Eclampsia-Preeclampsia

Evolución perinatal en eclampsia Perinatal outcome in eclampsia. Khuman V, Singh RL, Singh RM, Devi UA, Kom T. J Med Soc 2015;29:12-5 Abstract Introduction: Eclampsia is a major cause for perinatal morbidity and mortality worldwide and perinatal outcome is much worse in developing countries even today. The reasons are multi-fold and may be because eclampsia is poorly managed and not up to the prescribed standards as in industrialized countries. Also prematurity usually iatrogenic one is a major cause for high perinatal morbidity and mortality in eclampsia due to non-availability and of neonatal intensive care unit (NICU) facilities. Materials and Methods: All eclampsia patients admitted to the antenatal ward in JIPMER from October 2009 to May 2011 were followedup. The pregnancy outcome was duly recorded and analyzed. Results: Majority of the patients were unbooked, young and primigravida. Majority (65%) of women required labor induction in one or more forms. In the study 20% of cases required cesarean section for delivery. Sixty percent of the cases were preterm deliveries and 44% required NICU admissions. There were 52 (17.2%) stillbirths. There were a total of 16 neonatal deaths; mostly due to prematurity (62.5%). The perinatal mortality rate is 231 per 1000 births. Hundred babies had birth weights <1.5kg; and 212 babies less than 2.5 kg. Average birth weight was 1.825kg, which is much lesser than the institutional Average birth weight. of 2.88 kg during the same period. Prematurity was the most common cause for NICU admissions as well as neonatal deaths. Conclusions: Majority (65%) of the cases required induction of labor and only 23% went into spontaneous labor. Twenty percent of eclamptic women required cesarean delivery. Major indication for caesarean section as anticipated was fetal distress. Most common cause for neonatal death was prematurity and its attendant complications. Keywords: Eclampsia, Neonatal deaths, Perinatal morbidity, Prematurity PDF Evolución materna y fetal en pre-eclampsia en un hospital de segundo nivel en el sur de India Maternal and fetal outcome in pre-eclampsia in a secondary care hospital in South India. Aabidha PM, Cherian AG, Paul E, Helan J. J Family Med Prim Care. 2015 Apr-Jun;4(2):257-60. doi: 10.4103/2249-4863.154669. Abstract BACKGROUND: Hypertensive disorders in pregnancy are one of the common causes for perinatal and maternal morbidity and mortality in developing countries. Pre-eclampsia is a condition which typically occurs after 20 weeks of gestation and has high blood pressure as the main contributing factor. The aim was to study the effects of pre-eclampsia on the mother and the fetus in rural South Indian population. MATERIALS AND METHODS: This was a descriptive study conducted in a secondary level hospital in rural South India. A total of 1900 antenatal women were screened for pre-eclampsia during the period August 2010 to July 2011 to study the effects on the mother and fetus. RESULTS: Of the 1900 women screened 93 were detected with pre-eclampsia in the study. Among these, 46.23% were primigravida, 30.1% belonged to socio-economic class 4 and 48.8% were among those with BMI 26-30. The incidence of severe pre-eclampsia was higher in the unregistered women. The most common maternal complication was antepartum hemorrhage (13.9%) and the most common neonatal complication was prematurity (23.65%). CONCLUSIONS: Treating anemia and improving socioeconomic status will improve maternal and neonatal outcome in pre-eclampsia. Antenatal care and educating women on significance of symptoms will markedly improve perinatal morbidity and mortality. Prematurity, growth restriction and low birth weight are neonatal complications to be anticipated and dealt with when the mother has pre-eclampsia. A good neonatal intensive care unit will help improve neonatal outcomes. KEYWORDS: Fetal outcome; maternal outcome; pre-eclampsia PDF

