Towards Better Perioperative Pain Management in Mexico: A Study in a Network of Hospitals Using Quality Improvement Methods from PAIN OUT.

OBJECTIVE: This was a pre-post study in a network of hospitals in Mexico-City, Mexico. Participants developed and implemented Quality Improvement (QI) interventions addressing perioperative pain management. METHODS: PAIN OUT, an international QI and research network, provided tools for web-based auditing and feedback of pain management and patient-reported outcomes (PROs) in the clinical routine. Ward- and patient-level factors were evaluated with multi-level models. Change in proportion of patients reporting worst pain ≥6/10 between project phases was the primary outcome. RESULTS: Participants created locally adapted resources for teaching and pain management, available to providers in the form of a website and a special issue of a national anesthesia journal. They offered teaching to anesthesiologists, surgeons, including residents, and nurses. Information was offered to patients and families. A total of 2658 patients were audited in 9 hospitals, between July 2016 and December 2018. Participants reported that the project made them aware of the importance of: training in pain management; auditing one's own patients to learn about PROs and that QI requires collaboration between multi-disciplinary teams. Participants reported being unaware that their patients experienced severe pain and lacked information about pain treatment options. Worst pain decreased significantly between the two project phases, as did PROs related to pain interfering with movement, taking a deep breath/coughing or sleep. The opportunity of patients receiving information about their pain treatment options increased from 44% to 77%. CONCLUSIONS: Patients benefited from improved care and pain-related PROs. Clinicians appreciated gaining increased expertise in perioperative pain management and methods of QI.

Intraoperative US-guided large volume ethanol injection for hepatocellular carcinoma greater than 4 cm.

BACKGROUND: Percutaneous ethanol injection has been successfully used for hepatocellular carcinomas (HCC) smaller than 5 cm in size. For larger lesions large volume ethanol injection has not been well explored. AIM: Evaluate the results of intraoperative Ultrasonographic-guided large volume ethanol injection for HCC larger than 4 cm in size. PATIENTS AND METHODS: Ten patients were candidates for this treatment between June 1999 and July 2003. A retrospective review of the clinical files was performed. Absolute ethanol, average of 100 mL (range 80-120 mL) was administered intraoperatively. Follow-up evaluation included alpha-fetoprotein (AFP) and ultrasound or computed tomography. RESULTS: There were six women and four men, the median age was 62 years (range 56-80). The median lesion size was 8 cm (range 4-15 cm). Hepatitis C liver cirrhosis was the most common associated chronic liver disease (70%). A significant reduction of AFP levels after treatment was observed (Initial 966 ng/dL, post treatment levels: 42 ng/dL) US and CT scan showed tumor necrosis. Morbidity was 40%. No operative mortality was recorded. The one and four year survival rate was 60% and 20%. CONCLUSION: Intraoperative US-guided large volume ethanol injection is a safe palliative therapy for cirrhotic patients with HCC lesions greater than 5 cm in size. The impact on survival should be compared in a controlled double blind study.

Hepatocellular carcinoma and hepatitis C in Mexico.

BACKGROUND/AIMS: Hepatocellular carcinoma (HCC) has increased in many countries as a result of an increased frequency of hepatitis C virus (HCV) infection. In Mexico, the association of HCC to HCV infection has not been evaluated. This study aims to evaluate the epidemiological factors related to HCC in Mexican patients as well as the results of treatment. METHODOLOGY: A retrospective review of clinical files of patients with HCC diagnosed between May 1992 to July 2002 was performed. RESULTS: There were 63 males and 64 females with a median age of 57 years (range 17-82). Seventy-one patients were evaluated for hepatitis status. In 43 (60%) HCV was the etiological factor. Isolated HCV infection was present in 32 (45%), HCV infection and ethanol abuse was observed in 11 (15.5%). In six (8.4%) patients hepatitis B was the etiological factor. HCV and HBV infection were found in 9 (12.6%). HCV and HBV infection associated to ethanol abuse was present in one patient. Ethanol abuse alone was observed in six (8.4%) patients. The median size of the lesion was 8cm (range 3-20cm). Alpha-fetoprotein was measured in 113 patients and was higher than 500ng/dL in 60 (53%). Sixty-five patients received supportive measures. Sixty-two were treated. Eighteen were resected. Thirteen were treated with intraoperative large volume ethanol injection (ILVEI), 12 with chemotherapy and 19 with tamoxifen-talidomide. Patients without treatment had a median survival time of 11 months and patients who received treatment had a median survival time of 25.3 months. The median survival time in patients who received surgery was 26 months, the ILVEI group survival time was 18 months, the chemotherapy survival was 8.8 months, and the tamoxifen-talidomide survival time was 7 months. CONCLUSIONS: HCC is a rare neoplasm in Mexico and HCV infection is the main etiological factor. Surgical resection is the best form of treatment of HCC in our country. However, only 14% of the patients were candidates. For non-resectable lesions, ILVEI offers the best palliative results in our center.

