domingo, 19 de octubre de 2014

17 de octubre Día Mundial contra el Dolor

http://digaleadiosaldolor.blogspot.mx/2014/10/17-de-octubre-dia-mundial-contra-el-dolor.html?utm_source=feedburner&utm_medium=email&utm_campaign=Feed:+ElBienestarDgaleAdisAlDolor+(El+Bienestar,+D%C3%ADgale+adi%C3%B3s+al+Dolor)




17 de octubre Día Mundial contra el Dolor








El día 17 de octubre se conmemora el Día Mundial contra el Dolor, como iniciativa del Instituto Internacional para el Estudio del Dolor (IASP). Cada año los esfuerzos se centran en un tipo particular de dolor, hace dos años se dedicó en el estudio y tratamiento del dolor visceral, y para el periodo 2013 - 2014 le toco el turno al dolor orofacial.


El Dolor en cualquiera de sus formas es una alerta o alarma, lamentablemente este síntoma se ha satanizado y se ha catalogado como algo negativo y desagradable, lo cual representa un gran problema tanto para e paciente como para el médico ya que esta visión agrega factores emocionales que hacen que la experiencia del dolor sea aun más molesta y traumática, haciendo más difícil su tratamiento.


El dolor agudo, es decir, el dolor de corta duración más que un enemigo es un aliado, ya que nos hace tormar conciencia de hechos como que nos estamos lesionando, se esta sobrecargando una estructura y de continuar haciéndolo se prodrá desgarrar o bien, nos alerta sobre un funcionamiento anómalo de algún órgano interno como ocurre en el caso de los cólicos abdominales asociados con el consumo de algunos alimentos por citar un ejemplo.


Existe un tipo de dolor que es llamado dolor crónico, este se caracteriza por ser sostenido en el tiempo logrando permanecer meses o incluso años en algunas personas. El dolor crónico obedece a otras causas como las lesiones de las estructuras como los cartílagos, los discos intervertebrales, ligamentos, tendones, etc., este dolor es menos intenso sin embargo se hace molesto por lo continuo y persistente; incluso este dolor tiene también una razón de ser y es evitar el movimiento y por ende agravar aun más una lesión existente. Esto es lo que ocurre por ejemplo en personas con enfermedades degenerativas como laartrosis en donde mientras el paciente esta en reposo no tiene mayor molestia, pero si practica una actividad física excesiva puede presentar dolor de fuerte intensidad y limitación para movilizarse.









Existe un tipo particular de dolor en el cual no puede explicarse su presencia por un efecto meramente protector, este es el dolor neuropático y constituye un capitulo a parte en la materia del dolor. Este dolor obedece a otra causa, como lo es la perturbación o afectación del sistema nervioso por una lesión, haciendo que sus células, las neuronas, sean capaces de producir señales de sensaciones que no existen. Esto explica síntomas como los corrientazos, calambres, hormigueo, punzadas e incluso el ardor que se presentan en enfermedades como las neuropatías e incluso en la fibromialgia.


Aunque el dolor tenga un objeto, es necesario evaluarlo correctamente y tratarlo para poder mejorar la calidad de vida de quien lo padece, cada tipo de dolor y cada localización son muy particulares y pueden obedecer a una gran variedad de causas, por ello manejar pacientes con dolor es tan complejo y amerita no una, sino varias evaluaciones para poder ir orientando y trabajando con el paciente por metas y objetivos.


Esta labor no es fácil, ya que muchas veces el paciente con dolor se frustra y se cansa, por ello es tan importante que exista un buen canal de comunicación entre el médico y el paciente y que el equipo integre un grupo de profesionales que puedan abordar al paciente desde varios puntos de vista, incluyendo al médico psiquiatra quien muchas veces es un gran aliado al tratar fenómenos como la depresión, la ansiedad y el insomnio y ayudar al paciente a mantenerse motivado en el cumplimiento de su tratamiento, especialmente de la terapia del dolor.










como el Día Mundial contra el Dolor son de gran importancia para reorientar los esfuerzos, revisar lo nuevo, reevaluar lo ya conocido y ratificar el compromiso en continuar la lucha día a día para poder ayudar a los pacientes a vivir plenamente y sin dolor, e incluso cuando no se pueda lograr eliminarlo completamente poder lograr llevar los días malos y disfrutar mas los días buenos. Este es un trabajo de equipo que incluye al paciente, su médico, el fisioterapeuta, el nutricionista, el psicólogo y también a sus familiares.

Analgesia postoracotomía/Post thoracotomy analgesia

Comparación de la eficacia de analgesia y efectos secundarios de bloqueos paravertebrales comparado con bloqueo peridural en toracotomía. Un meta-análisis actualizado


A comparison of the analgesia efficacy and side effects of paravertebral compared with epidural blockade for thoracotomy: an updated meta-analysis.
Ding X, Jin S, Niu X, Ren H, Fu S, Li Q.
PLoS One. 2014 May 5;9(5):e96233. doi: 10.1371/journal.pone.0096233. eCollection 2014.
Abstract
OBJECTIVE:The most recent systematic review and meta-analysis comparing the analgesic efficacy and side effects of paravertebral and epiduralblockade for thoracotomy was published in 2006. Nine well-designed randomized trials with controversial results have been published since then. The present report constitutes an updated meta-analysis of this issue.
SUMMARY OF BACKGROUND:Thoracotomy is a major surgical procedure and is associated with severe postoperative pain. Epidural analgesia is the gold standard for post-thoracotomy pain management, but has its limitations and contraindications, and paravertebral blockade is increasingly popular. However, it has not been decided whether the analgesic effect of the two methods is comparable, or whether paravertebral blockade leads to a lower incidence of adverse side effects after thoracotomy. ... CONCLUSIONS:This meta-analysis showed that PVB can provide comparable pain relief to traditional EPI, and may have a better side-effect profile for pain relief after thoracic surgery. Further high-powered randomized trials are to need to determine whether PVB truly offers any advantages over EPI.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4010440/pdf/pone.0096233.pdf



Atentamente
Anestesiología y Medicina del Dolor
www.anestesia-dolor.org

Medwave

A continuación le informamos los artículos recientemente publicados en Medwave.

