Papel del PEEP en UCI y en la sala de cirugía. De la patofisiología a la práctica clínica

Septiembre 4, 2015. No. 2075

Papel del PEEP en UCI y en la sala de cirugía. De la patofisiología a la práctica clínica PEEP role in ICU and operating room: from pathophysiology to clinical practice. Vargas M, Sutherasan Y, Gregoretti C, Pelosi P. ScientificWorldJournal. 2014 Jan 14;2014:852356. doi: 10.1155/2014/852356. eCollection 2014. Abstract Positive end expiratory pressure (PEEP) may prevent cyclic opening and collapsing alveoli in acute respiratory distress syndrome (ARDS) patients, but it may play a role also in general anesthesia. This review is organized in two sections. The first one reports the pathophysiological effect of PEEP on thoracic pressure and hemodynamic and cerebral perfusion pressure. The second section summarizes the knowledge and evidence of the use of PEEP in general anesthesia and intensive care. More specifically, for intensive care this review refers to ARDS and traumatic brain injured patients. PDF  PEEP alto versus PEEP bajo en adultos con lesión pulmonar aguda y ARDS ventilados mecánicamente High versus low positive end-expiratory pressure (PEEP) levels for mechanically ventilated adult patients with acute lung injury and acute respiratory distress syndrome. Santa Cruz R, Rojas J, Nervi R, Heredia R, Ciapponi A. Cochrane Database Syst Rev. 2013 Jun 6;6:CD009098. doi: 10.1002/14651858.CD009098.pub2. Abstract BACKGROUND: Mortality in patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) remains high. These patients require mechanical ventilation, but this modality has been associated with ventilator-induced lung injury. High levels of positive end-expiratory pressure (PEEP) could reduce this condition and improve patient survival. OBJECTIVES: To assess the benefits and harms of high versus low levels of PEEP in patients with ALI and ARDS. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2013, Issue 4), MEDLINE (1950 to May 2013), EMBASE (1982 to May 2013), LILACS (1982 to May 2013) and SCI (Science Citation Index). We used the Science Citation Index to find references that have cited the identified trials. We did not specifically conduct manual searches of abstracts of conference proceedings for this review. We also searched for ongoing trials (www.trialscentral.org; www.clinicaltrial.gov and www.controlled-trials.com).  SELECTION CRITERIA: We included randomized controlled trials that compared the effects of two levels of PEEP in ALI and ARDS participants who were intubated and mechanically ventilated in intensive care for at least 24 hours. DATA COLLECTION AND ANALYSIS: Two review authors assessed the trial quality and extracted data independently. We contacted investigators to identify additional published and unpublished studies. MAIN RESULTS: We included seven studies that compared high versus low levels of PEEP (2565 participants). In five of the studies (2417 participants), a comparison was made between high and low levels of PEEP with the same tidal volume in both groups, but in the remaining two studies (148 participants), the tidal volume was different between high- and low-level groups. We saw evidence of risk of bias in three studies, and the remaining studies fulfilled all criteria for adequate trial quality.In the main analysis, we assessed mortality occurring before hospital discharge only in those studies that compared high versus low PEEP with the same tidal volume in both groups. With the three studies that were included, the meta-analysis revealed no statistically significant differences between the two groups (relative risk (RR) 0.90, 95% confidence interval (CI) 0.81 to 1.01), nor was any statistically significant difference seen in the risk of barotrauma (RR 0.97, 95% CI 0.66 to 1.42). Oxygenation was improved in the high-PEEP group, although data derived from the studies showed a considerable degree of statistical heterogeneity. The number of ventilator-free days showed no significant difference between the two groups. Available data were insufficient to allow pooling of length of stay in the intensive care unit (ICU). The subgroup of participants with ARDS showed decreased mortality in the ICU, although it must be noted that in two of the three included studies, the authors used a protective ventilatory strategy involving a low tidal volume and high levels of PEEP. AUTHORS' CONCLUSIONS: Available evidence indicates that high levels of PEEP, as compared with low levels, did not reduce mortality before hospital discharge. The data also show that high levels of PEEP produced no significant difference in the risk of barotrauma, but rather improved participants' oxygenation to the first, third, and seventh days. This review indicates that the included studies were characterized by clinical heterogeneity.   PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015

Medwave: Boletin eCampus y Edición Agosto 2015 Completa

Inscripciones aún abiertas para curso “Formulación y evaluación de proyectos en salud”.

