Test sensitivos cuantitativos («Quantitative Sensory Testing») en el diagnóstico y tratamiento del dolor. Breve revisión y propuesta de protocolización de empleo / Quantitative Sensory Testing in pain assesment and treatment. Brief review and algorithmic management proposal

Los estudios sensitivos cuantitativos, más conocidos por sus siglas en inglés QST (Quantitative Sensory Testing), son un conjunto de pruebas que permiten evaluar de forma integral el sistema nociceptivo y obtener información más objetiva de cómo se percibe el dolor. En los últimos años se ha convertido en una herramienta de uso común en muchas Unidades del Dolor y Departamentos de Anestesiología de muchos países. En 2013, el Grupo de Dolor Neuropático de la IASP propuso las primeras recomendaciones para su aplicación en la práctica clínica y en investigación. No obstante, existen multitud de variantes metodológicas publicadas, con estándares no armonizados, que hacen que resulte complejo introducirse en este campo y generalizar su uso. En este trabajo intentamos presentar los fundamentos, tipos de test y dispositivos, metodología de aplicación y su utilidad en Anestesiología y Tratamiento del Dolor

Quantitative Sensory Testing (QST) is used to globally analyze the nociceptive system in order to obtain a more objective understanding of pain perception. In recent years, QST has become a common tool in many pain clinics and anesthesiology departments worldwide. In 2013, the Neuropathic Pain Special Interest Group of the IASP put forward the first recommendations for conducting QST in clinical practice and research. However, the wide variety of QST methodologies and standards in the literature make it difficult to generalize the used of this tool in clinical practice. In this study, we present the basic concepts of QST, the type of tests and devices used, how they are applied, and the role of QST in anesthesiology and pain management

Quantitative Sensory Testing in pain assesment and treatment. Brief review and algorithmic management proposal. / Test sensitivos cuantitativos («Quantitative Sensory Testing¼) en el diagnóstico y tratamiento del dolor. Breve revisión y propuesta de protocolización de empleo.

Quantitative Sensory Testing (QST) is used to globally analyze the nociceptive system in order to obtain a more objective understanding of pain perception. In recent years, QST has become a common tool in many pain clinics and anesthesiology departments worldwide. In 2013, the Neuropathic Pain Special Interest Group of the IASP put forward the first recommendations for conducting QST in clinical practice and research. However, the wide variety of QST methodologies and standards in the literature make it difficult to generalize the used of this tool in clinical practice. In this study, we present the basic concepts of QST, the type of tests and devices used, how they are applied, and the role of QST in anesthesiology and pain management.

Tapentadol vs. pregabalina asociada a otros opioides en dolor crónico. Análisis de coste-efectividad / Tapentadol vs. pregabalin associated with other opioids in chronic pain management. Cost-effectiveness analysis

Fundamento: el tapentadol es un nuevo analgésico con mecanismo de acción dual como agonista opioide m e inhibidor de la recaptación de noradrenalina. El coste del tratamiento puede suponer un problema a la hora de prescribirlo. Objetivo: analizar si el tratamiento con tapentadol puede resultar coste-efectivo frente a otros opioides asociados a pregabalina. Pacientes y método: se incluyeron 21 pacientes en tratamiento por dolor crónico con opioides asociados a pregabalina y mal control analgésico (EVA > 4). Se les propuso rotar a tratamiento con tapentadol en dos fases: primero sustituyendo el opioide por tapentadol y posteriormente retirando progresivamente la pregabalina. Se registraron el dolor (EVA), el coste diario del tratamiento y la incidencia de efectos adversos antes y tras la introducción del nuevo tratamiento. Resultados: cuatro pacientes abandonaron el tratamiento y volvieron al previo por mayor incidencia de efectos secundarios. En el grupo restante el dolor mejoró de 5,7 (EVA) a 3,4 (EVA) (p < 0,001), mientras que el coste de tratamiento pasó de 4,57 Euros/día a 3,78 Euros/día (p < 0,05). Conclusión: el tratamiento con tapentadol puede resultar coste-efectivo frente a la combinación de otros opioides con pregabalina en pacientes con dolor crónico moderado-grave. Se requieren estudios más amplios que confirmen estos hallazgos (AU)

