Intubación en TCE / Intubation in Traumatic Brain-injured Adults

Julio 9, 2018. No. 3136

Intubación de secuencia rápida en adultos con trauma de cráneo Rapid Sequence Intubation in Traumatic Brain-injured Adults. Kramer N1, Lebowitz D2, Walsh M1, Ganti L3. Author information Cureus. 2018 Apr 25;10(4):e2530. doi: 10.7759/cureus.2530.   Resumen La decisión sobre la administración adecuada de medicamentos para el paciente con lesión cerebral traumática (TBI) sometida a intubación puede ser abrumadora y confusa. El pretratamiento con lidocaína y / o vecuronio ya no se recomienda; sin embargo, se puede utilizar fentanilo en dosis altas para ayudar a mitigar la estimulación simpática de la intubación. Se recomienda la inducción con etomidato; sin embargo, la ketamina puede considerarse en la población de pacientes adecuada, como aquellos con hipotensión. La parálisis se puede realizar con succinilcolina o rocuronio, con la advertencia de que el rocuronio puede provocar retrasos en los exámenes neurológicos adecuados debido a la parálisis prolongada. Las recomendaciones para los medicamentos de sedación continua posteriores a la intubación incluyen una combinación de propofol y fentanilo en la población de pacientes normotensos / hipertensos. Una combinación de midazolam y fentanilo o ketamina sola se puede considerar en el paciente hipotenso   Abstract Deciding on proper medication administration for the traumatic brain injury (TBI) patient undergoing intubation can be daunting and confusing. Pretreatment with lidocaine and/or vecuronium is no longer recommended; however, high-dose fentanyl can be utilized to help blunt the sympathetic stimulation of intubation. Induction with etomidate is recommended; however, ketamine can be considered in the proper patient population, such as those with hypotension. Paralysis can be performed with either succinylcholine or rocuronium, with the caveat that rocuronium can lead to delays in proper neurological examinations due to prolonged paralysis. Recommendations for post-intubation continuous sedation medications include a combination propofol and fentanyl in the normotensive/hypertensive patient population. A combination midazolam and fentanyl or ketamine alone can be considered in the hypotensive patient. KEYWORDS: emergency medicine; induction agents; intracranial pressure; intubation; ketamine; pretreatment; rapid sequence intubation; rocuronium; succinylcholine; traumatic brain injury (tbi) PDF Ver Programa Curso de Alta Especialidad en Medicina del Dolor y Paliativa 2019 Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán. Ciudad de México Convocatoria / Announcement  Información / Information Congresos Médicos por Especialidades en todo Mundo Medical Congresses by Specialties around the World Información / Information Safe Anaesthesia Worldwide Delivering safe anaesthesia to the world's poorest people Informes / Information

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

Vomitos en Pediatrìa

Dr. Douglas Umbría douglasumbria@hotmail.com [SALUD_LORETO] <SALUD_LORETO@yahoogroups.com>

Para:Ciberpeds,Pediatras Yahoo Chiquinquira,Salud Loreto,Pediatria Peru

8 jul a las 8:28

Vomitos en Pediatrìa

Vomiting in Children.

Shields, T.M et al.

Pediatrics in review. 2018; 39(7): 342 – 358

El vómito es un síntoma muy común en el niño y motivo frecuente en nuestra consulta. 

Se define como la expulsión forzada del contenido gástrico a través de la boca y / o nariz.

Puede presentarse en cualquier enfermedad y en cualquier momento de su evolución. 

Su importancia es variable, puede ser desde un síntoma acompañante de una enfermedad hasta un síntoma fundamental.

Hay 4 vías fisiológicas principales que pueden desencadenar el reflejo emético: toxinas mecánicas, transmitidas por la sangre, el movimiento y los desencadenantes emocionales.

Cada vía se desencadena por diferentes sistemas de órganos e involucra diferentes neurotransmisores.

Encontrar una etiología puede ser un reto porque los vómitos pueden implicar una

variedad de diferentes sistemas de órganos en el cuerpo.

En pediatría existen múltiples patologías que cursan con vómitos; las causas infecciosas son las más frecuentes (GEA, infecciones respiratorias, otitis, neumonías, infecciones del tracto urinario, sepsis, meningitis).

Los vómitos relacionados con patología quirúrgica generalmente se asocian a dolor abdominal.

La invaginación es la causa más frecuente de obstrucción intestinal entre los 3 meses y los 3 años.

El establecimiento de un diagnóstico diferencial para el vómito debe tener en cuenta tanto la edad del niño como las características temporales de su vómito.

El vómito difiere del reflujo gastroesofágico (GER) y la regurgitación ya que en estas dos últimas condiciones no hay expulsión de contenido duodenales.