CARTA A LA EDITORA

Cicatrices visibles de vacunación
Juan Enrique Berner, Pedro Vidal (Chile)
Medwave 2014 Oct;14(9):e6025

http://dx.doi.org/10.5867/medwave.2014.09.6025


RESÚMENES EPISTEMONIKOS DE LA EVIDENCIA

¿Es efectivo el uso de inmunoglobulina intravenosa en el manejo de necrólisis epidérmica tóxica y síndrome de Stevens-Johnson?
Lucas Navajas, Gabriel Rada (Chile)

Medwave 2014 Oct;14(9):e6024
http://dx.doi.org/10.5867/medwave.2014.09.6024


ESTUDIO PRIMARIO

Inasistencia de pacientes a consultas médicas de especialistas y su relación con indicadores ambientales y socioeconómicos regionales en el sistema de salud público de Chile
Elizabeth Angélica Salinas Rebolledo, Rolando De la Cruz Mesía, Gabriel Bastías Silva (Chile)

Medwave 2014 Oct;14(9):e6023
http://dx.doi.org/10.5867/medwave.2014.09.6023


REPORTE DE CASO

Divertículo de Meckel gigante en un adulto
Tomas Contreras Rivas, Nasser Eluzen Gallardo, Sebastian King Valenzuela, María Elena Molina Pezoa, José Miguel Zúñiga, Carol Bustamante Muñoz, Biserka Spralja Saralic (Chile)

Medwave 2014 Oct;14(9):e6022
http://dx.doi.org/10.5867/medwave.2014.09.6022


PORTADA MEDWAVE
http://www.medwave.cl

Lidocaína, remifentanilo/Lidocaine, remifentanil

Impacto de infusión perioperatoria de lidocaína y monitores con BIS sobre la dosis de remifentanil en anestesia hipotensiva


Impact of perioperative lidocaine infusion and bis monitorization on remifentanil dosage in hypotensive anesthesia.
Uzun S, Yuce Y, Erden A, Aypar U.
Eur Rev Med Pharmacol Sci. 2014;18(4):559-65.
Abstract
BACKGROUND: Combination of local and regional anesthetic agents are widely used in emergency and surgical setting and the interaction between the medications used in general anesthesia and these local and/or regional anesthetic becomes a growing concern in current patient management system. The interaction between general anesthetic agents and the local anesthetic agents given epidurally, spinally, intravenously or intramuscularly and the effects of BIS monitorisation on combined propofol-remifentanil anesthesia are examined in several studies. In literature, there is no research investigating the effect of lidocaine infusion on remifentanil and anesthetic dosage used in hypotensive anesthesia. The aim of this study is to examine this effect. PATIENTS AND METHODS: We studied 39, ASA I-II patients undergoing elective transsphenoidal endoscopic hypophyseal adenoma excision procedure. After preoperative examination and informed consent of the patient, monitorisation with non invasive blood pressure measurement, electrocardiography, pulse oxymeter and Bispectral Index (BIS) was performed. 0.9% NaCl infusion was started via a 20 G route. Lidocaine (1%) was given as 1.5 mg.kg(-1) hour-1 infusion after 1.5 mg.kg(-1) bolus dosage given in 10 minutes. Lidocaine infusion was started at the same time with anesthesia induction and was stopped after surgery. 0.9% NaCl was given as bolus dosage and as infusion in control group. Induction was maintained via propofol (1%) with 10 mg (1 ml) doses given in 5 seconds and it was applied in every 15 seconds until BIS < 45'. During maintenance of anesthesia desflurane-remifentanil-oxygen (50%)-air (50%) mixture was used. Desflurane was titrated by BIS measurement between 40 and 5012. Remifentanil infusion was started after propofol induction with 0.1 µg.kg(-1).min(-1) dosage and it was titrated between 0.1-0.5 µg.kg(-1).min(-1) levels. For intubation, rocuronium with 0.8 mg kg(-1) dosage was given during induction. After the surgical procedure, it was antagonised with neostigmine and atropine. For postoperative analgesia 1 g paracetamole was given IV after the surgery within 15 minutes and it was reapplied with 1 gr doses in every 6 hours. After extubation, the pain of the patients was examined at 15. minute at the recovery room with VRS (VRS; 0-no pain, 1-slight pain, 2-moderate pain, 3-severe pain). If VRS was greater than 2, 50 mg dolantine was given IM. For prevention of nausea and vomitting, 8 mg ondansetron was given IV. Perioperative total doses of remifentanil, desflurane (ml) (anesthesia machine records) and lidocaine (mg) were recorded after the surgery. Perioperative hemodynamic parameters (systolic, diastolic, mean blood pressures, heart rates) were recorded after monitorisation (basal), after intubation, after the start of the surgery and after extubation. RESULTS: There were no statistically significant difference between two groups with respect to patient characteristics (age, gender, weight, length, Basal Mass Index = BMI) (p > 0.05). The duration of anesthesia and surgery were also not different statistically (p > 0.05). There were no statistically significant difference between two groups with respect to remifentanil dose (p > 0.05). There were no statistically significant difference between two groups with respect to eye opening and extubation times (p > 0.05). When usage rates and amounts of dolantine, paracetamole and novalgine were compared, we found no statistically significant difference between two groups (p > 0.05). Basal mean arterial blood pressure measurements of the patients and mean arterial blood pressure measurements of the patients after induction, after intubation, 1 minute, 5 minutes, 10 minutes, 15 minutes after discharge of surgery and after extubation showed no statistically significant difference (p > 0.05). Basal heart rate measurements and the heart rates after induction, after intubation, 1 minute, 5 minutes, 10 minutes, 15 minutes after discharge of surgery and after extubation showed no statistically significant difference (p > 0.05). Basal BIS measurements and BIS measurements after induction, after intubation, 1 minute, 5 minutes, 10 minutes, 15 minutes after discharge of surgery and after extubation showed no statistically significant difference (p > 0.05). CONCLUSIONS: We found no statistically significant difference between two groups about different parameters. But new investigations with different local anesthetic agents may show significant difference and usage of these local anesthetic agents may be advised.

