Anestesia en geriatría /Geriatrics anesthesia

Octubre 21, 2015. No. 2121Octubre, mes de lucha contra cáncer de mama.

Estudio comparativo de eficacia y seguridad de la anestesia combinada espinal-epidural versus raquia en ancianos de alto riesgo para cirugías alrededor de la cadera A comparative study-efficacy and safety of combined spinal epidural anesthesia versus spinal anesthesia in high-risk geriatric patients for surgeries around the hip joint. Tummala V, Rao LN, Vallury MK, Sanapala A. Anesth Essays Res. 2015 May-Aug;9(2):185-8. doi: 10.4103/0259-1162.153764. Abstract CONTEXT: Combined spinal epidural anesthesia (CSEA) has a significant advantage by enabling the use of low dose intrathecal local anesthetic, with knowledge that the epidural catheter may be used to extend the block as necessary. CSEA is useful in high-risk geriatric patients by providing greater hemodynamic stability. AIM: This study is designed to compare the clinical effects of CSEA versus spinal anesthesia in high-risk geriatric patients undergoing surgeries around the hip joint. MATERIALS AND METHODS: Sixty patients aged >65 years, American Society of Anaesthesiology III and IV were randomly allocated into two equal groups. Group A (n = 30) received CSEA with 1 ml (5 mg) of 0.5% hyperbaric bupivacaine with 25 μg fentanyl through spinal route, and the expected incompleteness of spinal block was managed with small incremental dose of 0.5% isobaric bupivacaine through epidural catheter, 1-1.5 ml for every unblocked segment to achieve T10 sensory level. Group B (n = 30) received spinal anesthesia with 2.5 ml (12.5 mg) of 0.5% hyperbaric bupivacaine and 25 μg fentanyl. RESULT: Both the groups showed rapid onset, excellent analgesia and good quality motor block. Group A showed a significantly less incidence of hypotension (P < 0.01) along with the provision of prolonging analgesia as compared to Group B. CONCLUSION: CSEA is a safe, effective, reliable technique with better hemodynamic stability along with the provision of prolonging analgesia compared to spinal anesthesia for high-risk geriatric patients undergoing surgeries around the hip joint. KEYWORDS: Combined spinal epidural anesthesia; high-risk geriatric patients; spinal anesthesia; surgeries around the hip joint PDF   Anestesia general y el riesgo de demencia en ancianos: conocimientos actuales General anesthetic and the risk of dementia in elderly patients: current insights. Hussain M, Berger M, Eckenhoff RG, Seitz DP. Clin Interv Aging. 2014 Sep 24;9:1619-28. doi: 10.2147/CIA.S49680. eCollection 2014. Abstract In this review, we aim to provide clinical insights into the relationship between surgery, general anesthesia (GA), and dementia, particularly Alzheimer's disease (AD). The pathogenesis of AD is complex, involving specific disease-linked proteins (amyloid-beta [Aβ] and tau), inflammation, and neurotransmitter dysregulation. Many points in this complex pathogenesis can potentially be influenced by both surgery and anesthetics. It has been demonstrated in some in vitro, animal, and human studies that some anesthetics are associated with increased aggregation and oligomerization of Aβ peptide and enhanced accumulation and hyperphosphorylation of tau protein. Two neurocognitive syndromes that have been studied in relation to surgery and anesthesia are postoperative delirium and postoperative cognitive dysfunction, both of which occur more commonly in older adults after surgery and anesthesia. Neither the route of anesthesia nor the type of anesthetic appears to be significantly associated with the development of postoperative delirium or postoperative cognitive dysfunction. A meta-analysis of case-control studies found no association between prior exposure to surgery utilizing GA and incident AD (pooled odds ratio =1.05, P=0.43). The few cohort studies on this topic have shown varying associations between surgery, GA, and AD, with one showing an increased risk, and another demonstrating a decreased risk. A recent randomized trial has shown that patients who received sevoflurane during spinal surgery were more likely to have progression of preexisting mild cognitive impairment compared to controls and to patients who received propofol or epidural anesthesia. Given the inconsistent evidence on the association between surgery, anesthetic type, and AD, well-designed and adequately powered studies with longer follow-up periods are required to establish a clear causal association between surgery, GA, and AD. KEYWORDS: Alzheimer's disease; anesthesia; surgery PDF

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

Reacciones adversas en geriatría/Adverse drug reactions in geriatrics

Octubre 22, 2015. No. 2122Octubre, mes de lucha contra cáncer de mama.

