Alergia a drogas y anestesia / Drugs allergy and anesthesia

Enero 4, 2016. No. 2196

Tendencias en las reacciones de hipersensibilidad: más drogas, más patrones de respuestas, más heterogeneidad Trends in hypersensitivity drug reactions: more drugs, more response patterns, more heterogeneity. Doña I, Barrionuevo E, Blanca-Lopez N, Torres MJ, Fernandez TD, Mayorga C, Canto G,Blanca M. J Investig Allergol Clin Immunol. 2014;24(3):143-53; quiz 1 p following 153. Abstract Hypersensitivity drug reactions (HDRs) vary over time in frequency, drugs involved, and clinical entities. Specific reactions are mediated by IgE, other antibody isotypes (IgG or IgM), and T cells. Nonspecific HDRs include those caused by nonsteroidal anti-inflammatory drugs (NSAIDs). beta-Lactams--the most important of which are amoxicillin and clavulanic acid--are involved in specific immunological mechanisms. Fluoroquinolones (mainly moxifloxacin, followed by ciprofloxacin and levofloxacin) can also induce HDRs mediated by IgE and T cells. In the case of radio contrast media, immediate reactions have decreased, while nonimmediate reactions, mediated by T cells, have increased. There has been a substantial rise in hypersensitivity reactions to antibiotics and latex in perioperative allergic reactions to anesthetics. NSAIDs are the most frequent drugs involved in HDRs. Five well-defined clinical entities, the most common of which is NSAID-induced urticaria/angioedema, have been proposed in a new consensus classification. Biological agents are proteins including antibodies that have been humanized in order to avoid adverse reactions. Reactions can be mediated by IgE or T cells or they may be due to an immunological imbalance. Chimeric antibodies are still in use and may have epitopes that are recognized by the immune system, resulting in allergic reactions. PDF Alergia clorhexidina perioperatoria: ¿Es en serio? Perioperative chlorhexidine allergy: Is it serious? Abdallah C. J Anaesthesiol Clin Pharmacol. 2015 Apr-Jun;31(2):152-4. doi: 10.4103/0970-9185.155140. Abstract Chlorhexidine is an antiseptic agent, commonly used, in many different preparations, and for multiple purposes. Despite its superior antimicrobial properties, chlorhexidine is a potentially allergenic substance. The following is a review of the current evidence-based knowledge of allergic reactions to chlorhexidine associated with surgical and interventional procedures. KEYWORDS: Allergy; anesthesia; chlorhexidine; complications; perioperative PDF Reacciones anafilácticas durante anestesia y en el periodo perioperatorio Anaphylactic reactions during anaesthesia and the perioperative period. Michalska-Krzanowska G. Anaesthesiol Intensive Ther. 2012 Aug 8;44(2):104-11. Abstract Allergy and hypersensitivity occurring during anaesthesia remains a major cause of concern for anaesthesiologists.Drugs administered during surgery and various anaesthetic procedures can elicit two major groups of adverse reactions. The first group includes reactions that are usually dose-dependent and related to the pharmacological properties of a drug and/or its metabolites. The remaining reactions are mostly related to hypersensitivity and allergic responses. They do not depend on specific pharmacology and are usually not dose-dependent.Anaphylaxis is among the most severe of immune-mediated reactions; it generally occurs following re-exposure to specific antigens and release of proinflamatory mediators. The commonest drugs responsible for intraoperative anaphylaxis are muscle relaxants, but latex also accounts for a significant number of incidents, and the frequency of intraoperative latex anaphylactic reactions is increasing. Multiple organ failure, beginning with bronchospasm and cardiovascular collapse, is typical of latex reactions. An increased serum tryptase concentration confirms the diagnosis of an anaphylactic reaction, and triggers can be identified by skin prick, intradermal injection, or serologic testing.The elimination of triggers during subsequent medical episodes is essential to avoid major mortality and morbidity. PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015

Fibromialgia/Fibromyalgia