Tambien difieren de la rumiación, ya en esta los pacientes se auto promueven para regurgitar de manera electiva, y con frecuencia mastican y tragan sus alimentos regurgitados nuevamente. 

El tratamiento farmacológico no está indicado de forma rutinaria. 

Podemos emplear ondansetrón para garantizar la tolerancia oral en los niños con gastroenteritis aguda, este medicamento (a una dosis de i.v. a 0,15 mg/kg máximo 8 mg y v.o. a 2 mg para 8-15 kg, 4 mg para 15-30 kg y 8 > 30 kg) ha demostrado ser capaz de disminuir el número de vómitos en niños esta patología así como el número de ingresos y reconsultas en los servicios de urgencias, con mínimos efectos secundarios (diarrea leve), siendo un fármaco seguro.

Comparto interesante revisión sobre la fisiopatología, causas diagnóstico y tratamiento en Pediatrìa en el siguiente link:

https://drive.google.com/file/d/1RxLbZojKdHTa9ByTx3nGfoWTl97qKfL3/view?usp=sharing

Neuroprotección farmacológica / Pharmacological neuroprotection

Julio 5, 2018. No. 3132

PDF Un metaanálisis de neuroprotección farmacológica en cirugía no cardíaca: enfoque en estatinas, lidocaína, ketamina y sulfato de magnesio. A meta-analysis of pharmacological neuroprotection in noncardiac surgery: focus on statins, lidocaine, ketamine, and magnesium sulfate. Zeng ZW1, Zhang YN, Lin WX, Zhang WQ, Luo R. Author information Eur Rev Med Pharmacol Sci. 2018 Mar;22(6):1798-1811. doi: 10.26355/eurrev_201803_14599. Abstract OBJECTIVE: Non-cardiac surgery is associated with perioperative cerebral complications (delirium, postoperative cognition dysfunction, stroke). While rare, these complications can lead to disabilities and deaths. Information is ambiguous as to whether pharmacological preoperative treatment exerts neuroprotection. We wished to systematically assess potential modulation by statins, lidocaine, ketamine or magnesium sulfate of the relative risk of cerebral complications in noncardiac surgery. Selection of these pharmacological agents was based on their known neuroprotective abilities. PATIENTS AND METHODS: By searching Medline, EMBASE and Cochrane databases, we identified 4 suitable publications that collectively enrolled 1358 patients (intent-to-treat population), of which 679 patients were treated preoperatively with statins (404 patients on atorvastatin and 275 on rosuvastatin) and 679 patients with preoperative placebo. The reported cerebral outcome was stroke, assessed either within 30 days (4 publications) or 6 months (2 publications) after surgery. RESULTS: Episodes of stroke within 30 days and 6 months postoperatively were observed in several publications, enabling aggregate analyses. No modulation by statins of the relative risk of stroke at 30 days was observed (risk ratio 1.59, 95% confidence interval 0.08-30.97; p = 0.76). At 6 months, statins showed an insignificant trend toward neuroprotection (risk ratio 0.33, 95% confidence interval 0.05-2.10; p = 0.24). CONCLUSIONS: The available clinical data are still scarce. Our analyses indicate no protective effects by statins against perioperative stroke but some favorable trends toward delayed stroke. Further randomized trials are needed to unequivocally assess the neuroprotective potential of current pharmacological agents in non-cardiac surgery. PDF Congresos Médicos por Especialidades en todo Mundo Medical Congresses by Specialties around the World Información / Information Ver Programa Curso Regional de Sur Sureste de Medicina del Dolor y Cuidados Paliativos Agosto 24-25. Oaxaca, México Informacion / Information Información / Information Events of the California Society of Anesthesiologists Información / Information Safe Anaesthesia Worldwide Delivering safe anaesthesia to the world's poorest people Informes / Information

