Revisiones_bibliográficas TyO

Front Endocrinol (Lausanne). 2017 Oct 30;8:271. doi: 10.3389/fendo.2017.00271. eCollection 2017.

Abstract

Sepsis develops when an infection surpasses local tissue containment. A series of dysregulated physiological responses are generated, leading to organ dysfunction and a 10% mortality risk. When patients with sepsis demonstrate elevated serum lactates and require vasopressor therapy to maintain adequate blood pressure in the absence of hypovolemia, they are in septic shock with an in-hospital mortality rate >40%. Traditionally, it was thought that the complex interplay between inflammatory and anti-inflammatory responses led to sepsis-induced organ dysfunction and mortality. However, a closer examination of those who die long after sepsis subsides reveals that many initial survivors succumb to recurrent, nosocomial, and secondary infections. The comorbidly challenged, physiologically frail diabetic individuals suffer the highest infection rates. Recent reports suggest that even after clinical "recovery" from sepsis, persistent alterations in innate and adaptive immune responses exists resulting in chronic inflammation, immune suppression, and bacterial persistence. As sepsis-associated immune defects are associated with increased mortality long-term, a potential exists for immune modulatory therapy to improve patient outcomes. We propose that diabetes causes a functional immune deficiency that directly reduces immune cell function. As a result, patients display diminished bactericidal clearance, increased infectious complications, and protracted sepsis mortality. Considering the substantial expansion of the elderly and obese population, global adoption of a Western diet and lifestyle, and multidrug resistant bacterial emergence and persistence, diabetic mortality from sepsis is predicted to rise dramatically over the next two decades. A better understanding of the underlying diabetic-induced immune cell defects that persist following sepsis are crucial to identify potential therapeutic targets to bolster innate and adaptive immune function, prevent infectious complications, and provide more durable diabetic survival.

KEYWORDS: complications; diabetes; infections; resource utilization; sepsis; septic shock

Carga de líquido inicial para pacientes sépticos: ¿Se necesita algún límite de seguridad?

Early fluid loading for septic patients: Any safety limit needed?

Gong YC1, Liu JT1, Ma PL2.

Chin J Traumatol. 2017 Nov 8. pii: S1008-1275(16)30323-6. doi: 10.1016/j.cjtee.2017.06.005. [Epub ahead of print]

Abstract

Early adequate fluid loading was the corner stone of hemodynamic optimization for sepsis and septic shock. Meanwhile, recent recommended protocol for fluid resuscitation was increasingly debated on hemodynamic stability vs risk of overloading. In recent publications, it was found that a priority was often given to hemodynamic stability rather than organ function alternation in the early fluid resuscitation of sepsis. However, no safety limits were used at all in most of these reports. In this article, the rationality and safety of early aggressive fluid loading for septic patients were discussed. It was concluded that early aggressive fluid loading improved hemodynamics transitorily, but was probably traded off with a follow-up organ function impairment, such as worsening oxygenation by reduction of lung aeration, in a part of septic patients at least. Thus, a safeguard is needed against unnecessary excessive fluids in early aggressive fluid loading for septic patients.

KEYWORDS: Fluid loading; Hemodynamic stability; Safety; Sepsis

Miocardiopatía inducida por sepsis: Implicaciones oxidativas en la iniciación y resolución del daño.

Sepsis-Induced Cardiomyopathy: Oxidative Implications in the Initiation and Resolution of the Damage.

Tsolaki V1, Makris D1, Mantzarlis K1, Zakynthinos E1.