Abordaje clínico de la fibromialgia: síntesis de recomendaciones basadas en la evidencia, una revisión sistemática "Clinical approach to fibromyalgia: Synthesis of Evidence-based recommendations, a systematic review". Ángel García D, Martínez Nicolás I, Saturno Hernández PJ. Reumatol Clin. 2015 Oct 16. pii: S1699-258X(15)00110-2. doi: 10.1016/j.reuma.2015.06.001. [Epub ahead of print] Resumen Objetivos: Se han hecho esfuerzos en estandarizar una práctica basada en la evidencia, pero las guías de práctica clínica no siempre siguen métodos rigurosos de desarrollo. El objetivo de esta revisión es identificar las guías actuales, analizar la variabilidad de sus recomendaciones y hacer una síntesis para su uso clínico. Material y método: Se realizó una búsqueda sistemática de guías de práctica clínica en las bases de datos electrónicas y bases de guías; con los términos: «fibromyalgia» AND [«guideline» OR «Clinical Practice guideline»], desde enero de 2003 a julio de 2013. Se seleccionaron las guías según los siguientes criterios: a) dirigidas al tratamiento de la fibromialgia en población adulta, b) basadas en evidencia científica, buscada de forma sistemática, c) incluyen niveles de evidencia y fuerza de recomendación, d) escritas en inglés o espanol. ˜ Resultados: De los 249 resultados, 6 guías cumplieron con los criterios de inclusión. Las guías analizadas en esta revisión muestran gran variabilidad tanto en presencia como en nivel de evidencia y fuerza de recomendación de muchos tratamientos. El ejercicio físico y la terapia cognitivo-conductual son las terapias de primera elección, con alto nivel de evidencia. La amitriptilina, usada por periodos cortos para controlar el dolor, es el tratamiento farmacológico con evidencia más sólida. El abordaje multimodal reporta mejores resultados que la aplicación aislada de cualquier tratamiento. Conclusiones: Las recomendaciones finales identifican los tratamientos óptimos, facilitando la translación de la evidencia a la práctica y permitiendo mayor eficiencia y efectividad en una actividad asistencial de calidad.   Abstract OBJECTIVES: Efforts have been made to standardise evidence-based practice, but clinical practice guidelines do not always follow strict development methods. The objective of this review is to identify the current guidelines, analyse the variability of its recommendations and make a synthesis for clinical practice. MATERIAL AND METHODS:A systematic review of clinical practice guidelines was made in electronic databases and guidelines databases; using "fibromyalgia" AND ["guideline" OR "Clinical Practice guideline"] as terms, from January for 2003 to July of 2013. Guidelines were selected according to the following criteria: a) aimed to fibromyalgia treatment in adults; b) based on scientific evidence, systematically searched; c) evidence levels and strength of recommendation included; d) written in English or Spanish. RESULTS: From 249 initial results, six guides fulfilled the inclusion criteria. Clinical practice guidelines analysed in this review show great variability both in the presence and level of evidence and in the strength of recommendation of many treatments. Physical exercise and cognitive-behaviouraltherapy are first-line treatments, showing high level of evidence. Amitriptyline, used for short periods of time for pain control, is the pharmacologictreatment with the most solid evidence. The multimodal approach reported better results than the isolated application of any treatment. CONCLUSIONS: Final recommendations in this review identify optimal treatments, facilitating the translation of evidence into practice and enabling more efficient and effective quality care. PDF Aplicación del modelo de incertidumbre a la fibromialgia Triviño Martínez Á, Solano Ruiz MC, Siles González J Aten Primaria. 2015 Aug 12. pii: S0212-6567(15)00187-0. doi: 10.1016/j.aprim.2015.04.007. [Epub ahead of print] Resumen Objetivo: Conocer las experiencias vividas por las mujeres diagnosticadas de fibromialgia aplicando la Teoría de la Incertidumbre propuesta por M. Mishel. Diseno: ˜ Estudio cualitativo con enfoque fenomenológico. Emplazamiento una Asociación de enfermas de fibromialgia de la provincia de Alicante durante los meses de junio 2012 a noviembre de 2013. Participantes: Catorce mujeres diagnosticadas de fibromialgia con edades comprendidas entre 45 y 65 anos ˜ participaron de forma voluntaria. Método: Generación de información a través de entrevistas semiestructuradas con grabación y transcripción previo compromiso de confidencialidad y consentimiento informado. Análisis de contenido extrayendo diferentes categorías de acuerdo con la teoría propuesta. Resultados: Las pacientes del estudio perciben un elevado nivel de incertidumbre vinculado a la dificultad para hacer frente a los síntomas, incertidumbre ante el diagnóstico y la complejidad deltratamiento. Por otra parte, la capacidad de afrontamiento de la enfermedad se verá influida por el apoyo social, la relación con los profesionales de la salud y la búsqueda de ayuda e información acudiendo a las asociaciones de pacientes. Conclusiones: El profesional de la salud debe ofrecer una información clara sobre la patología a las enfermas de fibromialgia; cuanto mayor es el nivel de conocimientos de las pacientes sobre su enfermedad y mejor es la calidad de la información que se presta, se informa de menor ansiedad e incertidumbre en la vivencia de la enfermedad. Así mismo, las asociaciones de pacientes deberían disponer de profesionales de la salud para evitar sesgos en la información y el asesoramiento con evidencia científica.   