Analgesia intravenosa ambulatoria con bombas elastoméricas en pacientes sometidos a cirugía plástica: serie prospectiva de casos / Ambulatory intravenous analgesia using elastomeric pumps in patients undergoing plastic surgery: prospective case series

Abstract Introduction: Cosmetic plastic surgery interventions are usually associated with significant postoperative pain. As they are outpatient procedures, analgesic management is limited mostly to oral medication, resulting in suboptimal pain control, one of the most frequent complaints of patients undergoing these surgical procedures. Elastomeric pumps have been studied for continuous infusion of intravenous analgesics in other types of surgeries associated with significant pain. Objective: The main objective of this study was to evaluate postoperative pain control in adult patients who underwent mammoplasty, abdominoplasty, liposuction, or combined procedures using elastomeric pumps for postoperative analgesic management in continuous intravenous infusion. Materials and methods: A prospective sample of 100 patients who accepted postoperative pain management was collected. Satisfaction was evaluated using a survey, and pain control was assessed on postoperative days 1,3, and 5, and a determination of adverse reactions associated with analgesia using this device was also assessed. Results: Optimal pain control and a satisfaction greater than 90% were observed from the first postoperative day of the intervention. Conclusion: We recommend this analgesic strategy based on evidence of excellent postoperative ambulatory pain control.

Resumen Introducción: La cirugía plástica estética se caracteriza porque generalmente son intervenciones que originan un importante dolor posoperatorio, al ser procedimientos ambulatorios, el manejo analgésico se limita en la mayoría de las ocasiones a medicación vía oral, la que genera un control subóptimo del dolor, siendo una de las quejas más frecuentes de los pacientes sometidos a estas cirugías. Desde hace algún tiempo se han estudiado las bombas elastoméricas para la infusión continua de analgésicos intravenosos, con el propósito de controlar el dolor posoperatorio en otros tipos de cirugías con importante potencial doloroso. Objetivo: El objetivo principal de este estudio fue evaluar el control del dolor posoperatorio en pacientes adultos, quienes se sometieron a mamoplastia, abdominoplastia, liposucción o combinaciones de estas, con el uso de bombas elastoméricas para el manejo analgésico posoperatorio en infusión intravenosa continua. Materiales y métodos: Se recogió una muestra prospectiva de 100 pacientes quienes aceptaron el manejo del dolor posoperatorio, en quienes se evaluó por medio de una encuesta la satisfacción y el control del dolor de los pacientes al día 1, día 3 y día 5 posoperatorio, además si se presentaron reacciones adversas generadas por la analgesia aplicada a través de este dispositivo. Resultados: Se encontró un óptimo control del dolor y una satisfacción mayor del 90% desde el 1° día posoperatorio de la intervención realizada. Conclusiones: Recomendamos esta estrategia analgésica ya que se evidenció un excelente control del dolor posoperatorio ambulatorio.

The use of quadripolar left ventricular leads improves the hemodynamic response to cardiac resynchronization therapy.

BACKGROUND: The objective of the present study was to evaluate the usefulness of a left ventricle (LV) quadripolar lead in improving the hemodynamic response to cardiac resynchronization therapy (CRT). METHODS AND RESULTS: We included 27 consecutive patients implanted with a CRT device with an LV quadripolar lead. Hemodynamic parameters were evaluated at 3-month follow-up by using impedance cardiography. We assessed the highest cardiac output and the highest stroke volume (SV) obtained after atrioventricular and interventricular optimization with pacing from each of the four electrodes of the LV lead. Each patient was evaluated according to three different pacing configurations: unipolar-simulated, bipolar, and quadripolar. Biventricular pacing improved hemodynamics in comparison to the nonpaced measurements: cardiac index (CI): 2.69 L/min/m(2) versus 2.17 L/min/m(2) (P = 0.001). The hemodynamic response was highest in the quadripolar in comparison to unipolar-simulated and bipolar configurations, with an increase of 29%, 23%, and 27%, respectively, in relation to the reference CI and with an increase of 22%, 11%, and 18%, respectively, in relation to the reference indexed SV (P < 0.05, for the comparison between unipolar-simulated and quadripolar configurations). Twelve patients (44%) showed the best hemodynamic response by pacing from any of the two distal electrodes and 15 patients (56%) by pacing from the two proximal electrodes. Finally, CRT responder rates were higher in quadripolar versus bipolar and unipolar-simulated configurations: 90%, 85%, and 75%, respectively. CONCLUSIONS: The quadripolar LV lead was associated with a better hemodynamic response and higher CRT responder rates when compared with unipolar-simulated and bipolar LV leads.

Evaluation of a new standardized protocol for the perioperative management of chronically anticoagulated patients receiving implantable cardiac arrhythmia devices.

BACKGROUND: Perioperative management of oral anticoagulation (OAC) in patients receiving pacemakers or implantable cardioverter-defibrillators remains an issue of concern. OBJECTIVE: We sought to evaluate the safety and the effect on the hospital length of stay of a new standardized protocol for perioperative management of OAC in this setting. METHODS: The new standardized protocol classified patients according to a renewed evaluation of their thromboembolic (TE) risk. Briefly, patients were considered at moderate-to-high TE risk if they had a mechanical valvular prostheses irrespective of type and location or atrial fibrillation associated with a CHADS(2)score of ≥2, mitral stenosis or previous stroke, and underwent device implantation without stopping OAC (OAC continued, n = 129). Complete interruption of OAC before surgery was performed in low-TE-risk patients (OAC interrupted, n = 82). A retrospective cohort of patients managed with a classic heparin-bridging strategy served as a control group, with 62 patients considered at moderate-to-high TE risk according to previous guidelines (receiving pre- and postoperative low-molecular-weight heparin) and 146 considered at low TE risk (receiving only low doses of postoperative low-molecular-weight heparin). RESULTS: TE events were comparable between the 2 strategies. Patients entering the new standardized protocol had significantly lower rates of pocket hematoma (2.3% for OAC continued vs 17.7% for moderate-to-high TE risk bridging controls, P = .0001, and 0% for OAC interrupted vs 13% for low-TE-risk bridging controls, P <.0001) and shorter hospital stays. A mean of 3.34 hospitalization days per patient were saved with the new standardized protocol, with an estimated cost savings of €850.83 per patient. CONCLUSIONS: Implantation of the new standardized protocol resulted in a significant reduction in bleeding complications and hospital stays, with adequate protection against TE events and significant cost savings.

Cambios en los enfoques en salud / Changes in them approach in health

Entrevista con David Tejada, Asesor en Políticas Sociales para UNICEF, se hace una revisión del proceso de estos cambios desde Alma Ata y la concepción de atención Primaria de Salud hasta el actual enfoque de Derechos. Un proceso de poco más de 20 años que refleja visiones sustancialmente diferentes unas de otras en cuanto a las propuestas de abordaje de las políticas de salud

Interpretación de la cumbre mundial sobre desarrollo social

El desarrollo social es inseparable del entorno cultural, ecológicoEconómico, político y espiritual en que tiene lugar.