Mayor información en http://ecampus.medwave.cl/?page_id=761 donde también es posible concretar su inscripción.


Hemos completado la edición correspondiente al mes de Agosto 2015, los artículos incluidos son:


EDITORIAL

Resúmenes Epistemonikos en Medwave: evidencia confiable y amigable que llegó para quedarse
Gabriel Rada, Vivienne C. Bachelet

Medwave 2015 Ago;15(7):e6232
http://dx.doi.org/10.5867/medwave.2015.6232


DE LOS EDITORES

Cuatro estados de ánimo del clínico basado en evidencia: lo que nos dejó el primer suplemento de resúmenes Epistemonikos
Gabriel Rada (Chile)

Medwave 2015 Ago;15(7):6237
http://dx.doi.org/10.5867/medwave.2015.07.6237


ESTUDIOS PRIMARIOS

Respuesta y sobrevida en pacientes con leucemia mieloide aguda no candidatos a trasplante tratados con azacitidina versus medidas de soporte: estudio retrospectivo
Mauricio Sarmiento Maldonado, Mauricio Ocqueteau Tachini, Javier Pilcante, Pablo Ramírez Villanueva (Chile)

Medwave 2015 Ago;15(7):e6207
http://dx.doi.org/10.5867/medwave.2015.07.6207


Herramientas estadísticas en los artículos publicados en una revista de salud pública durante el periodo 2013-2014: estudio bibliométrico transversal
Víctor Arcila Quiceno, Elizabeth García Restrepo, Natalia Gómez Rúa, Gino Montenegro Martínez, Luis Carlos Silva Ayçaguer (Colombia, Cuba)

Medwave 2015 Ago;15(7):e6238
http://dx.doi.org/10.5867/medwave.2015.07.6238


ANÁLISIS CRÍTICO

Efectividad del entrenamiento interválico de alta intensidad comparado con entrenamiento continuo de moderada intensidad en la reducción de estrés oxidativo de pacientes adultos con diabetes mellitus tipo 2: CAT
Carlos Emilio Poblete Aro, Javier Antonio Russell Guzmán, Marcelo Enrique Soto Muñoz, Bastián Eduardo Villegas González (Chile)

Medwave 2015 Ago;15(7):e6212
http://dx.doi.org/10.5867/medwave.2015.07.6212


ARTÍCULO DE REVISIÓN

Enfermedades y riesgos laborales en trabajadores de servicios de urgencia: revisión de la literatura y acercamiento a Chile
Rosa Jiménez, Juan Ricardo Pavés (Chile)

Medwave 2015 ago;15(7):e6239
http://dx.doi.org/10.5867/medwave.2015.07.6239


Proximos cursos:

• 23 de septiembre, inicio curso de “Calidad en los procesos asistenciales”. Detalles e inscripciones en http://ecampus.medwave.cl/?page_id=746
• Nuevo ciclo del curso de “Prevención y control de infecciones asociadas a la atención en salud”. Información en http://ecampus.medwave.cl/?page_id=764


