Postoperative pain management in the elderly. Literature review

Timely post-operative pain management in elderly patients is critically important. Given their physiological changes and comorbidities, management in this group of patients is different from the rest of the population. Knowledge of potentially inappropriate medications (Beers criteria) is relevant because of the presence of comorbidities in this population. Although acetaminophen continues to be safe, non-steroidal anti-inflammatory agents produce several adverse effects which need to be considered before they are used. On the other hand, opioids continue to be one of the pillars in analgesia, with due consideration of their adverse affects and interactions, and the need for dose adjustments. Adequate postoperative pain management prevents adverse effects and the risk of developing chronic pain.

El manejo oportuno del dolor en la población anciana durante el periodo posoperatorio es de vital importancia. Este grupo de pacientes, dado sus cambios fisiológicos y comorbilidades, requieren un manejo diferente al resto de la población. Es relevante conocer cuáles medicamentos son potencialmente inapropiados para su uso (criterios de Beers) ante las comorbilidades de esta población. Si bien el acetaminofén continúa siendo seguro, los antiinflamatorios no esteroideos causan varios efectos adversos que ameritan consideración antes de su uso; por su parte, los opioides siguen siendo uno de los pilares analgésicos, teniendo en cuenta sus efectos adversos y valorando la necesidad de ajuste de dosis e interacciones. El adecuado manejo del dolor posoperatorio previene desenlaces adversos y el riesgo de cronificación.

Intermittent Fasting as a Trigger of Ketoacidosis in a Patient With Stable, Long-term Type 1 Diabetes.

Diabetic ketoacidosis (DKA) is an acute complication of type 1 diabetes (T1DM) with a high morbidity and mortality. Diabetic ketoacidosis is usually triggered by metabolic stressors that increase insulin requirements like infection, trauma, surgery, or some medications. Ketogenic diets are nutritional regimes that drastically reduce the intake of carbohydrates in order to increase circulating ketones and reduce appetite. Intermittent fasting diets similarly aim to impact appetite and body weight, but through the restriction of feeding to specific periods of time or days. A 58-year-old woman with T1DM and no prior episodes of DKA since her diagnosis 16 years ago was admitted to the emergency room with severe metabolic acidosis, ketosis, dehydration, and back pain after 9 days of practicing a ketogenic, intermittent fasting diet on the advice of a friend. The standard management of DKA led to the resolution of the symptoms and metabolic alterations, but this might not be the case in other patients. This case highlights the relevance of close professional monitoring of dietary and insulin schemes in patients with T1DM, and of the adequate nutritional education of patients in order to avoid having them follow fashionable dietary trends without knowledge of their implications.

An economic analysis of inadequate prescription of antiulcer medications for in-hospital patients at a third level institution in Colombia.

INTRODUCTION: The prescription and costs of antiulcer medications for in-hospital use have increased during recent years with reported inadequate use and underused. AIM: To determine the patterns of prescription-indication and also perform an economic analysis of the overcost caused by the non-justified use of antiulcer medications in a third level hospital in Colombia. MATERIALS AND METHODS: Cross-sectional study of prescription-indication of antiulcer medications for patients hospitalized in "Hospital Universitario San Jorge" of Pereira during July of 2012. Adequate or inadequate prescription of the first antiulcer medication prescribed was determined as well as for others prescribed during the hospital stay, supported by clinical practice guidelines from the Zaragoza I sector workgroup, clinical guidelines from the Australian Health Department, and finally the American College of Gastroenterology Criteria for stress ulcer prophylaxis. Daily defined dose per bed/day was used, as well as the cost for 100 beds/day and the cost of each bed/drug. A multivariate analysis was carried out using SPSS 21.0. RESULTS: 778 patients were analyzed, 435 men (55.9 %) and 343 women, mean age 56.6 +/- 20.1 years. The number of patients without justification for the prescription of the first antiulcer medication was 377 (48.5 %), and during the whole in-hospital time it was 336 (43.2 %). Ranitidine was the most used medication, in 438 patients (56.3 %). The cost/month for poorly justified antiulcer medications was € 3,335.6. The annual estimated cost for inadequate prescriptions of antiulcer medications was € 16,770.0 per 100 beds. CONCLUSION: A lower inadequate prescription rate of antiulcer medications was identified compared with other studies; however it was still high and is troubling because of the major costs that these inadequate prescriptions generates for the institution.

