Eficacia y complicaciones de las técnicas analgésicas para el tratamiento del dolor agudo postoperatorio moderado a intenso / Efficacy and complications of analgesic techniques for the treatment of moderate to severe postoperative acute pain

Introducción: A pesar de los esfuerzos y la evidencia disponible, el dolor agudo postoperatorio (DAP) moderado a intenso continúa teniendo una prevalencia elevada en nuestro medio. Como parte de una estrategia de analgesia balanceada o multimodal, las técnicas de analgesia regional ofrecen un adecuado control analgésico con menores efectos indeseables (que el uso exclusivo de opioides), aunque no están exentas de complicaciones y no son aplicables a todas las cirugías. El objetivo de este trabajo fue valorar la eficacia de las técnicas analgésicas para el tratamiento del DAP moderado a intenso, la incidencia de complicaciones asociadas a estas técnicas y la relación entre DAP y el antecedente de dolor crónico. Pacientes y métodos: Estudio retrospectivo que incluyó 728 pacientes en los que se indicaron técnicas analgésicas, como analgesia epidural, analgesia perineural continua y analgesia controlada por el paciente (PCA) con morfina intravenosa, para el tratamiento del DAP moderado a intenso entre octubre del 2018 y octubre del 2020. Los pacientes fueron valorados por la Unidad de Dolor Agudo Postoperatorio (UDAP) a las 24 y 48 horas, se registró el dolor con la ENV (Escala Numérica Verbal), la presencia de reacciones adversas y/o complicaciones, empleo de analgesia multimodal y consumo de morfina en equivalentes intravenosos. Los niveles de dolor se clasificaron en leve (ENV: 0-3), moderado (ENV: 4-6) e intenso (ENV mayor o igual a 7). Resultados: Cerca del 60 % de los pacientes presentaron dolor leve a las 24 horas y del 70 % a las 48 horas. Un 71,8 % de los portadores de analgésica continua epidural presentaron dolor leve el primer día y un 83 % al segundo. Las cirugías con niveles más altos de dolor moderado e intenso fueron la cirugía espinal en la que se empleó la PCA de morfina y la artroplastia de rodilla en que se utilizó analgesia a través de bloqueo femoral continuo...(AU)

Introduction: Despite the efforts and the available evidence, moderate to severe acute postoperative pain (APP) continues to have a high prevalence in our setting. As part of a balanced or multimodal analgesia strategy, regional analgesia techniques offer adequate analgesic control with fewer undesirable effects (that the exclusive use of opioids), although they are not free of complications and do not apply to all surgeries. This study aimed to assess the efficacy of analgesic techniques for the treatment of moderate to intense APP, the incidence of complications associated with these techniques, and the relationship between APP and the presence of chronic pain. Patients and methods: This retrospective study included 728 patients in which analgesic techniques such as epidural analgesia, continuous perineural analgesia, and morphine Patient Controlled Analgesia (PCA) were indicated to treat moderate to severe APP between October 2018 and October 2020. The patients were evaluated by the APP service at 24 and 48 hours, the pain was recorded with the NRS (Numerical Rating Scale), and the study also registered the presence of adverse reactions and/or complications, the use of multimodal analgesia, and the consumption of morphine in equivalent intravenous doses. Pain levels were classified as mild (NRS: 0-3), moderate (NRS: 4-6) and intense (NRS greater than or equal to 7). Results: Approximately 60 % of all patients presented mild pain at 24 hours and 70 % at 48. Epidural analgesia in abdominal surgery presented 71.8 % mild pain on the first day and 83 % on the second. The surgeries with the highest levels of moderate and severe pain were spinal surgery using morphine PCA and knee replacement with continuous femoral nerve block. The morphine consumption recorded in the PCA was 25.8 mg (SD 18.4) at 24 hours and 18.6 mg (SD: 14.6) at 48 hours...(AU)

Implicación en Cataluña de los Servicios de Anestesiología y Reanimación en la pandemia por SARS-CoV-2. Una solución real coste-efectiva para una crisis sanitaria sin precedentes / Involvement in Catalonia of the Anaesthesiology and Resuscitation Services in the SARS-CoV-2 pandemic. A real, cost-effective solution to an unprecedented health crisis

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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)

