Más de hipercapnia / More on hypercapnia

Debate Pro/Contra. ¿Debe el PaCO2 ser estrictamente controlado en todos los pacientes con lesiones cerebrales agudas? Pro/con debate: should PaCO2 be tightly controlled in all patients with acute brain injuries? Go SL, Singh JM. Crit Care. 2013 Jan 29;17(1):202. doi: 10.1186/cc11389. Abstract You are the attending intensivist in a neurointensive care unit caring for a woman five days post-rupture of a cerebral aneurysm (World Federation of Neurological Surgeons Grade 4 and Fisher Grade 3). She is intubated for airway protection and mild hypoxemia related to an aspiration event at the time of aneurysm rupture, but is breathing spontaneously on the ventilator. Your patient is spontaneously hyperventilating with high tidal volumes despite minimal support and has developed significant hypocapnia. She has not yet developed the acute respiratory distress syndrome. You debate whether to tightly control her partial pressure of arterial carbon dioxide, weighing the known risks of acute hypocapnia in other forms of brain injury against the potential loss of clinical neuromonitoring associated with deep sedation and neuromuscular blockade in this patient who is at high risk of delayed ischemia from vasospasm. You are also aware of the potential implications of tidal volume control if this patient were to develop the acute respiratory distress syndrome and the effect of permissive hypercapnia on her intracranial pressure. In this paper we provide a detailed and balanced examination of the issues pertaining to this clinical scenario, including suggestions for clinical management of ventilation, sedation and neuromonitoring. Until more definitive clinical trial evidence is available to guide practice, clinicians are forced to carefully weigh the potential benefits of tight carbon dioxide control against the potential risks in each individual patient based on the clinical issues at hand. PDF Hipercapnia. Un ambiente no permisivo para el pulmón. Hypercapnia: a nonpermissive environment for the lung. Vadász I, Hubmayr RD, Nin N, Sporn PH, Sznajder JI. Am J Respir Cell Mol Biol. 2012 Apr;46(4):417-21. doi: 10.1165/rcmb.2011-0395PS. Epub 2012 Jan 12. Abstract Patients with severe acute and chronic lung diseases develop derangements in gas exchange that may result in increased levels of CO(2) (hypercapnia), the effects of which on human health are incompletely understood. It has been proposed that hypercapnia may have beneficial effects in patients with acute lung injury, and the concepts of "permissive" and even "therapeutic" hypercapnia have emerged. However, recent work suggests that CO(2) can act as a signaling molecule via pH-independent mechanisms, resulting in deleterious effects in the lung. Here we review recent research on how elevated CO(2) is sensed by cells in the lung and the potential harmful effects of hypercapnia on epithelial and endothelial barrier, lung edema clearance, innate immunity, and host defense. In view of these findings, we raise concerns about the potentially deleterious effects hypercapnia may have in patients with acute and chronic lung diseases. PDF Investigación a la clínica. La acidosis hipercápnica en la lesión pulmonar - de permisiva a terapéutica. Bench-to-bedside review: hypercapnic acidosis in lung injury--from 'permissive' to 'therapeutic'. Ijland MM, Heunks LM, van der Hoeven JG. Crit Care. 2010;14(6):237. doi: 10.1186/cc9238. Epub 2010 Nov 3. Abstract Modern ventilation strategies for patients with acute lung injury and acute respiratory distress syndrome frequently result in hypercapnic acidosis (HCA), which is regarded as an acceptable side effect ('permissive hypercapnia'). Multiple experimental studies have demonstrated advantageous effects of HCA in several lung injury models. To date, however, human trials studying the effect of carbon dioxide per se on outcome in patients with lung injury have not been performed. While significant concerns regarding HCA remain, in particular the possible unfavorable effects on bacterial killing and the inhibition of pulmonary epithelial wound repair, the potential for HCA in attenuating lung injury is promising. The underlying mechanisms by which HCA exerts its protective effects are complex, but dampening of the inflammatory response seems to play a pivotal role. After briefly summarizing the physiological effects of HCA, a critical analysis of the available evidence on the potential beneficial effects of therapeutic HCA from in vitro, ex vivo and in vivo lung injury models and from human studies will be reviewed. In addition, the potential concerns in the clinical setting will be outlined. PDF

Atentamente Anestesia y Medicina del Dolor anestesia-dolor.org

El CNIO desarrolla un tratamiento antiobesidad en modelos animales

http://www.madrimasd.org/informacionidi/noticias/noticia.asp?id=63298&origen=notiweb&dia_suplemento=viernes


