The Chilean socio-ethno-genomic cline.

Studies of the current Chilean population performed using classical genetic markers have established that the Chilean population originated primarily from the admixture of European people, particularly Spaniards, and Amerindians. A socioeconomic-ethno-genetic cline was established soon after the conquest. Spaniards born in Spain or Chile occupied the highest Socioeconomic Strata, while Amerindians belonged to the lowest. The intermediate strata consisted of people with different degrees of ethnic admixture; the larger the European admixture, the higher the Socioeconomic Level. The present study of molecular genomic markers sought to calculate the percentage of Amerindian admixture and revealed a finer distribution of this cline, as well as differences between two Amerindian groups: Aymara and Mapuche. The use of two socioeconomic classifications - Class and Socioeconomic Level - reveals important differences. Furthermore, Self-reported Ethnicity (self-assignment to an ethnic group) and Self-reported Ancestry (self-recognition of Amerindian ancestors) show variations and differing relationships between socioeconomic classifications and genomic Amerindian Admixture. These data constitute a valuable input for the formulation of public healthcare policy and show that the notions of Ethnicity, Socioeconomic Strata and Class should always be a consideration in policy development.

Manejo farmacológico del dolor agudo postoperatorio en España. Datos de la encuesta nacional de la Sociedad Española del Dolor (SED) / Pharmacological management of acute postoperative pain in Spain. Data from the national survey from the Spanish Pain Society (SED) (iasp chapter)

Introducción: La Sociedad Española del Dolor (SED), y concretamente el Grupo de Trabajo de Dolor Agudo de la misma (GTDASED), llevó a cabo una encuesta a nivel nacional para conocer la situación del manejo del dolor postoperatorio en España así como las distintas pautas analgésicas empleadas. En este artículo se analizan estas pautas y se comparan atendiendo a la presencia o no de Unidad de Dolor Agudo (UDA) o Programas de Gestión del Dolor Postoperatorio (PGDPO) entre aquellos hospitales de más de 200 camas que participaron en la misma. Pacientes y métodos: Los miembros de la Sociedad Española del Dolor y todos los responsables del tratamiento del dolor postoperatorio de los hospitales españoles fueron invitados a contestar un cuestionario estructurado. Para el análisis los hospitales se dividieron en 2 grupos: < 200 camas y ≥ 200 camas. Las variables categóricas fueron descritas como porcentajes con el 95 % de intervalo de confianza y las continuas con la mediana y el rango intercuartil. Se analizaron las pautas farmacológicas empleadas, sus asociaciones así como las vías de administración. Resultados: En total las respuestas implicaron a 112 (78 con > 200 camas y 34 con < 200 camas) hospitales del Sistema Nacional de Salud Español. Se obtuvieron respuestas del 42,4 % de hospitales con ≥ 200 camas, y del 9,6 % de los de < 200 camas, por lo que solo se analizó el primer grupo en lo que respecta a pautas de administración de analgesia, mientras que en el caso aislado de los fármacos empleados se analizaron los 112 hospitales que respondieron la encuesta. Las pautas orales se emplean en el 60,3 % de los hospitales (sin diferencias entre aquellos con y sin UDA), las intramusculares (i.m.) en un 15,8 %, subcutáneas (s.c.) 48,3 %, intravenosas (i.v) en bolos 75,9 %, intravenosas continuas 77,6 %, intravenosas PCA 60,3 %, catéteres en plexo nervioso a bolos 51,7 %, catéteres en plexo nervioso e infusión continua 56,9 %, epidurales en bolos 40,4 %, epidurales continuas 75,9 %, epidurales en PCA 43,1 %, (63,8 % anestésico local y opioide y 15,8 % anestésico local con otros fármacos [adrenalina/clonidina/ opioide]). Solo hubo diferencia estadísticamente significativa en función de la presencia o no de UDA en el centro, en las pautas: intravenosas en PCA, catéteres en plexo nervioso con infusión continua y epidural en PCA (más empleadas en los hospitales con UDA) e intramusculares (menos empleadas en los hospitales con UDA). De los centros con > 200 camas un 81,3 % utilizaron AINE en sus prescripciones orales (ibuprofeno 38,1 % y dexketoprofeno 28,6 %); un 68,8 % utilizó paracetamol (asociado a AINE en un 22 %) y un 28,1 % empleó opioides orales (tramadol en el 21,9 %). Las pautas intramusculares fueron utilizadas por un 15,8 % de los encuestados. En 55 centros (de los 112 encuestados independientemente del número de camas hospitalarias) aún se utilizan pautas subcutáneas para tratar el dolor agudo postoperatorio y de ellos el 58,3% emplea cloruro mórfico. La protocolización de co-adyuvantes es del 2,3 %. El AINE más empleado es el dexketoprofeno por vía intravenosa y el ibuprofeno por vía oral. El opioide débil más empleado es el tramadol tanto por vía oral como intravenosa. La morfina es el opioide potente más empleado, especialmente en PCA intravenosa (i.v.). El paracetamol se emplea en el 54,7 % (112 hospitales) de las pautas i.v. a bolos. El concepto de analgesia multimodal, aunque es conocido, no se práctica de modo mayoritario entre los encuestados (solo un 30 % de los centros que respondieron la encuesta lo hacen). Conclusión: El paracetamol y los AINE se emplean tanto por vía oral (67,4 y 86,1 %, respectivamente) como intravenosa (54,7 y 56,6 %, respectivamente). Cuando los hospitales de > 200 camas disponen de UDA o PGDPO utilizan significativamente más las pautas: intravenosas en PCA, catéteres en plexo nervioso e infusión continua y epidural en PCA y menos las pautas i.m. La aplicación de analgesia multimodal es baja (AU)

