Effect of Analgesic Low-Dose Ketamine Infusions on the Cardiovascular Response: A Retrospective Analysis.

BACKGROUND: Low-dose ketamine infusion (LDKI) has shown effectiveness for treating acute pain associated with surgical and nonsurgical (traumatic, neuropathic, and acute cancer-related) origin as an adjuvant to opioids. The increasing use of LDKI as an opioid-sparing agent in multimodal analgesia requires a better understanding of its effects on the cardiovascular response, a known dose-dependent side effect of ketamine administration. We investigated the cardiovascular response of acute pain patients treated with LDKI. OBJECTIVES: The aim of the present study was to evaluate the effect of LDKI in hemodynamic variables (blood pressure [BP] and heart rate [HR]) during LDKI analgesia for up to 48 hours of treatment in an acute pain setting. Secondary objectives were to evaluate psychomimetic effects. STUDY DESIGN: Retrospective unicentric cohort design. SETTING: The study was conducted at an academic university hospital. METHODS: We conducted a single-center retrospective cohort analysis of adult patients who underwent LDKI to treat surgical and nonsurgical acute pain. We obtained data from the Hospital San Vicente Fundación Health Documentation System database and evaluated the medical records of 318 patients with surgical and nonsurgical pain. Patients received a 0.1 mg/kg/h ketamine infusion as part of a multimodal analgesic plan. Baseline systolic BP (SBP), diastolic BP (DBP), mean arterial pressure (MAP), and HR values were compared with those measured after 24 and 48 hours of treatment. Pain level and psychomimetic effects were measured at 24 and 48 hours. Cardiovascular complications and treatment duration were also recorded. Patients with a history of psychiatric, cardiovascular, or cognitive disease were excluded from the study. This study was registered in the clinicaltrials.gov database (identifier: NCT03979105). RESULTS: No statistical differences in SBP, DBP, MAP, or HR were observed when baseline and post-LDKI treatment values were compared (P < 0.05). When comparing hemodynamic variables after exposure to LDKI in patients with and without hypertension, we did not observe statistically significant differences in mean HR, systolic arterial pressure, diastolic arterial pressure, or MAP values at 24 and 48 hours. The frequency of severe pain was reduced from 72% on day 0 to 4.4% on day 1 and 6.2% on day 2 post-LDKI. Observed psychomimetic effects were confusion 4.39%, hallucinations 2.51%, and nightmares 1.25%. No major cardiovascular events were observed. LIMITATIONS: This study was limited by its retrospective design, the lack of a comparative matching cohort, and the good general condition of the majority of patients included in the study. CONCLUSIONS: LDKI (0.1 mg/kg/h) was not associated with significant changes in baseline BP or HR. Our results suggest that as an adjuvant in multimodal analgesia for surgical and nonsurgical acute pain, LDKI has a low impact on the cardiovascular response. KEY WORDS: Ketamine, adverse effects, tachycardia, hypertension, postoperative pain, chronic postsurgical pain.

Proceso de atención en enfermería basado en mapa de cuidados en persona mayor reintervenida quirúrgicamente por reemplazo de cadera. Reporte de un caso

El proceso de atención en enfermería (PAE) es un método sistemático y organizado que requiere de un entrenamiento específico, tener conocimientos y habilidades prácticas que proporcionan las herramientas para brindar cuidado abordando las dimensiones de forma holística a partir de una interacción directa con el paciente, la familia y el entorno social. Se presenta el PAE de una persona mayor, femenina, de 65 años de edad, con pluripatologías: síndrome purpúrico, monoparesia de miembro inferior derecho y síndrome convulsivo, reintervenida quirúrgicamente de un reemplazo de cadera derecha. Se plantea el PAE y sus cinco etapas: valoración, diagnóstico, planeación, ejecución y evaluación; siguiendo la valoración por dominios. El plan de cuidados se realiza con el enfoque de mapa de cuidados en la situación quirúrgica, diagnóstico NANDA International, lnc. La evaluación de intervenciones NIC (Nursing Interventions Classification) y resultados NOC (Nursing Outcomes Classification).

The Nursing Care Process (NCP) is a systematic and organized method that requires specific training, knowledge and practical skills that provide the tools needed to provide care by addressing the dimensions holistically from direct interaction with the patient, the family and social environment. Te NCP of a 65-year-old female elderly person with multiple pathologies; purpuric syndrome, right lower limb monoparesis and convulsive syndrome, who underwent surgery for a right hip replacement is presented. The Nursing Care Process (NCP) and its five stages are proposed: assessment, diagnosis, Outcomes/ Planning, Implementation and evaluation; following the valuation by domains. The care plan was carried out with the care map approach, NANDA Internacional Inc. Te evaluation of NIC (Nursing Interventions Classification) interventions and NOC (Nursing Outcomes Classification) results.