http://www.europeanreview.org/wp/wp-content/uploads/559-5651.pdf



Atentamente
Anestesiología y Medicina del Dolor
www.anestesia-dolor.org

viernes, 17 de octubre de 2014

Analgesia PO torácica/POA in chest surgery

La efectividad de analgesia preemptiva epidural torácica en cirugía de tórax


The effectiveness of preemptive thoracic epidural analgesia in thoracic surgery.
Erturk E, Aydogdu Kaya F1, Kutanis D1, Besir A1, Akdogan A1, Geze S1, Tugcugil E2.
Biomed Res Int. 2014;2014:673682. doi: 10.1155/2014/673682. Epub 2014 Mar 13.
Abstract
BACKGROUND:The aim of this study is to investigate the effectiveness of preemptive thoracic epidural analgesia (TEA) comparing conventional postoperative epidural analgesia on thoracotomy. MATERIAL AND METHODS:Forty-four patients were randomized in to two groups (preemptive: Group P, control: Group C). Epidural catheter was inserted in all patients preoperatively. In Group P, epidural analgesic solution was administered as a bolus before the surgical incision and was continued until the end of the surgery. Postoperative patient controlled epidural analgesia infusion pumps were prepared for all patients. Respiratory rates (RR) were recorded. Patient's analgesia was evaluated with visual analog scale at rest (VASr) and coughing (VASc). Number of patient's demands from the pump, pump's delivery, and additional analgesic requirement were also recorded. RESULTS:RR in Group C was higher than in Group P at postoperative 1st and 2nd hours. Both VASr and VASc scores in Group P were lower than in Group C at postoperative 1st, 2nd, and 4th hours. Patient's demand and pump's delivery count for bolus dose in Group P were lower than in Group C in all measurement times. Total analgesic requirements on postoperative 1st and 24th hours in Group P were lower than in Group C. CONCLUSION:We consider that preemptive TEA may offer better analgesia after thoracotomy.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3972946/pdf/BMRI2014-673682.pdf




http://www.hindawi.com/journals/bmri/2014/673682/


Bloqueos paravertebrales intraoperatorios para analgesia postoperatoria en toracotomía. Estudio randomizado, doble ciego y controlado con placebo

Intra-operative paravertebral block for postoperative analgesia in thoracotomy patients: a randomized, double-blind, placebo-controlled study.
Helms O, Mariano J, Hentz JG, Santelmo N, Falcoz PE, Massard G, Steib A.
Eur J Cardiothorac Surg. 2011 Oct;40(4):902-6. doi: 10.1016/j.ejcts.2011.01.067. Epub 2011 Mar 5.
Abstract
OBJECTIVE:Epidural analgesia is the gold standard for post-thoracotomy pain relief but is contraindicated in certain patients. An alternative is paravertebral block. We investigated whether ropivacaine, administered through a paravertebral catheter placed by the surgeon, reduced postoperative pain. METHODS:In a randomized double-blind study, adult patients with a paravertebral catheter placed by the thoracic surgeon after thoracotomy were randomly assigned to receive through this catheter, either a 0.1 mlkg(-1) bolus of 0.5% ropivacaine, followed by a continuous infusion of 0.1 mlkg(-1)h(-1) for 48 h, or saline at the same scheme of administration. Patients also benefited from patient-controlled analgesia with intravenous morphine (bolus 1mg, lockout time 7 min), paracetamol, and nefopam. The primary endpoint was pain intensity on a visual analog scale at rest and on coughing. Secondary endpoints were total morphine consumption and side effects during the first 48 postoperative hours. Surgeons, anesthesiologists, and all the nurses and caring staff involved in this study were blinded. Solutions of saline and ropivacaine were prepared identically by the central pharmacy, without any possible identification of the product. RESULTS:Forty-seven patients with contraindications to epidural anesthesia were included. There were no significant differences between the groups receiving ropivacaine and saline in terms of pain severity at rest and on coughing, mean postoperative morphine consumption (45.7 mg for ropivacaine, 43.2mg in controls), and incidence of morphine-related side effects (nausea and vomiting, urinary retention, pruritus, respiratory rate, and sedation). CONCLUSIONS:Paravertebral block using a catheter placed by the thoracic surgeon was ineffective on postoperative pain after thoracotomy and did not confirm the analgesic effect that has been observed after percutaneous catheter placement. A direct comparison of these two placement methods is required.

http://ejcts.oxfordjournals.org/content/40/4/902.full.pdf


Atentamente
Anestesiología y Medicina del Dolor
www.anestesia-dolor.org

martes, 14 de octubre de 2014

Líquidos iv en UCI/IV fluids in ICU patients

¿Que hay de nuevo sobre el volumen de líquidos en terapia intensiva?


What's new in volume therapy in the intensive care unit?
van Haren F, Zacharowski K.
Best Pract Res Clin Anaesthesiol. 2014 Sep;28(3):275-283. doi: 10.1016/j.bpa.2014.06.004. Epub 2014 Jul 17.
Abstract
The administration of intravenous fluid to critically ill patients is one of the most common but also one of the most fiercely debated interventions in intensive care medicine. During the past decade, a number of important studies have been published which provide clinicians with improved knowledge regarding the timing, the type and the amount of fluid they should give to their critically ill patients. However, despite the fact that many thousands of patients have been enrolled in these trials of alternative fluid strategies, consensus remains elusive and practice is widely variable. Early adequate resuscitation of patients in shock followed by a restrictive strategy may be associated with better outcomes. Colloids such as modern hydroxyethyl starch are more effective than crystalloids in early resuscitation of patients in shock, and are safe when administered during surgery. However, these colloids may not be beneficial later in the course of intensive care treatment and should best be avoided in intensive care patients who have a high risk of developing acute kidney injury. Albumin has no clear benefit over saline and is associated with increased mortality in neurotrauma patients. Balanced fluids reduce the risk of hyperchloraemic acidosis and possibly kidney injury. The use of hypertonic fluids in patients with sepsis and acute lung injury warrants further investigation and should be considered experimental at this stage. Fluid therapy impacts relevant patient-related outcomes. Clinicians should adopt an individualized strategy based on the clinical scenario and best available evidence. One size does not fit all.
http://www.clinicalanaesthesiology.com/article/S1521-6896(14)00052-4/pdf



¿Deberían las soluciones con hidroxietil almidón estar totalmente prohibidas?



