Revisiones_bibliográficas TyO

Reg Anesth Pain Med. 2018 Jun 5. doi: 10.1097/AAP.0000000000000808. [Epub ahead of print]

Abstract

BACKGROUND: Over the past 2 decades, the use of intravenous ketamine infusions as a treatment for chronic pain has increased dramatically, with wide variation in patient selection, dosing, and monitoring. This has led to a chorus of calls from various sources for the development of consensus guidelines. METHODS: In November 2016, the charge for developing consensus guidelines was approved by the boards of directors of the AmericanSociety of Regional Anesthesia and Pain Medicine and, shortly thereafter, the American Academy of Pain Medicine. In late 2017, the completed document was sent to the American Society of Anesthesiologists' Committees on Pain Medicine and Standards and Practice Parameters, after which additional modifications were made. Panel members were selected by the committee chair and both boards of directors based on their expertise in evaluating clinical trials, past research experience, and clinical experience in developing protocols and treating patients with ketamine. Questions were developed and refined by the committee, and the groups responsible for addressing each question consisted of modules composed of 3 to 5 panel members in addition to the committee chair. Once a preliminary consensus was achieved, sections were sent to the entire panel, and further revisions were made. In addition to consensus guidelines, a comprehensive narrative review was performed, which formed part of the basis for guidelines. RESULTS: Guidelines were prepared for the following areas: indications; contraindications; whether there was evidence for a dose-response relationship, or a minimum or therapeutic dose range; whether oral ketamine or another N-methyl-D-aspartate receptor antagonist was a reasonable treatment option as a follow-up to infusions; preinfusion testing requirements; settings and personnel necessary to administer and monitor treatment; the use of preemptive and rescue medications to address adverse effects; and what constitutes a positive treatment response. The group was able to reach consensus on all questions. CONCLUSIONS: Evidence supports the use of ketamine for chronic pain, but the level of evidence varies by condition and dose range. Most studies evaluating the efficacy of ketamine were small and uncontrolled and were either unblinded or ineffectively blinded. Adverse effects were few and the rate of serious adverse effects was similar to placebo in most studies, with higher dosages and more frequent infusionsassociated with greater risks. Larger studies, evaluating a wider variety of conditions, are needed to better quantify efficacy, improve patient selection, refine the therapeutic dose range, determine the effectiveness of nonintravenous ketamine alternatives, and develop a greater understanding of the long-term risks of repeated treatments.

Ketamina perioperatoria para dolor por toracotomía

Perioperative Ketamine Administration for Thoracotomy Pain.

Moyse DW1, Kaye AD, Diaz JH2, Qadri MY1, Lindsay D1, Pyati S3.

Pain Physician. 2017 Mar;20(3):173-184.

Abstract

BACKGROUND: Of all the postsurgical pain conditions, thoracotomy pain poses a particular therapeutic challenge in terms of its prevalence, severity, and ensuing postoperative morbidity. Multiple pain generators contribute to the severity of post-thoracotomy pain, and therefore a multimodal analgesic therapy is considered to be a necessary strategy. Along with opioids, thoracic epidural analgesia, and paravertebral blocks, N-Methyl-D-Aspartate (NMDA) receptor antagonists such as ketamine have been used as adjuvants to improve analgesia. OBJECTIVE: We reviewed the evidence for the efficacy of intravenous and epidural administration of ketamine in acute post-thoracotomy pain management, and its effectiveness in reducing chronic post-thoracotomy pain. STUDY DESIGN: Systematic literature review and an analytic study of a data subset were performed. METHODS: We searched PubMed, Embase, and Cochrane reviews using the key terms "ketamine," "neuropathic pain," "postoperative," and "post-thoracotomy pain syndrome." The search was limited to human trials and included all studies published before January 2015. Data from animal studies, abstracts, and letters were excluded. All studies not available in the English language were excluded. The manuscript bibliographies were reviewed for additional related articles. We included randomized controlled trials and retrospective studies, while excluding individual case reports. RESULTS: This systematic literature search yielded 15 randomized control trials evaluating the efficacy of ketamine in the treatment of acute post-thoracotomy pain; fewer studies assessed its effect on attenuating chronic post-thoracotomy pain. The majority of reviewed studies demonstrated that ketamine has efficacy in reduction of acute pain, but the evidence is limited on the long-term benefits of ketamine to prevent post-thoracotomy pain syndrome, regardless of the route of administration. A nested analytical study found there is a statistically significant reduction in acute post-thoracotomy pain with IV or epidural ketamine. However currently, the evidence for a role of ketamine as a preventative agent for chronic post-thoracotomy pain is insufficient due to the heterogeneity of the studies reviewed with regard to the route of administration, dosage, and outcome measures. LIMITATIONS: The evidence for a role of ketamine as a preventative agent for chronic post-thoracotomy pain is insufficient due to the heterogeneity of the studies reviewed. CONCLUSION: The majority of randomized controlled trials reviewed show no role for ketamine in attenuating or preventing post-thoracotomy pain syndrome at variable follow-up lengths. Therefore, additional research is warranted with consideration of risk factors and long-term follow-up for chronic post-thoracotomy pain though the evidence for benefit appears clear for acute post-thoracotomy pain.Key words: Ketamine, postoperative, thoracotomy pain, post thoracotomy pain syndrome, neuropathic pain.