Consenso GEDOS-SECOT sobre el proceso de atención a pacientes con artrosis de rodilla e indicación de artroplastia / GEDOS-SECOT consensus on the care process of patients with knee osteoarthritis and arthoplasty

Objetivo. Desarrollar recomendaciones sobre el proceso de evaluación y manejo del paciente con artrosis de rodilla e indicación de artroplastia basadas en la mejor evidencia científica disponible y la experiencia de un panel de expertos. Métodos. Se seleccionó un grupo multidisciplinar de 12 expertos que definieron: alcance, usuarios, apartados del documento, revisiones sistemáticas a realizar y a quienes se asignaron tareas. Se realizaron 3 revisiones sistemáticas en pacientes con indicación de artroplastia de rodilla sobre: 1) eficacia y seguridad de los protocolos de fast-track; 2) papel de las intervenciones cognitivo-conductuales en sujetos con catastrofismo, y 3) efecto del control del dolor agudo posquirúrgico en los resultados. Se realizaron 2 revisiones narrativas sobre la sensibilización central en este grupo y sobre la eficacia de la rehabilitación preoperatoria. Los expertos redactaron los apartados y generaron las recomendaciones. Estas recomendaciones se consensuaron mediante la metodología Delphi en un grupo multidisciplinar de 85 expertos. Se estableció también el nivel de evidencia de cada recomendación. Resultados. Se generaron 20 recomendaciones. Todas alcanzaron un nivel de acuerdo mayor del 80%. El mayor acuerdo se alcanzó en la necesidad de realizar informe de alta completo, en informar adecuadamente al paciente sobre el proceso y en seguir las recomendaciones de las guías clínicas disponibles. Conclusiones. Existe consenso entre los responsables del manejo de los pacientes con artrosis de rodilla e indicación de artroplastia en que es necesario protocolizar el proceso de sustitución articular, realizando una correcta evaluación y seguimiento del paciente, de forma integral y coordinada y con especial atención al procedimiento quirúrgico y al postoperatorio (AU)

Objective. To develop recommendations on the evaluation and management procedure in patients undergoing total knee replacement based on best evidence and the experience of a panel of experts. Methods. A multidisciplinary group of 12 experts was selected that defined the scope, users and the document parts. Three systematic reviews were performed in patients undergoing knee replacement: (I) efficacy and safety of fast-tracks; (II) efficacy and safety of cognitive interventions in patients with catastrophic pain, and (III) efficacy and safety of acute post-surgical pain management on post-surgical outcomes. A narrative review was conducted on the evaluation and management of pain sensitization, and about the efficacy and safety of pre-surgical physiotherapy. The experts generated the recommendations and explicative text. The level of agreement was evaluated in a multidisciplinary group of 85 experts with the Delphi technique. The level of evidence was established as well for each recommendation. Results. A total of 20 recommendations were produced. An agreement higher than 80% was reached in all of them. We found the highest agreement on the need for a full discharge report, on providing proper information about the process and on following available guidelines. Conclusions. There is consensus among professionals involved in the management of patients undergoing total knee replacement, in that it is important to protocolize the replacement process, performing a proper, integrated and coordinated patient evaluation and follow-up, paying special attention to the surgical procedure and postoperative period (AU)

Tramadol hydrochloride 75 mg/dexketoprofen 25 mg oral fixed-dose combination in moderate-to-severe acute pain: sustained analgesic effect over a 56-h period in the postoperative setting.

Multimodal analgesia constitutes a common strategy in pain management. A tramadol hydrochloride 75 mg/dexketoprofen 25 mg oral fixed combination (TRAM/DKP 75 mg/25 mg) has been recently registered and released in Europe for the treatment of moderate-to-severe acute pain. This paper provides additional analyses on the results of two phase III clinical trials (DEX-TRA-04 and DEX-TRA-05) on postoperative pain to document its sustained effect. The analysis was applied to a modified intention-to-treat population (mITT, n = 933) of patients undergoing active treatment from the first dose, to assess the sustained effect of TRAM/DKP 75 mg/25 mg on pain intensity (PI-VAS 0-100) over 56 h from first drug intake. The superior analgesic effect of TRAM/DKP 75 mg/25 mg over 56 h in terms of difference in PI-VAS (mean [SE]) was shown for DEX-TRA-04 (-11.0 [0.55] over dexketoprofen 25 mg and -9.1 [0.55] over tramadol 100 mg, P ≤ 0.0001) and for DEX-TRA-05 (-10.4 [0.51] over dexketoprofen 25 mg and -8.3 [0.51] over tramadol 100 mg, P ≤ 0.0001). The statistical analysis performed on data coming from both studies confirms the superior sustained analgesia of TRAM/DKP 75 mg/25 mg over tramadol 100 mg and dexketoprofen 25 mg. These results are consistent with the previously published data obtained on the ITT population and strongly support the role of this oral fixed-dose combination in the treatment of moderate-to-severe acute pain.