Should hydroxyethyl starch solutions be totally banned?
Vincent JL, Kellum JA, Shaw A, Mythen MG.

Crit Care. 2013 Oct 1;17(5):193. doi: 10.1186/cc13027.

Abstract

The choice of which intravenous solution to prescribe remains a matter of considerable debate in intensive care units around the world. Trends have been moving away from using hydroxyethyl starch solutions following concerns about safety. But are the available data sufficient to clearly assess the risk-benefit balance for all patients, and is there enough evidence of harm to justify removing these drugs completely from our hospitals?

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3871763/pdf/cc13027.pdf


Riesgo de insuficiencia renal aguda en pacientes tratados con soluciones que tienen hidroxietil almidón


The risk of AKI in patients treated with intravenous solutions containing hydroxyethyl starch.
Shaw AD, Kellum JA.

Clin J Am Soc Nephrol. 2013 Mar;8(3):497-503. doi: 10.2215/CJN.10921012. Epub 2013 Jan 18.

Abstract

Intravenous fluids are arguably one of the most commonly administered inpatient therapies and for the most part have been viewed as part of the nephrologist's toolkit in the management of acute kidney disease. Recently, findings have suggested that intravenous fluids may be harmful if given in excess (quantitative toxicity) and that some may be more harmful than others (qualitative toxicity), particularly for patients who already have AKI. Recent clinical trials have investigated hydroxyethyl starch solutions and found worrying results for the renal community. In this brief review, we consider the published literature on the role of hydroxyethyl starch solutions in AKI, with particular emphasis on two large recent randomized clinical trials conducted in Europe and Australia.

http://cjasn.asnjournals.org/content/8/3/497.full.pdf



Atentamente
Anestesiología y Medicina del Dolor
www.anestesia-dolor.org

lunes, 13 de octubre de 2014

Esteroides transforaminales/Transforaminalepidural steroids


La angiografía por sustracción digital no impide de manera fiable la paraplejia lumbar asociada con inyección transforaminal epidural de esteroides.


Digital subtraction angiography does not reliably prevent paraplegia associated with lumbar transforaminalepidural steroid injection.
Chang Chien GC1, Candido KD, Knezevic NN.
Pain Physician. 2012 Nov-Dec;15(6):515-23.
Abstract
Digital subtraction angiography (DSA) has been touted as a radiologic adjunct to interventional neuraxial procedures where it is imperative to identify vascular compromise during the injection. Transforaminal epidural steroid injections (TFESI) are commonly performed interventions for treating acute and chronic radicular spine pain. We present a case of instantaneous and irreversible paraplegia following lumbar TFESI wherein a local anesthetic test dose, as well as DSA, were used as adjuncts to fluoroscopy. An 80-year-old man with severe lumbar spinal stenosis and chronic L5 radiculopathic pain was evaluated at a university pain management center seeking symptomatic pain relief. Two prior lumbar interlaminar epiduralsteroid injections (LESI) provided only transient pain relief, and a decision was made to perform right-sided L5-S1 TFESI. A 5-inch, 22-gauge Quincke-type spinal needle with a curved tip was used. Foraminal placement of the needle tip was confirmed with anteroposterior, oblique, and lateral views on fluoroscopy. Aspiration did not reveal any blood or cerebrospinal fluid. Digital subtraction angiography was performed twice to confirm the absence of intravascular contrast medium spread. Subsequently, a 0.5 mL of 1% lidocaine test dose was performed without any changes in neurological status. Two minutes later, a mixture of one mL of 1% lidocaine with 80 mg triamcinolone acetonide was injected. Immediately followingthe completion of the injection, the patient reported extreme bilateral lower extremity pain. He became diaphoretic, followed by marked weakness in his bilateral lower extremities and numbness up to his lower abdomen. The patient was transferred to the emergency department for evaluation. Magnetic resonance imaging (MRI) of the lumbar and thoracic spine was completed 5 hours postinjection. It showed a small high T2 signal focus in the thoracic spinal cord at the T7-T8 level. The patient was admitted to the critical care unit for neurological observation and treatment with intravenous methylprednisolone. Follow-up MRI revealed a hyper-intense T2 and short-tau inversion recovery signal in the central portion of the spinal cord beginning at the level of the T6 superior endplate and extending caudally to the T9-T10 level with accompanying development of mild spinal cord expansion. The patient was diagnosed with paraplegia from acute spinal cord infarction. At discharge to an acute inpatient rehabilitation program, the patient had persistent bilateral lower extremity paralysis, and incontinence of bowel and bladder functions. In the present patient, DSA performed twice and an anesthetic test dose did not prevent a catastrophic spinal cord infarction and resulting paraplegia. DSA use is clearly not foolproof and may not be sufficient to identify potentially life-or-limb threatening consequences of lumbar TFESI. We believe that this report should open further discussion regarding adding the possibility of these catastrophic events in the informed consent process for lumbar TFESIs, as it has for cervical TFESI. Utilizing blunt needles or larger bevel needles in place of sharp, cutting needles may minimize the chances of this event occurring. Considering eliminating use of particulate steroids for TFESI should be evaluated, although the use of nonparticulate agents remains controversial due to the perception that their respective duration of action is less than that of particulate steroids.
http://www.painphysicianjournal.com/2012/december/2012;15;515-523.pdf