El CNIO desarrolla un tratamiento antiobesidad en modelos animales


Investigadores del Centro Nacional de Investigaciones Oncológicas (CNIO) han demostrado que la inhibición farmacológica parcial de la enzima PI3K en ratones y monos obesos reduce el peso corporal y las manifestaciones fisiológicas del síndrome metabólico, en concreto la diabetes y la esteatosis hepática (hígado graso), sin mostrar efectos secundarios ni toxicidad. El trabajo, publicado en la revista Cell Metabolism, es una colaboración entre el Grupo de Supresión Tumoral liderado por Manuel Serrano en el CNIO y el Translation Gerontology Branch liderado por Rafael de Cabo en el U.S. National Institute on Aging, de los National Institutes of Health (NIH) estadounidenses, con participación del grupo de investigación de NeurObesidad del CIMUS, dirigido por Miguel López en la Universidad de Santiago de Compostela.

La enzima PI3K (fosfatidilinositol-3-quinasa) regula el equilibrio entre la producción de los componentes bioquímicos celulares (anabolismo) y el gasto de nutrientes (catabolismo) que ocurre en las células. En concreto, la enzima favorece el anabolismo celular, un proceso que puede inducir el crecimiento y multiplicación celular, y que en última instancia puede favorecer el cáncer.

Por esta razón, los científicos que trabajan en cáncer han estado persiguiendo desde hace tiempo inhibidores farmacológicos de PI3K. Este es el caso del CNIO, donde han desarrollado su propio inhibidor experimental, el CNIO-PI3Ki, que está siendo estudiado en combinación con otros compuestos para el tratamiento del cáncer. Como parte de la caracterización de este compuesto y para entender cómo afectaría al equilibrio entre el consumo y almacenamiento de nutrientes a nivel de organismo, el equipo de Serrano decidió estudiar los efectos de CNIO-PI3Ki sobre el metabolismo.

"En este punto nos hemos desviado del propósito original anticanceroso de estos inhibidores. En estudios previos nuestros, habíamos visto que una de las funciones fisiológicas normales de la enzima PI3K es fomentar el almacenamiento de nutrientes. Esto nos pareció muy interesante porque precisamente este tipo de manipulación, la regulación del equilibrio entre almacenamiento y gasto de nutrientes, es lo que se persigue en el tratamiento de la obesidad", explica Ana Ortega-Molina, primera firmante del estudio, que en la actualidad trabaja en el centro de investigación Memorial Sloan-Kettering de Nueva York.

ESTUDIOS EN RATONES Y MONOS

Para probar este efecto sobre el metabolismo, los científicos del CNIO administraron durante cinco meses pequeñas dosis del inhibidor CNIO-PI3Ki a ratones obesos alimentados a base de una dieta rica en grasas. Durante los primeros 50 días, los animales obesos perdieron un 20% de su peso y en ese punto estabilizaron su peso corporal. El tratamiento se mantuvo durante 5 meses y durante todo este tiempo los ratones mantuvieron su pérdida de peso estable, mientras seguían alimentándose de la dieta rica en grasas. También mejoraron sus síntomas fisiológicos de diabetes (glucemia) y esteatosis hepática (hígado graso).

De izqda. a dcha., Ana Ortega-Molina, Elena López-Guadamillas y Manuel Serrano. / CNIO

"En obesidad no se puede estar perdiendo peso constantemente, esto sería muy peligroso. Lo deseable es alterar el equilibrio entre gasto y almacenamiento de nutrientes, para conseguir un nuevo equilibrio en el que haya más gasto y menos almacenamiento", explica Elena López-Guadamillas, del CNIO, que junto con Ana Ortega-Molina han realizado conjuntamente la mayor parte del trabajo experimental. Este estudio demostró también la ausencia de efectos secundarios del fármaco y que no tiene efectos irreversibles sobre el metabolismo, algo que es también deseable por su posible uso futuro como tratamiento en humanos.

En animales no obesos alimentados con dieta estándar la administración del fármaco no produjo ningún efecto, lo cual es otra garantía de seguridad. "Esto pone de manifiesto que la actividad de la enzima PI3K solo es relevante cuando hay un exceso de nutrientes, es decir, una dieta hipercalórica o grasa", añade López-Guadamillas.

