Analgesia epidural obstétrica: fallos y complicaciones neurológicas de la técnica / No disponible

Objetivos: Estudiar la incidencia de fallos y complicaciones neurológicas de la analgesia epidural en obstetricia, así como hacer un seguimiento y análisis de las mismas. Pacientes y método: Estudio observacional prospectivo de gestantes que recibieron analgesia epidural para el trabajo de parto en un hospital terciario durante 2009 y 2010. Se registraron los datos demográficos maternoinfantiles, del trabajo de parto y el tipo de parto así como las complicaciones que se produjeron tanto durante la realización de la técnica como durante el peri- y postparto. Se siguieron a todas las pacientes hasta su alta hospitalaria identificándose y tratándose las posibles complicaciones hasta su resolución. Resultados: Se incluyeron 438 gestantes. Se dividieron las complicaciones en 2 etapas: peripartum y postpartum. En el periparto se identificaron, de mayor a menor frecuencia, las siguientes complicaciones: analgesia lateralizada (16,4%), punción hemática (8,7%), parestesias (8,2%), técnica dificultosa (5,2%), analgesia ineficaz (2,7%), hipotensión arterial (2,5%) y bloqueo subdural (0,2%). En el postparto: lumbalgia (18,5%), retención urinaria (3,4%), cefalea postpunción dural (1,4%), neuropatías periféricas (0,9%) e hipoestesia prolongada (0,2%). Todas las complicaciones se resolvieron ad integrum con tratamiento conservador salvo un caso de cefalea que precisó la realización de un parche hemático. Conclusiones: La alta tasa de fallos de la analgesia epidural en obstetricia así como la posibilidad de complicaciones neurológicas pueden resolverse siguiendo unas normas de buena práctica que incluyen la aspiración previa a la inyección, la dosis test y la revisión periódica del catéter. Resulta imprescindible conocer dichas complicaciones para su evaluación y tratamiento precoz (AU)

Objectives: To determine the incidence of failures and neurological complications related to the epidural analgesia for labour and to analyze their evolution and pathogenesis. Patients and methods: Prospective and descriptive study in pregnant women who received an epidural analgesia for labour in a third level hospital over a 11-month period. The following data were registered: demographic mother and child information, labour, type of childbirth and complications during the procedure and during the peripartum and postpartum periods. All women were followed up to their hospitable discharge with an identification and treatment of the observed complications up to their resolution. Results: We enrolled 438 patients. Complications were separated in 2 phases: peripartum and postpartum. In the peripartum period were identified, from bigger than minor frequency, the following complications: unilateral analgesia (16,4%), hematic punction (8.7%), paresthesias (8.2%), difficult technique (5.2%), ineffective analgesia (2.7%), hypotension (2.5%) and subdural block (0.2%). In the postpartum period: lumbar pain (18.5%), urinary retention (3.4%), post-dural puncture headache (1.4%), peripheral neurophaty (0.9%) and prolonged hypoesthesia (0.2%). All complications were resolved ad integrum by a conservative treatment except one patient who needed an epidural blood patching because of a refractory headache. Conclusions: The high frequency of failure of the epidural analgesia in obstetrics as well as the possibility of neurological complications can be solved following several norms of a good practice that include the previous aspiration to the injection, the test-dose and the continuous inspection of the catheter. It´s essential to know these complications for their evaluation and precocious treatment (AU)

Lesión de nervios periféricos en anestesia obstétrica: descripción de cuatro casos / No disponible

El abordaje neuroaxial es de elección para el control del dolor en obstetricia, pero no está exento de riesgos. Las neuropatías periféricas posparto pueden producirse por diferentes condiciones médicas, quirúrgicas y anestésicas, por lo que debemos tenerlas presentes para diagnosticarlas y tratarlas precozmente y así evitar que se atribuyan, por defecto, a la técnica anestésica. Presentamos cuatro casos que se diagnosticaron en el periodo periparto, 2 meralgias parestésicas, 1 neuropatía del femoral y 1 lumbociatalgia, de las cuales solo la lumbociatalgia pudo ser atribuida parcialmente a la técnica anestésica. Tras confirmar su diagnóstico se instauró tratamiento conservador que resolvió ad integrum, dentro de los primeros siete días, todas las neuropatías salvo la lumbociatalgia. La baja incidencia de neuropatías periféricas tras técnicas neuroaxiales en obstetricia puede ser superior a la que se diagnostica. Resulta imprescindible una buena anamnesis preanestésica y conocer los diferentes mecanismos fisiopatológicos que pueden desencadenar neuropatías periféricas (AU)

