 versus 4.6 min) and motor block (5.9 versus 6 min) was also comparable between the groups. The duration of sensory blockade was prolonged in the midazolam group (90.8 versus 115.8 min, p-value is 0.001), while the duration of motor blockade was comparable (151.8 versus 151.3 min, p-value is 0.51). The duration of effective analgesia was significantly longer in the midazolam group compared to the control group (121.3 versus 221.1 min, p-value is 0.001). Sedation score was comparable in the two groups. Conclusion: The addition of preservative-free midazolam to bupivacaine intrathecally resulted in prolonged postoperative analgesia without increasing motor block

http://smj.sma.org.sg/5206/5206a7.pdf 
 

El uso de midazolam intratecal en los seres humanos: un estudio de caso del proceso
The use of intrathecal midazolam in humans: a case study of process.
Yaksh TL, Allen JW.
Department of Anesthesiology, University of California-San Diego, 9500 Gilman Drive, La Jolla, CA 92093-0818, USA. tyaksh@ucsd.edu
Anesth Analg. 2004 Jun;98(6):1536-45
Abstract
Early preclinical work demonstrated the potential role of spinal benzodiazepine pharmacology in regulating spinal nociceptive transmission. We review this preclinical activity and the evolving implementation of intrathecal midazolam in humans for pain management. Important elements in this development for use in humans are issues pertinent to safety and the preclinical reports that have increased our understanding of intrathecal midazolam toxicity. We seek to emphasize the time course of these studies and how they merged to provide enabling data that drove the clinical implementation. In the case of midazolam, we point to the potential issues that arose when preclinical safety data were unreasonably ignored and how consideration of preclinical safety data can serve to facilitate drug development by demonstrating reasonable safety profiles that document the minimal degree of potential risk to the patient. Issues that are of continuing relevance to the use of intrathecal midazolam, including issues of formulation and kinetics, are considered. IMPLICATIONS: The intrathecal use of midazolam has evolved over 20 years though a combination of preclinical and clinical investigations. We review the time course of this development to define critical elements that should be pursued in reducing the risk associated with the clinical use of a novel spinal drug

http://www.anesthesia-analgesia.org/content/98/6/1536.full.pdf+html 
 
Midazolam intratecal I: Estudio de cohortes investigando su seguridad
Intrathecal midazolam I: a cohort study investigating safety.
Tucker AP, Lai C, Nadeson R, Goodchild CS.
Department of Anaesthesia, Monash Medical Centre, Monash University, 246 Clayton Road, Victoria 3168, Australia.research@southernhealth.org.au
Anesth Analg. 2004 Jun;98(6):1512-20
Abstract
Despite conflicting evidence regarding the safety of intrathecal midazolam from animal investigations, its clinical use is increasing. We investigated the potential of intrathecal midazolam to produce symptomatology suggestive of neurological damage. This study compared two cohorts of patients who received intrathecal anesthesia with or without intrathecal midazolam (2 mg). Eighteen risk factors were evaluated with respect to symptoms representing potential neurological complications. The definitions of these symptoms were made wide to maximize the chance of counting patients with neurological sequelae after intrathecal injections. Eleven-hundred patients were followed up prospectively during the first postoperative week by a hospital chart review and 1 mo later by a mailed questionnaire. Symptoms suggestive of neurological impairment, including motor or sensory changes and bladder or bowel dysfunction, were investigated. Intrathecal midazolam was not associated with an increased risk of neurologic symptoms. In contrast, neurologic symptoms were found to be increased by age >70 yr (relative risk, 8.72) and the occurrence of a blood-stained spinal tap (relative risk, 8.07). The administration of intrathecal midazolam, 2 mg, did not increase the occurrence of neurologic or urologic symptoms, as suggested by some preclinical animal experimentation. IMPLICATIONS: Intrathecal midazolam provides segmental analgesia, but conflicting animal studies have cast doubts on its safety. This investigation studied the effect of intrathecal midazolam by observing two cohorts of patients. In clinical practice, intrathecal midazolam (2 mg) did not increase adverse neurological symptoms compared with conventional therapies
Midazolam intratecal II: combinación con fentanil intratecal en trabajo de parto 
Intrathecal midazolam II: combination with intrathecal fentanyl for labor pain.
Tucker AP, Mezzatesta J, Nadeson R, Goodchild CS.
Department of Anaesthesia, Monash Medical Centre, Monash University, 246 Clayton Road, Victoria 3168, Australia.adam.tucker@med.monash.edu.au
Anesth Analg. 2004 Jun;98(6):1521-7
Abstract
Recent investigations have sought to improve intrathecal analgesia by combining opioids with other classes of analgesics. In this study we assessed the ability of intrathecal midazolam to increase the potency and duration of the analgesic effects of intrathecal fentanyl without causing adverse effects. Thirty parturients with cervical dilations 2-6 cm were randomized to receive either intrathecal midazolam 2 mg, fentanyl 10 micro g, or both combined to initiate analgesia. Pain scores were recorded before and at 5-min intervals for 30 min after the injection and then every 30 minutes until the patient requested further analgesia. The presence and severity of nausea, emesis, pruritus, headache, and sedation, in addition to arterial blood pressure, heart rate, respiratory rate, sensory changes to ice, motor impairment, cardiotocograph, and Apgar score were also recorded. The parturients were assessed after 2 days and 1 mo for neurologic impairment. Preinjection pain scores were unaltered by intrathecal midazolam alone and moderately decreased by fentanyl. Intrathecal midazolam increased the analgesic effect of fentanyl. No treatment altered cardiorespiratory variables or caused motor impairment. The addition of intrathecal midazolam to fentanyl did not increase the occurrence of any maternal adverse event or abnormalities on the cardiotocograph. We conclude that intrathecal midazolam enhanced the analgesic effect of fentanyl without increasing maternal or fetal adverse effects. IMPLICATIONS: Treatment of labor pain with epidural injections of local anesthetic is complicated by decreases in arterial blood pressure and leg weakness. This study showed that a mixture of two drugs, fentanyl and midazolam, could provide powerful pain relief when the drugs were given together spinally without such side effects

