Actualizaciones en el abordaje terapéutico en el síndrome de dolor regional complejo / Therapeutic approach in patients with complex regional pain syndrome: an update

Introducción: El síndrome de dolor regional complejo abarca una sintomatología que puede ser autolimitada o terriblemente limitante. Pese al enorme interés que despierta en la comunidad científica, no tenemos claro qué determina su evolución. Actualmente, parece claro que hay que ajustar el tratamiento en base a los mecanismos fisiopatológicos predominantes en cada paciente en función de su estadio evolutivo. Fisiopatología: Se produce a causa de una compleja combinación de diferentes factores que se inician en el momento del traumatismo y que consisten en sensibilización del sistema nervioso, disfunción del sistema autónomo y cambios inflamatorios. Hay, además, un indudable componente inmunológico, con presencia de autoinmunización, una implicación genética y la constatación de que determinados estados psicológicos parecen influir en la progresión de la enfermedad. Prevención: Se recomienda la administración de la vitamina C tras traumatismos o cirugías sobre miembros, sobre todo cuando existen factores de riesgo (fracturas distales de radio). Asimismo, hay que incentivar la movilización precoz y tratar los altos niveles de ansiedad para prevenir su desarrollo. Tratamiento: El tratamiento debe ser precoz, multimodal y coordinado, con el objetivo fundamental no solo de aliviar el dolor, sino de recuperar funcionalmente el miembro afecto. La pieza angular del tratamiento es la rehabilitación. Se debe acompañar de farmacoterapia y de tratamiento psicológico. Dentro de la farmacoterapia, tienen especial relevancia los corticoides (en las fases más agudas), los bifosfonatos y los "free-radical scavengers". En fases avanzadas de la enfermedad, la ketamina intravenosa se plantea como una opción terapéutica.(AU)

Introduction: Complex Regional Pain Syndrome encompasses a symptomatology that can be self-limiting or terribly limiting. Despite the enormous interest it arouses in the scientific community, it is not clear what determines its evolution. Currently, it seems clear that treatment must be adjusted based on the predominant pathophysiological mechanisms in each patient according to its evolutionary stage. Physiopathology: It is caused by a complex combination of different factors that start at the time of the trauma and consist of sensitization of the nervous system, dysfunction of the autonomic system and inflammatory changes. There is also an undoubted immunological component, with the presence of autoimmunization, genetic involvement and the finding that certain psychological states seem to influence the progression of the disease. Prevention: The administration of vitamin C is recommended after trauma or surgery on limbs, especially when there are risk factors (distal radius fractures). Also, early mobilization should be encouraged and high levels of anxiety should be treated to prevent its development. Treatment: Treatment should be early, multimodal and coordinated, with the fundamental objective not only of relieving pain, but also of functionally recovering the affected limb. The cornerstone of treatment is rehabilitation. It should be accompanied by pharmacotherapy and psychological treatment. Within the pharmacotherapy, corticoids (in the most acute phases), bisphosphonates and free-radical scavengers are of special relevance. In advanced stages of the disease, intravenous ketamine is considered as a therapeutic option. Interventional treatments should be considered when the evolution of the syndrome is not optimal, especially sympathetic blocks, in case of predominant sympathetic dysfunction, or neuromodulation, which is the treatment modality with the most scientific evidence.(AU)

Localización de la membrana cricotiroidea en varones: influencia de las características morfológicas del cuello / Locating the cricothyroid membrane in males: Influence of the morphological characteristics of the neck

Introducción: La cricotirotomía es una técnica que forma parte de los algoritmos de manejo de vía aérea difícil. Para su adecuada realización se precisa una correcta localización de la membrana cricotiroidea (MCT). Diversos estudios han encontrado una alta tasa de error en la localización por palpación, lo que condiciona un fracaso en el resultado de la técnica. Objetivos: El propósito del estudio fue determinar si las características morfológicas del cuello del paciente influyen en la correcta localización de la MCT y en el tiempo empleado. Materiales y métodos: Estudio observacional donde participaron voluntariamente anestesiólogos e intensivistas en una simulación consistente en un escenario de «cannot intubate, cannot oxygenate» donde tenían que localizar en el menor tiempo posible la MCT en 2 varones seleccionados con diferentes características morfológicas de cuello. Se cronometró el tiempo empleado desde que el sujeto comenzaba a localizar la MCT hasta que la marcaba con un rotulador. Resultados y conclusiones: Se encontró que el modelo con mayor índice de masa corporal y mayor perímetro cervical tenía una tasa de fracaso en la localización de un 70%, empleando, además, mayor tiempo, comparado con el modelo de características estándares

Introduction: Cricothyrotomy is a recommended technique to restore oxygenation in most of guidelines for difficult airway management. A correct location of the cricothyroid membrane (CTM) is fundamental for a proper performance of the technique. Several studies have shown poor accuracy with the identification the CTM by palpation, resulting in a high failure rate of the technique. Objective: The aim of this study was to determine the impact of the patient's neck morphology on the accurate location of the CTM and on the time employed. Materials and method: Observational study in which anaesthesiologists and intensivists voluntarily participated in a simulation that consisted of a «cannot intubate, cannot oxygenate» scenario, where they had to locate the CTM, as soon as possible, in 2 selected male patients with different morphological characteristics of the neck. The time was measured from the beginning of CTM palpation to locating it with a marker. Results and Conclusions: A higher body mass index and a higher neck circumference correlated with a 70% location failure rate and with a longer time as compared with a standard model

Locating the cricothyroid membrane in males: Influence of the morphological characteristics of the neck. / Localización de la membrana cricotiroidea en varones: influencia de las características morfológicas del cuello.

INTRODUCTION: Cricothyrotomy is a recommended technique to restore oxygenation in most of guidelines for difficult airway management. A correct location of the cricothyroid membrane (CTM) is fundamental for a proper performance of the technique. Several studies have shown poor accuracy with the identification the CTM by palpation, resulting in a high failure rate of the technique. OBJECTIVE: The aim of this study was to determine the impact of the patient's neck morphology on the accurate location of the CTM and on the time employed. MATERIALS AND METHOD: Observational study in which anaesthesiologists and intensivists voluntarily participated in a simulation that consisted of a «cannot intubate, cannot oxygenate¼ scenario, where they had to locate the CTM, as soon as possible, in 2 selected male patients with different morphological characteristics of the neck. The time was measured from the beginning of CTM palpation to locating it with a marker. RESULTS AND CONCLUSIONS: A higher body mass index and a higher neck circumference correlated with a 70% location failure rate and with a longer time as compared with a standard model.