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Sedación/Sedation

Guías para el uso seguro de sedación y analgesia en procedimientos diagnósticos y terapéuticos en adultos: 2010 Guidelines for the safe use of procedural sedation and analgesia for diagnostic and therapeutic procedures in adults: 2010 PDF  Comparación de los efectos de ketamina, ketamina-dexmedetomidina y ketamina -midazolam en los pacientes quemados sometidos a cambios de apósitos Comparison of effects of ketamine, ketamine-dexmedetomidine and ketamine-midazolam on dressing changes of burn patients. Gunduz M, Sakalli S, Gunes Y, Kesiktas E, Ozcengiz D, Isik G. J Anaesthesiol Clin Pharmacol. 2011 Apr;27(2):220-4. doi: 10.4103/0970-9185.81823. Abstract OBJECTIVE: The aim of this randomized, controlled study was to compare the sedoanalgesic effects of ketamine-dexmedetomidine and ketamine-midazolam on dressing changes of burn patients. MATERIALS AND METHODS: Following Ethics Committee approval and informed patient consent, 90 ASA physical statuses I and II adult burn patients were included in the study. Patients were randomly divided into three groups. Ten minutes before dressing change, the dexmedetomidine group (group KD) (n = 30) received a continuous infusion of dexmedetomidine at a rate of 1 μg kg(-1), the midazolam group (group KM) (n = 30) received a continuous infusion of midazolam at a rate of 0.05 mg kg(-1) and the saline group (group KS) (n = 30) received a continuous infusion of saline intravenously. One minute before dressing change, each patient was administered 1 mg kg(-1) ketamine intravenously. Hemodynamic variables, pain and sedation scores, the number of patients requiring additional ketamine, time to dressing change and recovery time were recorded. RESULTS: Systolic blood pressure (SBP) values were significantly lower at, before and after ketamine administration; and 5, 10 and 15 minutes after the procedure in group KD in comparison with the other groups (P <0.05). There was no significant difference in pain scores among the groups during the study period. Sedation scores were significantly higher in group KD than in groups KM and KS at the end of the first hour (P <0.05). Time to dressing change and recovery time were similar in all the groups. CONCLUSION: In burn patients undergoing dressing changes, although both combinations ketamine-dexmedetomidine and ketamine-midazolam offered an effective sedoanalgesia without causing any significant side effect, the former resulted in higher sedation and lower hemodynamic discrepancy. KEYWORDS: Burn; dexmedetomidine; dressing changes; ketamine; midazolam PDF Dexmedetomidina vs sedación estándar con propofol o midazolam en UCI. Evaluación económica Dexmedetomidine versus standard care sedation with propofol or midazolam in intensive care: an economic evaluation. Turunen H1, Jakob SM2, Ruokonen E3, Kaukonen KM4,5, Sarapohja T6, Apajasalo M7, Takala J8. Crit Care. 2015 Feb 19;19:67. doi: 10.1186/s13054-015-0787-y. Abstract INTRODUCTION: Dexmedetomidine was shown in two European randomized double-blind double-dummy trials (PRODEX and MIDEX) to be non-inferior to propofol and midazolam in maintaining target sedation levels in mechanically ventilated intensive care unit (ICU) patients. Additionally, dexmedetomidine shortened the time to extubation versus both standard sedatives, suggesting that it may reduce ICU resource needs and thus lower ICU costs. Considering resource utilization data from these two trials, we performed a secondary, cost-minimization analysis assessing the economics of dexmedetomidine versus standard care sedation. METHODS: The total ICU costs associated with each study sedative were calculated on the basis of total study sedative consumption and the number of days patients remained intubated, required non-invasive ventilation, or required ICU care without mechanical ventilation. The daily unit costs for these three consecutive ICU periods were set to decline toward discharge, reflecting the observed reduction in mean daily Therapeutic Intervention Scoring System (TISS) points between the periods. A number of additional sensitivity analyses were performed, including one in which the total ICU costs were based on the cumulative sum of daily TISS points over the ICU period, and two further scenarios, with declining direct variable daily costs only. RESULTS: Based on pooled data from both trials, sedation with dexmedetomidine resulted in lower total ICU costs than using the standard sedatives, with a difference of €2,656 in the median (interquartile range) total ICU costs-€11,864 (€7,070 to €23,457) versus €14,520 (€7,871 to €26,254)-and €1,649 in the mean total ICU costs. The median (mean) total ICU costs with dexmedetomidine compared with those of propofol or midazolam were €1,292 (€747) and €3,573 (€2,536) lower, respectively. The result was robust, indicating lower costs with dexmedetomidine in all sensitivity analyses, including those in which only direct variable ICU costs were considered. The likelihood of dexmedetomidine resulting in lower total ICU costs compared with pooled standard care was 91.0% (72.4% versus propofol and 98.0% versus midazolam). CONCLUSIONS: From an economic point of view, dexmedetomidine appears to be a preferable option compared with standard sedatives for providing light to moderate ICU sedation exceeding 24 hours. The savings potential results primarily from shorter time to extubation. PDF Opciones de sedación para el paciente con obesidad mórbida en UCI. Encuesta concisa y una agenda para el desarrollo. Sedation options for the morbidly obese intensive care unit patient: a concise survey and an agenda for development. Aantaa R, Tonner P, Conti G, Longrois D, Mantz J, Mulier JP. Multidiscip Respir Med. 2015 Mar 7;10(1):8. doi: 10.1186/s40248-015-0007-2. eCollection 2015. Abstract BACKGROUND: We offer some perspectives and commentary on the sedation of obese patients in the intensive care unit (ICU). DISCUSSION: Sedation in morbidly obese patients should conform to the same broad principles now current in ICU practice. These include a general presumption against benzodiazepines as first-line agents. Opioids should be avoided in any situation where spontaneous breathing is required. Remifentanil is the preferred agent where continuous stable opioid levels using an infusion are required, because of its lack of context-sensitive accumulation. Volatile anaesthetics may be an option for the same reason but there are no substantial, controlled demonstrations of effectiveness/safety in short-term use in the ICU setting. Propofol is a valuable resource in the morbidly obese patients but the duration of continuous sedation should not exceed 6 days, in order to avoid propofol infusion syndrome. Alpha-2 agonists offer a range of theoretically positive features for the sedation of morbidly obese patients, but at present there is a lack of pharmacokinetic data and a critical mass of high-grade clinical data. Dexmedetomidine has the attraction of not causing respiratory depression or obstructive breathing during sedation and its sympatholytic effects should help deliver stable blood pressure and heart rate. Ketamine has a poor tolerability profile in adults so its use in the ICU context is largely confined to paediatrics. CONCLUSION: None of the agents currently available is ideal for every situation encountered in the management of morbidly obese patients. This article identifies additional research needed to place sedation practice of obese patients on a more systematic footing. KEYWORDS: Benzodiazepines; Clonidine; Dexmedetomidine; Intensive care; Ketamine; Obesity; Opioids; Propofol; Sedation; Volatile anaesthetics PDF

