GEDOS-SECOT consensus on the care process of patients with knee osteoarthritis and arthoplasty. / Consenso GEDOS-SECOT sobre el proceso de atención a pacientes con artrosis de rodilla e indicación de artroplastia.

OBJECTIVE: To develop recommendations on the evaluation and management procedure in patients undergoing total knee replacement based on best evidence and the experience of a panel of experts. METHODS: A multidisciplinary group of 12 experts was selected that defined the scope, users and the document parts. Three systematic reviews were performed in patients undergoing knee replacement: (i)efficacy and safety of fast-tracks; (ii)efficacy and safety of cognitive interventions in patients with catastrophic pain, and (iii) efficacy and safety of acute post-surgical pain management on post-surgical outcomes. A narrative review was conducted on the evaluation and management of pain sensitization, and about the efficacy and safety of pre-surgical physiotherapy. The experts generated the recommendations and explicative text. The level of agreement was evaluated in a multidisciplinary group of 85 experts with the Delphi technique. The level of evidence was established as well for each recommendation. RESULTS: A total of 20 recommendations were produced. An agreement higher than 80% was reached in all of them. We found the highest agreement on the need for a full discharge report, on providing proper information about the process and on following available guidelines. CONCLUSIONS: There is consensus among professionals involved in the management of patients undergoing total knee replacement, in that it is important to protocolize the replacement process, performing a proper, integrated and coordinated patient evaluation and follow-up, paying special attention to the surgical procedure and postoperative period.

SECOT-GEDOS consensus on pre-surgical pain management in knee and hip arthrosis.

OBJECTIVE: To develop recommendations, based on best evidence and experience, on pain management in patients undertaking total knee or hip replacement. METHODS: Nominal group methodology was followed. A group of experts was selected (5 orthopedics, 1 anesthesiologist), who defined the scope, users, topics, preliminary recommendations, and 3 systematic reviews: efficacy and safety of pre-surgical analgesia regarding to post-surgical pain, efficacy and safety of pre-emptive analgesia and pre-operative factors of post-operative pain. The level of evidence and grade of recommendation was established using the Oxford Centre for Evidence Based Medicine, and the level of agreement with the Delphi technique (2 rounds). The Delphi was extended to 39 orthopedics and anesthesiologists. The whole document was reviewed by all the experts. RESULTS: A total of 21 recommendations were produced. They include specific pharmacological treatment, as well as the evaluation and monitoring of patients on this treatment, and post-operative pre-emptive treatment. Agreement above 70% was reached in 19 recommendations. CONCLUSIONS: In patients undergoing total knee or hip replacement, a proper evaluation, follow-up, pharmacological and non-pharmacological treatment of predictors of poor surgical outcomes should be performed, especially those related to pre-operative pain. This can improve post-operative pain and surgery outcomes.

Tratamiento anestésico del neonato con atresia de esófago asociada a fístula traqueoesofágica y ano imperforado / Anesthetic management of a neonate with esophageal atresia, tracheoesophageal fistula and imperforate anus

La atresia de esófago es una malformación infrecuente (1:2.500-4.500 recién nacidos vivos), incompatible con la vida y una urgencia quirúrgica neonatal. El 30% de los pacientes son prematuros o presentan bajo peso al nacer y el 50% presentan anomalías asociadas, principalmente cardíacas. Las cardiopatías congénitas de orden mayor o el bajo peso al nacer son predictores independientes de mortalidad y eventos críticos perioperatorios. Presentamos el caso de un paciente intervenido de urgencia de atresia de esófago, fístula traqueoesofágica tipo iii b/C e imperforación anal. El objetivo de este artículo es la exposición de las consideraciones anestésicas en pacientes con esta afección, cuyo complejo manejo perioperatorio supone un importante reto y debe realizarse por equipos multidisciplinares con experiencia en neonatología. Establecer una vía aérea segura y obtener una ventilación pulmonar efectiva que minimice la fuga de aire al tracto digestivo debe ser uno de los objetivos prioritarios del manejo anestésico (AU)

Esophageal atresia is a rare condition (1:2,500-4,500), incompatible with life, and a surgical emergency in the neonatal period. It is associated with prematurity in 30% of cases, and to congenital abnormalities in 50% of cases, especially cardiac anomalies. Major congenital heart diseases and low weight are independent predictors of mortality and critical perioperative events. The aim of this article is to describe the most significant anaesthetic challenges presented in a case of a term neonate undergoing emergency surgery after being diagnosed with esophageal atresia, tracheoesophageal fistula type iiib/C, and imperforate anus. The major priorities during the anaesthetic management consist of establishing a safe airway and effective pulmonary ventilation that minimises air leakage to the upper digestive tract (AU)

[Anesthetic management of a neonate with esophageal atresia, tracheoesophageal fistula and imperforate anus]. / Tratamiento anestésico del neonato con atresia de esófago asociada a fístula traqueoesofágica y ano imperforado.