PORTADA MEDWAVE
www.medwave.cl

PORTADA eCAMPUS
http://ecampus.medwave.cl/

Trauma en pediatría/Pediatric tra

Septiembre 5, 2015. No. 2076

Neumotórax ocultos en niños traumatizados y ventilados. Una revisión Occult pneumothoraces in ventilated pediatric trauma patients: a review. Fulton C1, Bratu I1. Can J Surg. 2015 Jun;58(3):177-80. Abstract BACKGROUND: Currently there is no clinical consensus on how to treat occult pneumothoraces in adults, and even less research has been done in children. We sought to understand the outcomes of severely injured, ventilated children with occult pneumothoraces. METHODS: Using the Alberta Trauma Registry, we retrospectively reviewed the charts of all ventilated pediatric patients at a children's hospital from 2001 to 2011 who had an injury severity score greater than 12 and a diagnosis of occult pneumothorax (seen on computed tomography scan but not on supine chest radiograph). RESULTS: There were 1689 severely injured children, with 496 admitted to the pediatric intensive care unit (PICU) and ventilated. A total of 130 children were found to have pneumothoraces, and of those, 96 were admitted to the PICU. Of those, 15 children had a total of 19 occult pneumothoraces, and all were successfully treated without chest tubes. The average age was 13.4 (range 2.0-17.0) years, and 54% of these children were male. The average time spent on the ventilator was 2.3 (range 0-13) days, and 7 children had at least 1 operation. CONCLUSION: In our institution, occult pneumothoraces occur in very few severely injured, ventilated pediatric trauma patients. Our study adds to the increasing evidence in the adult and pediatric literature suggesting that occult pneumothoraces may be safely observed even while under positive-pressure ventilation. PDF Definiendo el trauma cerebral pediátrico utilizando la International Classification of Diseases Version 10. Revisión sistemática Defining pediatric traumatic brain injury using International Classification of Diseases Version 10 Codes: a systematic review. Chan V, Thurairajah P, Colantonio A BMC Neurol. 2015 Feb 4;15:7. doi: 10.1186/s12883-015-0259-7. Abstract BACKGROUND: Although healthcare administrative data are commonly used for traumatic brain injury (TBI) research, there is currently no consensus or consistency on the International Classification of Diseases Version 10 (ICD-10) codes used to define TBI among children and youth internationally. This study systematically reviewed the literature to explore the range of ICD-10 codes that are used to define TBI in this population. The identification of the range of ICD-10 codes to define this population in administrative data is crucial, as it has implications for policy, resource allocation, planning of healthcare services, and prevention strategies. METHODS: The databases MEDLINE, MEDLINE In-Process, Embase, PsychINFO, CINAHL, SPORTDiscus, and Cochrane Database of Systematic Reviews were systematically searched. Grey literature was searched using Grey Matters and Google. Reference lists of included articles were also searched for relevant studies. Two reviewers independently screened all titles and abstracts using pre-defined inclusion and exclusion criteria. A full text screen was conducted on articles that met the first screen inclusion criteria. All full text articles that met the pre-defined inclusion criteria were included for analysis in this systematic review. RESULTS: A total of 1,326 publications were identified through the predetermined search strategy and 32 articles/reports met all eligibility criteria for inclusion in this review. Five articles specifically examined children and youth aged 19 years or under with TBI. ICD-10 case definitions ranged from the broad injuries to the head codes (ICD-10 S00 to S09) to concussion only (S06.0). There was overwhelming consensus on the inclusion of ICD-10 code S06, intracranial injury, while codes S00 (superficial injury of the head), S03 (dislocation, sprain, and strain of joints and ligaments of head), and S05 (injury of eye and orbit) were only used by articles that examined head injury, none of which specifically examined children and youth. CONCLUSION: This review provides evidence for discussion on how best to use ICD codes for different goals. This is an important first step in reaching an appropriate definition and can inform future work on reaching consensus on the ICD-10 codes to define TBI for this vulnerable population. PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015