¿La adición de ketamina a la analgesia controlada por el paciente con morfina mejora de manera segura el dolor post-toracotomía?

Does adding ketamine to morphine patient-controlled analgesia safely improve post-thoracotomy pain?

Mathews TJ1, Churchhouse AM, Housden T, Dunning J.

Interact Cardiovasc Thorac Surg. 2012 Feb;14(2):194-9. doi: 10.1093/icvts/ivr081. Epub 2011 Nov 28.

Abstract

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was 'is the addition of ketamine to morphine patient-controlled analgesia (PCA) following thoracic surgery superior to morphine alone'. Altogether 201 papers were found using the reported search, of which nine represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. This consisted of one systematic review of PCA morphine with ketamine (PCA-MK) trials, one meta-analysis of PCA-MK trials, four randomized controlled trials of PCA-MK, one meta-analysis of trials using a variety of peri-operative ketamine regimes and two cohort studies of PCA-MK. Main outcomes measured included pain score rated on visual analogue scale, morphine consumption and incidence of psychotomimetic side effects/hallucination. Two papers reported the measurements of respiratory function. This evidence shows that adding ketamine to morphine PCA is safe, with a reported incidence of hallucination requiring intervention of 2.9%, and a meta-analysis finding an incidence of all central nervous system side effects of 18% compared with 15% with morphine alone, P = 0.31, RR 1.27 with 95% CI (0.8-2.01). All randomized controlled trials of its use following thoracic surgery found no hallucination or psychological side effect. All five studies in thoracic surgery (n = 243) found reduced morphine requirements with PCA-MK. Pain scores were significantly lower in PCA-MK patients in thoracic surgery papers, with one paper additionally reporting increased patient satisfaction. However, no significant improvement was found in a meta-analysis of five papers studying PCA-MK in a variety of surgical settings. Both papers reporting respiratory outcomes found improved oxygen saturations and PaCO(2) levels in PCA-MK patients following thoracic surgery. We conclude that adding low-dose ketamine to morphine PCA is safe and post-thoracotomy may provide better pain control than PCA with morphine alone (PCA-MO), with reduced morphine consumption and possible improvement in respiratory function. These studies thus support the routine use of PCA-MK instead of PCA-MO to improve post-thoracotomy pain control.

Papel de la ketamina en el tratamiento del dolor crónico por cáncer

The role of ketamine in the treatment of chronic cancer pain.

Zgaia AO1, Irimie A1, Sandesc D2, Vlad C1, Lisencu C1, Rogobete A2, Achimas-Cadariu P1.

Clujul Med. 2015;88(4):457-61. doi: 10.15386/cjmed-500. Epub 2015 Nov 15.