Hepatocellular carcinoma in the youth. A comparative analysis with hepatocellular carcinoma in adulthood.

BACKGROUND/AIMS: Hepatocellular carcinoma (HCC) is a very rare disease among young individuals. Epidemiological, clinical and histopathological features of this malignancy in the youth have not been thoroughly studied. METHODOLOGY: A review of the clinical files of patients with HCC younger than 40 years of age, who were treated between May 1990 and July 2002, was performed. RESULTS: Seventeen patients were included for analysis; nine were female and eight male. The mean age at diagnosis was 24 years (range 12-39 years). Abdominal pain was the main symptom, followed by vomiting and nausea. Enlargement of the liver was observed in 11 patients (65%). In seven patients (41%), an etiological factor was not found. Five of these cases were of the fibrolamellar variant (29%). Only four patients were resected (23%) two of which belonged to the fibrolamellar type. Three patients (18%) are still alive after 64.9 months of follow-up. CONCLUSIONS: HCC is a very uncommon disease in the youth and affects similarly both genders. It is discovered at an advanced stage. Hepatitis B and C are uncommon etiological factors. The frequency of fibrolamellar carcinoma is higher in this age group. Though resection is more feasible, the overall survival rates remain low.

Manejo perioperatorio de paciente con COVID-19 / Perioperative management of the patient with COVID-19

Resumen: En la actualidad, la pandemia de SARS-CoV-2 ha puesto a prueba los sistemas de salud en toda su extensión a lo largo del mundo. Se desconoce el impacto del estrés quirúrgico y de la anestesia sobre la predisposición a una nueva infección por COVID-19, o la exacerbación de la infección en un paciente infectado por este virus que se va a operar. Aunque la mortalidad de COVID-19 está entre 1-5%, la mayoría de las muertes han ocurrido en pacientes de edad avanzada con afecciones cardiopulmonares subyacentes, la mayoría de ellos hipertensos, diabéticos y con obesidad, por lo cual, se debe poner especial atención en su manejo. La preparación y planeación perioperatoria cuidadosa es clave para lograr con éxito una adecuada atención clínica y mantener la seguridad del equipo de salud en un momento difícil y de alto riesgo. Un papel adicional del anestesiólogo, considerando que es el médico con mayor experiencia en el manejo de la vía aérea, consiste en apoyar a los servicios de emergencia para la intubación endotraqueal de los pacientes que requieren apoyo ventilatorio, siendo un procedimiento con recomendaciones de protección muy específicas. Por lo tanto, existe un compromiso como especialistas de conocer el tema a fondo y protegernos, así como al equipo de profesionales de la salud que se exponen salvando vidas durante esta contingencia.

Abstract: Currently, the SARS-CoV-2 pandemic has put health systems to the test throughout their world. The impact of surgical stress and anesthesia on predisposition to a new COVID-19 infection or exacerbation of the infection in a COVID-19 infected patient to be operated on is unknown. Although COVID-19 mortality is between 1-5%, most deaths have occurred in elderly patients with underlying cardiopulmonary conditions, most of them hypertensive, diabetic and obese, therefore, it should be specially attention in its handling. Carefull perioperative preparation and planning is key in successfully achieving adequate clinical care and maintaining the safety of the health team in a difficult and high risk moment. An additional role for the anesthesiologist, considering that he has the most experience in the management of the airway, is to support the emergency services for endotracheal intubation of patients who require ventilatory support, being a procedure with very specific protection recommendations. Therefore, there is a commitment as specialists, to know the subject thoroughly and protect ourselves along with the health team involved in saving lives during this contingency.

