Propofol / Imagen del Mes/ Image of the month

Propofol. Ver galerí­a completa

Mujer de 65 años, 86.6 kg, talla 252 cm, ASA 2, obesa, con la pared abdominal péndula, que se sometió a abdominoplastia de pubis hasta xifoides. La analgesia se proporciona con 3 litros de solución tumescente (lidocaína 500 mg + 1000 mg de epinefrina/litro. Lidocaína total 1500 mg igual a 17.3 mg/kg) y 50 mg i.v. de ketamina. La paciente se fue monitorizada con ECG, presión arterial no invasiva, oximetría de pulso y BIS/EMG. Una bolsa de 1000 mL de solución i.v. se colocó bajo los hombros para aumentar la tensión en el músculo geniogloso y facilitar el mantenimiento de la vía aérea. Se utilizaron oxígeno nasal 2 litros/min y ketamina i.v. 50 mg 3 minutos antes de la infiltración de la pared abdominal. El nivel estable cerebral de propofol pre-ketamina fue facilitado con inducción de propofol con incrementos de 50 µg/kg titulados a 60 <BIS <75 con la línea base EMG. (Ver You Tube Going under with Goldilocks anesthesia). La sedación se continuó con propofol en bomba de infusión ajustado a 50 µg/kg/min) para tener 60 <BIS <75. Los picos en el EMG fueron tratados con 400 µg/kg de propofol hasta que el EMG regresó a la línea de base. La analgesia postoperatoria con 25 mL de bupivacaína 0.25% inyectada a través de cada uno de los tubos de drenaje, total de 125 mg (50 mL). Imágenes cortesía del Dr. Barry Friedberg     http://drfriedberg.com/  Women 65 years old, 191lbs, ASA 2, obese, with pendulous abdominal wall, which underwent pubis to xiphoid abdominoplasty. Analgesia was provided with 3 liters tumescent solution (lidocaine 500 mg + 1000 µg epinephrine/each liter. Total lidocaine 1500 mg equal to 17.3 mg/kg) and 50 mg i.v. ketamine. She was monitored with ECG, NIBP, pulse oximetry and BIS/EMG. A 1000 mL i.v. solution bag was placed under her shoulders to increase tension in the genioglossus muscle and facilitate the maintenance of the airway. Nasal oxygen 2 L/min and i.v. ketamine 50 mg 3 minutes prior to infiltration of the abdomen wall were used. Stable pre-ketamine propofol brain level was facilitated by incremental propofol induction @ 50 mcg/kg titrated to 60<BIS<75 with baseline EMG. (See You Tube Going under with Goldilocks) Sedation was continued with infusion pump propofol set to 50 mcg /kg/min) to have 60<BIS<75. EMG spikes were treated with 400 mcg/kg propofol until EMG returned to baseline. Postoperative analgesia with bupivacaine 0.25% 25 mL injected through each drain, total 125 mg (50 mL). Images courtesy of Barry Firedberg MD.     http://drfriedberg.com/  Propofol en cirugía Plástica "de consultorio" Propofol in office-based plastic surgery. Friedberg BL. Semin Plast Surg. 2007 May;21(2):129-32. doi: 10.1055/s-2007-979214. Abstract Propofol is the nearly ideal agent for office-based plastic surgery. Among all anesthetic agents, only propofol has the ability to elicit happiness in this special group of patients. Cosmetic surgery patients will tolerate discomfort in preference to postoperative nausea and vomiting. Propofol is a powerful antiemetic agent. Patient safety will not be optimized unless the person responsible for the administration of propofol has airway management skills. Dedicated anesthesia providers are highly skilled in airway management. Although the short half-life of propofol is seductive for a fast-acting, rapid emerging anesthetic, interindividual differences in propofol response make measurement of the target organ (i.e., the brain) with a bispectral index (BIS) monitor very important. BIS levels < 45 for > 1 hour are associated with increased 1-year anesthesia mortality thought to be associated with an inflammatory response. The only currently available way to avoid overmedicating with propofol is to monitor with a level of consciousness monitor like BIS. KEYWORDS: BIS monitor; Propofol; anesthesia; ketamine; office-based plastic surgery