Introduction: The Spanish Pain Society SED-IASP launched a national survey in order to determine how was postop pain managed throughout Spain. This article analyses the drugs and routes employed comparing them according to the presence or not of an Acute Pain Unit (APU) or Acute Pain Management program (APMP) in hospitals with > 200 beds that participated and answered the survey. Patients and methods: Members of the Spanish Pain Society and APS/APMP heads were asked to respond to a survey. Responses were stratified by hospital size (< 200 or ≥ 200 beds) and APS/APMP presence or not. Categorical variables were described by percentages and the 95 % confidence interval and continuous ones by the median and interquartile range. The drugs employed, associations of them and routes of administration were also analysed. Results: A total of 112/537 hospitals responded the survey (78 with >200 beds and 34 < 200) which represents a 20,9 % response tax). Responses were received from 42.4 % of hospitals with ≥ 200 beds (vs. 9.6 % of the smaller ones). We fully analysed data concerning routes and ways of administration only for the larger hospitals, 57.7 % of which had an APS or APMP. Solely drugs were analysed considering all 112 hospitals. Oral route is employed in 60,3 % hospitals (no differences between those with or not APU), intramuscular (IM) in 15,8 %, subcutaneous (SC) 48,3 %, intravenous (IV) bolus 75,9 %, IV continuous 77,6 %, IV PCA 60,3 %, catheters in nerve plexus using bolus 51,7 %, catheters in nerve plexus with continuous infusion 56,9 %, epidurals with bolus 40,4 %, continuous epidurals 75,9 %, epidural PCA 43,1 %, (63,8 % local anesthetic and opioid and 15,8 % local anesthetic with adrenaline/clonidine/opioid). Statistical significant differences were found in IV PCA route, continuous infusión through catheters in nervous plexus and epidural PCA (more employed in hospitals having an APU) and IM route (significantly less employed in them). A total of 81,3 % hospitals with > 200 beds used oral NSAIDs to treat postoperative pain (ibuprophen 38,1 % and dexketoprophen 28,6 %); paracetamol was employed in 68,8 % of them (associated to NSAID in 22 %) and 28,1 % employed oral opioids (tramadol 21,9 %). Coadjuvants are only employed in 2,3 % of 112 hospitals. IV dexketoprophen and oral ibuprophen were the most frequent NSAIDs employed. Tramadol is the most commonly IV and oral opioid employed. Morphine is the strong opiod more frequently used, especially in IV PCA. Paracetamol is used in 54,7 % (112 hospitals) of IV bolus way of administration. Multimodal analgesia concept although well known is not widely established among the survey responders (only 30 % apply it). Conclusion: Paracetamol and NSAIDs are used by IV (54,7 y 56,6 % respectively) and oral routes (67,4 y 86,1 % respectively). Hospitals with > 200 beds having an APU or APMP significantly employ more IV PCA, nerve plexus catheters continuous infusion and epidural PCA and less IM route to treat postoperative pain. Multimodal analgesia is not widely used in Spanish Hospitals (AU)

Management of postoperative pain in Spain: a nationwide survey of practice.

BACKGROUND: Although the need for structured assessment and management of acute postoperative pain has been recognized, practices and responsibilities vary between and within hospitals and countries. We sought to determine current pain management practices in Spanish hospitals with and without acute pain services (APSs) or acute pain management programmes (APMPs) and compare them to practices reported for 1997-1998. METHODS: Members of the Spanish Pain Society and APS/APMP heads were asked to respond to a survey. Responses were stratified by hospital size (< 200 or ≥ 200 beds) and APS/APMP presence or not. Categorical variables were described by percentages and the 95% confidence interval and continuous ones by the median and interquartile range. RESULTS: Responses were received from 42.4% of hospitals with ≥ 200 beds (vs. 9.6% of the smaller ones). We fully analysed only data for the larger hospitals, 57.7% of which had an APS or APMP. Full-time pain physicians were on staff in 28.6% of large hospitals; 25% had full-time nurses. Patients received written information about postoperative pain in 34.8% of APS/APMP hospitals, and 72% of them recorded pain assessments routinely. Protocols reflected interdepartmental consensus in 80.8%; training in postoperative pain was organised in 54%. Respondents thought pain was well or very well managed in 46.4%. In APS/APMP hospitals the following results had improved: provision of written information for patients (58.5% vs. 0%), the recording of pain assessments (93% vs. 43.8%), consensus on a pain scale (92.5% vs. 41.9%), use of protocols (99.7% vs. 55.2%), analysis of quality indicators (52.8% vs. 15.4%), training (73% vs. 26.9%), and respondents' satisfaction with pain management in their hospital (68.6% vs. 9.5%). CONCLUSIONS: The presence of an APS or APMP is associated with better results on indicators of quality of acute postoperative pain management.

Factores determinantes de la satisfacción del paciente con la consulta de anestesia / Factors determining patient satisfaction with the pre-anaesthesia consultation

Objetivo. Analizar el grado de satisfacción de los pacientes con la atención prestada en la consulta preanestésica y los factores determinantes. Material y método. Se realizó una encuesta anónima que se distribuyó de forma aleatoria entre los pacientes atendidos en la consulta de preanestesia, y que incluyó 4 preguntas con 5 respuestas posibles en una escala categórica (muy poco satisfecho, poco satisfecho, regular de satisfecho, satisfecho y muy satisfecho), relacionadas con la puntualidad, la comprensión de la información recibida, el respeto en el trato y el grado global de satisfacción, así como una quinta sobre el conocimiento del nombre del anestesiólogo que les atendió. Se aplicó un modelo de regresión logística binaria, que identificó las variables predictoras de la satisfacción, calculó la odds ratio (OR) y sus respectivos intervalos de confianza al 95% (IC 95%). Resultados. Se analizaron 4.006 encuestas. El 99,2% (3966) de los usuarios valoraron como satisfecho/muy satisfecho la pregunta sobre el respeto en el trato, el 98,4% (3.937) la información recibida y su comprensión, el 77,4% (3.096) la puntualidad en la atención y el 97,6% (3.909) el grado de satisfacción global. Un 71% (2844) no conocía el nombre del anestesiólogo. El análisis de regresión relacionó el mayor grado de satisfacción con el trato (OR: 17,44; p < 0,0005) y la información recibidos (OR: 14,94, p < 0,0005), mientras que la puntualidad (OR: 5,40; p < 0,0005) fue el factor que menos contribuyó en el resultado. Conclusión. En nuestra población el grado de satisfacción en el ámbito de la consulta de preanestesia está unido principalmente a la capacidad de comunicación del anestesiólogo (AU)