Resection of liver metastases from a virilizing steroid (lipoid) cell ovarian tumor.

The authors report the case of a 34-year-old woman who presented liver metastases from a virilizing lipoid cell ovarian tumor. The patient complained of right upper quadrant abdominal pain, strong virilization and secondary amenorrhea. She developed hirsutism and irregular menses at the age of 23, and a salpingo-ooforectomy for a right ovarian lipoid cell tumor was performed. She was asymptomatic but 6 months before admission she presented abdominal pain. The computed tomography scan showed a large right-side hypodense liver lesion. Tumor and viral markers were normal. Serum testosterone was 7 ng/mL and the dehydroepiandrosterone was 2.5 ng/mL. A right trisegmentectomy was performed. Her recovery was uneventful, hormone levels returned to normal, and she has been asymptomatic after a follow-up of 6 months.

A retrospective analysis of patients with gallbladder cancer treated with radical resection versus cholecystectomy plus external radiotherapy.

BACKGROUND/AIMS: To compare patients with gallbladder cancer treated with radical resection and regional lymphadenectomy (RR-RL) versus simple cholecystectomy and adjuvant external radiotherapy (SC-ERT) and determine outcome. METHODOLOGY: Presentation, operative data, complications and survival were examined in 137 patients. In particular, the 45 patients treated with RR-RL or SC-ERT. RESULTS: Twenty-five had SC-ERT and 20 had a RR-RL. There were no epidemiological differences between groups. Resection of segments IV-b and V and en bloc dissection of regional lymph nodes was the most frequently used procedure (75%). The morbidity and mortality of the radical procedure were 25% and 10%. The morbidity of SC-ERT was 16%. All patients with Nevin I are alive. For lesions Nevin II and Nevin III RR-RL offered a 100% 5-year survival rate and SC-ERT had a 62% and 39% 5-year survival rate respectively. For lesions Nevin IV and V there was no difference in long-term survival. CONCLUSIONS: RR-RL is better than SC-ERT in patients with Nevin II and III lesions because it improves survival rate. SC-ERT can be recommended as an alternative treatment. For more advanced lesions further trials are needed.

[Primary non-Hodgkin's lymphoma of the liver. Report of a case and review of the literature]. / Linfoma no Hodgkin primario de hígado. Presentación de un caso y revisión de la literatura.

Primary hepatic lymphoma (PHL) is a rare tumor and its clinical behavior remains unknown. We report a case of PHL in a 47 year-old male patient without chronic liver disease and with preoperative diagnosis of hepatocellular carcinoma. Hepatitis B surface antigen and antibody and anti-hepatitis C virus antibody were negative. The patient underwent a right trisegmentectomy, and pathologic examination revealed a diffuse large B-cell lymphoma. The clinical and pathologic features are presented. A review of the literature discussing clinical features, postulated pathogenetic mechanisms, and management options are also presented.

[Hepatocellular carcinoma in youth: a comparative analysis with hepatocarcinoma in adults]. / Carcinoma hepatocelular en jóvenes: un análisis comparativo con hepatocarcinoma en adultos.

INTRODUCTION: Hepatocellular carcinoma (HCC) is a very rare disease among young individuals. Epidemiological, clinical, and histopathological features of this malignancy in youth have not been thoroughly studied. PATIENTS AND METHODS: A review of clinical files of patients with HCC < 40 years of age treated between May 1990 and July 2002 was performed. RESULTS: Seventeen patients were included for analysis, nine were female and eight, male. Mean age at diagnosis was 24 years (range 12-39 years). Abdominal pain was the main symptom, followed by vomiting and nausea. Enlargement of liver was observed in 11 patients (65%). In seven patients (41%), etiologic factor was not found. Five of these cases were of fibrolamellar variant (29%). Only four patients were resected (23%) two of whom belonged to fibrolamellar type. Three patients (18%) are still alive after 64.9 months of follow-up. CONCLUSION: HCC is a very uncommon disease in youth and affects similarly both genders. It is discovered at advanced stage. Hepatitis B and C are uncommon etiologic factors. Frequency of fibrolamellar carcinoma is higher in this age group. Although resection is more feasible, overall survival rates remain low.

