27 y 28 de enero del 2018

Clin Pharmacokinet. 2017 Aug;56(8):893-913. doi: 10.1007/s40262-017-0507-7.

Abstract

Dexmedetomidine is an α2-adrenoceptor agonist with sedative, anxiolytic, sympatholytic, and analgesic-sparing effects, and minimal depression of respiratory function. It is potent and highly selective for α2-receptors with an α2:α1 ratio of 1620:1. Hemodynamic effects, which include transient hypertension, bradycardia, and hypotension, result from the drug's peripheral vasoconstrictive and sympatholytic properties. Dexmedetomidine exerts its hypnotic action through activation of central pre- and postsynaptic α2-receptors in the locus coeruleus, thereby inducting a state of unconsciousness similar to natural sleep, with the unique aspect that patients remain easily rousable and cooperative. Dexmedetomidine is rapidly distributed and is mainly hepatically metabolized into inactive metabolites by glucuronidation and hydroxylation. A high inter-individual variability in dexmedetomidine pharmacokinetics has been described, especially in the intensive care unit population. In recent years, multiple pharmacokinetic non-compartmental analyses as well as population pharmacokinetic studies have been performed. Body size, hepatic impairment, and presumably plasma albumin and cardiac output have a significant impact on dexmedetomidinepharmacokinetics. Results regarding other covariates remain inconclusive and warrant further research. Although initially approved for intravenous use for up to 24 h in the adult intensive care unit population only, applications of dexmedetomidine in clinical practice have been widened over the past few years. Procedural sedation with dexmedetomidine was additionally approved by the US Food and Drug Administration in 2003 and dexmedetomidine has appeared useful in multiple off-label applications such as pediatric sedation, intranasal or buccal administration, and use as an adjuvant to local analgesia techniques.

Utilidad de la dexmedetomidina en diversos contextos en la medicina actual

Dr. Orlando Carrillo-Torres,* Dra. María Guadalupe Pliego-Sánchez,* Dra. María Mónica Gallegos-Allier,* Dra. Lourdes Carmen Santacruz-Martínez*

Rev Mex Anestesiol Vol. 37. No. 1 Enero-Marzo 2014 pp 27-34

Resumen

En los últimos años se han creado fármacos para lograr una adecuada sedación y analgesia en los pacientes antes, durante y después de las intervenciones mé- dicas. Entre estos medicamentos se encuentra la dexmedetomidina, un fármaco altamente selectivo a los receptores alfa-2, que logra, en dosificación adecuada, analgesia, sedación y simpaticolisis sin efectos adversos importantes. Este fármaco se ha utilizado ampliamente en la terapia intensiva, para lo cual fue ideado, pero también se ha utilizado para diversos procedimientos anestesiológicos, ya sean en generales y regionales, así como para sedaciones superficiales y profundas, tanto en los adultos como en la población pediátrica. En esta revisión se abarcarán las generalidades de la dexmedetomidina, así como su uso en las diferentes especialidades hasta el día de hoy. Palabras clave: Alfa-2 agonista, dexmedetomidina, sedación, analgesia.

Dexmedetomidina: Rol Actual en Anestesia y Cuidados Intensivos

Joana Afonso 1, Flávio Reis 2 Resumen: Afonso J, Reis F

Rev Bras Anestesiol. 2012 Jan-Feb;62(1):118-33. doi: 10.1016/S0034-7094(12)70110-1.

Resumen

Justificativa y objetivos: Actualizar y analizar nuevamente la aplicación de la dexmedetomidina en la anestesia y en los cuidados intensivos. Este trabajo es una revisión bastante exhaustiva de los usos clínicos, farmacología, farmacocinética, mecanismo de acción, y de los efectos adversos de la dexmedetomidina. Contenido: El uso efectivo de los agentes sedativo-hipnóticos y analgésicos, forma parte integral de la comodidad y de la seguridad de los pacientes. La dexmedetomidina es un potente y altamente selectivo agonista de los adrenoceptores α-2 con propiedades simpaticolíticas, sedativas, amnésicas y analgésicas, que se ha venido describiendo como un adyuvante útil y seguro en varias aplicaciones clínicas. Proporciona una "sedación conciente" única, analgésica, y sin depresión respiratoria. Sus usos más comunes ya analizados, incluyen la sedación en la Unidad de Cuidados Intensivos (UCI) (adulta y pediátrica), en Urgencias, anestesia regional y general, neurocirugía, sedación para procedimientos pediá- tricos, intubación por fibra óptica en enfermos despiertos, cirugía cardíaca y cirugía bariátrica. Conclusiones: La dexmedetomidina ofrece la capacidad única de suministrar sedación y analgesia sin depresión respiratoria. Es un agente nuevo con un gran margen de seguridad, excelente capacidad sedativa y moderadas propiedades analgésicas. Aunque su amplio uso sea hoy por hoy, para pacientes de unidades de cuidados intensivos quirúrgicos y no quirúrgicos, la dexmedetomidina parece tener aplicaciones futuras promisorias en las áreas de neuroprotección, cardioprotección y renoprotección. Aunque de todas formas, son necesarios más estudios detallados para definir su rol como sedativo en los enfermos criticos, neuroquirúrgicos y pediátricos, como adyuvante en la anestesia y como sedativo durante los procedimientos. Descriptores: ANALGÉSICOS; Dexmedetomidina; ANALGESIA; ANESTESIA; Cuidados intensivos

