Analgesia epidural postoperatoria: ¿cuál es su papel en la práctica anestésica actual? / Postoperative epidural analgesia: what is its role in current anesthetic practice?

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Nuevos enfoques en el tratamiento del dolor agudo Postoperatorio / New approaches in the treatment of acute postoperative pain

El control eficaz del dolor postoperatorio se ha convertido en una parte esencial de los cuidados perioperatorios y su adecuado tratamiento, junto a otros factores como la movilización y la nutrición precoz, se relacionan directamente con la disminución de las complicaciones postoperatorias y de la estancia hospitalaria. En la actualidad se presentan diversos retos en el campo del tratamiento del DAP, que precisarán de nuevos enfoques y nuevas alternativas terapéuticas. Los protocolos analgésicos específicos para cada tipo de intervención quirúrgica, adaptados al contexto organizativo y de práctica clínica hospitalaria, son una garantía para individualizar los tratamientos y responder adecuadamente a las demandas analgésicas de cada paciente. Entre las recomendaciones de las recientes Guías del manejo del Dolor Agudo Postoperatorio de la American Pain Society (APS) destacamos: el uso de la analgesia multimodal, la analgesia regional y epidural en procedimientos específicos, las mínimas dosis de opioides y la preferencia de la vía oral frente a la intravenosa, y la modalidad de PCA. Ante la epidemia de consumo de opioides, las recomendaciones actuales se basan en minimizar la dosis de opioide postoperatorio, aplicar pautas multimodales y retirarlos precozmente cuando puedan ser sustituidos por otros analgésicos. En los programas de cirugía fast-track, el inicio precoz de la deambulación, de la fisioterapia o de la rehabilitación son factibles con un nivel moderado de dolor. Pretender eliminar totalmente el dolor en estos programas de fast-track puede asociarse a inmovilidad del paciente o a efectos secundarios de los analgésicos que retrasen la recuperación. Se han desarrollado nuevos dispositivos de administración de opioides no invasivos o «needel-free», con el fin de eliminar las desventajas de la morfina intravenosa. Las ventajas teóricas se basan en una mayor movilidad y satisfacción del paciente, en la autoadministración y en un mejor perfil farmacológico. Son opioides de inicio rápido y acción prolongada, sin metabolitos activos, por lo que teóricamente tienen un perfil farmacológico más eficaz y seguro. Estas nuevas alternativas podrían sustituir a la administración de la PCA de morfina a bolos en la cirugía mayor laparoscópica o en la cirugía de columna vertebral, entre otras. También podrían jugar un papel de analgesia de transición, en la retirada precoz de los catéteres epidurales o paravertebrales en cirugía torácica o en cirugía vascular (AU)

Effective control of postoperative pain, as well as other factors such as early mobilization and nutrition, are directly related to the reduction of postoperative complications and hospital stay, and have become an essential part of perioperative care There are actually several challenges in the field of the treatment of DAP, which require new approaches and therapeutic alternatives. The specific analgesic protocols for each type of surgery, adapted to the organizational context and clinical practice, are a guarantee to individualize the treatments and appropriately respond to the analgesic demands of any patient. Among the recommendations of the recent Guidelines for the Management of Acute Postoperative Pain of the American Pain Society (APS), we highlight: the use of Multimodal Analgesia, Regional and Epidural Analgesia in specific procedures, the minimum possible doses of opioids, the preference of the oral versus intravenous route, and PCA modality. Faced with the epidemic use of opioids, the current recommendations are based on minimizing the dose of postoperative opioids, together with, applying multimodal guidelines and early withdrawing, when they can be replaced by other analgesics. In fast-track surgery programs, the early onset of ambulation, physical therapy and/or rehabilitation are feasible with a moderate level of pain. Attempting to eliminate completely the pain in these fast-track programs can be associated with patients immobility, or analgesic side effects that may delay patients recovery. New devices for administering non-invasive opioids or «needel-free» have been developed in order to eliminate the disadvantages of intravenous morphine. The theoretical advantages are based on greater mobility and patient satisfaction, self-administration and a better pharmacological profile. They are fast onset opioids with a prolonged action and without active metabolites, which offer a theoretically more effective and safe pharmacological profile. These new alternatives could replace the administration of morphine PCA to boluses, in major laparoscopic surgery or in spinal surgery, among others. They may also play a role in the transition analgesia, in situations such as early withdrawal of epidural or paravertebral catheters in thoracic or vascular surgery (AU)