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Ketofol

Combinación de ketamina y propofol (Ketofol) para sedación y analgesia en procedimientos en el departamento de emergencias. Revisión Combining ketamine and propofol ("ketofol") for emergency department procedural sedation and analgesia: a review. Arora S. West J Emerg Med. 2008 Jan;9(1):20-3. PDF Comparación de ketamina-midazolam y ketofol para sedación en aspiración transbronquial guiada por ultrasonido. Estudio prospectivo, ciego y aleatorizado A comparison of ketamine-midazolam and ketamine-propofol combinations used for sedation in the endobronchial ultrasound-guided transbronchial needle aspiration: a prospective, single-blind, randomized study. Dal T, Sazak H, Tunç M, Sahin S, Yılmaz A. J Thorac Dis. 2014 Jun;6(6):742-51. doi: 10.3978/j.issn.2072-1439.2014.04.10. Abstract OBJECTIVE: We aimed to compare the effectiveness and safety of ketamine-midazolam and ketamine-propofol combinations for procedural sedation in endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA). METHODS: Sixty patients who were undergoing EBUS-TBNA were included in this study. Patients were randomly divided into two groups. Group 1 was given 0.25 mg/kg intravenous (iv) ketamine, 2 min later than 0.05 mg/kg iv midazolam. Group 2 received 0.125 mg/kg ketamine-propofol mixture (ketofol), 2 min subsequent to injection of 0.25 mg/kg each. Sedation was maintained with additional doses of ketamine 0.25 mg/kg, and ketofol0.125 mg/kg each in Group 1 and Group 2, respectively. Blood pressure, heart rate (HR), peripheral oxygen saturation, respiratory rate (RR), Ramsay Sedation Score (RSS), and severity of cough were recorded prior to and after administration of sedation agent in the beginning of fiberoptic bronchoscopy (FOB) and every 5 min of the procedure. The consumption of the agents, the satisfactions of the bronchoscopist and the patients, and the recovery time were also recorded. RESULTS: HR in the 10(th) min and RSS value in the 35(th) min of induction in Group 1 were higher than the other group (P<0.05). The recovery time in Group 1 was statistically longer than Group 2 (P<0.05). There was no statistically significant difference between groups with respect to other parameters (P>0.05). CONCLUSIONS:It was concluded that both ketamine-midazolam and ketamine-propofol combinations for sedation during EBUS-TBNA were similarly effective and safe without remarkable side effects. KEYWORDS:Transbronchial needle aspiration (TBNA); ketamine; midazolam; propofol; sedation PDF Simulaciones Ketofol para dosificación en anestesia pediátrica. Ketofol simulations for dosing in pediatric anesthesia. Coulter FL, Hannam JA, Anderson BJ. Paediatr Anaesth. 2014 Aug;24(8):806-12. doi: 10.1111/pan.12386. Epub 2014 Mar 26. Abstract BACKGROUND: Propofol mixed with racemic ketamine (or 'ketofol') is popular for short procedural sedation and analgesia. Use is creeping into anesthesia, yet neither the optimal combination nor infusion rate is known. The EC(50) of propofol's antiemetic effect is reported to be 0.343 mg*l(-1), while ketamine analgesia is thought to persist with concentrations above 0.2 mg*l(-1). We aimed to determine a ketofol dosing regimen for anesthesia 30-min and 1.5-h duration in a healthy child that did not unduly compromise recovery. METHODS: Pharmacokinetic-pharmacodynamic parameters were used to simulate drug concentration and effect profiles over time for different ratios of propofol to ketamine ratios (1 : 1 to 10 : 1) and rates. The target effect was the 95% probability of loss of response to a 5-s transcutaneous tetanus (P05). Combined effects were additive, with a propofol EC(50) of 3.1 mg*l(-1), ketamine EC(50) of 0.64 mg*l(-1), and slope of 5.4. The time to predicted 50% probability of return of this response after ceasing infusion (P(50)) was determined for a 5-year-old 20-kg healthy child. RESULTS: The addition of ketamine to propofol infused using a manual infusion regimen (loading dose 3 mg*kg(-1), then 15 mg*kg(-1) *h(-1) for 15 min, 13 mg*kg(-1) *h(-1) for 15 min, 11 mg*kg(-1) *h(-1) for 30 min, and 10 mg*kg(-1) *h(-1) for 1-2 h) caused prolonged