Complicaciones de la analgesia continua invasiva para el control del dolor agudo postoperatorio en un hospital de tercer nivel. Incidencia de complicaciones técnicas y uso de métodos de analgesia alternativos / Complications of continuous catheter analgesia for postoperative pain management in a tertiary care hospital. Incidence of technical complications and alternative analgesia methods used

Antecedentes: La analgesia continua invasiva es el método de referencia para el manejo del dolor postoperatorio en cirugía mayor pero no está exenta de posibles complicaciones. Existe poca información sobre las complicaciones de las técnicas analgésicas continuas con catéter (TACC) y su impacto en el control del dolor. Material y métodos: Diseñamos un estudio prospectivo longitudinal incluyendo a pacientes tratados mediante cirugía que recibieron una TACC postoperatoria. Se registraron el tipo de analgesia, la intensidad del dolor mediante escala NRS, las características de las TACC, sus complicaciones técnicas y la satisfacción de los pacientes. Se aplicó estadística descriptiva y análisis comparativo mediante t de Student. Resultados: Se registraron datos de 106 pacientes. La duración de las TACC fue 47,52 ± 21,23 h; 52 pacientes (49,1%) fueron controlados en hospitalización convencional y 54 (50,9%) en unidades de críticos o alta dependencia. La tasa global de complicaciones técnicas fue del 9,43%. Las complicaciones más frecuentes fueron desplazamiento del catéter (2,38%), inflamación en el punto de inserción del catéter IV (2,38%) y dosificación excesiva de analgésicos (2,38%). El valor medio de NRS fue ≤ 3 durante la permanencia de la TACC. La intensidad máxima de dolor fue mayor en los pacientes con complicaciones técnicas (media ± desviación estándar [x̅ ± DE]: 4,4 ± 2,8 vs. 2,9 ± 1,9; p < 0,05). La satisfacción con la comodidad de la técnica y la satisfacción global con el tratamiento del dolor se redujeron significativamente en presencia de complicaciones. Conclusiones: La incidencia de complicaciones técnicas de las TACC fue del 9,43% y tuvieron un impacto negativo en el control del dolor postoperatorio y en la satisfacción de los pacientes

Background: Continuous invasive analgesia remains the gold-standard method for managing acute post-operative pain after major surgery. However, this procedure is not exempt from complications that may have detrimental effects on the patient and affect the post-operative recovery process. Data of the complications of continuous catheter analgesic techniques (CCATs) and their impact on pain relief are scarce in the literature. Material and methods: We conducted a prospective longitudinal study and patients who underwent a surgical procedure and received continuous invasive analgesia after surgery were included. Post-operative analgesic strategy, pain scores (NRS), CCAT's characteristics and technical complications were recorded. Patient satisfaction was determined. Descriptive statistics and Student's t-tests were applied for the comparative analyses. Results: We collected data from 106 patients. Mean duration of the CCAT was 47.52±21.23hours and 52 patients (49.1%) were controlled in conventional hospitalisation units whereas 54 patients (50.9%) were controlled on intensive or high-dependency care units. The overall incidence of technical complications was 9.43%. The most common complications were catheter displacement (2.38%), inflammation at the IV catheter insertion point (2.38%) and excessive dosing of analgesic drugs (2.38%). Mean NRS scores were ≤3 during the permanence of CCATs. Maximum pain intensity was significantly higher in patients who suffered technical complications (mean±standard deviation [x̅ ± SD]: 4.4 ± 2.8 vs. 2.9 ± 1.9; P<0.05). Satisfaction levels with the technique and overall satisfaction with the pain management strategy were negatively impacted by the occurrence of complications. Conclusions: The incidence of technical complications of CCATs was 9.43% and had a negative impact in pain control and patient's satisfaction

Complications of continuous catheter analgesia for postoperative pain management in a tertiary care hospital. Incidence of technical complications and alternative analgesia methods used. / Complicaciones de la analgesia continua invasiva para el control del dolor agudo postoperatorio en un hospital de tercer nivel. Incidencia de complicaciones técnicas y uso de métodos de analgesia alternativos.

BACKGROUND: Continuous invasive analgesia remains the gold-standard method for managing acute post-operative pain after major surgery. However, this procedure is not exempt from complications that may have detrimental effects on the patient and affect the post-operative recovery process. Data of the complications of continuous catheter analgesic techniques (CCATs) and their impact on pain relief are scarce in the literature. MATERIAL AND METHODS: We conducted a prospective longitudinal study and patients who underwent a surgical procedure and received continuous invasive analgesia after surgery were included. Post-operative analgesic strategy, pain scores (NRS), CCAT's characteristics and technical complications were recorded. Patient satisfaction was determined. Descriptive statistics and Student's t-tests were applied for the comparative analyses. RESULTS: We collected data from 106 patients. Mean duration of the CCAT was 47.52±21.23hours and 52 patients (49.1%) were controlled in conventional hospitalisation units whereas 54 patients (50.9%) were controlled on intensive or high-dependency care units. The overall incidence of technical complications was 9.43%. The most common complications were catheter displacement (2.38%), inflammation at the IV catheter insertion point (2.38%) and excessive dosing of analgesic drugs (2.38%). Mean NRS scores were ≤3 during the permanence of CCATs. Maximum pain intensity was significantly higher in patients who suffered technical complications (mean±standard deviation [x̅ ± SD]: 4.4 ± 2.8 vs. 2.9 ± 1.9; P<0.05). Satisfaction levels with the technique and overall satisfaction with the pain management strategy were negatively impacted by the occurrence of complications. CONCLUSIONS: The incidence of technical complications of CCATs was 9.43% and had a negative impact in pain control and patient's satisfaction.