Objective. To analyse patient satisfaction with care provided in the pre-anaesthetic consultation and its determining factors. Material and method. An anonymous questionnaire was randomly distributed to patients attending a pre-anaesthesia clinic, which included 4 questions with 5 possible answers on a (very dissatisfied, dissatisfied, fairly satisfied, satisfied and very satisfied) categorical graduated scale related to punctuality, understanding of the information received, respectful treatment, and overall satisfaction. The fifth question was about the knowledge or the name of the anaesthesiologist who attended them. A binary logistic regression model was used, which identified the predictors of satisfaction, calculated the odds ratios, and their respective 95% confidence intervals. Results. A total of 4006 questionnaires were analysed, in which 99.2% (3966) of users rated as satisfied/very satisfied the question about the respectful treatment, 98.4% (3937) of the information received and understanding, 77.4% (3096) punctuality in attending, and 97, 6% (3909) overall satisfaction. Almost three-quarters (71%, 2844) did not know the name of the anaesthesiologist. Regression analysis associated the more satisfied with their treatment (OR 17.44; P<.0005) and the information received (OR 14.94, P < .0005), while punctuality (OR 5 40; P < .0005) was the factor that contributed less to the result. Conclusion. In our population satisfaction in pre-anaesthesia consultation is due mainly to the communication skills of the anaesthesiologist (AU)

[Factors determining patient satisfaction with the pre-anaesthesia consultation]. / Factores determinantes de la satisfacción del paciente con la consulta de anestesia.

OBJECTIVE: To analyse patient satisfaction with care provided in the pre-anaesthetic consultation and its determining factors. MATERIAL AND METHOD: An anonymous questionnaire was randomly distributed to patients attending a pre-anaesthesia clinic, which included 4 questions with 5 possible answers on a (very dissatisfied, dissatisfied, fairly satisfied, satisfied and very satisfied) categorical graduated scale related to punctuality, understanding of the information received, respectful treatment, and overall satisfaction. The fifth question was about the knowledge or the name of the anaesthesiologist who attended them. A binary logistic regression model was used, which identified the predictors of satisfaction, calculated the odds ratios, and their respective 95% confidence intervals. RESULTS: A total of 4006 questionnaires were analysed, in which 99.2% (3966) of users rated as satisfied/very satisfied the question about the respectful treatment, 98.4% (3937) of the information received and understanding, 77.4% (3096) punctuality in attending, and 97, 6% (3909) overall satisfaction. Almost three-quarters (71%, 2844) did not know the name of the anaesthesiologist. Regression analysis associated the more satisfied with their treatment (OR 17.44; P<.0005) and the information received (OR 14.94, P<.0005), while punctuality (OR 5 40; P<.0005) was the factor that contributed less to the result. CONCLUSION: In our population satisfaction in pre-anaesthesia consultation is due mainly to the communication skills of the anaesthesiologist.

¿Realmente es fácil evitar la variabilidad de la práctica clínica en el tratamiento del dolor postoperatorio? / No disponible

No disponible

La población fibromiálgica ante la cirugía. Estudio descriptivo y análisis del dolor posoperatorio en histerectomías / Fibromyalgia population before surgery: A descriptive study and analysis of post-hysterectomy pain

Objetivos. Este trabajo pretende determinar en primer lugar, la prevalencia, y el perfil clínico y demográfico de la población fibromiálgica de nuestra área sanitaria sometida a cirugía mayor; y en segundo lugar, analizar las características del dolor postoperatorio de las pacientes con fibromialgia intervenidas de Histerectomía abdominal, comparándolas con un grupo control. Materiales y método. Estudio retrospectivo realizado durante el periodo de enero de 2006 y mayo de 2008, seleccionando los casos con diagnóstico previamente establecido de fibromialgia reflejados en la historia de anestesia, para la realización a continuación de una entrevista telefónica sistematizada, en la que se completaron datos demográficos, clínicos, médicos, con especial atención al tratamiento y seguimiento de su enfermedad fibromiálgica, así como del recuerdo del dolor postoperatorio. Materiales y método. Estudio comparativo de la efectividad del tratamiento del dolor postoperatorio, mediante un sistema de PCA (Analgesia Controlada por el Paciente) intravenosa (iv) con Tramadol y Metamizol, de las pacientes con fibromialgia sometidas a Histerectomía abdominal frente a un grupo control. Resultados. Revisadas 11.814 historias de anestesia, se estimó una prevalencia de la enfermedad de un 0,86% durante el periodo de estudio. El perfil clínico medio fue: mujer de mediana edad, con sobrepeso, patología musculoesquelética y psiquiátrica acompañante, valorada generalmente con riesgo anestésico ASA II, en seguimiento para su patología fibromiálgica por su médico de atención primaria, polimedicada con AINES (antiinflamatorios no esteroideos), ansiolíticos y relajantes musculares, y sin un buen control del dolor. El estudio comparativo del dolor posoperatorio en las histerectomías demostró una efectividad similar en el tratamiento de ambos grupos; sin embargo las pacientes con fibromialgia solicitaron un 45% más de analgesia a la PCA que el grupo control. Conclusiones. Las pacientes fibromiálgicas podrían necesitar mayor cantidad de analgésicos que la población general tras una histerectomía abdominal. El sistema de PCA permite optar a un tratamiento más individualizado, ya que los pacientes pueden controlar la cantidad de analgesia que necesiten en función del dolor que presenten, sin incrementar los efectos secundarios (AU)