A neuroaxial approach is of choice for the management of pain in obstetrics but is not exempt of risks. Postpartum peripheral neuropathy may occur because of various medical, surgical, and anesthetic conditions, hence we should have them in mind in order to recognize them and treat them early enough to prevent their deffault attribution to the anesthetic technique. We report four cases diagnosed during the peripartum – 2 paresthetic meralgias, 1 femoral neuropathy, and 1 lumbosciatalgia, of which only the lumbosciatalgia could be partly attributed to the anesthetic technique. Once the diagnosis was confirmed a conservative therapy was initiated that solved ad integrum all neuropathies, except for the lumbosciatalgia episode, within seven days. The low incidence of peripheral neuropathy following neuroaxial techniques in obstetrics may be higher than diagnosed. Adequate history taking before anesthesia is crucial, as is an understanding of the various pathophysiological mechanisms that may trigger peripheral neuropathy (AU)

[Epidural analgesia in obstetrics: is there an effect on labor and delivery?]. / Analgesia epidural en obstetricia: cómo afecta al desarrollo y finalización del parto?

BACKGROUND AND OBJECTIVE: Epidural analgesia is routinely used in obstetrics but has been blamed for possible effects on labor that lead to greater use of instruments or conversion to cesarean delivery. We aimed to assess this possibility in a cohort of obstetric patients receiving or not receiving epidural analgesia. PATIENTS AND METHODS: Prospectively enrolled full-term obstetric patients were distributed in 2 groups according to whether they received epidural analgesia or not. We compared maternal and fetal characteristics, obstetric variables, and type of delivery between groups to record the likely causes of difficult labor and delivery and detect a possible influence of epidural analgesia. RESULTS: Of a total of 602 patients, 462 received epidural analgesia and 140 did not. Epidural analgesia was related to a higher rate of use of instruments but not cesareans (P < .01) and more frequent need for oxytocin (30.7% of the epidural analgesia group vs 0% of the group receiving no epidural analgesia, P < .001). The women receiving analgesia also had a longer mean (SD) duration of the dilatation phase of labor (6.4 [4.2] hours in the epidural group vs 4.7 [3.5] hours in the no-epidural group, P < .01) and of the expulsion phase (1.0 [0.6] hours vs 0.7 [0.6] hours, respectively; P<.01). We observed no effects on the incidence of tearing, rate of episiotomy, or other variables. Predictors of instrumentation or conversion to cesarean delivery were longer duration of the first phase (odds ratio [OR] 1.2; 95% confidence interval [CI], 1.1-1.3), longer duration of the second phase (OR 2.3; 95% CI, 1.3-3.9), and maternal obesity (OR, 1.1; 95% CI, 0.9-1.2). Previous deliveries and initiation of epidural analgesia after the fetus has reached Hodge's first plane decreased risk 2.7-fold and 3.03-fold, respectively. CONCLUSIONS: Although epidural analgesia has traditionally been associated with a higher incidence of difficult labor and delivery, this association was not unequivocally evident in this cohort of patients. The apparent increase seems to be attributable to such obstetric factors as longer duration of stages of labor, higher body mass index, and first delivery.

Analgesia epidural en obstetricia: ¿cómo afecta al desarrollo y finalización del parto? / Epidural analgesia in obstetrics: Is there an effect on labor and delivery?

Introducción: La analgesia epidural es el estándar de la analgesia obstétrica, pero se le atribuye una posible influencia en la dinámica del parto que puede provocar un aumento de los partos instrumentados y cesáreas. Nuestro objetivo fue valorar en una cohorte de pacientes obstétricas la finalización del parto en relación con el tipo de analgesia empleado. Pacientes y método: Estudio prospectivo de cohorte de gestantes a término divididas en 2 grupos. El grupo A recibió analgesia epidural y el grupo B no recibió analgesia epidural. Se compararon las variables demográficas materno-fetales, obstétricas y tipo de parto en cada grupo y se estudiaron la influencia de la analgesia epidural y las causas probables que provocaron partos distócicos. Resultados: Se incluyeron 602 pacientes: 462 en grupo A y 140 en grupo B. La analgesia epidural se relacionó con una mayor tasa de partos instrumentales pero no de cesáreas (p < 0,01), mayor necesidad de oxitócicos (30,7% en grupo A vs 0% en grupo B, p < 0,001) y una mayor duración de las fases del parto (fase de dilatación 6,4 ± 4,2 h en grupo A frente a 4,7 ± 3,5 h en grupo B y fase expulsivo 1,0 ± 0,6 h frente a 0,7 ± 0,6 h, p < 0,01), sin influir en la tasa de desgarros, episiotomías ni otras variables. La mayor duración del primer (OR 1,2 IC95% 1,1-1,3) y segundo estadios del parto (OR 2,3 IC95% 1,3-3,9) del trabajo de parto y la obesidad materna (OR: 1,1 IC95% 0,9-1,2) se relacionaron con aumento del riesgo de partos distócicos, mientras que la multiparidad e iniciar la analgesia epidural con una presentación en el I plano de Hodge o superior lo disminuyeron 2,7 y 3,03 veces respectivamente. Discusión: Pese a que clásicamente se ha relacionado la analgesia epidural con un aumento de partos distócicos, en nuestra cohorte dicha influencia es discutible. El posible incremento pareció deberse a factores obstétricos como mayor duración de los estadios del parto, mayor índice de masa corporal y la primiparidad(AU)

