Paracetamol. Revisión enfocada en los efectos hemodinámicos de la administración intravenosa

Paracetamol. Revisión enfocada en los efectos hemodinámicos de la administración intravenosa Paracetamol: a review with specific focus on the haemodynamic effects of intravenous administration. Chiam E, Weinberg L, Bellomo R. Heart Lung Vessel. 2015;7(2):121-32. Abstract Paracetamol is one of the most commonly used drugs worldwide with non-prescription sales exceeding 25 thousand million doses per year in the United States of America. The haemodynamic effects of the intravenous paracetamol formulations are largely understudied. There is an emerging body of evidence suggesting that intravenous paracetamol may cause iatrogenic hypotension. Little is known as to the mechanisms of this phenomenon or if intravenous paracetamol indeed does cause hypotension. As paracetamol has negligible solubility in aqueous solutions, many of the commercially available intravenous formulations contain mannitol (up to 3.91 g/100 mL paracetamol) as a stabilising ingredient. It is unknown if mannitol is a contributing factor in the observed hypotension. In this review, we outline the development of paracetamol's current intravenous formulations, describe the composition of these formulations, and overview the literature pertaining to the proposed phenomenon of paracetamol-induced altered hypotension. Understanding the pharmacokinetic and pharmacodymanic properties of intravenous paracetamol may have important clinical implications for vulnerable patients in subgroups where haemodynamic stability is at risk such as those undergoing elective and emergency surgery. KEYWORDS: Intravenous; acetaminophen; blood pressure; haemodynamic; paracetamol PDF

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Tramadol y eyaculación prematura / Tramadol and premature ejaculation

