domingo, 20 de marzo de 2011

Auditoría Nacional de la American Pediatric Association sobre infusiones de opioides


Auditoría Nacional de la American Pediatric Association sobre infusiones de opioides
APA national audit of pediatric opioid infusions.
Morton NS, Errera A.
Pediatric Anesthesia & Pain Management, Royal Hospital for Sick Children, Glasgow, Scotland. neilmorton@mac.com
Paediatr Anaesth. 2010 Feb;20(2):119-25. Epub 2009 Nov 3.
Abstract
INTRODUCTION: A prospective audit of neonates, infants, and children receiving opioid infusion techniques managed by pediatric acute pain teams from across the United Kingdom and Eire was undertaken over a period of 17 months. The aim was to determine the incidence, nature, and severity of serious clinical incidents (SCIs) associated with the techniques of continuous opioid infusion, patient-controlled analgesia, and nurse-controlled analgesia in patients aged 0-18. METHODS: The audit was funded by the Association of Paediatric Anaesthetists (APA) and performed by the acute pain services of 18 centers throughout the United Kingdom. Data were submitted weekly via a web-based return form designed by the Document Capture Company that documented data on all patients receiving opioid infusions and any SCIs. Eight categories of SCI were identified in advance, and the reported SCIs were graded in terms of severity (Grade 1 (death/permanent harm); Grade 2 (harm but full recovery and resulting in termination of the technique or needing significant intervention); Grade 3 (potential but no actual harm). Data were collected over a period of 17 months (25/06/07-25/11/08) and stored on a secure server for analysis. RESULTS: Forty-six SCIs were reported in 10 726 opioid infusion techniques. One Grade 1 incident (1 : 10,726) of cardiac arrest occurred and was associated with aspiration pneumonitis and the underlying neurological condition, neurocutaneous melanosis. Twenty-eight Grade 2 incidents (1 : 383) were reported of which half were respiratory depression. The seventeen Grade 3 incidents (1 : 631) were all drug errors because of programming or prescribing errors and were all reported by one center. CONCLUSIONS: The overall incidence of 1 : 10,000 of serious harm with opioid infusion techniques in children is comparable to the risks with pediatric epidural infusions and central blocks identified by two recent UK national audits (1,2). Avoidable factors were identified including prescription and pump programming errors, use of concurrent sedatives or opioids by different routes and overgenerous dosing in infants. Early respiratory depression in patients with specific risk factors, such as young age, neurodevelopmental, respiratory, or cardiac comorbidities, who are receiving nurse-controlled analgesia or continuous opioid infusion suggests that closer monitoring for at least 2 h is needed for these cases. As a result of this audit, we can provide parents with better information on relative risks to help the process of informed consent.
  
Seguridad de administración simultánea de opioides epidurales e intravenosos para dolor postoperatorio en pacientes pediátricos oncológicos
The safety of concurrent administration of opioids via epidural and intravenous routes for postoperative pain in pediatric oncology patients.
Anghelescu DL, Ross CE, Oakes LL, Burgoyne LL.
Division of Anesthesia and Pain Management Service, Division of Patient Care Services, St. Jude Children's Research Hospital, Memphis, TN 38105-2794, USA. doralina.anghelescu@stjude.org<doralina.anghelescu@stjude.org>
J Pain Symptom Manage. 2008 Apr;35(4):412-9. Epub 2008 Mar 4.
Abstract
Supplementation of epidural opioid analgesia with intravenous opioids is usually avoided because of concern about respiratory depression. However, the choice of adjunct analgesic agents for pediatric oncology patients is limited. Antipyretic drugs may mask fever in neutropenic patients, and nonsteroidal anti-inflammatory agents may exert antiplatelet effects and interact with chemotherapeutic agents. We examined the safety of concurrent use of epidural and intravenous opioids in a consecutive series of 117 epidural infusions in pediatric patients and compared our findings to those reported by other investigators. We observed a 0.85% rate of clinically significant respiratory complications. The single adverse event was associated with an error in dosage. In our experience, the supplementation of epidural opioid analgesia with intravenous opioids has been a safe method of postoperative pain control for pediatric patients with cancer.


