jueves, 25 de agosto de 2011

8 Herramientas de Influencia


8 Herramientas de Influencia

 
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1.- ESCUCHAR
Cuando prestas atención y escuchas verdaderamente al otro , lo estas engrandeciendo porque lo haces sentir importante.
2.- PARTICIPACIÓN
No solo es comunicar a otro una cosa, sino que permites que forme parte de ella, y que se sienta que es tomado en cuenta.
3.- MODELAJE
Es la mejor manera de enseñar algo, es hacer tu lo que quieres que otros hagan y poder demostrar con hechos que si es posible.
4.- VALORACIÓN 
Es decirle a alguien cuanto lo apreciamos , respetamos y entregar reconocimiento, sabiendo que así la engrandecemos.
5.- EXPECTATIVAS
Lo que eres y lo que puedes llegar a ser, tratar a alguien como si tuviera un desempeño superior al que tiene  hará que lo logre.
6.- AMBIENTE Y RECURSOS
Dotar a un equipo de trabajo con ambiente y recursos superiores, mas allá de su desempeño, aumenta su rendimiento.
7.- CONFIANZA
Cuando entregas a otro un acto de confianza, le estas diciendo con hechos que valoras sus capacidades, talentos y capacidades.
8.- ENTUSIASMO
Cuando hablamos de nuestros propósitos entusiasmados, inevitablemente despertaremos en el otro ganas de unirse al proyecto.
Saludos

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Propofol y obesidad


Influencia de la obesidad sobre la farmacocinética del propofol: derivación de un modelo farmacocinético
Influence of obesity on propofol pharmacokinetics: derivation of a pharmacokinetic model.
Cortínez LI, Anderson BJ, Penna A, Olivares L, Muñoz HR, Holford NH, Struys MM, Sepulveda P.
Departamento de Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Hospital Clínico U. Católica, Marcoleta 367, PO Box 114-D, Santiago, Chile. licorti@med.puc.cl
Br J Anaesth. 2010 Oct;105(4):448-56. Epub 2010 Aug 14.
Abstract
BACKGROUND: The objective of this study was to develop a pharmacokinetic (PK) model to characterize the influence of obesity on propofol PK parameters. METHODS: Nineteen obese ASA II patients undergoing bariatric surgery were studied. Patients received propofol 2 mg kg(-1) bolus dose followed by a 5-20-40-120 min, 10-8-6-5 mg kg(-1) h(-1) infusion. Arterial blood samples were withdrawn at 1, 3, 5 min after induction, every 10-20 min during propofol infusion, and every 10-30 min for 2 h after stopping the propofol infusion. Arterial samples were processed by high-performance liquid chromatography. Time-concentration data profiles from this study were pooled with data from two other propofol PK studies available at http://www.opentci.org. Population PK modelling was performed using non-linear mixed effects model. RESULTS: The study involved 19 obese adults who contributed 163 observations. The pooled analysis involved 51 patients (weight 93 sd 24 kg, range 44-160 kg; age 46 sd 16 yr, range 25-81 yr; BMI 33 sd 9 kg m(-2), range 16-52 kg m(-2)). A three-compartment model was used to investigate propofol PK. An allometric size model using total body weight (TBW) was superior to all other models investigated (linear TBW, free fat mass, lean body weight, normal fat mass) for all clearance parameters. Variability in V2 and Q2 was reduced by a function showing a decrease in both parameters with age. CONCLUSIONS: We have derived a population PK model using obese and non-obese data to characterize propofol PK over a wide range of body weights. An allometric model using TBW as the size descriptor of volumes and clearances was superior to other size descriptors to characterize propofol PK in obese patients.
Efectos de las concentraciones en sitio de remifentanil en el mantenimiento de la homeostasis cardiovascular en respuesta al estímulo quirúrgico durante la anestesia con propofol guiada con BIS en pacientes seriamente obesos.
Effect site concentrations of remifentanil maintaining cardiovascular homeostasis in response to surgical stimuli during bispectral index guided propofol anesthesia in seriously obese patients.
Albertin A, La Colla G, La Colla L, Bergonzi PC, Deni F, Moizo E.
Department of Anesthesiology, IRCCS H. San Raffaele, Vita-Salute University of Milan, Milan, Italy. albertin.andrea@hsr.it
Minerva Anestesiol. 2006 Nov;72(11):915-24.
Abstract
AIM: The aim of this prospective study was to determine the effect site concentrations of remifentanil maintaining cardiovascular homeostasis in response to surgical stimuli during bispectral index (BIS) guided propofol anesthesia in seriously obese patients. METHODS: Twenty-two patients, female/male 15/7, ASA physical status II - III, aged 29-69 years, body mass index (BMI) 54.5+/-12, undergoing major open bariatric surgery, were enrolled to receive a propofol-remifentanil total intravenous anesthesia. All patients were intubated by using a flexible fiberoptic bronchoscopic technique facilitated by a target controlled effect site concentration of remifentanil set at 2.5 ng/mL. After endotracheal intubation, anesthesia was started with a target controlled infusion of propofol initially set at 6 microg/mL, then adjusted to maintain a BIS value between 40 and 50. The mean effect site concentration of remifentanil was recorded at different intervals time during surgery: skin incision-opening of peritoneum (T1), bowel resection (T2), cholecystojejunal anastomosis (T3), ileojejunal anastomosis (T4), closing of peritoneum (T5). RESULTS: The mean plasma concentrations of propofol required to maintain a BIS value between 40 and 50 were 4+/-0.55, 3.8+/-0.64, 3.8+/- 0.63, 3.8+/-0.65 and 3.8+/-0.63 microg/mL at T1, T2, T3, T4 and T5 interval time, respectively. The mean values of remifentanil target effect site concentration were 5.2+/-1.3, 7.7+/-1.7, 9.1+/-1.8, 9.7+/- 2.2 and 9.9+/-2.5 ng/mL at T1, T2, T3, T4 and T5 interval time. CONCLUSIONS: This study suggests that tolerance to remifentanil infusion is profound and develops very rapidly in morbidly obese patients submitted to open bariatric surgery during BIS guided propofol anesthesia. The administration of opiates during anesthesia based on target-controlled infusion should include
corrections for the development of tolerance
http://www.minervamedica.it/en/getfreepdf/ZOSA%252BA9LOLjgCQTSBOMAEvIT2ZMiR5o1I%252BEFcCh1Ko9GGU8ay27fLzd6uHpEWpvrqXn6sT9JXwQqRnyLnMOKag%253D%253D/R02Y2006N11A0915.pdf 
 