PDF Anestesia disociativa para cirugía plástica en el ¨consultorio¨ Dissociative anesthesia in an office-based plastic surgery practice. Vinnik CA. Semin Plast Surg. 2007 May;21(2):109-14. doi: 10.1055/s-2007-979211. Abstract In 1974, the author began to use ketamine in association with diazepam for cosmetic and reconstructive procedures. Since then, through courses in the United States and abroad, well over a thousand plastic surgeons have been taught the technique. Ketamine, by itself, ablates sensory input of pain at the thalamic level but has been associated with hallucinations, bad dreams, and other untoward effects. These can be prevented by the use of benzodiazepines, which "bracket" the use of ketamine. If the patient is sedated and awakens under the influence of these agents, there is no adverse ketamine effect. Specific techniques and adjunct agents are described. KEYWORDS: Ketamine; Robinul®; Valium®; Versed®; dissociative anesthesia; fentanyl; midazolam PDF Protocolo con ketamina-diazepam para sedación intravenosa. Experiencia en el hospital de cirugía estética. Ketamine-diazepam protocol for intravenous sedation: The cosmetic surgery hospital experience. Quttainah A, Carlsen L, Voice S, Taylor J. Can J Plast Surg. 2004 Fall;12(3):141-3. Abstract Rising hospital costs and operating room scheduling difficulties have influenced plastic surgeons to rely more often on intravenous sedation in office surgical settings. The use of ketamine as an intravenous sedation agent has enjoyed some popularity, but this has been far from universal. Its reputation for producing psychological sequelae such as nightmares, flashbacks and schizophrenic-like reactions have made many anesthesiologists and plastic surgeons reluctant to use this drug. The authors' experience using a ketamine/diazepam protocol with approximately 11,400 patients since 1971 at the Cosmetic Surgery Hospital in Woodbridge, Ontario is presented. The methodology consists of intravenous diazepam followed with low-dose ketamine (0.5 mg/kg to a maximum of 40 mg) 2 min later. This provides the surgeon with a period of profound amnesia to allow for infiltration of the local anesthetic. It is this local anesthetic delivered during the dissociative state that provides prolonged analgesia throughout thesurgery. The patient is maintained throughout the procedure with increments of diazepam and midazolam. This protocol is found to be effective, reliable and reproducible, and the experience of the patient and plastic surgeon has been overwhelmingly favourable. KEYWORDS: Intravenous sedation; Ketamine; Office anesthesia PDF Procedimientos de sedación y analgesia para la cirugía de mama fuera del hospital: una visión general de la técnica de sedación y analgesia. Procedural sedation and analgesia for out-of-hospital breast surgery: an overview of the procedural sedation and analgesia technique Louw AJ, South Afr J Anaesth Analg 2014;20(1):89-92 Abstract Out-of-hospital surgical procedures are a rapidly growing market. This has led to surgical procedures that were previously limited to the hospital operating room, with general anaesthesia being performed outside the hospital with sedation and regional anaesthesia. Breast surgery, whether cosmetic, reconstructive or diagnostic, also follows this trend. The aim of this refresher course is to give an overview of the nerve supply to the breast, to explain the type of blocks used and to provide an overview of the sedation technique. The audience should have a better acceptance of performing procedural sedation and analgesia (PSA) for this type of surgery out of hospital after this overview. The author will also provide an overview during the presentation of his own current practice of performing these procedures. PDF Consejos de expertos Tips from the tops Barry Friedberg PDF Videoclips sobre propofol y anestesia Videos on propofol and anesthesia Videos