Utilidad de un cuestionario autoadministrado multidimensional para la gestión de una unidad clínica de tratamiento de dolor / Usefulness of a multidimensional self-administered questionnaire for the clinical management of a pain treatment unit

Objective. To study the feasibility of a multidimensional self-administered questionnaire before the patient is seen at the first visit in a clinical Pain Treatment Unit (PTU) of a tertiary hospital, and its impact on the management of patients in the first visit. Patients and methods. Cross-sectional study. Self-administered questionnaire that gathered: socio-demographic data, medical history of pain, pain perception (intensity and characteristics), comorbidity of pain and patient expectations of analgesic treatment ("What do you expect from our treatment? If we cannot resolve your pain, what level of pain would you be willing to live with?). A descriptive analysis was performed. Results. A total of 293 consecutive patients (31% men, 69% women), mean age (SD) 62 (16) years-old, were included in 2011. All patients completed and returned the questionnaire before the first visit to the PTU. The questionnaire was completed fully and correctly by 80% (234, 95% CI: 75-84) of the patients, and the rest completed the questionnaire with some points unanswered. About 24% (70/293, 95% CI: 19-29) of the patients should not have been referred to the PTU [20% were not attended]. A small percentage (9%,26/293, 95% CI: 6-13) were evaluated as «urgent’» and visited over the following 7 days, with 19% (56/293, 95%CI: 15-24) being «preferential» (visited before 15 days) and 52% (152/293, 95% CI: 46-58) as «non-urgent/non-preferential» (visited before 60 days). Almost one third (30%, 87/293, 95% CI: 25-35) did not need a second visit to the PTU. Patient expectations: 21% expected complete pain relief and 64% would accept a lower pain intensity score of 4. Conclusion. The use of a multidimensional self-administered questionnaire before the first visit to a clinical Pain Treatment Unit of a tertiary hospital was a practicable and useful tool for the management of patients on the first visit. Likewise, the questionnaire provided information on the patient's perception of pain and the expectations concerning the analgesic treatment (AU)

Objetivo. Estudiar la factibilidad de un cuestionario autoadministrado multidimensional antes de que el paciente sea atendido en primera visita en la unidad de tratamiento del dolor (UTD) de un hospital terciario, y su impacto en la gestión de pacientes en la primera visita. Pacientes y métodos. Estudio transversal. Cuestionario autoadministrado: características sociodemográficas, historia clínica del dolor, percepción del dolor (intensidad y sus características), comorbilidad del dolor y expectativas del paciente al tratamiento analgésico («¿qué es lo que usted espera de nuestro tratamiento?», si no podemos resolver su dolor «¿qué nivel de dolor aceptaría?»). Se realizó un análisis descriptivo. Resultados. Durante el año 2011 fueron incluidos 293 pacientes consecutivos (31% hombres, 69% mujeres; edad media 62 ± 16 años). Todos los pacientes cumplimentaron y entregaron el cuestionario antes de la primera visita en la UTD. El 80% (234/293, IC 95%: 75-84) de pacientes lo cumplimentaron completa y correctamente; el resto lo aportaron con algunos puntos sin contestar. El 24% (70/293, IC 95%: 19-29) de pacientes no deberían haber sido remitidos a la UTD (un 20% no llegaron a ser visitados en la UTD). Un 9% (26/293, IC 95%: 6-13) de las primeras visitas se consideraron «urgentes» (y estos pacientes fueron visitados en la UTD antes de 7 días), mientras que el 19% (56/293, IC 95%: 15-24) se calificaron de «preferentes» (atendidos antes de 15 días) y el 52% (152/293, IC 95%: 46-58) de «no-urgentes/no-preferentes» (atendidos antes de 60 días). Un 30% (87/293, IC 95%: 25-35) de los casos no necesitaron una segunda visita en la UTD. Respecto a las expectativas del paciente cabe reseñar que el 21% esperaban un alivio completo de su dolor, y el 64% aceptarían continuar con un dolor de intensidad < 4. Conclusión. El uso del cuestionario autoadministrado multidimensional antes de la primera visita en una Unidad Clínica del Tratamiento del Dolor de un hospital terciario fue practicable y útil como instrumento para la gestión de los pacientes en primera visita. Asimismo, proporcionó información sobre la percepción del dolor y las expectativas del paciente referente al tratamiento analgésico (AU)

[Usefulness of a multidimensional self-administered questionnaire for the clinical management of a pain treatment unit]. / Utilidad de un cuestionario autoadministrado multidimensional para la gestión de una unidad clínica de tratamiento de dolor.