Application of an uncertainty model for fibromyalgia. Abstract OBJECTIVES: Finding out women's experiences diagnosed with fibromyalgia applying the Theory of Uncertainty proposed by M. Mishel. DESIGN: A qualitative study was conducted, using a phenomenological approach. LOCATION: An Association of patients in the province of Alicante during the months of June 2012 to November 2013. PARTICIPANTS: A total of 14 women diagnosed with fibromyalgia participated in the study as volunteers, aged between 45 and 65years. METHOD: Information generated through structured interviews with recording and transcription, prior confidentiality pledge and informed consent. Analysis content by extracting different categories according to the theory proposed. RESULTS: The study patients perceive a high level of uncertainty related to the difficulty to deal with symptoms, uncertainty about diagnosis andtreatment complexity. Moreover, the ability of coping with the disease it is influenced by social support, relationships with health professionals and help and information attending to patient associations. CONCLUSIONS: The health professional must provide clear information on the pathology to the fibromyalgia suffers, the larger lever of knowledge of the patients about their disease and the better the quality of the information provided, it is reported to be the less anxiety and uncertainty in the experience of the disease. Likewise patient associations should have health professionals in order to avoid bias in the information and advice with scientific evidence.  PDF Revisión de la farmacoterapia en el síndrome de fibromialgia Review of pharmacological therapies in fibromyalgia syndrome. Häuser W, Walitt B, Fitzcharles MA, Sommer C. Arthritis Res Ther. 2014 Jan 17;16(1):201. doi: 10.1186/ar4441. Abstract This review addresses the current status of drug therapy for the management of fibromyalgia syndrome (FMS) and is based on interdisciplinary FMS management guidelines, meta-analyses of drug trial data, and observational studies. In the absence of a single gold-standard medication, patients are treated with a variety of drugs from different categories, often with limited evidence. Drug therapy is not mandatory for the management of FMS. Pregabalin, duloxetine, milnacipran, and amitriptyline are the current first-line prescribed agents but have had a mostly modest effect. With only a minority of patients expected to experience substantial benefit, most will discontinue therapy because of either a lack of efficacy or tolerability problems. Many drug treatments have undergone limited study and have had negative results. It is unlikely that these failed pilot trials will undergo future study. However, medications, though imperfect, will continue to be a component of treatment strategy for these patients. Both the potential for medication therapy to relieve symptoms and the potential to cause harm should be carefully considered in their administration. PDF Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015

Errores médicos/Medical errors

Encuesta voluntaria para pacientes de los eventos médicos adversos: perspectiva de 696 pacientes y familiares lesionados. A patient-initiated voluntary online survey of adverse medical events: the perspective of 696 injured patients and families. Southwick FS, Cranley NM, Hallisy JA. BMJ Qual Saf. 2015 Oct;24(10):620-9. doi: 10.1136/bmjqs-2015-003980. Epub 2015 Jun 19. Abstract BACKGROUND: Preventable medical errors continue to be a major cause of death in the USA and throughout the world. Many patients have written about their experiences on websites and in published books.METHODS:As patients and family members who have experienced medical harm, we have created a nationwide voluntary survey in order to more broadly and systematically capture the perspective of patients and patient families experiencing adverse medical events and have used quantitative and qualitative analysis to summarise the responses of 696 patients and their families.RESULTS:Harm was most commonly associated with diagnostic and therapeutic errors, followed by surgical or procedural complications, hospital-associated infections and medication errors, and our quantitative results match those of previous provider-initiated patient surveys. Qualitative analysis of 450 narratives revealed a lack of perceived provider and system accountability, deficient and disrespectful communication and a failure of providers to listen as major themes. The consequences of adverse events included death, post-traumatic stress, financial hardship and permanent disability. These conditions and consequences led to a loss of patients' trust in both the