Opioides intratecales/Spinal opioids

#Opioides intratecales #Spinal opioids Recomendaciones de opioides subaracnoideos en la práctica clínica del manejo del dolor postoperatorio Recommendations for spinal opioids clinical practice in the management of postoperative pain Borja Mugabure Bujedo Journal of Anesthesiology and Clinical Science 2013 Abstract Opioids have been considered the strongest option in clinical practice for the treatment of postoperative pain. However, in this setting, the spinal administration of an opioid drug does not always guarantee selective action and segmental analgesia in the spine due to partial reuptake to blood systemic circulation reaching brain receptors. Recent evidence from experimental studies indicates that bioavailability in the spinal cord biophase is negatively correlated with liposolubility, which is higher for hydrophilic opioids, than for lipophilic ones. Clinical guidelines recommend using a mixture of local anesthetic plus a strong opioid to improve the analgesic effect, minimize adverse effects and improve the overall patient´s satisfaction. Moreover, sometimes an opioid alone, typically morphine, can be administered to provide a long period of postoperative analgesia for 24 h, or even 48 h when an extended release epidural formulation is used. In all cases a vigilance protocol must be recommended to prevent either early or delayed respiratory depression. Keywords: Spinal analgesia, epidural opioids, intrathecal opioids, and postoperative pain PDF ¿Una dosis de morfina intratecal es suficiente como adyuvante en la analgesia controlada por el paciente para tratar en dolor postoperatorio después de cirugía de la columna lumbar? Estudio preliminar Is a single low dose of intrathecal morphine a useful adjunct to patient-controlled analgesia for postoperative pain control following lumbar spine surgery? A preliminary report. Yen D, Turner K, Mark D. Pain Res Manag. 2015 May-Jun;20(3):129-32. Abstract BACKGROUND: Several studies addressing intrathecal morphine (ITM) use following spine surgery have been published either involving the pediatric population, using mid- to high-dose ITM, or not in conjunction with morphine patient-controlled analgesia (PCA). OBJECTIVES: To determine whether low-dose ITM is a useful adjunct to PCA for postoperative pain control following elective lumbar spine surgery in adults. METHODS: Thirty-two patients were enrolled in a double-blinded randomized controlled trial, and received either ITM or intrathecal placebo. Postoperatively, all patients were given a PCA pump and observed for the first 24 h in a step-down unit. Measurements of: total PCA morphine consumed in the first 24 h; intensity of pain; pruritus; nausea at 4 h, 8 h and 24 h; time to first ambulation; length of hospital stay; and occurrences of respiratory depression were recorded. RESULTS: The total PCA use was significantly lower in the ITM group. There were lower average pain scores in the ITM group, which increased to that of the intrathecal placebo group over 24 h; however, this failed to attain statistical significance. There were no differences in nausea, pruritus, time to first ambulation or hospital length stay. There were no cases of respiratory depression in either group. CONCLUSIONS: ITM may be a useful adjunct to PCA, but did not decrease time to ambulation or length of stay. PDF Anestesia espinal con morfina en pacientes de hemorroidectomía abierta. Análisis prospectivo del control del dolor y complicaciones postoperatorias Morphine spinal block anesthesia in patients who undergo an open hemorrhoidectomy: a prospective analysis of pain control and postoperative complications. Moreira H Jr, Moreira JP, Isaac RR, Alves-Neto O, Moreira TA, Vieira TH, Brasil AM. Ann Coloproctol. 2014 Jun;30(3):135-40. doi: 10.3393/ac.2014.30.3.135. Epub 2014 Jun 23. Abstract PURPOSE: This study evaluated the use of adding morphine to bupivacaine in spinal anesthesia for pain control in patients who underwent an open hemorrhoidectomy. METHODS: Forty patients were prospectively selected for an open hemorrhoidectomy at the same institution and were randomized into two groups of 20 patients each: group 1 had a spinal with 7 mg of heavy bupivacaine associated with 80 µg of morphine (0.2 mg/mL). Group 2 had a spinal with 7 mg of heavy bupivacaine associated with distilled water, achieving the same volume of spinal infusion as that of group 1. Both groups were prescribed the same pain control medicine during the postoperative period. Pain scores were evaluated at the anesthetic recovery room and at 3, 6, 12, and 24 hours after surgery. Postoperative complications, including pruritus, nausea, headaches, and urinary retention, were also recorded. RESULTS: There were no anthropometric statistical differences between the two groups. Pain in the anesthetic recovery room and 3 hours after surgery was similar for both groups. However, pain was better controlled in group 1 at 6 and 12 hours after surgery. Although pain was better controlled for group 1 after 24 hours of surgery, the difference between the groups didn't achieved statistical significance. Complications were more common in group 1. Six patients (6/20) presented coetaneous pruritus and 3 with (3/20) urinary retention. CONCLUSION: A hemorrhoidectomy under a spinal with morphine provides better pain control between 6 and 12 hours after surgery. However,postoperative complications, including cutaneous pruritus (30%) and urinary retention (15%), should be considered as a negative side of this procedure. KEYWORDS: Hemorroidectomy; Postoperative pain; Urinary retention PDF Eficacia de la morfina vía subaraconidea en la analgesia postoperatoria de la histerectomía total abdominal y vaginal Oscar Urbina Peralta Actas Peru Anestesiol. 2012;20:92-7 Resumen Objetivo: Determinar la eficacia de la morfina vía subaracnoidea en la analgesia postoperatoria de la histerectomía total abdominal y vaginal. Material y métodos: Se formaron dos grupos, el grupo M que recibió morfina intratecal, tramadol y metamizol endovenosos, y el grupo S que recibió tramadol y metamizol endovenosos. Se evaluó la intensidad del dolor a través de la escala visual análoga (EVA), la dosis necesaria de los analgésicos empleados para lograr un adecuado control del dolor postoperatorio, el número de episodios de dolor y la presencia de efectos adversos (prurito, náuseas, vómitos, retención urinaria, grado de sedación y depresión respiratoria). Resultados: El grupo que recibió morfina subaracnoidea tenía una menor puntuación en la EVA en promedio durante las primeras 24 horas (p < 0.001), menor consumo de pentazocina (p < 0.001) y un menor número de episodios dolorosos (p < 0.001). La presencia de prurito y sedación fue mayor en el grupo M (p < 0.001), mientras que el número de episodios de náuseas fue mayor en el grupo S (p < 0.001) y no hubo diferencia en cuanto a la retención urinaria y al número de eventos de náuseas en ambos grupos (p > 0.05). No se presentaron casos de depresión respiratoria en ninguno de los dos grupos. Conclusión: La morfina por vía subaracnoidea (0.1 mg) es eficaz en el control del dolor postoperatorio en la histerectomía total abdominal y vaginal, su efecto adverso más frecuente es el prurito y no produce depresión respiratoria, lo que la convierte en una técnica analgésica sencilla y segura. DeCS: Eficacia; morfina; anestesia raquídea; analgesia; dolor postoperatorio; histerectomía. PDF Fisiología y farmacología clínica de los opioides epidurales e intratecales B. Mugabure , E. Echaniz y M. Marín Rev. Soc. Esp. del Dolor, Vol. 12, N.º 1, Enero-Febrero 2005 RESUMEN La historia de la anestesia intratecal y epidural ha discurrido en paralelo al desarrollo de la anestesia general. La primera reseña publicada sobre el uso de opioides para anestesia intradural la realizó un cirujano rumano, que presentó su experiencia en 1901 en París. Ha pasado casi un siglo hasta conseguir la utilización de opioides por vía epidural. En nuestros días, el uso de opioides intradurales y epidurales constituye una práctica clínica habitual para conseguir analgesia intra y postoperatoria. En los últimos 30 años, el uso de opioides epidurales se ha convertido en rutinario para el tratamiento del dolor del trabajo del parto y del manejo tanto del dolor agudo como crónico. Ha sido ampliamente asumido que cualquier opioide depositado en el espacio epidural o intratecal producirá una analgesia altamente selectiva medular y que esta será superior a la conseguida por otras técnicas analgésicas o vías de administración. Desafortunadamente esto simplemente no es verdad. De hecho, en multitud de ocasiones, los opioides son utilizados vía perimedular a pesar de que la evidencia clínica nos demuestra que no producen un efecto específico medular, o que la analgesia producida no es superior a la conseguida tras su administración intravenosa. Para realizar un uso apropiado de los opioides espinales, debemos comprender adecuadamente la fisiología y la farmacología clínica de estos fármacos y cuál produce analgesia selectiva medular y cuál no. Las diferencias son producto de la biodisponibilidad en los receptores específicos de su biofase medular en la sustancia gris. Esta es menor para los opioides lipofílicos, ya que son aclarados hacia el plasma con mayor rapidez que los hidrofílicos, y consecuentemente producen con mayor antelación efectos adversos supramedulares y su vida media es de menor duración. La morfina es probablemente el opioide con mayor acción selectiva medular tras su administración epidural o intradural. La metadona es otro fármaco al que se le ha observado una selectividad medular moderada tras su administración epidural. Sin embargo, su prolongada vida media puede resultar en su acumulación plasmática y presencia de efectos supraespinales a lo largo del tiempo. La administración epidural de fentanilo ofrece muy pocas ventajas sobre su utilización intravenosa, salvo en obstetricia donde parece producir una analgesia selectiva medular de grado moderado. Finalmente, la administración epidural de sufentanilo o alfentanilo parece producir analgesia por recaptación sistémica y redistribución hacia los receptores opioides cerebrales. Palabras clave: Epidural. Intradural. Opioides. Espinal. Analgesia. PDF