postoperative sedation. The P(50) after a 1.5-h infusion using a 1 : 1 mixture was 4.5 h, 2 : 1 mixture was 3.25 h, 5 : 1 mixture was 1.6 h, and 10 : 1 mixture was 40 min. These P(50) estimates could be reduced by slowing administration infusion rates to 20%, 33%, 50%, 67%, 80%, and 90% for mixtures 1 : 1, 2 : 1, 3 : 1, 5 : 1, 6.7 : 1, and 10 : 1, respectively. These rates achieve a P(50) of approximately 20 min for 30-min duration anesthesia and 60 min for 1.5-h duration anesthesia. CONCLUSIONS: The addition of ketamine to propofol infusion will prolong recovery unless infusion rates are decreased. We suggest an optimal ratio of racemic ketamine to propofol of 1 : 5 for 30-min anesthesia and 1 : 6.7 for 90-min anesthesia. Delivery of these ratios achieves propofol concentrations above an antiemetic threshold for longer than the ketamine concentration above the analgesic threshold during, potentially reducing postoperative nausea incidence. KEYWORDS: anesthesia; ketamine; pediatric; pharmacodynamics; pharmacokinetics; propofol; sedation; target concentration PDF Ketofol para la inducción del paciente grave versus etomidato (Ensayo KEEP PACE). Protocolo de estudio para un ensayo aleatorizado y controlado Ketamine/propofol admixture (ketofol) at induction in the critically ill against etomidate (KEEP PACE trial): study protocol for a randomized controlled trial. Smischney NJ, Hoskote SS, Gallo de Moraes A, Racedo Africano CJ, Carrera PM, Tedja R, Pannu JK, Hassebroek EC, Reddy DR, Hinds RF,Thakur L. Trials. 2015 Apr 21;16(1):177. doi: 10.1186/s13063-015-0687-0. Abstract BACKGROUND: Endotracheal intubation (ETI) is commonly performed as a life-saving procedure in the intensive care unit (ICU). It is often associated with significant hemodynamic perturbations and can severely impact the outcome of ICU patients. Etomidate is often chosen by many critical care providers for the patients who are hypotensive because of its superior hemodynamic profile compared to other induction medications. However, recent evidence has raised concerns about the increased incidence of adrenal insufficiency and mortality associated with etomidate use. A combination of ketamine and propofol (known as ketofol) has been studied in various settings as an alternative induction agent. In recent years, studies have shown that this combination may provide adequate sedation while maintaining hemodynamic stability, based on the balancing of the hemodynamic effects of these two individual agents. We hypothesized that ketofol may offer a valuable alternative to etomidate in critically ill patients with or without hemodynamic instability. METHODS/DESIGN: A randomized controlled parallel-group clinical trial of adult critically ill patients admitted to either a medical or surgical ICU at Mayo Clinic in Rochester, MN will be conducted. As part of planned emergency research, informed consent will be waived after appropriate community consultation and notification. Patients undergoing urgent or emergent ETI will receive either etomidate or a 1:1 admixture of ketamine and propofol (ketofol). The primary outcome will be hemodynamic instability during the first 15 minutes following drug administration. Secondary outcomes will include ICU length of stay, mortality, adrenal function, ventilator-free days and vasoactive medication use, among others. The planned sample size is 160 total patients. DISCUSSION: The overall goal of this trial is to assess the hemodynamic consequences of a ketamine-propofol combination used in critically ill patients undergoing urgent or emergent ETI compared to etomidate, a medication with an established hemodynamic profile. The trial will address a crucial gap in the literature regarding the optimal induction agent for ETI in patients that may have potential or established hemodynamic instability. Greater experience with planned emergency research will, hopefully, pave the way for future prospective randomized clinical trials in the critically ill population. PDF Ketofol: combinación de ketamina y propofol Ketofol: A combination of ketamine and propofol Amornyotin S J Anesth Critical Care: Open Access 2014:1(5) PDF