Objective. This study attempts to determine, firstly, the prevalence, and clinical and demographic profile of the fibromyalgia population in our health area subjected to major surgery, and secondly, to analyse the characteristics of the pain of fibromyalgia patients after abdominal hysterectomy, and comparing them with a control group. Material and method. A retrospective study conducted over the period January 2006 to May 2008, selecting cases with a previously established diagnose of fibromyalgia recorded in the Anaesthesia medical records. A standardised telephone interview was then carried out, in which the demographic, clinical and medical data was collected, paying particular attention to the treatment and follow-up of their fibromyalgia, as well as noting the post-surgical pain. Material and method. A comparative study on the efficacy of the treatment of post-surgical pain, using a an intravenous (iv) PCA (Patient Controlled Analgesia) system with Tramadol and Metamizole, of patients with fibromyalgia who had an abdominal hysterectomy versus a control group. Results. Out of a total of 11,814 anaesthesia medical records were reviewed, there was a prevalence of 0.86% of the disease during the study period. The average clinical profile was: middle-aged woman, overweight, musculoskeletal and accompanying psychiatric disease, generally assessed as anaesthetic risk ASA II, on follow-up due to her fibromyalgia disease by her primary care doctor, multiple medication with NSAIDs (non-steroidal anti-inflammatory drugs), tranquillisers and muscle relaxants, and poorly controlled pain. The comparative study of post-operative pain in hysterectomies showed a similar efficacy in the treatment of both groups. However the patients with fibromyalgia requested 45% more analgesia by PCA than the control group. Conclusions. Patients with fibromyalgias could need a greater amount of analgesics than the general population after an abdominal hysterectomy. The PCA system enables a more individualised treatment to be chosen, since the patients can control the amount of analgesia they need depending on their pain, without increasing secondary effects (AU)

¿Se debe mantener la analgesia epidural como técnica de base en la UDA? / Should epidural analgesia still be a routine technique in pain units?

La analgesia epidural se ha convertido en una técnica rutinaria en el manejo perioperatorio de los pacientes quirúrgicos que se ha extendido fuera de los quirófanos y de las unidades de alta dependencia hacia las salas de hospitalización. La irrupción en este nuevo escenario ha mejorado la analgesia postoperatoria con aceptables márgenes de seguridad, lo que le ha servido para colocarse en un lugar predominante entre las pautas analgésicas de las Unidades de Dolor Agudo (UDA). La analgesia epidural con anestésicos locales y opioides frente a la sistémica con opioides ha presentado históricamente una superior eficacia analgésica, y una disminución de complicaciones derivadas de la atenuación del estrés quirúrgico y de la mejora en la función cardiorrespiratoria. Sin embargo, frente a estas ventajas la analgesia epidural también presenta inconvenientes como la hipotensión arterial o la retención urinaria, junto a las potencialmente graves derivadas del daño neurológico ocasionado por un hematoma epidural, una infección o una lesión directa del tejido nervioso. Si sus ventajas han resultado consistentes y fundamentadas, en este momento no lo parecen tanto. El avance que ha supuesto la cirugía mínimamente invasiva con altas más precoces, junto al desarrollo de estrategias multimodales, está conduciendo a un replanteamiento de la utilización de técnicas como la epidural y a una reevaluación de sus indicaciones. Las últimas evidencias nos inducen a pensar que la epidural probablemente haya tocado techo en el tratamiento del dolor postoperatorio y comenzará a perder terreno frente a otras técnicas igualmente efectivas, con menores complicaciones y efectos secundarios. Este será un proceso lento en el que deberá quedar asegurado que las alternativas analgésicas ofrecen realmente mejores resultados en cuanto a eficacia, seguridad, tolerabilidad y calidad de la recuperación desde la perspectiva del paciente (AU)

Epidural analgesia has become a routine process in the peri-operative management of surgical patients which has been extended from the operating rooms and high dependency units to hospital wards. The irruption into this new scenario has improved post-surgical analgesia with acceptable safety margins, and has secured a predominant place in the analgesia guidelines of Acute Pain Units (APU). Epidural analgesia with local anaesthetics and opioids, compared to systemic with opioids, has historically been more effective, with a decrease in complications due to the reduction in surgical stress and the improved cardiorespiratory function. However, as well as these these advantages, epidural analgesia also has some disadvantages such as lowering of blood pressure or urinary retention, along with potentially serious ones arising from neurological damage caused by epidural haematoma, infection or direct injury of the nerve tissue. Although its advantages have been consistent and solid, it does seem to be the case today. The advances made in minimally invasive surgery, with earlier hospital discharge, together with multimodal strategies, are leading to the re-establishment of the use of techniques such as epidural and a re-evaluation of its indications. The latest evidence leads us to believe that epidural analgesia has reached its limit in the treatment of post-surgical pain and will begin to lose ground with the introduction of equally effective techniques, with less complications and secondary effects. This will be a slow process in which it must be assured that the alternative analgesics really give better results as regards efficacy, safety, tolerability and quality of recovery from the perspective of the patient (AU)

Valoración de la actividad de una Unidad de Dolor Agudo Postoperatorio por los cuidadores del paciente quirúrgico / Assessment of the activity of an Acute Postoperative Pain Unit by the staff taking care of surgical patients