Tramadol para eyaculación prematura. Revisión sistemática y meta-análisis Tramadol for premature ejaculation: a systematic review and meta-analysis. Martyn-St James M, Cooper K, Kaltenthaler E, Dickinson K, Cantrell A, Wylie K, Frodsham L, Hood C. BMC Urol. 2015 Jan 30;15(1):6. [Epub ahead of print] Abstract BACKGROUND: Tramadol is a centrally acting analgesic prescribed off-label for the treatment of premature ejaculation (PE). However, tramadol may cause addiction and difficulty in breathing and the beneficial effect of tramadol in PE is yet not supported by a high level of evidence. The purpose of this study was to systematically review the evidence from randomised controlled trials (RCT) for tramadol in the management of PE. METHODS: We searched bibliographic databases including MEDLINE to August 2014 for RCTs. The primary outcome was intra-vaginal ejaculatory latency time (IELT). Methodological quality of RCTs was assessed. Between-group differences in IELT and other outcomes were pooled across RCTs in a meta-analysis. Statistical and clinical between-trial heterogeneity was assessed. RESULTS: A total of eight RCTs that evaluated tramadol against a comparator were included. The majority of RCTs were of unclear methodological quality due to limited reporting. Pooled evidence (four RCTs, 721 participants), suggests that tramadol is significantly more effective than placebo at increasing IELT over eight to 12 weeks (p = 0.0007). However, a high level of statistical heterogeneity is evident (I-squared = 74%). Single RCT evidence indicates that tramadol is significantly more effective than paroxetine taken on-demand, sildenafil, lidocaine gel, or behavioural therapy on IELT in men with PE. Tramadol is associated with significantly more adverse events including: erectile dysfunction, constipation, nausea, headache, somnolence, dry mouth, dizziness, pruritus, and vomiting, than placebo or behavioural therapy over eight to 12 weeks of treatment. However, addiction problems or breathing difficulties reported by patients for PE is not assessed in the current evidence base. CONCLUSIONS: Tramadol appears effective in the treatment of PE. However, these findings should be interpreted with caution given the observed levels of between-trial heterogeneity and the reporting quality of the available evidence. The variability across placebo-controlled trials in terms of the tramadol dose evaluated and the treatment duration does not permit any assessment of a safe and effective minimum daily dose. The long-term effects and side effects, including addiction potential, for men with PE have not been evaluated in the current evidence base PDF Estudio aletorizado, doble ciego, controlado con placebo, cruzado de tramadol a demanda para manejo de eyaculación prematura A randomized, double-blind, placebo-controlled, crossover trial of "on-demand" tramadol for treatment of premature ejaculation. Kurkar A, Elderwy AA, Abulsorour S, Awad SM, Safwat AS, Altaher A. Urol Ann. 2015 Apr-Jun;7(2):205-10. doi: 10.4103/0974-7796.150481. Abstract OBJECTIVES: The objective of this study is to assess the dose-related effects of tramadol on a group of patients with premature ejaculation (PE). SUBJECTS AND METHODS: During the period of months between June 2010 and July 2012, 180 PE patients presented to outpatient clinic of our hospital. Patients were randomized in a 1:1:1 fashion to receive different sequences of the three medications: placebo, 50 mg of tramadol and 100 mg of tramadol. Every patient received 10 doses of each medication for 2 months. Intra-vaginal ejaculatory latency time (IELT) was recorded in seconds initially and for each arm. Successful treatment of PE is defined if IELT exceeded 120 s. Side-effects of medications were reported. RESULTS: Of patients enrolled, 125 (69.4%) continued the study. Patients' age range was 20-55 years with PE complaint of 1 to 10 years duration. Mean IELT was 72 at presentation, 82 for placebo, 150 for tramadol 50 mg, and 272 for tramadol 100 mg (P < 0.001 for all comparisons). PE was successfully treated in only 2.4% of patients with placebo, in contrast to 53.6% and 85.6% with 50 and 100 mg tramadol, respectively (P < 0.001 for all comparisons). On multivariate logistic regression analysis, baseline IELT was the only predictor of successful treatment of PE with both tramadol50 mg (odds ratio [OR]: 1.05, 95% confidence interval [CI]: 1.03-1.07, P < 0.001) and tramadol 100 mg (OR: 1.07, 95% CI: 1.04-1.11, P < 0.001). Postmicturition dribble annoyed 12.8% of those who received 50 mg tramadol and 33.6% of those who received 100 mg tramadol (P < 0.001). Weak scanty ejaculation was the main complaint in 7.2% versus 21.6% of those using 50 and 100 mg tramadol, respectively (P = 0.002). Two patients discontinued tramadol 100 mg due to side-effects. CONCLUSION: Tramadol hydrochloride exhibits a significant dose-related efficacy and side-effects over placebo for treatment of PE. KEYWORDS: Intra-vaginal ejaculatory latency time; premature ejaculation; tramadol hydrochloride PDF

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Ventilación mecánica / Mechanical ventilation

