Recomendaciones perioperatorias para los nuevos fármacos antifibróticos en la fibrosis pulmonar idiopática / Recommendations for perioperative management of new pharmacological antifibrotic therapy in idiopathic pulmonary fibrosis

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Sulodexida: un nuevo fármaco antitrombótico / Sulodexide: a new antithrombotic agent

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Eficacia de la ropivacaína 0, 1 % intraperitoneal en el control del dolor postoperatorio en cirugía ginecológica laparoscópica / Effectiveness of intraperitoneal 0.1% ropivacaine to control postoperative pain after undergoing gynaecological laparoscopic surgery

Introduccion: Determinar la eficacia de la administration pre-incisional de ropivacaina al 0,1 % intraperitoneal en el control del dolor abdominal y/o de hombro, durante la primera semana de la cirugia laparoscopica ginecologica benigna. Diseho: Ensayo clinico aleatorizado y doble ciego. Material y metodos: Se realizo un ensayo clinico aleatorizado y doble ciego donde participaron 64 pacientes ASA I-III sometidas a cirugia laparoscopica ginecologica por patologia benigna. Tras la realization del neumoperitoneo, se administraron 100 ml de ropivacaina 0,1 % o suero fisiologico intraperitoneal, dependiendo del grupo al que pertenecieran. Las pacientes recibieron, ademas, AINE junto con una bomba de PCA con option de morfina de rescate como analgesia multimodal asociada. Se evaluo el dolor abdominal y/o de hombro al despertar, en reposo y en movimiento, a los 5, 30, 60 y 120 minutos, asi como a las 24 horas. Se registro el consumo de morfina en las primeras 24 horas y la incidencia de nauseas y/o vomitos postoperatorios. A la semana, mediante encuesta telefonica, se registro la presencia de dolor de hombro a partir de las 24 horas, asi como de dolor abdominal persistente al 1° dia. Resultados: No se observaron diferencias significativas en el ENV durante las primeras 24 horas. Tampoco se observaron diferencias en el consumo de morfina, en la incidencia de nauseas y/o vomitos o en el dolor de hombro. Se evidenciaron diferencias estadisticamente significativas en la incidencia de dolor abdominal persistente al 7a dia (18,52 % en grupo tratamiento vs. 57,58 % en grupo control con p = 0,04). Conclusiones: La administration intraperitoneal preincisional de 100 ml de ropivacaina 0,1 % en comparacion con la administration de suero fisiologico, en el contexto de una tecnica anestesica y analgesica multimodal, no ha demostrado reducir el dolor postoperatorio, el consumo de opioides ni la incidencia de nauseas y vomitos postoperatorios en las primeras 24 horas. Tampoco ha demostrado reduction del dolor de hombro a partir del primer dia tras cirugia laparoscopica ginecologica. El uso de ropivacaina al 0,1 % intraperitoneal preincisional presenta una diminution estadisticamente significativa en la incidencia de dolor abdominal persistente al septimo dia de postoperatorio (AU)

Introduction: Determine the efficacy of preincisional ropivacaine 0,1 % intraperitoneal administration to control abdominal and/or shoulder pain after gynaecological laparoscopic surgery during the first week. Design: Randomized and double-blinded trial. Material and methods: 64 ASA I-III patients undergoing gy-naecological laparoscopic surgery for benign pathology were selected. After the pneumoperitoneum was done, 100 ml of 0.1 % ropivacaine or saline were administered intraperioteneally. Patients received multimodal analgesia. Besides, a morphine PCA pump with a bolus option was prescribed. Abdominal and/or shoulder pain were assessed, at rest and in motion, on waking up from anaesthesia, to 5,30,60 and 120 minutes and at 24 hours from the surgery. Morphine consumption were recorded in the first 24 hours and the presence of nausea and/or vomiting postoperatively. A week after the surgery, by a telephone survey, the shoulder pain after and the persistent abdominal pain on the seventh day was recorded. Results: No significant differences in the ENV scale during the first 24 hours were observed. No differences in morphine consumption, in the incidence of nausea and/or vomiting or shoulder pain were observed. Statistically significant differences were noted in the incidence of persistent abdominal pain on the seventh day (18.52 treatment group vs. 57,58 % in control group with a p value 0.04). Conclusions: The preincisional intraperitoneal administration of 100 ml of ropivacaine 0.1 % compared to administration of saline, in the context of an anesthetic and analgesic multimodal technique has not been shown to reduce postoperative pain, opioid consumption and the incidence of nausea and postoperative vomiting in the first 24 hours. Nor has it shown reduction of shoulder pain from the first day after undergoing gynecological laparoscopic surgery. Ropivacaine 0.1 % intraperitoneal preincisional may be useful in the control of abdominal pain which persists on the seventh day (AU)