Detección de flujo intravascular durante inyecciones epidurales transforaminales: Evaluación prospectiva

Intravascular flow detection during transforaminal epidural injections: a prospective assessment.
El Abd OH, Amadera JE1, Pimentel DC, Pimentel TS.
Pain Physician. 2014 Jan-Feb;17(1):21-7.
Abstract
BACKGROUND: Transforaminal epidural steroid injections (TFESI) are a mainstay in the treatment of spine pain. Though this commonly performed procedure is generally felt to be safe, devastating complications following inadvertent intra-arterial injections of particulate steroid have been reported. The use of digital subtraction angiography (DSA) has been suggested as a means of detecting intra-arterial needle placements prior to medication injection.OBJECTIVE:To examine the efficacy of DSA in detecting intra-arterial needle placements during TFESI.STUDY DESIGN:Prospective cohort study evaluating the impact of DSA on detecting intra-arterial needle placements during TFESI.METHODS:We enrolled 150 consecutive patients presenting to a university-affiliated spine center with discogenic and/or radicular symptoms affecting the cervical, lumbar, and sacral regions. For each injection, prior to imaging with DSA, traditional methods for vascular penetration detection were employed, including the identification of blood in the needle hub (flash), negative aspiration of blood prior to injection, and live fluoroscopic injection of contrast. Once these tests were performed and negative for signs of intra-arterial needle placement, DSA imaging was utilized prior to medication administration for identification of vascular flow.RESULTS:A total number of 222 TFESI were performed, 41 injections at the cervical levels (18.47%), 113 at the lumbar levels (50.9%), and 68 at the sacral levels (30.36%). Flash was observed in 13 injections performed (5.85% of the total number of injections): one (0.45%) in the cervical, 2 (0.9%) in the lumbar, and 10 (4.5%) in the sacral levels. In 11 TFESI blood aspiration was obtained (4.95% of all injections): 3 (1.3%) in cervical, 4 (1.8%) in lumbar, and 4 (1.8%) in sacral injections. Live fluoroscopy during contrast injection detected 46 (20.72%) intravascular flow patterns: 7 (3.1%) cervical, 17 (7.6%) lumbar, and 22 (9.9%) sacral. DSA identified an additional 5 intravascular injections after all previous steps had resulted in negative vascular penetration signs, which accounted for 2.25% of all injections.LIMITATIONS:This is a prospective, single-center study with a relatively small number of patients and no control group.CONCLUSION:
DSA detected additional 5.26% intravascular needle placements following traditional methods. Our findings also support other studies that conclude TFESI are generally a safe procedure. We recommend that special attention should be paid to the sacral injections as vascular penetration was statistically higher than at other levels.

http://www.painphysicianjournal.com/2014/january/2014;17;21-27.pdf




Atentamente
Anestesiología y Medicina del Dolor
www.anestesia-dolor.org

Medwave

Hemos completado la edición correspondiente al mes de Septiembre 2014, los artículos incluídos son los siguientes.


RESÚMENES EPISTEMONIKOS DE LA EVIDENCIA

¿Es efectivo el ácido ursodeoxicólico en cirrosis biliar primaria?
Gabriel Rada, Macarena Mac-Namara (Chile)

Medwave 2014 Sep;14(8):e6019
http://dx.doi.org/10.5867/medwave.2014.08.6019


ANÁLISIS CRÍTICO

Entrenamiento de fuerza isométrica para la disminución de la presión arterial sistólica: CAT
Alexis Espinoza Salinas, Pablo Sánchez Aguilera, Edson Zafra Santos, Cristian Cofre Bolados, Hugo Prado Núñez, Gustavo Pavés Von Martens (Chile)

Medwave 2014 Sep;14(8):e601
http://dx.doi.org/10.5867/medwave.2014.08.6017


ESTUDIOS PRIMARIOS

Calidad de sueño y atención selectiva en estudiantes universitarios: estudio descriptivo transversal
Silvia Alicia Fontana, Waldina Raimondi, María Laura Rizzo (Argentina)

Medwave 2014 Sep;14(8):e6015.
http://dx.doi.org/10.5867/medwave.2014.08.6015


Estudio de exactitud diagnóstica que compara fosfatasa alcalina total con paratohormona intacta 1-84 para el diagnóstico de osteodistrofia renal de alto recambio en la insuficiencia renal crónica en hemodiálisis
Andrés Marcelo Rojas González, Marcela Opazo Valenzuela, Sergio Muñoz Navarro (Chile)

Medwave 2014 Sep;14(8):e6014
http://dx.doi.org/10.5867/medwave.2014.08.6014


ACTUALIDAD

Comisión presidencial sobre reforma de seguros privados de salud encaminada a proponer más que ajustes acotados de un sistema no mancomunado
Tania Herrera (Chile)

Medwave 2014 Sep;14(8):e6018
http://dx.doi.org/10.5867/medwave.2014.08.6018


TEMAS Y CONTROVERSIAS EN BIOESTADÍSTICA

Causalidad y predicción: diferencias y puntos de contacto
Luis Carlos Silva Ayçaguer (Cuba)

Medwave 2014 Sep;14(8):e6016
http://dx.doi.org/10.5867/medwave.2014.08.6016


PORTADA MEDWAVE
http://www.medwave.cl

Glutamato y daño isquémico/Glutamateand ischemic damage

Una reciente investigación ha descubierto en animales de experimentación un nuevo mecanismo que contribuye al mejor conocimiento del daño neuronal ocurrido tras un ictus. El trabajo abre la puerta al desarrollo de nuevos tratamientos neuroprotectores que palien los trastornos neurológicos provocados por la isquemia cerebral. Una parte importante del deterioro neuronal causado por una isquemia cerebral se debe a la alteración en los niveles de glutamato, el neurotransmisor excitador más abundante del cerebro, que actúa a su vez como una potente neurotoxina cuando su concentración se eleva, como ocurre durante la isquemia. El nuevo hallazgo pone de manifiesto la importancia de una molécula, el intercambiador cistina-glutámico (xCT), en el aumento de la concentración de glutamato hasta niveles tóxicos en modelos experimentales que reproducen las principales características del ictus en pacientes. Los resultados evidencian que, durante la isquemia, el glutamato se transporta fuera de la célula a través del intercambiador xCT, acumulándose hasta niveles letales para las neuronas. A su vez, mediante tomografía por emisión de positrones se ha observado que los niveles de xCT están elevados en ratas sometidas a isquemia, lo cual subraya su importancia en el proceso de ictus.