Evaluation of Sensory Mapping of Erector Spinae Plane Block.

BACKGROUND: Erector spinae plane (ESP) block is an effective regional analgesic technique for thoracic and abdominal pain. The volume of local anesthetic (LA) needed to produce sensory block in the spinal segment is unknown. OBJECTIVES: The aim of the present study was to examine the extent of dermatomal spread following ultrasound-guided administration of ESP block, with a fixed-volume dose of a LA at the midthoracic area for analgesia in acute thoracic pain patients. Secondary objectives were postprocedure analgesia and patient satisfaction. STUDY DESIGN: This research used a prospective unicentric exploratory cohort design. SETTING: The study was conducted at an academic university hospital. METHODS: A total of 18 patients with acute severe chest pain including rib fractures, thoracic postoperative rescue analgesia, zoster herpetic neuritis, and myofascial pain syndrome received ESP block under ultrasound guidance at the T5-T7 levels. Twenty mL of 0.5% plain bupivacaine was injected. Evaluation of the sensory block was carried out 60 minutes following the completion of the ESP block via a change in sensation to pinprick and cold methods. The Visual Analog Scale (VAS) for pain was recorded one hour after the procedure. Patient satisfaction was reported using a 4-point Likert scale. This study was registered with the clinicaltrials.gov database (identifier: NCT03831581). RESULTS: Sixteen patients had a successful ESP block; 2 patients were excluded for a failed block. The mean dermatomal spread was 9 (range, 8-11). VAS scores improved by at least 50% from baseline (P < .05), one hour after the ESP block. The degree of satisfaction reported by all patients on the Likert scale was 4 points. No major complications were observed. LIMITATIONS: This study was limited by its sample size. CONCLUSIONS: An ultrasound-guided ESP block with a single injection at the midthoracic level with 20 mL of 0.5% plain bupivacaine provides a mean dermatomal spread of 9 dermatomes (range, 8-11) with a high rate of analgesic efficacy and low incidence of adverse effects. KEY WORDS: Acute pain, dermatomal spread, erector spine plane nerve block, thoracic pain, thoracic postoperative analgesia.

Cierre por segunda intención de abdomen abierto en un paciente masculino de 27 años de edad: reporte de caso / A 27 year-old men with an open abdominal wound healing by second intention: case report

Resumen Se presenta el caso de un paciente masculino de 27 años de edad, con abdomen abierto, diagnóstico de sepsis abdominal severa y falla multiorgánica asociada a una pancreatitis aguda recurrente. Con presencia de dolor abdominal agudo, distensión abdominal, obesidad, taquipnea, xantomas en piel, signos de secuestro de líquidos. Triglicéridos 3450 mg/dL, amilasa 1212 U/L. Tomografía abdominal mostró proceso inflamatorio pancreático con índice de severidad estadio E (4 puntos), necrosis y derrames laminares en páncreas. Se realizó manejo en Unidad de Cuidados Intensivos Adulto. Se realizó laparotomía exploratoria y descomprensión abdominal por síndrome compartimental con el fin de efectuar lavado peritoneal terapéutico y necrosectomía. Se colocó bolsa de Bogotá durante el manejo. Por aplicación de criterios, se inició cierre por segunda intención con utilización del método de curación avanzada con productos de alta tecnología, un tratamiento complejo que mostró un resultado favorable en la recuperación del paciente.

Abstract A 27-year-old male is presented with a complex open abdominal wound, diagnosis of severe abdominal sepsis and multisystem organ failure associated to recurrent acute pancreatitis. Other signs and symptoms were acute abdominal pain and distension, obesity, tachypnea, xanthomas and signs of fluid sequestration. Triglycerides 3450mg / dL, amylase 1212 U / L were some lab results. Abdominal tomography showed a pancreatic inflammatory process with severity index E (4 points), necrosis and laminar effusions in the pancreas. Management in the Adult Intensive Care Unit (ICU) was necessary. Exploratory laparotomy and abdominal decompression were performed due to compartment syndrome, in order to do therapeutic peritoneal lavage and necrosectomy . A Bogota bag was installed during management. Using criteria, the surgical wound closure was initiated by secondary intention using advanced wound care treatment. It showed favorable results in patient recovery.