Background: Tapentadol is a new oral analgesic with a dual mode of action as a mu-opioid receptor agonist and as norepinephrine reuptake inhibitor. The cost of treatment can be argued as a problem for prescribing it. Objective: The aim of this study was to compare the cost-effectiveness of tapentadol to that of associations of other opioids with pregabalin. Patients and methods: 21 patients suffering chronic pain under treatment with opioids and pregabalin for more than 3 months and pain poorly controlled (VAS > 4) were proposed to change to tapentadol in a progressive manner: First changing the opioid to tapentadol and then removing pregabalin. Pain(VAS), daily cost of treatments and adverse effects incidence were registered. Results: Four patients returned to prior treatment becauseof higher incidence of adverse effects. In the group of 17 patients who completed the change of treatment pain improved from 5.7 (VAS) to 3.4 (VAS) (p < 0.001), and the cost of treatment from 4.57 Euros/day to 3.78 Euros/day (p < 0.05). Conclusion: Tapentadol treatment may be cost-effective when compared with associations of other opioids and pregabalin in patients suffering moderate to severe chronic pain. More extensive studies must be done in this sense (AU)

Validación externa de la escala Risk Quantification of Early Outcome After Lung Transplantation / External validation of the Risk Quantification of Early Outcome After Lung Transplantation scale

Objetivo: Validar la escala Risk Quantification of Early Outcome After Lung Transplantation (RQLT) en una cohorte de enfermos trasplantados de pulmón. Diseño: Prospectivamente se recogieron los parámetros incluidos en la escala RQLT. Pacientes: Se analizaron 74 enfermos trasplantados de pulmón en el Hospital Universitario Marqués de Valdecilla (Santander) entre septiembre de 2004 y marzo de 2008. Variables de interés principales: Asociación de la puntuación de la escala RQLT con la mortalidad a 30 días y la estancia en unidad de cuidados intensivos prolongada. Ajuste de la escala mediante modelo de regresión logística teniendo como variable dependiente la mortalidad a 30 días. Valoración de la eficacia diagnóstica mediante curva receiver operating characteristics, y calibración del sistema sobre la muestra mediante el test de bondad del ajuste de Hosmer y Lemeshow. Resultados: La mortalidad a 30 días en los enfermos trasplantados de pulmón es significativamente mayor conforme aumenta el valor del RQLT, y muestra una odds ratio de 2,20 (1,24-3,93) por cada punto de más en la escala. El área bajo la curva receiver operating characteristics, con respecto a la mortalidad a 30 días, fue de 0,79 (0,68-0,88); p=0,01. El test de bondad de ajuste de Hosmer y Lemeshow describió un valor p=0,58. Conclusiones: La escala RQLT es una herramienta útil como indicador de mortalidad a 30 días en los pacientes trasplantados (AU)

Objective: To validate the «Risk Quantification of Early Outcome After Lung Transplantation» (RQLT) scale in a cohort of lung transplantation patients. Design: The parameters included in the RQLT scale were recorded prospectively. Patient: A total of 74 lung transplant patients in the University Hospital Marquis of Valdecilla (Santander) were analyzed between September 2004 and March 2008. Main variables of interest: This was the association of the score on the RQLT scale with mortality at 30 days and prolonged ICU stay. The dependent variable of mortality at 30 days was adjustment of scale using the logistic regression model. Diagnostic efficacy was evaluated using the ROC curve and calibration of the system on the sample with the Hosmer and Lemeshow goodness of fit test. Results: The 30-day mortality in lung transplant patients increases significantly as the RQLT score increases, with an odds ratio (OR) of 2.20 (1.24-3.93) for each point increase on the RQLT scale. The area under the ROC curve for 30-day mortality was 0.79 (0.68-0.88; P=0.01). The Hosmer and Lemeshow goodness of fit test described a value p=0.58. Conclusions: The RQLT scale is a useful tool as an indicator of 30-day mortality in transplant patients (AU)

[External validation of the Risk Quantification of Early Outcome after Lung Transplantation scale]. / Validación externa de la escala Risk Quantification of Early Outcome After Lung Transplantation.

