ABSTRACT
Objetivo: Estudiar la efectividad de la analgesia preventiva con diclofenaco en las primeras 24 horas del postoperatorio de la colecistectomía laparoscópica electiva (CLE). Pacientes y Métodos: Estudio prospectivo, aleatorizado, placebo-controlado y doble ciego que incluyó 90 pacientes de ambos sexos entre 17 a 76 años de edad, con peso entre 45 y 100 Kg y estado físico ASA I-II sometidos a CLE. Fueron asignados a uno de los tres grupos siguientes: Grupo control DD (diclofenaco-diclofenaco) diclofenaco 1 mg/Kg IM 60 minutos antes de la cirugía y después de la extubación 0,35 mg/Kg IV en bolo, seguido por una infusión de 1,5 mg/Kg durante 24 horas. Grupo estudio DP (diclofenaco-placebo) diclofenaco 1mg/Kg IM 60 minutos antes de la cirugía y después de la extubación solución fisiológica simulando la administración del grupo DD. Grupo control PD (placebo-diclofenaco) solución fisiológica IM 60 minutos antes de la cirugía y después de la extubación diclofenaco como en DD. La intensidad del dolor fue medida usando la escala visual análoga (EVA) de 0 a 10 y registrada junto a la analgesia de rescate y los efectos indeseables a las 1 (T1), 6 (T2), 12 (T3) y 24 (T4) horas posteriores a la extubación; la gasometría arterial se valoró 1 (T0) hora antes de la cirugía y en T4. Resultados: Los valores de la EVA en T1 para los grupos DD, DP y PD fueron 2,67ñ0,54, 2,82ñ0,63 y 2,88ñ0,58 respectivamente. En ningún momento del estudio hubo diferencias significativas en la intensidad del dolor y en la analgesia de rescate y en los valores gasométricos entre los grupos. Se registraron 22 efectos indeseables en el grupo DD, 21 en el DP y 21 en el PD, ninguno de ellos grave. Los más frecuentes fueron nauseas y vómitos. Conclusiones: La analgesia preventiva simple con diclofenaco 1mg/Kg IM 60 minutos antes de la inducción no mejora la intensidad del dolor, ni la necesidad de analgesia de rescate durante las primeras 24 horas del postoperatorio de la CLE (AU)
Subject(s)
Middle Aged , Adolescent , Adult , Aged , Male , Female , Humans , Preoperative Care , Cholecystectomy, Laparoscopic , Pain, Postoperative , Prospective Studies , Anti-Inflammatory Agents, Non-Steroidal , Double-Blind Method , DiclofenacABSTRACT
OBJECTIVE: To study the safety and efficacy of diclofenac for preemptive analgesia in the first 24 hours after elective laparoscopic cholecystectomy (ELC). PATIENTS AND METHODS: This prospective, randomized, placebo-controlled, double-blind study enrolled 90 patients of both sexes undergoing ECL. The patients were 17 to 76 years old and weighed between 45 and 100 Kg (ASA I and II). Assignment was to one of the following groups. A control group received diclofenac before and after surgery (DD) as follows: diclofenac 1 mg/Kg i.m. 60 minutes before surgery and a loading dose of 0.35 mg/Kg i.v. after surgery followed by continuous infusion of 1.5 mg/Kg over 24 hours. The study group received diclofenac and placebo (DP) as follows: diclofenac 1 mg/Kg i.m. 60 minutes before surgery and infused saline solution after extubation. A second control group received placebo before surgery and diclofenac afterwards (PD) as follows: a physiological solution was given intramuscularly 60 minutes before the operation and diclofenac was given after extubation as in the DD group. Pain intensity was assessed on a visual analog scale at four times: 1 hour (T1), 6 hours (T2), 12 hours (T3) and 24 hours (T4) after extubation. At those times we also recorded the need for rescue analgesia and side effects. Arterial blood gases and vital signs were recorded 1 hour before surgery (T0) and at T4. RESULTS: Pain intensity at T1 was 2.67 +/- 0.54, 2.82 +/- 0.63 and 2.88 +/- 0.58 for the DD, DP and PD groups, respectively (p = 0.96). The differences in mean pain between T1 and T2, T3 and T4 were -0.2 +/- 0.66, -0.7 +/- 0.51 and 0.0 +/- 0.72 in the DD group (p = 0.723); -0.9 +/- 0.60, -0.4 +/- 0.57 and -1.3 +/- 0.65 in the DP group (p = 0.578); and -1.0 +/- 0.59, -0.5 +/- 0.77 and -1.0 +/- 0.69 in the PD group (p = 0.816). No significant differences in pain intensity or need for rescue analgesia were observed. Although 22 side effects were observed in group DD, 21 in DP and 21 in PD, none was serious. CONCLUSIONS: Simple preemptive analgesia with 1 mg/Kg i.m. of diclofenac 60 minutes before induction of anesthesia does not decrease pain intensity or the need for rescue analgesia in the first 24 hours after ELC.