En colaboración con los National Institutes of Health (NIH) estadounidenses, los científicos del CNIO probaron el compuesto CNIO-PI3Ki en monos obesos (macacos). Para asegurar unos márgenes de seguridad más altos, la dosis administrada fue muy baja. Aun así, el tratamiento diario de estos animales obesos durante 3 meses disminuyó la cantidad total de tejido graso en un 7,5% y mejoró los síntomas de diabetes.

EFECTOS SECUNDARIOS Y SEGURIDAD

La obesidad es uno de los factores de riesgo más importantes del conjunto de enfermedades graves que constituyen el síndrome metabólico. Se han descubierto muchos agentes farmacológicos que inducen la pérdida de peso, pero muy a menudo con efectos tóxicos inaceptables (en parte debido a que actúan en los centros cerebrales que controlan el apetito). En este sentido, CNIO-PI3Ki parece ser excepcional pues, al menos en modelos animales, no se han detectado este tipo de efectos, incluso después del tratamiento a largo plazo (5 meses en ratones, 3 meses en monos).

A continuación se muestran una serie de características de seguridad que se han demostrado en ratones:

• Selectivo: CNIO-PI3Ki solo produce pérdida de peso en ratones bajo un exceso nutricional, no en ratones que comen una dieta normal equilibrada. Esto indica que PI3K es importante para el almacenamiento de nutrientes cuando la ingesta de comida es excesiva, pero no es tan importante cuando es normal.

• La pérdida de peso en los ratones se debe exclusivamente a una pérdida de tejido graso, no existe pérdida en otros tejidos como masa hepática, muscular u ósea.

• No hay efectos sobre el cerebro: CNIO-PI3Ki no cruza la barrera hematoencefálica.

• No hay efectos en el hipotálamo: El hipotálamo es una estructura especializada del encéfalo que es excepcional porque carece de la barrera hematoencefálica (la estructura encargada de regular el paso de sustancias desde la sangre al sistema nervioso central) y controla muchos procesos metabólicos, incluyendo el apetito y la saciedad. En ratones, no se han detectado efectos sobre los principales neuropéptidos producidos por el hipotálamo relacionados con el apetito y la saciedad. Estos últimos estudios se han hecho en colaboración con el grupo de investigación dirigido por Miguel López en la Universidad de Santiago de Compostela.

• Funciona durante un largo plazo: Los efectos del CNIO-PI3Ki se mantienen durante al menos 5 meses de tratamiento en ratones, lo cual sugiere que no se desarrollan mecanismos de resistencia. Esto es muy importante, dado que es un problema común en otros compuestos que afectan el metabolismo.

• Reversibilidad: Los efectos de CNIO-PI3Ki fueron reversibles, es decir, cuando se interrumpió el tratamiento y se mantuvo la dieta rica en grasa, los ratones volvieron a aumentar de peso. Esto indica que CNIO-PI3Ki no está produciendo cambios irreversibles.

FUTUROS ENSAYOS CLÍNICOS EN HUMANOS

El siguiente paso lógico, una vez demostrados los efectos beneficiosos de CNIO-PI3Ki sobre ratones y monos obesos, es la realización de ensayos clínicos en humanos. "El salto de animales a humanos es complejo, caro y lleno de incertidumbres. Muchos tratamientos prometedores en animales luego resultan no ser eficaces en humanos o aparecen toxicidades que no se habían observado en los animales. Pero obviamente, a pesar de las incertidumbres, hay que intentarlo", dice Manuel Serrano. "Los ensayos clínicos requieren inversiones enormes y se realizan con el ánimo de llegar a comercializar un tratamiento. Somos muy optimistas con respecto a poder establecer pronto un acuerdo con alguna multinacional farmacéutica interesada en la realización de ensayos clínicos con CNIO-PI3Ki para tratar la obesidad y el síndrome metabólico en humanos", puntualiza Serrano.

El trabajo realizado en el CNIO ha sido financiado por el Ministerio de Economía y Competitividad, la Unión Europea, el Consejo Europeo de Investigación (ERC), la Comunidad de Madrid, la Fundación Botín y el Banco Santander a través de su División Global Santander Universidades, la Fundación Ramón Areces y la Fundación AXA. Los estudios desarrollados en el NIA forman parte del Intramural Research Program del U.S. National Institute on Aging, National Institutes of Health. La contribución de la Universidad de Santiago de Compostela ha sido financiada por el Consejo Europeo de Investigación (ERC Starting Grant) y la Xunta de Galicia.