GEDOS-SECOT consensus on the care process of patients with knee osteoarthritis and arthoplasty. / Consenso GEDOS-SECOT sobre el proceso de atención a pacientes con artrosis de rodilla e indicación de artroplastia.

OBJECTIVE: To develop recommendations on the evaluation and management procedure in patients undergoing total knee replacement based on best evidence and the experience of a panel of experts. METHODS: A multidisciplinary group of 12 experts was selected that defined the scope, users and the document parts. Three systematic reviews were performed in patients undergoing knee replacement: (i)efficacy and safety of fast-tracks; (ii)efficacy and safety of cognitive interventions in patients with catastrophic pain, and (iii) efficacy and safety of acute post-surgical pain management on post-surgical outcomes. A narrative review was conducted on the evaluation and management of pain sensitization, and about the efficacy and safety of pre-surgical physiotherapy. The experts generated the recommendations and explicative text. The level of agreement was evaluated in a multidisciplinary group of 85 experts with the Delphi technique. The level of evidence was established as well for each recommendation. RESULTS: A total of 20 recommendations were produced. An agreement higher than 80% was reached in all of them. We found the highest agreement on the need for a full discharge report, on providing proper information about the process and on following available guidelines. CONCLUSIONS: There is consensus among professionals involved in the management of patients undergoing total knee replacement, in that it is important to protocolize the replacement process, performing a proper, integrated and coordinated patient evaluation and follow-up, paying special attention to the surgical procedure and postoperative period.

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)

[Assessment of learning in blind orotracheal intubation with Fastrach masks using a cumulative sum curves (CuSum) in the SimMan Universal Simulator]. / Evaluación del aprendizaje de intubación orotraqueal a ciegas a través de mascarillas Fastrach mediante curvas de sumas acumulativas (CuSum) en el Simulador Universal SimMan.

OBJECTIVE: To assess training in blind intubation with the Fastrach laryngeal mask in a simulation model by applying the cumulative sums (CuSum) method. MATERIAL AND METHODS: Six anaesthesiology resident doctors, with no previous experience of the technique, participated, three in their first year, and three in the second. The study was conducted with the help of the SimMan Universal Simulator. Fifty attempts by each one of them over a four month period, divided into two stages: the first 20 with minimum airway difficulty, and the next 30 with limitations of flexion-extension movements to <80°. An unacceptable failure rate was set at 10% after a second failed attempt. The time limit set to be considered a success was 60seconds. RESULTS: A total of 120 attempts in the first stages, and the remaining 180 in the second were analysed individually, all managing to achieve acceptable success rates of 90%: 84% in the first attempt and 13.33% in the second. A total of 2.66% failures were recorded. The learning curve showed that the residents began to achieve an acceptable 90% success rate in case number 25±11.76 of the 50 attempts. CONCLUSIONS: This statistical method and the SimMan simulator, used together, have demonstrated to be very useful tools in assessing learning curves in this technique.

Evaluación del aprendizaje de intubación orotraqueal a ciegas a través de mascarillas Fastrach mediante curvas de sumas acumulativas (CuSum) en el Simulador Universal SimMan / Assessment of learning in blind orotracheal intubation with Fastrach masks using a cumulative sum curves (CuSum) in the SimMan Universal Simulator