Aclaración sobre el manejo perioperatorio de los IECA y ARA-II / Comment on perioperative managment of ACE inhibitors and ARBs

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Actualización en el tratamiento de la osteoporosis: algoritmo de decisión. Manejo desde una unidad del dolor (2.ª parte) / Update on the treatment of osteoporosis: Decision algorithm. Management from a unit of pain (II)

La heterogeneidad de los pacientes con osteoporosis hace necesaria una aproximación individualizada para conseguir un equilibrio entre los beneficios y limitaciones de los tratamientos disponibles. La indicación de este se realiza en función del riesgo absoluto de fractura por fragilidad. En los pacientes con un bajo riesgo de fractura son suficientes las medidas higiénicas, prevención de caídas y mantener una ingesta adecuada de calcio y vitamina D. En los pacientes con un riesgo moderado se debe individualizar la necesidad de tratamiento farmacológico e iniciar el tratamiento en aquellos con alto riesgo de fractura. Los fármacos más utilizados son los bifosfonatos, inhibidores de la reabsorción ósea, también se utilizan fármacos osteoanabólicos como la hormona teriparatida, y anticuerpos monoclonales como el denosumab. En los pacientes cuyo dolor no se controla de manera satisfactoria se ha de valorar la indicación de tratamientos mínimamente invasivos como bloqueos espinales, vertebroplastia o cifoplastia (AU)

The heterogeneity of patients with osteoporotic vertebral compression necessitates a tailored approach of balancing the benefits and limitations of available treatments. The indication for treatment is made based on the absolute risk of fragility fracture. In patients with a low risk of fracture are sufficient hygienic measures, preventing falls and maintaining an adequate intake of calcium and vitamin D. In patients with a moderate risk should be individualized drug treatment need and initiate treatment in those at high risk of fracture. The most commonly used drugs are bisphosphonates, inhibitors of bone resorption, also used as hormone teriparatide, osteoanabolic drug and monoclonal antibodies such as denosumab. In patients whose pain is not controlled can satisfactorily assessed the indication for minimally invasive treatments like vertebroplasty, kyphoplasty or spinal blocks (AU)

Actualización en el tratamiento de la osteoporosis. Manejo desde una unidad del dolor (1.ª parte) / Update on the treatment of osteoporosis: management from a unit of pain (I)

La osteoporosis (OP) se define como una enfermedad esquelética caracterizada por una resistencia ósea disminuida que predispone a un aumento en el riesgo de fracturas. En Europa se producen 2,7 millones de fracturas por fragilidad, tanto en hombres como mujeres, con un coste directo de 36 billones de euros. Estas fracturas se asocian con un incremento en la morbilidad y mortalidad. El riesgo de fractura osteoporótica viene determinado por la presencia de uno o más factores de riesgo y el descenso de la densidad mineral ósea (DMO) valorado mediante la técnica Dual Energy X-ray absortiometry (DEXA), densitometría. La indicación de tratamiento se realiza en función del riesgo absoluto de fractura por fragilidad. En los pacientes con un bajo riesgo de fractura son suficientes las medidas higiénicas, prevención de caídas y mantener una ingesta adecuada de calcio y vitamina D. En los pacientes con un riesgo moderado se debe individualizar la necesidad de tratamiento farmacológico e iniciar el tratamiento en aquellos con alto riesgo de fractura. Los fármacos más utilizados son los bifosfonatos, inhibidores de la reabsorción ósea, también se utilizan fármacos osteoanabólicos como la hormona teriparatida y anticuerpos monoclonales como el denosumab (AU)