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

UCI / ICU

Julio 2, 2018. No. 3129

Novela en PDF El papel del ultrasonido en la atención crítica prehospitalaria: una revisión sistemática. The role of point of care ultrasound in prehospital critical care: a systematic review. Bøtker MT1,2, Jacobsen L3,4, Rudolph SS5,6, Knudsen L7. Author information Scand J Trauma Resusc Emerg Med. 2018 Jun 26;26(1):51. doi: 10.1186/s13049-018-0518-x. Abstract BACKGROUND: In 2011, the role of Point of Care Ultrasound (POCUS) was defined as one of the top five research priorities in physician-provided prehospital critical care and future research topics were proposed; the feasibility of prehospital POCUS, changes in patient management induced by POCUS and education of providers. This systematic review aimed to assess these three topics by including studies examining all kinds of prehospital patients undergoing all kinds of prehospital POCUS examinations and studies examining any kind of POCUS education in prehospital critical care providers. METHODS AND RESULTS: By a systematic literature search in MEDLINE, EMBASE, and Cochrane databases, we identified and screened titles and abstracts of 3264 studies published from 2012 to 2017. Of these, 65 studies were read in full-text for assessment of eligibility and 27 studies were ultimately included and assessed for quality by SIGN-50 checklists. No studies compared patient outcome with and without prehospital POCUS. Four studies of acceptable quality demonstrated feasibility and changes in patient management in trauma. Two studies of acceptable quality demonstrated feasibility and changes in patient management in breathing difficulties. Four studies of acceptable quality demonstrated feasibility, outcome prediction and changes in patient management in cardiac arrest, but also that POCUS may prolong pauses in compressions. Two studies of acceptable quality demonstrated that short (few hours) teaching sessions are sufficient for obtaining simple interpretation skills, but not image acquisition skills. Three studies of acceptable quality demonstrated that longer one- or two-day courses including hands-on training are sufficient for learning simple, but not advanced, image acquisition skills. Three studies of acceptable quality demonstrated that systematic educational programs including supervised examinations are sufficient for learning advanced image acquisition skills in healthy volunteers, but that more than 50 clinical examinations are required for expertise in a clinical setting. CONCLUSION: Prehospital POCUS is feasible and changes patient management in trauma, breathing difficulties and cardiac arrest, but it is unknown if this improves outcome. Expertise in POCUS requires extensive training by a combination of theory, hands-on training and a substantial amount of clinical examinations - a large part of these needs to be supervised. KEYWORDS: Cardiac arrest; Critical care; Dyspnea; Education; Point of care; Prehospital; Systematic review; Trauma; Ultrasound PDF Antiepiléticos en el paciente grave Antiepileptic drugs in critically ill patients. Farrokh S1, Tahsili-Fahadan P2,3, Ritzl EK2,4, Lewin JJ 3rd5, Mirski MA5. Author information Crit Care. 2018 Jun 7;22(1):153. doi: 10.1186/s13054-018-2066-1. Abstract BACKGROUND: The incidence of seizures in intensive care units ranges from 3.3% to 34%. It is therefore often necessary to initiate or continue anticonvulsant drugs in this setting. When a new anticonvulsant is initiated, drug factors, such as onset of action and side effects, and patient factors, such as age, renal, and hepatic function, should be taken into account. It is important to note that the altered physiology of critically ill patients as well as pharmacological and nonpharmacological interventions such as renal replacement therapy, extracorporeal membrane oxygenation, and target temperature management may lead to therapeutic failure or toxicity. This may be even more challenging with the availability of newer antiepileptics where the evidence for their use in critically ill patients is limited. MAIN BODY: This article reviews the pharmacokinetics and pharmacodynamics of antiepileptics as well as application of these principles when dosing antiepileptics and monitoring serum levels in critically ill patients. The selection of the most appropriate anticonvulsant to treat seizure and status epileptics as well as the prophylactic use of these agents in this setting are also discussed. Drug-drug interactions and the effect of nonpharmacological interventions such as renal replacement therapy, plasma exchange, and extracorporeal membrane oxygenation on anticonvulsant removal are also included. CONCLUSION: Optimal management of antiepileptic drugs in the intensive care unit is challenging given altered physiology, polypharmacy, and nonpharmacological interventions, and requires a multidisciplinary approach where appropriate and timely assessment, diagnosis, treatment, and monitoring plans are in place. KEYWORDS: Antiepileptic drugs; Critical care; Drug-drug Interaction; Pharmacodynamics; Pharmacokinetics; Seizure PDF Biomarcadores en falla renal inducida por sepsis Biomarkers of Sepsis-Induced Acute Kidney Injury. Wang K1, Xie S1, Xiao K1, Yan P1, He W2, Xie L1. Author information Biomed Res Int. 2018 Apr 24;2018:6937947. doi: 10.1155/2018/6937947. eCollection 2018. Abstract Sepsis, an infection-induced systemic disease, leads to pathological, physiological, and biochemical abnormalities in the body. Organ dysfunction is caused by a dysregulated host response to infection during sepsis which is a major contributing factor to acute kidney injury (AKI) and the mortality rate for sepsis doubles due to coincidence of AKI. Sepsis-induced AKI is strongly associated with increased mortality and other adverse outcomes. More timely diagnosis would allow for earlier intervention and could improve patient outcomes. Sepsis-induced AKI is characterized by a distinct pathophysiology compared with other diseases and may also have unique patterns of plasma and urinary biomarkers. This concise review summarizes properties and perspectives of the biomarkers for their individual clinical utilization. PDF Ver programa Información / Information Congresos Médicos por Especialidades en todo Mundo Medical Congresses by Specialties around the World Información / Information Events of the California Society of Anesthesiologists Información / Information Safe Anaesthesia Worldwide Delivering safe anaesthesia to the world's poorest people Informes / Information

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