Clinical practice guidelines for evidence-based management of sedoanalgesia in critically ill adult patients.

INTRODUCTION: Optimal management of sedation, analgesia and delirium offers comfort and security for the critical care patient, allows support measures to be applied more easily and enables an integral approach of medical care, at the same time that lowers the incidence of complications, wich translates in better patient outcomes. OBJECTIVE: To update the Guía de práctica clínica basada en la evidencia para el manejo de la sedoanalgesia en el paciente adulto críticamente enfermo published in Medicina Intensiva in 2007, and give recommendations for the management of sedation, analgesia, and delirium. METHODOLOGY: A group of 21 intensivists from 9 countries of the Federación Panamericana e Ibérica de Sociedades de Medicina Crítica y Terapia Intensiva, 3 of them also specialists in clinical epidemiology and methodology, gathered for the development of guidelines. Assessment of evidence quality and recommendations were made based on the Grading of Recommendations Assessment, Development and Evaluation system. Strength of recommendations was classified as 1=strong, or 2=weak, and quality of evidence as A=high, B=moderate, or C=low. Two authors searched the following databases: MEDLINE through PUBMED, The Cochrane Library and Literatura Latinoamericana y del Caribe en Ciencias de la Salud and retrieved pertinent information. Members assigned to the 11 sections of the guidelines, based on the literature review, formulated the recommendations, that were discussed in plenary sessions. Only those recommendations that achieved more than 80% of consensus were approved for the final document. The Colombian Association of Critical Medicine and Intensive Care (AMCI) supported the elaboration of this guidelines. RESULTS: Four hundred sixty-seven articles were included for review. An increase in number and quality of publications was observed. This allowed to generate 64 strong recommendations with high and moderate quality of evidence in contrast to the 28 recommendations of the previous edition. CONCLUSIONS: This Guidelines contains recommendations and suggestions based on the best evidence available for the management of sedation, analgesia and delirium of the critically ill patient, including a bundle of strategies that serves this purpose. We highlight the assessment of pain and agitation/sedation through validated scales, the use of opioids initially to apropiate analgesic control, associated with multimodal strategies in order to reduce opioide consumption; to promote the lowest level of sedation necessary avoiding over-sedation. Also, in case of the need of sedatives, choose the most appropiate for the patient needs, avoiding the use of benzodiazepines and identify risk factors for delirium, in order to prevent its occurrence, diagnose delirium and treat it with the most suitable pharmacological agent, whether it is haloperidol, atypical antipsychotics or dexmedetomidine, once again, avoiding the use of benzodiazepines and decreasing the use of opioids.

Effect of Pesticides on Peroxisome Proliferator-Activated Receptors (PPARs) and Their Association with Obesity and Diabetes.

Obesity and diabetes mellitus are considered the most important diseases of the XXI century. Recently, many epidemiological studies have linked exposure to pesticides to the development of obesity and type 2 diabetes mellitus. The role of pesticides and their possible influence on the development of these diseases was investigated by examining the relationship between these compounds and one of the major nuclear receptor families controlling lipid and carbohydrate metabolism: the peroxisome proliferator-activated receptors (PPARs), PPARα, PPARß/δ, and PPARγ; this was possible through in silico, in vitro, and in vivo assays. The present review aims to show the effect of pesticides on PPARs and their contribution to the changes in energy metabolism that enable the development of obesity and type 2 diabetes mellitus.

Different radiation dose rate as radioprotection and the cross effect with chromium using in vivo somatic cells of Drosophila.

Ionizing radiation plays a key role in the adaptation of an individual organism to environmental pollution, at the same time, it has biological effects that depend on radiation intensity or dose rate (DR). Although the effect of DR has been studied in vitro, the phenomenon known as the inverse effect of DR, which indicates as it decreases that the induction of damage is greater, has not been widely studied in vivo. The present study is aimed to test 0.5 and 1 Gy in somatic cells of the wing of D. melanogaster, administered at 5.4 or 34.3 Gy/h and from 0.037 to 0.3 mM of CrO3 as conditioning treatment. No changes were found in larva-to-adult viability. A protective as well as a cross effect of pre-exposure to different DR and CrO3 concentrations against genetic damage induced by 20 Gy or 1 mM CrO3 was evident.