Rendimiento predictivo del la ¨formula de Servin¨ durante la infusión de propofol-remifentanil controlada al órgano blanco y guiada con BIS en obesos mórbidos 
Predictive performance of 'Servin's formula' during BIS-guided propofol-remifentanil target-controlled infusion in morbidly obese patients.
Albertin A, Poli D, La Colla L, Gonfalini M, Turi S, Pasculli N, La Colla G, Bergonzi PC, Dedola E, Fermo I.
Department of Anaesthesiology--IRCCS San Raffaele, Milan, Italy. albertin.andrea@hsr.it
Br J Anaesth. 2007 Jan;98(1):66-75. Epub 2006 Nov 27.
Abstract
BACKGROUND: The aim of this study was to assess the predictive performance of 'Servin's formula' for bispectral index (BIS)-guided propofol-remifentanil target-controlled infusion (TCI) in morbidly obese patients. METHODS: Twenty patients (ASA physical status II-III, age 32-64 yr) undergoing bilio-intestinal bypass surgery, were recruited. Anaesthesia was induced by using a TCI of propofol with an initial target plasma concentration of 6 microg ml(-1), then adapted to maintain stable BIS values ranging between 40 and 50. A TCI of remifentanil was added to achieve pain control and haemodynamic stability. For propofol, weight was corrected as suggested by Servin and colleagues. With ideal body weight (IBW) corrected according to formula suggested by Lemmens and colleagues. For remifentanil, weight was corrected according to IBW. Arterial blood samples for the determination of blood propofol concentrations were collected at different surgical times. The predictive performance of propofol TCI was evaluated by examining performance accuracy. RESULTS: Median prediction error and median absolute prediction error were -32.6% (range -53.4%; -2.5%) and 33.1% (10.8%; 53.4%), respectively. Wobble median value was 5.9% (2.5%; 25.2%) while divergence median value was -1.5% h(-1) (-7.7; 33.8% h(-1)). CONCLUSION: Significant bias between predicted and measured plasma propofol concentrations was found while the low wobble values suggest that propofol TCI system is able to maintain stable drug concentrations over time. As already suggested before, a computer simulation confirmed that the TCI system performance could be significantly improved when total body weight is used