Estenosis de arteria subclavia: importancia de medir la presión arterial en ambas extremidades y su asociación con el riesgo cardiovascular / Subclavian artery stenosis: Importance of measuring blood pressure in both limbs and its association with cardiovascular risk

La incidencia de la estenosis de la arteria subclavia oscila entre el 3-4% en la población general. Una diferencia de presión arterial de mayor o igual a 10 mmHg entre ambas extremidades superiores sugiere el diagnóstico. La angiografía es la prueba diagnóstica definitiva y el control de los factores de riesgo cardiovascular es obligado. El abordaje quirúrgico es el tratamiento de elección en pacientes sintomáticos. Describimos un caso de estenosis crítica de la arteria subclavia izquierda, resuelta con angioplastia endovascular

The incidence of subclavian artery stenosis ranges from 3-4% in the general population. A blood pressure difference of ≥10 mmHg between both upper limbs suggests the diagnosis. Angiography is the gold standard test, control of cardiovascular risk factors being obligatory. The surgical approach is the treatment of choice in symptomatic patients. We describe a case of critical stenosis of the left subclavian artery resolved by endovascular angioplasty

Selective vitamin D receptor activation as anti-inflammatory target in chronic kidney disease.

Paricalcitol, a selective vitamin D receptor (VDR) activator used for treatment of secondary hyperparathyroidism in chronic kidney disease (CKD), has been associated with survival advantages, suggesting that this drug, beyond its ability to suppress parathyroid hormone, may have additional beneficial actions. In this prospective, nonrandomised, open-label, proof-of-concept study, we evaluated the hypothesis that selective vitamin D receptor activation with paricalcitol is an effective target to modulate inflammation in CKD patients. Eight patients with an estimated glomerular filtration rate between 15 and 44 mL/min/1.73 m(2) and an intact parathyroid hormone (PTH) level higher than 110 pg/mL received oral paricalcitol (1 µg/48 hours) as therapy for secondary hyperparathyroidism. Nine patients matched by age, sex, and stage of CKD, but a PTH level <110 pg/mL, were enrolled as a control group. Our results show that five months of paricalcitol administration were associated with a reduction in serum concentrations of hs-CRP (13.9%, P < 0.01), TNF-α (11.9%, P = 0.01), and IL-6 (7%, P < 0.05), with a nonsignificant increase of IL-10 by 16%. In addition, mRNA expression levels of the TNFα and IL-6 genes in peripheral blood mononuclear cells decreased significantly by 30.8% (P = 0.01) and 35.4% (P = 0.01), respectively. In conclusion, selective VDR activation is an effective target to modulate inflammation in CKD.

Serum and gene expression profile of tumor necrosis factor-alpha and interleukin-6 in hypertensive diabetic patients: effect of amlodipine administration.

Pro-inflammatory cytokines are critical factors in type 2 diabetes-associated atherosclerosis. We aim to analyze in hypertensive type 2 diabetic patients the serum concentrations and the mRNA expression levels in peripheral blood mononuclear cells (PBMC) of the pro-inflammatory cytokine tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6), as well as to evaluate the effect of amlodipine administration. Twenty-one hypertensive diabetic patients and 10 healthy non-diabetic controls were included in the study. Serum levels of cytokines were measured by chemiluminescent immunometric assay, and mRNA expression levels by RT-PCR. The mean serum concentrations of TNF-alpha and IL-6 in diabetic patients showed a 6.1-fold and 2.9-fold increase with respect to non-diabetic control subjects, respectively (p less than 0.0001). Likewise, there was a 3.3- and a 4-fold increase in the PBMC mRNA expression level of TNF-alpha and IL-6 (p less than 0.0001) in diabetic subjects. After amlodipine administration, a significant decrease (p less than 0.01) was observed in the serum TNF-alpha and IL-6 levels. In addition, pre-treatment mRNA expression of TNF-alpha and IL-6 also decreased, with a mean percent reduction of 26 percent (p less than0.01) and 25 percent (p less than 0.001), respectively. In conclusion, serum concentrations and PBMC mRNA expression levels of TNF-alpha and IL-6 are significantly elevated in hypertensive type 2 diabetic patients. Administration of amlodipine is associated with a significant reduction of the increased levels of these inflammatory parameters, both at the protein as well as at the transcriptional level. These modulatory effects of amlodipine on proinflammatory cytokine level and expression may be related to its suggested anti-atherosclerotic actions.