OBJECTIVE: To study the feasibility of a multidimensional self-administered questionnaire before the patient is seen at the first visit in a clinical Pain Treatment Unit (PTU) of a tertiary hospital, and its impact on the management of patients in the first visit. PATIENTS AND METHODS: Cross-sectional study. Self-administered questionnaire that gathered: socio-demographic data, medical history of pain, pain perception (intensity and characteristics), comorbidity of pain and patient expectations of analgesic treatment ("What do you expect from our treatment? If we cannot resolve your pain, what level of pain would you be willing to live with?). A descriptive analysis was performed. RESULTS: A total of 293 consecutive patients (31% men, 69% women), mean age (SD) 62 (16) years-old, were included in 2011. All patients completed and returned the questionnaire before the first visit to the PTU. The questionnaire was completed fully and correctly by 80% (234, 95% CI: 75-84) of the patients, and the rest completed the questionnaire with some points unanswered. About 24% (70/293, 95% CI: 19-29) of the patients should not have been referred to the PTU [20% were not attended]. A small percentage (9%,26/293, 95% CI: 6-13) were evaluated as «urgent'¼ and visited over the following 7 days, with 19% (56/293, 95%CI: 15-24) being «preferential¼ (visited before 15 days) and 52% (152/293, 95% CI: 46-58) as «non-urgent/non-preferential¼ (visited before 60 days). Almost one third (30%, 87/293, 95% CI: 25-35) did not need a second visit to the PTU. Patient expectations: 21% expected complete pain relief and 64% would accept a lower pain intensity score of 4. CONCLUSION: The use of a multidimensional self-administered questionnaire before the first visit to a clinical Pain Treatment Unit of a tertiary hospital was a practicable and useful tool for the management of patients on the first visit. Likewise, the questionnaire provided information on the patient's perception of pain and the expectations concerning the analgesic treatment.

Comparación de 3 combinaciones de levobupivacaína al 0,5 por ciento y de mepivacaína al 1 por ciento en el bloqueo del nervio ciático poplíteo, en la cirugía ambulatoria del hallux valgus / Comparison of 3 combinations of 0.5 percent levobupivacaine and 1percent mepivacaine in popliteal sciatic block in hallux valgus outpatient surgery

Objetivo: Comparar 3 combinaciones de levobupivacaína 0,5% con mepivacaína 1% en bloqueo del ciático poplíteo con dosis única para cirugía del hallux valgus. Métodos: Estudio prospectivo, doble ciego, en pacientes programados para cirugía ambulatoria de hallux valgus con bloqueo del nervio ciático poplíteo guíado por ultrasonidos. Los pacientes se distribuyeron aleatoriamente en 3 grupos, según el volumen de cada uno de los anestésicos locales: G1, levobupivacaína 20 mL + mepivacaína 10 mL, G2, levobupivacaína 10 mL + mepivacaína 20 mL y G3, levobupivacaína 15 mL + mepivacaína 15 mL. Fueron evauados el tiempo de inicio, de reversión y el tiempo total del bloqueo de los nervios tibial y peroneo; control del dolor postoperatorio a las 12, 24, 72 h y al séptimo día del postoperatorio mediante escala visual analógica (EVA), escala descriptiva simple (EDS) y la calidad del descanso nocturno; complicaciones postoperatorias y satisfacción del paciente. Resultados: Se incluyó a 120 pacientes, 40 por grupo. Los grupos fueron homogéneos y ningún paciente precisó anestesia complementaria. El tiempo de latencia del bloqueo fue significativamente mayor en el G1 respecto a G2 y G3 (39,4 ± 14,7 min frente a 32,2 ± 16,5 y 33,2 ± 12 min). El tiempo de reversión del bloqueo sensitivo y motor fue significativamente mayor en G1 respecto a G2 y G3 (29,5 ± 9,3 h frente a 22,2 ± 8,2 y 24,8 ± 7,9 h). El nivel máximo de dolor se registró a las 24 h del postoperatorio y fue significativamente superior en el G2 respecto al G1. El descanso nocturno también fue peor la primera noche en el G2 respecto al G1. La satisfacción del paciente fue buena o muy buena y no se registraron complicaciones. Conclusiones: El tiempo de latencia del bloqueo y la eficacia anestésica fueron adecuados en los 3 grupos. La combinación de levobupivacaína 0,5% 20 ml y mepivacaína 1% 10 ml es una buena alternativa para una analgesia postoperatoria más duradera(AU)