Vídeo explicativo (Youtube canalcnio): https://www.youtube.com/watch?v=NjpzSDa7Wro

Artículo de referencia:
Pharmacological inhibition of PI3K reduces adiposity and metabolic syndrome in obese mice and rhesus monkeys. Ana Ortega-Molina, Elena Lopez-Guadamillas, Julie A. Mattison, Sarah J. Mitchell, Maribel Muñoz-Martin, Gema Iglesias, Vincent M. Gutierrez, Kelli L. Vaughan, Mark D. Szarowicz, Ismael González-García, Miguel López, David Cebrián, Sonia Martinez, Joaquin Pastor, Rafael de Cabo and Manuel Serrano. Cell Metabolism (2015) doi: 10.1016/j.cmet.2015.02.017.

Identidad bibliotecaria. Alerta

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Factores potenciales de riesgo para inicio del síndrome de dolor regional complejo tipo I: una revisión sistemática de la literatura

Factores potenciales de riesgo para inicio del síndrome de dolor regional complejo tipo I: una revisión sistemática de la literatura Potential risk factors for the onset of complex regional pain syndrome type 1: a systematic literature review. Pons T, Shipton EA, Williman J, Mulder RT. Anesthesiol Res Pract. 2015;2015:956539. doi: 10.1155/2015/956539. Epub 2015 Jan 26. Abstract Anaesthetists in the acute and chronic pain teams are often involved in treating Complex Regional Pain Syndromes. Current literature about the risk factors for the onset of Complex Regional Pain Syndrome Type 1 (CRPS 1) remains sparse. This syndrome has a low prevalence, a highly variable presentation, and no gold standard for diagnosis. In the research setting, the pathogenesis of the syndrome continues to be elusive. There is a growing body of literature that addresses efficacy of a wide range of interventions as well as the likely mechanisms that contribute to the onset of CRPS 1. The objective for this systematic search of the literature focuses on determining the potential risk factors for the onset of CRPS 1. Eligible articles were analysed, dated 1996 to April 2014, and potential risk factors for the onset of CRPS 1 were identified from 10 prospective and 6 retrospective studies. Potential risk factors for the onset of CRPS 1 were found to include being female, particularly postmenopausal female, ankle dislocation or intra-articular fracture, immobilisation, and a report of higher than usual levels of pain in the early phases of trauma. It is not possible to draw definite conclusions as this evidence is heterogeneous and of mixed quality, relevance, and weighting strength against bias and has not been confirmed across multiple trials or in homogenous studies. PDF

Atentamente Anestesia y Medicina del Dolor anestesia-dolor.org

Hígado y anestesia / Liver and anaesthesia

Regímenes hipnóticos por vía intravenosa en pacientes con enfermedad hepática; un artículo de revisión. Intravenous hypnotic regimens in patients with liver disease; a review article. Soleimanpour H, Safari S, Rahmani F, Jafari Rouhi A, Alavian SM5. Anesth Pain Med. 2015 Feb 24;5(1):e23923. doi: 10.5812/aapm.23923. eCollection 2015. Abstract CONTEXT:The liver as an important organ in the body has many essential functions in physiological processes. One of the major activities of liveris drug metabolism. Hepatic dysfunction affecting hepatic physiological activities, especially drug metabolism can cause many problems duringanesthesia and administration of different drugs to patients. EVIDENCE ACQUISITION: Studies on hepatic disorders and hypnotic anesthetics prescribed in hepatic disorders were included in this review. For this purpose, reliable databases were used. RESULTS:Anesthesia should be performed with caution in patients with hepatic dysfunction and drugs with long half-life should be avoided in these patients. CONCLUSIONS: A review of the literature on the use of hypnotic drugs in patients with liver dysfunction showed that some hypnotic drugs used during anesthesia could be safely used in patients with impaired liver function. In these patients, certain drugs should be used with caution. KEYWORDS:Anesthesia; Hypnotics Drugs; Liver Disease PDF Anestesia en pacientes con enfermedad hepática Anesthesia for patients with liver disease. Rahimzadeh P, Safari S, Faiz SH, Alavian SM. Hepat Mon. 2014 Jul 1;14(7):e19881. doi: 10.5812/hepatmon.19881. eCollection 2014. Abstract CONTEXT: Liver plays an important role in metabolism and physiological homeostasis in the body. This organ is unique in its structure and physiology. So it is necessary for an anesthesiologist to be familiar with various hepatic pathophysiologic conditions and consequences of liver dysfunction. EVIDENCE ACQUISITION:WE SEARCHED MEDLINE (PUB MED, OVID, MD CONSULT), SCOPUS AND THE COCHRANE DATABASE FOR THE FOLLOWING KEYWORDS: liver disease, anesthesia and liver disease, regional anesthesia in liver disease, epidural anesthesia in liver disease and spinal anesthesia in liver disease, for the period of 1966 to 2013. RESULTS: Although different anesthetic regimens are available in modern anesthesia world, but anesthetizing the patients with liver disease is still really tough. Spinal or epidural anesthetic effects on hepatic blood flow and function is not clearly investigated, considering both the anesthetic drug-induced changes and outcomes. Regional anesthesia might be used in patients with advanced liver disease. In these cases lower drug dosages are used, considering the fact that locally administered drugs have less systemic effects. In case of general anesthesia it seems that using inhalation agents (Isoflurane, Desflurane or Sevoflurane), alone or in combination with small doses of fentanyl can be considered as a reasonable regimen. When administering drugs, anesthetist must realize and consider the substantially changed pharmacokinetics of some other anesthetic drugs. CONCLUSIONS: Despite the fact that anesthesia in chronic liver disease is a scary and pretty challenging condition for every anesthesiologist, this hazard could be diminished by meticulous attention on optimizing the patient's condition preoperatively and choosing appropriate anesthetic regimen and drugs in this setting. Although there are paucity of statistics and investigations in this specific group of patients but these little data show that with careful monitoring and considering the above mentioned rules a safe anesthesia could be achievable in these patients. KEYWORDS: Anesthesia; Epidural Anesthesia; Liver Disease; Regional Anesthesia; Spinal Anesthesia PDF