OBJECTIVE: To validate the "Risk Quantification of Early Outcome After Lung Transplantation" (RQLT) scale in a cohort of lung transplantation patients. DESIGN: The parameters included in the RQLT scale were recorded prospectively. PATIENT: A total of 74 lung transplant patients in the University Hospital Marquis of Valdecilla (Santander) were analyzed between September 2004 and March 2008. MAIN VARIABLES OF INTEREST: This was the association of the score on the RQLT scale with mortality at 30 days and prolonged ICU stay. The dependent variable of mortality at 30 days was adjustment of scale using the logistic regression model. Diagnostic efficacy was evaluated using the ROC curve and calibration of the system on the sample with the Hosmer and Lemeshow goodness of fit test. RESULTS: The 30-day mortality in lung transplant patients increases significantly as the RQLT score increases, with an odds ratio (OR) of 2.20 (1.24-3.93) for each point increase on the RQLT scale. The area under the ROC curve for 30-day mortality was 0.79 (0.68-0.88; P=0.01). The Hosmer and Lemeshow goodness of fit test described a value p=0.58. CONCLUSIONS: The RQLT scale is a useful tool as an indicator of 30-day mortality in transplant patients.

Safety and complications of percutaneous tracheostomy in a cohort of 800 mixed ICU patients.

Percutaneous tracheostomy is used primarily to assist weaning from mechanical ventilation in the intensive care unit. We report our experiences of 800 such procedures performed in the intensive care unit by a collaborative team (critical care and ENT specialists). Most procedures (85.6%) were performed by residents supervised by the intensive care unit staff. Complications occurred in 32 patients (4%). Intraprocedural complications occurred in 17 patients (2.1%), early postprocedural complications in six (0.75%), and late postprocedural complications in nine (1.1%). No deaths were directly related to percutaneous tracheostomy. The incidence of complications was greater in percutaneous tracheostomy performed by the residents during their initial five attempts compared to their later attempts (9.2% vs 2.6%, p < 0.05). The low incidence of complications indicates that bedside percutaneous tracheostomy can be performed safely as a routine procedure in daily care of intensive care unit patients.

Interlaminar approach for epiduroscopy in patients with failed back surgery syndrome.

BACKGROUND: Epiduroscopy is a relatively new diagnostic and therapeutic technique used in patients with chronic low back pain with or without radiculopathy. We present our experience with a new interlaminar approach in patients with failed back surgery syndrome (FBSS). METHODS: Patients with severe symptoms of FBSS who did not respond to other treatments were included. Lumbar epiduroscopy was performed via interlaminar approach through a 14 G epidural needle under fluoroscopy. A flexible, 0.77 mm, endoscope was introduced through a 4F catheter into the epidural space and advanced in a cephalad direction. Flushes of normal saline through the catheter (via a Y-adapter/haemostasis valve) enabled distension of the space. Adhesions were mechanically mobilized under direct vision. A mixture of triamcinolone 60 mg, hyaluronidase 600 IU, and bupivacaine 0.0625% was instilled. RESULTS: Nineteen patients were included. The mean number of operations at lumbar level was 2.26. Major findings included adhesions, inflammation, stenosis, and nerve root hypotrophia. The visual analogue scale (VAS) score was 7.89 at baseline, 5.95 (P<0.001) 3 months later, and 6.05 (P<0.001) 6 months later. Six patients (31.6%) did not show any improvement, and six other patients showed a very significant improvement (at least three points reduction in the VAS) 3 months later. We had four cases of dural puncture, but only one patient required hospital admission. CONCLUSIONS: We have described a new procedure for epiduroscopy with approximately 50% reduced outer diameter of the catheter, which allows interlaminar approach. Its diagnostic efficacy is clear and there were a significant number of patients who had improved outcome.

[Comparative study of two preservation solutions in the initial function after bilateral human lung transplantation]. / Estudio comparativo de dos soluciones de preservación en la función inicial del trasplante bipulmonar en humanos.

OBJECTIVE: Compare the influence of two preservation liquids, Euro-Collins (EC) and Perfadex (P) in the pulmonary graft function in the initial phase of lung transplant in humans. DESIGN: Retrospective study. SCOPE: Lung transplant unit of the ICU of a university hospital. PATIENTS: A total of 79 patients were subjected to a transplant of both lungs. The pulmonary grafts were preserved with EC in 23 cases and with P in 56 cases. VARIABLES OF INTEREST: Pulmonary function was assessed on admission in the intensive care unit (ICU) with the PaO2/FiO2 ratio. Mortality, graft dysfunction stay in ICU and time of mechanical ventilation were also assessed at 30 days. RESULTS: The PaO2/FiO2 ratio was significantly greater in the P group than in the EC both on admission (p<0.006) and at 12 hours (p=0.032) in the ICU. Graft dysfunction incidence was less in group P than in EC (p<0.045). There were no differences in regards to mortality at 30 days, stay in ICU and time of mechanical ventilation between both groups. CONCLUSION: Preservation of the pulmonary graft with P as preservation liquid compared with EC is associated with better graft function in the initial phases of transplant of both lungs and with a decrease in the incidence of graft dysfunction.