Background: To compare 3 combinations of 0.5% levobupivacaine (L) and 1% mepivacaine (M) for popliteal block for hallux valgus surgery. Methods: Prospective, double blind study of 120 patients undergoing unilateral hallux valgus outpatient surgery with posterior popliteal block with ultrasound-guided single injection. Patients were randomly allocated into three groups: G1: 20 mL L + 10 mL M; G2: 10 mL L + 20 mL M; and G3: 15 mL L + 15 mL M. Recorded variables were: time of block, onset and reversal times for tibial and peroneal nerves block; postoperative pain until the 7th day by means of visual analogue scale (VAS), simple descriptive scale and the quality of nocturnal rest, complications, and patient satisfaction. ANOVA and chi2 were applied in the statistical analysis, with a P < 0.05 considered significant. Results: Groups were homogeneous for demographic and surgical characteristics. None of the patients required intraoperative complementary analgesia or anaesthesia. Block onset was significantly longer in G1 than in G2 and G3 (39.4 ± 14.7 versus 32.2 ± 16.5 and 33.2 ± 12 minutes). Recovery time from sensory and motor block was significantly longer in G1 than in G2 and G3 (29.5 ± 9.3 versus 22.2 ± 8.2 and 24.8 ± 7.9 hours). Postoperative pain level was below VAS 30 (1-100) in the three groups; none of the patients experienced severe pain. Maximum pain level appeared at 24 h postoperatively. Patient satisfaction was high and there were no complications. Conclusions: Block onset time and anaesthetic efficacy was adequate in the three groups. The combination of 20 mL levobupivacaine 0.5% with 10 mL mepivacaine 1% provide a good alternative for a lasting postoperative analgesia(AU)

[Comparison of 3 combinations of 0.5% levobupivacaine and 1% mepivacaine in popliteal sciatic block in hallux valgus outpatient surgery]. / Comparación de 3 combinaciones de levobupivacaína al 0,5% y de mepivacaína al 1% en el bloqueo del nervio ciático poplíteo, en la cirugía ambulatoria del hallux valgus.

BACKGROUND: To compare 3 combinations of 0.5% levobupivacaine (L) and 1% mepivacaine (M) for popliteal block for hallux valgus surgery. METHODS: Prospective, double blind study of 120 patients undergoing unilateral hallux valgus outpatient surgery with posterior popliteal block with ultrasound-guided single injection. Patients were randomly allocated into three groups: G1: 20mL L+10mL M; G2: 10mL L+20mL M; and G3: 15mL L+15mL M. Recorded variables were: time of block, onset and reversal times for tibial and peroneal nerves block; postoperative pain until the 7(th) day by means of visual analogue scale (VAS), simple descriptive scale and the quality of nocturnal rest, complications, and patient satisfaction. ANOVA and chi2 were applied in the statistical analysis, with a P<0.05 considered significant. RESULTS: Groups were homogeneous for demographic and surgical characteristics. None of the patients required intraoperative complementary analgesia or anaesthesia. Block onset was significantly longer in G1 than in G2 and G3 (39.4±14.7 versus 32.2±16.5 and 33.2±12minutes). Recovery time from sensory and motor block was significantly longer in G1 than in G2 and G3 (29.5±9.3 versus 22.2±8.2 and 24.8±7.9hours). Postoperative pain level was below VAS 30 (1-100) in the three groups; none of the patients experienced severe pain. Maximum pain level appeared at 24h postoperatively. Patient satisfaction was high and there were no complications. CONCLUSIONS: Block onset time and anaesthetic efficacy was adequate in the three groups. The combination of 20mL levobupivacaine 0.5% with 10mL mepivacaine 1% provide a good alternative for a lasting postoperative analgesia.

Utilización de tramadol/paracetamol oral en única preparaciónfarmacéutica en analgesia multimodal en cirugía mayor ambulatoria / No disponible

La combinación en una misma presentación farmacológica de paracetamol y tramadol a dosis bajas permite un rápido inicio de acción y un efecto sostenido de la analgesia, con disminución de los efectos secundarios derivados de ambos fármacos, dosis dependiente. En cirugía mayor ambulatoria la analgesia multimodal es el tratamiento de elección para poder incluir cada vez procesos de mayor complejidad. Es por ello que la asociación a dosis bajas de un opioide menor, con paracetamol, presenta una analgesia superior por acción sinérgica de los dos componentes, utilizándose en dolor moderado-severo, evitando reingresos y facilitando el cumplimiento del tratamiento analgésico en el domicilio (AU)

The combination of paracetamol, and low doses of tramadol, enables an immediate and constant analgesic response, while at the same time avoiding the negative side effects of both these drugs. Multimodal analgesia in ambulatory surgery permits a better control of pain and the subsequent inclusion of more complex surgery. The use of both components in one tablet, presents a synergic action useful in moderate-severe pain, reducing hospital re-admittance and enhancing the probability of the completion of home treatment (AU)

Alternativas para la descarga de la úlcera neuropática en el pie diabético / Alternatives for pressure relief of neuropathic ulcer in the diabetic foot