Dexmedetomidine: current role in anesthesia and intensive care.

Afonso J1, Reis F.

Rev Bras Anestesiol. 2012 Jan-Feb;62(1):118-33. doi: 10.1016/S0034-7094(12)70110-1.

Abstract

BACKGROUND AND OBJECTIVES: To update and review the application of dexmedetomidine in anesthesia and intensive care. This study is a comprehensive review of clinical uses, pharmacology, pharmacokinetics, mechanism of action and adverse effects of dexmedetomidine.CONTENT: The effective use of sedative-hypnotic agents and analgesics is an integral part of comfort and safety of patients. Dexmedetomidine is a potent and highly selective α-2 adrenoceptor agonist with sympatholytic, sedative, amnestic, and analgesic properties, which has been described as a useful and safe adjunct in many clinical applications. It provides a unique "conscious sedation", analgesia, without respiratory depression. The current reviewed uses include sedation at Intensive Care Unit-ICU (both adult and pediatric), emergency department, regional and general anesthesia, neurosurgery, sedation for pediatric procedures, awake fiber-optic intubation, cardiac surgery and bariatric surgery. CONCLUSIONS: Dexmedetomidine offers a unique ability of providing both sedation and analgesia without respiratory depression. It is a new agent with a wide safety margin, excellent sedative capacity and moderate analgesic properties. Although its wide use is currently in patients of surgical and non-surgical intensive care units, dexmedetomidine seems to have promising future applications in neuroprotection, cardioprotection and renoprotection. More detailed studies are required to define its role as sedative in critical, neurosurgical and pediatric patients, as anesthesia adjunct and sedative during procedures.

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Dexmedetomidina: un adyuvante que se adentra en la práctica clínica.

Dexmedetomidine: an adjuvant making large inroads into clinical practice.

Bajwa S1, Kulshrestha A2.

Ann Med Health Sci Res. 2013 Oct;3(4):475-83. doi: 10.4103/2141-9248.122044.

Abstract

The introduction of newer more selective α(-2) adrenergic agonist, dexmedetomidine has made a revolution in the field of anesthesia owing to its varied application. The aim of the current review is to highlight the various clinical and pharmacological aspects of dexmedetomidine in daily routine practice of anesthesiology and intensive care besides its potential role in other clinical specialties. This review of dexmedetomidine was carried out after searching the medical literature in Pubmed, Science direct, Scopus, Google scholar and various text books and journal articles using keywords anesthesia, dexmedetomidine, neurosurgery, pediatric surgery, regional dexmedetomidine, anesthesia, regional, neurosurgery, and pediatric surgery. Dexmedetomidine has made its application from a novel sedating agent in the intensive care unit to its use as an adjuvant in various regional anesthetic techniques because of its "cooperative sedation" without any respiratory depression. It has a favorable pharmacokinetic profile suitable to be used in the perioperative period to reduce the requirements of opioids and anesthetic drugs. There are few side-effects of dexmedetomidine, which should always be kept in mind before choosing the patients for its use. The various side-effects associated with dexmedetomidine include, but are not limited to hypotension, bradycardia, worsening of heart block, dry mouth, and nausea. However, large scale randomized controlled trials are still needed to establish various effects of dexmedetomidine and to clearly define its safety profile.

KEYWORDS: Dexmedetomidine; General anesthesia; Regional anesthesia; α−2 adrenergic agonist

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http://dx.doi.org/10.5772/65921

Neurotoxicidad y anestesia / Anesthesia neurotoxicity

Enero 11, 2018. No. 2960

Neurotoxicidad anestésica en pacientes pediátricos

Anesthetic Neurotoxicity in Pediatric Patients

Ayse B. Ozer and Sibel Ozcan

Current Topics in Anesthesiology

book edited by Riza Hakan Erbay, ISBN 978-953-51-2918-9, Print ISBN 978-953-51-2917-2, Published: February 8, 2017 under CC BY 3.0 license. © The Author(s).

