Oxido nitroso / Nitrous oxide

Noviembre 28, 2015. No. 2159

Efectos analgésicos y fisiológicos en sedación consciente con diferentes concentraciones de óxido nitroso Analgesic and physiological effects in conscious sedation with different nitrous oxide concentrations. Bonafé-Monzó N, Rojo-Moreno J, Catalá-Pizarro M. J Clin Exp Dent. 2015 Feb 1;7(1):e63-8. doi: 10.4317/jced.52034. eCollection 2015. Abstract OBJECTIVES: to study the physiological changes, as well as the psychosedative and analgesic effects of nitrous oxide, in experimental conditions. STUDY DESIGN: 101 dental students volunteers participated in a single nitrous oxide sedation session without dental treatment. Signs and symptoms were registered during and after the procedure. Pulse rate and hemoglobin oxygen saturation were monitored at: 100 per cent O2, 30 per cent N2O, 50 per cent N2O and 5 minutes after 100 per cent O2. A Likert scale was used to evaluate pain perception. The analgesic effects of nitrous oxide were evaluated at: 30 per cent N2O, 50 per cent N2O, and five minutes postoperatively. RESULTS: Pulse rate and hemoglobin oxygen saturation decreased significantly through all the procedure and after recovery. However, oxygen saturation recovered after the final oxygenation. Only 8.2% of subjects reported the pain stimulus as being quite annoying when they inhaled 30 per cent N2O, while this percentage was of 15.8 % when inhaling 50 per cent N2O, and of 32.7 % during the recovery period. The most common effects of nitrous oxide sedation were bright eyes (99%), voice change (98%) and smiling (91%). Most of the subjects reported tingling (98%) and relax (91.1%) CONCLUSIONS: nitrous oxide causes a significant decrease in heart rate and oxygen saturation, but always within safety limits. Maintaining an appropriate level of consciousness was confirmed as a feature in 50 per cent dose in this study. The analgesic effect of nitrous oxide was confirmed but a dose dependency could not be established. Key words:Nitrous oxide, conscious sedation, anxiolysis, safety, physiogical parameters, signs, symptoms, analgesia. PDF Técnicas basadas con óxido nitroso versus técnicas sin óxido nitroso en anestesia general Nitrous oxide-based techniques versus nitrous oxide-free techniques for general anaesthesia. Sun R, Jia WQ, Zhang P, Yang K, Tian JH, Ma B, Liu Y, Jia RH, Luo XF, Kuriyama A. Cochrane Database Syst Rev. 2015 Nov 6;11:CD008984. [Epub ahead of print] Abstract BACKGROUND: Nitrous oxide has been used for over 160 years for the induction and maintenance of general anaesthesia. It has been used as a sole agent but is most often employed as part of a technique using other anaesthetic gases, intravenous agents, or both. Its low tissue solubility (and therefore rapid kinetics), low cost, and low rate of cardiorespiratory complications have made nitrous oxide by far the most commonly used general anaesthetic. The accumulating evidence regarding adverse effects of nitrous oxide administration has led many anaesthetists to question its continued routine use in a variety of operating room settings. Adverse events may result from both the biological actions of nitrous oxide and the fact that to deliver an effective dose, nitrous oxide, which is a relatively weak anaesthetic agent, needs to be given in high concentrations that restrict oxygen delivery (for example, a common mixture is 30% oxygen with 70% nitrous oxide). As well as the risk of low blood oxygen levels, concerns have also been raised regarding the risk of compromising the immune system, impaired cognition, postoperative cardiovascular complications, bowel obstruction from distention, and possible respiratory compromise. OBJECTIVES: To determine if nitrous oxide-based anaesthesia results in similar outcomes to nitrous oxide-free anaesthesia in adults undergoing surgery. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014 Issue 10); MEDLINE (1966 to 17 October 2014); EMBASE (1974 to 17 October 2014); and ISI Web of Science (1974 to 17 October 2014). We also searched the reference lists of relevant articles, conference proceedings, and ongoing trials up to 17 October 2014 on specific websites (http://clinicaltrials.gov/, http://controlled-trials.com/, and http://www.centerwatch.com). SELECTION CRITERIA: We included randomized controlled trials (RCTs) comparing general anaesthesia where nitrous oxide was part of the anaesthetic technique used for the induction or maintenance of general anaesthesia (or both) with any general anaesthesia using a volatile anaesthetic or propofol-based maintenance of anaesthesia but no nitrous oxide for adults undergoing surgery. Our primary outcome was inhospital case fatality rate. Secondary outcomes were complications and length of stay. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality and extracted the outcome data. We used meta-analysis for data synthesis. Heterogeneity was examined with the Chi² test and by calculating the I² statistic. We used a fixed-effect model if the measure of inconsistency was low for all comparisons (I² statistic < 50%); otherwise we used a random-effects model for measures with high inconsistency. We undertook subgroup analyses to explore inconsistency and sensitivity analyses to evaluate whether the results were robust. We assessed the quality of evidence of the main outcomes using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. MAIN RESULTS: We included 35 trials (13,872 adult participants). Seven included studies were at low risk of bias. We identified eight studies as awaiting classification since we could not obtain the full texts, and had insufficient information to include or exclude them. We included data from 24 trials for quantitative synthesis. The results of meta-analyses showed that nitrous oxide-based techniques increased the incidence of pulmonary atelectasis (odds ratio (OR) 1.57, 95% confidence interval (CI) 1.18 to 2.10, P = 0.002), but had no effects on the inhospital case fatality rate, the incidence of pneumonia, myocardial infarction, stroke, severe nausea and vomiting, venous thromboembolism, wound infection, or the length of hospital stay. The sensitivity analyses suggested that the results of the meta-analyses were all robust except for the outcomes of pneumonia, and severe nausea and vomiting. Two trials reported length of intensive care unit (ICU) stay but the data were skewed so were not pooled. Both trials reported that nitrous oxide-based techniques had no effects on the length of ICU stay. We rated the quality of evidence for two outcomes (pulmonary atelectasis, myocardial infarction) as high, four outcomes (inhospital case fatality rate, stroke, venous thromboembolism, length of hospital stay) as moderate, and three (pneumonia, severe nausea and vomiting, wound infection rate) as low. AUTHORS' CONCLUSIONS: Given the evidence from this Cochrane review, the avoidance of nitrous oxide may be reasonable in participants with pre-existing poor pulmonary function or at high risk of postoperative nausea and vomiting. Since there are eight studies awaiting classification, selection bias may exist in our systematic review. PDF