Accumulation of heavy metals in mosses: a biomonitoring study.

The metropolitan area of the Toluca Valley (MATV) extends over an area of 1208.55 km(2) and has 1,361,500 inhabitants making it the fifth highest populated area in the country and the second highest in the state. The MATV has several environmental problems, with regards to the air quality. Particles PM10 and PM2.5 are considered to be the main pollutant due to these particles frequently exceeding the limit laid down in the standards of the air quality in the country. For this reason, samples of the mosses Fabriona ciliaris and Leskea angustata were collected at different sites in MATV, Mexico in order to establish the atmospheric deposition of heavy metals by means of the analysis of the mosses tissues. Results show the average metal concentrations in the mosses in the order of: Zn > Pb > Cr > Cd. The concentration capacities of heavy metals were higher in Fabriona ciliaris than Leskea angustata. Enrichment factors for Cr, Zn, Pb and Cd were obtained using the soils from the same sampling area. Enrichment factors results show that Cr is conservative in both sampling seasons with a terrigenous origin; Zn is moderately enriched in both sampling seasons and mainly associated to pedological-soil or substrate contribution and anthropogenic activities and Cd is highly enriched in the rainy season and Pb is highly enriched in both sampling seasons, with a predominantly anthropogenic origin. This study provides information to be considered in the strategies for similar environmental problems in the world.

Detection of adrenocorticotropin-related and alpha-melanocyte-stimulating hormone-related substances in the anterior pituitary of larval and adult Ambystoma tigrinum (class: Amphibia).

Immunohistochemical analysis revealed the colocalization of ACTH-related immunoreactive forms and alpha-MSH-related immunoreactive forms in corticotropic cells of the anterior pituitary of larval Ambystoma tigrinum. Subsequent analysis of acid extracts of anterior pituitaries obtained from larval, neotene, and postmetamorphic adults indicated that the molar ratio of ACTH(1-39) to alpha-MSH was, respectively, 2.5:1, 1:1.5, and 1:1.3. However, in sexually mature adults the molar ratio of ACTH(1-39) to alpha-MSH was 8:1. These results indicate that before and immediately after metamorphosis, both ACTH(1-39) and alpha-MSH are major end products of corticotropic cells in this species. As postmetamorphic animals reach sexual maturity, ACTH(1-39) is a major end product of corticotropic cells and only trace amounts of alpha-MSH are produced. Thus in A. tigrinum the proteolytic processing of ACTH in corticotropic cells is developmentally regulated. The alpha-MSH-related peptide produced by the corticotropic cells appears to be an ACTH(1-13)amide-like form.

Developmental changes in the processing of ACTH in the anterior pituitary of the amphibian, Ambystoma tigrinum.

Acid extracts of anterior pituitaries obtained from larval, neotene, postmetamorphic young adult, and sexually active adult Ambystoma tigrinum were fractionated by gel filtration and analyzed by RIA. In larval, neotene, and postmetamorphic adults the molar ratio of ACTH(1-39) to alpha-MSH was, respectively, 1.3:1, 1:1.3, and 1:1.3. However, in sexually mature adults the molar ratio of ACTH(1-39) to alpha-MSH was 8:1. These results indicate that prior to and immediately after metamorphosis, both ACTH(1-39) and alpha-MSH are major end products of corticotropic cells in this species. As postmetamorphic animals reach sexual maturity, there is a shift in the processing of ACTH which yields ACTH(1-39) as the major end product of corticotropic cells. In the corticotropic cells of adults only trace amounts of alpha-MSH are produced.

Guía de práctica clínica basada en la evidencia para el manejo de la sedo-analgesia en el paciente adulto críticamente enfermo / Clinical practice guideline based on the evidence for the management of sedoanalgesia in the critically ill adult patient

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