Esophageal atresia is a rare condition (1:2,500-4,500), incompatible with life, and a surgical emergency in the neonatal period. It is associated with prematurity in 30% of cases, and to congenital abnormalities in 50% of cases, especially cardiac anomalies. Major congenital heart diseases and low weight are independent predictors of mortality and critical perioperative events. The aim of this article is to describe the most significant anaesthetic challenges presented in a case of a term neonate undergoing emergency surgery after being diagnosed with esophageal atresia, tracheoesophageal fistula type iiib/C, and imperforate anus. The major priorities during the anaesthetic management consist of establishing a safe airway and effective pulmonary ventilation that minimises air leakage to the upper digestive tract.

Análisis de la no elección de la analgesia epidural durante el parto en las mujeres andaluzas / No disponible

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Evaluación y preparación psicológicas de los pacientes candidatos a terapias implantables para tratamiento del dolor crónico / Evaluation and psychological preparation of the patient candidates to implantables therapies for treatment of chronic pain

Las técnicas de neuroestimulación eléctrica Junto con las técnicas de infusión intratecal de fármacos, son el abordaje de elección para el tratamiento del dolor crónico refractario a otras terapias. La selección indiscriminada de pacientes, o la evaluación incompleta de éstos, conduce a un mayor número de fracasos del implante y por tanto de la terapia. La mayoría de expertos coinciden en que los factores psicológicos del paciente con dolor crónico deberían ser evaluados como parte de la intervención terapéutica antes y después de la realización de técnica en el marco de un abordaje multidisciplinar. En este artículo proponemos que además de la valoración se debería realizar la preparación psicológica de los pacientes para que afronten esta situación y obtener un mayor beneficio terapéutico. Se aborda también el papel que desempeña el psicólogo dentro del equipo, por qué es importante realizar una evaluación psicológica, cómo y cuándo debería tener lugar, así como las características específicas de ambas técnicas de neuromodulación. Creemos que la preparación psicológica del paciente con dolor crónico candidato al tratamiento mediante sistemas implantables podría ser un objetivo importante a tener en cuenta antes y después de las técnicas de implante para aquellos pacientes con mejor pronóstico de adaptación (AU)

Electric neurostimulation techniques along with intrathecal drugs infusión techniques are of choice for the treatment of chronic pain refractory to other therapies. An indiscriminate selection of patients, or their incomplete assessment, leads to increase the rate of implantation failure, and therefore of therapeutic failures. Most of experts agreed that psychological factors of the patient with chronic pain should be evaluated as part of the interventional pain management before and after to carry out the implant in the frame of a multidisciplinary approach. In this article, we propose to perform not only the psychological assessment but also a training of the patients so they face up this particular situation and that permit them to obtain better therapeutic results. Why is important to accomplish a psychological assessment, when and how should has to be done, and which are the particular profile for each one of the techniques, are other topics discussed here. We have reasons to believe that psychological training for the patient with chronic pain candidate to interventional therapy with implantable systems could be an important goal to bear in mind before and after to perform the implant for those patients with better adaptative prognostic profile (AU)

Analgesia del Trabajo de Parto con Remifentanilo por vía intravenosa mediante un Sistema de Analgesia Controlada por la Paciente (PCIA) / Labour analgesia with Remifentanil by PCIA

Objetivo: Valorar la eficacia analgésica y seguridad en el parto de Remifentanilo por vía intravenosa mediante un sistema deanalgesia controlada por la paciente.Material y MétodoEl grupo de estudio lo componen 25 gestantes sanas, primigestasa término, con parto eutócico instaurado, que solicitananalgesia durante el trabajo de parto.ResultadosSe produce un alivio significativo del dolor desde la primerahora de tratamiento en todos los casos. La analgesiase mantiene hasta el final en el 80% de los casos. El 20%restante solicitó anestesia regional en el período expulsivo.Se produjo un grado de sedación de leve a moderado durantetodo el estudio, que las pacientes valoraron positivamente.Solo en dos casos el grado de sedación fuemoderado-severo, a pesar de lo cual las gestantes decidieroncontinuar en el estudio. No se registraron efectos adversosmaterno-fetales. ConclusionesLa analgesia del parto con Remifentanilo por vía intravenosacontrolada por la paciente es un método efectivo y presentaun aceptable perfil de seguridad materno y fetal

Objective: To assess the analgesic efficacy of patient-controlled intravenousanalgesia with remifentanil and its potential side effectsduring labour.MethodWe analyzed 25 healthy nulliparas at full term pregnancy,in established uncomplicated labour, who demanded pain relief.ResultsAll the patients experienced a significant pain relief duringthe first hour of treatment which was maintained on untildelivery on 80%. The other 20% required additional regionalanaesthesia at the end of second stage. The level of sedationwas mild to moderate and treatment was well toleratedexcept for two, who presented heavy sedation. No maternalor neonatal side effects were registered.ConclusionsPatient-controlled intravenous analgesia with remifentanilis effective for labour pain relief and produces no major maternal and neonatal side effects (AU)