Atentamente Anestesia y Medicina del Dolor anestesia-dolor.org

Más de hígado y anestesia/More on liver and anaesthesia

Papel de los anestésicos inhalados en pacientes con disfunción hepática. Una revisión. The role of inhalational anesthetic drugs in patients with hepatic dysfunction: a review article. Soleimanpour H1, Safari S2, Rahmani F3, Ameli H4, Alavian SM5. Anesth Pain Med. 2015 Jan 7;5(1):e23409. doi: 10.5812/aapm.23409. eCollection 2015Author Abstract CONTEXT: Anesthetic drugs including halogenated anesthetics have been common for many years. Consequent hepatic injury has been reported in the literature. The mechanism of injury is immunoallergic. The first generation drug was halothane; it had the most toxicity when compared to other drugs. The issue becomes more important when the patient has an underlying hepatic dysfunction. EVIDENCE ACQUISITION: In this paper, reputable internet databases from 1957-2014 were analyzed and 43 original articles, 3 case reports, and 3 books were studied. A search was performed based on the following keywords: inhalational anesthesia, hepatic dysfunction, halogenated anesthetics, general anesthesia in patients with hepatic diseases, and side effects of halogenated anesthetics from reliable databases. Reputable websites like PubMed and Cochrane were used for the searches. RESULTS: In patients with hepatic dysfunction in addition to hepatic system and dramatic hemostatic dysfunction, dysfunction of cardiovascular, renal, respiratory, gastrointestinal, and central nervous systems may occur. On the other hand, exposure to inhalational halogenated anesthetics may have a negative impact (similar to hepatitis) on all aforementioned systems in addition to direct effects on liver function as well as the effects are more pronounced in halothane. CONCLUSIONS: Despite the adverse effects of inhalational halogenated anesthetics (especially halothane) on hepatic patients when necessary. The effects on all systems must be considered and the necessary preparations must be provided. These drugs are still used, if necessary, due to the presence of positive effects and advantages mentioned in other studies as well as the adverse effects of other drugs. KEYWORDS: Halothane; Hepatitis; Inhalational Anesthetics PDF Riesgos perioperatorios en pacientes con enfermedad hepática sometidos a cirugía no hepática Perioperative risk factors in patients with liver disease undergoing non-hepatic surgery. Pandey CK1, Karna ST, Pandey VK, Tandon M, Singhal A, Mangla V. World J Gastrointest Surg. 2012 Dec 27;4(12):267-74. doi: 10.4240/wjgs.v4.i12.267. Abstract The patients with liver disease present for various surgical interventions. Surgery may lead to complications in a significant proportion of thesepatients. These complications may result in considerable morbidity and mortality. Preoperative assessment can predict survival to some extent inpatients with liver disease undergoing surgical procedures. A review of literature suggests nature and the type of surgery in these patientsdetermines the peri-operative morbidity and mortality. Optimization of premorbid factors may help to reduce perioperative mortality and morbidity. The purpose of this review is to discuss the effect of liver disease on perioperative outcome; to understand various risk scoring systems and their prognostic significance; to delineate different preoperative variables implicated in postoperative complications and morbidity; to establish the effect of nature and type of surgery on postoperative outcome in patients with liver disease and to discuss optimal anaesthesia strategy in patients withliver disease. KEYWORDS: Cirrhosis; Liver disease; Perioperative risk PDF