Dentro de las complicaciones crónicas asociadas a la diabetes mellitus encontramoslas úlceras localizadas en el pie, que llegan a padecer el 15% de lospacientes alguna vez en el curso de su enfermedad y que a menudo derivan enuna amputación. La etiología de estas úlceras está normalmente asociada a lapresencia de una neuropatía diabética y una peor respuesta al estrés mecánico,que provoca altas presiones plantares. El uso de descargas como tratamientoetiológico es una parte integral del proceso de curación, ya que produce modificaciones en la histología de la úlcera, que pasa de un estado infl amatorio crónicoa una condición mucho más evolutiva. Existen múltiples estrategias para lareducción de la presión plantar que deben utilizarse de manera protocolizadapara poder conseguir resultados favorables. Este artículo presenta diferentesmétodos de reducción de la presión, de manera que el profesional reconozca laimportancia de su uso en la gestión de las úlceras del pie diabético(AU)

Among the chronic complications associated with diabetes mellitus, foot ulcersare present in 15% of patients sometimes in the course of their disease, andoften leads to amputation. These ulcers are usually neuropatic and have a poorresponse to mechanical stress that causes high plantar pressures. Using offloadingis an integral part of the healing process, which causes favorable histologicchanges in the ulcer, from a chronic inflammatory state to a better evolutionarycondition. There are many strategies for reducing plantar pressurewhich have to be used in a protocol manner to obtain favorable results. Thisarticle presents different methods of pressure reduction underling the importancefor professionals of their use in the management of diabetic foot ulcers(AU)

[Ultrasound-guided single dose injection of 0.5% levobupivacaine or 0.5% ropivacaine for a popliteal fossa nerve block in unilateral hallux valgus surgery]. / Levobupivacaína 0.5% frente a ropivacaína 0.5% en el bloqueo poplíteo con dosis única de anestésico local por abordaje posterior dirigido por ecografía para cirugía de hallux valgus unilateral.

OBJECTIVE: To compare the perioperative analgesic efficacy of 0.5% levobupivacaine and 0.5% ropivacaine injected in a single dose to block the tibial and peroneal nerves for surgery using a posterior (popliteal fossa) approach. MATERIAL AND METHODS: Prospective randomized trial in patients undergoing hallux valgus surgery; anesthesia was provided by blocking nerves in the popliteal fossa with either 0.5% levobupivacaine or 0.5% ropivacaine. Variables studied were times until anesthetic block onset and reversal, need for additional sedation or peripheral block anesthetic, course of postoperative pain at 12, 24 and 48 hours and at 7 days, nighttime rest, need for additional analgesia, and patient satisfaction. RESULTS: Forty-six patients were enrolled. Times until onset of the sensory and motor blocks were similar in the 2 groups. For 57.1% of the patients, the sensory and motor block lasted 24 hours after surgery, with no between-group differences. The levobupivacaine group had less pain at rest 24 hours after surgery (mean [SD] visual analog scale score of 0.16 [0375] vs. 1.17 [1.88] in the ropivacaine group; P < .05). No patient reported severe pain or required additional analgesics. None were readmitted. More than 80% rested well at night. No between-group differences were observed. CONCLUSIONS: The use of a single dose of either levobupivacaine or ropivacaine to provide anesthesia for a popliteal approach to hallux valgus surgery is effective for controlling postoperative pain.

Levobupivacaína 0.5 % frente a ropivacaína 0.5 % en el bloqueo poplíteo con dosis única de anestésico local por abordaje posterior dirigido por ecografía para cirugía de hallux valgus unilateral / Ultrasound-guided single dose injection of 0.5% levobupivacaine or 0.5% ropivacaine for a popliteal fossa nerve block in unilateral hallux valgus surgery

OBJETIVOS: Comparar la eficacia analgésica perioperatoriade levobupivacaína 0,5% frente a ropivacaína0,5% en el bloqueo con punción única de los nerviostibial y peroneo por abordaje poplíteo.MATERIAL Y MÉTODOS: Estudio prospectivo, randomizadoen pacientes sometidos a cirugía de hallux valgus. Bloqueoen el hueco poplíteo con levobupivacaína 0,5% o ropivacaína0,5%. Se estudiaron tiempo de inicio y reversióndel bloqueo anestésico, necesidad de sedación adicional orefuerzo anestésico periférico, evolución del dolor postoperatoriotras la cirugía y a las 12 h, 24 h, 48 h y 7º día postoperatorio,valoración del descanso nocturno, necesidadde analgesia adicional y satisfacción del paciente.RESULTADOS: Se incluyeron 46 pacientes. El tiempo deinstauración de bloqueo sensitivo y motor fue similar enambos grupos. En el 57,1% de los pacientes la recuperacióndel bloqueo motor y sensitivo se produjo durantelas 24 primeras horas de postoperatorio, sin diferenciasentre los grupos. Se constató menor grado de dolor postoperatorioen reposo a las 24 horas de la intervención enel grupo de levobupivacaína (EVA medio 0,16 ± 0,375)frente al grupo de ropivacaína (EVA medio 1,17 ± 1,88),p<0,05. Ningún paciente acusó dolor severo ni precisóanalgesia suplementaria, no se produjo ningún reingreso,más del 80% de los pacientes presentaron buen descansonocturno, sin diferencias entre ambos grupos.CONCLUSIONES: La utilización de levobupivacaína oropivacaína en dosis única por abordaje poplíteo es altamenteeficaz para el control del dolor postoperatorio dela cirugía por hallux valgus(AU)

