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.

http://onlinelibrary.wiley.com/doi/10.1111/j.1460-9592.2009.03187.x/pdf

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.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2390900/pdf/nihms45925.pdf

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.

http://www.anesthesia-analgesia.org/content/110/3/754.full.pdf+html

Atentamente

Dr. Enrique Hernández-Cortez

Anestesiología y Medicina del Dolor

www.anestesia-dolor.org

20 DE MARZO DE 2011

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 http://ow.ly/4hxkc

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….

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:

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

The Listings

Museum and Gallery Listings for March 18-24

Art in Review

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

By CAROL VOGEL

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

By EVE M. KAHN

As Asia Week arrives, and with it concerns over forgeries, dealers are focusing more than ever on pieces from well-researched collections

Multimedia

Slide Show

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.

Video

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.)

Video

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.

Slide Show

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, Ceramic Artist, Dies at 88

By WILLIAM GRIMES

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

By DAVID W. DUNLAP

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

INSIDE ART

Simultaneous Shows, One Indoors, One Out

By CAROL VOGEL

Robert Whitman’s “Passport” will have its premiere simultaneously at Dia:Beacon in the Hudson Valley and at Montclair State University in New Jersey.

March 18, 2011

Clark Art Institute Tries to Deaccession a Renoir at Maastricht Art Fair

In an unusual move, the Sterling and Francine Clark Art Institute in Williamstown, Mass., is trying to sell a Renoir from its collection at the European Fine Art Fair in Maastricht, the Netherlands.

March 18, 2011

Rockwell Group to Design Blue School Interiors

The Blue School is getting a permanent home in the former Seamen's Church Institute building, with interiors designed by the Rockwell Group.

March 17, 2011

Smithsonian Plan to Remove Murals From Los Angeles Lobby Is Criticized

The Smithsonian's National Museum of African American History and Culture is planning to buy and remove murals by the African-American painters Charles Alston and Hale Woodruff that now cover the lobby walls of a building in Los Angeles, over the objections of preservationists.

More Design News in ArtsBeat »

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

By RANDY KENNEDY

For months, unknown to museumgoers, artisans from overseas have been at work high above the Greek and Roman galleries, effecting a transformation.

Video | Slide Show

SPOTLIGHT | GREAT NECK

3-D Glasses Are Not Just for Movies Anymore

By STEVEN McELROY

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’

By MERYLE SECREST
Reviewed by HOLLAND COTTER

Meryle Secrest reassesses the painter Modigliani’s notoriously self-destructive life and his place in the modernist firmament.