Atentamente Anestesia y Medicina del Dolor anestesia-dolor.org

Bibliotecologia. Alerta

bibliotecologia

NOTICIAS

Estudiantes de Buenos Aires visitarán la Biblioteca Pública de Misiones
Noticiasdel6.com
Más de 50 alumnos de la carrera de Bibliotecología, junto con sus docentes, recorrerán y estudiarán las tareas y servicios que ofrece la institución del ...

Anestesia y obesidad/Anaesthesia and obseity

Rápido despertar en los pacientes obesos: ¿Qué anestesia es mejor? Fast wake-up time in obese patients: Which anesthetic is best? Katznelson R. CJA June, 2015 PDF Comparación de los criterios de recuperación en pacientes con obesidad mórbida sometidos a manga gástrica laparoscópica después del uso de sevoflurano e isoflurano. Comparison of recovery criteria in morbidly obese patients undergoing laparoscopic gastric sleeve resection following use of sevoflurane and isoflurane. Rajan S, Narendran H, Andrews S. Anesth Essays Res. 2014 May-Aug;8(2):150-5. doi: 10.4103/0259-1162.134484. Abstract CONTEXT: The favorable kinetic properties of sevoflurane could be advantageous in obese patients undergoing bariatric surgery, improving recovery from general anesthesia (GA). AIMS: To compare the recovery criteria following anesthesia with sevoflurane and isoflurane in morbidly obese patients undergoing laparoscopic gastric sleeve resection. SETTINGS AND DESIGN: This was a prospective randomized controlled study conducted in 50 patients undergoing laparoscopic sleeve gastrectomy. MATERIALS AND METHODS: Following awake fiberoptic intubation, GA was induced and maintained with sevoflurane in Group A and isoflurane in Group B. 2% sevoflurane and 1.2% isoflurane were used and concentration varied to maintain a mean arterial pressure (MAP) of >75 mm of Hg, maximum concentration being 3% for sevoflurane and 2% for isoflurane. Inhalational agent was terminated at time of skin suturing and patients were extubated when completely awake. Recovery criteria followed were eye opening on call, voluntary head raising on command for 5 s and orientation assessed by answering name and location. STATISTICAL ANALYSIS USED: Student's t-test was used to test statistical significance of difference in mean values between the groups, analysis of covariance was used to test diastolic blood pressure (DBP) changes and Chi-square test to assess association between categorical variables. RESULTS: There was no significant variability in heart rate, systolic blood pressure, DBP and MAP between 2 groups up to 210 min. Group A patients had significantly faster eye opening compared to Group B (4.4 ± 1.6 vs. 9.2 ± 2.18 min), were significantly faster in obeying commands (6.08 ± 1.6 vs. 10.08 ± 2.02 min), had a significantly shorter extubation time (7.08 ± 1.6 vs. 11.16 ± 2.18 min) and significantly faster orientation in time as compared to Group B (9.24 ± 1.7 vs. 12.32 ± 2.42 min). CONCLUSION: Sevoflurane has a better recovery profile based on eye opening, obeying commands, time for extubation and orientation, than isoflurane in morbidly obese patients undergoing laparoscopic sleeve gastrectomy. KEYWORDS:Isoflurane; laparoscopic sleeve gastrectomy; obese; recovery; sevoflurane PDF Manejo anestésico de pacientes de cirugía bariátrica. Experiencia de dos años en una hospital en Suiza Anesthetic management of patients undergoing bariatric surgery: two year experience in a single institution in Switzerland. Lindauer B, Steurer MP, Müller MK, Dullenkopf A. BMC Anesthesiol. 2014 Dec 18;14:125. doi: 10.1186/1471-2253-14-125. eCollection 2014. Abstract BACKGROUND: In the field of anesthesia for bariatric surgery, a wide variety of recommendations exist, but a general consensus on the perioperative management of such patients is missing. We outline the perioperative experiences that we gained in the first two years after introducing a bariatric program. METHODS: The perioperative approach was established together with all relevant disciplines. Pertinent topics for the anesthesiologists were; successful airway management, indications for more invasive monitoring, and the planning of the postoperative period and deposition. This retrospective analysis was approved by the local ethics committee. Data are mean [SD]. RESULTS: 182 bariatric surgical procedures were performed (147 gastric bypass procedures (GBP; 146 (99.3%) performed laparascopically). GBP patients were 43 [10] years old, 78% female, BMI 45 [7] kg/m(2), 73% ASA physical status of 2. 42 patients (28.6%) presented with obstructive sleep apnea syndrome. 117 GBP (79.6%) patients were intubated conventionally by direct laryngoscopy (one converted to fiber-optic intubation, one aspiration of gastric contents). 32 patients (21.8%) required an arterial line, 10 patients (6.8%) a central venous line. Induction lasted 25 [16] min, the procedure itself 138 [42] min. No blood products were required. Two patients (1.4%) presented with hypothermia (<35 °C) at the end of their case. The emergence period lasted 17 [9] min. Postoperatively, 32 patients (21.8%) were transferred to the ICU (one ventilated). The other patients spent 4.1 [0.7] h in the post anesthesia care unit. 15 patients (10.2%) required take backs for surgical revision (two laparotomies). CONCLUSIONS: The physiology and anatomy of bariatric patients demand a tailored approach from both the anesthesiologist and the perioperative team. The interaction of a multi-disciplinary team is key to achieving good outcomes and a low rate of complications. KEYWORDS: Anesthesia; Bariatric surgery; Complications; Obesity PDF La influencia de laparoscopía vs. bypass gástrico abierto sobre las funciones hemodinámicas en la morbilidad de los obesos durante anestesia general The influence of laparoscopic vs. open gastric bypass on hemodynamic function in morbidly obese patients during general anesthesia. Gaszynski T, Szewczyk T. Wideochir Inne Tech Maloinwazyjne. 2014 Mar;9(1):83-8. doi: 10.5114/wiitm.2014.40988. Epub 2014 Feb 26. Abstract INTRODUCTION: The open or laparoscopic procedure has an important influence on the hemodynamic function in morbidly obese patients undergoing bariatric surgery. The anesthesiologist and surgeon must be aware of changes in hemodynamic performance during laparoscopy or laparotomy under general anesthesia. AIM: TO EVALUATE AND COMPARE THE HEMODYNAMICS IN TWO TYPES OF SURGERY: open vs. laparoscopic. MATERIAL AND METHODS: After obtaining the local ethics committee approval 60 morbidly obese (MO) patients (body mass index ≥ 40 kg/m(2)) scheduled for elective open or laparoscopic Roux-en-Y gastric bypass were included. Patients were allocated to study groups depending on the scheduled type of surgery (no randomization). General anesthesia with sevoflurane was performed. The hemodynamic parameters were recorded using a HemoSonic 100 device - a transesophageal Doppler measurement at time points: T1 - initial, T2 - after creating pneumoperitoneum (group PP) or opening the abdomen (group OP). RESULTS: Complete data were collected on 28 patients in group LP and 21 in group OP. There was no statistical difference between groups in demographic data. At time point T2 in both groups the parameters stroke volume, peak velocity and cardiac index decreased, and total systemic vascular resistance increased significantly compared to T1 (p < 0.05). In group LP the parameters cardiac output and acceleration (Acc) of blood decreased significantly compared to T1 (p < 0.05). There were significant differences between groups (p > 0.05) in cardiac output, total systemic vascular resistance and Acc, which were significantly higher in the OP group. In both groups mean arterial pressure increased and heart rate stayed similar to T1 with no significant difference (p > 0.05). No complications were observed. CONCLUSIONS: Pneumoperitoneum has a significant negative influence on hemodynamic function during laparoscopic bariatric procedures compared to open surgery in morbidly obese patients. KEYWORDS: anesthesia; hemodynamics; laparoscopy; laparotomy; obesity PDF