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

E-books, librerias, bibliotecarios, bibliotecas

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Medwave, edición noviembre 2015 completa

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


DE LOS EDITORES

Impacto y pertinencia en la revista: publicando en inglés y gran número de visitas únicas
Vivienne C. Bachelet

Medwave 2015 Nov;15(10):e6301
http://dx.doi.org/10.5867/medwave.2015.10.6301


REPORTE DE CASO

Inmunoglobulina intravenosa en el tratamiento del síndrome de Morvan secundario a la recurrencia de un carcinoma tímico
Gabriel Horta Baas (México)

Medwave 2015 Nov;15(10):e6323
http://dx.doi.org/10.5867/medwave.2015.10.6323


ESTUDIO PRIMARIO

Prevalencia del delirium en pacientes hospitalizados en un servicio de medicina interna
Bernardita Claudia Carrillo Venezian, Ana Carolina González Pezoa (Chile)

Medwave 2015 Nov;15(10):e6311
http://dx.doi.org/10.5867/medwave.2015.10.6311


MÉTODOS DE INVESTIGACIÓN Y REPORTE
Normas para la excelencia en los reportes sobre mejoras de la calidad (SQUIRE 2.0): guías de publicación revisadas a partir de un proceso de consenso detallado
Greg Ogrinc, Louise Davies, Daisy Goodman, Paul Batalden, Frank Davidoff, David Stevens (Estados Unidos)

Medwave 2015 Nov;15(10):e6318
http://dx.doi.org/10.5867/medwave.2015.10.6318


ANÁLISIS

Aterosclerosis y estatinas: rol de la epigenética
Marcelo Storino Farina, Jairo Rojano Rada, Antony Molina Garrido, Xiomara Martínez, Alfredo Pulgar, Roxanna Paniagua, Jorge Garrido (Venezuela)

Medwave 2015 Nov;15(10):e6324
http://dx.doi.org/10.5867/medwave.2015.10.6324


CARTA A LA EDITORA

Sobre los ensayos clínicos: algunas consideraciones metodológicas y bioéticas
Carlos Alva Díaz, Wilfor Aguirre Quispe (Perú)