Background and objective: Epidural analgesia is routinely used in obstetrics but has been blamed for possible effects on labor that lead to greater use of instruments or conversion to cesarean delivery. We aimed to assess this possibility in a cohort of obstetric patients receiving or not receiving epidural analgesia. Patients and methods: Prospectively enrolled full-term obstetric patients were distributed in 2 groups according to whether they received epidural analgesia or not. We compared maternal and fetal characteristics, obstetric variables, and type of delivery between groups to record the likely causes of difficult labor and delivery and detect a possible influence of epidural analgesia. Results: Of a total of 602 patients, 462 received epidural analgesia and 140 did not. Epidural analgesia was related to a higher rate of use of instruments but not cesareans (P<.01) and more frequent need for oxytocin (30.7% of the epidural analgesia group vs 0% of the group receiving no epidural analgesia, P<.001). The women receiving analgesia also had a longer mean (SD) duration of the dilatation phase of labor (6.4 [4.2] hours in the epidural group vs 4.7 [3.5] hours in the no-epidural group, P<.01) and of the expulsion phase (1.0 [0.6] hours vs 0.7 [0.6] hours, respectively; P<.01). We observed no effects on the incidence of tearing, rate of episiotomy, or other variables. Predictors of instrumentation or conversion to cesarean delivery were longer duration of the first phase (odds ratio [OR] 1.2; 95% confidence interval [CI], 1.1-1.3), longer duration of the second phase (OR 2.3; 95% CI, 1.3-3.9), and maternal obesity (OR, 1.1; 95% CI, 0.9-1.2). Previous deliveries and initiation of epidural analgesia after the fetus has reached Hodge’s first plane decreased risk 2.7-fold and 3.03-fold, respectively. Conclusions: Although epidural analgesia has traditionally been associated with a higher incidence of difficult labor and delivery, this association was not unequivocally evident in this cohort of patients. The apparent increase seems to be attributable to such obstetric factors as longer duration of stages of labor, higher body mass index, and first delivery(AU)

Abordaje de la analgesia postoperatoria en cirugía de cadera: comparativa de 3 técnicas / Post-operative analgesia in hip surgery: a comparison of 3 techniques

Introducción. Resulta indispensable tratar el dolor postoperatorio de cirugía de cadera para iniciar una rehabilitación precoz y para disminuir la morbimortalidad. Dada la pluripatología y la edad de los pacientes, la analgesia locorregional se revela como el arma más eficaz para tratarlo. Objetivos. Valorar la eficacia del bloqueo iliofascial y del bloqueo de los nervios obturador y femorocutáneo frente a analgesia intravenosa, así como registrar el grado de satisfacción, las complicaciones, el inicio de rehabilitación y los costes económicos en cada grupo. Pacientes y método. Estudio prospectivo con 90 pacientes sometidos a cirugía de cadera. Se dividieron en tres grupos aleatorios: A: solo analgesia intravenosa; B: bloqueo iliofascial, y C: bloqueo de los nervios obturador y femorocutáneo lateral. Se investigó el grado de dolor y la satisfacción con la analgesia, el tiempo transcurrido hasta el inicio de la sedestación, el consumo total de analgésicos postoperatorios, los efectos secundarios y los costes económicos farmacéuticos en cada grupo. Resultados. La eficacia analgésica y el grado de satisfacción fueron significativamente mayores en los pacientes con bloqueos nerviosos (escala visual analógica [EVA] media 2,14±1,24, satisfacción 3,75±0,8) que en los que solo recibieron analgesia intravenosa (EVA media 5,57±0,64, satisfacción 2,83±0,7) (p<0,001), con una duración superior a las 24h (p<0,01) y un menor consumo de analgésicos suplementarios y otros fármacos que en el grupo A, por lo que tuvieron menos reacciones adversas (p<0,01), iniciaron la rehabilitación más precozmente (31,2±5,01h frente a 44,62±7,9h) (p<0,001) y supusieron un menor coste económico farmacéutico (13,26±6,34€/paciente frente a 30,26±1,88€/paciente), no encontrándose complicaciones en la realización de los bloqueos. No se encontraron diferencias significativas entre la eficacia de ambos bloqueos, evolución de las EVA media, grado de satisfacción ni gasto económico entre los pacientes que recibieron algún tipo de bloqueo. Conclusiones. Los bloqueos realizados son una técnica efectiva, fácil y segura, que proporciona numerosas ventajas: analgesia postoperatoria prolongada, recuperación más rápida, menor coste y escasas complicaciones (AU)