Atentamente Anestesia y Medicina del Dolor anestesia-dolor.org

Hígado y anestesia / Liver and anaesthesia

Regímenes hipnóticos por vía intravenosa en pacientes con enfermedad hepática; un artículo de revisión. Intravenous hypnotic regimens in patients with liver disease; a review article. Soleimanpour H, Safari S, Rahmani F, Jafari Rouhi A, Alavian SM5. Anesth Pain Med. 2015 Feb 24;5(1):e23923. doi: 10.5812/aapm.23923. eCollection 2015. Abstract CONTEXT:The liver as an important organ in the body has many essential functions in physiological processes. One of the major activities of liveris drug metabolism. Hepatic dysfunction affecting hepatic physiological activities, especially drug metabolism can cause many problems duringanesthesia and administration of different drugs to patients. EVIDENCE ACQUISITION: Studies on hepatic disorders and hypnotic anesthetics prescribed in hepatic disorders were included in this review. For this purpose, reliable databases were used. RESULTS:Anesthesia should be performed with caution in patients with hepatic dysfunction and drugs with long half-life should be avoided in these patients. CONCLUSIONS: A review of the literature on the use of hypnotic drugs in patients with liver dysfunction showed that some hypnotic drugs used during anesthesia could be safely used in patients with impaired liver function. In these patients, certain drugs should be used with caution. KEYWORDS:Anesthesia; Hypnotics Drugs; Liver Disease PDF Anestesia en pacientes con enfermedad hepática Anesthesia for patients with liver disease. Rahimzadeh P, Safari S, Faiz SH, Alavian SM. Hepat Mon. 2014 Jul 1;14(7):e19881. doi: 10.5812/hepatmon.19881. eCollection 2014. Abstract CONTEXT: Liver plays an important role in metabolism and physiological homeostasis in the body. This organ is unique in its structure and physiology. So it is necessary for an anesthesiologist to be familiar with various hepatic pathophysiologic conditions and consequences of liver dysfunction. EVIDENCE ACQUISITION:WE SEARCHED MEDLINE (PUB MED, OVID, MD CONSULT), SCOPUS AND THE COCHRANE DATABASE FOR THE FOLLOWING KEYWORDS: liver disease, anesthesia and liver disease, regional anesthesia in liver disease, epidural anesthesia in liver disease and spinal anesthesia in liver disease, for the period of 1966 to 2013. RESULTS: Although different anesthetic regimens are available in modern anesthesia world, but anesthetizing the patients with liver disease is still really tough. Spinal or epidural anesthetic effects on hepatic blood flow and function is not clearly investigated, considering both the anesthetic drug-induced changes and outcomes. Regional anesthesia might be used in patients with advanced liver disease. In these cases lower drug dosages are used, considering the fact that locally administered drugs have less systemic effects. In case of general anesthesia it seems that using inhalation agents (Isoflurane, Desflurane or Sevoflurane), alone or in combination with small doses of fentanyl can be considered as a reasonable regimen. When administering drugs, anesthetist must realize and consider the substantially changed pharmacokinetics of some other anesthetic drugs. CONCLUSIONS: Despite the fact that anesthesia in chronic liver disease is a scary and pretty challenging condition for every anesthesiologist, this hazard could be diminished by meticulous attention on optimizing the patient's condition preoperatively and choosing appropriate anesthetic regimen and drugs in this setting. Although there are paucity of statistics and investigations in this specific group of patients but these little data show that with careful monitoring and considering the above mentioned rules a safe anesthesia could be achievable in these patients. KEYWORDS: Anesthesia; Epidural Anesthesia; Liver Disease; Regional Anesthesia; Spinal Anesthesia PDF

Atentamente Anestesia y Medicina del Dolor anestesia-dolor.org

http://www.madrimasd.org/informacionidi/noticias/noticia.asp?id=63217&origen=notiweb&dia_suplemento=lunes

La 'luchadora' a la que Einstein consideró una 'genio de las matemáticas'