Ventilación mecánica en el síndrome de falla respiratoria aguda Mechanical ventilation of acute respiratory distress syndrome. Ochiai R. J Intensive Care. 2015 May 29;3(1):25. doi: 10.1186/s40560-015-0091-6. eCollection 2015. Abstract Acute respiratory distress syndrome (ARDS) has been intensively and continuously studied in various settings, but its mortality is still as high as 30-40 %. For the last 20 years, lung protective strategy has become a standard care for ARDS, but we still do not know the best way to ventilate patients with ARDS. Tidal volume itself does not seem to have an important role to develop ventilator-induced lung injury (VILI), but the driving pressure, which is inspiratory plateau pressure-PEEP, is the most important to predict and affect the outcome of ARDS, though there is no safe limit for the driving pressure. There is so much controversy regarding what the best PEEP is, whether collapsed lung should be recruited, and what parameters should be measured and evaluated to improve the outcome of ARDS. Since the mechanical ventilation for patients with respiratory failure, including ARDS, is a standard care, we need more dynamic and regional information of ventilation and pulmonary circulation in the injured lungs to evaluate the efficacy of new type of treatment strategy. In addition to the CT scanning of the lung as the gold standard of evaluation, the electrical impedance tomography (EIT) of the lung has been clinically available to provide such information non-invasively and at the bedside. Various parameters have been tested to evaluate the homogeneity of regional ventilation, and EIT could provide us with the information of ventilator settings to minimize VILI. KEYWORDS: Acute respiratory distress syndrome; Baby lung; Electrical impedance tomography; Gravitational effect; Lung protective strategy; Prone positioning; Ventilator-induced lung injury PDF PReVENT- ventilación protectiva en pacientes sin ARDS al iniciar la ventilación. Protocolo de estudio para una investigación controlada randomizada PReVENT - protective ventilation in patients without ARDS at start of ventilation: study protocol for a randomized controlled trial. Simonis FD, Binnekade JM, Braber A, Gelissen HP, Heidt J, Horn J, Innemee G, de Jonge E, Juffermans NP, Spronk PE, Steuten LM, Tuinman PR, Vriends M, de Vreede G, de Wilde RB, Serpa Neto A, Gama de Abreu M, Pelosi P, Schultz MJ. Trials. 2015 May 24;16:226. doi: 10.1186/s13063-015-0759-1. Abstract BACKGROUND: It is uncertain whether lung-protective mechanical ventilation using low tidal volumes should be used in all critically ill patients, irrespective of the presence of the acute respiratory distress syndrome (ARDS). A low tidal volume strategy includes use of higher respiratory rates, which could be associated with increased sedation needs, a higher incidence of delirium, and an increased risk of patient-ventilator asynchrony and ICU-acquired weakness. Another alleged side-effect of low tidal volume ventilation is the risk of atelectasis. All of these could offset the beneficial effects of low tidal volume ventilation as found in patients with ARDS. METHODS/DESIGN: PReVENT is a national multicenter randomized controlled trial in invasively ventilated ICU patients without ARDS with an anticipated duration of ventilation of longer than 24 hours in 5 ICUs in The Netherlands. Consecutive patients are randomly assigned to a low tidal volume strategy using tidal volumes from 4 to 6 ml/kg predicted body weight (PBW) or a high tidal volume ventilation strategy using tidal volumes from 8 to 10 ml/kg PBW. The primary endpoint is the number of ventilator-free days and alive at day 28. Secondary endpoints include ICU and hospital length of stay (LOS), ICU and hospital mortality, the incidence of pulmonary complications, including ARDS, pneumonia, atelectasis, and pneumothorax, the cumulative use and duration of sedatives and neuromuscular blocking agents, incidence of ICU delirium, and the need for decreasing of instrumental dead space. DISCUSSION: PReVENT is the first randomized controlled trial comparing a low tidal volume strategy with a high tidal volume strategy, in patients without ARDS at onset of ventilation, that recruits a sufficient number of patients to test the hypothesis that a low tidal volume strategy benefits patients without ARDS with regard to a clinically relevant endpoint. TRIAL REGISTRATION: The trial is registered at www.clinicaltrials.gov under reference number NCT02153294 on 23 May 2014. PDF

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Vía aérea difícil / The dificult airway

Vía aérea difícil The dificult airway The airway is the portal of entry for oxygen into the human body. Establishing an airway is the first priority of resuscitation because, without an adequate airway, all other medical treatments are futile. All airways established in the out-of hospital setting must be considered difficult airways; the importance of knowing when to intubate and what to do in the case of a technically challenging airway is not often appreciated. Several recent studies have highlighted the high failure rate for prehospital intubations as well as significant complications with this procedure. The most devastating is unrecognized esophageal intubation. In this chapter, we will briefly review some basic principles of airway assessment and the approach to tracheal intubation. Capítulo/Chapter