Una encuesta nacional de la American Pediatric Anesthesiologists: La analgesia controlada por el paciente y otras terapias por vía intravenosa de opioides en el manejo del dolor pediátrico agudo.
A national survey of American Pediatric Anesthesiologists: patient-controlled analgesia and other intravenous opioid therapies in pediatric acute pain management.
Nelson KL, Yaster M, Kost-Byerly S, Monitto CL.
Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Anesth Analg. 2010 Mar 1;110(3):754-60.
Abstract
BACKGROUND: The influence of patient characteristics, institutional demographics, and published practice guidelines on the provision of IV opioid analgesia, particularly as delivered through a patient-controlled analgesia (PCA) delivery device, to pediatric patients is unknown.
METHODS: We sent a national, web-based, descriptive survey of pediatric pain management practice to select members of the Society for Pediatric Anesthesia to assess institutional demographics, availability and implementation of IVPCA and PCA by proxy, and recalled occurrence of serious and life-threatening opioid-related side effects. RESULTS: Data from respondents at 252 institutions throughout the United States were collected and analyzed. Sixty-nine percent of respondents practiced in a children's hospital or children's center within a general hospital, and 51% of institutions had a pediatric pain service. Virtually all pediatric pain services (91%) were administered by departments of anesthesiology. Pediatric pain service availability correlated with the number of pediatric beds. IVPCA was available to pediatric patients at 96% of institutions surveyed, whereas IVPCA by proxy was available at only 38%. Eleven percent of respondents reported that their hospital no longer provided IVPCA by proxy as a result of the 2004 Joint Commission on Accreditation of Hospitals Sentinel Event Warning. Instructional material concerning IVPCA was provided to patients or their families by 40% of institutions. IVPCA orders were handwritten by 55% of respondents, despite 39% having computerized provider order entry systems. Ninety percent of respondents reported using pulse oximetry monitoring when patients were administered IVPCA. Forty-two respondents recalled patients having received naloxone to counteract the cardiopulmonary side effects of opioids during the year before receipt of the survey. Eight respondents recalled patient deaths having occurred over the past 5 years in patients receiving IVPCA, IVPCA by proxy, and continuous non-IVPCA opioid infusions. CONCLUSIONS: Although IVPCA was available to pediatric patients at most institutions surveyed, prescribing practices and supervision of pediatric pain management were influenced by patient characteristics, institutional demographics, and published national guidelines. Recalled life-threatening events were reported in conjunction with all modes of opioid infusion therapy. Interventions that might diminish the incidence of adverse events but are not used to their fullest extent include improved education and implementation of systems designed to minimize human error involved in the prescribing of opioids. Providing a more accurate accounting of complications would require institutions to participate in a prospective data-collecting consortium designed to track both the incidence of therapy and associated complications.


Atentamente
Dr. Enrique Hernández-Cortez 
Anestesiología y Medicina del Dolor

La puerta de San Pedro


20 DE MARZO DE 2011


La puerta de San Pedro


El coche llegó a recogerme; yo ya estaba allí esperando con la chaqueta negra que se lleva a este tipo de lugares.


-Hola.
-Hola, hijo, ¿cómo estás?
-Bien. ¿Cuándo ha sido?
-Ayer.


(...)


-Oíd, papá, mamá, estaba pensando...
-¿Sí?
-Los padres que veo en el hospital a los que se les han muerto los hijos...
-¿Qué les pasa?
-...se quedan hechos polvo de por vida. No se recuperan.
-No sé, es lógico.
-¿Sí?
-Sí.
-Si yo me muero antes que vosotros, no me gustaría que estuvieseis así de mal.
-¿Cómo?
-Quiero decir, que no es lo más probable, pero puede ocurrir.
-Pero hijo, ¿estás pensando en matarte?
-Para nada, estoy muy contento de estar vivo.
-¿Entonces?
-Si yo me muero, con el hecho de que vosotros estéis tristes el resto de vuestra vida, no vais a conseguir nada.
-Hombre, visto así...
-En serio, si eso ocurre, no me gustaría que vuestra vida se hundiera, porque no beneficiaría a nadie. Preferiría que siguiérais disfrutando todo lo posible. No sé si es descabellado, pero si vosotros podéis tener algo que yo ya no, ¿por qué ibais a renunciar a ello?
-Hemos llegado.