Reacciones adversas en poblaciones especiales. El anciano Adverse drug reactions in special populations - the elderly. Davies EA, O'Mahony MS. Br J Clin Pharmacol. 2015 Oct;80(4):796-807. doi: 10.1111/bcp.12596. Epub 2015 May 22. Abstract The International Conference on Harmonization considers older people a 'special population', as they differ from younger adults in terms of comorbidity, polypharmacy, pharmacokinetics and greater vulnerability to adverse drug reactions (ADRs). Medical practice is often based on single disease guidelines derived from clinical trials that have not included frail older people or those with multiple morbidities. This presents a challenge caring for older people, as drug doses in trials may not be achievable in real world patients and risks of ADRs are underestimated in clinical trial populations. The majority of ADRs in older people are Type A, potentially avoidable and associated with commonly prescribed medications. Several ADRs are particularly associated with major adverse consequences in the elderly and their reduction is therefore a clinical priority. Falls are strongly associated with benzodiazepines, neuroleptics, antidepressants and antihypertensives. There is good evidence for medication review as part of a multifactorial intervention to reduce falls risk in community dwelling elderly. Multiple medications also contribute to delirium, another multifactorial syndrome resulting in excess mortality particularly in frail older people. Clostridium difficile associated with use of broad spectrum antibiotics mainly affects frail older people and results in prolonged hospital stay with substantial morbidity and mortality. Antipsychotics increase the risk of stroke by more than three-fold in patients with dementia. Inappropriate prescribing can be reduced by adherence to prescribing guidelines, suitable monitoring and regular medication review. Given the heterogeneity within the older population, providing individualized care is pivotal to preventing ADRs. PDF

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

Delirio en ancianos / Delirium in older people

Octubre 23, 2015. No. 2123Octubre, mes de lucha contra cáncer de mama.