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“Eutanasia en pediatría

Estimado Pediatra te invito al Seminario de Pediatría, Cirugía Pediátrica y Lactancia Materna. El día 22 de Julio 2015 las 21hrs (Centro, México DF, Guadalajara y Lima Perú) a la Conferencia: “Eutanasia en pediatría” por el “Dr. Jorge Chuck Sepúlveda”, Pediatra Bioeticista de la Cd. de Guadalajara, Jal. 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/eutanasia_pediatria/
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
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Tel-Fax 52 81 83482940 y 52 81 81146053
Celular 8183094806
www.conapeme.org
www.pediatramendoza.com
enrique@pediatramendoza.com
emendozal@yahoo.com.mx

Medwave edición de julio 2015

A continuación le informamos los artículos recientemente publicados en Medwave.


REVISIÓN CLÍNICA

Factores maternos y perinatales influyentes en la morbilidad neonatal: revisión narrativa de la literatura
Jónathan Hernández Núñez, Magel Valdés Yong, Yoanca de la Caridad Suñol Vázquez, Marelene de la Caridad López Quintana (Cuba)

Medwave 2015 Jul;15(6):e6182
http://dx.doi.org/10.5867/medwave.2015.06.6182


RESUMENES EPISTEMONIKOS

¿Sirve agregar azatioprina a los corticoides en pacientes con polimiositis?
Cristina Meneses, Gabriel Rada (Chile)

Medwave 2015 Jul;15(suppl 1):e6179
http://dx.doi.org/10.5867/medwave.2015.6179


¿Existe alguna diferencia entre los inhibidores de la enzima convertidora y los antagonistas del receptor de angiotensina para la insuficiencia cardiaca?
Carmen Rain, Gabriel Rada (Chile)

Medwave 2015 Jul;15(suppl 1):e6177
http://dx.doi.org/10.5867/medwave.2015.6177


CARTA A LA EDITORA

Diplomas adicionales y proyectos de investigación: construyendo bases académicas
Dipesh Pravin Gopal, Pieter Mackeith (Reino Unido)

Medwave 2015 Jul;15(6):e6175
http://dx.doi.org/10.5867/medwave.2015.06.6175


EDITORIAL
Queremos publicar más estudios cualitativos en salud
Vivienne C. Bachelet, Bernardita Baeza (Chile)

Medwave 2015 Jul;15(5):e6167
http://dx.doi.org/10.5867/medwave.2015.05.6167


Se encuentran abiertas las inscripciones para ciclo especial del curso Economía de la salud. Inicio 29 de julio.

Para información más detallada: http://www.medwave.cl/link.cgi/eCampus/ges02/

Y para el curso Prevención y Control de Infecciones Asociadas a la Atención de Salud

Mas información en: http://www.medwave.cl/link.cgi/eCampus/IAAS

Toda nuestra oferta de cursos y diplomados e-learning en http://www.medwave.cl/link.cgi/eCampus/Capacitacion