Siempre es muy difícil aparcar en estos sitios.


Foto: La puerta de San Pedro.

Diabetic Neuropathy and Neuroarthropathy

Diabetic Neuropathy and Neuroarthropathy by Nihal Thomas, Christian Medical College and Hospital, Vellore, India 

Globalización y lentitud en la toma de decisiones en dos imágenes


Posted: 20 Mar 2011 01:00 AM PDT
Hablamos a menudo de un nosotros cada vez más amplio, de una sociedad más empática y sensible gracias a los múltiples mecanismos de interconectividad, de fluidez informativa abundante en la sociedad red.
También de cómo echamos de menos la flexibilidad, la rapidez en la toma de decisiones institucionales en unas sociedades cada vez más complejas e imprevisibles. Libia es el ejemplo más reciente y sangrante de ello y somos muchos/as los que, además de tener claro que la violencia solo generará más violencia (“La guerra es la paz” decía una terrible frase del Gran Hermano en el 1984 de Orwell), pensamos que las decisiones se han tomado demasiado tarde, que sea como sea son muchas las vidas que han quedado ya por el camino.
Hablábamos hace poco de cómo perdían fuerza los estados, de cómo la globalización hacia aparecer nuevas instituciones y normas en áreas en las que casi la única jurisdicción era hasta hace poco nacional.
¿Quizás estemos creando en su lugar, como vemos en el primer diagrama, que nos deja Cory Doctorow, burocracias excesivas?
Parlamento Europeo, Comisión Europea, diversos consejos de ministros corren en paralelo a las instituciones de cada territorio, cuyo trabajo consiste, cada vez más, en resolver los dilemas políticos y conflictos que un dibujo como el siguiente genera.  En el caso de Libia se añade la OTAN….

5509980924_8227fac906_b

Creo que nos queda claro que globalización significa complejidad, más si miramos, como lo hacen en Global Sociology, el organigrama de Naciones Unidas, estructurado por agencias transnacionales y que termina teniendo la siguiente estructura:

unchart
En fin, sea como sea, en un mundo en duelo permanente, #prayforlibia.

The Listings


INSIDE ART
“Embrace” (1982) is part of “Robert Mapplethorpe: 50 Americans,” to open in May at the Sean Kelly Gallery in Chelsea.

Simultaneous Shows, One Indoors, One Out

Robert Whitman’s “Passport” will have its premiere simultaneously at Dia:Beacon in the Hudson Valley and at Montclair State University in New Jersey.
ANTIQUES
A 19th-century Japanese lacquer container to hang from clothing is in the Elinor T. Nordskog collection at Sydney L. Moss.

Asia Week Dealers Stress Provenance

As Asia Week arrives, and with it concerns over forgeries, dealers are focusing more than ever on pieces from well-researched collections
    Multimedia
    Bringing the Met Into the 1300s
    Moroccan craftsmen are creating a new 14th-century courtyard in the Islamic art galleries of the Metropolitan Museum of Art.
    Moroccan Artisans at the Met
    A look at some of the Moroccan craftsmen at work in a courtyard being created in the Islamic art galleries of the Metropolitan Museum of Art. (Video courtesy of the Met.)
    Ancient Chinese Art
    Maxwell Hearn, the new head of Asian Art at The Metropolitan Museum of Art, demonstrates the ancient art of understanding and appreciating Chinese scroll paintings.
    Elegant Attire of a Cereal Heiress
    An exhibit shows off wedding dresses and other riches of the Marjorie Merriweather Post family.

    Arts


    Toshiko Takaezu in 1990 with some of her “closed form” works outside her studio in Quakertown, N.J.
    Toshiko Takaezu in 1990 with some of her “closed form” works outside her studio in Quakertown, N.J.
    Ms. Takaezu helped to move clay from a functional role to one of abstraction and creative expression.