Novedades en el campo de los factores de progresión en la Enfermedad Renal Crónica / No disponible

La lucha contra la progresión de la enfermedad renal crónica es uno de los aspectos más relevantes de la práctica nefrológica, tanto desde la perspectiva de la actividad clínica como desde el campo de la investigación dentro del campo de la Nefrología. En este breve artículo presentamos, de forma muy resumida, algunos de los aspectos que a los autores nos han resultado de interés en el último año en este contexto. Dado que lo que en estas pocas páginas se recoge ha de pasar de forma obligada por el filtro de la subjetividad de quien escribe, asumimos que otros muchos temas de gran interés quedan fuera de este resumen. En cualquier caso, esperamos que lo aquí publicado sea de interés y utilidad, y al mismo tiempo, sirva como elemento de debate en los foros nefrológicos (AU)

The fight against chronic kidney disease is one of the most relevant aspects of nephrological practice, from both the perspective of clinical activity and research within the field of nephrology. In this brief article, we present in very summarized form some of the aspects in this field in the last year that the authors found of interest. Because the content of the next few pages was necessarily chosen on the basis of the authors’ preferences, we assume that many other topics of great interest have been left out of this summary. In any case, we hope that this article will be interesting and useful and also serve as an subject of debate in nephrology forums (AU)

[Novelties in the field of progression factors in chronic kidney disease]. / Novedades en el campo de los factores de progresión en la Enfermedad Renal Crónica.

The fight against chronic kidney disease is one of the most relevant aspects of nephrological practice, from both the perspective of clinical activity and research within the field of nephrology. In this brief article, we present in very summarized form some of the aspects in this field in the last year that the authors found of interest. Because the content of the next few pages was necessarily chosen on the basis of the authors' preferences, we assume that many other topics of great interest have been left out of this summary. In any case, we hope that this article will be interesting and useful and also serve as an subject of debate in nephrology forums.

[Characteristics of the diabetic patients referred for the first time to the nephrologist]. / Características de los pacientes diabéticos referidos por primera vez a las consultas de atención especializada de Nefrología.

BACKGROUND: Diabetic nephropathy (DN) has become the main cause of end-stage renal disease. In our country, this problem is specially relevant in Canary Islands, where DN is the cause of renal failure in 39% of patients included in dialysis programs. The importance of this situation and the relevance of an adequate referral to the nephrologist, prompt us to study the characteristics of diabetic patients referrred to our outpatient clinic. SUBJECTS AND METHODS: One-hundred and fifty patients with diabetes consecutively referred to the outpatient nephrology clinic at the Hospital Universitario Nuestra Señora de Candelaria were included in the study. We analysed demographic and epidemiologic characteristics, therapeutic strategies, as well as serum and urine biochemical parameters. RESULTS: Ninety-eight percent of patients suffered from type 2 diabetes, and 90% were referred by the primary physician. Renal insufficiency and proteinuria were the main causes of referral (48% and 30.6%, respectively). Overweight or obesity were present in 82.6% of patients, 97% were hypertensive and 92.6% presented dyslipidemia. Medical history of cardiovascular disease was present 16% of patients. Two-thirds of patients had a creatinine clearance below 60 ml/min. One-third of patients did not receive therapy with blockers of the renin-angiotensin system, and only 37% were treated with statins. CONCLUSIONS: An elevated percentage of diabetic patients referred to nephrologist did not reach the recommended therapeutic goals. These findings prompt us to reflect on the therapeutic approach in these patients and the referral to the nephrologist.