Anestesia y el cerebro neonatal/Anesthesia and neonatal brain

Septiembre 6, 2015. No. 2077

En animales inmaduros que son expuestos a los anestésicos generales se ha visto muerte celular, daño neuronal, y deterioro neurocognitivo. Esto ha preocupado a los investigados y a los clínicos sobre los efectos similares que puedan ocurren en los niños pequeños. Aunque los estudios epidemiológicos no son concluyentes por diversos factores, los descubrimientos actuales  sugieren que la anestesia general para un procedimiento quirúrgico en la primera infancia puede estar asociada con la disminución a largo plazo de las habilidades del lenguaje y la cognición, así como alteraciones volumétricas regionales en la estructura del cerebro.   In immature animals exposed to general anesthetics has been demosntrated  cell death, neuronal damage, and neurocognitive impairment. This has worried investigators and clinicians about that similar effects can occur in young children. Although epidemiological studies are inconclusive by several factors, the current findings suggest that general anesthesia for a surgical procedure in early childhood may be associated with long-term decline of language skills and cognition, as well as regional volumetric changes in brain structure   Em animais imaturos são expostos a anestésicos gerais tem sido a morte celular, as lesões neuronais e comprometimento neurocognitivo. Isso tem preocupado investigados e clínicos sobre os efeitos semelhantes podem ocorrer em crianças pequenas. Embora os estudos epidemiológicos são inconclusivos por diversos fatores, os resultados atuais sugerem que a anestesia geral para um procedimento cirúrgico na primeira infância pode estar associada com declínio a longo prazo das competências linguísticas e cognição, bem como mudanças volumétricas regionais na estrutura do cérebro Efectos de la anestesia en el cerebro de niños en desarrollo Effects of Anesthesia on Children's Brain Development Hernández-Cortez E J Anesth Crit Care Open Access 2015; 2(6): 00079. DOI: 10.15406/ jaccoa.2015.02.00079 J Anesth Crit Care Open Access 2015, 2(6): 00079 Abstract Nowadays, the administration of most of the anesthetics is being questioned. The quality of reversibility of these medications is being questioned, especially when administered to children under 3 years old. The administration of isoflurane elevates intracellular calcium levels which are critical for cell damage resulting in apoptosis. The NMDA and GABA receptors are indirectly involved in the effect of immature brains. The immaturity of the central nervous system associated to the administration of anesthetic agents such as inhaled anesthetics, ketamine, midazolam, nitrous oxide, and others, produces important changes in the brain that  have  an  impact  in  the  child's  later  life.  There  are  two  important  elements in the neurotoxicity of anesthetics, dosage and time administration. Repeating anesthetics produces more brain changes. There are two important elements in the neurotoxicity of anesthetics, dosage and time administration. Repeating anesthetics produces more brain changes. These modifications have resulted in serious behavioral and memory changes in experiments. Keywords. Apotosis, anesthesia, children  PDF Asociación entre daño cerebral, exposición perioperatoria a los anestésicos, y el neurodesarrollo a los 12 meses después de cirugía cardiaca neonatal. Estudio retrospectivo de cohortes The association between brain injury, perioperative anesthetic exposure, and 12-month neurodevelopmental outcomes after neonatal cardiac surgery: a retrospective cohort study. Andropoulos DB, Ahmad HB, Haq T, Brady K, Stayer SA, Meador MR, Hunter JV, Rivera C, Voigt RG,Turcich M, He CQ, Shekerdemian LS, Dickerson HA, Fraser CD, Dean McKenzie E, Heinle JS, Blaine Easley R. Paediatr Anaesth. 2014 Mar;24(3):266-74. doi: 10.1111/pan.12350. Abstract BACKGROUND: Adverse neurodevelopmental outcomes are observed in up to 50% of infants after complex cardiac surgery. We sought to determine the association of perioperative anesthetic exposure with neurodevelopmental outcomes at age 12 months in neonates undergoing complex cardiac surgery and to determine the effect of brain injury determined by magnetic resonance imaging (MRI). METHODS: Retrospective cohort study of neonates undergoing complex cardiac surgery who had preoperative and 7-day postoperative brain MRI and 12-month neurodevelopmental testing with Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III). Doses