Abstract

BACKGROUND AND AIM: Ketamine is a drug used for the induction and maintenance of general anesthesia, for the treatment of postoperative and posttraumatic acute pain, and more recently, for the reduction of postoperative opioid requirements. The main mechanism of action of ketamine is the antagonization of N-methyl-D-aspartate (NMDA) receptors that are associated with central sensitization. In the pathogenesis of chronic pain and particularly in neuropathic pain, an important role is played by the activation of NMDA receptors. Although ketamine is indicated and used for the treatment of chronic cancer pain as an adjuvant to opioids, there are few clinical studies that clearly demonstrate the effectiveness of ketamine in this type of pain. The aim of this study is to analyze evidence-based clinical data on the effectiveness and safety of ketamine administration in the treatment of chronic neoplastic pain, and to summarize the evidence-based recommendations for the use of ketamine in the treatment of chronic cancer pain. METHOD: We reviewed the literature from the electronic databases of MEDLINE, COCHRANE, PUBMED, MEDSCAPE (1998-2014), as well as chapters of specialized books (palliative care, pain management, anesthesia). RESULTS: A number of studies support the effectiveness of ketamine in the treatment of chronic cancer pain, one study does not evidence clear clinical benefits for the use of ketamine, and some studies included too few patients to be conclusive. CONCLUSIONS: Ketamine represents an option for neoplasic pain that no longer responds to conventional opioid treatment, but this drug should be used with caution, and the development of potential side effects should be carefully monitored.

KEYWORDS: cancer pain; chronic cancer pain treatment; ketamine; neuropathic pain; pain treatment

Quienes están en el extranjero así pueden ayudar a las víctimas de la erupción

You Can Help Guatemalans Affected By The Fuego Volcano Eruption

How To Help Guatemalans Affected By The Fuego Volcano Eruption From Wherever You Are

Eruption From Wherever You Are

Congresos Médicos por Especialidades en todo Mundo

Medical Congresses by Specialties around the World

Safe Anaesthesia Worldwide

Delivering safe anaesthesia to the world's poorest people

vwhizar@anestesia-dolor.org

Anestesiología y Medicina del Dolor

52 664 6848905

anestesia-dolor.org

lunes, 28 de mayo de 2018

Músculos anómalos del antebrazo y su relevancia clínica.

http://www.clinicademano.com.mx/academia/musculos-anomalos-del-antebrazo-y-su-relevancia-clinica/

Anomalous Forearm Muscles and Their Clinical Relevance.

Fuente

Este artículo es publicado originalmente en:
https://www.ncbi.nlm.nih.gov/pubmed/29602650
https://www.jhandsurg.org/article/S0363-5023(17)30571-3/fulltext

De:
Andring N1, Kennedy SA1, Iannuzzi NP2.
J Hand Surg Am. 2018 May;43(5):455-463. doi: 10.1016/j.jhsa.2018.02.028. Epub 2018 Mar 27.

Todos los derechos reservados para:
© 2018 by the American Society for Surgery of the Hand. All rights reserved.

Abstract

Despite their relatively low prevalence in the population, anomalous muscles of the forearm may be encountered by nearly all hand and wrist surgeons over the course of their careers. We discuss 6 of the more common anomalous muscles encountered by hand surgeons: the aberrant palmaris longus, anconeus epitrochlearis, palmaris profundus, flexor carpi radialis brevis, accessory head of the flexor pollicis longus, and the anomalous radial wrist extensors. We describe the epidemiology, anatomy, presentation, diagnosis, and treatment of patients presenting with an anomalous muscle. Each muscle often has multiple variations or subtypes. The presence of most anomalous muscles is difficult to diagnose based on patient history and examination alone, given that symptoms may overlap with more common pathologies. Definitive diagnosis typically requires soft tissue imaging or surgical exploration. When an anomalous muscle is present and symptomatic, it often requires surgical excision for symptom resolution.