Estudio comparativo de dos soluciones de preservación en la función inicial del trasplante bipulmonar en humanos / Comparative study of two preservation solutions in the initial function after bilateral human lung transplantation

Objetivo. Comparar la influencia de dos líquidosde preservación, Euro-Collins (EC) y Perfadex(P), en la función del injerto pulmonar en la faseinicial del trasplante pulmonar en humanos.Diseño. Estudio retrospectivo.Ámbito. Unidad de trasplante pulmonar de laUnidad de Cuidados Intensivos (UCI) de un hospitaluniversitario.Pacientes. Un total de 79 pacientes fueron sometidosa un trasplante bipulmonar. Los injertospulmonares fueron preservados con EC en 23casos y con P en 56 casos.Variables de interés. Se valoró la función pulmonaral ingreso en la UCI mediante el cocientede presión parcial de oxígeno/fracción inspiradade oxígeno (PaO2/FiO2). También se valoró lamortalidad a los 30 días, la disfunción del injerto,así como la estancia en la UCI y el tiempo deventilación mecánica.Resultados. El cociente PaO2/FiO2 fue significativamentemejor en el grupo P que en el ECtanto al ingreso (258 ± 116 frente a 176 ± 105, p <0,01) como a las 12 horas (313 ± 109 frente a 248± 116, p < 0,05) del ingreso en UCI. La incidenciade disfunción del injerto fue menor en el grupo Pque en el EC (p < 0,045). No hubo diferencias encuanto a la mortalidad a los 30 días, estancia enla UCI y el tiempo de ventilación mecánica entreambos grupos.Conclusión. La preservación del injerto pulmonarcon P como líquido de preservación, comparadocon EC, se asocia con una mejor funcióndel injerto en las fases iniciales del trasplante bipulmonary con un descenso en la incidencia dela disfunción del injerto

Objective. Compare the influence of two preservationliquids, Euro-Collins (EC) and Perfadex(P) in the pulmonary graft function in the initialphase of lung transplant in humans.Design. Retrospective study.Scope. Lung transplant unit of the ICU of auniversity hospital.Patients. A total of 79 patients were subjectedto a transplant of both lungs. The pulmonarygrafts were preserved with EC in 23 cases andwith P in 56 cases.Variables of interest. Pulmonary function wasassessed on admission in the intensive care unit(ICU) with the PaO2/FiO2 ratio. Mortality, graftdysfunction stay in ICU and time of mechanicalventilation were also assessed at 30 days. Results. The PaO2/FiO2 ratio was significantlygreater in the P group than in the EC both on admission(p < 0.006) and at 12 hours (p = 0.032) inthe ICU. Graft dysfunction incidence was less ingroup P than in EC (p < 0.045). There were no differencesin regards to mortality at 30 days, stayin ICU and time of mechanical ventilation betweenboth groups.Conclusion. Preservation of the pulmonarygraft with P as preservation liquid compared withEC is associated with better graft function in theinitial phases of transplant of both lungs andwith a decrease in the incidence of graft dysfunction

Influence of nutritional status in lung transplant recipients.

OBJECTIVE: To assess the influence of nutritional status on mortality in lung transplant (LT) recipients. METHODS: A total of 114 patients underwent lung-transplantation between January 1999 and June 2005. Mortality after lung transplantation was examined based upon body mass index (BMI) categories: BMI < 18.5 kg/m(2) (group I); BMI 18.5 to 24.9 kg/m(2) (group II, reference group); BMI 25 to 27.5 kg/m(2) (group III); and BMI > 27.5 kg/m(2) (group IV). Levels of serum albumin and serum prealbumin were determined before transplantation. We constructed a Cox proportional hazards model for overall survival considering mortality as the outcome. The final model was adjusted by age. RESULTS: We analyzed 114 transplants in 112 patients. The population included 44 single and 70 bilateral LTs. Mean recipient age was 53.9 +/- 10.9 years. The hazard ratio of the risk of death in group IV was higher than in the reference group (hazard ratio: 3.55, 95% CI: 1.19 to 10.66; P = .024). Serum prealbumin 27.5 kg/m(2) was a predictor of increased mortality after transplantation. Low pretransplant prealbumin levels in lung recipients were associated with mortality after transplantation.