Atentamente Anestesia y Medicina del Dolor anestesia-dolor.org

Medwave: Edición Junio 2015 y Boletin eCampus

Los últimos artículos publicados en Medwave son los siguientes:


RESUMENES EPISTEMONIKOS

¿Es el carvedilol superior a otros betabloqueadores en pacientes con insuficiencia cardiaca?
Carmen Rain, Gabriel Rada (Chile)

Medwave 2015 Jun;15(Suppl 1):e6168
http://dx.doi.org/10.5867/medwave.2015.6168


¿Sirve la goma de mascar para acelerar la recuperación luego de una cirugía abdominal? – Primera actualización
Gabriel Rada, José Viñuela (Chile)

Medwave 2015;15(Suppl 1):e6162
http://dx.doi.org/10.5867/medwave.2015.6162


ESTUDIOS PRIMARIOS

Uso incorrecto de inhaladores de dosis medida en pacientes adultos de un hospital de Callao, Perú, 2014: estudio transversal
Alexandra Cayo-Quiñe, Valeria Martínez-Vargas, Rossi Bustamante-Voysest, Alejandro Piscoya, Yeny Alberca (Perú)

Medwave 2015;15(5):e6163
http://dx.doi.org/10.5867/medwave.2015.05.6163


RESUMENES EPISTEMONIKOS

¿Debemos agregar vancomicina en polvo a la profilaxis antibiótica en cirugía de columna?
Mario López, Marcelo Molina (Chile)

Medwave 2015 Jun;15(Suppl 1):e6160
http://dx.doi.org/10.5867/medwave.2015.6160


¿Tienen un rol los digitálicos en la insuficiencia cardiaca crónica? - Primera actualización
Carmen Rain, Gabriel Rada (Chile)

Medwave 2015 Jun;15(supl 1):e6149
http://dx.doi.org/10.5867/medwave.2015.6149


TEMAS Y CONTROVERSIAS EN BIOESTADÍSTICA

Uso de modelos de regresión para la determinación de factores de riesgo
Sergio Muñoz Navarro, Jorge Rodríguez Tobar (Chile)

Medwave 2015 Jun;15(5):e6154
http://dx.doi.org/10.5867/medwave.2015.05.6154


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GES05 Centros de responsabilidad en al ámbito de la salud a dictarse entre el 22 de julio y el 13 de octubre
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IAAS Prevención y control de infecciones asociadas a la atención de salud
http://www.medwave.cl/link.cgi/eCampus/IAAS

DGC Diplomado Gestión y protocolización de los cuidados
http://www.medwave.cl/link.cgi/eCampus/dipGCE/


PORTADA MEDWAVE
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PORTADA eCAMPUS
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Bibliotecas populares. Alerta

Bibliotecas populares
Notificaciones semanales ⋅ 24 de junio de 2015
NOTICIAS


Crónica Digital

Entregaron el libro “Trelew 72” a las bibliotecas populares
Crónica Digital
La Subsecretaría de Derechos Humanos de Chubut presentó el libro “Trelew 72” y entregó un ejemplar a cada una de las bibliotecas populares de la ...




Crónica Digital

El Gobierno Provincial entregó ejemplares del libro “Trelew 72” abibliotecas populares de ...
Crónica Digital
Del encuentro participaron integrantes de las distintas bibliotecas populares: la Biblioteca Municipal, la “Sofía Moll de Milton” de Kilómetro 8, ...




El Patagonico

“Trelew 72” fue entregado a bibliotecas para fomentar los Derechos Humanos
El Patagonico
“Trelew 72” fue entregado a bibliotecas para fomentar los Derechos ... de Chubut presentó “Trelew 72” a los referentes de bibliotecas populares.




FM Alba

82 años de la Biblioteca Juan Bautista Alberdi
FM Alba
Como todos los años, la Biblioteca Popular celebró un nuevo año más, destacando a socios y representantes locales de las letras, en un acto llevado ...




RapiDiario

“Ciencia en un clic” 2015
El Eco de Sunchales (Comunicado de prensa)
Leonardo Viotti, informó que el mismo está dirigido a jóvenes integrantes de Clubes de Ciencia, instituciones educativas, bibliotecas populares, ...




Perspectiva Sur

Hoy es la última jornada de Historia de Quilmes
Perspectiva Sur
Este año el curso se desarrolló como un trabajo en red entre dos Bibliotecas Populares. Fue una experiencia enriquecedora llevar la historia de ...