    Brian Lanker, Pulitzer-Winning Photojournalist, Dies at 63

    Mr. Lanker, who won a Pulitzer Prize in 1973, focused on intimate portrayals of American lives.
    INSIDE ART

    Simultaneous Shows, One Indoors, One Out

    Robert Whitman’s “Passport” will have its premiere simultaneously at Dia:Beacon in the Hudson Valley and at Montclair State University in New Jersey.
    Abderrazak Bahij and other craftsmen from Morocco at work on the arches in a courtyard being created at the heart of the Islamic art galleries of the Metropolitan Museum of Art.

    History’s Hands

    For months, unknown to museumgoers, artisans from overseas have been at work high above the Greek and Roman galleries, effecting a transformation.
    SPOTLIGHT | GREAT NECK
    RE-VIEW “Hologramic Energy #13.”

    3-D Glasses Are Not Just for Movies Anymore

    The work of two artists who paint complex images that gradually reveal additional layers to viewers who step to one side or dons 3-D glasses is being displayed at the Great Neck Arts Center.
    “All charm, all impulsiveness, all disdain”: Amedeo Modigliani, circa 1916.

    ‘Modigliani: A Life’

    Meryle Secrest reassesses the painter Modigliani’s notoriously self-destructive life and his place in the modernist firmament.
    ART REVIEW
    Manabu Ikeda's “Existence” (2004) represents the world as a giant, decomposing tree.

    Anxiety on the Fault Line

    A new exhibition of 16 artists at Japan Society highlights recent Japanese works that reveal a mood of anxiety.
    ART REVIEW
    “Emaciated Siddhartha” can be seen until Thursday at the Nancy Wiener Gallery.

    Big Continent, Much to See

    A quick guide to the highlights of Asia Week at galleries around New York.
    ART REVIEW
    Sonia Delaunay in Paris, 1925.

    Swatches Illuminate a Painter’s Other Art

    Fabric designs predominate in this exhibition of the work of Sonia Delaunay at the Cooper-Hewitt, National Design Museum.
    ART REVIEW
    “The Glass House” is a near-miniature rendering of the interior of Philip Johnson's Glass House.

    Dispatches From the Kvetchnyan Ambassador

    “Various Illuminations (of a Crazy World),” at the Jewish Museum, explores Maira Kalman’s typically wry, gently satiric take on the delights and discomfitures of metropolitan life.

    Promising Exhibitions From Coast to Coast

    Museums are offering ambitious shows, including the first large-scale United States exhibition of Helmut Newton’s work and the only East Coast booking of a traveling showcase of Picasso’s career.
    Ian Padgham of the San Francisco Museum of Modern Art, Erin Coburn of the Metropolitan Museum of Art, Robert Stein of the Indianapolis Museum of Art and Shelley Bernstein, chief technology officer at the Brooklyn Museum

    The Spirit of Sharing

    Social media technology has created new opportunities for museums to create interactivity inside and outside of their walls.
    A model of Frank Ghery's planned Guggenheim Abu Dhabi.

    Abu Dhabi Guggenheim Faces Protest

    More than 130 artists are demanding better conditions for workers building a Guggenheim museum in Abu Dhabi.

    A Growing Use of Private Art in Public Spaces

    The artistic and ethical issues raised by single-collector exhibitions are being overshadowed by their convenience and cost savings.
    ORGANIZED Lisa Freiman, American commissioner for the 2011 Venice Biennale.

    A Curator With a Penchant for the Collective

    Lisa Freiman, the commissioner of the American pavilion at this year’s Venice Biennale, has long held an interest in artistic duos.

    Revista Evidencias en Pediatría

    Revista Evidencias en Pediatría 
    Asociación Española de Pediatría




    Semana repleta de interesantes noticias y tvweets. Vamos al tajo.

