Avances farmacológicos en el manejo multimodal de la analgesia perioperatoria / Pharmacological advances in the multimodal management of perioperative analgesia

El concepto de analgesia multimodal está actualmente muy extendido en nuestra práctica clínica. El objetivo de la analgesia multimodal es la disminución de efectos secundarios derivados de los fármacos o técnicas utilizados para el control del dolor junto a una mayor efectividad (combinación de múltiples mecanismos de acción) con la máxima eficiencia, es decir, combinar diferentes farmacodinamias (efectos sinérgicos o aditivos) y farmacocinéticas en el contexto de un modelo de dolor agudo previsible y por lo tanto que nos permite una estrategia previa como es el modelo del dolor agudo postoperatorio. El dolor es un fenómeno fisiológico complejo. En el dolor postoperatorio intervienen múltiples vías incluyendo fuentes nociceptivas, inflamatorias y neuropáticas. En la transmisión del dolor por lo tanto, participan distintas moléculas; este hecho supone que existen múltiples dianas farmacológicas sobre las que actuar y por lo tanto una amplio abanico de fármacos a utilizar siguiendo la fisiología del dolor (AU)

The concept of multimodal analgesia is currently widespread in our clinical practice. The aim of multimodal analgesia is to reduce the side effects derived from the drugs or techniques used for the control of pain together with greater effectiveness (combination of multiple mechanisms of action) with the maximum efficiency, that is, to combine different pharmacodynamics (synergistic or additive effects) and pharmacokinetics, in the context of a predictable acute pain model, thus allowing a prior strategy such as the model of acute postoperative pain. Pain is a complex physiological phenomenon. Postoperative pain involves multiple pathways including nociceptive, inflammatory, and neuropathic sources. In the transmission of pain therefore, different molecules participate, which means that there are multiple pharmacological targets on which to act, and therefore a wide range of drugs to be used following the physiology of pain (AU)

Pharmacological advances in the multimodal management of perioperative analgesia. / Avances farmacológicos en el manejo multimodal de la analgesia perioperatoria.

The concept of multimodal analgesia is currently widespread in our clinical practice. The aim of multimodal analgesia is to reduce the side effects derived from the drugs or techniques used for the control of pain together with greater effectiveness (combination of multiple mechanisms of action) with the maximum efficiency, that is, to combine different pharmacodynamics (synergistic or additive effects) and pharmacokinetics, in the context of a predictable acute pain model, thus allowing a prior strategy such as the model of acute postoperative pain. Pain is a complex physiological phenomenon. Postoperative pain involves multiple pathways including nociceptive, inflammatory, and neuropathic sources. In the transmission of pain therefore, different molecules participate, which means that there are multiple pharmacological targets on which to act, and therefore a wide range of drugs to be used following the physiology of pain.

Ibuprofeno endovenoso. Seguridad y utilización en población con comorbilidad / No disponible

La oferta en el mercado farmacéutico de antiinflamatorios no esteroideos (AINE) que se puedan administrar por vía endovenosa es escasa. La formulación de ibuprofeno endovenoso nos ofrece una nueva opción terapéutica que nos permite utilizar una vía de administración en aquellos periodos en los que la vía oral no es posible o no es la más deseable, minimizando los efectos secundarios de este AINE, que ya por sus características tiene un muy buen perfil de seguridad. Más de 40 años de experiencia con ibuprofeno utilizado como un medicamento de venta libre en la práctica clínica, en aproximadamente 80 países de todo el mundo, ha servido para valorar a lo largo del tiempo la eficacia y seguridad de este fármaco. El mes de junio de 2009, el ibuprofeno por vía intravenosa (Caldolor®) fue aprobado por la FDA de Estados Unidos para el tratamiento del dolor leve-moderado como agente único, y del dolor moderado-severo como un complemento a los opioides y como antipirético. La administración endovenosa implica el uso a corto plazo, por lo que las ventajas son indiscutibles dado que muchos de sus efectos adversos están asociados a la cronicidad de su administración. Con un buen manejo adaptando sus indicaciones a los distintos grupos de pacientes (comorbilidad) y situaciones de riesgo (perioperatorio), el ibuprofeno endovenoso es una excelente opción terapéutica analgésica, antiinflamatoria y antipirética. En este capítulo, a través de una revisión de la literatura disponible en GoPubMed® hasta febrero 2016, haciendo referencia al uso tanto por vía oral como endovenosa del ibuprofeno, analizamos la seguridad de este fármaco por vía endovenosa (AU)

In the pharmaceutical market we have only a few nonsteroidal antiinflammatory drugs (NSAIDs) that can be administered intravenously. The formulation of intravenous ibuprofen offers a new therapeutic option that allows us to use a route of administration in those periods when the oral route is not possible or is not the most desirable, minimizing the side effects of NSAIDs, which already for their features has a very good safety profile. More than 40 years of experience with ibuprofen used as a nonprescription drug in clinical practice in approximately 80 countries around the world has served to assess over time the effectiveness and safety of this fármaco (1). The month of june 2009, ibuprofen intravenously (Caldolor®) was approved by the US FDA for the treatment of mild to moderate pain as a single agent and pain of moderate to severe pain as an adjunct to opioids and as antipirético (2). Intravenous administration involves short-term use so that the benefits are indisputable since many of its adverse effects are associated with chronic administration. With good management to adapt its indications to different groups of patients (comorbidity) and risk (perioperative). Intravenous ibuprofen is an excellent analgesic, whith antipyretic and anti-inflammatory therapeutic action. In this chapter, through a review of the available literature on GoPubMed® until february 2016 referring to the use of both oral and intravenous ibuprofen, we analyze the safety of this drug intravenously (AU)