Ondansetron y embarazo/Ondansetron and pregnancy

Actualización en riesgo materno. ¿Es el ondansetron seguro durante el embarazo? Motherisk update. Is ondansetron safe for use during pregnancy? Koren G. Can Fam Physician. 2012 Oct;58(10):1092-3. Abstract QUESTION: While I usually prescribe doxylamine-pyridoxine for morning sickness, some of my patients with severe nausea and vomiting of pregnancy (NVP) receive ondansetron in hospital. I have read some new precautions recommended by the US Food and Drug Administration (FDA). Is ondansetron safe to use during pregnancy? ANSWER: During the past decade ondansetron has been increasingly used in the United States for NVP, owing to the lack of an FDA-approved drug for this condition. While fetal safety data for doxylamine-pyridoxine are based on more than a quarter of a million pregnancies, the fetal safety data for ondansetron are based on fewer than 200 births. Moreover, a recent case-control study suggested there was an increased risk of cleft palate associated with ondansetron. Recently, the FDA issued a warning about potentially serious QT prolongation and torsade de pointes associated withondansetron use; the warning included a list of precautions and tests that must be followed. The drug is not labeled for use in NVP in either the United States or Canada. Based on the data available today, ondansetron use cannot be assumed to be safe during pregnancy. PDF  Uso "fuera de etiqueta" de ondansetron en el embarazo, en Australia Occidental Off-label use of ondansetron in pregnancy in Western Australia. Colvin L, Gill AW, Slack-Smith L, Stanley FJ, Bower C. Biomed Res Int. 2013;2013:909860. doi: 10.1155/2013/909860. Epub 2013 Dec 12. Abstract AIMS: Nausea and vomiting of pregnancy is the most common medical condition in pregnancy. There is an increasing trend to prescribeondansetron although its safety for use in pregnancy has not been established. METHODS: Exposed pregnancies were all births in Western Australia, 2002-2005, where the mother was dispensed ondansetron under the Australian Pharmaceutical Benefits Scheme, compared with all other births during the same period. Outcomes investigated include maternal and child characteristics, birth defects, pregnancy, and delivery characteristics. RESULTS: There were 96,968 births from 2002 to 2005. Ondansetron was dispensed to 251 pregnant women during this period. The women dispensed ondansetron were more likely to be privately insured (OR: 5.8; 95% CI: 4.3-7.9), to be Caucasian (3.3; 1.9-5.7), not to smoke during their pregnancy (2.9; 1.8-4.7), to have a multiple birth (2.7; 1.5-5.0), and to have used fertility treatment (1.8; 1.0-3.4). There was a small but not significantly increased risk of a major birth defect with first trimester exposure (1.2; 0.6-2.2). CONCLUSIONS:Our study did not detect any adverse outcomes from the use of ondansetron in pregnancy but could not conclude that ondansetronis safe to use in pregnancy. PDF Ondansetron en el embarazo y riesgo de resultados adversos Ondansetron in pregnancy and risk of adverse fetal outcomes. Pasternak B, Svanström H, Hviid A. N Engl J Med. 2013 Feb 28;368(9):814-23. doi: 10.1056/NEJMoa1211035. Abstract BACKGROUND: Ondansetron is frequently used to treat nausea and vomiting during pregnancy, but the safety of this drug for the fetus has not been well studied. METHODS: We investigated the risk of adverse fetal outcomes associated with ondansetron administered during pregnancy. From a historical cohort of 608,385 pregnancies in Denmark, women who were exposed to ondansetron and those who were not exposed were included, in a 1:4 ratio, in propensity-score-matched analyses of spontaneous abortion (1849 exposed women vs. 7396 unexposed women), stillbirth (1915 vs. 7660), any major birth defect (1233 vs. 4932), preterm delivery (1792 vs. 7168), and birth of infants at low birth weight and small for gestational age (1784 vs. 7136). In addition, estimates were adjusted for hospitalization for nausea and vomiting during pregnancy (as a proxy for severity) and the use of other antiemetics. RESULTS: Receipt of ondansetron was not associated with a significantly increased risk of spontaneous abortion, which occurred in 1.1% of exposed women and 3.7% of unexposed women during gestational weeks 7 to 12 (hazard ratio, 0.49; 95% confidence interval [CI], 0.27 to 0.91) and in 1.0% and 2.1%, respectively, during weeks 13 to 22 (hazard ratio, 0.60; 95% CI, 0.29 to 1.21). Ondansetron also conferred no significantly increased risk of stillbirth (0.3% for exposed women and 0.4% for unexposed women; hazard ratio, 0.42; 95% CI, 0.10 to 1.73), any major birthdefect (2.9% and 2.9%, respectively; prevalence odds ratio, 1.12; 95% CI, 0.69 to 1.82), preterm delivery (6.2% and 5.2%; prevalence odds ratio, 0.90; 95% CI, 0.66 to 1.25), delivery of a low-birth-weight infant (4.1% and 3.7%; prevalence odds ratio, 0.76; 95% CI, 0.51 to 1.13), or delivery of a small-for-gestational-age infant (10.4% and 9.2%; prevalence odds ratio, 1.13; 95% CI, 0.89 to 1.44). CONCLUSIONS: Ondansetron taken during pregnancy was not associated with a significantly increased risk of adverse fetal outcomes. (Funded by the Danish Medical Research Council.). PDF Medicamentos para nausea y vomito en el embarazo y el riesgo de defectos de nacimiento seleccionados. Medications used to treat nausea and vomiting of pregnancy and the risk of selected birth defects. Anderka M1, Mitchell AA, Louik C, Werler MM, Hernández-Diaz S, Rasmussen SA; National Birth Defects Prevention Study. Birth Defects Res A Clin Mol Teratol. 