Oxid Med Cell Longev. 2017;2017:7393525. doi: 10.1155/2017/7393525. Epub 2017 Sep 19.Abstract

Cardiac dysfunction may complicate the course of severe sepsis and septic shock with significant implications for patient's survival. The basic pathophysiologic mechanisms leading to septic cardiomyopathy have not been fully clarified until now. Disease-specific treatment is lacking, and care is still based on supportive modalities. Septic state causes destruction of redox balance in many cell types, cardiomyocytes included. The production of reactive oxygen and nitrogen species is increased, and natural antioxidant systems fail to counterbalance the overwhelming generation of free radicals. Reactive species interfere with many basic cell functions, mainly through destruction of protein, lipid, and nucleic acid integrity, compromising enzyme function, mitochondrial structure and performance, and intracellular signaling, all leading to cardiac contractile failure. Takotsubo cardiomyopathy may result from oxidative imbalance. This review will address the multiple aspects of cardiomyocyte bioenergetic failure in sepsis and discuss potential therapeutic interventions.

Safe Anaesthesia Worldwide

Delivering safe anaesthesia to the world's poorest people

World Congress on Regional Anesthesia & Pain Medicine

April 19-21, 2018, New York City, USA

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vwhizar@anestesia-dolor.org

Anestesiología y Medicina del Dolor

52 664 6848905

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Dolor neuropático / Neurophatic pain

Enero 2, 2018. No. 2951

Una revisión del manejo del dolor del miembro fantasma: desafíos y soluciones.

A review of the management of phantom limb pain: challenges and solutions.

Richardson C1, Kulkarni J2.

J Pain Res. 2017 Aug 7;10:1861-1870. doi: 10.2147/JPR.S124664. eCollection 2017.

Abstract

BACKGROUND: Phantom limb pain (PLP) occurs in 50% and 80% of amputees. Although it is often classified as a neuropathic pain, few of the large-scale trials of treatments for neuropathic pain included sufficient numbers of PLP sufferers to have confidence that they are effective in this condition. Many therapies have been administered to amputees with PLP over the years; however, as of yet, there appears to be no first-line treatment. OBJECTIVES: To comprehensively review the literature on treatment modalities for PLP and to identify the challenges currently faced by clinicians dealing with this pain. METHOD: MEDLINE, EMBASE, CINAHL, British Nursing Index, Cochrane and psycINFO databases were searched using "Phantom limb" initially as a MeSH term to identify treatments that had been tried. Then, a secondary search combining phantom limb with each treatment was performed to find papers specific to each therapy. Each paper was assessed for its research strength using the GRADE system. RESULTS: Thirty-eight therapies were identified. Overall, the quality of evidence was low. There was one high-quality study which used repetitive transcutaneous magnetic stimulation and found a statistical reduction in pain at day 15 but no difference at day 30. Significant results from single studies of moderate level quality were available for gabapentin, ketamine and morphine; however, there was a risk of bias in these papers. Mirror therapy and associated techniques were assessed through two systematic reviews, which conclude that there is insufficient evidence to support their use. CONCLUSION: No decisions can be made for the first-line management of PLP, as the level of evidence is too low. Robust studies on homogeneous populations, an understanding of what amputees consider a meaningful reduction in PLP and agreement of whether painintensity is the legitimate therapeutic target are urgently required.

KEYWORDS: pain; phantom limb pain; review; treatment

La ketamina en el tratamiento del dolor crónico según medicina basada en la evidencia