Estudio comparativo aleatorizado de la intervención quirúrgica temprana frente a la demorada en los pacientes con fractura de cadera tratados con antiagregantes plaquetarios. Determinación de la agregabilidad plaquetaria y el sangrado perioperatorio, y la revisión de la mortalidad al año / Randomised comparative study of early versus delayed surgery in hip-fracture patients on concomitant treatment with antiplatelet drugs. Determination of platelet aggregation, perioperative bleeding and a review of annual mortality

Revisar el tratamiento perioperatorio de los pacientes con fracturas de cadera y tratamiento concomitante con antiagregantes plaquetarios, así como analizar las diferencias de mortalidad al año, y el sangrado perioperatorio según la pauta de cirugía precoz (< 48 h) vs. demorada (> 5 días). Paralelamente, determinar al ingreso y en el preoperatorio inmediato la agregabilidad plaquetaria en todos los pacientes incluidos en el estudio. Pacientes y método. Sobre 175 pacientes mayores de 65 años con fractura de cadera de baja energía se aleatorizaron 3 grupos: antiagregados con cirugía precoz, antiagregados con cirugía demorada, y no antiagregados con cirugía precoz; se recogieron prospectivamente los mismos datos clínicos y analíticos para todos ellos. La agregabilidad plaquetaria se determinó mediante un sistema informatizado semicuantitativo basado en la agregometría por impedancia en sangre completa. Resultados. El sangrado, los requerimientos transfusionales y los resultados analíticos no mostraron diferencias estadísticamente significativas entre los grupos. Un 59,8% de los pacientes que no referían tomar antiagregantes se encontraban analíticamente antiagregados al ingreso, mientras que un 13,5% de los que tomaban antiagregantes no se encontraban correctamente antiagregados. El análisis multivariante mostró mayor mortalidad a 12 meses para las variables del índice de Barthel bajo previo a la fractura (OR: 0,9-0,9) y número de transfusiones (OR: 1,1-1,5). La estancia media fue de 4,1 días mayor en el grupo demorado. Conclusión. La pauta de cirugía precoz para los pacientes en tratamiento antiagregante tiene resultados clínicos parecidos a la demorada, pero mejora la eficiencia hospitalaria al reducir la estancia media. La antiagregación farmacológica referida por el paciente resultó poco concordante con la determinación de la agregabilidad(AU)

Objective. A review of the perioperative management of patients with hip fractures and concomitant therapy with antiplatelet agents, and to analyse the differences in mortality and perioperative bleeding in early surgery (<48 h) versus delayed surgery (>5 days). Platelet aggregation was measured on admission and immediately before surgery in all patients included in the study. Patients and methods. A total of 175 patients over 65 years old, with low energy hip fracture were randomised into 3 groups: Patients on antiplatelet therapy undergoing early surgery, patients on antiplatelet therapy undergoing delayed surgery, and patients not on antiplatelet therapy undergoing early surgery. The same clinical and laboratory data were collected prospectively up to 12 months for all the patients. The platelet aggregation was determined by a semi-quantitative computerised system based on impedance aggregometry in whole blood. Results. Bleeding, transfusion requirements and analytical results showed no significant differences between groups. More than half (59.8%) of the patients not taking antiplatelet therapy had normal platelet aggregation on admission, while 13.5% of those taking antiplatelet agents did not. Multivariate analysis showed increased mortality at 12 months for the variables, low Barthel index before hip fracture (OR: 0.9-0.9) and number of transfusions (OR: 1.1-1.5). The average lenth of stay was 4.1 days greater in the delayed surgery group. Conclusion. Early surgery for patients receiving antiplatelet therapy has similar clinical outcomes to the delayed, but improves hospital efficiency by reducing the average length of stay. The antiplatelet drug reported by the patient showed low concordance with the determination of the platelet aggregation(AU)

[Randomised comparative study of early versus delayed surgery in hip-fracture patients on concomitant treatment with antiplatelet drugs. Determination of platelet aggregation, perioperative bleeding and a review of annual mortality]. / Estudio comparativo aleatorizado de la intervención quirúrgica temprana frente a la demorada en los pacientes con fractura de cadera tratados con antiagregantes plaquetarios. Determinación de la agregabilidad plaquetaria y el sangrado perioperatorio, y la revisión de la mortalidad al año.

OBJECTIVE: A review of the perioperative management of patients with hip fractures and concomitant therapy with antiplatelet agents, and to analyse the differences in mortality and perioperative bleeding in early surgery (<48 h) versus delayed surgery (>5 days). Platelet aggregation was measured on admission and immediately before surgery in all patients included in the study PATIENTS AND METHODS: A total of 175 patients over 65 years old, with low energy hip fracture were randomised into 3 groups: Patients on antiplatelet therapy undergoing early surgery, patients on antiplatelet therapy undergoing delayed surgery, and patients not on antiplatelet therapy undergoing early surgery. The same clinical and laboratory data were collected prospectively up to 12 months for all the patients. The platelet aggregation was determined by a semi-quantitative computerised system based on impedance aggregometry in whole blood. RESULTS: Bleeding, transfusion requirements and analytical results showed no significant differences between groups. More than half (59.8%) of the patients not taking antiplatelet therapy had normal platelet aggregation on admission, while 13.5% of those taking antiplatelet agents did not. Multivariate analysis showed increased mortality at 12 months for the variables, low Barthel index before hip fracture (OR: 0.9-0.9) and number of transfusions (OR: 1.1-1.5). The average lenth of stay was 4.1 days greater in the delayed surgery group. CONCLUSION: Early surgery for patients receiving antiplatelet therapy has similar clinical outcomes to the delayed, but improves hospital efficiency by reducing the average length of stay. The antiplatelet drug reported by the patient showed low concordance with the determination of the platelet aggregation.