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Propofol / Imagen del Mes/ Image of the month

Propofol. Ver galerí­a completa

Mujer de 65 años, 86.6 kg, talla 252 cm, ASA 2, obesa, con la pared abdominal péndula, que se sometió a abdominoplastia de pubis hasta xifoides. La analgesia se proporciona con 3 litros de solución tumescente (lidocaína 500 mg + 1000 mg de epinefrina/litro. Lidocaína total 1500 mg igual a 17.3 mg/kg) y 50 mg i.v. de ketamina. La paciente se fue monitorizada con ECG, presión arterial no invasiva, oximetría de pulso y BIS/EMG. Una bolsa de 1000 mL de solución i.v. se colocó bajo los hombros para aumentar la tensión en el músculo geniogloso y facilitar el mantenimiento de la vía aérea. Se utilizaron oxígeno nasal 2 litros/min y ketamina i.v. 50 mg 3 minutos antes de la infiltración de la pared abdominal. El nivel estable cerebral de propofol pre-ketamina fue facilitado con inducción de propofol con incrementos de 50 µg/kg titulados a 60 <BIS <75 con la línea base EMG. (Ver You Tube Going under with Goldilocks anesthesia). La sedación se continuó con propofol en bomba de infusión ajustado a 50 µg/kg/min) para tener 60 <BIS <75. Los picos en el EMG fueron tratados con 400 µg/kg de propofol hasta que el EMG regresó a la línea de base. La analgesia postoperatoria con 25 mL de bupivacaína 0.25% inyectada a través de cada uno de los tubos de drenaje, total de 125 mg (50 mL). Imágenes cortesía del Dr. Barry Friedberg     http://drfriedberg.com/  Women 65 years old, 191lbs, ASA 2, obese, with pendulous abdominal wall, which underwent pubis to xiphoid abdominoplasty. Analgesia was provided with 3 liters tumescent solution (lidocaine 500 mg + 1000 µg epinephrine/each liter. Total lidocaine 1500 mg equal to 17.3 mg/kg) and 50 mg i.v. ketamine. She was monitored with ECG, NIBP, pulse oximetry and BIS/EMG. A 1000 mL i.v. solution bag was placed under her shoulders to increase tension in the genioglossus muscle and facilitate the maintenance of the airway. Nasal oxygen 2 L/min and i.v. ketamine 50 mg 3 minutes prior to infiltration of the abdomen wall were used. Stable pre-ketamine propofol brain level was facilitated by incremental propofol induction @ 50 mcg/kg titrated to 60<BIS<75 with baseline EMG. (See You Tube Going under with Goldilocks) Sedation was continued with infusion pump propofol set to 50 mcg /kg/min) to have 60<BIS<75. EMG spikes were treated with 400 mcg/kg propofol until EMG returned to baseline. Postoperative analgesia with bupivacaine 0.25% 25 mL injected through each drain, total 125 mg (50 mL). Images courtesy of Barry Firedberg MD.     http://drfriedberg.com/  Propofol en cirugía Plástica "de consultorio" Propofol in office-based plastic surgery. Friedberg BL. Semin Plast Surg. 2007 May;21(2):129-32. doi: 10.1055/s-2007-979214. Abstract Propofol is the nearly ideal agent for office-based plastic surgery. Among all anesthetic agents, only propofol has the ability to elicit happiness in this special group of patients. Cosmetic surgery patients will tolerate discomfort in preference to postoperative nausea and vomiting. Propofol is a powerful antiemetic agent. Patient safety will not be optimized unless the person responsible for the administration of propofol has airway management skills. Dedicated anesthesia providers are highly skilled in airway management. Although the short half-life of propofol is seductive for a fast-acting, rapid emerging anesthetic, interindividual differences in propofol response make measurement of the target organ (i.e., the brain) with a bispectral index (BIS) monitor very important. BIS levels < 45 for > 1 hour are associated with increased 1-year anesthesia mortality thought to be associated with an inflammatory response. The only currently available way to avoid overmedicating with propofol is to monitor with a level of consciousness monitor like BIS. KEYWORDS: BIS monitor; Propofol; anesthesia; ketamine; office-based