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PRURITO / PRURITUS

El receptor H4 de histamina: del huérfano a la clínica. The histamine H4 receptor: from orphan to the clinic. Thurmond RL. Front Pharmacol. 2015 Mar 31;6:65. doi: 10.3389/fphar.2015.00065. eCollection 2015. Abstract The histamine H4 receptor (H4R) was first noted as a sequence in genomic databases that had features of a class A G-protein coupled receptor. This putative receptor was found to bind histamine consistent with its homology to other histamine receptors and thus became the fourth member of the histamine receptor family. Due to the previous success of drugs that target the H1 and H2 receptors, an effort was made to understand the function of this new receptor and determine if it represented a viable drug target. Taking advantage of the vast literature on the function of histamine, a search for histamine activity that did not appear to be mediated by the other three histamine receptors was undertaken. From this asthma andpruritus emerged as areas of particular interest. Histamine has long been suspected to play a role in the pathogenesis of asthma, but antihistamines that target the H1 and H2 receptors have not been shown to be effective for this condition. The use of selective ligands in animal models of asthma has now potentially filled this gap by showing a role for the H4R in mediating lung function and inflammation. A similar story exists for chronicpruritus associated with conditions such as atopic dermatitis. Antihistamines that target the H1 receptor are effective in reducing acute pruritus, but are ineffective in pruritus experienced by patients with atopic dermatitis. As for asthma, animal models have now suggested a role for the H4R in mediating pruritic responses, with antagonists of the H4R reducing pruritus in a number of different conditions. The anti-pruritic effect of H4R antagonists has recently been shown in human clinical studies, validating the preclinical findings in the animal models. A selective H4R antagonist inhibited histamine-induced pruritus in health volunteers and reduced pruritus in patients with atopic dermatitis. The history to date of the H4R provides an excellent example of the deorphanization of a novel receptor and the translation of this into clinical efficacy in humans. KEYWORDS: arthritis; asthma; atopic dermatitis; histamine; pruritus PDF Hidrocloruro de Nalfurafina para tratar el prurito. Una revisión Nalfurafine hydrochloride to treat pruritus: a review. Inui S. Clin Cosmet Investig Dermatol. 2015 May 11;8:249-55. doi: 10.2147/CCID.S55942. eCollection 2015. Abstract Uremic pruritus has a great negative influence on quality of life in hemodialysis (HD) patients and, importantly, negatively affects mortality risk. Recently, nalfurafine hydrochloride, an opioid κ-selective agonist, has been officially approved for resistant pruritus in HD patients on the basis of a well-evidenced clinical trial in Japan. From clinical observation, it has been suggested that the upper neuron system plays a role in its pathogenesis. According to previous experimental results, using mice injected with opioids, dynorphin suppresses itch through binding κ-opioid receptors, suggesting that κ-opioid opioid receptor agonists act as potential therapeutic reagents for pruritus in HD patients. In Japan, a large-scale placebo-controlled study was performed to examine the efficacy and safety of oral nalfurafine hydrochloride for intractable pruritus in 337 HD patients. Two daily doses of 2.5 or 5 μg nalfurafine or placebo were orally administered for 2 weeks, and clinical responses were analyzed. The results showed that the mean decrease in the visual analog scale for pruritus from baseline was 22 mm in the 5 μg nalfurafine hydrochloride group (n=114) and 23 mm in the 2.5 μg group (n=112). These reductions were statistically significant compared with 13 mm, which is the mean decrease of visual analog scale in the placebo group (n=111), demonstrating that nalfurafine is