Transfusión en trauma craneoencefálico / Transfusion traumatic brain injury

Julio 16, 2018. No. 3143

Lo Mejor de Octavio Paz. PDF Trasfusión en trauma craneoencefálico Transfusion practices in traumatic brain injury Curr Opin Anaesthesiol. 2018 Apr;31(2):219-226. doi: 10.1097/ACO.0000000000000566. East JM1, Viau-Lapointe J1, McCredie VA1,2. Author information Abstract PURPOSE OF REVIEW: The aim of this review is to summarize the recent studies looking at the effects of anemia and red blood cell transfusion in critically-ill patients with traumatic brain injury (TBI), describe the transfusion practice variations observed worldwide, and outline the ongoing trials evaluating restrictive versus liberal transfusion strategies for TBI. RECENT FINDINGS: Anemia is common among critically-ill patients with TBI, it is also thought to exacerbate secondary brain injury, and is associated with an increased risk of poor outcome. Conversely, allogenic red blood cell transfusion carries its own risks and complications, and has been associated with worse outcomes. Globally, there are large reported differences in the hemoglobin threshold used for transfusion after TBI. Observational studies have shown differential results for improvements in cerebral oxygenation and metabolism after red blood cell transfusion in TBI. SUMMARY: Currently, there is insufficient evidence to make strong recommendations regarding which hemoglobin threshold to use as a transfusion trigger in critically-ill patients with TBI. There is also uncertainty whether the restrictive transfusion strategy used in general critical care can be extrapolated to acutely brain injured patients. Ultimately, the consequences of anemia-induced cerebral injury need to be weighed up against the risks and complications associated with red blood cell transfusion. PDF Lesión hemorrágica progresiva después de una lesión cerebral traumática grave: efecto de los umbrales de transfusión de hemoglobina. Progressive hemorrhagic injury after severe traumatic brain injury: effect of hemoglobin transfusion thresholds. Vedantam A1, Yamal JM2, Rubin ML2, Robertson CS1, Gopinath SP1. Author information J Neurosurg. 2016 Nov;125(5):1229-1234. Epub 2016 Mar 4. Abstract OBJECT. There is limited literature available to guide transfusion practices for patients with severe traumatic brain injury (TBI). Recent studies have shown that maintaining a higher hemoglobin threshold after severe TBI offers no clinical benefit. The present study aimed to determine if a higher transfusion threshold was independently associated with an increased risk of progressive hemorrhagic injury (PHI), thereby contributing to higher rates of morbidity and mortality. METHODS The authors performed a secondary analysis of data obtained from a recently performed randomized clinical trial studying the effects of erythropoietin and blood transfusions on neurological recovery after severe TBI. Assigned hemoglobin thresholds (10 g/dl vs 7 g/dl) were maintained with packed red blood cell transfusions during the acute phase after injury. PHI was defined as the presence of new or enlarging intracranial hematomas on CT as long as 10 days after injury. A severe PHI was defined as an event that required an escalation of medical management or surgical intervention. Clinical and imaging parameters and transfusion thresholds were used in a multivariate Cox regression analysis to identify independent risk factors for PHI. RESULTS Among 200 patients enrolled in the trial, PHI was detected in 61 patients (30.5%). The majority of patients with PHI had a new, delayed contusion (n = 29) or an increase in contusion size (n = 15). The mean time interval between injury and identification of PHI was 17.2 ± 15.8 hours. The adjusted risk of severe PHI was 2.3 times higher for patients with a transfusion threshold of 10 g/dl (95% confidence interval 1.1-4.7; p = 0.02). Diffuse brain injury was associated with a lower risk of PHI events, whereas higher initial intracranial pressure increased the risk of PHI (p < 0.001). PHI was associated with a longer median length of stay in the intensive care unit (18.3 vs 14.4 days, respectively; p = 0.04) and poorer Glasgow Outcome Scale scores (42.9% vs 25.5%, respectively; p = 0.02) at 6 months. CONCLUSIONS A higher transfusion threshold of 10 g/dl after severe TBI increased the risk of severe PHI events. These results indicate the potential adverse effect of using a higher hemoglobin transfusion threshold after severe TBI. KEYWORDS: EPO = erythropoietin; ER = emergency room; GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; ICP = intracranial pressure; PHI = progressive hemorrhagic injury; PT = prothrombin time; PTT = partial thromboplastin time; RCT = randomized controlled trial; TBI = traumatic brain injury; hemoglobin transfusion threshold; progressive hemorrhagic injury; secondary brain injury; severe traumatic brain injury PDF Efecto de la eritropoyetina y el umbral de transfusión en la recuperación neurológica después de la lesión cerebral traumática: un ensayo clínico aleatorizado. Effect of erythropoietin and transfusion threshold on neurological recovery after traumatic brain injury: a randomized clinical trial. Robertson CS1, Hannay HJ2, Yamal JM3, Gopinath S1, Goodman JC4, Tilley BC3; Epo Severe TBI Trial Investigators, Baldwin A1, Rivera Lara L1, Saucedo-Crespo H1, Ahmed O1, Sadasivan S1, Ponce L1, Cruz-Navarro J1, Shahin H1, Aisiku IP5, Doshi P5, Valadka A5, Neipert L2, Waguspack JM2, Rubin ML3, Benoit JS3, Swank P3. Author information JAMA. 2014 Jul 2;312(1):36-47. doi: 10.1001/jama.2014.6490. Abstract IMPORTANCE: There is limited information about the effect of erythropoietin or a high hemoglobin transfusion threshold after a traumatic brain injury. OBJECTIVE: To compare the effects of erythropoietin and 2 hemoglobin transfusion thresholds (7 and 10 g/dL) on neurological recovery after traumatic brain injury. ...Intravenous erythropoietin (500 IU/kg per dose) or saline. Transfusion threshold maintained with packed red blood cells. ....CONCLUSIONS AND RELEVANCE: In patients with closed head injury, neither the administration of erythropoietin nor maintaining hemoglobin concentration of greater than 10 g/dL resulted in improved neurological outcome at 6 months. The transfusion threshold of 10 g/dL was associated with a higher incidence of adverse events. These findings do not support either approach in this setting. PDF 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  Ver Programa Información / Information Congresos Médicos por Especialidades en todo Mundo Medical Congresses by Specialties around the World Información / Information Curso Regional de Sur Sureste de Medicina del Dolor y Cuidados Paliativos Agosto 24-25. Oaxaca, México Informacion / 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

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