Medwave 2015 Nov;15(10):e6313
http://dx.doi.org/10.5867/medwave.2015.10.6313


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Hemorragia obstétrica/Obstetric hemorrhage

Noviembre 27, 2015. No. 2158

Manejo hemostático de la hemorragia obstétrica Haemostatic management of obstetric haemorrhage. Collis RE, Collins PW. Anaesthesia. 2015 Jan;70 Suppl 1:78-86, e27-8. doi: 10.1111/anae.12913. Abstract The haemostatic management of major obstetric haemorrhage remains challenging, and current published guidance relies heavily on experience from the non-pregnant population and expert opinion. In recent years, an interest in the implications of relative hypofibrinogenaemia, point-of-care monitoring of coagulation abnormalities, and the potential to give goal-directed therapy to correct coagulopathies, have created the possibility of significantly challenging and changing guidance. There is evidence that the haemostatic impairment in the pregnant population is different from trauma-induced bleeding, and the type and rate of onset of coagulopathies differ depending on the underlying cause. This review examines areas such as possible intervention points, describes evidence for over-transfusion of fresh frozen plasma in some situations and challenges conventional thinking on formulaic management. It also examines the rationale for other therapeutic options, including fibrinogen concentrate and tranexamic acid PDF Avances médicos en el tratamiento de la hemorragia postparto Medical advances in the treatment of postpartum hemorrhage. Ducloy-Bouthors AS1, Susen S, Wong CA, Butwick A, Vallet B, Lockhart E. Anesth Analg. 2014 Nov;119(5):1140-7. doi: 10.1213/ANE.0000000000000450. Abstract Postpartum hemorrhage (PPH) is a leading cause of maternal mortality worldwide. Recent advances in the management of severe bleeding for trauma patients may provide insight into PPH management, but must be applied with caution considering the significant differences between trauma and obstetric patients. In this review, we summarized evidence for current management strategies for patients with major obstetric hemorrhage, including (1) rapid laboratory assessment of coagulopathy, (2) early transfusion of plasma and high plasma-to-red blood cell transfusion ratios in massive PPH, and (3) use of tranexamic acid and fibrinogen concentrates in the setting of PPH complicated by coagulopathy. PDF