Análisis económico de la prescripción inadecuada de antiulcerosos en pacientes hospitalizados en institución de tercer nivel de Colombia / An economic analysis of inadequate prescription of antiulcer medications for in-hospital patients at a third level institution in Colombia

Introducción: la prescripción y coste de antiulcerosos a nivel hospitalario se incrementaron en años recientes, reportándose usos inadecuados. Objetivo: determinar los patrones de prescripción-indicación y el análisis económico del sobrecoste por uso injustificado de antiulcerosos en un hospital de tercer nivel de atención en Colombia. Materiales y métodos: estudio de corte transversal, de prescripción-indicación de antiulcerosos en pacientes internados en el Hospital Universitario San Jorge de Pereira en julio 2012. Se determinaron: indicación adecuada o inadecuada del primer antiulceroso prescrito y del prescrito durante la hospitalización, apoyados en guías de práctica clínica del Grupo de Trabajo Sector Zaragoza I, del Departamento Gubernamental Australiano de la Salud y los criterios del Colegio Americano de Gastroenterología para profilaxis de úlceras de estrés. Se definió la dosis diaria definida por cama/día, se obtuvo el coste por 100 camas/día y costes de cada medicamento. Se hizo análisis multivariado mediante SPSS 21.0. Resultados: se analizaron 778 pacientes, 435 hombres (55,9 %) y 343 mujeres, edad promedio 56,6 ± 20,1 años. No tenían justificación para la prescripción del primer antiulceroso 377 pacientes (48,5 %), ni durante toda la hospitalización 336 pacientes (43,2 %). Ranitidina fue el más usado en 438 pacientes (56,3 %). El coste/mes por antiulcerosos no indicados fue 3.335,62 Euros. El coste anual estimado por inadecuada prescripción de antiulcerosos fue 16.770,0 Euros por 100 camas. Conclusión: se presentó una menor prescripción inadecuada de antiulcerosos en comparación con otros estudios, sin embargo sigue siendo alta y preocupante por los importantes costes en que incurre la institución para financiar medicamentos que no requieren los pacientes (AU)

Introduction: The prescription and costs of antiulcer medications for in-hospital use have increased during recent years with reported inadequate use and underused. Aim: To determine the patterns of prescription-indication and also perform an economic analysis of the overcost caused by the non-justified use of antiulcer medications in a third level hospital in Colombia. Materials and methods: Cross-sectional study of prescription-indication of antiulcer medications for patients hospitalized in "Hospital Universitario San Jorge" of Pereira during July of 2012. Adequate or inadequate prescription of the first antiulcer medication prescribed was determined as well as for others prescribed during the hospital stay, supported by clinical practice guidelines from the Zaragoza I sector workgroup, clinical guidelines from the Australian Health Department, and finally the American College of Gastroenterology Criteria for stress ulcer prophylaxis. Daily defined dose per bed/day was used, as well as the cost for 100 beds/day and the cost of each bed/drug. A multivariate analysis was carried out using SPSS 21.0. Results: 778 patients were analyzed, 435 men (55.9 %) and 343 women, mean age 56.6 ± 20.1 years. The number of patients without justification for the prescription of the first antiulcer medication was 377 (48.5 %), and during the whole in-hospital time it was 336 (43.2 %). Ranitidine was the most used medication, in 438 patients (56.3 %). The cost/month for poorly justified antiulcer medications was Euros 3,335.6. The annual estimated cost for inadequate prescriptions of antiulcer medications was Euros 16,770.0 per 100 beds. Conclusion: A lower inadequate prescription rate of antiulcer medications was identified compared with other studies; however it was still high and is troubling because of the major costs that these inadequate prescriptions generates for the institution (AU)