[Cavernous hemangioma of the liver and hepatic hemangiomatosis. Indications and results of the surgical resection]. / Hemangioma cavernoso de hígado y hemangiomatosis hepática. Indicaciones y resultados de la resección quirúrgica.

INTRODUCTION: Cavernous hemangioma is the most frequent focal liver lesion. It affects mainly women and may cause symptoms such as abdominal pain, mass, and early satiety, or complications such as heart failure or coagulopathy. There are several options for treatment in symptomatic patients. However, it seems that surgical resection is the only curative treatment. AIM: Evaluate indications and results of liver resection in patients with cavernous hemangiomas and hepatic hemangiomatosis. PATIENTS AND METHODS: We conducted a retrospective analysis of clinical files of patients treated at the Instituto Nacional de Cancerología (INCan) and the Centro Médico ISSEMYM during a 8-year period. Epidemiological data as well as diagnostic work-up and treatment were analyzed. RESULTS: From August 1995 to May 2003, 24 patients with liver hemangiomas were resected at both institutions. Twenty three were female (95.8%) and one, male (4.1%). Indications for surgery were presence of symptoms in 20 patients (83.3%), undefined diagnosis in three (12.5%), and rapid growth in one (4.1%). Most frequent symptoms were abdominal pain in 20 (83.3%) patients, followed by abdominal mass in five (20.8%), and early gastric satiety in four (16.6%). Abdominal computed tomography (CT) scan was the most frequent imaging study used in 22 patients (91.6%), followed by ultrasound in 20 (83.3%). Size of lesion ranged from 4-30 cm (X: 8.7 cm), 16 patients were submitted to formal liver resection (66.6%), and eight to enucleation (33.3%). Four patients presented operative complications (16.6%) that included postoperative bleeding in two (8.3%), fever in one (4.1%) and abdominal haematoma in one (4.1%). There was no operative mortality. Twenty two patients were asymptomatic at time of evaluation (91%). CONCLUSIONS: This lesion affects mainly women, and presence of symptoms is the most common indication for treatment. Choice of surgical procedure to be carried out depends on location and morphology of the lesion. Liver resection or enucleation are safe forms of treatment that properly controlled symptomatology.

PAIN OUT: red mexicana para la optimización del dolor postoperatorio / PAIN OUT: Mexican network for the optimization of postoperative pain

Resumen: PAIN OUT es un sistema de gestión en calidad que consiste en un registro internacional (http://.www.pain-out.eu), y tiene la finalidad de realizar auditorías internas que permiten la evaluación y la optimización del tratamiento de pacientes con dolor postoperatorio. En 2016, se inició un proyecto internacional, donde 10 hospitales de la Ciudad de México participaron para mejorar la calidad en la atención del dolor postoperatorio, los cuales fueron coordinados por la Universidad de Jena, Alemania y el Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán (para más detalles visite http://www.painoutmexico.com).

Abstract: PAIN OUT is a quality management system that consists of an international register (http://.www.pain-out.eu), which aims to perform internal audits that allow the evaluation and optimization of the treatment of patients with postoperative pain. In 2016 an international project was initiated where 10 hospitals in Mexico City participated to improve the quality of postoperative pain care, coordinated by the University of Jena, Germany and the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán (for more details visit http://www.painoutmexico.com).

Papel de la analgesia regional en el dolor postoperatorio / Role of regional analgesia in postoperative pain

Resumen: La anestesia y la analgesia regional son consideradas herramientas que, desde sus primeras descripciones, han ganado terreno en el arsenal del anestesiólogo, se han convertido en parte integral del cuidado moderno perioperatorio. La historia de la anestesia regional y neuroaxial se ha caracterizado por la búsqueda de métodos más efectivos y seguros durante los procedimientos quirúrgicos. Con base en lo anterior, el advenimiento del ultrasonido en anestesia regional permite realizar procedimientos bajo la visualización 2D de tejidos blandos, vasos sanguíneos y nervios, además de referencias óseas, siempre en tiempo real, con la posibilidad de visualización directa de aguja o punzones, brindando seguridad y aumentando la tasa de éxito al visualizar la administración, comportamiento y distribución del anestésico local utilizado. En años recientes, nuevas técnicas analgésicas como el uso de bloqueos interfasciales o troncales guiados por ultrasonido han sido empleadas como parte de modalidades analgésicas durante el perioperatorio.