La liberación de glutamato contribuye al daño isquémico


Extrasynaptic glutamate release through cystine/glutamate antiporter contributes to ischemic damage.
Soria FN, Pérez-Samartín A, Martin A, Gona KB, Llop J, Szczupak B, Chara JC, Matute C, Domercq M.
J Clin Invest. 2014 Aug 1;124(8):3645-55. doi: 10.1172/JCI71886. Epub 2014 Jul 18.
Abstract
During brain ischemia, an excessive release of glutamate triggers neuronal death through the overactivation of NMDA receptors (NMDARs); however, the underlying pathways that alter glutamate homeostasis and whether synaptic or extrasynaptic sites are responsible for excess glutamate remain controversial. Here, we monitored ischemia-gated currents in pyramidal cortical neurons in brain slices from rodents in response to oxygen and glucose deprivation (OGD) as a real-time glutamate sensor to identify the source of glutamate release and determined the extent of neuronal damage. Blockade of excitatory amino acid transporters or vesicular glutamate release did not inhibit ischemia-gated currents or neuronal damage after OGD. In contrast, pharmacological inhibition of the cystine/glutamate antiporter dramatically attenuated ischemia-gated currents and cell death after OGD. Compared with control animals, mice lacking a functional cystine/glutamate antiporter exhibited reduced anoxic depolarization and neuronal death in response to OGD. Furthermore, glutamate released by the cystine/glutamate antiporter activated extrasynaptic, but not synaptic, NMDARs, and blockade of extrasynaptic NMDARs reduced ischemia-gated currents and cell damage after OGD. Finally, PET imaging showed increased cystine/glutamate antiporter function in ischemic rats. Altogether, these data suggest that cystine/glutamate antiporter function is increased in ischemia, contributing to elevated extracellular glutamate concentration, overactivation of extrasynaptic NMDARs, and ischemic neuronal death.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4109556/pdf/JCI71886.pdf




http://www.jci.org/articles/view/71886/pdf


Atentamente
Anestesiología y Medicina del Dolor
www.anestesia-dolor.org

domingo, 12 de octubre de 2014

Valoración preoperatoria/Preoperative testing

¿Deberían todos los pacientes tiener un ECG de reposo de 12 derivaciones antes de la cirugía electiva no cardiaca?


Should all patients have a resting 12-lead ECG before elective noncardiac surgery?
Sharma P, Dhungel S, Prabhakaran A.
Clev Clin J Med October 2014
http://www.ccjm.org/content/81/10/594.full.pdf+html

Valoración preoperatoria. De las pruebas de rutina a la investigación individualizada


Preoperative risk assessment--from routine tests to individualized investigation.
Böhmer AB1, Wappler F, Zwissler B.
Dtsch Arztebl Int. 2014 Jun 20;111(25):437-45; quiz 446. doi: 10.3238/arztebl.2014.0437.
Abstract
BACKGROUND:Risk assessment in adults who are about to undergo elective surgery (other than cardiac and thoracic procedures) involves history-taking, physical examination, and ancillary studies performed for individual indications. Further testing beyond the history and physical examination is often of low predictive value for perioperative complications.METHOD:
This review is based on pertinent articles that were retrieved by a selective search in the Medline and Cochrane Library databases and on the consensus-derived recommendations of the German specialty societies. RESULTS:The history and physical examination remain the central components of preoperative risk assessment. Advanced age is not, in itself, a reason for ancillary testing. Laboratory testing should be performed only if relevant organ disease is known or suspected, or to assess the potential side effects of pharmacotherapy. Electrocardiography as a screening test seems to add little relevant information, even in patients with stable heart disease. A chest X-ray should be obtained only if a disease is suspected whose detection would have clinical consequences in the perioperative period. CONCLUSION:In preoperative risk assessment, the history and physical examination are the strongest predictors of perioperative complications. Ancillary tests are indicated on an individual basis if the history and physical examination reveal that significant disease may be present.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4095591/pdf/Dtsch_Arztebl_Int-111-0437.pdf


Beneficios y daño de las pruebas preoperatorias de rutina. Efectividad comparativa


Benefits and Harms of Routine Preoperative Testing: Comparative Effectiveness [Internet].
Editors Balk EM, Earley A, Hadar N, Shah N, Trikalinos TA.
Rockville (MD): Agency for Healthcare Research and Quality (US); 2014 Jan. Report No.: 14-EHC009-EF. AHRQ Comparative Effectiveness Reviews.