De origen judío, Noether nació en la Baviera alemana hace 133 años -de ahí que Google lo celebre con un 'doodle'- en una familia de matemáticos. Hasta tres generaciones se habían dedicado a los números y ella no quiso ser menos. Aprendió acudiendo a las clases que impartía su padre en la universidad, ya que era una época en la que no se admitían mujeres en las aulas. Iba de simple oyente. Dada su persistencia, Emmy Noether consiguió que la dejasen matricularse en Erlangen, la universidad de su ciudad natal, donde se doctoró con un célebre trabajo sobre los invariantes. Tal fue su éxito, que el profesor David Hilbert la invitó a impartir una serie de conferencias en Gotinga, aunque no consiguió llevarlas a cabo por la oposición de parte del profesorado. Solo le permitieron acceder a un puesto no oficial de profesora asociada. Consiguió revolucionar el campo de las matemáticas con teorías sobre anillos, cuerpos y álgebras. También el de la física, con el teorema que lleva su nombre y que relaciona dos ideas básicas: la invariancia de la forma que una ley física toma con respecto a cualquier transformación y la ley de conservación de una magnitud física. Un teorema que se suele formular como "a cada simetría le corresponde una ley de conservación, y viceversa". EXILIADA EN ESTADOS UNIDOS Reconocida en su mundo, no lo era por su propia nación, que le dio la espalda tras el ascenso de Hitler al poder. Aquella Alemania no estaba hecha para genios; no si eran judíos y Emmy Noether fue un caso más de los dotados que fueron ninguneados y olvidados. Le fue imposible seguir dando clase en la Universidad de Gotinga tras la aprobación de la Ley para la Restauración del Servicio Civil Profesional, que impedía mantener su puesto a los funcionarios judíos y políticamente sospechosos. Sin poder dar clases ni conferencias bajo su nombre, Emmy Noether tuvo que exiliarse en Estados Unidos, donde continuó sus estudios y trabajos en el Instituto de Estudios Avanzados de Princeton, compaginándolos con su labor de profesora en Bryn Mawr. Allí desarrolló su labor hasta que, dos años más tarde, le descubrieron un tumor pélvico y falleció a consecuencia de la operación.

Falla hepática aguda en el embarazo. Factores etiológicos y pronósticos

Falla hepática aguda en el embarazo. Factores etiológicos y pronósticos Acute liver failure in pregnancy: Causative and prognostic factors. Sahai S, Kiran R. Saudi J Gastroenterol [serial online] 2015 [cited 2015 Feb 11];21:30-4. Abstract Background/Aims: Acute liver failure (ALF) in pregnancy is often associated with a poor prognosis. In this single-center observational study we aim to study the incidence, causes, and factors affecting mortality in pregnant women with ALF. Patients and Methods: Sixty-eight pregnant women reporting with clinical features of liver dysfunction were enrolled as "cases." Their clinical course was followed and laboratory studies were performed. The presence of ALF was defined as the appearance of encephalopathy. The results were compared with a "control" group of 16 nonpregnant women presenting with similar complaints. The cases were further subdivided into two groups of "survivors" and "nonsurvivors" and were compared to find out the factors that contribute to mortality. Results: ALF was seen in significantly more number of pregnant women than the controls (P = 0.0019). The mortality rate was also significantly higher (P = 0.0287). Hepatitis E virus (HEV) caused jaundice in a higher number of pregnant women (P < 0.001). It also caused ALF in majority (70.3%) of pregnant women, but HEV infection was comparable between the survivors and nonsurvivors (P = 0.0668), hence could not be correlated with mortality.Conclusions: Pregnant women appear to be more susceptible for HEV infection and development of ALF. The mortality of jaundiced pregnant women increased significantly with appearance of ALF, higher bilirubin, lower platelet count, higher international normalized ratio, and spontaneous delivery. Keywords: Acute liver failure, HEV infection, pregnancy PDF