PORTADA MEDWAVE
www.medwave.cl

Mas de ventilación mecánica/More on mechanical ventilation

En algunos envios podrá notar que se incluye el hiperlik de los PDFs. Esto le facilita ampliar la información sobre los autores y las revistas con tan solo hacer click sobre los datos incluidos. In some e-mails you may notice that the hyperlinks are included. This makes it easy more information about the authors and journals just clicking on the data included. Em alguns e-mails que você perceber que podem os hiperlinks estão incluídos. Isto torna mais fácil obter mais informações sobre os autores e periódicos apenas clicando sobre os dados incluídos. در برخی از ایمیل شما متوجه است که ممکن است لینک گنجانده شده است. این باعث می شود آن را آسان اطلاعات بیشتر در مورد نویسندگان و مجلات تنها با کلیک کردن بر روی داده ها گنجانده شده است. Beneficios de la ventilación protectora. Viendo más allá de UCI Benefits of lung-protective ventilation: looking beyond the ICU. Gupta N, Yende S. Crit Care. 2014 Sep 25;18(5):530. doi: 10.1186/s13054-014-0530-0. PDF Avances recientes en ventilación mecánica en pacientes sin ARDS Recent advances in mechanical ventilation in patients without acute respiratory distress syndrome. Serpa Neto A, Filho RR, Rocha LL, Schultz MJ. F1000Prime Rep. 2014 Dec 1;6:115. doi: 10.12703/P6-115. eCollection 2014. Abstract While being an essential part of general anesthesia for surgery and at times even a life-saving intervention in critically ill patients, mechanical ventilation has a strong potential to cause harm. Certain ventilation strategies could prevent, at least to some extent, the injury caused by this intervention. One essential element of so-called 'lung-protective' ventilation is the use of lower tidal volumes. It is uncertain whether higher levels of positive end-expiratory pressures have lung-protective properties as well. There are indications that too high oxygen fractions of inspired air, or too high blood oxygen targets, are harmful. Circumstantial evidence further suggests that spontaneous modes of ventilation are to be preferred over controlled ventilation to prevent harm to respiratory muscle. Finally, the use of restrictive sedation strategies in critically ill patients indirectly prevents ventilation-induced injury, as daily spontaneous awakening and breathing trials and bolus instead of continuous sedation are associated with shorter duration of ventilation and shorten the exposure to the injurious effects of ventilation. PDF Enfoques para la ventilación en cuidados intensivos. Approaches to ventilation in intensive care. Spieth PM, Koch T, Gama de Abreu M. Dtsch Arztebl Int. 2014 Oct 17;111(42):714-20. doi: 10.3238/arztebl.2014.0714. Abstract BACKGROUND: Mechanical ventilation is a common and often life-saving intervention in intensive care medicine. About 35% of all patients in intensive care are mechanically ventilated; about 15% of these patients develop a ventilation-associated pneumonia. The goal of ventilation therapy is to lessen the work of respiration and pulmonary gas exchange and thereby maintain or restore an adequate oxygen supply to the body's tissues.Mechanical ventilation can be carried out in many different modes; the avoidance of ventilation-induced lung damage through protective ventilationstrategies is currently a major focus of clinical interest. METHOD: This review is based on pertinent articles retrieved by a selective literature search. RESULTS: Compared to conventional lung-protecting modes of mechanical ventilation, the modern modes of ventilation presented here are further developments that optimize lung protection while improving pulmonary function and the synchrony of the patient with the ventilator. In high-frequencyventilation, tidal volumes of 1-2 mL/kgBW (body weight) are given, at a respiratory rate of up to 12 Hz. Assisted forms of spontaneous respiration are also in use, such as proportional assist ventilation (PAV), neurally adjusted ventilatory assist (NAVA), and variable pressure-support ventilation. Computer-guided closed-loop ventilation systems enable automated ventilation; according to a recent meta-analysis, they shorten weaning times by 32% . CONCLUSION: The currently available scientific evidence with respect to clinically relevant endpoints is inadequate for all of these newer modes ofventilation. It appears, however, that they can lower both the invasiveness and the duration of mechanical ventilation, and thus improve the care of patients who need ventilation. Randomized trials with clinically relevant endpoints must be carried out before any final judgments can be made. PDF

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Tramadol y piernas inquietas / Tramadol for restless legs syndrome