Excerpt

OBJECTIVES:Preoperative testing is used to guide the action plan for patients undergoing surgical and other procedures that require anesthesia and to predict potential postoperative complications. There is uncertainty whether routine or per-protocol testing in the absence of a specific indication prevents complications and improves outcomes, or whether it causes unnecessary delays, costs, and harms due to false-positive results.DATA SOURCES:We searched MEDLINE® and Ovid Healthstar® (from inception to July 22, 2013), as well as Cochrane Central Trials Registry and Cochrane Database of Systematic Reviews.REVIEW METHODS:We included comparative and cohort studies of both adults and children undergoing surgical and other procedures requiring either anesthesia or sedation (excluding local anesthesia). We included all preoperative tests that were likely to be conducted routinely (in all patients) or on a per-protocol basis (in selected patients). For comparative studies, the comparator of interest was either no testing or ad hoc testing done at the discretion of the clinician. We also looked for studies that compared routine and per-protocol testing. The outcomes of interest were mortality, perioperative events, complications, patient satisfaction, resource utilization, and harms related to testing.RESULTS:Fifty-seven studies (14 comparative and 43 cohort) met inclusion criteria for the review. Well-conducted randomized controlled trials (RCTs) of cataract surgeries suggested that rout
i ne testing with electrocardiography, complete blood count, and/or a basic metabolic panel did not affect procedure cancellations (2 RCTs, relative risks [RRs] of 1.00 or 0.97), and there was no clinically important difference for total complications (3 RCTs, RR = 0.99; 95% confidence interval, 0.86 to 1.14). Two RCTs and six nonrandomized comparative studies of general elective surgeries in adults varied greatly in the surgeries and patients included, along with the routine or per-protocol tests used. They also mostly had high risk of bias due to lack of adjustment for patient and clinician factors, making their results unreliable. Therefore, they yielded insufficient evidence regarding the effect of routine or per-protocol testing on complications and other outcomes. There was also insufficient evidence for patients undergoing other procedures. No studies reported on quality of life, patient satisfaction, or harms related to testing. CONCLUSIONS:There is high strength of evidence that, for patients scheduled for cataract surgery, routine preoperative testing has no effect on total perioperative complications or procedure cancellation. There is insufficient evidence for all other procedures and insufficient evidence comparing routine and per-protocol testing. There is no evidence regarding quality of life or satisfaction, resource utilization, or harms of testing and no evidence regarding other factors that may affect the balance of benefits and harms. The findings of the cataract surgery studies are not reliably applicable to other patients undergoing other higher risk procedures. Except arguably for cataract surgery, numerous future adequately powered RCTs or well-conducted and analyzed observational comparative studies are needed to evaluate the benefits and harms of routine preoperative testing in specific groups of patients with different risk factors for surgical and anesthetic complications undergoing specific types of procedures and types of anesthesia.
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0063242/pdf/TOC.pdf



Atentamente
Anestesiología y Medicina del Dolor
www.anestesia-dolor.org

Cuidados paliativos/Palliative care

Acceso a Cuidados Paliativos y Control del dolor



Segundo Seminario Internacional "Hacia la Universalidad Efectiva del Sistema de Salud:

Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán"

México D. F. Octubre 13, 2014

http://tomateloapecho.org.mx/Pdfs/Agenda%20Foro%20131014%20(preliminar).pdf




Cuidados Paliativos
Atlas de Cuidados Paliativos en Latinoamérica 2012

http://cuidadospaliativos.org/atlas-de-cp-de-latinoamerica/

Cerrando la brecha de cáncer

http://isites.harvard.edu/fs/docs/icb.topic1063570.files//vision_en_conjunto.pdf

Código de buena práctica para el control del dolor oncológico
http://scielo.isciii.es/pdf/dolor/v18n2/especial.pdf

Evaluación de los cuidados paliativos. España

http://www.aeval.es/comun/pdf/evaluaciones/E26-ECP-SNS.pdf

Cuidados paliativos. México

http://www.cenetec.salud.gob.mx/descargas/gpc/CatalogoMaestro/445_GPC_Cuidados_paliativos/GER_Cuidados_Paliativosx1x.pdf


Papel y significancia de las enfermeras en el manejo de las transiciones al cuidado paliativo. Un estudio de calidad

The role and significance of nurses in managing transitions to palliative care: a qualitative study.
Kirby E, Broom A, Good P.
BMJ Open. 2014 Sep 30;4(9):e006026. doi: 10.1136/bmjopen-2014-006026.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4179576/pdf/bmjopen-2014-006026.pdf

Cuidado colaborativo en cáncer pulmonar de células no pequeñas. Papel del cuidado paliativo temprano
Collaborative Care in NSCLC; the Role of Early Palliative Care.
Howe M, Burkes RL.
Front Oncol. 2014 Jul 30;4:192. doi: 10.3389/fonc.2014.00192. eCollection 2014.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4115633/pdf/fonc-04-00192.pdf


Programas de control de cáncer en Asia Oriental. Evidencia desde la literaura internacional
Cancer control programs in East Asia: evidence from the international literature.
Moore MA.
J Prev Med Public Health. 2014 Jul;47(4):183-200. doi: 10.3961/jpmph.2014.47.4.183. Epub 2014 Jul 31.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4162122/pdf/jpmph-47-4-183.pdf


Atentamente
Anestesiología y Medicina del Dolor
www.anestesia-dolor.org

jueves, 9 de octubre de 2014

Errores diagnósticos y de tratamiento en cefalalgias trigeminales autonómicas y hemicrania continua. Revisión sistemática

Errores diagnósticos y de tratamiento en cefalalgias trigeminales autonómicas y hemicrania continua. Revisión sistemática


Diagnostic and therapeutic errors in trigeminal autonomic cephalalgias and hemicrania continua: a systematic review.
Viana M, Tassorelli C, Allena M, Nappi G, Sjaastad O, Antonaci F.
J Headache Pain. 2013 Feb 18;14(1):14. doi: 10.1186/1129-2377-14-14.
Abstract
Trigeminal autonomic cephalalgias (TACs) and hemicrania continua (HC) are relatively rare but clinically rather well-defined primary headaches. Despite the existence of clear-cut diagnostic criteria (The International Classification of Headache Disorders, 2nd edition - ICHD-II) and severaltherapeutic guidelines, errors in workup and treatment of these conditions are frequent in clinical practice. We set out to review all available published data on mismanagement of TACs and HC patients in order to understand and avoid its causes. The search strategy identified 22 published studies. The most frequent errors described in the management of patients with TACs and HC are: referral to wrong type of specialist, diagnostic delay, misdiagnosis, and the use of treatments without overt indication. Migraine with and without aura, trigeminal neuralgia, sinus infection, dental pain and temporomandibular dysfunction are the disorders most frequently overdiagnosed. Even when the clinical picture is clear-cut, TACs and HC are frequently not recognized and/or mistaken for other disorders, not only by general physicians, dentists and ENT surgeons, but also by neurologists and headache specialists. This seems to be due to limited knowledge of the specific characteristics and variants of these disorders, and it results in the unnecessary prescription of ineffective and sometimes invasive treatments which may have negative consequences for patients. Greater knowledge of and education about these disorders, among both primary care physicians and headache specialists, might contribute to improving the quality of life of TACs and HC patients.