of volatile anesthetics (VAA), benzodiazepines, and opioids were determined during the first 12 months of life. RESULTS: From a database of 97 infants, 59 met inclusion criteria. Mean ± sd composite standard scores were as follows: cognitive = 102.1 ± 13.3, language = 87.8 ± 12.5, and motor = 89.6 ± 14.1. After forward stepwise multivariable analysis, new postoperative MRI injury (P = 0.039) and higher VAA exposure (P = 0.028) were associated with lower cognitive scores. ICU length of stay (independent of brain injury) was associated with lower performance on all categories of the Bayley-III (P < 0.02). CONCLUSIONS: After adjustment for multiple relevant covariates, we demonstrated an association between VAA exposure, brain injury, ICU length of stay, and lower neurodevelopmental outcome scores at 12 months of age. These findings support the need for further studies to identify potential modifiable factors in the perioperative care of neonates with CHD to improve neurodevelopmental outcomes. PDF Daño perioperatorio del sistema nervioso central en neonatos Perioperative central nervous system injury in neonates. McCann ME, Soriano SG. Br J Anaesth. 2012 Dec;109 Suppl 1:i60-i67. doi: 10.1093/bja/aes424.Author information Abstract Anaesthetic-induced developmental neurotoxicity (AIDN) has been clearly established in laboratory animal models. The possibility of neurotoxicity during uneventful anaesthetic procedures in human neonates or infants has led to serious questions about the safety of paediatric anaesthesia. However, the applicability of animal data to clinical anaesthesia practice remains uncertain. The spectre of cerebral injury due to cerebral hypoperfusion, metabolic derangements, coexisting disease, and surgery itself further muddles the picture. Given the potential magnitude of the public health importance of this issue, the clinician should be cognisant of the literature and ongoing investigations on AIDN, and raise awareness of the risks of both surgery and anaesthesia. PDF Anestesia general en pediatría. Influencias sobre el cerebro en desarrollo General anesthetics in pediatric anesthesia: influences on the developing brain. McCann ME, Soriano SG. Curr Drug Targets. 2012 Jun;13(7):944-51. Abstract Millions of newborn and infants receive anesthetic, sedative and analgesic drugs for surgery and painful procedures on a daily basis. However, recent laboratory reports clearly demonstrate that anesthetic and sedative drugs induced both neuroapoptosis and neurocognitive deficits in laboratory models. This issue is of paramount interest to pediatric anesthesiologists and intensivists because it questions the safety of anesthetics used for fetal and neonatal anesthesia. Most clinically utilized anesthetic drugs have been found to induce neuronal cell death in the developing brain and to potentially cause long-term neurological impairment. Conversely, painful stimuli without analgesia and anesthesia have been implicated in triggering neuro-apoptosis in juvenile mammalian models. Published retrospective reviews demonstrate temporary neurological sequelae after prolonged anesthetic exposure in young children and larger studies identify long-term neurodevelopmental impairment after neonatal surgery and anesthesia. This paper examines the evidence for the effects of commonly used anesthetics on neuronal structure and neurocognitive function in laboratory models and reviews the relevant clinical human epidemiologic data. PDF  Control de dolor neonatal y efectos neurológicos de los anestésicos y sedantes en infantes de pretérmino Neonatal pain control and neurologic effects of anesthetics and sedatives in preterm infants. McPherson C, Grunau RE. Clin Perinatol. 2014 Mar;41(1):209-27. doi: 10.1016/j.clp.2013.10.002. Epub 2013 Dec 17. Abstract Preclinical and clinical studies have demonstrated the adverse consequences of untreated pain and stress on brain development in the preterm infant. Sucrose has widely been implemented as standard therapy for minor procedural pain. Anesthetics are commonly utilized in preterm infants during major surgery. Pharmacologic agents (benzodiazepines and opioids) have been examined in clinical trials of preterm infants requiring invasive mechanical ventilation. Controversy exists regarding the safety and long-term impact of these interventions. Ongoing multidisciplinary research will help define the impact of these agents and identify potential alternative therapies. PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015