Abstract: Anesthesia and regional analgesia are considered tools that, since their first descriptions, have become an integral part of modern perioperative care. The history of regional and neuroaxial anesthesia has been characterized by the search for more effective and safe methods during surgical procedures. Based on the above, the advent of ultrasound in regional anesthesia allows performing procedures under 2D visualization of soft tissues, blood vessels and nerves, as well as bone references, always in real time, with the possibility of direct visualization of needle or punches, providing safety and increasing the success rate when visualizing the administration, behavior and distribution of the local anesthetic used. In recent years, new analgesic techniques, such as the use of interfascial or ultrasound-guided trunks, have been used as part of analgesic modalities during the perioperative period.

Evaluación del dolor postoperatorio, estandarización de protocolos de actuación, y mejora continua basada en resultados / Evaluation of postoperative pain, standardization of protocols of action, and continuous improvement based on goals and results

Resumen: La valoración del dolor postoperatorio mediante escalas unidimensionales como la escala verbal análoga (EVA), están siendo abandonadas. Actualmente la evaluación se realiza con base a las actividades que, de acuerdo con el tipo de cirugía, el paciente pueda realizar durante las primeras horas del postoperatorio. El tratamiento del dolor requiere de un marco organizativo, que debe incluir el diseño de protocolos de actuación que permitan la mejora continua basada en resultados, de acuerdo con las necesidades de cada hospital. La implementación y planeación de estrategias mediante auditorias internas como el sistema Pain Out, son una base para la gestión de nuevas unidades de dolor agudo (visitehttp://www.painoutmexico.com ) .

Abstract: The assessment of postoperative pain using unidimensional scales such as the verbal analog scale (VAS), are being abandoned. Currently the evaluation is made based on the activities that, according to the type of surgery, the patient can perform during the first hours of postoperative period. The treatment of pain requires an organizational framework, which must include the design of protocols that allow continuous improvement based on results, according to the needs of each hospital. The implementation and planning of strategies through internal audits such as the Pain Out system, are a basis for the management of new units of acute pain (visithttp://www.painoutmexico.com ).

Analgesia en cirugía torácica videoasistida / Analgesia in video-assisted thoracic surgery

Resumen: En los últimos años, la cirugía torácica videoasistida (VATS) se ha realizado con más frecuencia. Aunque la VATS reduce el dolor postoperatorio debido a sus incisiones más pequeñas, el control del dolor después de ésta sigue siendo un desafío. Hasta la fecha, no existen recomendaciones internacionales específicas para este procedimiento, en donde se ha demostrado que el dolor en las primeras 24 horas no difiere mucho del provocado por una toracotomía, dado que los drenajes son un común denominador entre ambos procedimientos y son causa principal de molestia importante entre los pacientes; razón por la cual deben implementarse medidas analgésicas que prevengan este tipo de dolor. Otra consideración importante es la persistencia del dolor, que puede ocasionar síndrome postoracotomía, que se asocia con una disminución significativa de la calidad de vida y a un aumento en la necesidad de medicamentos a largo plazo contra el dolor. El bloqueo eficaz de los aferentes neurales en el postoperatorio reduce el dolor agudo postoracotomía y, por lo tanto, puede entorpecer el desarrollo de dolor crónico. Por lo tanto, se ha sugerido un manejo multimodal efectivo enfocado al procedimiento específico para prevenir el dolor descontrolado en el postoperatorio inmediato; pero sobre todo, para limitar la persistencia de éste a largo plazo. Se debe procurar la utilizacion de técnicas regionales con anestésico local, como el bloqueo del plano erector spinae, el bloqueo paravertebral, el bloqueo serrato y el BRILMA (bloqueo de las ramas intercostales de la línea media axilar), de acuerdo a las necesidades de cada paciente, para lograr un buen alivio del dolor con la mínima administración sistémica de opiáceos, ya que esto mejorará la satisfacción del paciente y su recuperación al reducir los efectos secundarios relacionados con los opioides facilitando la movilización, la fisioterapia efectiva y el alta temprana (para ver el artículo completo visite http://www.painoutmexico.com).