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

Ácido tranexámico en obstetricia / Tranexamic acid in obstetrics

Noviembre 26, 2015. No. 2157 Ácido tranexámico para prevenir la hemorragia postparto Tranexamic acid for preventing postpartum haemorrhage. Novikova N, Hofmeyr GJ, Cluver C. Cochrane Database Syst Rev. 2015 Jun 16;6:CD007872. doi: 0.1002/14651858.CD007872.pub3. Abstract BACKGROUND: Postpartum haemorrhage (PPH) is a common and potentially life-threatening complication of labour. Several options for preventing PPH are available, but further advances in this field are important, especially the identification of safe, easy to use and cost-effective regimens. Tranexamic acid (TA), which is an antifibrinolytic agent that is used widely to prevent and treat haemorrhage, merits evaluation to assess whether it meets these criteria.OBJECTIVES: To determine, from the best available evidence, whether TA is effective and safe for preventing PPH in comparison to placebo or no treatment (with or without uterotonic co-treatment), or to uterotonic agents.SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 January 2015) and reference lists of retrieved studies.SELECTION CRITERIA: All published, unpublished and ongoing randomised controlled trials (RCTs) evaluating the use of TA alone or in addition to uterotonics in the third stage of labour or during caesarean section (CS) to prevent PPH.DATA COLLECTION AND ANALYSIS: Two review authors independently assessed for inclusion all the potential studies identified as a result of the search strategy. We entered the data into Review Manager software and checked for accuracy. MAIN RESULTS: Twelve trials involving 3285 healthy women at low risk of excessive bleeding undergoing elective CS (nine trials, 2453 participants) or spontaneous birth (three trials, 832 participants) satisfied inclusion criteria and contributed data to the analysis. All participants received routine prophylactic uterotonics in accordance with the local guideline in addition to TA or placebo or no intervention. Overall, included studies had moderate risk of bias for random sequence generation, allocation concealment, blinding, selective reporting and low risk of bias for incomplete data. The quality of evidence was also as assessed using GRADE.Blood loss greater than 400 mL or 500 mL, and more than 1000 mL was less common in women who received TA versus placebo or no intervention (risk ratio (RR) 0.52, 95% confidence interval (CI) 0.42 to 0.63, six trials, 1398 women; moderate quality evidence) and (RR 0.40, 95% CI 0.23 to 0.71, six trials, 2093 women; moderate quality evidence), respectively. TA was effective in decreasing the incidence of blood loss greater than 1000 mL in women who had undergone CS (RR 0.43, 95% CI 0.23, 0.78, four trials, 1534 women), but not vaginal birth (RR 0.28, 95% CI 0.06, 1.36, two trials 559 women). The effect of TA on blood loss greater than 500 mL or 400 mL was more pronounced in the group of women having vaginal birth than in women who had CS. Mean blood loss (from delivery until two hours postpartum) was lower in women who received TA versus placebo or no intervention (mean difference MD - 77.79 mL, 95% CI -97.95, -57.64, five trials, 1186 women) and this effect was similar following vaginal birth and CS.Additional medical interventions (moderate quality evidence) and blood transfusions were less frequent in women receiving TA versus placebo or no interventions. Mild side effects such as nausea, vomiting, dizziness were more common with the use of TA (moderate quality evidence). The effect of TA on maternal mortality, severe morbidity and thromboembolic events is uncertain (low quality evidence).AUTHORS' CONCLUSIONS: TA (in addition to uterotonic medications) decreases postpartum blood loss and prevents PPH and blood transfusions following vaginal birth and CS in women at low risk of PPH based on studies of mixed quality. There is insufficient evidence to draw conclusions about serious side effects, but there is an increase in the incidence of minor side effects with the use of TA. Effects of TA on thromboembolic events and mortality as well as its use in high-risk women should be investigated further. PDF Protocolo de estudio TRAAP- Ácido TRAxenámico para Prevención de hemorragia postparto después de parto vaginal. Estudio multicéntrico randomizado, doble ciego, controlado con placebo Study protocol. TRAAP - TRAnexamic Acid for Preventing postpartum hemorrhage after vaginal delivery: a multicenter randomized, double-blind, placebo-controlled trial. Sentilhes L, Daniel V, Darsonval A, Deruelle P, Vardon D, Perrotin F, Le Ray C, Senat MV, Winer N,Maillard F, Deneux-Tharaux C. BMC Pregnancy Childbirth. 2015 Jun 14;15:135. doi: 10.1186/s12884-015-0573-5. Abstract BACKGROUND: Postpartum hemorrhage (PPH) is a major cause of maternal mortality, accounting for one quarter of all maternal deaths worldwide. Estimates of its incidence in the literature vary widely, from 3 % to 15 % of deliveries. Uterotonics after birth are the only intervention that has been shown to be effective in preventing PPH. Tranexamic acid (TXA), an antifibrinolytic agent, has been investigated as a potentially useful complement to uterotonics for prevention because it has been proved to reduce blood loss in elective surgery, bleeding in trauma patients, and menstrual blood loss. Randomized controlled trials for PPH prevention after cesarean (n = 10) and vaginal (n = 2) deliveries show that women who received TXA had significantly less postpartum blood loss without any increase in their rate of severe adverse effects. However, the quality of these trials was poor and they were not designed to test the effect of TXA on the reduction of PPH incidence. Large, adequately powered, multicenter randomized controlled trials are required before the widespread use of TXA to prevent PPH can be recommended. METHODS AND DESIGN: A multicenter, double-blind, randomized controlled trial will be performed. It will involve 4000 women in labor for a planned vaginal singleton delivery, at a term ≥ 35 weeks. Treatment (either TXA 1 g or placebo) will be administered intravenously just after birth. Prophylactic oxytocin will be administered to all women. The primary outcome will be the incidence of PPH, defined by blood loss ≥500 mL, measured with a graduated collector bag. This study will have 80 % power to show a 30 % reduction in the incidence of PPH, from 10.0 % to 7.0 %. DISCUSSION: In addition to prophylactic uterotonic administration, a complementary component of the management of third stage of labor acting on the coagulation process may be useful in preventing PPH. TXA is a promising candidate drug, inexpensive, easy to administer, and simple to add to the routine management of deliveries in hospitals. This large, adequately powered, multicenter, randomized placebo-controlled trial seeks to determine if the risk-benefit ratio favors the routine use of TXA after delivery to prevent PPH. PDF

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