Telemedicina, una nueva herramienta para la gestión del dolor. Resultados de su implementación en una estructura organizativa de gestión integral (EOXI) / E-consults, a new tool for pain management. Results of its implementation in an organizational structure of integrated management (EOXI)

INTRODUCCIÓN: En diciembre de 2014, en el contexto del Plan de Atención del Dolor Crónico del SERGAS, se aplicó la primera experiencia de teleconsultas en unidades de dolor (UD). Se escogió la Estructura Organizativa de Gestión Integrada (EOXI) de Vigo para su aplicación. MATERIAL Y MÉTODOS: Se realizó un estudio descriptivo longitudinal retrospectivo de todas las teleconsultas enviadas a la UD en el periodo comprendido entre el 1 de enero de 2015 hasta el 31 de diciembre de 2018. RESULTADOS: Entre enero de 2015 y diciembre de 2018 se han solicitado un total de 2218 teleconsultas. Fueron realizadas desde 42 centros de salud de un total de 42 del EOXI. De las 2218 teleconsultas recibidas, el 49 % fueron preferentes. Respecto a la capacidad de resolución, el 26 % (586) de los pacientes son dados de alta de forma telemática y el 74 % (1632) son citados en la UD. Los tiempos de respuesta medios para el periodo de tiempo estudiado fueron: 21 días para las teleconsultas preferentes y de 22 para las ordinarias. CONCLUSIONES: La teleconsulta contribuye a que se conozca y mejore la coordinación entre diferentes niveles asistenciales, evitando derivaciones innecesarias a consulta presencial, mejorando la accesibilidad del paciente y descongestionando los servicios hospitalarios. Pone de manifiesto la importancia de unos protocolos consensuados de remisión y la necesidad de actualizar la información sobre la cartera de servicios. Permite detectar defectos de comunicación entre Atención Primaria y UD. Permite poner en marcha acciones correctoras

INTRODUCTION: On 2014 the Galician Health Service (SERGAS)starts the first teleconsult experience applied to pain unit, and the Sanitary Area of Vigo was chosen for its pilot implementation. MATERIAL AND METHODS: A retrospective longitudinal descriptive study was undertaken during the lapse time January 2015 to December 2018. RESULTS: In the period of study a total of 2218 teleconsults were requested from the 42 primare care centers of the Sanitary Area.49% of the teleconsults were preferent.26% (586) of the requests were rejected and 74% (1632) were evaluated at the Pain Unit. The mean time for response were: 21 days for preferents and 22 for non-preferents. CONCLUSIONS: Teleconsult allows an improvement in the relationship between specialized and primary care levels. Remarks the importance on consensuated protocols for patient referal. Remarks the need of an updated and well documented portfolio of services. It allows to correct errors of information transmission between assistance levels and implement correction actions

Esmolol versus ketamine-remifentanil combination for early postoperative analgesia after laparoscopic cholecystectomy: a randomized controlled trial.

PURPOSE: Controversy surrounds the optimal technique to moderate pain after laparoscopic cholecystectomy (LC). Opioid analgesics, sympatholytic drugs, and adjuvants, such as ketamine, have all been used. We compared esmolol with a combination of remifentanil plus ketamine in patients undergoing LC to determine the impact of these drugs on morphine requirements and pain control. METHODS: Sixty American Society of Anesthesiologists physical status I-II patients undergoing LC and anesthetized with sevoflurane were randomized to one of two groups. Group E patients received a bolus of esmolol 0.5 mg·kg(-1) iv at induction followed by an infusion of 5-15 µg·kg(-1)·min(-1), and Group R-K patients received a bolus of ketamine 0.5 mg·kg(-1) iv and remifentanil 0.5 µg·kg(-1) iv at induction followed by a remifentanil infusion titrated over a range of 0.1-0.5 µg·kg(-1)·min(-1). All patients received paracetamol, dexketoprofen, and levobupivacaine via infiltration of laparoscopic port sites. After surgery, a predetermined bolus of morphine was administered according to a verbal numerical rating scale (VNRS) for pain intensity. The primary outcome of interest was postoperative morphine requirement. RESULTS: Median consumption of morphine was higher in Group R-K than in Group E (5 mg [4-6] vs 0 mg [0-2], respectively; P < 0.001). In the postanesthesia care unit, patients in Group R-K had higher pain scores than patients in Group E (difference in maximum VNRS, -11; 95% confidence interval (CI), -19 to -3). The concentration of sevoflurane to maintain a bispectral index~40 was higher in Group E than in Group R-K (between-group difference 0.3%; 95% CI, 0.15 to 0.40). The incidence of postoperative nausea and vomiting was similar between the two groups. CONCLUSION: Intraoperative esmolol infusion reduces morphine requirements and provides more effective analgesia compared with a combination of remifentanil-ketamine given by infusion in patients undergoing LC.

[Lung transplantation for emphysema: retrospective study of 65 patients]. / Trasplante pulmonar por enfisema: análisis retrospectivo de 65 pacientes.