http://www.thejournalofheadacheandpain.com/content/pdf/1129-2377-14-14.pdf



Atentamente
Anestesiología y Medicina del Dolor
www.anestesia-dolor.org

Hipotermia para neuroprotección/Hypothermia for neuroprotection

Hipotermia terapéutica para neuroprotección. Historia, mecanismos, riesgos y aplicaciones clínicas


Therapeutic hypothermia for neuroprotection: history, mechanisms, risks, and clinical applications.
Karnatovskaia LV1, Wartenberg KE2, Freeman WD3.
Neurohospitalist. 2014 Jul;4(3):153-63. doi: 10.1177/1941874413519802.
Abstract
The earliest recorded application of therapeutic hypothermia in medicine spans about 5000 years; however, its use has become widespread since 2002, following the demonstration of both safety and efficacy of regimens requiring only a mild (32°C-35°C) degree of cooling after cardiac arrest. We review the mechanisms by which hypothermia confers neuroprotection as well as its physiological effects by body system and its associated risks. With regard to clinical applications, we present evidence on the role of hypothermia in traumatic brain injury, intracranial pressure elevation, stroke, subarachnoid hemorrhage, spinal cord injury, hepatic encephalopathy, and neonatal peripartum encephalopathy. Based on the current knowledge and areas undergoing or in need of further exploration, we feel that therapeutic hypothermia holds promise in the treatment of patients with various forms of neurologic injury; however, additional quality studies are needed before its true role is fully known.
KEYWORDS:
clinical; clinical specialty; nervous system; neurocritical care; neurophysiology; techniques; trauma
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4056415/pdf/10.1177_1941874413519802.pdf



Atentamente
Anestesiología y Medicina del Dolor
www.anestesia-dolor.org

miércoles, 8 de octubre de 2014

Los principales temas en 2013 de anestesia cardiotorácica y vascular y terapia intensiva

Los principales temas en 2013 de anestesia cardiotorácica y vascular y terapia intensiva


Major themes for 2013 in cardiothoracic and vascular anaesthesia and intensive care.
Gutsche JT, Riha H, Patel P, Sahota GS, Valentine E, Ghadimi K, Silvay G, Augoustides JG.
Heart Lung Vessel. 2014;6(2):79-87.
Abstract
There has been significant progress throughout 2013 in cardiothoracic and vascular anaesthesia and intensive care. There has been a revolution in the medical and interventional management of atrial fibrillation. The medical advances include robust clinical risk scoring systems, novel oral anticoagulants, and growing clinical experience with a new antiarrhythmic agent. The interventional advances include left atrial appendage occlusion for stroke reduction, generalization of ablation techniques in cardiac surgery, thoracoscopic ablation techniques, and the emergence of the hybrid ablation procedure. Recent European guidelines have defined the organization and practice of two subspecialties, namely general thoracic surgery and grown-up congenital heart disease. The pivotal role of an effective multidisciplinary milieu is a central theme in both these clinical arenas. Theanaesthesia team features prominently in each of these recent guidelines aimed at harmonizing delivery of perioperative care for these patient cohorts across Europe. Web-Enabled Democracy-Based Consensus is a system that allows physicians worldwide to agree or disagree with statements and expert consensus meetings and has the potential to increase the understanding of global practice and to help clinicians better define research priorities. This "Democratic based medicine", firstly used to assess the interventions that might reduce perioperative mortality has been applied in 2013 to the setting of critically ill patient with acute kidney injury. These advances in 2013 will likely further improve perioperative outcomes for our patients.
KEYWORDS: European Society of Cardiology.; ablation therapy; anaesthesia team; apixaban; atrial fibrillation; bleeding; clinical risk scoring system; dabigatran; general thoracic surgery; grown-up congenital heart disease; guidelines; hybrid procedure; left atrial appendage occlusion; minimally invasive surgery; multidisciplinary milieu; novel oral anticoagulants; rivaroxaban; stroke; vernakalant
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4095834/pdf/hlv-06-079.pdf



Atentamente
Anestesiología y Medicina del Dolor
www.anestesia-dolor.org

Enfermedad Meconial

Estimado Pediatra te invito al Seminario de Pediatría, Cirugía Pediátrica y Lactancia Materna. El día 8o de Octubre 2014 las 21hrs (Centro, México DF, Guadalajara y Lima Perú) a la Conferencia: “Enfermedad Meconial” por el “Dr. Arnulfo Gonzalez Farias”, Cirujano Pediatra de la Cd. de Monclova Coah. La sesión inicia puntualmente las 21 hrs.
Para entrar a la Sala de Conferencia:
1.- hacer click en la siguiente liga, o cópiala y escríbela en tu buscador http://connectpro60196372.adobeconnect.com/ileo_meconial/
2.- “Entra como Invitado” Escribes tu nombre y apellido en el espacio en blanco
3.- Hacer click en el espacio que dice “Entrar en la Sala”
5.- A disfrutar la conferencia 6.- Recomendamos que dejes tu Nombre Completo, Correo electrónico y que participes.


Henrys




Dr. Enrique Mendoza López
Webmaster: CONAPEME
Coordinador Nacional: Seminario Ciberpeds-Conapeme
Av La clinica 2520-310
Colonia Sertoma ,Mty N.L. México
CP 64710
Tel-Fax 52 81 83482940 y 52 81 81146053
Celular 8183094806
www.conapeme.org
www.pediatramendoza.com
enrique@pediatramendoza.com
emendozal@yahoo.com.mx