Atentamente Anestesia y Medicina del Dolor anestesia-dolor.org

Esteroides epidurales / Epidural steroids

Controversia-advertencia sobre esteroides epidurales en la FDA. Epidural steroid warning controversy still dogging FDA. Manchikanti L, Candido KD, Singh V, Gharibo CG, Boswell MV, Benyamin RM, Falco FJ, Grider JS, Diwan S, Hirsch JA. Pain Physician. 2014 Jul-Aug;17(4):E451-74. Abstract On April 23, 2014, the Food and Drug Administration (FDA) issued a letter of warning that injection of corticosteroids into the epidural space of the spine may result in rare, but serious adverse events, including "loss of vision, stroke, paralysis, and death." The advisory also advocated that patients should discuss the benefits and risks of epidural corticosteroid injections with their health care professionals, along with the benefits and risks associated with other possible treatments. In addition, the FDA stated that the effectiveness and safety of the corticosteroids for epidural use have not been established, and the FDA has not approved corticosteroids for such use. To raise awareness of the risks of epidural corticosteroid injections in the medical community, the FDA's Safe Use Initiative convened a panel of experts including pain management experts to help define the techniques for such injections with the aim of reducing preventable harm. The panel was unable to reach an agreement on 20 proposed items related to technical aspects of performing epidural injections. Subsequently, the FDA issued the above referenced warning and a notice that a panel will be convened in November 2014. This review assesses the inaccuracies of the warning and critically analyzes the available literature. The literature has been assessed in reference to alternate techniques and an understanding of the risk factors when performing transforaminal epidural injections in the cervical, thoracic, and lumbar regions, ultimately resulting in improved safety. The results of this review show the efficacy of epidural injections, with or without steroids, in a multitude of spinal ailments utilizing caudal, cervical, thoracic, and lumbar interlaminar approaches as well as lumbar transforaminal epidural injections . The evidence also shows the superiority of steroids in managing lumbar disc herniation utilizing caudal and lumbar interlaminar approaches without any significant difference as compared to transforaminal approaches, either with local anesthetic alone or local anesthetic and steroids combined. In conclusion, the authors request that the FDA modify the warning based on the evidence. PDF Inyección torácica epidural interlaminar en el manejo del dolor crónico del tórax. Estudio randomizado.... Thoracic interlaminar epidural injections in managing chronic thoracic pain: a randomized, double-blind, controlled trial with a 2-year follow-up. Manchikanti L, Cash KA, McManus CD, Pampati V, Benyamin RM. Pain Physician. 2014 May-Jun;17(3):E327-38 Abstract BACKGROUND: Reports of prevalence of spinal pain indicate the prevalence of thoracic pain in approximately 13% of the general population compared to 32% of the population with neck pain and 43% of the population with low back pain during the past year. Even though, thoracic pain is less common than neck or low back pain, the degree of disability resulting from thoracic pain disorders seems to be similar to other painful conditions. Interventions in managing chronic thoracic pain are also less frequent, leading to the paucity of literature about various interventions in managing chronic thoracic pain. Thoracic intervertebral discs and thoracic facet joints have been shown to be pain generators, even though thoracicradicular pain is very infrequent. Thoracic epidural injections are one of the commonly performed procedures in managing thoracic pain. The efficacy of thoracic epidural injections has not been well studied. STUDY DESIGN: A randomized, double-blind, active controlled trial. SETTING: Private interventional pain management practice and specialty referral center in the United States. OBJECTIVE: The primary objective was to assess the effectiveness of thoracic interlaminar epidural injections in providing effective pain relief and improving function in patients with chronic mid and/or upper back pain. METHODS: One hundred and ten patients were randomly assigned into 2 groups with 55 patients in each group receiving either local anesthetic alone (Group I) or local anesthetic with steroids (Group II). Randomization was performed by computer-generated random allocation sequence by simple randomization. OUTCOMES ASSESSMENT: Outcomes were assessed utilizing Numeric Rating Scale (NRS), the Oswestry Disability Index (ODI) 2.0, employment status, and opioid intake. The patients experiencing greater than 3 weeks of significant improvement with the first 2 procedures were considered as successful. Others were considered as failed participants. Significant improvement was defined as a decrease of greater than 50% NRS scores and ODI scores with measurements performed at baseline, 3, 6, 12, 18, and 24 months post treatment. RESULTS: Significant improvement was seen in 71% in Group I and 80% in Group II at the end of 2 years with all participants; however, improvement was seen in 80% and 86% when only successful patients were considered. Therapeutic procedural characteristics showed 5 to 6 procedures per 2 years with total average relief of 80 weeks in Group I and 78 weeks in Group II in the successful patient category; whereas, it was 71 and 72 weeks when all patients were considered. LIMITATIONS: Limitations of this assessment include lack of a placebo group. CONCLUSIONS: Based on the results of this trial, it is concluded that chronic thoracic pain of non-facet joint origin may be managed conservatively with thoracic interlaminar epidural injections with or without steroids. 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