BACKGROUND AND OBJECTIVE: Our goal was to analyze the incidence of perioperative complications in patients with pulmonary emphysema who underwent lung transplantation and to identify variables associated with the incidence of morbidity and mortality during the immediate postoperative period. PATIENTS AND METHOD: We undertook a retrospective study of 65 pulmonary emphysema patients who received lung transplants from 1994 through 2002 with the aim of determining the most common intra- and early postoperative complications in the ICU. An univariate analysis was carried out in order to identify variables associated with the incidence of mortality and postoperative complications. Those variables showing statistical significance underwent a multivariate analysis, by means of a pattern of logistic regression, in order to calculate the odds ratio and confidence interval. RESULTS: Seventeen patients received single-lung transplants (SLT) and 48 patients received sequential double-lung transplants (DLT). Intraoperative complications appeared more frequently in the DLT group. Most frequent complications during surgery were reperfusion syndrome (44.6%) and pulmonary hypertension (16.9%). The intraoperative survival was 100%. Fifty-five patients had some type of postoperative complication. Commonest postoperative complications were infection (56.9%) and primary graft failure (36.6%). In the early postoperative period the mortality rate was 16.9%. Main cause of death in the ICU was sepsis (54.5%). A time of mechanical ventilation > 48 hours and postoperative hemorrhage were the variables with a higher predictive value for mortality in the early postoperative period. CONCLUSIONS: Patients with SLT had a lower rate of perioperative complications and a higher survival during their stay in the ICU. Time of mechanical ventilation > 48 hours and postoperative hemorrhage were the variables that best predicted death in the early postoperative period following lung transplantation. Despite our experience, however, perioperative mortality in lung transplantation remains high up to this day.

Trasplante pulmonar por enfisema: análisis retrospectivo de 65 pacientes / Lung transplantation for emphysema: retrospective study of 65 patients

Fundamento y objetivo: Describir la incidencia de complicaciones perioperatorias de los pacientes trasplantados de pulmón por enfisema pulmonar y estudiar los factores de riesgo asociados a la morbimortalidad en el postoperatorio inmediato. Pacientes y método: Estudio retrospectivo que incluye a 69 pacientes trasplantados de pulmón por enfisema pulmonar durante los años 1994-2002. Se realizó un análisis univariante para identificar las variables asociadas con la incidencia de la mortalidad en la Unidad de Reanimación o con el aumento de complicaciones postoperatorias. Las variables que presentaron significación estadística se sometieron a análisis multivariante mediante el modelo de regresión logística. Resultados: Se incluyó a 65 pacientes. Diecisiete recibieron un trasplante unipulmonar (TUP) y 48 un transplante bilateral secuencial (TBP). Las complicaciones intraoperatorias fueron más habituales en el grupo del trasplante bipulmonar (35,3% en el TBP frente a 72,9% en el TUP, p < 0,006), y las complicaciones intraoperatorias más frecuentes fueron el síndrome posreperfusión y la hipertensión pulmonar . No hubo ningún caso de mortalidad intraoperatoria en la serie. Las complicaciones postoperatorias más frecuentes fueron la infección (56,9%) y el fallo primario del injerto (36,6%). Cincuenta y cinco pacientes presentaron alguna complicación en el postoperatorio inmediato. La mortalidad global en el postoperatorio fue del 16,9%, y que la sepsis (54,5%) la causa más frecuente de fallecimiento en el postoperatorio inmediato. La ventilación mecánica durante más de 48 h y la hemorragia posquirúrgica fueron las variables con mayor valor predictivo de mortalidad en el postoperatorio Conclusiones: Los pacientes con TUP tienen menor número de complicaciones en el perioperatorio, lo que condiciona una mayor supervivencia durante la estancia en reanimación. La ventilación mecánica durante más de 48 h y la hemorragia posquirúrgica fueron las variables que mejor predijeron la mortalidad en el postoperatorio inmediato

Background and objective: Our goal was to analyze the incidence of perioperative complications in patients with pulmonary emphysema who underwent lung transplantation and to identify variables associated with the incidence of morbidity and mortality during the immediate postoperative period. Patients and method: We undertook a retrospective study of 65 pulmonary emphysema patients who received lung transplants from 1994 through 2002 with the aim of determining the most common intra- and early postoperative complications in the ICU. An univariate analysis was carried out in order to identify variables associated with the incidence of mortality and postoperative complications. Those variables showing statistical significance underwent a multivariate analysis, by means of a pattern of logistic regression, in order to calculate the odds ratio and confidence interval. Results: Seventeen patients received single-lung transplants (SLT) and 48 patients received sequential double-lung transplants (DLT). Intraoperative complications appeared more frecuently in the DLT group. Most frequent complications during surgery were reperfusion syndrome (44.6%) and pulmonary hypertension (16.9%). The intraoperative survival was 100%. Fifty-five patients had some type of postoperative complication. Commonest postoperative complications were infection (56.9%) and primary graft failuree (36.6%). In the early postoperative period the mortality rate was 16.9 %. Main cause of death in the ICU was sepsis (54.5%). A time of mechanical ventilation > 48 hours and postoperative hemorrhage were the variables with a higher predictive value for mortality in the early postoperative period. Conclusions: Patients with SLT had a lower rate of perioperative complications and a higher survival during their stay in the ICU. Time of mechanical ventilation > 48 hours and postoperative hemorrhage were the variables that best predicted death in the early postoperative period following lung transplantation. Despite our experience, however, perioperative mortality in lung transplantation remains high up to this day