OBJETIVE: To compare the perioperative analgesicefficacy of 0.5% levobupivacaine and 0.5% ropivacaineinjected in a single dose to block the tibial and peronealnerves for surgery using a posterior (popliteal fossa)approach.MATERIAL AND METHODS: Prospective randomizedtrial in patients undergoing hallux valgus surgery;anesthesia was provided by blocking nerves in thepopliteal fossa with either 0.5% levobupivacaine or0.5% ropivacaine. Variables studied were times untilanesthetic block onset and reversal, need for additionalsedation or peripheral block anesthetic, course ofpostoperative pain at 12, 24 and 48 hours and at 7 days,nighttime rest, need for additional analgesia, and patientsatisfaction.RESULTS: Forty-six patients were enrolled. Times untilonset of the sensory and motor blocks were similar in the2 groups. For 57.1% of the patients, the sensory andmotor block lasted 24 hours after surgery, with nobetween-group differences. The levobupivacaine grouphad less pain at rest 24 hours after surgery (mean [SD]visual analog scale score of 0.16 [0.375] vs 1.17 [1.88] inthe ropivacaine group; P<.05). No patient reportedsevere pain or required additional analgesics. None werereadmitted. More than 80% rested well at night. Nobetween-group differences were observed.CONCLUSIONS: The use of a single dose of eitherlevobupivacaine or ropivacaine to provide anesthesia fora popliteal approach to hallux valgus surgery is effectivefor controlling postoperative pain(AU)

Estudio dinámico de la presión en el pie: podobarografía / Dynamic study of foot pressure: a pedographic analysis

La planta del pie está sujeta a importantes presiones que están influenciadas por factores dinámicos (locomoción, velocidad, etc) y por parámetros relativos al sujeto (peso corporal, edad, posibles patologías, etc). El estudio de estas presiones permite la localización y cuantificación de las zonas de hiperpresión, aspecto de vital importancia en pacientes diabéticos. La disponibilidad y uso de sistemas de medida de presión (plataformas de fuerza dentro del zapato), ha hecho posible la comprensión de una parte fundamental de los problemas de los pies. El efecto acumulativo de presiónde bajo nivel no se ha tenido en cuenta ni se ha evaluado suficientemente, principalmente debido a que la mayoría de los dispositivos de medida de presión funcionan con precisión únicamente durante unas horas. Algunos trabajos recientes, sugieren que la medida combinada de presiones plantares y actividad, evaluada como número de pasos reales frente al tiempo, pueden apoyar la hipótesis de que la destrucción del tejido en la planta del pie, que precede a la formación de una úlcera, es el resultado de la combinación al menos del estrés repetitivo a presiones bajas y de la acción de picos de presiones localizadas. Los nuevos sistemas de podobarografía deberían permitir el seguimiento de los pacientes durante su vida diaria, siempre y cuando la cantidad y calidad de los datos sea de utilidad clínica práctica

There are important pressures applying under the foot, which are influenced by many dynamic factors (such as locomotion, speed, etc) and parameters related to the subject (such as body weight, age, other diseases, etc. The study of foot pressures allow the localisation and quantification of the hyperpressure areas, which is very important for diabetic patients. The availability and use of footpressure measuring systems (force platforms and in-shoe systems) has made possible the understanding of an essential part of foot related problems. The cumulative effect of low pressure has not been sufficiently considered and evaluated, mainly due to the fact that most of the pressure measuring devices work accurately for only a few hours. Some recent studies suggest that the combined measurement of plantar pressures and activity, assessed as the actual number of steps vs. time, may support the hypothesis that the destruction of foot sole tissue prior to the ulcer formation results from the combination at least of repetitive stress at low pressures and the action of localized peak pressures. Therefore, it the new systems of baropodography should permit the monitoring of patients on a daily basis, provided that the quantity and quality of gathered data might be useful in the clinical practice

Kidney-specific proteins in patients receiving aprotinin at high- and low-dose regimens during coronary artery bypass graft with cardiopulmonary bypass.

BACKGROUND AND OBJECTIVE: The aim was to determine whether the administration of aprotinin can cause deleterious effects on renal function in cardiac surgery with cardiopulmonary bypass (CPB). METHODS: Sixty consecutive patients with normal preoperative renal function undergoing elective coronary artery bypass surgery with CPB using the same anaesthetic; CPB and surgical protocols were randomized into three groups. Patients received placebo (Group 1), low-dose aprotinin (Group 2) or high-dose aprotinin (Group 3). Renal parameters measured were plasma creatinine, alpha1-microglobulin and beta-glucosaminidase (beta-NAG) excretion. Measurements were performed before surgery, during CPB and 24 and 72 h, and 7 and 40 days postoperatively. RESULTS: In the three groups, alpha1-microglobulin and beta-NAG excretions significantly increased during CPB, at 24 and 72 h, and 7 days postoperatively (P < 0.05) and had returned to preoperative levels at postoperative day 40. Plasma creatinine levels were within normal values at times recorded. In Groups 2 and 3, alpha1-microglobulin excretion during CPB was significantly higher than in Group 1 (P < 0.001), and 24h after surgery it still remained significantly higher in Group 3 compared to Groups 1 and 2 (P < 0.05). CONCLUSIONS: Aprotinin caused a significant increase in alpha1-microglobulin excretion but not in beta-NAG excretion during CPB, which may be interpreted as a greater renal tubular overload without tubular damage. This effect persisted for 24 h after surgery when high-dose aprotinin doses had been administered. Creatinine plasma levels were not sensitive to detect these prolonged renal effects in our study.