an effective and safe drug for uremic pruritus in HD patients. Moreover, another open-label trial (n=145) examining the long-term effect of 5 μg oral nalfurafine revealed the maintenance of the antipruritic effect of nalfurafine for 52 weeks. In addition, on the basis of recent data showing κ-opioid receptor expression in the epidermis of atopic dermatitis and psoriasis, nalfurafine hydrochloride also can be potentially used for these two skin diseases. KEYWORDS: hemodialysis; nalfurafine hydrochloride; opioid κ-selective agonist; uremic pruritus PDF Tratamiento del prurito en hepatopatias crónicas Management of pruritus in chronic liver disease. Bhalerao A, Mannu GS. Dermatol Res Pract. 2015;2015:295891. doi: 10.1155/2015/295891. Epub 2015 Mar 10. Abstract Background. There continues to be uncertainty on the ideal treatment of pruritus in chronic liver disease. The aim of this study was to gather the latest information on the evidence-based management of pruritus in chronic liver disease. Methodology. A literature search for pruritus in chronic liver disease was conducted using Pubmed and Embase database systems using the MeSH terms "pruritus," "chronic liver disease," "cholestatic liver disease," and "treatment." Results. The current understanding of the pathophysiology of pruritus is described in addition to detailing research into contemporary treatment options of the condition. These medical treatments range from bile salts, rifampicin, and opioid receptor antagonists to antihistamines. Conclusion. The burden of pruritus in liver disease patients persists and, although it is a common symptom, it can be difficult to manage. In recent years there has been greater study into the etiology and treatment of the condition. Nonetheless, pruritus remains poorly understood and many patients continue to suffer, reiterating the need for further research to improve our understanding of the etiology and treatment for the condition. PDF Medicamentos para el tratamiento del adulto en cuidado paliativo Drug treatments for pruritus in adult palliative care. Siemens W, Xander C, Meerpohl JJ, Antes G, Becker G. Dtsch Arztebl Int. 2014 Dec 12;111(50):863-70. doi: 10.3238/arztebl.2014.0863. Abstract BACKGROUND: Pruritus is a rare but troublesome symptom in palliative-care patients with a variety of underlying diseases. The pharmacotherapy ofpruritus is often off-label, and an evidence-based evaluation is needed. METHODS: A Cochrane Review published in 2013 was updated with a systematic literature search up to January 2014. Randomized and controlled trials (RCTs) with adult palliative-care patients were included. RESULTS: In the 43 RCTs that were analyzed, three of which were more recent than the Cochrane Review, 8 clinically relevant active substances were investigated in a total of 19 RCTs. Effective drugs for pruritus in palliative-care patients included paroxetine for pruritus of diverse origins (1 RCT; strong effect) and indomethacin for HIV-induced prutitus (1 RCT; median effect = moderate reduction). Effective drugs for pruritus in uremia were gabapentin (2 RCTs; strong effect), nalfurafin (3 RCTs; moderate effect), naltrexone (3 RCTs; heterogeneous effects, ranging from weak to strong), and cromoglicic acid (2 RCTs; moderate to strong effect). Effective drugs for cholestatic pruritus were rifampicin (3 RCTs; moderate effect), flumecinol (2 RCTs; weak to moderate effect), and naltrexone (2 RCTs; moderate to strong effect). Undesired effects were most common with naltrexone (dizziness: 0% -50% , http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4296209/pdf/Dtsch_Arztebl_Int-111-0863.pdf nausea: 0% -50% ) and nalfurafin (nasopharyngitis: 8% -12% , insomnia: 7% -15%). CONCLUSION: In view of the diverse etiologies of pruritus in palliative-care patients, careful consideration should be given to the choice of drug used to treat it. The substances listed here have moderate to strong antipruritic effects and merit further study in RCTs of high methodological quality. PDF