Osteoporosis (OP) is defined as a skeletal disorder characterized by decreased bone strength, which predisposes to an increase in fracture risk. In Europe produced 2.7 million fragility fractures in both men and women with a direct cost of 36 billion euros. These fractures are associated with increased morbidity and mortality. The risk of osteoporotic fracture is determined by the presence of one or more risk factors and decreased bone mineral density (BMD) assessed by Dual Energy technique absortiometry X-ray (DEXA) densitometry. The indication for treatment is made based on the absolute risk of fragility fracture. In patients with a low risk of fracture are sufficient hygienic measures, preventing falls and maintaining an adequate intake of calcium and vitamin D. In patients with a moderate risk should be individualized drug treatment need and initiate treatment in those at high risk of fracture. The most commonly used drugs are bisphosphonates, inhibitors of bone resorption, also used as hormone teriparatide, osteoanabolic drug and monoclonal antibodies such as denosumab (AU)

[Fascia iliaca compartment block for analgesia following total hip replacement surgery]. / Bloqueo iliofascial para analgesia postoperatoria de prótesis total de cadera.

OBJECTIVE: The objective of this pilot study was to evaluate the effectiveness of the fascia iliaca compartment block to control pain following total hip replacement by assessing pain intensity 24 hours after surgery and recording the use of opiates for rescue analgesia. MATERIAL AND METHODS: We performed a prospective observational study of 41 patients undergoing total hip replacement surgery. The patients were divided into 2 groups: a group that received a fascia iliaca compartment block with 0.45% ropivacaine at a dosage of 0.3 mL/kg (maximum dose, 30 mL) and a control group in which no block was performed. Patients were enrolled consecutively as they entered the postanesthetic recovery unit. Postoperative pain was assessed on a visual analog scale (VAS) immediately after surgery and 24 hours later. Other variables recorded were opiate use for rescue analgesia and adverse effects due to the use of opiates. RESULTS: The VAS scores recorded in the postanesthetic recovery unit were significantly different in the 2 groups, with lower scores in the group receiving the fascia iliaca compartment block (P < .001). However, no significant between-group differences were observed in VAS scores recorded on the ward 24 hours after surgery (P = .57). CONCLUSIONS: A single-injection fascia iliaca compartment block was effective in controlling initial postoperative pain in a postanesthetic recovery unit. It was effective on the ward in the first few hours after surgery but not for the entire 24-hour period because of the limited duration of the block.

Bloqueo iliofascial para analgesia postoperatoria de prótesis totalde cadera / Fascia iliaca compartment block for analgesia following total hip replacement surgery

OBJETIVO: El objetivo de este estudio preliminar esmedir la efectividad del bloqueo iliofascial en el controldel dolor postoperatorio tras la colocación de prótesistotal de cadera, en cuanto a la intensidad del dolor 24horas tras la intervención y el consumo de opiáceos derescate.MATERIAL Y MÉTODOS: Estudio observacional, prospectivo,de cohortes, en el que se han incluido a 41 pacientesoperados de prótesis total de cadera, los cuales fuerondivididos en 2 grupos según se les practicara (grupo bloqueo)o no (grupo control) bloqueo iliofascial con ropivacaínaal 0,45%, 0,3 ml/kg (dosis máxima 30 ml). Se realizóun muestreo consecutivo simple según iban ingresandoen la Unidad de Recuperación Postanestésica. El dolorpostoperatorio se midió inmediatamente tras la intervencióny 24 horas después mediante una escala visual analógica.Otras variables de resultado evaluadas fueron elconsumo de opiáceos de rescate y la presencia de efectossecundarios derivados del uso de opiáceos.RESULTADOS: Se han encontrado diferencias estadísticamentesignificativas en las puntuaciones de la escalavisual analógica en la unidad de recuperación postanestésicaentre ambos grupos, obteniendo el grupo bloqueouna puntuación en la escala visual analógica menor queel grupo control (p < 0,001). Sin embargo, no hubo diferenciassignificativas entre ambos grupos respecto a laspuntuaciones de la escala visual analógica en la sala dehospitalización a las 24 horas (p = 0,57).CONCLUSIONES: El bloqueo iliofascial en inyecciónúnica es efectivo para el control del dolor postoperatorioinicial en la unidad de recuperación postanestésica. Posteriormenteen la sala es eficaz en las primeras horas deestancia, aunque no llega a cubrir las 24 horas por lalimitación de duración del bloqueo (AU)