Objetivos: Evaluar el aprendizaje de intubación a ciegas a través de mascarilla laríngea Fastrach en un modelo de simulación, mediante la aplicación del método de sumas acumulativas CuSum. Material y métodos: Participaron seis médicos residentes de Anestesiología, tres en su primer año y tres en el segundo, sin experiencia previa en la técnica. El estudio se realizó con la ayuda del Simulador Universal SimMan. A lo largo de 4 meses, se registraron 50 intentos en cada uno de ellos, divididos en dos etapas: los primeros 20 con mínima dificultad de vía aérea y los siguientes 30 con limitación a los movimientos de flexoextensión a < 80°. Se aceptó como índice inaceptable de fallo el 10% tras un segundo intento fallido. El límite temporal fijado para considerarlo éxito fue de 60 s. Resultados: Se analizaron 120 intentos en la primera etapa y los 180 restantes en la segunda, individualmente; todos lograron unos índices aceptables de éxito del 90%: el 84% en el primer intento y el 13,33% en el segundo. Se registró un 2,66% de fallos del total. La curva de aprendizaje mostró que los residentes lograron alcanzar el índice aceptable de éxito del 90% como media en el caso número 25 ± 11,76, de 50 casos. Conclusiones: Se ha demostrado que este método estadístico y el simulador SimMan utilizados conjuntamente son unas herramientas muy útiles en la evaluación del aprendizaje de esta técnica(AU)

Objective: To assess training in blind intubation with the Fastrach laryngeal mask in a simulation model by applying the cumulative sums (CuSum) method. Material and methods: Six anaesthesiology resident doctors, with no previous experience of the technique, participated, three in their first year, and three in the second. The study was conducted with the help of the SimMan Universal Simulator. Fifty attempts by each one of them over a four month period, divided into two stages: the first 20 with minimum airway difficulty, and the next 30 with limitations of flexion-extension movements to <80°. An unacceptable failure rate was set at 10% after a second failed attempt. The time limit set to be considered a success was 60 seconds. Results: A total of 120 attempts in the first stages, and the remaining 180 in the second were analysed individually, all managing to achieve acceptable success rates of 90%: 84% in the first attempt and 13.33% in the second. A total of 2.66% failures were recorded. The learning curve showed that the residents began to achieve an acceptable 90% success rate in case number 25±11.76 of the 50 attempts. Conclusions: This statistical method and the SimMan simulator, used together, have demonstrated to be very useful tools in assessing learning curves in this technique(AU)

Propuesta sobre las competencias en Anestesiología, Reanimación y Terapéutica del Dolor de un graduado de Medicina. Consenso del profesorado de las universidades de Cataluña / No disponible

No disponible

[Headache caused by endocranial hypotension secondary to sacrococcygeal trauma in a patient with a congenital arachnoid cyst]. / Cefalea por hipotensión endocraneal secundaria a un traumatismo sacrococcígeo en un paciente con un quiste aracnoideo congénito.

Headache caused by intracranial hypotension after sacrococcygeal trauma, is a rare syndrome with very similar symptoms and physiopathology to post dural puncture headache. In both situations, cerebrospinal fluid (CSF) leaks through a dural tear, leading to a decrease in its pressure. A 13 year old patient presented a frontal and occipital positional headache, after undergoing sacrococcygeal trauma. In magnetic resonance images, the presence of a spinal arachnoid diverticulum (cyst) and CSF leak were confirmed. After the establishment of conservative medical treatment, complete clinical remission was observed. The diagnosis of intracranial hypotension headache syndrome is mainly clinical, once other possible headache etiologies have been discarded. Magnetic resonance imaging can be used to detect small CSF leaks, and in this case, magnetic resonance imaging clearly showed the existence of an arachnoid cyst. The presence of some meningeal diverticulums such as arachnoid cyst, constitute a risk to undergo this syndrome, due to the possibility of its rupture by minor traumatisms. The initial treatment should be conservative, as the dural tear seals spontaneously and the liquid is reabsorbed.

Percutaneous anterior approach to the coeliac plexus using ultrasound.

A new approach is described to the neurolytic block of the coeliac plexus through the anterior abdominal wall using ultrasonic guidance. In nine patients, ultrasound was used for needle placement and examination of the spread of injection. Total pain relief was obtained in seven of the patients after 2 weeks and in five patients after 6 months. No serious complications were observed. The anterior approach is simple and useful in those patients with chronic pancreatic pain undergoing biopsy of the pancreas, and in those terminally ill or heavily sedated patients who have difficulty in tolerating the prone flexed position.