Introduction. The treatment of postoperative pain after hip surgery is essential for an early start of rehabilitation and for reducing morbidity and mortality. Given that patients are elderly and have multiple medical conditions, local-regional analgesia can be an effective approach. Objectives. Our aim was to compare the efficacy of the fascia iliaca compartment block, the obturator and femoral cutaneous nerve blocks and total intravenous analgesia in terms of level of patient satisfaction, complications, start of rehabilitation and cost in each group. Patients and methods. A prospective study of 90 patients undergoing hip surgery. Patients were randomised to receive intravenous analgesia only, fascia iliaca compartment block or blockade of the obturator and femoral cutaneous nerves. In each group we recorded visual analogue scale (VAS) pain scores, satisfaction with postoperative analgesia, time elapsed until start of rehabilitation, need for postoperative analgesics, side effects, and the cost of drugs. Results. Analgesia and level of patient satisfaction were significantly more effective in patients with nerve blocks than in those who received only intravenous analgesia (mean [SD] VAS scores, 2.14 [1.24], mean [SD] satisfaction scores 3.75 [0.8] and mean [SD] VAS scores, 5.57 [0.64], mean [SD] satisfaction scores 2.83 [0.7], respectively) (p<0.001). Patients with nerve blocks also had a pain-free period of more than 24h (p<0.01), needed fewer doses of supplementary analgesics or other drugs, had fewer side effects (p<0.01), started rehabilitation earlier (31.2 [5.01] hours vs. 44.62 [7.9] hours) (p<0.001), generated less expenditure (€13.26 [€6.34]/patient vs. €30.26 [€1.88]/patient), with no complications in the blocking techniques. No significant differences were found between the efficacy of both blocks, VAS scores, level of satisfaction or cost between the patients who received a block. Conclusions. The nerve blocks were effective, easy to perform, and safe. They afforded numerous advantages: extended period of postoperative analgesia, fast recovery, lower costs, and no complications (AU)

[Local and regional analgesia after pediatric surgery: study in 116 patients]. / Técnicas locorregionales para analgesia perioperatoria en anestesia pediátrica: estudio en 116 pacientes.

OBJECTIVES: Pain control is essential to patient comfort and reduced stress response, morbidity, and mortality after pediatric anesthesia. We assessed analgesic quality and the incidence of complications of regional blocks in combination with general anesthesia. MATERIAL AND METHODS: Prospective study of 116 patients under 3 years of age who underwent surgery in our hospital over a period of 2 years. The studied patients were classified in 3 groups according to whether they received general anesthesia only, a regional block by single injection, or a caudal nerve block via catheter. We recorded demographic and intraoperative variables, postoperative analgesic requirements, and the time the first postoperative analgesic dose was needed. RESULTS: Analgesia was significantly more effective in the patients who received either type of regional block. The patients who received general anesthesia alone needed supplemental analgesia earlier than the others (P < .001); patients with nerve blocks required fewer doses of rescue analgesics (P < .001). The incidence of complications was low and all were minor. No case of caudal catheter contamination occurred. CONCLUSIONS: Regional nerve blocks combined with general anesthesia in children are effective and safe. Advantages of providing nerve blocks include hemodynamic stability, prolonged postoperative analgesia, lower consumption of analgesics, and few complications.

Técnicas locorregionales para analgesia perioperatoria en anestesia pediátrica: estudio en 116 pacientes / Local and regional analgesia after pediatric surgery: study in 116 patients

OBJETIVOS: El tratamiento del dolor es imperativopara mejorar el confort del paciente y disminuir la respuestaal estrés y la morbi-mortalidad durante el periodopostoperatorio en anestesia pediátrica. En este estudioevaluamos la calidad analgésica y la incidencia decomplicaciones de los bloqueos regionales, asociados aanestesia general.MATERIAL Y MÉTODOS: Estudio prospectivo de 116pacientes menores de 3 años, intervenidos en nuestrohospital en un periodo de 2 años. Los pacientes se dividieronen 3 grupos: (A) sólo anestesia general, (B) bloqueoregional de punción única y (C) catéter caudal. Serecogieron las variables demográficas e intraoperatorias,la necesidad de analgésicos en el postoperatorio y elmomento en que se precisó la primera dosis analgésica.RESULTADOS: La eficacia analgésica fue significativamentemayor en los grupos B y C. Los pacientes del grupoA precisaron analgesia suplementaria más precozmenteque los de los grupos B y C (p < 0,001) y elnúmero de dosis de analgésicos de rescate fue significativamentemenor (p < 0,001). Se produjo una baja incidenciade complicaciones, todas ellas leves y ningunacontaminación de catéter caudal.CONCLUSIONES: Los bloqueos regionales asociados a laanestesia general en niños son efectivos y seguros puesproporcionan numerosas ventajas: estabilidad hemodinámica,analgesia postoperatoria prolongada, menorconsumo de analgésicos y escasas complicaciones(AU)