plastic surgery PDF Anestesia disociativa para cirugía plástica en el ¨consultorio¨ Dissociative anesthesia in an office-based plastic surgery practice. Vinnik CA. Semin Plast Surg. 2007 May;21(2):109-14. doi: 10.1055/s-2007-979211. Abstract In 1974, the author began to use ketamine in association with diazepam for cosmetic and reconstructive procedures. Since then, through courses in the United States and abroad, well over a thousand plastic surgeons have been taught the technique. Ketamine, by itself, ablates sensory input of pain at the thalamic level but has been associated with hallucinations, bad dreams, and other untoward effects. These can be prevented by the use of benzodiazepines, which "bracket" the use of ketamine. If the patient is sedated and awakens under the influence of these agents, there is no adverse ketamine effect. Specific techniques and adjunct agents are described. KEYWORDS: Ketamine; Robinul®; Valium®; Versed®; dissociative anesthesia; fentanyl; midazolam PDF Protocolo con ketamina-diazepam para sedación intravenosa. Experiencia en el hospital de cirugía estética. Ketamine-diazepam protocol for intravenous sedation: The cosmetic surgery hospital experience. Quttainah A, Carlsen L, Voice S, Taylor J. Can J Plast Surg. 2004 Fall;12(3):141-3. Abstract Rising hospital costs and operating room scheduling difficulties have influenced plastic surgeons to rely more often on intravenous sedation in office surgical settings. The use of ketamine as an intravenous sedation agent has enjoyed some popularity, but this has been far from universal. Its reputation for producing psychological sequelae such as nightmares, flashbacks and schizophrenic-like reactions have made many anesthesiologists and plastic surgeons reluctant to use this drug. The authors' experience using a ketamine/diazepam protocol with approximately 11,400 patients since 1971 at the Cosmetic Surgery Hospital in Woodbridge, Ontario is presented. The methodology consists of intravenous diazepam followed with low-dose ketamine (0.5 mg/kg to a maximum of 40 mg) 2 min later. This provides the surgeon with a period of profound amnesia to allow for infiltration of the local anesthetic. It is this local anesthetic delivered during the dissociative state that provides prolonged analgesia throughout thesurgery. The patient is maintained throughout the procedure with increments of diazepam and midazolam. This protocol is found to be effective, reliable and reproducible, and the experience of the patient and plastic surgeon has been overwhelmingly favourable. KEYWORDS: Intravenous sedation; Ketamine; Office anesthesia PDF Procedimientos de sedación y analgesia para la cirugía de mama fuera del hospital: una visión general de la técnica de sedación y analgesia. Procedural sedation and analgesia for out-of-hospital breast surgery: an overview of the procedural sedation and analgesia technique Louw AJ, South Afr J Anaesth Analg 2014;20(1):89-92 Abstract Out-of-hospital surgical procedures are a rapidly growing market. This has led to surgical procedures that were previously limited to the hospital operating room, with general anaesthesia being performed outside the hospital with sedation and regional anaesthesia. Breast surgery, whether cosmetic, reconstructive or diagnostic, also follows this trend. The aim of this refresher course is to give an overview of the nerve supply to the breast, to explain the type of blocks used and to provide an overview of the sedation technique. The audience should have a better acceptance of performing procedural sedation and analgesia (PSA) for this type of surgery out of hospital after this overview. The author will also provide an overview during the presentation of his own current practice of performing these procedures. PDF Consejos de expertos Tips from the tops Barry Friedberg PDF Videoclips sobre propofol y anestesia Videos on propofol and anesthesia Videos