health system and providers. Patients and family members offered suggestions for preventing future adverse events and emphasised the importance of shared decision-making.CONCLUSIONS:This large voluntary survey of medical harm highlights the potential efficacy of patient-initiated surveys for providing meaningful feedback and for guiding improvements in patient care. KEYWORDS: Communication; Medical error, measurement/epidemiology; Patient safety; Qualitative research; Surveys PDF Evaluación de la confiabilidad de la revisión de historia clínica para la detección del eventos adversos hospitalarios. Assessing Reliability of Medical Record Reviews for the Detection of Hospital Adverse Events. Ock M, Lee SI, Jo MW, Lee JY, Kim SH. J Prev Med Public Health. 2015 Sep;48(5):239-48. doi: 10.3961/jpmph.14.049. Epub 2015 Sep 11. Abstract OBJECTIVES: The purpose of this study was to assess the inter-rater reliability and intra-rater reliability of medical record review for the detection of hospital adverse events. METHODS: We conducted two stages retrospective medical records review of a random sample of 96 patients from one acute-care general hospital. The first stage was an explicit patient record review by two nurses to detect the presence of 41 screening criteria (SC). The second stage was an implicit structured review by two physicians to identify the occurrence of adverse events from the positive cases on the SC. The inter-rater reliability of two nurses and that of two physicians were assessed. The intra-rater reliability was also evaluated by using test-retest method at approximately two weeks later. RESULTS: In 84.2% of the patient medical records, the nurses agreed as to the necessity for the second stage review (kappa, 0.68; 95% confidence interval [CI], 0.54 to 0.83). In 93.0% of the patient medical records screened by nurses, the physicians agreed about the absence or presence of adverse events (kappa, 0.71; 95% CI, 0.44 to 0.97). When assessing intra-rater reliability, the kappa indices of two nurses were 0.54 (95% CI, 0.31 to 0.77) and 0.67 (95% CI, 0.47 to 0.87), whereas those of two physicians were 0.87 (95% CI, 0.62 to 1.00) and 0.37 (95% CI, -0.16 to 0.89). CONCLUSIONS: In this study, the medical record review for detecting adverse events showed intermediate to good level of inter-rater and intra-rater reliability. Well organized training program for reviewers and clearly defining SC are required to get more reliable results in the hospital adverse event study. KEYWORDS: Adverse event; Inter-rater reliability; Intra-rater reliability; Medical record review; Patient safety PDF Comprobación cruzada para reducir los eventos adversos derivados de los errores médicos en elservicio de urgencias: protocolo de estudio del estudio aleatorizado clúster CHARMED. Cross-checking to reduce adverse events resulting from medical errors in the emergency department: study protocol of the CHARMED cluster randomized study. Freund Y, Rousseau A, Berard L, Goulet H, Ray P, Bloom B, Simon T, Riou B. BMC Emerg Med. 2015 Sep 4;15:21. doi: 10.1186/s12873-015-0046-1. Abstract BACKGROUND: Medical errors and preventable adverse events are a major cause of concern, especially in the emergency department (ED) where its prevalence has been reported to be roughly of 5-10% of visits. Due to a short length of stay, emergency patients are often managed by a sole physician - in contrast with other specialties where they can benefit from multiples handover, ward rounds and staff meetings. As some studies report that the rate and severity of errors may decrease when there is more than one physician involved in the management in different settings, we sought to assess the impact of regular systematic cross-checkings between physicians in the ED.DESIGN: The CHARMED (Cross-checking to reduce adverse events resulting from medical errors in the emergency department) study is a multicenter cluster randomized study that aim to evaluate the reduction of the rate of severe medical errors with implementation of systematic cross checkings between emergency physician, compared to a control period with usual care. This study will evaluate the effect of this intervention on the rate of severe medical errors (i.e. preventable adverse events or near miss) using a previously described two-level chart abstraction. We made the hypothesis that implementing frequent and systematic cross checking will reduce the rate of severe medical errors from 10 to 6% - 1584 patients will be included, 140 for each period in each center. DISCUSSION: The CHARMED study will be the largest study that analyse unselected ED charts for medical errors. This could provide evidence that frequent systematic cross-checking will reduce the incidence of severe medical errors. PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015