F. Neira Reina y J. L. Ortega García

Rev. Soc. Esp. Dolor vol.23 no.6 Madrid nov./dic. 2016

RESUMEN

La ketamina es un antagonista no competitivo de los receptores NMDA y tiene un amplio mecanismo de acción que involucra, además, a los receptores AMPA, kainato, ácido gamma-aminobutírico, opioides, monoaminérgicos, muscarínicos y nicotínicos. Actúa sobre los canales de calcio y sodio voltaje-dependientes, interviene en la síntesis y liberación del óxido nítrico e inhibe la recaptación de serotonina. La interacción con todos estos mecanismos de acción hace que tenga una importante participación sobre mecanismos del dolor, inflamación, neuroprotección y tolerancia de opioides. En este trabajo se revisan las diferentes vías de administración de la ketamina, su dosificación, las modalidades de administración, la duración del tratamiento, las indicaciones según los niveles de evidencia disponibles y los efectos secundarios; para establecer su eficacia en la terapéutica del dolor crónico y promover un tratamiento más específico, en aquellas patologías en las que se ha demostrado una mayor eficacia. Se realizó una búsqueda en Trip Database Population Intervention Comparison Outcome (PICO), National Guidelines Clearinghouse, Cochrane Library, Medline, CMA infobase, Health Services/Technology Assessment, New Zealand Guidelines Group y Scottish Intercollegiate Guidelines Network. La ketamina tiene una gran versatilidad en cuanto a sus vías de administración (intravenosa, intramuscular, subcutánea, sublingual, oral, rectal, nasal, transdérmica, epidural y subaracnoidea), así como modalidades de administración (bolos, infusión continua). No obstante, la vía oral es la más utilizada y preferida para el tratamiento del dolor crónico. Sin embargo, no disponemos de una formulación oral comercializada, lo que dificulta su utilización. El empleo clínico de la ketamina requiere una cuidadosa selección del paciente y valoración de la relación riesgo/beneficio. Se debe tener presente los antecedentes de abuso de drogas ante el riesgo potencial de abuso del fármaco. Se dispone de evidencia sobre la eficacia de la ketamina en pacientes con dolor oncológico refractario y en el síndrome doloroso regional complejo (SDRC). Hay evidencia moderada sobre la eficacia de la ketamina intravenosa a dosis bajas, en el SDRC, que no justifica su utilización sistemática en este síndrome. En el dolor neuropático, la ketamina se ha mostrado especialmente eficaz en el control de la alodinia, hiperalgesia e hiperpatía, pero existen controversias sobre su utilización. La ketamina oral puede tener un lugar en el tratamiento del dolor crónico de los pacientes refractarios a tratamientos habituales. Se ha mostrado útil como coadyuvante de otros analgésicos, especialmente en pacientes en tratamiento con opioides, permitiendo disminuir la dosis e incrementando el control analgésico de los pacientes con dolor crónico.

Palabras clave: Ketamina, dolor crónico, dolor neuropático, síndrome doloroso regional complejo.

Manejo del dolor crónico neuropático con metadona combinada con ketamina: un ensayo clínico aleatorizado, doble ciego, con control activo.

Management of Neuropathic Chronic Pain with Methadone Combined with Ketamine: A Randomized, Double Blind, Active-Controlled Clinical Trial.

Rigo FK1, Trevisan G2, Godoy MC3, Rossato MF4, Dalmolin GD5, Silva MA6, Menezes MS3, Caumo W7, Ferreira J5.

Pain Physician. 2017 Mar;20(3):207-215.

Abstract

BACKGROUND: Methadone and ketamine are used in neuropathic pain management. However, the benefits of both drugs association are uncertain in the treatment of neuropathic pain. OBJECTIVE: Our primary objective was test the hypothesis that oral methadone combined with oral ketamine is more effective than oral methadone or ketamine alone in reducing neuropathic pain. STUDY DESIGN: We conducted a randomized, double blind, active-controlled parallel-group clinical trial. METHODS: Forty-two patients with neuropathic pain refractory to conventional therapy were randomly assigned to receive oral methadone (n = 14), ketamine (n = 14), or methadone plus ketamine (n = 14) over a 3-month period. RESULTS: During these 90 days, we observed pain scores using a visual analogical scale (VAS), allodynia, burning/shooting pain, and some side effects. All treatments were effective in reducing pain scores by at least 40%. However, a significant improvement in pain was observed only in the ketamine alone group compared with both the methadone or methadone/ketamine groups. No significant differences were observed among the treatment groups for the reduction of burning or shooting pain, while ketamine alone was more effective than methadone or methadone/ketamine for the reduction of allodynia. LIMITATIONS: Formal assessment for awareness of the allocation was not performed, some co-intervention bias may have occurred, our results could be only relevant to the patient population investigated and the use of VAS as the primary outcome detect changes in pain intensity but not to assess neuropathic pain symptoms. CONCLUSION: This study indicates that ketamine was better than methadone or methadone/ketamine for treating neuropathic pain.Key words: Multimodal analgesia, refractory pain, NMDA receptor, opioid.