Intervenciones para la prevención del delirio en las personas mayores en la atención institucional a largo plazo. Interventions for preventing delirium in older people in institutional long-term care. Clegg A, Siddiqi N, Heaven A, Young J, Holt R. Cochrane Database Syst Rev. 2014 Jan 31;1:CD009537. doi: 10.1002/14651858.CD009537.pub2. Abstract BACKGROUND: Delirium is a common and distressing complication of a range of stressor events including infection, new medications and environment change that is often experienced by older people with frailty and dementia. Older people living in institutional long-term care (LTC)are at high risk of delirium, which increases the risk of admission to hospital, development of or worsening of dementia, and mortality.Delirium is also associated with substantial healthcare costs. Although it is possible to prevent delirium in the hospital setting by providing multicomponent delirium prevention interventions it is currently unclear whether interventions to prevent delirium in LTCare effective. OBJECTIVES: To assess the effectiveness of interventions for preventing delirium in older people in long term care. SEARCH METHODS: We searched ALOIS (www.medicine.ox.ac.uk/alois) - the Cochrane Dementia and Cognitive Improvement Group's Specialised Register- on 23 April 2013. The search was as sensitive as possible to identify all studies on ALOIS relating to delirium. We ran additional separate searches in major healthcare databases, trial registers, the Cochrane Central Register of Controlled Trials (CENTRAL) and grey literature sources, to ensure that the search was as comprehensive as possible. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and cluster-randomised controlled trials (cluster-RCTs) of single- and multi componentn on-pharmacological and pharmacological interventions for preventing delirium in older people (aged 65 years and over) in permanent LTC residence. DATA COLLECTION AND ANALYSIS: Two independent review authors examined the titles and abstracts of citations identified by the search for eligibility and extracted data, with any disagreements settled by consensus. Primary outcomes were prevalence, incidence and severity of delirium. Secondary outcomes included new diagnosis of dementia, activities of daily living, quality of life and adverse outcomes. We used risk ratios (RRs)as measures of treatment effect for dichotomous outcomes and hazard ratios (HR) for time to event data.Main results We included two trials that recruited 3636 participants.Both were complex single-component non-pharmacological delirium prevention interventions. Risk of bias for many items was unclear due to inadequate reporting. Notably, there was no evidence of blinding of trial participants or assessors in either trial. One small cluster-RCT (n = 98) of a hydration-based intervention reported no reduction in delirium incidence in the intervention group compared to control (RR 0.85, 95% confidence interval (CI) 0.18 to 4.00, analysis not adjusted for clustering, very low quality evidence). Results were imprecise and there were serious limitations evident in trial design.One large cluster-RCT (n = 3538) of a computerised system to identify medications that may contribute to delirium risk and trigger a pharmacist-led medication review reported a large reduction in delirium incidence (12-month HR 0.42, CI 0.34 to 0.51, moderat equality evidence) but no clear evidence of reduction in hospital admissions (HR 0.89, CI 0.72 to 1.10, moderate quality evidence), in mortality (HR 0.88, CI 0.66 to 1.17, moderate quality evidence) or in falls risk (HR 1.03, CI 0.92 to 1.15, moderate quality evidence).Authors' conclusions Our review identified very limited evidence on interventions for preventing deliriumin older people in LTC. Introduction of a software based intervention to identify medications that could contribute to delirium risk so that a pharmacist-led medication review and monitoring plan can be initiated may reduce incidence of delirium for older people in institutional LTC. This is based on one large RCT in the United States and may not be practical in other countries which do not have comparable information technology services available in care homes. Our review identified only one ongoing pilot trial of a multicomponent delirium prevention intervention and no trials of pharmacological agents. Future trials of computerised medication management systems and multicomponent non-pharmacological and pharmacological delirium prevention interventions for older people in LTC are needed to help inform the provision of evidence based care for this vulnerable group. PDF Efectos de dos métodos de anestesia-analgesia sobre la incidencia de delirio postoperatorio en los ancianos operados de cirugía mayor torácica y abdominal Effects of two different anesthesia-analgesia methods on incidence of postoperative delirium in elderly patients undergoing major thoracic and abdominal surgery: study rationale and protocol for a multicenter randomized controlled trial. Li YW, Li HJ, Li HJ1, Feng Y, Yu Y, Guo XY, Li Y, Zhao BJ, Hu XY, Zuo MZ, Zhang HY, Wang MR, Ji P,Yan XY, Wu YF, Wang DX. BMC Anesthesiol. 2015 Oct 13;15(1):144. doi: 10.1186/s12871-015-0118-5. Abstract BACKGROUND: Delirium is a common complication in elderly patients after surgery and associated with increased morbidity and mortality. Studies suggest that deep anesthesia and intense pain are important precipitating factors of postoperative delirium. Neuraxial block is frequently used in combination with general anesthesia for patients undergoing major thoracic and abdominal surgery. Compared with general anesthesia alone and postoperative intravenous analgesia, combined epidural-general anesthesia and postoperative epidural analgesia decreases the requirement of general anesthetics during surgery and provided better pain relief after surgery. However, whether combined epidural-general anesthesia plus epidural analgesia is superior to general anesthesia plus intravenous analgesia in decreasing the incidence of postoperative delirium remains unknown. METHODS/DESIGN: This is a multicenter, open-label, randomized, parallel-controlled clinical trial. One thousand eight hundred elderly patients (age range 60-90 years) who are scheduled to undergo major thoracic or abdominal surgery are randomized to receive either general anesthesia plus postoperative intravenous analgesia or combined epidural-general anesthesia plus postoperative epidural analgesia. The primary outcome is the 7-day incidence of postoperative delirium. Secondary outcomes include the duration of postoperative delirium, the intensity of pain during the first three days after surgery, the 30-day incidences of postoperative non-delirium complications, the length of stay in hospital after surgery and 30-day all-cause mortality. DISCUSSION: Results of the present study will provide information to guide clinical practice in choosing appropriate anesthesia-analgesia method for elderly patients undergoing major thoracic and abdominal surgery. PDF

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

Dexmedetomidina en ancianos/Dexmedetomidine in the elderly

Octubre 24, 2015. No. 2124Octubre, mes de lucha contra cáncer de mama.