KEYWORDS:

Anatomy; forearm; hand; muscle; variant

Resumen

A pesar de su prevalencia relativamente baja en la población, casi todos los cirujanos de manos y muñecas pueden encontrar músculos anómalos del antebrazo en el transcurso de sus carreras. Discutimos 6 de los músculos anómalos más comunes encontrados por cirujanos de mano: el aberrante palmar largo, anconeus epitroclear, palmar profundo, flexor radial corto del carpo, cabeza accesoria del flexor largo del pulgar, y los extensores anómalos de la muñeca radial. Describimos la epidemiología, la anatomía, la presentación, el diagnóstico y el tratamiento de pacientes que presentan un músculo anómalo. Cada músculo a menudo tiene múltiples variaciones o subtipos. La presencia de la mayoría de los músculos anómalos es difícil de diagnosticar según la historia del paciente y el examen solo, dado que los síntomas pueden solaparse con las patologías más comunes. El diagnóstico definitivo generalmente requiere imágenes de tejidos blandos o exploración quirúrgica. Cuando un músculo anómalo está presente y es sintomático, a menudo requiere una escisión quirúrgica para la resolución de los síntomas.

PALABRAS CLAVE:

Anatomía; antebrazo; mano; músculo; variante

PMID: 29602650 DOI: 10.1016/j.jhsa.2018.02.028

Lesión del cono medular / Conus medullaris trauma

Mayo 28, 2018. No. 3094

Trauma del cono medular. ¿Hay un mayor riesgo en parturientas?

Conus medullaris trauma: is there a greater risk in parturients?

Verkooijen J1, Coppejans H1, Mertens E1, Saldien V1, Vercauteren M1.

Rom J Anaesth Intensive Care. 2017 Oct;24(2):107-110. doi: 10.21454/rjaic.7518.242.ver.

Abstract

BACKGROUND: There is some evidence that anaesthetists often perform neuraxial blocks at a higher lumbar interspace than intended. It may be questioned whether parturients are at greater risk for neurological damage when the dura is perforated at a more cephalad interspace than L2-L3. METHODS: Thirty-six patients scheduled for elective Caesarean delivery under CSE anaesthesia were selected for study. Using a B-D Durasafe Adjustable needle combination, the skin-to-epidural distance and the width of the epidural space were measured and matched with 36 female patients undergoing the same anaesthetic technique for orthopaedic procedures. RESULTS: Pregnant patients had a higher bodyweight (77 vs. 67 kg, p = 0.007) than those scheduled for orthopaedic surgery. The skin-to-epidural distance was similar in both groups (5.3 vs. 5.1 cm, p = 0.3). The width of the epidural space was 1.1 mm larger in parturients (8.2 vs. 7.1 mm, p = 0.04). More patients in this group had tip-to-tip distances exceeding 10 mm (25 vs. 12%). CONCLUSION:

The greater epidural space or tip-to-tip distance between the epidural and spinal needle points in term parturients results in a lower margin of safety with respect to the distance from the dura to spinal cord or conus medullaris. Puncturing the correct interspace is, therefore, of crucial importance in pregnant patients.

Congresos Médicos por Especialidades en todo Mundo

Medical Congresses by Specialties around the World

X Foro Internacional de Medicina del Dolor y Paliativa

Taller de Bloqueos guiados por Ultrasonido con el Dr. Philip Peng

Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán

Ciudad de México, 7 al 9 de junio de 2018.

Información/ Information

V Congreso Internacional de Vía Aérea, EVALa, México

Junio 7-9, 2018. Guadalajara. México

Congreso Nacional de Residentes de Anestesiología

7 al 9 de junio, 2018. Lima, Perú

Safe Anaesthesia Worldwide

Delivering safe anaesthesia to the world's poorest people

vwhizar@anestesia-dolor.org

Anestesiología y Medicina del Dolor

52 664 6848905

anestesia-dolor.org

Utilidad de los modelos modernos de simulación artroscópica: un metanálisis y una revisión sistemática actualizada.

http://www.ortotrauma.xyz/academia/utilidad-de-los-modelos-modernos-de-simulacion-artroscopica-un-metanalisis-y-una-revision-sistematica-actualizada/

Utility of Modern Arthroscopic Simulator Training Models: A Meta-analysis and Updated Systematic Review.

Fuente
Este artículo es originalmente publicado en:

https://www.ncbi.nlm.nih.gov/pubmed/29366742

https://www.arthroscopyjournal.org/article/S0749-8063(17)31431-7/fulltext

De:

Frank RM¹, Wang KC², Davey A², Cotter EJ², Cole BJ², Romeo AA², Bush-Joseph CA², Bach BR Jr², Verma NN².