2012 Jan;94(1):22-30. doi: 10.1002/bdra.22865. Epub 2011 Nov 19. Abstract BACKGROUND: Nausea and vomiting of pregnancy (NVP) occurs in up to 80% of pregnant women, but its association with birth outcomes is not clear. Several medications are used for the treatment of NVP; however, data are limited on their possible associations with birth defects. METHODS: Using data from the National Birth Defects Prevention Study (NBDPS)-a multi-site, population-based, case-control study-we examined whether NVP or its treatment was associated with the most common noncardiac defects in the NBDPS (nonsyndromic cleft lip with or without cleft palate [CL/P], cleft palate alone [CP], neural tube defects, and hypospadias) compared with randomly selected nonmalformed live births. RESULTS: Among the 4524 cases and 5859 controls included in this study, 67.1% reported first-trimester NVP, and 15.4% of them reported using at least one agent for NVP. Nausea and vomiting of pregnancy was not associated with CP or neural tube defects, but modest risk reductions were observed for CL/P (adjusted odds ratio [aOR] = 0.87; 95% confidence interval [CI], 0.77-0.98) and hypospadias (aOR = 0.84; 95% CI, 0.72-0.98). Regarding treatments for NVP in the first trimester, the following adjusted associations were observed with an increased risk: proton pump inhibitors and hypospadias (aOR = 4.36; 95% CI, 1.21-15.81), steroids and hypospadias (aOR = 2.87; 95% CI, 1.03-7.97), and ondansetron and CP (aOR = 2.37; 95% CI, 1.18-4.76), whereas antacids were associated with a reduced risk for CL/P (aOR = 0.58; 95% CI, 0.38-0.89). CONCLUSIONS: NVP was not observed to be associated with an increased risk of birth defects; however, possible risks related to three treatments (i.e., proton pump inhibitors, steroids and ondansetron), which could be chance findings, warrant further investigation. PDF Tratamiento de las náuseas del embarazo en los Estados Unidos. Se necesitan cambios en la prescripción Treating morning sickness in the United States--changes in prescribing are needed. Koren G. Am J Obstet Gynecol. 2014 Dec;211(6):602-6. doi: 10.1016/j.ajog.2014.08.017. Epub 2014 Aug 20. Abstract Presently, 97.7% of prescriptions for the treatment of nausea and vomiting in pregnancy in the United States are with medications not labeled for use in pregnancy, not indicated for nausea and vomiting in pregnancy, and not classified as safe in pregnancy by the Food and Drug Administration. The use of ondansetron for nausea and vomiting in pregnancy has increased from 50,000 monthly prescriptions in 2008 to 110,000 at the end of 2013, despite unresolved issues regarding fetal safety and Food and Drug Administration warnings about serious dysrhythmias. In April 2013, the Food and Drug Administration approved the combination of doxylamine and pyridoxine, specifically for nausea and vomiting in pregnancy symptoms. Now that a safe and effective drug is available in the United States, there is no reason for women to be exposed to a drug of unproven maternal and fetalsafety. PDF Nausea y vomito en el embarazo temprano Nausea and vomiting in early pregnancy. Festin M. BMJ Clin Evid. 2009 Jun 3;2009. pii: 1405. Abstract INTRODUCTION: More than half of pregnant women suffer from nausea and vomiting, which typically begins by the 4th week and disappears by the 16th week of pregnancy. The cause of nausea and vomiting in pregnancy is unknown, but may be due to the rise in human chorionic gonadotrophin concentration. In 1 in 200 women, the condition progresses to hyperemesis gravidarum, which is characterised by prolonged and severe nausea and vomiting, dehydration, and weight loss. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatment for nausea and vomiting in early pregnancy? What are the effects of treatments for hyperemesis gravidarum? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2008 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 30 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions: acupressure; acupuncture; antihistamines; corticosteroids; corticotrophins; diazepam; dietary interventions other than ginger; domperidone; ginger; metoclopramide; ondansetron; phenothiazines; and pyridoxine (vitamin B6). PDF