Abstract In recent years, an increasing number of publications have shown the negative effects of anesthetics on the developing brain and have made inquiries about anesthesia for pediatric patients in practice. Anesthesia is applied to millions of children for surgery, imaging, and other invasive procedures; the issue is very serious and concerns. In this chapter, experimental and clinical studies about the issue have been summarized. As a result, anesthetic drugs except alpha-2 adrenergic agonist anesthetic (NMDA antagonist or a GABA agonist) used in pediatric patients (especially if there is no painful situation) have potential neurotoxicity. Particularly, if anesthesia exposure was applied in the fragile period (the first 4 years) and if used at higher concentrations or repeated anesthesia application, adverse effects of anesthesia exposure on the developing brain have been claimed. But, the issue is not fully clarified yet. Keywords: anesthesia, neurotoxicity, neonatal, developing brain

Un mecanismo celular reversible por presión de anestésicos generales capaz de alterar un posible mecanismo para la conciencia

A pressure-reversible cellular mechanism of general anesthetics capable of altering a possible mechanism for consciousness

Kunjumon I. Vadakkan

Springerplus. 2015; 4: 485. Published online 2015 Sep 7. doi: 10.1186/s40064-015-1283-1

ASbstract

Different anesthetics are known to modulate different types of membrane-bound receptors. Their common mechanism of action is expected to alter the mechanism for consciousness. Consciousness is hypothesized as the integral of all the units of internal sensations induced by reactivation of inter-postsynaptic membrane functional LINKs during mechanisms that lead to oscillating potentials. The thermodynamics of the spontaneous lateral curvature of lipid membranes induced by lipophilic anesthetics can lead to the formation of non-specific inter-postsynaptic membrane functional LINKs by different mechanisms. These include direct membrane contact by excluding the inter-membrane hydrophilic region and readily reversible partial membrane hemifusion. The constant reorganization of the lipid membranes at the lateral edges of the postsynaptic terminals (dendritic spines) resulting from AMPA receptor-subunit vesicle exocytosis and endocytosis can favor the effect of anesthetic molecules on lipid membranes at this location. Induction of a large number of non-specific LINKs can alter the conformation of the integral of the units of internal sensations that maintain consciousness. Anesthetic requirement is reduced in the presence of dopamine that causes enlargement of dendritic spines. Externally applied pressure can transduce from the middle ear through the perilymph, cerebrospinal fluid, and the recently discovered glymphatic pathway to the extracellular matrix space, and finally to the paravenular space. The pressure gradient reduce solubility and displace anesthetic molecules from the membranes into the paravenular space, explaining the pressure reversal of anesthesia. Changes in membrane composition and the conversion of membrane hemifusion to fusion due to defects in the checkpoint mechanisms can lead to cytoplasmic content mixing between neurons and cause neurodegenerative changes. The common mechanism of anesthetics presented here can operate along with the known specific actions of different anesthetics.

Keywords: Consciousness, General anesthetics, Pressure reversal, Semblance hypothesis, Inter-membrane contact, Membrane hemifusion, Partial hemifusion, Complete hemifusion, Membrane fusion, Neurodegeneration

Una espada de doble filo: efectos anestésicos volátiles en el cerebro neonatal

A Double-Edged Sword: Volatile Anesthetic Effects on the Neonatal Brain

Sunny Chiao, Zhiyi Zuo

Brain Sci. 2014 Jun; 4(2): 273-294. Published online 2014 Apr 16. doi: 10.3390/brainsci4020273

Abstract

The use of volatile anesthetics, a group of general anesthetics, is an exceedingly common practice. These anesthetics may have neuroprotective effects. Over the last decade, anesthetic induced neurotoxicity in pediatric populations has gained a certain notoriety based on pre-clinical cell and animal studies demonstrating that general anesthetics may induce neurotoxicity, including neuroapoptosis, neurodegeneration, and long-term neurocognitive and behavioral deficits. With hundreds of millions of people having surgery under general anesthesia worldwide, and roughly six million children annually in the U.S. alone, the importance of clearly defining toxic or protective effects of general anesthetics cannot be overstated. Yet, with our expanding body of knowledge, we have come to learn that perhaps not all volatile anesthetics have the same pharmacological profiles; certain ones may have a more favorable neurotoxic profile and may actually exhibit neuroprotection in specific populations and situations. Thus far, very few clinical studies exist, and have not yet been convincing enough to alter our practice. This review will provide an update on current data regarding volatile anesthetic induced neurotoxicity and neuroprotection in neonatal and infant populations. In addition, this paper will discuss ongoing studies and the trajectory of further research over the coming years.

