Manejo del dolor irruptivo asociado a la cura de úlceras cutáneas / Management of breakthrough pain associated with the cure of skin ulcers

OBJETIVOS: Valorar el manejo profiláctico del dolor irruptivo asociado a la cura de úlceras cutáneas, teniendo en cuenta los diferentes tratamientos que se usan en la práctica clínica para la prevención y la reducción del dolor. MATERIAL Y MÉTODOS: Estudio multicéntrico, observacional y transversal. El estudio se llevó a cabo en 11 hospitales en España. Se recopilaron datos sobre las características de las úlceras, además de variables demográficas y clínicas de los pacientes. La valoración del dolor, la ansiedad y la satisfacción del paciente se midieron mediante el cuestionario del dolor de McGill, la escala de ansiedad de Hamilton y escalas visuales analógicas. RESULTADOS: La mayoría de los pacientes presentaba niveles bajos de ansiedad (74,2 %, ninguna o leve), mientras que la satisfacción de los pacientes y los profesionales sanitarios era alta (8,3 y 7,7, respectivamente). Se administraron medicamentos opioides al 73,8 % de los pacientes, que experimentaron significativamente (p < 0,0001) menos dolor que aquellos que no recibieron tratamiento o que recibieron medicamentos no opioides. El tipo de tratamiento se relacionó con la edad del paciente, la percepción del dolor durante la cura, los años de experiencia del profesional, el uso de guías clínicas y el servicio o unidad en el que se llevó a cabo la cura. El uso de profilaxis se relacionó significativamente con el tratamiento del dolor irruptivo, con úlceras más graves y con el tratamiento realizado por un profesional con menos de 20 años de experiencia, que siguió las guías clínicas. Otros factores relacionados con el uso de opioides fueron la presencia de ansiedad, la unidad donde se realizaron los cuidados y los años de experiencia del profesional de la salud. CONCLUSIONES: Las diferencias en el manejo del paciente dependieron de numerosos factores. La profilaxis con opioides se asoció con una menor percepción del dolor para el paciente

OBJECTIVE: to assess the prophylactic management of breakthrough pain associated with skin ulcers care procedures, considering the different treatments used in clinical practice for the prevention and minimization of pain. MATERIAL AND METHODS: A multicenter, cross-sectional, observational study. The study was conducted in 11 hospitals distributed throughout Spain. Ulcer features, patient demographics and clinical characteristics were recorded. Pain assessment, and patients' anxiety and satisfaction were measured using McGill Pain Questionnaire, Hamilton Anxiety Rating Scale and visual analogue scales (VAS). RESULT: Low levels of anxiety were registered (74.2%, none or mild) and patient and healthcare professional satisfaction was high (8.3 and 7.7, respectively). Opioid drugs were administered to 73.8% of patients, who experienced significantly less pain than those who did not receive treatment or who received non-opioid drugs (p < 0.0001). Type of management was related to patient age, ulcer characteristics, treatment for background pain, patient anxiety levels, perception of pain during the procedure, years of experience of the healthcare professional, the use of clinical guidelines, and the unit in which it was performed. Factors significantly related to the use of prophylaxis were treatment for background pain, more severe ulcers, and treatment by a professional with <20 years of experience who followed clinical guidelines. Significant factors related to the use of opioids were anxiety, the care unit, and the years of experience of the healthcare professional. CONCLUSIÓN: Differences in patient management depended on numerous factors. Prophylaxis with opioids, mainly fentanyl, resulted in less pain for the patient

Calidad de las guías de práctica clínica sobre úlceras venosas de la extremidad inferior / Quality of clinical practice guidelines of lower extremity venous ulcers

La variabilidad clínica y la incertidumbre profesional en la prevención y tratamiento de las úlceras venosas de la extremidad inferior (UV) traen, como principal consecuencia, el hecho de que los pacientes puedan verse sometidos a pruebas diagnósticas y terapéuticas, a veces de dudosa utilidad, o incluso que estas puedan resultar nocivas para la salud del paciente o que, en otras ocasiones, puedan llegar a omitirse determinados procedimientos o procesos que sí podrían resultar adecuados a la situación y necesidades del paciente. Es por ello que surgen una serie de documentos específicos denominados guías de práctica clínica para el abordaje de las UV (GPC-UV), con la finalidad de mejorar la efectividad y la calidad de los cuidados, disminuir la variabilidad injustificada y establecer criterios homogéneos para su manejo. Sin embargo, la literatura recoge que no todas las GPC tienen el mismo criterio metodológico y de elaboración de la evidencia, por lo que muchas de ellas son de escasa calidad científica y rigor editorial. Esto implica que las GPC deben ser revisadas y actualizadas periódicamente en función de la evidencia más actual, y su calidad contrastada con instrumentos validados como el AGREE-II. Tras un análisis de la calidad de 6 GPC-UV disponibles en la actualidad, se ha podido identificar qué guías son recomendables para su implementación en la práctica asistencial y cuáles deberían modificarse para mejorar su aplicabilidad y desarrollo de las evidencias (AU)

