Ventilación perioperatoria / Perioperative ventilation

Septiembre 6, 2017. No. 2803

Epidemiología, práctica de ventilación y resultado en pacientes con mayor riesgo de complicaciones pulmonares postoperatorias: LAS VEGAS - un estudio observacional en 29 países. Epidemiology, practice of ventilation and outcome for patients at increased risk of postoperative pulmonary complications: LAS VEGAS - an observational study in 29 countries. LAS VEGAS investigators. Collaborators (492) Eur J Anaesthesiol. 2017 Aug;34(8):492-507. doi: 10.1097/EJA.0000000000000646. Abstract BACKGROUND: Limited information exists about the epidemiology and outcome of surgical patients at increased risk of postoperative pulmonary complications (PPCs), and how intraoperative ventilation was managed in these patients. OBJECTIVES: To determine the incidence of surgical patients at increased risk of PPCs, and to compare the intraoperative ventilation management and postoperative outcomes with patients at low risk of PPCs.  CONCLUSION: The incidence of patients with a predicted increased risk of PPCs is high. A large proportion of patients receive high VT and low PEEP levels. PPCs occur frequently in patients at increased risk, with worse clinical outcome. TRIAL REGISTRATION: The study was registered at Clinicaltrials.gov, number NCT01601223. PDF Ventilación intraoperatoria protectora con niveles más altos o más bajos de presión positiva de expiración final en pacientes obesos (PROBESE): protocolo de estudio para un ensayo controlado aleatorio. Protective intraoperative ventilation with higher versus lower levels of positive end-expiratory pressure in obese patients (PROBESE): study protocol for a randomized controlled trial. Bluth T1, Teichmann R1, Kiss T1, Bobek I2, Canet J3, Cinnella G4, De Baerdemaeker L5, Gregoretti C6, Hedenstierna G7, Hemmes SN8,9, Hiesmayr M10,11,12,13, Hollmann MW8,9, Jaber S14, Laffey JG15,16,17,18, Licker MJ19, Markstaller K13, Matot I20, Müller G21, Mills GH22, Mulier JP23, Putensen C24, Rossaint R25, Schmitt J21, Senturk M26, Serpa Neto A27,28, Severgnini P29, Sprung J30, Vidal Melo MF31, Wrigge H32, Schultz MJ9,33, Pelosi P34, Gama de Abreu M35; PROBESE investigators; and the PROtective VEntilation Network (PROVEnet); Clinical Trial Network of the European Society of Anaesthesiology (ESA). Collaborators (157) Author information Trials. 2017 Apr 28;18(1):202. doi: 10.1186/s13063-017-1929-0. Erratum to Protective intraoperative ventilation with higher versus lower levels of positive end-expiratory pressure in obese patients (PROBESE): study protocol for a randomized controlled trial. [Trials. 2017] Abstract BACKGROUND: Postoperative pulmonary complications (PPCs) increase the morbidity and mortality of surgery in obese patients. High levels of positive end-expiratory pressure (PEEP) with lung recruitment maneuvers may improve intraoperative respiratory function, but they can also compromise hemodynamics, and the effects on PPCs are uncertain. We hypothesized that intraoperative mechanical ventilation using high PEEP with periodic recruitment maneuvers, as compared with low PEEP without recruitment maneuvers, prevents PPCs in obese patients. METHODS/DESIGN: The PRotective Ventilation with Higher versus Lower PEEP during General Anesthesia for Surgery in OBESE Patients (PROBESE) study is a multicenter, two-arm, international randomized controlled trial. In total, 2013 obese patients with body mass index ≥35 kg/m2 scheduled for at least 2 h of surgery under general anesthesia and at intermediate to high risk for PPCs will be included. Patients are ventilated intraoperatively with a low tidal volume of 7 ml/kg (predicted body weight) and randomly assigned to PEEP of 12 cmH2O with lung recruitment maneuvers (high PEEP) or PEEP of 4 cmH2O without recruitment maneuvers (low PEEP). The occurrence of PPCs will be recorded as collapsed composite of single adverse pulmonary events and represents the primary endpoint. DISCUSSION: To our knowledge, the PROBESE trial is the first multicenter, international randomized controlled trial to compare the effects of two different levels of intraoperative PEEP during protective low tidal volume ventilation on PPCs in obese patients. The results of the PROBESE trial will support anesthesiologists in their decision to choose a certain PEEP level during general anesthesia for surgery in obese patients in an attempt to prevent PPCs. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02148692. Registered on 23 May 2014; last updated 7 June 2016. KEYWORDS: Mechanical ventilation; Obesity; Positive end-expiratory pressure; Postoperative pulmonary complication; Recruitment maneuver PDF XIV Congreso Virtual Mexicano de Anestesiología 2017 Octubre 1-Diciembre 31, 2017 Información / Information Video informativo Convocatoria para el Curso de Posgrado en Medicina del Dolor y Paliativa 2018 para Mexicanos y extranjeros. Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán Informes (52) 55 5487 0900 ext. 5011 de lunes a viernes de 9.00 a 14 h (hora de Ciudad de México).  Informes / Information California Society of Anesthesiologists Reuniones / Events Informacion / Information

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

Complicaciones respiratorias en cirugía / Respiratory complications of the surgical patient