OBJETIVES: Pain control is essential to patient comfort and reduced stress response, morbidity, and mortality after pediatric anesthesia. We assessed analgesic quality and the incidence of complications of regional blocks in combination with general anesthesia. MATERIAL AND METHODS: Prospective study of 116 patients under 3 years of age who underwent surgery in our hospital over a period of 2 years. The studied patients were classified in 3 groups according to whether they received general anesthesia only, a regional block by single injection, or a caudal nerve block via catheter. We recorded demographic and intraoperative variables, postoperative analgesic requirements, and the time the first postoperative analgesic dose was needed. RESULTS: Analgesia was significantly more effective in the patients who received either type of regional block. The patients who received general anesthesia alone needed supplemental analgesia earlier than the others (P<.001); patients with nerve blocks required fewer doses of rescue analgesics (P<.001). The incidence of complications was low and all were minor. No case of caudal catheter contamination occurred. CONCLUSIONS: Regional nerve blocks combined with general anesthesia in children are effective and safe. Advantages of providing nerve blocks include hemodynamic stability, prolonged postoperative analgesia, lower consumption of analgesics, and few complications(AU)

Abordaje de la analgesia postoperatoria en cirugía de cadera: comparativa de 3 técnicas / Post-surgical analgesia in hip surgery: a comparison of three techniques

Introducción. Resulta indispensable tratar el dolor postoperatorio de cirugía de cadera para iniciar una rehabilitación precoz y para disminuir la morbimortalidad. Dada la pluripatología y edad de los pacientes, la analgesia locorregional se revela como el arma más eficaz para tratarlo. Objetivos. Valorar la eficacia del bloqueo iliofascial y del bloqueo de los nervios obturador y femorocutáneo frente a analgesia intravenosa, así como registrar el grado de satisfacción, las complicaciones, inicio de rehabilitación y costes económicos en cada grupo. Pacientes y método. Estudio prospectivo con 90 pacientes sometidos a cirugía de cadera. Se dividieron en 3 grupos aleatorios: A: solo analgesia intravenosa, B: bloqueo iliofascial y C: bloqueo de los nervios obturador y femorocutáneo lateral. Se investigó el grado de dolor y satisfacción analgésica, tiempo transcurrido hasta el inicio de la sedestación, necesidad de analgésicos postoperatorios, efectos secundarios y los costes económicos farmacéuticos en cada grupo. Resultados. La eficacia analgésica y el grado de satisfacción fueron significativamente mayores en los pacientes con bloqueos nerviosos (EVA medio 2,14±1,24, satisfacción 3,75±0,8) que en los que solo recibieron analgesia intravenosa (EVA medio 5,57±0,64, satisfacción 2,83±0,7) (p<0,001), con una duración superior a las 24h (p<0,01) y un menor consumo de analgésicos suplementarios y otros fármacos que en el grupo A, por lo que tuvieron menos reacciones adversas (p<0,01), iniciaron la rehabilitación más precozmente (31,2±5,01h vs 44,62±7,9h) (p<0,001) y supusieron un menor coste económico farmacéutico (13,26±6,34€/paciente vs 30,26±1,88€/paciente) no encontrándose complicaciones en la realización de los bloqueos. No se encontraron diferencias significativas entre la eficacia de ambos bloqueos, evolución de los EVAs medio, grado de satisfacción ni gasto económico entre los pacientes que recibieron algún tipo de bloqueo...(AU)

Introduction. The treatment of postoperative pain after hip surgery is essential for an early start of rehabilitation and for reducing morbidity and mortality. Given that patients are elderly and have multiple medical conditions, local-regional analgesia can be an effective approach. Objectives. Our aim was to compare the efficacy of the fascia iliaca compartment block, the obturator and femoral cutaneous nerve blocks and total intravenous analgesia in terms of level of patient satisfaction, complications, start of rehabilitation and cost in each group. Patients and methods. Prospective study of 90 patients undergoing hip surgery. Patients were randomised to receive intravenous analgesia only, fascia iliaca compartment block or blockade of the obturator and femoral cutaneous nerves. In each group, we recorded visual analogue scale (VAS) pain scores, satisfaction with postoperative analgesia, time elapsed until start of rehabilitation, need for postoperative analgesics, side effects, and the cost of drugs. Results. Analgesia and level of patient satisfaction were significantly more effective in patients with nerve blocks than in those who received intravenous analgesia only (mean [SD] VAS scores, 2.14 [1.24], mean [SD] satisfaction scores 3.75 [0.8] and mean [SD] VAS scores, 5.57[0.64], mean [SD] satisfaction scores 2.83[0.7], respectively) (p<0.001). Patients with nerve blocks also had a pain-free period of more than 24h (p<0.01), needed fewer doses of supplementary analgesics or other drugs, had fewer side effects (p<0.01), started rehabilitation earlier (31.2 [5.01]h vs 44.62 [7.9]h) (p<0.001), generated less expenditure (€13.26 [€6.34]/patient vs €30.26 [€1.88]/patient), with no complications in the blockade techniques. No significant differences were found between the efficacy of both blockades, VAS scores, level of satisfaction, or the cost between the patients who received a blockade...(AU)