Analgesia del trabajo de parto con remifentanilo por vía intravenosa mediante un sistema de analgesia controlada por el paciente (PCIA) en un caso de esclerosis múltiple / Intravenous patient-controlled analgesia with remifentanil for labor and childbirth in a woman with multiple sclerosis

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Rotura espontánea y migración hacia la arteria bronquial de un catéter vascular central implantable / Spontaneous rupture of an implanted central venous catheter and migration to the bronchial artery

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Utilización de ketamina en el tratamiento del dolor agudo y crónico / Current use of ketamine for the treatment of acute and chrnic pain

La ketamina es un fármaco anestésico clásico escasamente utilizado en la actualidad para inducir o mantener anestesia, pero con una creciente indicación como analgésico para el tratamiento del dolor agudo y crónico. A pesar de que la ketamina se conoce ampliamente desde el punto de vista farmacológico y su efecto analgésico se atribuye principalmente al antagonismo de los receptores excitadores N-metil-D-aspartato, ofrece en la práctica clínica resultados muy dispares. La ausencia de diferentes formas de presentación del fármaco, contrasta con la amplia variedad de indicaciones y formas de administración que se siguen en la práctica, y las múltiples indicaciones, posologías, y combinaciones con otros analgésicos de primera línea. Esta heterogeneidad es en parte causante de los pobres resultados que se obtienen en muchos de los estudios, la mayoría de ellos con un bajo nivel de evidencia científica. La creciente demanda de nuevos analgésicos y sustancias neuromoduladoras en general para el tratamiento del dolor hace necesario estandarizar el uso de los mismos así como potenciar el desarrollo de nuevas fórmulas de utilización para los fármacos clásicos

Ketamine is an old drug, with low utilization as an anesthetic but an increasing indication in the treatment of acute and chronic pain. Its pharmacological properties and mechanism of action as N-methyl-D-aspartic acid (NMDA) receptor antagonist are well known, but in clinical practice it offers uneven results. Commercialized just as soluble ketamine for injection, it has been used in multiple indications, routes of administration, doses and in combination with many other first line analgesic drugs. This heterogeneity may be responsible for the poor results shown in many clinical studies, most of them with limited clinical evidence. An increasing demand for new analgesics and neuromodulators in general to treat pain, bring to us the need to standarize its regular use as well as to develop new ways of utilization for the old ones

[Obstetric analgesia for a patient with a history of 3 previous operations on the spine]. / Analgesia obstétrica en una paciente con tres cirugías previas de columna.

A history of spinal surgery is not currently considered a contraindication for regional obstetric analgesia. However, there are highly complex cases in which choosing the best analgesic technique presents genuine problems. We report the case of a woman in labor at full-term with 4-cm dilatation of the cervix who had undergone 3 operations for scoliosis and a herniated disk treated by T5-L4 and L4-sacral arthrodesis, laminectomy, and diskectomy. No previous anesthetic plan was in place, so we chose intravenous patient-controlled analgesia for labor and vaginal delivery and spinal anesthesia for a cesarean delivery. However, general anesthesia became necessary because it was impossible to reach the dura mater. The literature was reviewed to assess alternative forms of obstetric analgesia for patients who have undergone scoliosis surgery.

Analgesia obstétrica en una paciente con tres cirugías previas de columna / Obstetric analgesia for a patient with a history of 3 previous operations on the spine

En la actualidad se considera que la cirugía previa dela columna no es una contraindicación para la analgesiaobstétrica locorregional. No obstante, existen casos degran complejidad en los que la elección de la mejor técnicaanalgésica es un auténtico problema. Presentamosel caso de una gestante a término con trabajo de parto y4 centímetros de dilatación con el antecedente de 3 intervencionessobre columna, por escoliosis y hernia discal,a la que se había realizado artrodesis T5-L4, L4-sacro,laminectomía y discectomía. Sin un plan anestésico previo,optamos por PCA intravenosa para el trabajo departo y anestesia intradural para la cesárea, pero porimposibilidad técnica para alcanzar la duramadre fuenecesario recurrir a la anestesia general. La revisión dela bibliografía permite valorar las alternativas para laanalgesia obstétrica en pacientes sometidas a cirugíaprevia de la escoliosis

A history of spinal surgery is not currently considereda contraindication for regional obstetric analgesia.However, there are highly complex cases in which choosingthe best analgesic technique presents genuine problems.We report the case of a woman in labor atfull-term with 4-cm dilatation of the cervix who hadundergone 3 operations for scoliosis and a herniateddisk treated by T5-L4 and L4-sacral arthrodesis, laminectomy,and diskectomy. No previous anesthetic planwas in place, so we chose intravenous patient-controlledanalgesia for labor and vaginal delivery and spinalanesthesia for a cesarean delivery. However, generalanesthesia became necessary because it was impossibleto reach the dura mater. The literature was reviewed toassess alternative forms of obstetric analgesia forpatients who have undergone scoliosis surgery