OBJECTIVE: The objective of this pilot study was toevaluate the effectiveness of the fascia iliaca compartmentblock to control pain following total hip replacement byassessing pain intensity 24 hours after surgery andrecording the use of opiates for rescue analgesia.MATERIAL AND METHODS: We performed a prospectiveobservational study of 41 patients undergoing total hipreplacement surgery. The patients were divided into 2groups: a group that received a fascia iliaca compartmentblock with 0.45% ropivacaine at a dosage of 0.3 mL/kg(maximum dose, 30 mL) and a control group in which noblock was performed. Patients were enrolledconsecutively as they entered the postanesthetic recoveryunit. Postoperative pain was assessed on a visual analogscale (VAS) immediately after surgery and 24 hours later.Other variables recorded were opiate use for rescueanalgesia and adverse effects due to the use of opiates.RESULTS: The VAS scores recorded in thepostanesthetic recovery unit were significantly differentin the 2 groups, with lower scores in the group receivingthe fascia iliaca compartment block (P<.001). However,no significant between-group differences were observedin VAS scores recorded on the ward 24 hours aftersurgery (P=.57).CONCLUSIONS: A single-injection fascia iliacacompartment block was effective in controlling initialpostoperative pain in a postanesthetic recovery unit. Itwas effective on the ward in the first few hours aftersurgery but not for the entire 24-hour period because ofthe limited duration of the block (AU)

Interacciones farmacológicas de interés en anestesiología / Pharmacological interactions of interest in anesthesiology

Las interacciones medicamentosas farmacodinámicas y farmacocinéticas juegan un papel importante en la práctica clínica diaria. Además, muchos pacientes que van a ser operados reciben distintos fármacos que pueden alterar tanto la inducción como el mantenimiento y la recuperación de la anestesia. La anestesia depende de las interacciones medicamentosas. Las técnicas actuales para la inducción de anestesia general se basan en el uso de combinaciones de fármacos con capacidad aditiva o sinérgica, para disminuir las dosis de cada sustancia aislada

Pharmacodynamic and pharmacokinetic drug interactions play an important role in the daily clinical practice. Furthermore, many patients transferred to the operating theatre receive a variety of standard drugs that might potentially alter the course of induction and maintenance of anesthesia, as well as recovery. Anesthesia as a therapeutic goal is dependent on drug interactions. Currently, the standard techniques of inducing general anesthesia are based on the use of a combination of different drugs, with the aim of minimizing the dose of each substance using additive or synergistic drug interactions

[Silent pulmonary aspiration of barium after esophagogastroduodenography and subtotal gastrectomy]. / Aspiración pulmonar silente de bario tras esofagogastroduodenografía y gastrectomía subtotal.

We describe a 66-year-old patient who underwent subtotal gastrectomy and omentectomy for gastric adenocarcinoma six days after esophago-gastro-duodenography with barium contrast medium. In the postoperative period a series of chest films showed bronchogram due to aspiration of the contrast medium from the stomach, and finally multiple cottony infiltrates bilaterally. The patient had no respiratory symptoms and 6 days after admission to the intensive care recovery unit, he was moved to the general surgery ward for observation. Follow-up later passed to the outpatient with satisfactory evolution. We conclude that pulmonary aspiration occurred after extubation in the operating theater, since during the operation the patient remained stable hemodynamically and respiratorily. This case corroborates the theory of the existence of silent aspiration without pulmonary complications and the need to adjust clinical treatment, which can be conservative when, once the process is diagnosed, no symptoms present.

[Influence of needle bevel, age and sex on the appearance of post-puncture headaches]. / Influencia del bisel de la aguja, edad y sexo en la aparición de cefalea pospunción dural.

Two types of intradural needles, 25 gauge (Qincke bevel) and 24 gauge (Sprotte type bevel) in 535 intradural anaesthesias were compared. Sprotte type needle is a modification of the Withacre needle. Postspinal total headache had an incidence of 8.9%, being significantly less (p less than 0.01) with the Sprotte needles (4.9 versus 11.8%). Spinal headache were significantly more frequent in women and in patients with an age less than 40 years, and there was no significance between the two needles when patients were older than forty. We conclude that Sprotte bevel needle decreases significatively the incidence of post-puncture headache if the patients are younger than forty, but it is an important fact that the different factors involved: age, sex and needle type, might be taken into account when we need conclusions to be drawn.