Pattern of renal dysfunction associated with myocardial revascularization surgery and cardiopulmonary bypass.

BACKGROUND AND OBJECTIVE: A variable incidence rate of renal dysfunction (3-35%) after cardiac surgery with cardiopulmonary bypass has been reported. The aim was to define the typical pattern of renal dysfunction that follows coronary surgery with cardiopulmonary bypass using albumin, immunoglobulin (IgG), alpha1-microglobulin and beta-glucosaminidase (beta-NAG) excretion as indicators. METHODS: Twenty patients with preoperative normal renal function, defined by plasma creatinine, creatinine clearance, fractional excretion of sodium and renal excretion of proteins, undergoing elective myocardial revascularization surgery with cardiopulmonary bypass, were prospectively studied. Variables recorded were demographic and haemodynamic variables, duration of cardiopulmonary bypass and aortic clamping, intra- and postoperative urine output, plasma creatinine concentration, creatinine clearance and excretion of sodium, albumin, IgG, beta-glucosaminidase (beta-NAG), and alpha1-microglobulin. Measurements were made preoperatively, immediately before and then during and immediately after cardiopulmonary bypass, and again at 1, 24, 72 h, 7 and 40 days following surgery. RESULTS: Albumin and IgG excretion rose significantly during cardiopulmonary bypass (P < 0.05), remaining at these levels at 24 h postoperatively. An increase of alpha1-microglobulin and beta-NAG concentrations was observed during cardiopulmonary bypass (P < 0.05), which were maintained until the seventh postoperative day and remained elevated in some patients at the 40th postoperative day. This correlated with preoperative diabetes mellitus (P < 0.001), low cardiac output after cardiopulmonary bypass (P < 0.001) and the duration of stay in the intensive care unit (P < 0.001). CONCLUSIONS: The pattern of renal dysfunction after cardiopulmonary bypass for myocardial revascularization is characterized by temporary renal dysfunction at both glomerular and tubular levels with an onset within 24 h of surgery and which lasts between 24 h and 40 days, respectively, following surgery.

[Subarachnoid anesthesia in the repair of urinary stress incontinence using a Burch-type colposuspension by means of extraperitoneal laparoscopy]. / Anestesia subaracnoidea en la reparación de la incontinencia urinaria al esfuerzo mediante la colposuspensión tipo Burch por laparoscopia extraperitoneal.

UNLABELLED: Extraperitoneal laparoscopy does not lead to increased intra-abdominal pressure, meaning that the mainly respiratory physiological changes that develop derive from CO2 absorption from the extraperitoneal cavity that is created. Therefore, subarachnoid anesthesia might possibly be appropriate for this type of procedure. OBJECTIVE: To assess the efficacy of subarachnoid anesthesia for correcting urinary incontinence by extraperitoneal Burch laparoscopic colposuspension. PATIENTS AND METHODS: Six consecutive patients undergoing extraperitoneal Burch laparoscopic colposuspension under intradural anesthesia. A lateral decubitus puncture was made and 12 mg of 0.5% hyperbaric bupivacaine was infused with 20 micrograms of fentanyl. We monitored hemodynamic variables, end-tidal CO2 and respiratory frequency. Complications occurring during surgery and recovery were recorded. RESULTS: Four patients presented intraperitoneal CO2 leaks upon insufflation of the extraperitoneal cavity, with dyspnea and chest-shoulder pain in addition to anxiety and agitation, such that general anesthesia had to be provided. Subcutaneous emphysema was observed to the cervical zone after surgery but discharge was not delayed. The study was halted in view of the results obtained. CONCLUSION: Subarachnoid anesthesia was not effective for extraperitoneal Burch laparoscopic colposuspension because of the impossibility of alleviating discomfort from intraperitoneal leakage and subcutaneous emphysema that can develop during the procedure.