Características de los paciente diabéticos referidos por primera vez a las consultas de atención especializada de Nefrología / Characteristics of the diabetic patients referred for the first time to the nephrologist

Introducción: La nefropatía diabética (ND) se ha convertido en la primera causa de insuficiencia renal crónica en nuestro país. Esta patología es especialmente relevante en las Islas Canarias, donde el porcentaje de pacientes en programas de diálisis con ND como enfermedad de base era a 31 de diciembre de 2005 del 39%. Dada la importancia de esta situación, y la trascendencia que en los últimos años ha cobrado la problemática relacionada con la remisión de los pacientes con enfermedad renal a los servicios de Nefrología, el objetivo del presente estudio ha sido analizar las características de la población diabética que es derivada a las unidades de atención especializada de Nefrología. Pacientes y Métodos: Estudio de los 150 primeros pacientes diabéticos que, a partir de octubre de 2001, fueron remitidos de forma consecutiva a las consultas de Nefrología del Hospital Universitario Nuestra Señora de Candelaria de Santa Cruz de Tenerife. Se realizó una historia clínica y exploración física completas, se recogieron datos relativos a las pautas terapéuticas, se realizó una analítica de sangre y orina de 24 horas. Resultados: El 98% de los pacientes eran diabéticos tipo 2, y en el 90% de los casos fueron remitidos por su médico de Atención Primaria. La presencia de insuficiencia renal y de proteinuria fueron los dos motivos más frecuentes de derivación (48% y 30,6%, respectivamente). El 82,6% de los pacientes presentaba sobrepeso u obesidad, el 88% hipertensión arterial y el 92,6% dislipemia. Un 16% de los pacientes 6% presentaba algún antecedente de enfermedad cardiovascular. Dos tercios de los pacientes presentaban un aclaramiento de creatinina inferior a 60 ml/min. Un tercio de los pacientes no recibían tratamiento con bloqueadores del sistema renina-angiotensina, y sólo un 37% estaban tratados con estatinas. Conclusiones: Un elevado porcentaje de los pacientes diabéticos remitidos a los Servicios de Nefrología no presenta un cumplimiento adecuado de los objetivos terapéuticos. Es preciso reflexionar sobre la actitud terapéutica en estos pacientes y su remisión al nefrólogo

Background: Diabetic nephropathy (DN) has become the main cause of endstage renal disease. In our country, this problem is specially relevant in Canary Islands, where DN is the cause of renal failure in 39% of patients included in dialysis programs. The importance of this situation and the relevance of an adequate referral to the nephrologist, prompt us to study the characteristics of diabetic patients refered to our outpatient clinic. Subjects and methods: One-hundred and fifty patients with diabetes consecutively referred to the outpatient nephrology clinic at the Hospital Universitario Nuestra Señora de Candelaria were included in the study. We analysed demographic and epidemiologic characteristics, therapeutic strategies, as well as serum and urine biochemical parameters. Results: Ninety-eight percent of patients suffered from type 2 diabetes, and 90% were referred by the primary physician. Renal insufficiency and proteinuria were the main causes of referral (48% and 30.6%, respectively). Overweight or obesity were present in 82.6% of patients, 97% were hypertensive and 92.6% presented dyslipidemia. Medical history of cardiovascular disease was present 16% of patients. Two-thirds of patients had a creatinine clearance below 60 ml/min. One-third of patients did not receive therapy with blockers of the renin-angiotensin system, and only 37% were treated with statins. Conclusions: An elevated percentage of diabetic patients referred to nephrologist did not reach the recommended therapeutic goals. These findings prompt us to reflect on the therapeutic approach in these patients and the referral to the nephrologist

[Paraquat poisoning: report of two cases and literature review]. / Intoxicación por paraquat: presentación de dos casos y revisión de la literatura.

Cases of poisoning with pesticides, especially suicidal ones, continue to be an important therapeutic problem. The heribicide paraquat (1.1' dimethyl-4.4' bipyridylium dichloride) is the second cause of pesticide poisoning in our country, which is associated with a high mortality rate. We report two cases of suicidal ingestion of paraquat who developed multiorgan failure with a lethal outcome. We also present a brief review of the literature, mainly focused on the different therapeutic options.