http://bja.oxfordjournals.org/content/98/1/66.full.pdf+html 
 
Atentamente
Anestesiología y Medicina del Dolor

Esteroides y dolor postoperatorio


Esteroides para mejorar el dolor postoperatorio
Steroids to Ameliorate Postoperative Pain
Alparslan Turan, M.D., Daniel I. Sessler, M.D., Department
of Outcomes Research, The Cleveland Clinic, Cleveland,
Ohio. turana@ccf.orgwww.OR.org
Anesthesiology 2011; 115:457-9
Surgical tissue injury provokes a neuroendocrine stress response and inflammation. The neuroendocrine response can be moderated by regional or neuraxial anesthesia. However, the inflammatory response results largely from local release of mediators that then act systemically. It is widely believed that the inflammatory response to surgical tissue injury is responsible for serious complications including prolonged fatigue, atrial fibrillation, delirium, and prolonged intensive care unit stay. It is also likely that inflammation contributes to acute postoperative pain. A variety of antiinflammatory medications including lidocaine, selective cyclooxygenase-inhibitors, and other nonsteroidal anti-inflammatory drugs have thus been used in attempts to reduce surgical pain. The ultimate anti-inflammatory drugs, however, are steroids.

http://journals.lww.com/anesthesiology/Fulltext/2011/09000/Steroids_to_Ameliorate_Postoperative_Pain.6.aspx  
Dosis única perioperatoria de dexametasona para el dolor postoperatorio
Perioperative Single Dose Systemic Dexamethasone for Postoperative Pain: A Meta-analysis of Randomized Controlled Trials
De Oliveira, Gildàsio S. Jr M.D; Almeida, Marcela D. M.D.; Benzon, Honorio T. M.D., McCarthy, Robert J. Pharm.D.
Anesthesiology September 2011 - Volume 115 - Issue 3 - p 575-588
Background: Dexamethasone is frequently administered in the perioperative period to reduce postoperative nausea and vomiting. In contrast, the analgesic effects of dexamethasone are not well defined. The authors performed a meta-analysis to evaluate the dose-dependent analgesic effects of perioperative dexamethasone. Methods: We followed the PRISMA statement guidelines. A wide search was performed to identify randomized controlled trials that evaluated the effects of a single dose systemic dexamethasone on postoperative pain and opioid consumption. Meta-analysis was performed using a random-effect model. Effects of dexamethasone dose were evaluated by pooling studies into three dosage groups: low (less than 0.1 mg/kg), intermediate (0.11-0.2 mg/kg) and high (≥0.21 mg/kg). Results: Twenty-four randomized clinical trials with 2,751 subjects were included. The mean (95% CI) combined effects favored dexamethasone over placebo for pain at rest (≤4 h, −0.32 [0.47 to −0.18], 24 h, −0.49 [−0.67 to −0.31]) and with movement (≤ 4 h, −0.64 [−0.86 to −0.41], 24 h, −0.47 [−0.71 to −0.24]). Opioid consumption was decreased to a similar extent with moderate −0.82 (−1.30 to −0.42) and high −0.85 (−1.24 to −0.46) dexamethasone, but not decreased with low-dose dexamethasone −0.18 (−0.39-0.03). No increase in analgesic effectiveness or reduction in opioid use could be demonstrated between the high- and intermediate-dose dexamethasone. Preoperative administration of dexamethasone appears to produce a more consistent analgesic effect compared with intraoperative administration. Conclusion: Dexamethasone at doses more than 0.1 mg/kg is an effective adjunct in multimodal strategies to reduce postoperative pain and opioid consumption after surgery. The preoperative administration of the drug produces less variation of effects on pain outcomes
Dexametasona preoperatoria reduce el dolor postoperatorio, la nausea y vomito despues de mastectomía por cáncer de mama
Preoperative dexamethasone reduces postoperative pain, nausea and vomiting following mastectomy for breast cancer.
Gómez-Hernández J, Orozco-Alatorre AL, Domínguez-Contreras M, Oceguera-Villanueva A, Gómez-Romo S, Alvarez Villaseñor AS, Fuentes-Orozco C, González-Ojeda A.
Breast Tumor Clinic. Oncologic Institute of Jalisco, Health Secretary, CalleCoronel Calderon 715, Colonia El Retiro, Postal code 44280, Guadalajara, Jalisco, México.
BMC Cancer. 2010 Dec 23;10:692.
Abstract
BACKGROUND: Dexamethasone has been reported to reduce postoperative symptoms after different surgical procedures. We evaluated the efficacy of preoperative dexamethasone in ameliorating postoperative nausea and vomiting (PONV), and pain after mastectomy.
METHODS: In this prospective, double-blind, placebo-controlled study, 70 patients scheduled for mastectomy with axillary lymph node dissection were analyzed after randomization to treatment with 8 mg intravenous dexamethasone (n = 35) or placebo (n = 35). All patients underwent standardized procedures for general anesthesia and surgery. Episodes of PONV and pain score were recorded on a visual analogue scale. Analgesic and antiemetic requirements were also recorded. RESULTS: Demographic and medical variables were similar between groups. The incidence of PONV was lower in the dexamethasone group at the early postoperative evaluation (28.6% vs. 60%; p = 0.02) and at 6 h (17.2% vs. 45.8%; p = 0.03). More patients in the placebo group required additional antiemetic medication (21 vs. 8; p = 0.01). Dexamethasone treatment significantly reduced postoperative pain just after surgery (VAS score, 4.54 ± 1.55 vs. 5.83 ± 2.00; p = 0.004), at 6 h (3.03 ± 1.20 vs. 4.17 ± 1.24; p < 0.0005) and at 12 h (2.09 ± 0.85 vs. 2.54 ± 0.98; p = 0.04). Analgesics were required in more patients of the control group (21 vs. 10; p = 0.008). There were no adverse events, morbidity or mortality. CONCLUSIONS: Preoperative intravenous dexamethasone (8 mg) can significantly reduce the incidence of PONV and pain in patients undergoing mastectomy with axillary dissection for breast cancer.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3017064/pdf/1471-2407-10-692.pdf 
 