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PRURITO / PRURITUS

El receptor H4 de histamina: del huérfano a la clínica. The histamine H4 receptor: from orphan to the clinic. Thurmond RL. Front Pharmacol. 2015 Mar 31;6:65. doi: 10.3389/fphar.2015.00065. eCollection 2015. Abstract The histamine H4 receptor (H4R) was first noted as a sequence in genomic databases that had features of a class A G-protein coupled receptor. This putative receptor was found to bind histamine consistent with its homology to other histamine receptors and thus became the fourth member of the histamine receptor family. Due to the previous success of drugs that target the H1 and H2 receptors, an effort was made to understand the function of this new receptor and determine if it represented a viable drug target. Taking advantage of the vast literature on the function of histamine, a search for histamine activity that did not appear to be mediated by the other three histamine receptors was undertaken. From this asthma andpruritus emerged as areas of particular interest. Histamine has long been suspected to play a role in the pathogenesis of asthma, but antihistamines that target the H1 and H2 receptors have not been shown to be effective for this condition. The use of selective ligands in animal models of asthma has now potentially filled this gap by showing a role for the H4R in mediating lung function and inflammation. A similar story exists for chronicpruritus associated with conditions such as atopic dermatitis. Antihistamines that target the H1 receptor are effective in reducing acute pruritus, but are ineffective in pruritus experienced by patients with atopic dermatitis. As for asthma, animal models have now suggested a role for the H4R in mediating pruritic responses, with antagonists of the H4R reducing pruritus in a number of different conditions. The anti-pruritic effect of H4R antagonists has recently been shown in human clinical studies, validating the preclinical findings in the animal models. A selective H4R antagonist inhibited histamine-induced pruritus in health volunteers and reduced pruritus in patients with atopic dermatitis. The history to date of the H4R provides an excellent example of the deorphanization of a novel receptor and the translation of this into clinical efficacy in humans. KEYWORDS: arthritis; asthma; atopic dermatitis; histamine; pruritus PDF Hidrocloruro de Nalfurafina para tratar el prurito. Una revisión Nalfurafine hydrochloride to treat pruritus: a review. Inui S. Clin Cosmet Investig Dermatol. 2015 May 11;8:249-55. doi: 10.2147/CCID.S55942. eCollection 2015. Abstract Uremic pruritus has a great negative influence on quality of life in hemodialysis (HD) patients and, importantly, negatively affects mortality risk. Recently, nalfurafine hydrochloride, an opioid κ-selective agonist, has been officially approved for resistant pruritus in HD patients on the basis of a well-evidenced clinical trial in Japan. From clinical observation, it has been suggested that the upper neuron system plays a role in its pathogenesis. According to previous experimental results, using mice injected with opioids, dynorphin suppresses itch through binding κ-opioid receptors, suggesting that κ-opioid opioid receptor agonists act as potential therapeutic reagents for pruritus in HD patients. In Japan, a large-scale placebo-controlled study was performed to examine the efficacy and safety of oral nalfurafine hydrochloride for intractable pruritus in 337 HD patients. Two daily doses of 2.5 or 5 μg nalfurafine or placebo were orally administered for 2 weeks, and clinical responses were analyzed. The results showed that the mean decrease in the visual analog scale for pruritus from baseline was 22 mm in the 5 μg nalfurafine hydrochloride group (n=114) and 23 mm in the 2.5 μg group (n=112). These reductions were statistically significant compared with 13 mm, which is the mean decrease of visual analog scale in the placebo group (n=111), demonstrating that nalfurafine is an effective and safe drug for uremic pruritus in HD patients. Moreover, another open-label trial (n=145) examining the long-term effect of 5 μg oral nalfurafine revealed the maintenance of the antipruritic effect of nalfurafine for 52 weeks. In addition, on the basis of recent data showing κ-opioid receptor expression in the epidermis of atopic dermatitis and psoriasis, nalfurafine hydrochloride also can be potentially used for these two skin diseases. KEYWORDS: hemodialysis; nalfurafine hydrochloride; opioid κ-selective agonist; uremic pruritus PDF Tratamiento del prurito en hepatopatias crónicas Management of pruritus in chronic liver disease. Bhalerao A, Mannu GS. Dermatol Res Pract. 2015;2015:295891. doi: 10.1155/2015/295891. Epub 2015 Mar 10. Abstract Background. There continues to be uncertainty on the ideal treatment of pruritus in chronic liver disease. The aim of this study was to gather the latest information on the evidence-based management of pruritus in chronic liver disease. Methodology. A literature search for pruritus in chronic liver disease was conducted using Pubmed and Embase database systems using the MeSH terms "pruritus," "chronic liver disease," "cholestatic liver disease," and "treatment." Results. The current understanding of the pathophysiology of pruritus is described in addition to detailing research into contemporary treatment options of the condition. These medical treatments range from bile salts, rifampicin, and opioid receptor antagonists to antihistamines. Conclusion. The burden of pruritus in liver disease patients persists and, although it is a common symptom, it can be difficult to manage. In recent years there has been greater study into the etiology and treatment of the condition. Nonetheless, pruritus remains poorly understood and many patients continue to suffer, reiterating the need for further research to improve our understanding of the etiology and treatment for the condition. PDF Medicamentos para el tratamiento del adulto en cuidado paliativo Drug treatments for pruritus in adult palliative care. Siemens W, Xander C, Meerpohl JJ, Antes G, Becker G. Dtsch Arztebl Int. 2014 Dec 12;111(50):863-70. doi: 10.3238/arztebl.2014.0863. Abstract BACKGROUND: Pruritus is a rare but troublesome symptom in palliative-care patients with a variety of underlying diseases. The pharmacotherapy ofpruritus is often off-label, and an evidence-based evaluation is needed. METHODS: A Cochrane Review published in 2013 was updated with a systematic literature search up to January 2014. Randomized and controlled trials (RCTs) with adult palliative-care patients were included. RESULTS: In the 43 RCTs that were analyzed, three of which were more recent than the Cochrane Review, 8 clinically relevant active substances were investigated in a total of 19 RCTs. Effective drugs for pruritus in palliative-care patients included paroxetine for pruritus of diverse origins (1 RCT; strong effect) and indomethacin for HIV-induced prutitus (1 RCT; median effect = moderate reduction). Effective drugs for pruritus in uremia were gabapentin (2 RCTs; strong effect), nalfurafin (3 RCTs; moderate effect), naltrexone (3 RCTs; heterogeneous effects, ranging from weak to strong), and cromoglicic acid (2 RCTs; moderate to strong effect). Effective drugs for cholestatic pruritus were rifampicin (3 RCTs; moderate effect), flumecinol (2 RCTs; weak to moderate effect), and naltrexone (2 RCTs; moderate to strong effect). Undesired effects were most common with naltrexone (dizziness: 0% -50% , http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4296209/pdf/Dtsch_Arztebl_Int-111-0863.pdf nausea: 0% -50% ) and nalfurafin (nasopharyngitis: 8% -12% , insomnia: 7% -15%). CONCLUSION: In view of the diverse etiologies of pruritus in palliative-care patients, careful consideration should be given to the choice of drug used to treat it. The substances listed here have moderate to strong antipruritic effects and merit further study in RCTs of high methodological quality. PDF