Objetivo:Implantada en nuestra institución desde el año 2000una Unidad de Dolor Agudo Postoperatorio (UDAP) basada en enfermería y supervisada por el Servicio de Anestesiología,pretendemos evaluar cómo es percibida su actividadpor los cuidadores del paciente quirúrgico.Material y método:El Servicio de Anestesiología y Reanimación con la Unidadde Recuperación Postanestésica (URPA) mantienenuna UDAP basada en enfermería que trata de forma planificaday protocolizada el dolor postoperatorio de más de1.000 pacientes/año que reciben las cirugías más agresivasy dolorosas en un hospital de segundo nivel. De formaanónima y voluntaria se les solicitó a la enfermería y los facultativosresponsables de los pacientes que respondieran aun cuestionario escrito de 15 preguntas (12 de respuestacerrada agrupada en 4 categorías y 3 de respuesta abierta)en el que valorar diferentes aspectos de su actividad.Resultados:De 168 encuestas distribuidas se valoraron 87 cuestionariosdevueltos (52%), 48 de facultativos y 39 de enfermería.El papel de UDAP resultó bien o muy bien comprendidopor el 97% de los respondedores y su actividadfue percibida con bastante unanimidad como útil, efectiva ynecesaria por el 98, el 93 y el 97%, respectivamente. Lasindicaciones del tratamiento fueron consideradas apropiadaso muy apropiadas por el 87%, la actitud de su personalante las consultas fue considerada satisfactoria o muy satisfactoriapor el 90% y las técnicas analgésicas eran suficientementecomprendidas por el 89%. El 67% consideraronque los pacientes estaban bien o muy bien informados. Facultativosy enfermería discreparon en la percepción delgrado de complementación de la actividad de la UDAP conla del resto de los cuidadores (poco o muy poco para el51% de la enfermería frente a sólo el 19% de los facultativos;p = 0,001) y en la fluidez de la comunicación con supersonal (poca o muy poca para el 41% de la enfermeríafrente al 19% de los facultativos; p=0,01). El aspecto mejorvalorado de la UDAP fue la mejora en el control del dolorpostoperatorio; el peor, la comunicación entre los profesionalesy, la sugerencia más referida, la de intentarmejorarla.Conclusiones:El papel de la UDAP es muy bien comprendido en nuestrohospital por los cuidadores del paciente quirúrgico yaunque su actividad es unánimemente percibida como útil ynecesaria, existen problemas de integración y comunicación,especialmente con la enfermería de planta. La identificaciónde situaciones como esta mediante estudios deopinión sobre su actividad, puede ser útil para dirigir mejorasen el funcionamiento de las Unidades de Dolor Agudocon modelos organizativos similares al nuestro

Objective:An Acute Postoperative Pain Unit (APPU) staffed bynurses and supervised by the Service of Anesthesiologywas created in our center in 2.000. The aim of this studywas to assess how the staff taking care of surgical patientsperceive its activity.Material and method:The Service of Anesthesiology and Resuscitation andthe Post-Anesthetic Recovery Unit (PARU) maintain anAPPU staffed by nurses that provides planned and protocolizedmanagement of postoperative pain to more than1.000 patients/year undergoing the most aggressive andpainful surgical procedures in a second-level hospital. Nursesand doctors taking care of the patients were requestedto anonymously and voluntarily answer a written questionnairewith 15 questions (12 close-ended questions groupedin 4 categories and 3 open-ended questions) that assessedseveral aspects of their activity.Results:Out of 168 questionnaires handed out, 87 questionnairesreturned were considered (52%), 48 from doctors and39 from nurses. The role of the APPU was well or verywell understood by 97% of the responders and its activitywas perceived rather unanimously as useful, effective andnecessary by 98, 93 and 97%, respectively. Treatment indicationswere considered appropriate or very appropriateby 87%, staff attitude towards consultation was consideredsatisfactory or very satisfactory by 90% and analgesic techniqueswere sufficiently understood by 89%. A 67% consideredthat patients were well or very well informed. Doctorsand nurses disagreed in their perception of the degreeto which the APPU activity complemented that of otherhealth care staff (low or very low for 51% of nurses versus19% of doctors; p=0.001) and in the fluency of communicationwith the staff (little or very little for 41% of nursesversus 19% of doctors; p=0.01). The most valued aspectof the UPPA was the management of postoperative pain;the least valued aspect was the communication betweenprofessionals and the most frequent suggestion: attempt toimprove such communication.Conclusions:The role of the UPPA is very well understood in our hospitalby the staff taking care of surgical patients and while itsactivity is unanimously perceived as useful and necessary,there are integration and communication problems, speciallywith the general nursing staff. The identification of this typeof situations through opinion polls about its activity can beuseful in order to improve the operation of acute pain unitswith organizational models similar to ours

Influencia de la monitorización BIS en los requerimientos de analgesia postoperatoria / Influence of BIS monitoring on the need of postoperative analgesia

Objetivos: La monitorización del indice biespectral (BIS) durante la anestesia total intravenosa (ATIV) suele conllevar una disminución de la administración dé propofol cuando se compara con la dosificación estándar. Este hecho puede asociarse con el incremento de las necesidades intraoperatorias de opioides. El objetivo de este estudio es determinar si estas circunstancias pueden influir, y en qué medida, sobre los requerimientos de analgesia postoperatoria. Material y métodos: Ensayo controlado, aleatorizado y parcialmente doble ciego en 40 pacientes ASA I y II sometidas a cirugía mayor ginecológica bajo ATIV. En el grupo BIS la administración de propofol fue dirigida por las variaciones de este indice, mientras que en el grupo control se realizó según una dosificación estándar. En ambos grupos el fentanilo se administró según las respuestas hemodinámicas. La analgesia postoperatoria consistió en tramado! y metamizol i.v. mediante PCA, con morfina de rescate. Los dos grupos de tratamiento se compararon en cuanto a vaviables relativas a la analgesia y el dolor postoperatorio de las primeras 24 horas. Resultados: Una paciente fue excluida. El grupo BIS (n=17) recibió menos propofol y más fentanilo que el grupo control (n=22) (429 mg frente 630 mg y 620 microg frente a 544 microg, respectivamente; p<0,0001) y también recuperó antes la ,consciencia (7,5 min frente a 10,5 min, p<0,003). No se observaron diferencias significativas en cuanto al inicio de la analgesia postoperatoria, el consumo de fármacos ni los efectos secundarios. La valoración del dolor y la satisfacción con su tratamiento fue similar en ambos grupos de pacientes. Las pacientes del grupo control, no obstante, fueron más precozmente dadas de alta de la URPA (115 min frente a 159 min, p=0,04).Conclusiones: En las condiciones referidas en este estudio la monitorización BIS durante la anestesia, y con ella las variaciones inducidas` en la administración de propofol y fentanilo, no influyeron significativamente sobre la analgesia postoperatoria (AU)