Anestesia subaracnoidea en la reparación de la incontinencia urinaria al esfuerzo mediante la colposuspensión tipo Burch por laparoscopia extraperitoneal / Anestesia subaracnoidea en la reparación de la incontinencia urinaria al esfuerzo mediante la colposuspensión tipo Burch por laparoscopia extraperitoneal

La laparoscopia extraperitoneal no conlleva aumento en la presión intraabdominal por lo que las alteraciones fisiológicas que aparecen, básicamente respiratorias, son derivadas de la absorción de CO2 desde la cavidad extraperitoneal creada. Por lo tanto, la anestesia subaracnoidea podría realizarse en este tipo de intervenciones. OBJETIVO: Valorar la eficacia de la anestesia subaracnoidea en la corrección de la incontinencia urinaria al esfuerzo mediante la colposuspensión tipo Burch por laparoscopia extraperitoneal. PACIENTES Y MÉTODOS: Se incluyeron 6 pacientes consecutivas sometidas a colposuspensión tipo Burch por laparoscopia extraperitoneal bajo anestesia intradural.La punción se realizó en decúbito lateral y se administraron 12 mg de bupivacaína 0,5 por ciento hiperbara con 20 µg de fentanilo. Las variables controladas fueron; hemodinámicas, ETCO2, frecuencia respiratoria, así como las complicaciones aparecidas en el período peroperatorio. RESULTADOS: Cuatro pacientes, coincidiendo con la insuflación de la cavidad extraperitoneal, presentaron fuga intraperitoneal del CO2, con disnea y dolor torácico y hombros, junto con ansiedad y agitación, que obligaron a realizar anestesia general. Se objetivó enfisema subcutáneo hasta la zona cervical en el posotperatorio. Esta complicación no retrasó el alta hospitalaria. El estudio se interrumpió debido a los resultados. CONCLUSIÓN: La anestesia subaracnoidea no ha resultado efectiva para la coloposuspensión de Burch por laparoscopia extraperitoneal debido a la imposibilidad de paliar el malestar derivado de la fuga intraperitoneal y del enfisema subcutáneo que pueden presentarse en este tipo de cirugía (AU)

Comparative hemodynamic effects of urapidil and labetalol after electroconvulsive therapy.

Urapidil, a postsynaptic alpha 1 -adrenergic antagonist, has been reported to improve intraoperative hemodynamic stability, although it has never been used to prevent the hemodynamic response of electroconvulsive therapy (ECT). This study was designed to evaluate the clinical effectiveness of urapidil, as an alternative to labetalol, in preventing the hemodynamic response of ECT. Twenty-seven patients undergoing a series of six consecutive ECT treatments were studied. Each patient received all three pretreatments twice: no drug, labetalol 0.2 mg/kg, or urapidil 25 mg. Systolic, diastolic, and mean blood pressure and heart rate (HR) were recorded during the awake state, after anesthesia induction, and 1, 2, 5, 10 and 30 minutes after electroencephalographic (EEG) seizure ended. The duration of the EEG convulsion was also recorded. After induction, the HR increased for no drug and urapidil pretreatments, whereas it decreased when labetalol was given. Labetalol and urapidil attenuated the peak increase of blood pressure and returned it to earlier baseline values. There were no differences in the duration of EEG convulsion between the three pretreatments. Urapidil seems to be a good alternative to labetalol for attenuating the hypertensive response to ECT in cases where there is a contraindication to beta-antagonists.

[Efficacy of topical administration of lidocaine through a Malinckrodt Hi-Lo Jet tube in lessening cough during recovery from general anesthesia]. / La eficacia de la administración tópica de lidocaína a través del tubo Malinckrodt Hi-Lo Jet para atenuar la tos en el despertar de la anestesia general.

To achieve tracheal anesthesia during intubation, an endotracheal tube was purposely designed. The tube had multiple laser-induced perforations in its lower portion produced that allowed administration of the local anesthetic in a pulverized form. We evaluated the efficacy of lidocaine 2% in preventing cough during recovery from general anesthesia. The goal of this study was to perform a topical anesthesia of the hypopharynx, larynx, and trachea. This attenuates the laryngeal reflex occurring during anesthesia recovery and therefore, prevents from potential complications. Sixteen patients ASA I-II underwent surgery with general anesthesia. They were prospectively studied following a randomized double blind protocol. The control group received saline infusion (n = 6) whereas the experimental group (n = 10) was treated with lidocaine. At the end of the anesthesia period, the presence of cough was treated with the test solution. In 90% of cases treated with lidocaine, cough disappeared in about 30 seconds and patients tolerated the endotracheal tube until extubation was performed. All patients who received saline solution presented cough until extubation.

[Chylothorax. An infrequent complication in surgical exeresis of the esophagus]. / Quilotórax. Una complicación poco frecuente en la cirugía exerética de esófago.

We report a case of massive bilateral chylothorax occurring after surgical resection of the esophagus in a patient with esophageal neoplasm. The surgical approach consisted of a thoracotomy and a cervicostomy. The relevance of this case is based on the low incidence of chylothorax after esophageal surgery. The literature indicates an incidence of about 0.9 to 3%. In our series of 200 patients operated on during the last 10 years we found and incidence of 2%. The patient herein reported presented an immediate postoperative clinical picture of respiratory insufficiency associated with the presence of milky fluid in the pleural drainage. Hematologic and biochemical examination of the pleural fluid confirmed the diagnosis of chylothorax. During the first 24 hours we collected a total volume of 2,500 ml of chyle. The patient was treated with conservative procedures including parenteral nutrition and intravenous reposition of fluids. After 48 hours the total volume of chyle reached 8,500 ml and the patient died.