Arthroscopy. 2018 May;34(5):1650-1677. doi: 10.1016/j.arthro.2017.10.048. Epub 2018 Jan 20.

Copyright © 2017 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.

Abstract

PURPOSE:

To determine the utility of modern arthroscopic simulators in transferring skills learned on the model to the operating room.

CONCLUSIONS:

This review suggests that (1) training on arthroscopic simulators improves performance on arthroscopic simulators and (2) performance on simulators for basic diagnostic arthroscopy correlates with experience level. Limited data suggest that simulator training can improve basic diagnostic arthroscopy skills in vivo.

Resumen

PROPÓSITO:

Determinar la utilidad de los simuladores artroscópicos modernos para transferir las habilidades aprendidas en el modelo a la sala de operaciones.

CONCLUSIONES:

Esta revisión sugiere que (1) el entrenamiento en simuladores artroscópicos mejora el rendimiento en simuladores artroscópicos y (2) el rendimiento en simuladores para correlaciones artroscópicas diagnósticas básicas con el nivel de experiencia. Datos limitados sugieren que el entrenamiento con simulador puede mejorar las habilidades básicas de diagnóstico de artroscopia en vivo.

PMID: 29366742 DOI: 10.1016/j.arthro.2017.10.048

sábado, 26 de mayo de 2018

Ideas no confirmadas en UCI / ICU unconfirmed ideas.

Mayo 24, 2018. No. 3090

Siete ideas no confirmadas para mejorar la práctica futura de la UCI.

Seven unconfirmed ideas to improve future ICU practice.

Marini JJ1, De Backer D2, Ince C3,4, Singer M5, Van Haren F6,7,8, Westphal M9, Wischmeyer P10.

Crit Care. 2017 Dec 28;21(Suppl 3):315. doi: 10.1186/s13054-017-1904-x.

Abstract

With imprecise definitions, inexact measurement tools, and flawed study execution, our clinical science often lags behind bedside experience and simply documents what appear to be the apparent faults or validity of ongoing practices. These impressions are later confirmed, modified, or overturned by the results of the next trial. On the other hand, insights that stem from the intuitions of experienced clinicians, scientists and educators-while often neglected-help place current thinking into proper perspective and occasionally point the way toward formulating novel hypotheses that direct future research. Both streams of information and opinion contribute to progress. In this paper we present a wide-ranging set of unproven 'out of the mainstream' ideas of our FCCM faculty, each with a defensible rationale and holding clear implications for altering bedside management. Each proposition was designed deliberately to be provocative so as to raise awareness, stimulate new thinking and initiate lively dialog.

KEYWORDS: Adaptive clinical trials; Melatonin; Metabolic monitoring; Microcirculation; Personalized medicine; Resuscitation; Sepsis; Shock; Ventilator-induced lung injury

Algunas de nuestras ideas favoritas sin confirmar.

A few of our favorite unconfirmed ideas.

Marini JJ, Gattinoni L, Ince C, Kozek-Langenecker S, Mehta RL, Pichard C, Westphal M, Wischmeyer P, Vincent JL.

Crit Care. 2015;19 Suppl 3:S1. doi: 10.1186/cc14719. Epub 2015 Dec 18.Abstract

Medical practice is rooted in our dependence on the best available evidence from incremental scientific experimentation and rigorous clinical trials. Progress toward determining the true worth of ongoing practice or suggested innovations can be glacially slow when we insist on following the stepwise scientific pathway, and a prevailing but imperfect paradigm often proves difficult to challenge. Yet most experienced clinicians and clinical scientists harbor strong thoughts about how care could or should be improved, even if the existing evidence base is thin or lacking. One of our Future of Critical Care Medicine conference sessions encouraged sharing of novel ideas, each presented with what the speaker considers a defensible rationale. Our intent was to stimulate insightful thinking and free interchange, and perhaps to point in new directions toward lines of innovative theory and improved care of the critically ill. In what follows, a brief background outlines the rationale for each novel and deliberately provocative unconfirmed idea endorsed by the presenter.

Congresos Médicos por Especialidades en todo Mundo

Medical Congresses by Specialties around the World

Safe Anaesthesia Worldwide

Delivering safe anaesthesia to the world's poorest people