Abstract: In recent years, video-assisted thoracic surgery (VATS) has been performed more frequently. Although VATS reduces postoperative pain due to its smaller incisions, pain control after this remains a challenge. Actually there are no specific international recommendations for this procedure where it has been shown that pain in the first 24 hrs does not differ much from that caused by thoracotomy, due to drains are a common denominator between both procedures and are a major cause of significant discomfort among patients, which is why they should have analgesic measures to prevent this type of pain. Another important consideration is the persistence of pain, which can cause post-thoracotomy syndrome that is associated with a significant decrease in quality of life and an increase in the need for long-term pain medication. Effective blockade of neural afferents in the postoperative period reduces acute post-thoracotomy pain and, therefore, may hinder the development of chronic pain. Therefore, effective multimodal management focused on the specific procedure has been suggested to prevent uncontrolled pain in the immediate postoperative period, but above all to limit its persistence in the long term. The use of regional techniques with local anesthetic, such as the blockade of the erector spinae plane, paravertebral block, serratus block and BRILMA (Intercostal branches of the mid-axillary line block), should be sought, according to the needs of each patient, to achieve good pain relief with minimal systemic administration of opioids, as this will improve patient satisfaction and recovery by reducing side effects related to facilitating mobilization, effective physiotherapy and early discharge (visit http://www.painoutmexico.com to see the full article and recommendations diagram).

El ABC de la analgesia controlada por el paciente / The ABCs of patient-controlled analgesia

Resumen La analgesia controlada por el paciente (PCA, por sus siglas en inglés: patient controlled analgesia) es la administración continua y/o intermitente de analgésicos opioides y no opioides a través de un dispositivo con dosis a demanda y control del paciente. Su mecanismo de acción antinociceptivo tiene efecto en la percepción del control del dolor por el propio paciente, en sinergia, con la acción de los medicamentos. Bajo el concepto de concentración mínima efectiva analgésica, las bombas PCA permiten mantener las concentraciones plasmáticas estables de los fármacos, particularmente de los opioides, disminuyendo la carga de atención al personal de enfermería y la administración de medicamentos «por razón necesaria¼. Las bombas de PCA cuentan con un intervalo de seguridad que impide la sobredosificación por intentos repetitivos de activación por el paciente de las dosis en bolos, y se ha demostrado que brindan mejores resultados en la analgesia durante las primeras 24 horas (nivel de evidencia moderada). Las rutas más utilizadas son la vía intravenosa y la vía epidural. En esta revisión se presentan los pasos básicos para el uso de estos dispositivos, preparación y programación de bolos o infusiones analgésicas, así como los pasos seguros que deben considerarse durante su empleo (visite http://www.painoutmexico.com para obtener el artículo completo y videos).

Abstract Patient-controlled analgesia (PCA) is the continuous and/or intermittent administration of opioid and non-opioid analgesics through a device with on-demand doses and patient control. Its mechanism anti-nociceptive has an effect on the perception of pain controlled by the patient himself, in synergy, with the action of the medications. Under the concept of minimum effective analgesic concentration, PCA pumps allow the stable plasma concentrations of the drugs, particularly opioids, to be maintained, reducing the nursing staff attention and the administration of drugs «for necessary reason¼. PCA pumps have a safety interval that prevents overdosing due to repetitive attempts by the patient to activate bolus and has been shown to provide better analgesia during the first 24 hours (moderate level of evidence). The most commonly routes are the intravenous and the epidural. In this review we present the basic steps for the use of these devices, preparation and programming of boluses or analgesic infusions, as well as safety steps during their use (visit http://www.painoutmexico.com to see the full article and videos).

Uso de coadyuvantes en dolor postoperatorio / Use of adjuvants in postoperative pain

Resumen: Los analgésicos coadyuvantes son compuestos que tienen una baja potencia analgésica. Sin embargo, la sinergia con opioides incrementa su efecto y favorece una reducción en los eventos adversos de los narcóticos para el control del dolor postoperatorio. Las estrategias ahorradoras de opioides están relacionadas con el efecto de una variedad de receptores, de los cuales podemos nombrar: los antagonistas NMDA como la ketamina, magnesio y dextrometorfano, los agonistas α-2 como la clonidina y la dexmedetomidina, los inhibidores de la subunidad α-2δ de los canales de calcio como la pregabalina y la gabapentina, los bloqueadores de los canales de sodio como la lidocaína y, finalmente, los glucocorticoides. En esta revisión se describirán las características, indicaciones, dosis y niveles de evidencia del uso de los coadyuvantes de uso intravenoso y regional en el contexto perioperatorio. (visite http://www.painoutmexico.com para ver artículo completo y Tablas).