Descripción de un caso de síndrome de hipoventilación-apnea alveolar central adquirido / No disponible

No disponible

Eficacia del bloqueo de los nervios obturador y femorocutáneo para analgesia postoperatoria en cirugía de cadera / Efficacy of obturator and femoral cutaneous nerve blocks for postoperative analgesia in hip surgery

OBJETIVOS: Tratar el dolor postoperatorio de fracturade cadera es imperativo para iniciar una rehabilitaciónprecoz y para disminuir la morbimortalidad. Dada la pluripatologíay edad de los pacientes, la analgesia locorregionalpuede ser eficaz para tratarlo. Los objetivos planteadosfueron valorar la eficacia analgésica del bloqueo delos nervios obturador y femorocutáneo frente a analgesiaintravenosa total, así como registrar el grado de satisfacción,las complicaciones, inicio de rehabilitación y costeseconómicos en cada grupo.PACIENTES Y MÉTODO: Estudio prospectivo en 75pacientes sometidos a cirugía de fractura de cadera. Sedividieron en 3 grupos distribuidos aleatoriamente, grupoA, recibió sólo analgesia intravenosa; grupo B, recibiódoble bloqueo, y grupo C recibió bloqueo del nervioobturador. Se investigó el grado de dolor y satisfaccióncon la analgesia postoperatoria, el tiempo transcurridohasta el inicio de la rehabilitación, necesidad de analgésicospostoperatorios, efectos secundarios y los costeseconómicos farmacéuticos en cada grupo.RESULTADOS: La eficacia analgésica fue significativamentemayor en los pacientes con bloqueos nerviosos(EVA medio 2,6±1,4) que en los que recibieron sólo analgesiaintravenosa (5,6±0,7), mostrando además un periodolibre de dolor de más de 24 horas (p<0,001), un menorconsumo de analgésicos suplementarios y otros fármacos,menos reacciones adversas (p<0,01), un inicio de la rehabilitaciónmás precoz (32,6±5,4h frente a 45,7±8,2h), unmenor coste económico (2,6±1,5 frente a 7,0±0,4 €/paciente)y una ausencia total de complicaciones de las técnicas.CONCLUSIONES: Los bloqueos realizados son una técnicaefectiva, fácil y segura que proporciona numerosasventajas: analgesia postoperatoria prolongada, recuperaciónmás rápida, menor coste y escasas complicaciones(AU)

OBJECTIVES: The treatment of pain after surgery torepair a hip fracture is essential for an early start ofrehabilitation and for reducing morbidity and mortality.Given that patients are elderly and have multiplemedical conditions, local-regional analgesia can be aneffective approach. Our aim was to compare the efficacyof obturator and femoral cutaneous nerve blocks andtotal intravenous analgesia in terms of level of patientsatisfaction, complications, start of rehabilitation, andcost.PATIENTS AND METHODS: Prospective study of 75patients undergoing surgery to repair hip fractures.Patients were randomized to receive intravenousanalgesia only, blockade of both nerves, or blockade ofonly the obturator nerve. In each group we recordedvisual analog scale (VAS) pain scores, satisfaction withpostoperative analgesia, time elapsed until start ofrehabilitation, need for postoperative analgesics, sideeffects, and the cost of drugs.RESULTS: Analgesia was significantly more effective inpatients with nerve blocks than in those who receivedonly intravenous analgesia (mean [SD] VAS scores, 2.6[1.4] and 5.6 [0.7], respectively). Patients with nerveblocks also had a pain-free period of more than 24 hours(P<.001), needed fewer doses of supplementaryanalgesics or other drugs, had fewer side effects (P<.01),started rehabilitation earlier (32.6 [5.4] hours vs 45.7[8.2] hours), generated less expenditure (€2.6[€1.5]/patient vs €7.0 [€0.4]/patient). The testedtechniques had no complications.CONCLUSIONS: The nerve blocks were effective, easy toperform, and safe. They afforded numerous advantages:extended period of postoperative analgesia, fastrecovery, lower costs, and no complications(AU)

Refeeding syndrome.