Intoxicación por paraquat: presentación de dos casos y revisión de la literatura / Paraquat poisoning: report of two cases and literature review

La intoxicación por pesticidas, especialmente con fines suicidas, continua siendo un importante problema terapéutico. El herbicida paraquat (1,1' dimetil-4,4' bipiridilo dicloro) es el 2º agente causal de intoxicación por pesticidas en nuestro país, estando asociada a una alta tasa de mortalidad. Presentamos dos casos de intoxicación por paraquat con fines autolíticos que desarrollaron fracaso multiorgánico y tuvieron una evolución fatal. Presentamos también una breve revisión de la literatura centrada principalmente en las diferentes opciones terapéuticas. (AU)

Relationship between serum parathyroid hormone levels and lipid profile in hemodialysis patients. Evolution of lipid parameters after parathyroidectomy.

To determine the influence of parathyroid hormone (PTH) on lipid disturbances of uremia, the lipid profile was determined in 34 hemodialysis (HD) patients, comparing lipid parameters among subjects classified according to their intact PTH level. Furthermore, the effect of correction of severe secondary hyperparathyroidism on serum lipids was evaluated in 7 patients after parathyroidectomy. Total cholesterol, high-density lipoproteins (HDL), triglycerides, apolipoproteins A-I and B-100 (Apo B and Apo B), lipoprotein(a) and the ratios of cholesterol/HDL and Apo A/Apo B were analyzed. There was no correlation between serum lipids and PTH levels in the total group. Lipid profile was similar among patients classified according to their PTH level. No correlations were observed in either group between lipids and PTH. Lipid profile did not change in the seven patients with severe secondary hyperparathyroidism after parathyroidectomy. In conclusion, there was no relationship between PTH and lipids and risk ratios in HD patients. Lipid profile did not change in patients with severe secondary hyperparathyroidism after parathyroidectomy. These findings suggest that PTH does not play a significant role in the dyslipidemia of renal failure.

Androgens for the treatment of anemia in peritoneal dialysis patients.

Before the advent of recombinant human erythropoietin (EPO), androgens were used for treatment of anemia in dialysis patients. However, after the availability of recombinant EPO in the 1980s, the use of these substances was abondoned. We have previously reported that androgens have beneficial actions on anemia in selected hemodialysis patients. In the present study we have analyzed the effects of androgen administration on hematologic parameters in peritoneal dialysis patients. We evaluated 9 patients treated for 6 months with nandrolone decanoate (200 mg/week intramuscularly). Hemoglobin and hematocrit values experienced a significant increment with respect to basal values during the study (9.2 +/- 0.7 g/dL and 27.7% +/- 2.3% at basal vs. 11.9 +/- 0.5 g/dL and 35.3% +/- 1.6% at month 6, respectively; P < 0.001). In addition to the effects on the hematologic parameters, androgen administration also had beneficial anabolic actions with a significant increment in the serum concentration of total proteins and albumin (basal, 6.1 +/- 0.3 g/dL and 3.1 +/- 0.4 g/dL vs. 6.7 +/- 0.4 g/dL and 3.8 +/- 0.4 g/dL at month 6, respectively, P < 0.01). The only adverse effect was a rise in the serum concentration of triglycerides (176 +/- 54 mg/dL vs. 144 +/- 53 mg/dL, P < 0.01). In conclusion, androgen administration has beneficial effects on erythropoiesis as well as positive anabolic actions in patients under peritoneal dialysis.

Errors in the selection of dialysate concentrates cause severe metabolic acidosis during bicarbonate hemodialysis.

Severe metabolic acidosis occurred during bicarbonate hemodialysis as the result of an error made in the selection of the dialysate concentrate. We questioned whether or not it was possible for the dialysis equipment to regulate the proportions in the dialysate fluid using an incorrect dialysate concentrate and still obtain the proper conductivity. We simulated this situation in vitro and found that during bicarbonate dialysis an inappropriately acidic dialysate fluid could replace the normal dialysate with an adequate range of conductivity still being maintained and therefore no triggering of alarms. The investigation showed that the dialysis machines were not adequately adjusted for sensitivity to the concentrates being employed during dialysis. We concluded that dialysis equipment should be fitted with on-line pH meters with alarm systems.