Subject(s)
Anti-Inflammatory Agents, Non-Steroidal/administration & dosage , Cholecystectomy, Laparoscopic/adverse effects , Diclofenac/administration & dosage , Pain, Postoperative/etiology , Pain, Postoperative/prevention & control , Preoperative Care , Adolescent , Adult , Aged , Double-Blind Method , Female , Humans , Male , Middle Aged , Prospective StudiesABSTRACT
Arteritis of giant cells compromising extracranial and particularly intestinal tissues is not frequent. Therefore, it is common practice to make the diagnosis retrospectively after analyzing the surgical sample. A case is presented of an 83 year old woman admitted to the Clinical Department with a clinical course of 3 days of evolution characterized by fever and pain in the left hemiabdomen. Her personal medical history included multiple diverticulosis of colon, collecistectomy and appendicectomy. Laboratory tests showed that uremia was 0.75 g/L (N.L to 0.45 g/L), V.E.S. 90 mm at the first hour, and the rest of the determinations were normal. The chest and abdomen rays as well as the abdomen and pelvis ecographies were normal. A diagnosis was reached as acute diverticulitis and the patient was treated with 400 mgr of ciprofloxacina and 2,000 mgr a day of metronidazol. She continued in a feverish state and with abdominal pain, so that an anexial tomography of abdomen was taken. It showed a widening of peritoneal fascias with scarce liquid in the left parietocolic dripping and Douglas septum. After 96 hours, surgery exploration was done and injuries in the left colon revealed compatibility with an infarct of the colon which had to be extirpated. Pathological examination revealed an infarct of colon due to a secondary arterial thrombosis characteristic of giant cell arteritis. After the diagnosis, immunological studies and biopsy of the left temporal artery were performed and reported as normal. The patient was treated with 40 mgr of prednisone a day improving rapidly.
Subject(s)
Colon/blood supply , Giant Cell Arteritis/complications , Infarction/etiology , Aged , Aged, 80 and over , Colon/pathology , Colon/surgery , Female , Humans , Infarction/diagnosisABSTRACT
Arteritis of giant cells compromising extracranial and particularly intestinal tissues is not frequent. Therefore, it is common practice to make the diagnosis retrospectively after analyzing the surgical sample. A case is presented of an 83 year old woman admitted to the Clinical Department with a clinical course of 3 days of evolution characterized by fever and pain in the left hemiabdomen. Her personal medical history included multiple diverticulosis of colon, collecistectomy and appendicectomy. Laboratory tests showed that uremia was 0.75 g/L (N.L to 0.45 g/L), V.E.S. 90 mm at the first hour, and the rest of the determinations were normal. The chest and abdomen rays as well as the abdomen and pelvis ecographies were normal. A diagnosis was reached as acute diverticulitis and the patient was treated with 400 mgr of ciprofloxacina and 2,000 mgr a day of metronidazol. She continued in a feverish state and with abdominal pain, so that an anexial tomography of abdomen was taken. It showed a widening of peritoneal fascias with scarce liquid in the left parietocolic dripping and Douglas septum. After 96 hours, surgery exploration was done and injuries in the left colon revealed compatibility with an infarct of the colon which had to be extirpated. Pathological examination revealed an infarct of colon due to a secondary arterial thrombosis characteristic of giant cell arteritis. After the diagnosis, immunological studies and biopsy of the left temporal artery were performed and reported as normal. The patient was treated with 40 mgr of prednisone a day improving rapidly.