Atentamente
Dr. Juan Carlos Flores-Carrillo
Anestesiología y Medicina del Dolor

Writing problems common in kids with ADHD


Writing problems common in kids with ADHD

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NEW YORK | Mon Aug 22, 2011 5:14pm EDT
(Reuters Health) - Kids with attention-deficit hyperactivity disorder are more likely to have writing problems such as poor spelling and grammar than their peers, suggests a new study. And the difference may be especially conspicuous in girls with ADHD.
Reading and math problems often raise red flags for teachers and parents, but "written-language disorder is kind of overlooked," said study author Dr. Slavica Katusic, from the Mayo Clinic in Rochester, Minnesota.
Writing "is a critical skill for academic success, social and behavioral well-being," she added. And if writing problems aren't noticed early on and addressed in kids with ADHD, they can suffer long into adulthood, Katusic told Reuters Health.
According to the Centers for Disease Control and Prevention, close to 10 percent of kids ages four to 17 in the U.S. have ever been diagnosed with ADHD -- a number that has been on the rise in recent years.
The current study included close to 6,000 kids -- everyone born in Rochester between 1976 and 1982 who was still living there after age 5. Katusic and her colleagues tracked school, tutoring and medical records to see which kids showed signs of ADHD, as well as how well they performed on writing, reading and general intelligence tests through high school.
In total, 379 of the kids fit the criteria for ADHD, which was more common in boys than girls, the study authors report in Pediatrics. Of all kids in the study, just over 800 scored poorly on tests of writing abilities. Most kids who had trouble with writing also had reading difficulties.
Writing problems were much more common in both boys and girls with ADHD. Close to two-thirds of boys with ADHD had trouble with writing, compared to one in six boys without ADHD.
For girls, 57 percent with ADHD had a writing problem, compared to less than 10 percent without ADHD. And girls with ADHD were almost ten times more likely to have a combination of writing and reading disorders compared to girls without the condition.
Memory and planning problems in kids with ADHD may affect the writing process, the authors explain, and ADHD has been linked to learning disorders in the past.
Annette Majnemer, who has studied handwriting in kids with ADHD at McGill University in Montreal, Canada, said that many with the disorder seem to have difficulty with that component of writing.
"It might be partially the fact that they're inattentive and distractable and hyperactive," she told Reuters Health. It's also possible that motor skills and coordination problems are partly to blame, said Majnemer, who was not involved in the new research.
Katusic added that genetics might be behind both ADHD and some writing problems, but that in general, it's very hard to tease out exactly how ADHD is linked to writing and reading disorders.
Treatment for the ADHD, as well as individual education plans that address some of those related difficulties, can help, Katusic said -- especially if they're started when problems first arise.
"When parents notice something or teachers notice something, (kids) have to be treated not only for ADHD, but they have to be tested to see if they have other learning problems," she said.
"Clinicians and the teachers have to emphasize that the testing has to be done for everything, every kind of learning disability," Katusic said. "It has to be identified early and the treatment has to start early."
SOURCE: bit.ly/n0SSfj Pediatrics, online August 22, 2011.

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