Septiembre 5, 2017. No. 2802

Prevención de complicaciones respiratorias del paciente quirúrgico: plan de acción para la mejora continua del proceso. Prevention of respiratory complications of the surgical patient: actionable plan for continued process improvement. Ruscic KJ1, Grabitz SD, Rudolph MI, Eikermann M. Author information Curr Opin Anaesthesiol. 2017 Jun;30(3):399-408. doi: 10.1097/ACO.0000000000000465. Abstract PURPOSE OF REVIEW:  Postoperative complication (PRCs) increase hospitalization time, 30 day mortality and costs up to $35,000. These outcomes measures have gained prominence as bundled payments have become more common. RECENT FINDINGS: Results of recent quantitative effectiveness studies and clinical trials provide a framework that helps develop center-specific treatment guidelines, tailored to minimize the risk of PRCs. The implementation of those protocols should be guided by a local, respected, and visible facilitator who leads proper implementation while inviting center-specific input from surgeons, anesthesiologists, and other perioperative stakeholders. SUMMARY: Preoperatively, patients should be risk-stratified for PRCs to individualize intraoperative choices and postoperative pathways. Laparoscopic compared with open surgery improves respiratory outcomes. High-risk patients should be treated by experienced providers based on locally developed bundle-interventions to optimize intraoperative treatment and ICU bed utilization. Intraoperatively, lung-protective ventilation (procedure-specific positive end-expiratory pressure utilization, and low driving pressure) and moderately restrictive fluid therapy should be used. To achieve surgical relaxation, high-dose neuromuscular blocking agents (and reversal agents) as well as high-dose opioids should be avoided; inhaled anesthetics improve surgical conditions while protecting the lungs. Patients should be extubated in reverse Trendelenburg position. Postoperatively, continuous positive airway pressure helps prevent airway collapse and protocolized, early mobilization improves cognitive and respiratory function. PDF XIV Congreso Virtual Mexicano de Anestesiología 2017 Octubre 1-Diciembre 31, 2017 Información / Information Video informativo Convocatoria para el Curso de Posgrado en Medicina del Dolor y Paliativa 2018 para Mexicanos y extranjeros. Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán Informes (52) 55 5487 0900 ext. 5011 de lunes a viernes de 9.00 a 14 h (hora de Ciudad de México).  Informes / Information California Society of Anesthesiologists Reuniones / Events Informacion / Information

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

Codeína / Codeine

Septiembre 2, 2017. No. 2799

Codeína y metabolismo opioide: implicaciones y alternativas para el manejo pediátrico del dolor. Codeine and opioid metabolism: implications and alternatives for pediatric pain management. Chidambaran V1, Sadhasivam S, Mahmoud M. Author information Curr Opin Anaesthesiol. 2017 Jun;30(3):349-356. doi: 10.1097/ACO.0000000000000455. Abstract PURPOSE OF REVIEW: Use of perioperative opioids for surgical pain management of children presents clinical challenges because of concerns of serious adverse effects including life-threatening respiratory depression. This is especially true for children with history of obstructive sleep apnea. This review will explore current knowledge of clinically relevant factors and genetic polymorphisms that affect opioidmetabolism and postoperative outcomes in children. RECENT FINDINGS: Within the past several years, an increasing number of case reports have illustrated clinically important respiratory depression, anoxic brain injuries and even death among children receiving appropriate weight-based dosages of codeine and other opioids for analgesia at home setting particularly following tonsillectomy. Several national and international organizations have issued advisories on use of codeine in pediatrics, based on cytochrome P450 family 2 subfamily D type 6 (CYP2D6) pharmacogenetics. We have discussed the pros and cons of alternatives to codeine for pain management. SUMMARY: Although routine preoperative genotyping to identify children at risk and personalized opioid use for pediatric perioperative painmanagement is still a distant reality, current known implications of CYP2D6 pharmacogenetics on codeine use shows that pharmacogenetics has the potential to guide anesthesia providers on perioperative opioid selection and dosing to maximize efficacy and safety. PDF Codeína: Momento de decir "No" Codeine: Time to Say "No". Tobias JD, Green TP, Coté CJ; SECTION ON ANESTHESIOLOGY AND PAIN MEDICINE; COMMITTEE ON DRUGS. Collaborators (11) Pediatrics. 2016 Oct;138(4). pii: e20162396. Epub 2016 Sep 19. Abstract Codeine has been prescribed to pediatric patients for many decades as both an analgesic and an antitussive agent. Codeine is a prodrug with little inherent pharmacologic activity and must be metabolized in the liver into morphine, which is responsible for codeine's analgesic effects. However, there is substantial genetic variability in the activity of the responsible hepatic enzyme, CYP2D6, and, as a consequence, individual patient response to codeine varies from no effect to high sensitivity. Drug surveillance has documented the occurrence of unanticipated respiratory depression and death after receiving codeine in children, many of whom have been shown to be ultrarapid metabolizers. Patients with documented or suspected obstructive sleep apnea appear to be at particular risk because of opioid sensitivity, compounding the danger among rapid metabolizers in this group. Recently, various organizations and regulatory bodies, including the World Health Organization, the US Food and Drug Administration, and the European Medicines Agency, have promulgated stern warnings regarding the occurrence of adverse effects of codeine in children. These and other groups have or are considering a declaration of a contraindication for the use of codeine for children as either an analgesic or an antitussive. Additional clinical research must extend the understanding of the risks and benefits of both opioid and nonopioid alternatives for orally administered, effective agents for acute and chronic pain. PDF XIV Congreso Virtual Mexicano de Anestesiología 2017 Octubre 1-Diciembre 31, 2017 Información / Information Video informativo California Society of Anesthesiologists Reuniones / Events Informacion / Information

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