[Influence of bispectral index monitoring on fentanyl requirements during total intravenous anesthesia for major gynecological surgery]. / Influencia de la monitorización BIS en los requerimientos de fentanilo durante la anestesia intravenosa total en cirugía mayor ginecológica.

OBJECTIVE: To determine the influence that bispectral index (BIS) monitoring of hypnosis might have on need for analgesia during surgery under total intravenous anesthesia provided by bolus administration of fentanyl. PATIENTS AND METHOD: Prospective, randomized and partially double-blind study of 40 patients undergoing major gynecological surgery under total intravenous anesthesia with propofol and fentanyl. In the BIS group (n = 20) propofol administration was adjusted to maintain BIS between 40 and 60. In the control group (n = 20) standard doses were given: 10 mg/kg-1/h-1 after anesthetic induction and for 5 minutes, 8 mg/kg-1/h-1 over the next 5 minutes and 6 mg/kg-1/h-1 throughout the rest of the operation. All patients received intravenous bolus administration of 150 or 75 microg of fentanyl to maintain analgesia whenever systolic blood pressure and heart rate increased 20% over baseline. We compared propofol and fentanyl requirements, intraoperative changes in BIS, and awakening from anesthesia. RESULTS: Patient and surgical characteristics were similar in both groups. BIS monitoring allowed propofol administration to be decreased a mean 24% during maintenance of anesthesia, and this in turn was associated with a significant increase in mean dose of fentanyl (415 microg versus 253 microg in the BIS and control groups, respectively; p = 0.01). Mean values of BIS were higher in the BIS group (46.4 versus 42.2; p = 0.04) and patients in the BIS group awoke sooner (in 7.7 min versus 11.1 min; p = 0.01) and tended to report less pain upon arrival at the postanesthetic recovery room, although the difference was not statistically significant. CONCLUSIONS: BIS monitoring of depth of hypnosis can influence requirements for fentanyl during total intravenous anesthesia by bolus dosing for maintenance of analgesia. This is probably due to changes in the administration of propofol made possible by BIS monitoring.

Influencia de la monitorización bis en los requerimientos de fentanilo durante la anestesia intravenosa total en cirugía mayor ginecológica / The influence of bispectral index monitoring on fentanyl requirements during total intravenous anesthesia for major gynecological surgery

OBJETIVO. Determinar la influencia que la monitorización del índice biespectral (BIS), como guía para controlar la hipnosis, puede tener sobre las necesidades analgésicas intraoperatorias durante la anestesia intravenosa total (AIVT) cuando se administra fentanilo en bolo. PACIENTES Y MÉTODO. Estudio prospectivo, aleatorio y parcialmente doble ciego en 40 pacientes sometidas a cirugía mayor ginecológica bajo AIVT con propofol y fentanilo. En el grupo BIS (n = 20) la administración de propofol se modificaba lo necesario para mantener los valores de este índice entre 40 y 60, mientras que en el grupo control (n = 20) se realizaba según un procedimiento estándar a razón de 10 mg/kg-1/h-1 tras la inducción anestésica y durante 5 min, 8 mg/kg-1/h-1 los siguientes 5 min y 6 mg/kg-1/h-1 el resto de la intervención. En todas las pacientes se administraron bolos intravenosos de 150 o 75 µg de fentanilo para el mantenimiento de la analgesia ante incrementos superiores al 20 por ciento de los valores basales de la presión arterial sistólica y la frecuencia cardíaca. Junto con los requerimientos de propofol y fentanilo, también se compararon las variaciones intraoperatorias del BIS, así como variables del despertar anestésico. RESULTADOS. Ambos grupos resultaron homogéneos en cuanto a los datos demográficos y las características de las intervenciones. La utilización de la monitorización BIS posibilitó una reducción media del 24 por ciento en la administración de propofol durante el mantenimiento anestésico, lo que a su vez se relacionó con un incremento significativo de las dosis medias de fentanilo (415 frente a 253 µg en los grupos BIS y control, respectivamente; p = 0,01). Los valores medios del BIS fueron superiores en el grupo BIS (46,4 frente a 42,2; p = 0,04) y, a la vez, las pacientes de este grupo recuperaron la conciencia de forma más temprana (7,7 frente a 11,1 min; p = 0,01) y presentaron, aunque sin llegar a la significación estadística, menos dolor a su llegada a la sala de recuperación postanestésica. CONCLUSIONES. La monitorización de la profundidad hipnótica mediante el BIS puede influir en las necesidades de fentanilo durante la AIVT, cuando se administra en bolos para el mantenimiento de la analgesia. Este hecho probablemente derive de los cambios que esta monitorización induce en la administración de propofol (AU)

[The efficacy and safety of continuous epidural analgesia versus intradural-epidural analgesia during labor]. / Estudio comparativo de la eficacia y seguridad de la analgesia epidural continua y la analgesia intradural-epidural para el trabajo de parto.