Revisión de las estrategias de manejo en el síndrome de piernas inquietas o enfermedad de Willis-Ekbon A review of current treatment strategies for restless legs syndrome (Willis-Ekbom disease). Klingelhoefer L, Cova I, Gupta S, Chaudhuri KR. Clin Med. 2014 Oct;14(5):520-4. doi: 10.7861/clinmedicine.14-5-520. Abstract Restless legs syndrome (RLS), recently renamed Willis-Ekbom disease (WED), is a common movement disorder. It is characterised by the need to move mainly the legs due to uncomfortable, sometimes painful sensations in the legs, which have a diurnal variation and a release with movement. Management is complex. First, centres should establish the severity of RLS using a simple 10-item RLS severity rating scale (IRLS). They should also exclude secondary causes, in particular ensuring normal iron levels. Mild cases can be managed by lifestyle changes, but patients with a IRLS score above 15 usually require pharmacological treatment. Dopaminergic therapies remain the mainstay of medical therapies, with recent evidence suggesting opioids may be particularly effective. This article focuses on the different treatment strategies in RLS, their associated complications and ways to manage them. KEYWORDS: RLS; Restless legs syndrome; medical treatment; side effects; therapy PDF Consenso revisado de la Fundación Willis-Ekbom Disease Foundation sobre el tratamiento del síndrome de piernas inquietas. Willis-Ekbom Disease Foundation revised consensus statement on the management of restless legs syndrome. Silber MH1, Becker PM, Earley C, Garcia-Borreguero D, Ondo WG; Medical Advisory Board of the Willis-Ekbom Disease Foundation. Collaborators (12) Mayo Clin Proc. 2013 Sep;88(9):977-86. doi: 10.1016/j.mayocp.2013.06.016. Abstract Restless legs syndrome (RLS)/Willis-Ekbom disease (WED) is a common disorder, occurring at least twice a week and causing at least moderate distress in 1.5% to 2.7% of the population. It is important for primary care physicians to be familiar with this disorder and its management. Much has changed in its management since our previous algorithm was published in 2004, including the availability of several new drugs. This revised algorithm was written by members of the Medical Advisory Board of the Willis-Ekbom Disease Syndrome Foundation based on scientific evidence and expert opinion. It considers the management of RLS/WED under intermittent RLS/WED, chronic persistent RLS/WED, and refractory RLS/WED. Nonpharmacological approaches, including mental alerting activities, avoiding substances or medications that may exacerbate RLS, and the role of iron supplementation, are outlined. Chronic persistent RLS/WED should be treated with either a nonergot dopamine agonist or a calcium channel α-2-δ ligand. We discuss the available drugs, the factors determining which to use, and their adverse effects. We define refractory RLS/WED and describe management approaches, including combination therapy and the use of high-potency opioids. KEYWORDS: MAB; Medical Advisory Board; RLS; WED; Willis-Ekbom disease; restless legs syndrome PDF

Atentamente Anestesia y Medicina del Dolor anestesia-dolor.org

Farmacología clínica neonatal

Farmacología clínica neonatal Neonatal clinical pharmacology. Allegaert K, van de Velde M, van den Anker J. Paediatr Anaesth. 2014 Jan;24(1):30-8. doi: 10.1111/pan.12176. Epub 2013 Apr 26. Abstract Effective and safe drug administration in neonates should be based on integrated knowledge on the evolving physiological characteristics of the infant who will receive the drug and the pharmacokinetics (PK) and pharmacodynamics (PD) of a given drug. Consequently, clinical pharmacology in neonates is as dynamic and diverse as the neonates we admit to our units while covariates explaining the variability are at least as relevant as median estimates. The unique setting of neonatal clinical pharmacology will be highlighted based on the hazards of simple extrapolation of maturational drug clearance when only based on 'adult' metabolism (propofol, paracetamol). Second, maturational trends are not at the same pace for all maturational processes. This will be illustrated based on the differences between hepatic and renal maturation (tramadol, morphine, midazolam). Finally, pharmacogenetics should be tailored to neonates, not just mirror adult concepts. Because of this diversity, clinical research in the field of neonatal clinical pharmacology is urgently needed and facilitated through PK/PD modeling. In addition, irrespective of already available data to guide pharmacotherapy, pharmacovigilance is needed to recognize specific side effects. Consequently, pediatric anesthesiologists should consider to contribute to improved pharmacotherapy through clinical trial design and collaboration, as well as reporting on adverse effects of specific drugs. PDF

Atentamente Anestesia y Medicina del Dolor anestesia-dolor.org