Keywords: anesthesia, anesthetics, neuroprotection, neurotoxicity, pediatrics, volatile anesthetics, preconditioning, postconditioning, ischemic conditioning

Safe Anaesthesia Worldwide

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World Congress on Regional Anesthesia & Pain Medicine

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

International Anesthesia Research Society Annuals Meetings

USA

Anestesiología y Medicina del Dolor

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www.mihombroycodo.com.mx/academia/mi-hombro-y-codo-basta-de-sentir-dolor/

5°Maratón del hombro y codo doloroso. Mi hombro y codo ¡Basta de sentir dolor!

¡Basta de sentir dolor!

Este 27 y 28 de enero del 2018, tendrás a un grupo de expertos en Traumatología y Ortopedia, entre ellos a un servidor, totalmente dispuestos a ayudarte para sanar tu hombro o codo doloroso en el Hospital de Especialidades Catalina, ubicado en la calle Pablo Valdez 719, Col. San Juan de Dios.

¿En qué consiste el Maratón del Hombro y Codo Doloroso?

Se trata de un fin de semana completo en el que los especialistas te ayudarán a diagnosticar con exactitud la causa de tu dolor. El paquete de diagnóstico consiste en:
Una radiografía
Un ultrasonido
Consulta especializada con doctor ortopedista
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El paquete completo estará al precio especial de $1,350.00 MXN

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Llama y haz tu cita con el Dr. Carlos Cortés al tel. +52 (33) 1204 0143 o directamente al Hospital de Especialidades Catalina al +52 (33) 3883 1080.

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27 y 28 de enero del 2018

lunes, 8 de enero de 2018

Shock

Enero 7, 2018. No. 2956

El sangriento desastre de la transfusión de glóbulos rojos.

The bloody mess of red blood cell transfusion.

Chandra S1, Kulkarni H2, Westphal M3,4.

Crit Care. 2017 Dec 28;21(Suppl 3):310. doi: 10.1186/s13054-017-1912-x.

Abstract

Red blood cell (RBC) transfusion might be life-saving in settings with acute blood loss, especially uncontrolled haemorrhagic shock. However, there appears to be a catch-22 situation reflected by the facts that preoperative anaemia represents an independent risk factor for postoperative morbidity and mortality, and that RBC transfusion might also contribute to adverse clinical outcomes. This dilemma is further complicated by the difficulty to define the "best" transfusion trigger and strategy. Since one size does obviously not fit all, a personalised approach is merited. Attempts should thus be made to critically reflect on the pros and cons of RBC transfusion in each individual patient. Patient blood management concepts including preoperative, intraoperative and postoperative optimisation strategies involving the intensive care unit are warranted and are likely to provide benefits for the patients and the healthcare system. In this context, it is important to consider that "simply" increasing the haemoglobin content, and in proportion oxygen delivery, may not necessarily contribute to a better outcome but potentially the contrary in the long term. The difficulty lies in identification of the patients who might eventually profit from RBC transfusion and to determine in whom a transfusion might be withheld without inducing harm. More robust clinical data providing long-term outcome data are needed to better understand in which patients RBC transfusion might be life-saving vs life-limiting.

Una revisión sistemática de las estrategias neuroprotectoras durante la hipovolemia y el shock hemorrágico.

A Systematic Review of Neuroprotective Strategies during Hypovolemia and Hemorrhagic Shock.

Nistor M1, Behringer W2, Schmidt M3, Schiffner R4,5.

Int J Mol Sci. 2017 Oct 26;18(11). pii: E2247. doi: 10.3390/ijms18112247.