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Ondansetron

Estudio comparativo de ondansetron y dosis subhipnóticas de propofol en el control y tratamiento del prurito inducido por sufentanil intratecal en cesárea electiva The comparative study of intravenous Ondansetron and sub-hypnotic Propofol dose in control and treatment of intrathecal Sufentanil-induced pruritus in elective caesarean surgery. Hirmanpour A, Safavi M, Honarmand A, Hosseini AZ, Sepehrian M. J Res Pharm Pract. 2015 Apr-Jun;4(2):57-63. doi: 10.4103/2279-042X.155751. Abstract OBJECTIVE: Pruritus is a common and disturbing side effect of neuraxial opioids after cesarean section. The purpose of this study was to compare the efficacy of intravenous ondansetron and sub-hypnotic dose of propofol in control and treatment of intrathecal sufentanil induced pruritus in cesarean surgery. METHODS: Totally, 90 parturient with American Society of Anesthesiology physical status grade I-II, undergoing spinal anesthesia with 2.5 μg sufentanil and 10 mg bupivacaine 0.5% were enrolled to this randomized, prospective, double-blind study. The women were randomly assigned to two groups who received 8 mg ondansetron or 10 mg propofol to treat pruritus grade ≥3. The patient was evaluated after 5 min and in the lack of successful treatment, the doses of two drugs repeated and if the pruritus is on-going, the exact treatment with naloxone was done. FINDINGS: The incidence of pruritus was 69.3%. Both groups were well-matched. The peak time pruritus was 30-75 min after injection. The percentage of individuals consumed naloxone were 6.8% and 15.9% in ondansetron and propofol groups, respectively (P = 0.18). The mean score of satisfaction (according to visual analog scale criteria) was 9.09 ± 1.1 in ondansetron group and 9.3 ± 1.07 in the propofol group (P = 0.39). CONCLUSION: Ondansetrone and sub-hypnotic dose of propofol are both safe and well-tolerated. Due to their same efficacy in the treatment of intrathecal sufentanil-induced pruritus, they can be widely used in clinical practice. KEYWORDS: Caesarean surgery; Ondansetron; Propofol; intrathecal opioid; pruritus PDF   Administración profiláctica de ondansetron en la prevención de prurito y nausea y vomito inducidos por morfina intratecal en pacientes con cesárea. Prophylactic administration of ondansetron in prevention of intrathecal morphine-induced pruritus and post-operative nausea and vomiting in patients undergoing caesarean section. Koju RB, Gurung BS, Dongol Y. BMC Anesthesiol. 2015 Feb 17;15:18. doi: 10.1186/1471-2253-15-18. Abstract BACKGROUND: Intrathecal morphine is commonly used for post caesarean analgesia. However, their use is frequently associated with the incidence of troublesome side effects such as nausea, vomiting and pruritus. Various mechanisms have been postulated for the opioid-inducedpruritus, with a variety of medications with different mechanisms of actions formulated for the prevention and treatment. But, the results are inconsistent and hence the prevention and treatment of opioid-induced pruritus still remains a challenge. Ondansetron which is antiemetic, non-sedative and has no antianalgesic effect is an antagonist to 5-HT3 receptor, the receptor with which opioids interacts and imparts its effects.Ondansetron, thus, would be an attractive treatment strategy for both opioid-induced pruritus and post-operative nausea and vomiting. METHODS: After the approval from institutional review committee and written consent received from the patient, 50 healthy parturients of ASA I and II physical status undergoing caesarean section under spinal anaesthesia were enrolled for the study. They were randomly categorized into placebo group (2 ml normal saline) and treatment group (2 ml of 4 mg ondansetron), each group containing 25 patients. Pruritus and post-operative nausea and vomiting scores were recorded up to 24 hours after the administration of intrathecal morphine. Statistical analysis was performed using chi-square test. RESULTS: The incidence, severity and necessity of treatment for pruritus in the treatment group was significantly reduced compared to the placebo group (16% vs 88%). Similarly, the risk of post-operative nausea and vomiting in the treatment group was less compared to the placebo group (8% vs 56%). CONCLUSION: Prophylactic administration of ondansetron to parturients receiving intrathecal morphine for post-operative analgesia provides a significant reduction of intrathecal morphine-induced pruritus and nausea and vomiting. PDF