    Azucena Santillán ("Enfermería Basada en la Evidencia") nos habla de "Lectura Crítica 2.0". ¿A qué se refiere? Se refiere a la actualización y colocación en una plataforma web de las fichas de lectura crítica de OSTEBA. Quizá algunos de vosotros las conozcais ya y las hayais usado. Y si no es así, teneis una oportunidad estupenda de familiarizaros con este instrumento que tanto facilita la labor de valoración critica de artículos científicos. El acceso a la herramienta es gratuito previo registro. ¿Os animais?.

    En "Sala de Lectura", Carlos Fernández Oropesa nos informa de cómo, pese a todas las evidencias disponibles, se siguen publicando en revistas indizadas en bases de datos internacionales, revistas "de prestigio", artículos que siguen recomendando intervenciones no ya ineficaces sino perjudiciales para la salud. El nombre de su entrada es autoexplicativa y a su lectura os remito: "(PLoS Med) La opinión de expertos como forma de promocionar los medicamentos".

    En "Biblioteca Médica Virtual", María García Puente nos notifica que PubMed ya se puede consultar desde dispositivos móviles. La herramienta en cuestión se llama de momento PubMed Mobile Beta. Así que, para aquellos de vosotros que no podais pasaros sin hacer búsquedas en PubMed cuando esteis desconectados de vuestro ordenador, ya teneis la posibilidad de seguir vuestra labor con los dispositivos móviles que useis.

    A la hora de interpretar los resultados de cualquier estudio sabemos que los mismos, representados de forma relativa, "impactan más" sobre el lector que cuando se muestran de forma absoluta (que es la situación ideal). De ello nos habla esta semana Giordano Pérez Gaxiola ("Sin Estetoscopio") en su entrada titulada "Lo relativo es más persuasivo".

    Sobre la introducción de la estrategia de la Atención Integral a Enfermedades Prevalentes en la Infancia (AIEPI) nos hablan en "Hij@s de Eva y Adán". Escriben lo siguiente: "La estrategia AIEPI ofrece ventajas frente a otras estrategias basadas en enfoques centrados en una única enfermedad. En la mayoría de ocasiones, en los países en vías de desarrollo, un diagnóstico único resulta inviable y en cierta medida irreal, ya que suelen padecer más de una enfermedad. La AIEPI toma en consideración de forma integrada los factores de riesgos graves que pueden afectar a la salud infantil, garantizando el tratamiento combinado de las principales enfermedades infatiles y poniendo énfasis en la vertiente preventiva a través de las vacunaciones y la mejora de la nutrición".

    En "El Médico de mi hij@", Jesús Martínez nos ofrece un repaso de la alimentación infantil durante el primer año.

    En "Con Estetoscopio" abordan el difícil tema de la reanimación cardiopulmonar pediátrica y sobre cuando parar ("Pienso que es tiempo de parar...").

    Existiendo como existen tantos y tan graves problemas sanitarios a nivel mundial, es triste que en el "primer mundo" nos interesemos de "tontinoticias" sobre salud. Noticias sonrojantes. Vicente Baos nos las cuenta en clave de humor y de denuncia. Tiene razón (Blog "El Supositorio", entrada "Tonterías que nos distraen"). Leed las "noticias" que nos cuenta Vicente. Merece la pena.

    Mediante la cuenta de twitter de la Colaboración Cochrane me entero de que esta organización ha inaugurado blog propio. Aquí lo teneis: http://www.cochrane.org/blog. Ya lo he añadido al blogroll de esta bitácora. Y mediante la cuenta en twitter de "El rincón de Sísifo" nos enteramos de un importanteestudio publicado en Lancet sobre los valores de normalidad de las frecuencia cardiaca y respiratoria de los niños desde el nacimiento hasta los 18 años. Se trata de una revisión sistemática de estudios observacionales que habrá que leer con detenimiento.

    El Victor Ravens Diario

    El Victor Ravens Diario: "Domingo, Mar. 20, 2011

    El Victor Ravens Diario
    compartido por Victor Ravens + 1197 usuarios seguidos en Twitter"

    sábado, 19 de marzo de 2011

    Treatment of Renal and Mesenteric Aneurysms

    Treatment of Renal and Mesenteric Aneurysms by Nicholas J. Morrssey, MD Columbia University, New York, NY

    Busqueda bibliográfica