OBJECTIVE: To determine the efficacy and safety of intradural-epidural analgesia in comparison with continuous epidural analgesia during labor and childbirth. PATIENTS AND METHOD: Forty-two women whose labor began spontaneously were enrolled and distributed randomly in two groups. The intradural-epidural analgesia group (IEA, n = 21) received 25 microgram of intradural fentanyl with 2.5 mg of isobaric bupivacaine with adrenalin, after which analgesia was maintained with epidural administration of one 8 mL bolus of 0.125% bupivacaine, followed by perfusion of a balanced concentration at a rate of 8 ml/h. Patients in the continuous epidural analgesia group (CEA, n = 21) were given 8 ml of 0.25% bupivacaine with adrenalin; the epidural perfusion of 0.125% bupivacaine and 1 microgram/ml of fentanyl was started at the same rate as in the IEA group. We recorded pain as assessed on a visual analog scale, extension of sensory and motor block, maternal hemodynamic constants, number of boluses of bupivacaine used, total doses of bupivacaine and oxytocin, instruments needed for childbirth, and side effects (pruritus, nausea and vomiting). RESULTS: Analgesic efficacy during the first 30 minutes was greater in the IEA group. The total dose of bupivacaine, required top-up boluses, and the extension of sensory block at 30 minutes, one hour and two hours were also significantly less in the IEA group. The incidence of pruritus was higher in the IEA group. No significant differences were observed for other variables. CONCLUSIONS: Intradural-epidural analgesia provides effective analgesia for labor, with rapid onset, reduced extension of sensory block, lower total doses of local anesthetics and few side effects.

Estudio comparativo de la eficacia y seguridad de la analgesia epidural continua y la analgesia intradural-epidural para el trabajo de parto / The efficacy and safety of continuous epidural analgesia versus intradural-epidural analgesia during labor

OBJETIVOS. Determinar la eficacia y seguridad de la analgesia intradural-epidural frente a la analgesia epidural continua en gestantes durante el trabajo de parto. PACIENTES Y MÉTODO. Se seleccionaron 42 gestantes que iniciaron el trabajo de parto de forma espontánea, las cuales fueron distribuidas aleatoriamente en dos grupos. En el grupo de analgesia intradural-epidural (AIEC) (n = 21) se administraron por vía intradural 25 µg de fentanilo asociados a 2,5 mg de bupivacaína isobara con adrenalina, y se continuó la analgesia con la administración epidural de un bolo de 8 ml de bupivacaína al 0,125 por ciento, seguido de una perfusión a igual concentración y a 8 ml/h. En el grupo de analgesia epidural continua (AEC) (n = 21) se administraron 8 ml de bupivacaína al 0,25 por ciento con adrenalina, y se inició la perfusión epidural de bupivacaína al 0,125 por ciento y 1 µg/ml de fentanilo a igual velocidad que en el grupo 1. Se evaluó el dolor mediante la escala analógica visual (EAV), así como el bloqueo sensitivo y motor, las constantes hemodinámicas maternas, el número de bolos de bupivacaína, la dosis total de bupivacaína y oxitocina, la instrumentación del parto y los efectos secundarios (prurito, náuseas y vómitos). RESULTADOS. La eficacia analgésica durante los primeros 30 min fue superior en el grupo de AIEC. La dosis total de bupivacaína, los requerimientos de bolos de rescate y la extensión del bloqueo sensitivo a los 30 min, a la hora y a las 2 h también fueron significativamente menores en este grupo. La incidencia de prurito fue superior en el grupo de AIEC. No se objetivaron diferencias en el resto de las variables analizadas. CONCLUSIONES. La analgesia intradural-epidural proporciona una instauración rápida y efectiva de la analgesia en el trabajo de parto, con menor grado de bloqueo sensitivo, dosis totales reducidas de anestésicos locales y mínimos efectos secundarios (AU)

No disponible

The influence of the menstrual cycle in postdural puncture headache.

BACKGROUND AND OBJECTIVES: We performed a preliminary study to analyze the influence of the menstrual cycle on the incidence of postdural puncture headache (PDPH). METHODS: One hundred sixty female patients with regular menstrual cycles who received spinal anesthesia were observed. Based on the day within the menstrual cycle that they received the puncture, the patients were classified into period A (perimenstrual) or period B (postmenstrual). The possible relationship among headaches, lifestyle habits, and anesthetic technique, and the presence of PDPH were analyzed, as were the levels of female sex hormones with PDPH in comparison with a control group. RESULTS: Seven cases of PDPH (4.3%) were observed--one within the perimenstrual group and six in the postmenstrual group. No significant differences were observed between the two periods or were there any differences in relating PDPH to the other variables analyzed. CONCLUSIONS: According to our results, the menstrual cycle and hormonal levels may not have any influence on the appearance of PDPH in female patients, although a larger series is required to validate these results.

[Explicit and implicit memory during inhalation and intravenous anesthesia]. / Memoria explícita e implícita durante anestesia inhalatoria e intravenosa.

OBJECTIVE: Patients rarely report memory or knowledge of surgery after general anesthesia. During apparently adequate surgical anesthesia, however, information processing of high level functions, such as language comprehension and learning, can continue unconsciously. Our objective is to assess whether different anesthetic techniques (two inhalational and two intravenous) guarantee the absence of both types of memory. PATIENTS AND METHOD: One hundred patients were randomly assigned to receive the following anesthetic procedures: desflurane/N2O (group 1), isoflurane/N2O (group 2), fentanyl/N2O (group 3) and total intravenous anesthesia (group 4). A cassette with the same music was played in all cases, and an order requiring a nonverbal response was given to 15 randomly chosen patients in each group. Response was evaluated at a visit 24 to 48 hours after surgery. Fifteen patients, therefore, constituted the study group for each anesthetic procedure, and 10 patients formed the control group. We assessed the presence of explicit memory in a structured interview, and implicit memory by way of the relation between the number of times the nonverbal order was obeyed and the time of the interview. RESULTS: Explicit memory was absent in all patients. The presence of implicit memory was confirmed, however, in the isoflurane (p = 0.02) group. Significant differences between the isoflurane group and both the desflurane and total intravenous anesthesia groups (p = 0.03) were found. CONCLUSION: Explicit memory was absent with all four anesthetic techniques used in our study. Implicit memory was more difficult to inhibit, however, with isoflurane/N2O.