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Recordarán a Rafael Bernal con curso sobre novela criminal y ciclo de cine en el CC Elena Garro

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Recordarán a Rafael Bernal con curso sobre novela criminal y ciclo de cine en el CC Elena Garro Posted: 22 Jun 2015 04:59 PM PDT El Centro Cultural Elena Garro brinda un homenaje al escritor Rafael Bernal, a cien años de su nacimiento, con la programación de dos actividades que tienen como marco el llamado género negro, cultivado con éxito en varias de las obras de Bernal. El pretexto perfecto será la más memorable de las novelas policiacas hechas en este país: El complot mongol, libro de culto entre los amantes de este género, y obra con la que Bernal alcanzara la inmortalidad en las letras mexicanas. Inician los festejos con la programación del curso México Negro: panorama de la novela criminal contemporánea en México, impartido por el también escritor Eduardo Antonio Parra, quien realizará un repaso sobre las características del género negro, desde su aparición en la literatura anglosajona, su devenir a través de los años, los modelos extranjeros que han influido en los escritores mexicanos para adaptarlos a nuestra cultura y a nuestro país, y subrayará su evolución en la literatura mexicana. A partir de la segunda sesión hasta el final del curso se comentarán las obras que fueron conformando la novela criminal en México: partiremos Ensayo de un crimen, de Rodolfo Usigli. El complot mongol, de Rafael Bernal, que será la pieza angular del curso, para seguir con Dos crímenes, de Jorge Ibargüengoitia, Cosa fácil, de Paco Ignacio Taibo II, Luna de escarlata, de Rolo Díez, Linda 67, de Fernando del Paso, El miedo a los animales, de Enrique Serna y Balas de plata, de Élmer Mendoza. Mediante la charla con los participantes se identificará el valor literario de estas obras, y el tipo de sociedad y de país que cada uno de los autores plasmó en sus páginas como telón de fondo de sus historias. México Negro: panorama de la novela criminal contemporánea en México inicia el próximo martes, 23 de junio, en un horario de 12 a 14 horas. La segunda invitación responde a una muestra del género negro llevada a la pantalla grande, como parte de los ciclos de Cineclub, que se realizan todos los lunes a las 18:30 horas en el Centro Cultural. El ciclo es Cine negro, y tomará, nuevamente como pretexto para hablar de Bernal, su novela El complot mongol, adaptada al cine en 1977 por Antonio Eceiza. A pesar de no ser una producción de gran factura, la proyección servirá para charlar del escritor, de la obra original y de lo que se queda y lo que se va al realizar esta adaptación. En ese marco, se contemplan algunas películas que conformarán el ciclo Cine negro. Entre los nombres que están por confirmar se encuentran El Halcón Maltés de John Huston, de 1941, La sombra de una duda, de Alfred Hitchcock, 1943,  Ensayo de un crimen, de Luis Buñuel, 1955, Cadena perpetua, de Arturo Ripstein, 1979 y Terciopelo Azul, de David Lynch, 1986. Todas las películas, como cada  lunes de Cineclub serán presentadas y comentadas por gente de cine o literatura, especialistas en el tema. La cita es a las 18:30 horas, los lunes del mes de agosto en el Centro Cultural Elena Garro. La entrada es libre. Sobre los autores Rafael Bernal nació en la Ciudad de México el 28 de junio de 1915. Sus primeras obras publicadas datan de 1941, pero fue hasta 1969 cuando alcanza un mayor reconocimiento en las letras mexicanas con la publicación de El complot mongol, Pero la creación literaria de Rafael Bernal fue más que un solo libro. Hizo dramaturgia, cuentos, y programas para radio y televisión. Algunas de sus obras en la línea policiaca son las novelas Su nombre era muerte, Tres novelas policíacas, Un muerto en su tumba. Publicó algunas obras de teatro como Antonia, El maíz en la casa y La paz contigo, de corte histórico y social, y su único libro de versos Improperio a Nueva York y otros poemas. Bernal fue además un viajero incansable, gracias a su participación en la diplomacia mexicana. Estudió en el Colegio Francés de San Borja y en el Instituto de Ciencias y Letras de Ciudad de México; el bachillerato lo hizo en el Loyola College de Montreal, Canadá. Después de recibir el doctorado en literatura en la Universidad de Friburgo, Suiza,  en 1972, murió a la edad de 57 años. Eduardo Antonio Parra es narrador y ensayista, autor de cuentos y novelas enmarcadas en la corriente narrativa denominada Literatura del Norte. Entre su obra publicada se encuentran los libros de cuentos Los límites de la noche, Tierra de nadie, Parábolas del silencio; las novelas Nostalgia de la sombra y Juárez. El rostro de piedra. Ha sido merecedor de diferentes premios como el Internacional de Cuento Juan Rulfo 2000, El Premio Nacional de cuento Efrén Hernández 2004 y Premio Antonin Artaud 2010, entre otros galardones. El Centro Cultural Elena Garro está ubicado en el número 43 de la calle Fernández Leal, en el Barrio de la Concepción, Coyoacán, México, D. F.