Atentamente
Anestesiología y Medicina del Dolor

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Conferencia de Neonatologia- Problemas en el niño ventilado del panico al exito


  Estimado Pediatra  te invito al Seminario de Pediatría, Cirugía Pediátrica y Lactancia Materna. Iniciamos el Programa 2011, el día 24 de Agosto  las 21hrs (Centro, México DF, Guadalajara y Lima Perú) a la Conferencia: “Problemas en el niño Ventilado del Pánico al Éxito”, por el   “Dr. Jorge Beyer Obeso” Pediatra Neonatólogo de la Cd. De Monclova Coah.  La sesión inicia puntualmente las 21 hrs. 
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5.- A disfrutar la conferencia                                                                                                                            6.- Recomendamos que dejes tu Nombre Completo, Correo electrónico y que participes.

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Prevención de la neumonía asociada a la ventilación mecánica con antisépticos orales


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Artículo nº 1669. Vol 11 nº 8, agosto 2011.
Autor: Ramón Díaz-Alersi

Prevención de la neumonía asociada a la ventilación mecánica con antisépticos orales
Artículo original: Prevention of ventilator-associated pneumonia with oral antiseptics: a systematic review and meta-analysis. Labeau SO, Van de Vyver K, Brusselaers N, Vogelaers D, Blot SI. Lancet Infect Dis 2011 Jul 26. [Resumen] [Artículos relacionados]
Introducción: La neumonía asociada a ventilación mecánica (NAV) es una de las infecciones nosocomiales más frecuente en la UCI, afectando hasta a un 30% de los pacientes en ventilación mecánica (VM), con una mortalidad cruda entre 24 y 76%. La mortalidad atribuible (exceso de riesgo de muerte, HR), según el último estudio que ha utilizado la base de datos del registro europeo HELICS oscila entre 1,7 para el Staphylococcus aureus y 3,7 para la Pseudomonas aeruginosa [1]. Su mecanismo de desarrollo principal es la aspiración de las secreciones orofaríngeas colonizadas. Por ello, la reducción del número de microorganismos orales puede tener un papel importante en su prevención. Tanto la clorhexidina como la povidona yodada han sido propuestas y estudiadas como antisépticos orales. Este metanálisis estudia la efectividad de ambos antisépticos en comparación con los cuidados orales normales.
Resumen: A través de una búsqueda en PubMed, CINAHL, WOS, CENTRAL y Clinical Trial, se localizaron 14 ensayos clínicos aleatorizados en pacientes adultos (2.481 en total) en VM que fueron tratados con uno de los dos antisépticos. En conjunto, el uso de un antiséptico resultó en una reducción significativa del riesgo de NAV (RR 0,67; IC 95% 0,50-0,88, P = 0,004), siendo la clorhexidina más efectiva que la povidona yodada, cuyo efecto individual no llegó a ser estadísticamente significativo. Dentro de las soluciones de clorhexidina, la del 2% fue la más efectiva (RR 0,53; IC 95% 0,31-0,91). El efecto fue más pronunciado en los estudios de pacientes de cirugía cardiaca (RR 0,41; IC 95% 0,17-0,98). La heterogeneidad fue moderada para los ensayos que emplearon la clorhexidina y alta para los de la povidona yodada.
Comentario: Este metanálisis muestra un efecto beneficioso de la descontaminación oral en la prevención de la NAV, especialmente cuando se emplea clorhexidina, y más en una dilución del 2%. Sin embargo, hay algunos hechos que hay que tener en cuenta. En primer lugar, la comparación se hizo unas veces contra placebo y otra contra los cuidados higiénicos orales habituales, distintos según cada estudio. Además no se especificaron otras medidas de prevención de la NAV que pudieran haberse empleado. En segundo lugar, el diagnóstico de NAV no se realizó de manera igual en todos los ensayos, empleándose varios conjuntos de criterios diferentes. Finalmente, se observa que el efecto más potente se da en pacientes de cirugía cardiaca, siendo estos pacientes un subgrupo algo especial y quizás no comparables a los de una unidad médico-quirúrgica no especializada (intubación reglada y en condiciones de asepsia, mejor estado previo del paciente y menos tiempo de VM). Aún así, estos datos son suficientes para recomendar el empleo de la clorhexidina en los cuidados orales de los pacientes ventilados, tal como se hace en el protocolo Neumonía Zero [2, 3].
Ramón Díaz-Alersi
Hospital Universitario Puerto Real, Cádiz.
© REMI, http://medicina-intensiva.com. Agosto 2011.
Enlaces:
  1. Clinical outcomes of health-care-associated infections and antimicrobial resistance in patients admitted to European intensive-care units: a cohort study. Lambert ML, Suetens C, Savey A, Palomar M, Hiesmayr M, Morales I, Agodi A, Frank U, Mertens K, Schumacher M, Wolkewitz M. Lancet Infect Dis 2011; 11(1): 30-38. [PubMed] [REMI]
  2. Prevención de la neumonía asociada a la ventilación mecánica. Proyecto Neumonía Zero [Enlace]
  3. Módulo de formación sobre el proyecto Neumonía Zero [Enlace]
Búsqueda en PubMed:
  • Enunciado: Prevención de la neumonía asociada a ventilación mecánica con antisépticos orales
  • Sintaxis: Prevention AND ventilator-associated pneumonia AND oral antiseptics
  • [Resultados]