[Satisfaction with locoregional anesthesia in women who had undergone cesarean section]. / Satisfacción con la anestesia locorregional en mujeres intervenidas de cesárea.

OBJECTIVES: To compare satisfaction with local-regional and general anesthesia in women undergoing cesarean, the possible influence of time of evaluation and recall of the anesthesiologist. PATIENTS AND METHODS: Retrospective study performed in all women who delivered by cesarean in the 6 first months of 1997. The women were assigned to two groups according to type of anesthesia, local-regional or general. Their satisfaction with anesthesia was evaluated by questionnaire 48 to 72 hours after surgery and two weeks after release. Most items required discrete-point answers, including a satisfaction of a scale of 0 to 10. During the second interview we also evaluated satisfaction with the procedure and hospital in general, as well as recall of the anesthesiologist. Group homogeneity was based on demographic, sociocultural, obstetric and surgical variables. RESULTS: In a context of high satisfaction with anesthesia, 189 (76%) of the 247 women receiving local-regional anesthesia gave high evaluations to the anesthesia (8.90 +/- 1.5; mean: 10), compared with 58 (24%) of those receiving general anesthesia (8 +/- 2; mean 8.5) (p = 0.001). Both groups were homogeneous except for the distribution of emergencies, which occurred more often in those receiving general anesthesia (p < 0.001). Women who had received local-regional anesthesia expressed greater willingness to repeat or recommend the technique (p < 0.001). The highest score in this group was from women receiving intradural anesthesia along with fentanyl for local anesthesia, with significant differences only in comparison to epidural anesthesia. The differences in responses between the first and second interview were scarce. The hospital received a lower evaluation than did either anesthesia or surgery (p < 0.001). The anesthesiologist, who was less well recognized than the obstetrician was remembered better among women receiving local-regional anesthesia (p = 0.008). CONCLUSIONS: Local-regional anesthesia can improve levels of satisfaction over that of general anesthesia among women undergoing cesarean surgery, and contributes to maintaining recall of the anesthesiologist. These results may be related to the fact of being conscious during the birth of a child.

[Prophylaxis of intraoperative nausea and vomiting with sub-hypnotic dose of propofol during intradural anesthesia in cesarean section]. / Profilaxis de las náuseas y los vómitos intraoperatorios con dosis subhipnóticas de propofol durante la anestesia intradural en cesáreas.

OBJECTIVES: To determine the preventive and therapeutic effect of 10 mg of propofol administered after delivery on the incidence of intraoperative nausea and vomiting (IONV) during intradural anesthesia for cesarean delivery. PATIENTS AND METHOD: Controlled, randomized double blind study of 60 women (ASA I-II) receiving intradural anesthesia for elective or deferred emergency cesarean delivery. The propofol group received 10 mg i.v. immediately after fetal extraction. The control group received an equal volume of Intralipid. The presence of IONV after administration of the prophylactic bolus was treated with a second bolus, and if nausea had not subsided completely after two minutes, treatment was topped up with dehydro-benzoperidol. RESULTS: The control group included 31 women and the propofol group 29, of whom 3 were excluded. Control variables were similar in the two groups. There were no significant differences in the incidence and severity of IONV between the two groups (22.5 versus 23%). The top-up antiemetic drug was used in the same number of patients in each group. CONCLUSIONS: Although 10 mg propofol has been described as an effective direct antiemetic, episodes of IONV were neither prevented nor reversed by its use during intradural anesthesia for cesarean delivery.

[Effect of the local anesthetic on visceral pain in cesarean sections done under intradural anesthesia]. / Influencia del anestésico local en el dolor visceral de cesáreas bajo anestesia intradural.

OBJECTIVES: To evaluate the influence of local anesthetic on the incidence and severity of visceral pain during cesarean section performed under subarachnoid anesthesia. PATIENTS AND METHOD: This was a randomized double blind study of 90 parturients undergoing scheduled or emergency cesareans. The women were distributed among three groups according to local anesthetic used: 2% isobaric mepivacaine in group 1, 0.5% hyperbaric bupivacaine in group 2, and 0.5% isobaric bupivacaine with adrenalin in group 3. The total anesthetic dose was selected based on height, and pain was defined as silent and dull, or a sensation of pressure that was poorly defined, diffuse or referred to another area and accompanied or not by nausea and/or vomiting. Pain was assessed on a visual analog scale at various moments during surgery. Other variables recorded were metameric level of blockade, hemodynamic function and presence of nausea and/or vomiting. RESULTS: One patient in each group was excluded. The incidences of visceral pain and 95% confidence intervals were as follows: 38% (23-56%) in group 1 and 10% (3.5-25%) in groups 2 and 3 (p = 0.002). The metameric level of blockade differed significantly among the groups. The highest level (T1-5) was reached in group 1 but level was the most consistent (T3-5) in group 2. Systolic arterial pressures in all groups were significantly lower than baseline levels 5 min after puncture and the decrease was greatest in group 3. The highest incidence (p = 0.01) of nausea and/or vomiting occurred in the isobaric bupivacaine group. CONCLUSION: Use of hyperbaric bupivacaine offers advantages over the other techniques, as it assures more consistent attainment of metameric level, an incidence of visceral pain that is lower than that of isobaric mepivacaine, and fewer hemodynamic repercussions than isobaric bupivacaine with vasoconstrictor.