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El camino neuronal que conduce al placer

Fuente
Este artículo es originalmente publicado en:
http://www.madrimasd.org/informacionidi/noticias/noticia.asp?id=63914&origen=notiweb&dia_suplemento=lunes
mi+dtv: El camino neuronal que conduce al placer


Esta semana mi+dtv trata sobre la caracterización de los mecanismos neuronales que intervienen en la sensación del placer; los efectos beneficiosos de la vacuna contra el sarampión y los genes que regulan el tamaño de algunas frutas.

FUENTE | madri+d

Dexmedetomidina en cirugía ambulatoria/Dexmedetomidine in day case surgery

¿Es la dexmedetomidina mejor que la combinación de propofol y fentanil en casos de cirugía menor ambulatoria? Estudio prospectivo, aleatorizado y doble ciego Is dexmedetomidine better than propofol and fentanyl combination in minor day care procedures? A prospective randomised double-blind study. Tomar GS, Singh F, Ganguly S, Gaur N. Indian J Anaesth 2015;59:359-64 Abstract Background and Aims: The growing popularity and trend of day care (ambulatory) anaesthesia has led to the development of newer and efficient drug regimen. We decided to evaluate the efficacy of two drug regimens namely dexmedetomidine and propofol with midazolam and fentanyl for moderate sedation characteristics in minor surgical procedures in terms of analgesia, intra-operative sedation, haemodynamic stability and side effects related. Methods: Totally, 60 adult American Society of Anaesthesiologists class I-II patients posted for day care surgeries of duration <45 min divided into two groups; Group D, where dexmedetomidine loading dose at 1 μg/kg was administered over 10 min followed by maintenance infusion initiated at 0.6 μg/kg/h and titrated to achieve desired clinical effect with dose ranging from 0.2 to 0.7 μg/kg, Group P, where midazolam at 0.02 mg/kg and fentanyl at 2 μg/kg IV boluses were given followed by propofol infusion. Statistical analysis was done using student t-test, analysis of variance and Chi-square analysis. P < 0.05 was considered to be significant. Results:Degree of sedation (Observer's Assessment of Activity and Sedation Scale ≤3) was comparable in both groups (P > 0.05). Rescue analgesia with fentanyl was needed in 30% patients of Group D compared to 17.63% patients of Group P (P < 0.05). The level of arousal was faster and better in Group D at 5 min after the procedure (P < 0.05). Haemodynamics were stable in Group D as with Group P patients (P < 0.005). Dry mouth reported by 16.67% patients. Conclusion: Dexmedetomidine can be a useful adjuvant rather than the sole sedative-analgesic agent during minor surgeries and be a valuable alternative to propofol in terms of moderate sedation, haemodynamic stability with minimal transient side effects. Keywords: Day care, dexmedetomidine, fentanyl, moderate sedation, propofol PDF

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Corte optimo de cordon umbilical ¡cuando y como!

Estimado Ciberpediatra te invito al Seminario de Pediatría, Cirugía Pediátrica y Lactancia Materna. El día 1o de Julio 2015 las 21hrs (Centro, México DF, Guadalajara y Lima Perú) a la Conferencia: “Corte optimo de cordon umbilical ¡cuando y como!” por el “Dr. Harold Honold”, Neonatologo de la Cd de San Diego Ca. La sesión inicia puntualmente las 21 hrs.
Para entrar a la Sala de Conferencia:
1.- hacer click en la siguiente liga, o cópiala y escríbela en tu buscador 
http://connectpro60196372.adobeconnect.com/corte_cordonumbilical/
2.- “Entra como Invitado” Escribes tu nombre y apellido en el espacio en blanco
3.- Hacer click en el espacio que dice “Entrar en la Sala”
5.- A disfrutar la conferencia
6.- Recomendamos que dejes tu Nombre Completo, Correo electrónico y que participes.


Henrys


Dr. Enrique Mendoza López
Webmaster: CONAPEME
Coordinador Nacional: Seminario Ciberpeds-Conapeme

Av La clinica 2520-310
Colonia Sertoma ,Mty N.L. México
CP 64710
Tel-Fax 52 81 83482940 y 52 81 81146053
Celular 8183094806
www.conapeme.org
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enrique@pediatramendoza.com
emendozal@yahoo.com.mx

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

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Medwave: Edición Junio 2015 y Boletin eCampus

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Notificaciones semanales ⋅ 24 de junio de 2015
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