Abstract

Severe trauma constitutes a major cause of death and disability, especially in younger patients. The cerebral autoregulatory capacity only protects the brain to a certain extent in states of hypovolemia; thereafter, neurological deficits and apoptosis occurs. We therefore set out to investigate neuroprotective strategies during haemorrhagic shock. This review was performed in accordance to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Before the start of the search, a review protocol was entered into the PROSPERO database. A systematic literature search of Pubmed, Web of Science and CENTRAL was performed in August 2017. Results were screened and evaluated by two researchers based on a previously prepared inclusion protocol. Risk of bias was determined by use of SYRCLE's risk of bias tool. The retrieved results were qualitatively analysed. Of 9093 results, 119 were assessed in full-text form, 16 of them ultimately adhered to the inclusion criteria and were qualitatively analyzed. We identified three subsets of results: (1) hypothermia; (2) fluid therapy and/or vasopressors; and (3) other neuroprotective strategies (piracetam, NHE1-inhibition, aprotinin, human mesenchymal stem cells, remote ischemic preconditioning and sevoflurane). Overall, risk of bias according to SYRCLE's tool was medium; generally, animal experimental models require more rigorous adherence to the reporting of bias-free study design (randomization, etc.). While the individual study results are promising, the retrieved neuroprotective strategies have to be evaluated within the current scientific context-by doing so, it becomes clear that specific promising neuroprotective strategies during states of haemorrhagic shock remain sparse. This important topic therefore requires more in-depth research.

KEYWORDS: bleeding; brain damage; haemorrhage; hypovolemia; neuroprotection; neuroprotective strategies; resuscitation; shock

Shock hemorrágico

Shock, Hemorrhagic.

Authors

Hooper N1, Armstrong TJ2.

StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2017-.
2017 Nov 27.

Excerpt

Shock refers to the inadequate perfusion of tissues due to the imbalance between oxygen demand of tissues and the body's ability to supply it. Classically, there are four categories of shock: hypovolemic, cardiogenic, obstructive, and distributive shock. Hypovolemic shock occurs when there is decreased intravascular volume to the point of cardiovascular compromise. The hypovolemic shock could be due to severe dehydration through a variety of mechanisms or from blood loss. The pathophysiology, diagnosis, and treatment of hemorrhagic shock, a subset of hypovolemic shock, will be explored in this article.

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Diabetes y embarazo / Diabetes and pregnancy

Enero 8, 2018. No. 2957

Manejo de la diabetes en el embarazo: Estándares del cuidado médico en diabetes : 2018

Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes: 2018

Diabetes Care 2018;41(Suppl. 1):S137-S143 | https://doi.org/10.2337/dc18-S013

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Diabetes y embarazo: Manejo de la diabetes y sus complicaciones desde la preconcepción al periodo postnatal

Diabetes in Pregnancy: Management of Diabetes and Its Complications from Preconception to the Postnatal Period.

Editors

National Collaborating Centre for Women's and Children's Health (UK).

Source

London: National Institute for Health and Care Excellence (UK); 2015 Feb.
National Institute for Health and Care Excellence: Clinical Guidelines .

Excerpt

Clinical guidelines have been defined as 'systematically developed statements which assist clinicians and patients in making decisions about appropriate treatment for specific conditions'. This clinical guideline concerns the management of diabetes and its complications from preconception to the postnatal period. It has been developed with the aim of providing guidance on: preconception information; diagnosis and management of gestational diabetes; glycaemic control in the preconception, antenatal and intrapartum periods; changes to medications for diabetes and its complications before or during pregnancy; management of diabetic emergencies (for example, hypoglycaemia and ketoacidosis) and diabetic complications (such as retinopathy) during pregnancy; the timetable of antenatal appointments to be offered to women with diabetes; timing and mode of birth (including induction of labour, caesarean section, analgesia and anaesthesia, and the use of steroids for fetal lung maturation); initial care of the newborn baby; management of diabetes and its complications during the postnatal period.

Diabetes mellitus y el anestesiólogo, cuidados perioperatorios

Elsa Elisa Jiménez Morales, Rogelio Sánchez García

Revista de Investigación Médica Sur, México Vol. 15, núm. 1, Enero-Marzo 2008

Resumen

La diabetes mellitus es uno de los padecimientos con mayor prevalencia, por lo que los médicos involucrados en su manejo antes, durante y después de un acto quirúrgico, deben conocer su terapéutica. Los criterios actuales de diagnóstico para diabetes son: síntomas de diabetes (poliuria, polidipsia, y pérdida de peso inexplicable) más el resultado de una muestra aleatoria mayor o igual a 200 mg/dL de glucosa, glucosa en ayuno (> 8 horas) de 126 mg/dL o mayor. Glucosa mayor o igual a 200 mg/dL 2 horas después de la administración oral de 75 g de glucosa. Los protocolos de manejo perioperatorio de pacientes diabéticos aceptados actualmente son tres y se conocen como; régimen clásico amplio, régimen estricto tipo I y escala móvil. Palabras clave: alabras clave: Diabetes mellitus, cuidados perioperatorios, anestesiología.

Safe Anaesthesia Worldwide

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World Congress on Regional Anesthesia & Pain Medicine

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

Anestesiología y Medicina del Dolor

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