Abstract: The adjuvant analgesics are compounds that have a low analgesic potency. However, with these compounds, the adverse effects of opioids may be diminished for the control of postoperative pain. Opioid-sparing strategies are related to the effect on a variety of receptors, of which we should name: the NMDA antagonists such as ketamine, magnesium and dextromethorphan, the α-2 agonists such as clonidine and dexmedetomidine, subunit α-2δ of calcium channels inhibitors; such as pregabalin and gabapentin, sodium channels blockers such as lidocaine and finally glucocorticoids. In this review we describe the characteristics, indications, doses and levels of evidence of use of adjuvants in the perioperative context (visit http://www.painoutmexico.com to see the full article and Tables).

Intervencionismo guiado por ultrasonido en cirugía torácica y pared abdominal / Ultrasound-guided intervention in thoracic surgery and abdominal wall

Resumen: Cada vez es más frecuente el uso de la ecografía para identificar las capas interfasciales, el cual ha llevado al desarrollo de varias técnicas de inyección para la analgesia del tórax y la pared abdominal. Para la realización de este tipo de abordajes es importante tener el conocimiento y dominio del ultrasonido, de los bloqueos troncales, anestésicos locales y toxicidad. Estos bloqueos interfasciales se desarrollaron como alternativas al bloqueo epidural, paravertebral, intercostal e intrapleural torácico, principalmente para la analgesia perioperatoria. En esta revisión incluimos diferentes abordajes guiados por ultrasonido como son el bloqueo del plano del erector espinal (ESP), el bloqueo del serrato anterior, bloqueo PEC1 y PEC2, bloqueo BRILMA, bloqueo paravertebral, bloqueo del plano del transverso abdominal (TAP), bloqueo del cuadrado lumbar, bloqueo de la vaina de los rectos. Se incluyen enlaces con videos para poder revisar la técnica, indicaciones y dosis (visite http://www.painoutmexico.com para ver artículo completo y videos).

Abstract: The increasing use of ultrasound to identify the interfascial layers has led to the development of several injection techniques for analgesia of the thorax and abdominal wall. For this type of approach it is important to have knowledge of ultrasound, trunk blocks, local anesthetics and toxicity. These interfascial blocks were developed as alternatives to epidural, paravertebral, intercostal and intrapleural thoracic block, mainly for perioperative analgesia. In this review, we include different approaches guided by ultrasound such as: erector spinae plane block (ESP), anterior serratus block, PEC1 and PEC2 block, BRILMA block, paravertebral block, transverse abdominal plane block (TAP), quadratus lumbar block (QLB) and rectus sheath block. Links with videos are included to review the technique, indications and dosage (visit http://www.painoutmexico.com obtain full version and videos).

Educación para pacientes / Education for patients

Resumen: Una parte fundamental en todo proyecto de mejora continua es la apropiada información y educación para el paciente y su familia. Las expectativas de una intervención quirúrgica, del curso perioperatorio y de la experiencia del dolor, puede ser distinta, de acuerdo con las creencias y el estado previo de ansiedad provocado por la incertidumbre y el miedo a lo desconocido, lo cual puede provocar un manejo del dolor menos efectivo. Esta variabilidad en la respuesta frente al evento quirúrgico puede ser optimizada en el momento que se proporciona la información de todo el proceso de manera objetiva. Dentro del proyecto de Investigación de PAIN OUT para la optimización del manejo del dolor perioperatorio, coordinado por el departamento de Anestesiología en el INCMNSZ, se planteó la posibilidad de implementar estrategias de educación para la población general. El Departamento de Educación para la Salud del INCMNSZ, tiene como objetivo apoyar y asesorar a las distintas áreas del hospital en materia de educación y promoción de la salud, que contribuyan a generar una cultura de prevención y autocuidado en el paciente y su familia. En un esfuerzo conjunto de estos dos departamentos se planteó la posibilidad de generar material audiovisual que cumpliera con el objetivo primordial de educar en el contexto perioperatorio. Se crearon tres audiovisuales con el apoyo de diseñadores gráficos del Instituto Tecnológico y de Estudios Superiores de Monterrey, Campus Ciudad de México. El primero incluye información acerca del proceso anestésico; el segundo habla del dolor postoperatorio, su evaluación por parte del paciente y las alternativas de manejo durante la hospitalización y el egreso; mientras que el tercero tiene información sobre los mitos y realidades del uso de opioides como parte de una estrategia analgésica. Este material tiene el objetivo de ser difundido entre la población general, a través del sitio web de la Red Mexicana PAIN OUT para la optimización del manejo del dolor perioperatorio http://www.painoutmexico.com y del sitio webhttps://www.epsnutricion.com.mx/quienes.php