Refeeding syndrome is a complex syndrome that occurs as a result of reintroducing nutrition (oral, enteral or parenteral) to patients who are starved or malnourished. Patients can develop fluid-balance abnormalities, electrolyte disorders (hypophosphataemia, hypokalaemia and hypomagnesaemia), abnormal glucose metabolism and certain vitamin deficiencies. Refeeding syndrome encompasses abnormalities affecting multiple organ systems, including neurological, pulmonary, cardiac, neuromuscular and haematological functions. Pathogenic mechanisms involved in the refeeding syndrome and clinical manifestations have been reviewed. We provide suggestions for the prevention and treatment of refeeding syndrome. The most important steps are to identify patients at risk, reintroduce nutrition cautiously and correct electrolyte and vitamin deficiencies properly.

Síndrome de realimentación / Refeeding syndrome

El síndrome de realimentación (SR) es un cuadro clínico complejo que ocurre como consecuencia de la reintroducción de la nutrición (oral, enteral o parenteral) en pacientes malnutridos. Los pacientes presentan trastornos en el balance de fl uidos, anomalías electrolíticas —como hipofosfatemia, hipopotasemia e hipomagnesemia— alteraciones en el metabolismo hidrocarbonado y déficits vitamínicos. Esto se traduce en la aparición de complicaciones neurológicas, respiratorias, cardíacas, neuromusculares y hematológicas. En este artículo se han revisado la patogenia y las características clínicas del SR, haciendo alguna sugerencia para su prevención y tratamiento. Lo más importante en la prevención del SR es identificar a los pacientes en riesgo, instaurar el soporte nutricional de forma prudente y realizar una corrección adecuada de los déficits de electrolitos y vitaminas (AU)

Refeeding syndrome is a complex syndrome that occurs as a result of reintroducing nutrition (oral, enteral or parenteral) to patients who are starved or malnourished. Patients can develop fluid-balance abnormalities, electrolyte disorders (hypophosphataemia, hypokalaemia and hypomagnesaemia), abnormal glucose metabolism and certain vitamin defi ciencies. Refeeding syndrome encompasses abnormalities affecting multiple organ systems, including neurological, pulmonary, cardiac, neuromuscular and haematological functions. Pathogenic mechanisms involved in the refeeding syndrome and clinical manifestations have been reviewed. We provide suggestions for the prevention and treatment of refeeding syndrome. The most important steps are to identify patients at risk, reintroduce nutrition cautiously and correct electrolyte and vitamin defi ciencies properly (AU)

[Efficacy of obturator and femoral cutaneous nerve blocks for postoperative analgesia in hip surgery]. / Eficacia del bloqueo de los nervios obturador y femorocutáneo para analgesia postoperatoria en cirugía de cadera.

OBJECTIVES: The treatment of pain after surgery to repair a hip fracture is essential for an early start of rehabilitation and for reducing morbidity and mortality. Given that patients are elderly and have multiple medical conditions, local-regional analgesia can be an effective approach. Our aim was to compare the efficacy of obturator and femoral cutaneous nerve blocks and total intravenous analgesia in terms of level of patient satisfaction, complications, start of rehabilitation, and cost. PATIENTS AND METHODS: Prospective study of 75 patients undergoing surgery to repair hip fractures. Patients were randomized to receive intravenous analgesia only, blockade of both nerves, or blockade of only the obturator nerve. In each group we recorded visual analog scale (VAS) pain scores, satisfaction with postoperative analgesia, time elapsed until start of rehabilitation, need for postoperative analgesics, side effects, and the cost of drugs. RESULTS: Analgesia was significantly more effective in patients with nerve blocks than in those who received only intravenous analgesia (mean [SD] VAS scores, 2.6 [1.4] and 5.6 [0.7], respectively). Patients with nerve blocks also had a pain-free period of more than 24 hours (P < .001), needed fewer doses of supplementary analgesics or other drugs, had fewer side effects (P < .01), started rehabilitation earlier (32.6 [5.4] hours vs 45.7 [8.2] hours), generated less expenditure (2.6 Euros [1.5 Euros]/patient vs 7.0 Euros [0.4 Euros]/patient). The tested techniques had no complications. CONCLUSIONS: The nerve blocks were effective, easy to perform, and safe. They afforded numerous advantages: extended period of postoperative analgesia, fast recovery, lower costs, and no complications.

[Hyponutrition prevalence among patients with digestive neoplasm before surgery]. / Prevalencia de desnutrición en pacientes con neoplasia digestiva previa cirugía.