Safe Anaesthesia Worldwide

Delivering safe anaesthesia to the world's poorest people

World Congress on Regional Anesthesia & Pain Medicine

April 19-21, 2018, New York City, USA

International Anesthesia Research Society Annuals Meetings

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vwhizar@anestesia-dolor.org

Anestesiología y Medicina del Dolor

52 664 6848905

anestesia-dolor.org

Anestesia general y desarrollo cerebral en niños / General anesthesia and pediatric brain development

Enero 3, 2018. No. 2952

La anestesia general de larga duración influye en la inteligencia de los niños en edad escolar.

Long-duration general anesthesia influences the intelligence of school age children.

Zhang Q1, Peng Y1, Wang Y2.

BMC Anesthesiol. 2017 Dec 19;17(1):170. doi: 10.1186/s12871-017-0462-8.

Abstract

BACKGROUND: General anesthesia has been linked to impaired brain development in immature animals and young children. In this study the influence of orthopedic surgery under general anesthesia on the intelligence of school age children has been evaluated. CONCLUSIONS: More than 3 h general anesthesia influenced the IQ of school age children for up to 3 months after orthopedic surgery. Beside extended exposure time to anesthetics additional factors for post-operative IQ reduction were younger children age, mothers with low educational levels and premature birth.

TRIAL REGISTRATION: Chinese Clinical Trial Registry with registration number ChiCTR-OOC-17013497 retrospectively registered on 11/23/2017.

KEYWORDS: Children; Cognition; General anesthesia; Intelligence; Orthopedic surgery

Efectos de la anestesia en el cerebro en desarrollo. Infantes y fetos

Effect of Anesthesia on the Developing Brain: Infant and Fetus.

Andropoulos DB1.

Fetal Diagn Ther. 2017 Jun 7. doi: 10.1159/000475928. [Epub ahead of print]

Abstract

The potential for commonly used anesthetics and sedatives to cause neuroapoptosis and other neurodegenerative changes in the developing mammalian brain has become evident in animal studies over the past 15 years. This concern has led to a number of retrospective studies in human infants and young children, and some of these studies observed an association between exposure to general anesthesia as an infant, and later neurobehavioral problems in childhood. This association is particularly evident for prolonged or repeated exposures. Because of the significant growth of fetal interventions requiring sedation and analgesia for the fetus, or because of maternal anesthetic effects, this concern about anesthetic neurotoxicity is relevant for the fetus. The potential for anesthetic neurotoxicity is the most important clinical and research problem in the field of pediatric anesthesiology. This review will first briefly summarize the rapid brain growth and development in the fetus and neonate. Next, animal model data of anesthetic neurotoxicity in the fetus and neonate will be presented, followed by a review of recent human clinical anesthetic neurotoxicity trials. Finally, the rationale for studying dexmedetomidine as a potential neuroprotectant agent in anesthetic neurotoxicity will be reviewed along with study design for two human clinical trials involving dexmedetomidine.

KEYWORDS: Anesthetic neurotoxicity; Dexmedetomidine; Fetus; Isoflurane; Neonate; Sevoflurane

Efectos de la anestesia sobre el desarrollo cerebral de los niños

Effects of Anesthesia on Children's Brain Development

Hernández-Cortez Enrique

J Anesth Crit Care Open Access 2015, 2(6): 00079

Summary

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. These modifications have resulted in serious behavioral and memory changes in experiments in animals. It is suspected that a similar situation may arise in children who manifest learning disabilities in later stages.

Keywords: Apoptosis; Anesthetics; Children

Safe Anaesthesia Worldwide

Delivering safe anaesthesia to the world's poorest people

World Congress on Regional Anesthesia & Pain Medicine

April 19-21, 2018, New York City, USA

International Anesthesia Research Society Annuals Meetings

USA