Ventilación por presión positiva no invasiva intraoperatoria en un paciente con enfermedad pulmonar obstructiva crónica reagudizada / Noninvasive positive pressure ventilation during surgery in a patient with exacerbated chronic obstructive pulmorary disease

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Rotura bronquial en traumatismo torácico cerrado / Bronchial rupture in closed chest trauma

La rotura bronquial es una complicación infrecuente pero potencialmente grave en el traumatismo torácico cerrado, con una mortalidad asociada del 30 por ciento. En las últimas décadas se está presenciando un incremento en su incidencia paralelamente al desarrollo de los medios de transporte. El 80 por ciento de las lesiones se localizan a 2,5 cm de la carina. El diagnóstico está basado en las manifestaciones clínicas, hallazgos radiológicos y en la broncoscopia. El enfisema subcutáneo y la insuficiencia respiratoria son los síntomas más frecuentes. A escala radiológica destaca la presencia de neumotórax, neumomediastino o ambos. La broncoscopia es el método diagnóstico de elección y se debe realizar de forma temprana. El tratamiento es el restablecimiento de la continuidad anatómica del árbol traqueobronquial mediante la reparación quirúrgica de la lesión, tan pronto como sea posible, si ésta es mayor de un tercio de la circunferencia y/o el neumotórax no se resuelve con dos drenajes torácicos. Es muy importante que este tipo de lesión sea reconocida y tratada de forma temprana, tanto para restaurar con éxito la función pulmonar, como para evitar las complicaciones asociadas con el retraso diagnóstico y terapéutico. No obstante, los hallazgos iniciales son a menudo inespecíficos, y requieren un alto índice de sospecha, por lo que en un porcentaje elevado de pacientes el diagnóstico es tardío. (AU)

[Bronchial rupture in blunt thoracic trauma]. / Rotura bronquial en traumatismo torácico cerrado.

In closed chest trauma, bronchial rupture is an unusual but potentially serious complication, with an associated mortality rate of 30%. Recent decades have seen an increase in incidence parallel to greater use of transport. Eighty percent of injuries are located 2.5 cm from the carina. Diagnosis is based on clinical signs, imaging and bronchoscopy. Subcutaneous emphysema and respiratory insufficiency are the most common findings. Images show the presence of pneumothorax, pneumomediastinum or both. Bronchoscopy is the diagnostic method of choice and must be performed early. Treatment consists of reestablishing anatomical continuity of the tracheobronchial tree by surgical repair if the lesion affects more than a third of the circumference and/or pneumothorax is not resolved after two chest drainages. This type of injury should be recognized and treated early, both to restore lung function and to prevent associated complications caused by delay. However, initial findings are seldom specific, requiring the physician to display a high degree of suspicion and explaining why diagnosis often comes late.

[Traumatic bilateral chylothorax (author's transl)]. / Quilotórax bilateral traumático.

A case is presented of a bilateral chylothorax caused by rupture of the thoracic duct, secondary to a closed traumatism of the thorax in a polytraumatized patient, and produced by a mechanism of hyperextension of the dorsal segment of the vertebral column. Considerations are made with reference to the anatomy of the thoracic duct, the rupture mechanism, diagnosis, complications and treatment. The chylothorax could not be distinguished clinically and by simple radiology from the traumatic hemothorax. The preliminary diagnosis will be made according to the macroscopic appearance of the drained fluid, and the definite diagnosis by the analytical and histopathologic characteristics of the same fluid. The lymphographic examination reveals the exact point of the lesion. The immediate complications are related to the respiratory insufficiency due to the occupation of the pleural space, and under a long period of time undernutrition provoked by the loss of fats and proteins. The treatment of choice is based upon the early drainage of the chylothorax and on the absolute suppression of the oral intake, establishing a complete parenteral feeding during at least 15 days. Afterwards oral diet can be initiated with a gradual increase in its quantity and always without fat content, while at the same time the parenteral nutrition is reduced. Following this protocol a great number of ruptures of the thoracic duct can be corrected, achieving a spontaneous closure of the duct. In the cases in which this not occur, at the end of 15 days it would be advisable to perform a surgical operation according to the Lampson's ligature technique.