OBJECTIVE: To analyze the prevalence and degree of hyponutrition among patients with resectable digestive neoplasm that will be submitted to surgery. MATERIAL AND METHODS: Observational cross-sectional descriptive study carried out from november of 2005 to march of 2006, assessing the nutritional status of all patients aged > or = 18 years with resectable digestive neoplasm submitted to scheduled surgery at the General and Digestive Surgery Department of the Hospital Complex of Orense (Spain). Eighty patients were studied, 41 men and 39 women aged 27-92 years. RESULTS: Diagnosis categorization was as follows: colonic neoplasm 27 patients, rectal neoplasm 24, gastric neoplasm 23, and pancreatic neoplasm 6. Fifty-three percent of the patients assessed had lost 5% of their usual weight within the previous 3 months. Serum albumin levels were lower than 3.5 mg/dL in 49% of the cases. Patient-Generated Subjective Global Assessment shows a hyponutrition prevalence of 50% (29% with moderate hyponutrition or at risk for hyponutrition and 21% with severe hyponutrition). Hyponutrition was related to age, increasing with increasing age (p < 0.05), and to the kind of digestive neoplasm (higher prevalence among patients with gastric neoplasm). CONCLUSIONS: Hyponutrition prevalence among patients with resectable digestive neoplasm is high. There is a similarity between the relative data relating to percentage of weight loss, serum albumin levels, and nutritional assessment obtained by applying the Patient-Generated Subjective Global Assessment. Further studies on hyponutrition prevalence among oncologic patients at our setting would be desirable.

Prevalencia de desnutrición en pacientes con neoplasia digestiva previa cirugía / Hyponutrition prevalence among patients with digestive beoplasm befote surgery

Objetivo: Analizar la prevalencia y el grado de desnutrición de los pacientes con neoplasia digestiva resecable que van a ser sometidos a intervención quirúrgica. Material y método: Estudio transversal, observacional y descriptivo de noviembre de 2005 a marzo de 2006 basado en la valoración nutricional de todos los pacientes mayores de edad con neoplasia digestiva resecable programados para intervención quirúrgica en el Servicio de Cirugía General y Digestiva del Complexo Hospitalario de Ourense. Se incluyeron 80 pacientes, 41 hombres y 39 mujeres de edades comprendidas entre los 27 y los 92 años. Resultados: La distribución por diagnósticos fue la siguiente: neoplasia de colon 27 pacientes, neoplasia de recto 24, neoplasia gástrica 23 y neoplasia pancreática 6. El 53% de los pacientes valorados había perdido más de un 5% de su peso habitual en los 3 meses previos. Las cifras de albúmina plasmática eran inferiores a 3,5 mg/dl en el 49% de los casos. La Valoración Global Subjetiva Generada por el Paciente muestra una prevalencia de desnutrición del 50% (29% desnutrición moderada o riesgo de desnutrición y 21% desnutrición severa). La desnutrición se relacionó con la edad, siendo más frecuente al aumentar ésta (p < 0,05) y con el tipo de neoplasia digestiva (mayor prevalencia en pacientes con neoplasia gástrica). Conclusiones: La prevalencia de desnutrición en pacientes con neoplasia digestiva resecable es elevada. Existe similitud entre los datos relativos al porcentaje de pérdida de peso, cifras de albúmina plasmática y valoración nutricional obtenida al aplicar la Valoración Global Subjetiva Generada por el Paciente. Sería deseable que se realizasen más estudios de prevalencia de desnutrición en pacientes oncológicos en nuestro medio (AU)

Objective: To analyze the prevalence and degree of hyponutrition among patients with resectable digestive neoplasm that will be submitted to surgery. Material and methods: Observational cross-sectional descriptive study carried out from november of 2005 to march of 2006, assessing the nutritional status of all patients aged ≥18 years with resectable digestive neoplasm submitted to scheduled surgery at the General and Digestive Surgery Department of the Hospital Complex of Orense (Spain). Eighty patients were studied, 41 men and 39 women aged 27-92 years. Result: Diagnosis categorization was as follows: colonic neoplasm 27 patients, rectal neoplasm 24, gastric neoplasm 23, and pancreatic neoplasm 6. Fifty-three percent of the patients assessed had lost 5% of their usual weight within the previous 3 months. Serum albumin levels were lower than 3.5 mg/dL in 49% of the cases. Patient-Generated Subjective Global Assessment shows a hyponutrition prevalence of 50% (29% with moderate hyponutrition or at risk for hyponutrition and 21% with severe hyponutrition). Hyponutrition was related to age, increasing with increasing age (p < 0.05), and to the kind of digestive neoplasm (higher prevalence among patients with gastric neoplasm). Conclusion: Hyponutrition prevalence among patients with resectable digestive neoplasm is high. There is a similarity between the relative data relating to percentage of weight loss, serum albumin levels, and nutritional assessment obtained by applying the Patient-Generated Subjective Global Assessment. Further studies on hyponutrition prevalence among oncologic patients at our setting would be desirable (AU)