ABSTRACT
La hepatitis tóxica por nimesulida es una patología rara. Para su diagnóstico se requiere un alto grado de sospecha clínica y la confirmación por biopsia hepática. Se presenta el caso de una mujer de 70 años que ingresó al servicio de Clínica Quirúrgica por dolor epigástrico irradiado a ambos hipocondrios e ictericia. Antecedentes: Ingesta 200 mg. de nimesulida durante 1 mes. Laboratorio TGO 526 UI/1(VN:O-31), TGP 414 UI/1 (VN: 0-37), FA 537 UI (VN: 98-276), bilirrubina total 12,9 mg/dl, bilirrubina directa 9,8 mg/dl (VN:0-0,4), el resto de los análisis fueron normales. Ecografía: vesícula aumentada de tamaño con paredes engrosadas y un cálculo de 20 mm en su interior. Se trató con antibióticos y medidas de sostén con mejoría del estado general, al tercer día se le practicó colecistectomía y biopsia hepática. Al cuarto día disminuyó el ritmo diurético y fue trasladada a UTI donde se diagnosticó IRA oligoanúrica que se trató con hemodiálisis. Al décimo día de postoperatorio presentó cuadro de Sepsis severa causada por klebsiella sp. que a pesar de tratamiento intensivo tuvo una evolución sumamente tórpida falleciendo a los 26 días del postoperatorio. El estudio anatomopatológico de la vesícula demostró la presencia de un proceso inflamatorio crónico con pouse aguda y el de la muestra hapática lesiones compatibles con hepatopatía tóxica. Conclusiones: La lesión hepática por nimesulida, aunque rara, debe ser considerada en todo enfermo con necrosis hepatocelular de causa no evidente y el antecedente de haber sido tratado con esa droga
Subject(s)
Humans , Female , Aged , Anti-Inflammatory Agents, Non-Steroidal/adverse effects , Chemical and Drug Induced Liver Injury/etiology , Chemical and Drug Induced Liver Injury/diagnosis , Drug-Related Side Effects and Adverse Reactions/diagnosis , Drug-Related Side Effects and Adverse Reactions/etiology , LiverABSTRACT
La hepatitis tóxica por nimesulida es una patología rara. Para su diagnóstico se requiere un alto grado de sospecha clínica y la confirmación por biopsia hepática. Se presenta el caso de una mujer de 70 años que ingresó al servicio de Clínica Quirúrgica por dolor epigástrico irradiado a ambos hipocondrios e ictericia. Antecedentes: Ingesta 200 mg. de nimesulida durante 1 mes. Laboratorio TGO 526 UI/1(VN:O-31), TGP 414 UI/1 (VN: 0-37), FA 537 UI (VN: 98-276), bilirrubina total 12,9 mg/dl, bilirrubina directa 9,8 mg/dl (VN:0-0,4), el resto de los análisis fueron normales. Ecografía: vesícula aumentada de tamaño con paredes engrosadas y un cálculo de 20 mm en su interior. Se trató con antibióticos y medidas de sostén con mejoría del estado general, al tercer día se le practicó colecistectomía y biopsia hepática. Al cuarto día disminuyó el ritmo diurético y fue trasladada a UTI donde se diagnosticó IRA oligoanúrica que se trató con hemodiálisis. Al décimo día de postoperatorio presentó cuadro de Sepsis severa causada por klebsiella sp. que a pesar de tratamiento intensivo tuvo una evolución sumamente tórpida falleciendo a los 26 días del postoperatorio. El estudio anatomopatológico de la vesícula demostró la presencia de un proceso inflamatorio crónico con pouse aguda y el de la muestra hapática lesiones compatibles con hepatopatía tóxica. Conclusiones: La lesión hepática por nimesulida, aunque rara, debe ser considerada en todo enfermo con necrosis hepatocelular de causa no evidente y el antecedente de haber sido tratado con esa droga (AU)