The clinical variability and professional uncertainty in the prevention and treatment of lower extremity venous ulcers (VU) has as a main consequence, the fact that patients can be subjected to diagnostic and therapeutic tests, sometimes of dubious utility, these may even be harmful to the health of the patient and that, at other times, certain procedures or processes that may be appropriate to the patient's situation and needs may be omitted. It is for this reason that a series of specific documents called clinical practice guidelines for the approach of VU (CPG-VU) have been created, with the aim of improving the effectiveness and quality of care, reducing unjustified variability and establishing homogeneous criteria for its handling. Nevertheless, the literature shows that not all CPGs have the same methodological and evidence-drawing criteria. Many of them are of poor scientific quality and editorial rigor. This implies that CPGs should be periodically reviewed and updated based on the most current evidence and their quality contrasted with validated instruments such as AGREE-II. After an analysis of the quality of six CPG-VU available today, it has been possible to identify what guidelines are recommended for its implementation in the practice of care, which should be modified to improve their applicability and development of the evidence (AU)

Quality of clinical practice guidelines of lower extremity venous ulcers. / Calidad de las guías de práctica clínica sobre úlceras venosas de la extremidad inferior.

The clinical variability and professional uncertainty in the prevention and treatment of lower extremity venous ulcers (VU) has as a main consequence, the fact that patients can be subjected to diagnostic and therapeutic tests, sometimes of dubious utility, these may even be harmful to the health of the patient and that, at other times, certain procedures or processes that may be appropriate to the patient's situation and needs may be omitted. It is for this reason that a series of specific documents called clinical practice guidelines for the approach of VU (CPG-VU) have been created, with the aim of improving the effectiveness and quality of care, reducing unjustified variability and establishing homogeneous criteria for its handling. Nevertheless, the literature shows that not all CPGs have the same methodological and evidence-drawing criteria. Many of them are of poor scientific quality and editorial rigor. This implies that CPGs should be periodically reviewed and updated based on the most current evidence and their quality contrasted with validated instruments such as AGREE-II. After an analysis of the quality of six CPG-VU available today, it has been possible to identify what guidelines are recommended for its implementation in the practice of care, which should be modified to improve their applicability and development of the evidence.

[Clinical evaluation of a silver dressing in the treatment of infected and colonized ulcers]. / Evaluación clinica de un apósito liberador de plata en el tratamiento de heridas colonizadas e infectadas.

In the event of ulcers with critical colonization, a correct diagnosis and adequate treatment are vital for healing to occur since the presence of a possible infection would impede an adequate evolution leading to healing the ulcer The authors publish a prospective and multi-centric study which included 375 patients who were evaluated regarding the healing of their ulcers over a 12 week period in which the "Biatain Plata" dressing was used. The average initial size of their ulcers was 30 cm2 +/- 67. After 72 weeks of treatment, patients' ulcers were reduced by 80% in relative value. 33% of these ulcers showed a complete healing, while another 47.4% evidenced a noticeable improvement. The product studied proved to be highly effective in the treatment of chronic ulcers with critical colonization. Regarding the safety of this dressing, the authors did not observe any adverse reaction to it, nor did they observe any toxicity associated with the release of silver, in spite of having used this dressing over 12 weeks. In the same way, the authors did not notice any indications of possible development of bacterial resistance to the dressing's anti-bacterial action.

Evaluación clínica de un apósito liberador de plata en el tratamiento de heridas colonizadas e infectadas / Clinical evaluation of a silver dressing in the treatment of infected and colonized ulcers

En el caso de úlceras con colonización crítica, una correcta diagnosis y su adecuado tratamiento son vitales para conseguir la cicatrización, dado que la presencia de una posible infección imposibilitará la idónea evolución de la úlcera hacia la curación. Se presenta un estudio prospectivo y multicéntrico, en el que se incluyeron 375 pacientes y en los que se evaluó la evolución de las úlceras durante 12 semanas de tratamiento con Biatain Plata. La media del tamaño inicial de las úlceras era 30 cm2 ± 61. Se consiguió una reducción del área de la úlcera en valores relativos del 80% después de 12 semanas de tratamiento. El 33% de las úlceras cicatrizó completamente, mientras que un 47,4% de ellas experimentó una mejora notable. El producto estudiado ha demostrado una elevada eficacia en el tratamiento de úlceras crónicas con colonización crítica. En lo relativo a la seguridad del apósito, no se ha descrito ningún acontecimiento adverso relacionado con él, ni se ha visto toxicidad alguna asociada a la liberación de plata, a pesar de haberlo utilizado durante el periodo de 12 semanas. Del mismo modo, tampoco se han apreciado indicios del posible desarrollo de resistencias bacterianas a su acción bactericida(AU)

In the event of ulcers with critical colonization, a correct diagnosis and adequate treatment are vital for healing to occur since the presence of a possible infection would impede an adequate evolution leading to healing the ulcer. The authors publish a prospective and multi-centric study which included 375 patients who were evaluated regarding the healing of their ulcers over a 12 week period in which the "Biatain Plata" dressing was used. The average initial size of their ulcers was 30 cm2 ± 61. After 12 weeks of treatment, patients' ulcers were reduced by 80% in relative value. 33% of these ulcers showed a complete healing, while another 47.4% evidenced a noticeable improvement. The product studied proved to be highly effective in the treatment of chronic ulcers with critical colonization. Regarding the safety of this dressing, the authors did not observe any adverse reaction to it, nor did they observe any toxicity associated with the release of silver, in spite of having used this dressing over12 weeks. In the same way, the authors did not notice any indications of possible development of bacterial resistance to the dressing's anti-bacterial action(AU)