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El camino neuronal que conduce al placer

Fuente
Este artículo es originalmente publicado en:
http://www.madrimasd.org/informacionidi/noticias/noticia.asp?id=63914&origen=notiweb&dia_suplemento=lunes
mi+dtv: El camino neuronal que conduce al placer


Esta semana mi+dtv trata sobre la caracterización de los mecanismos neuronales que intervienen en la sensación del placer; los efectos beneficiosos de la vacuna contra el sarampión y los genes que regulan el tamaño de algunas frutas.

FUENTE | madri+d

Dexmedetomidina en cirugía ambulatoria/Dexmedetomidine in day case surgery

¿Es la dexmedetomidina mejor que la combinación de propofol y fentanil en casos de cirugía menor ambulatoria? Estudio prospectivo, aleatorizado y doble ciego Is dexmedetomidine better than propofol and fentanyl combination in minor day care procedures? A prospective randomised double-blind study. Tomar GS, Singh F, Ganguly S, Gaur N. Indian J Anaesth 2015;59:359-64 Abstract Background and Aims: The growing popularity and trend of day care (ambulatory) anaesthesia has led to the development of newer and efficient drug regimen. We decided to evaluate the efficacy of two drug regimens namely dexmedetomidine and propofol with midazolam and fentanyl for moderate sedation characteristics in minor surgical procedures in terms of analgesia, intra-operative sedation, haemodynamic stability and side effects related. Methods: Totally, 60 adult American Society of Anaesthesiologists class I-II patients posted for day care surgeries of duration <45 min divided into two groups; Group D, where dexmedetomidine loading dose at 1 μg/kg was administered over 10 min followed by maintenance infusion initiated at 0.6 μg/kg/h and titrated to achieve desired clinical effect with dose ranging from 0.2 to 0.7 μg/kg, Group P, where midazolam at 0.02 mg/kg and fentanyl at 2 μg/kg IV boluses were given followed by propofol infusion. Statistical analysis was done using student t-test, analysis of variance and Chi-square analysis. P < 0.05 was considered to be significant. Results:Degree of sedation (Observer's Assessment of Activity and Sedation Scale ≤3) was comparable in both groups (P > 0.05). Rescue analgesia with fentanyl was needed in 30% patients of Group D compared to 17.63% patients of Group P (P < 0.05). The level of arousal was faster and better in Group D at 5 min after the procedure (P < 0.05). Haemodynamics were stable in Group D as with Group P patients (P < 0.005). Dry mouth reported by 16.67% patients. Conclusion: Dexmedetomidine can be a useful adjuvant rather than the sole sedative-analgesic agent during minor surgeries and be a valuable alternative to propofol in terms of moderate sedation, haemodynamic stability with minimal transient side effects. Keywords: Day care, dexmedetomidine, fentanyl, moderate sedation, propofol PDF

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