Opioides i.v. / I.V. opioids

Revisión clínica de opioides intravenosos en cuidado agudo Clinical review of intravenous opioids in acute care Mark J. McKeen and Sadeq A. Quraishi Journal of Anesthesiology and Clinical Science 2013, Abstract Opioids are routinely used in the management of moderate to severe pain. However, in the acute care setting, consistently undertreated and suboptimally managed pain continues to be a problem. Given the potential for opioids to result in lifethreatening situations, and the increasing complexity of the patients that are cared for in acute care facilities, a thorough understanding of intravenous opioid therapy is a necessity for hospital-based clinicians. Opioids can be classified by chemical structure and/or drug effect (i.e. action on Mu, Kappa, and Delta opioid receptors throughout the body). Endogenous opioids include endorphins, enkephalins, and dynorphins, which moderate the body's natural response to pain. Commonly used exogenous intravenous opioids include morphine, hydromorphone, fentanyl, meperidine, methadone, buprenorphine, butorphanol, and nalbuphine, which vary greatly in potency, duration of action, metabolism, and in their adverse effect profile. A growing body of evidence suggests that patient controlled analgesia may be superior to conventional methods (need for analgesia determined by clinicians) of treating pain in the acute care setting. Newer pump delivery systems may also decrease the risks of human and equipment errors as well as enhance patient safety and satisfaction. The purpose of this review is to help guide clinicians in the safe and effective management of pain in patients requiring intravenous opioid therapy in the acute care setting. Keywords: Acute pain, acute care, opioid, PCA PDF Impacto de la edad, sexo y ruta de administración sobre los eventos adversos de los opioides en el departamento de emergencias. Estudio retrospectivo Impact of age, sex and route of administration on adverse events after opioid treatment in the emergency department: a retrospective study. Daoust R, Paquet J, Lavigne G, Piette É, Chauny JM. Pain Res Manag. 2015 Jan-Feb;20(1):23-8. PDF Estudio clínico aleatorizado de un protocolo con hidromorfona intravenosa versus el cuidado habitual en el dolor agudo de los ancianos en el departamento de urgencias. Randomized clinical trial of an intravenous hydromorphone titration protocol versus usual care for management of acute pain in older emergency department patients. Chang AK, Bijur PE, Davitt M, Gallagher EJ. Drugs Aging. 2013 Sep;30(9):747-54. doi: 10.1007/s40266-013-0103-y. Abstract BACKGROUND AND OBJECTIVES: Opioid titration is an effective strategy for treating pain; however, titration is generally impractical in the busy emergency department (ED) setting. Our objective was to test a rapid, two-step, hydromorphone titration protocol against usual care in older patients presenting to the ED with acute severe pain. METHODS: This was a prospective, randomized clinical trial of patients 65 years of age and older presenting to an adult, urban, academic ED withacute severe pain. The study was registered at http://www.clinicaltrials.gov (NCT01429285). Patients randomized to the hydromorphone titration protocol initially received 0.5 mg intravenous hydromorphone. Patients randomized to usual care received any dose of any intravenous opioid. At 15 min, patients in both groups were asked, 'Do you want more pain medication?' Patients in the hydromorphone titration group who answered 'yes' received a second dose of 0.5 mg intravenous hydromorphone. Patients in the usual care group who answered 'yes' had their ED attending physician notified, who then could administer any (or no) additional medication. The primary efficacy outcome was satisfactory analgesia defined a priori as the patient declining additional analgesia at least once when asked at 15 or 60 min after administration of the initial opioid. Dose was calculated in morphine equivalent units (MEU: 1 mg hydromorphone = 7 mg morphine). The need for naloxone to reverse adverse opioid effects was the primary safety outcome. RESULTS: 83.0 % of 153 patients in the hydromorphone titration group achieved satisfactory analgesia compared with 82.5 % of 166 patients in the usual care group (p = 0.91). Patients in the hydromorphone titration group received lower mean initial doses of opioids at baseline than patients in the usual care group (3.5 MEU vs. 4.7 MEU, respectively; p ≤ 0.001) and lower total opioids through 60 min (5.3 MEU vs. 6.0 MEU; p = 0.03). No patient needed naloxone. CONCLUSIONS: Low-dose titration of intravenous hydromorphone in increments of 0.5 mg provides comparable analgesia to usual care with lessopioid over 60 min. PDF Comparación de nalbufina con morfina en sus efectos analgésicos y seguridad. Meta-análisis de estudios aleatorizados controlados A comparision of nalbuphine with morphine for analgesic effects and safety : meta-analysis of randomized controlled trials. Zeng Z, Lu J, Shu C, Chen Y, Guo T, Wu QP, Yao SL, Yin P. Sci Rep. 2015 Jun 3;5:10927. doi: 10.1038/srep10927. PDF

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