Efectos de dexmedetomidina sobre despertar suave de la anestesia en ancianos de cirugía ortopédica Effects of dexmedetomidine on smooth emergence from anaesthesia in elderly patients undergoing orthopaedic surgery. Kim DJ, Kim SH, So KY, Jung KT. BMC Anesthesiol. 2015 Oct 7;15(1):139. doi: 10.1186/s12871-015-0127-4.  CONCLUSIONS: Dexmedetomidine may be an effective intraoperative adjuvant for a reducing emergence agitation and smooth emergence from anaesthesia after orthopaedic surgery in elderly patients. PDF

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

Medwave. Edición completa del mes de octubre

Medwave <cursos@medwave.cl>



oct 31 a las 3:31 A.M.

Hemos completado la edición correspondiente al mes de octubre de 2015. Los artículos incluidos son los siguientes:


CARTA A LA EDITORA

Ensayos clínicos en países latinoamericanos
José Kelvin Gálvez-Olortegui, Tomas Vladimir Gálvez-Olortegui, Yudy Cley Cóndor-Rojas (Perú)

Medwave 2015 Oct;15(9):e6294
http://dx.doi.org/10.5867/medwave.2015.09.6294


REPORTES DE CASO

Hernia pulmonar espontánea: a propósito de un caso clínico
Felipe Petour Gazitúa, Javiera Pérez Velásquez, Felipe Quintanilla Guidobono, Jeanne Marie Chehade (Chile)

Medwave 2015 Oct;15(9):e6284
http://dx.doi.org/10.5867/medwave.2015.09.6284


Bloqueo de rama alternante taquicardia-dependiente en cardiopatía isquémica con disfunción sistólica: descripción de caso y revisión de implicancias pronósticas
Federico Ferrando, Alejandro Vidal, Roberto Ricca-Mallada, Romina Nogara, Pablo Marichal, Fabián Martínez (Uruguay)

Medwave 2015 Oct;15(9):e6285
http://dx.doi.org/10.5867/medwave.2015.09.6285


Púrpura de Henoch Schonlein asociada a picadura de abeja: reporte de caso
José Gálvez-Olortegui, Mayita Álvarez-Vargas, Juan Durand-Vergara, Marisol Díaz-Lozano, Tomas Gálvez-Olortegui, Indira Armas-Ramírez, Julio Hilario-Vargas (Perú)

Medwave 2015 Oct;15(9):e6297
http://dx.doi.org/10.5867/medwave.2015.09.6297


ANÁLISIS

El desafío de los sistemas de salud en el siglo XXI: ¿cómo incorporar el enfoque de los determinantes sociales de la salud?
Cristóbal Cuadrado (Chile)

Medwave 2015 Oct;15(9):e6289
http://dx.doi.org/10.5867/medwave.2015.09.6289


REVISIÓN CLÍNICA

El uso de corticoides antenatales en cesáreas electivas de término, ¿reduce la morbilidad respiratoria?
Felipe Petour Gazitúa, Javiera Pérez Velásquez (Chile)

Medwave 2015 Oct;15(9):e6280
http://dx.doi.org/10.5867/medwave.2015.09.6280


ARTÍCULO DE REVISIÓN

Periodontitis como determinante del inicio y progresión de la enfermedad de Huntington: revisión de la literatura
María Lourdes Rodríguez Coyago, Victoria Emilia Sánchez Temiño (Argentina)

Medwave 2015 Oct;15(9):e6293
http://dx.doi.org/10.5867/medwave.2015.09.6293


ANÁLISIS CRÍTICO

Revisión de las guías actuales de hipertensión arterial
Mayita Lizbeth Álvarez-Vargas, José Kelvin Galvez-Olortegui, Tomas Vladimir Galvez-Olortegui, José Manuel Sosa-Rosado, Luis Arturo Camacho-Saavedra (Perú)

Medwave 2015 Oct;15(9):e6290
http://dx.doi.org/10.5867/medwave.2015.09.6290



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