Abstract: A fundamental part of any continuous improvement project is the appropriate information and education for the patient and his family. The expectations of a surgical intervention, of the perioperative course and of the experience of pain, can be different, according to the beliefs and previous state of anxiety caused by uncertainty and fear of the unknown, which can favor a less effective management of pain. This variability in the response to the surgical event can be optimized if the information of the entire process is provided objectively beforehand. The PAIN OUT Research project for the optimization of perioperative pain management, coordinated by the Department of Anesthesiology at INCMNSZ, provides the possibility of implementing education strategies for the general population was raised. The Department of Health Education of INCMNSZ aims to support and advise the different areas of the hospital in terms of education and health promotion, which contribute to generate a culture of prevention and self-care in the patient and his family. In a joint effort of these two departments, the possibility of generating audiovisual material that met the primary objective of educating in the perioperative context was done. Three audiovisuals were created with the support of graphic designers from the Tecnológico y Estudios Superiores de Monterrey, Mexico City Campus. The first includes information about the anesthetic process, the second includes information about postoperative pain, its evaluation by the patient and management alternatives during hospitalization and discharge, and the third includes information about the myths and realities of the use of opioids as part of an analgesic strategy. This material is intended to be disseminated to the general population, through the website of the Mexican PAIN OUT Network for the optimization of perioperative pain management http://www.painoutmexico.com and the website https://www.epsnutricion.com.mx/quienes.php

Cirugía en tumores hepáticos benignos / Surgery in bening liver tumors

Objetivo: evaluar las indicaciones y los resultados de la cirugía en los tumores hepáticos benignos (THB). La resección continúa siendo la mejor forma de manejo para los THB sintomáticas, en los últimos años los resultados operatorios han mejorado en centros de gran experiencia.Pacientes y método: se revisaron los expedientes clínicos de pacientes con THB operados durante el periodo de mayo de 1995 a diciembre de 1999.Resultados: se operaron 17 pacientes, 15 fueron mujeres y dos hombres. La edad promedio fue de 45 años (margen 32-68 años). Fueron 11 hemangiomas cavernosos, dos adenomas hepáticos, dos hiperplasias nodulares focales, un angiomiolipoma hepático y un adenofibroma biliar. Presentaban síntomas doce pacientes (70 por ciento), tres fueron operados con imágenes sospechosas de malignidad, uno por crecimiento acelerado y otro por su estirpe histológica. El tamaño promedio de la lesión fue de 7 cm (margen 3-19 cm). Se realizaron siete resecciones mayores que incluyeron cinco hepatectomías derechas y una izquierda, así como una trisegmentectomía izquierda. Diez resecciones menores (cinco resecciones del segmento lateral izquierdo, tres enucleaciones, dos segmentectomías). La hemorragia intraoperatoria promedio fue de 1,200 mL (margen de 100 a 3,000 mL). Dos pacientes (11.7 por ciento) presentaron complicaciones y no se presentó mortalidad operatoria. El seguimiento promedio fue de 26 meses (margen de 2 a 52 meses) y todos se encuentran asintomáticos al momento de la publicación. Se concluye que la selección cuidadosa de los casos permite realizar la resección de estas lesiones, con adecuados márgenes de seguridad, que permiten eliminar la sintomatología.