Manejo de la deprivación de altas dosis de morfina intratecal en el postoperatorio de paciente sometido a retirada de sistema intratecal por infección: Propuesta de manejo

Patients with chronic pain disease, bearers of intrathecal drug release systems, currently pose a challenge of handling, when in the perioperative period, we are forced to discontinue the administration of such drugs, as the clinical case set out sharply. It addresses the problem of countering the effects of the deprivation of high dose of intrathecal morphine in a patient undergoing withdrawal of the intrathecal system, with a proposal for management and clinical outcomes observed.Los pacientes afectos de dolor crónico, portadores de sistemas de liberación de fármacos intratecales, actualmente plantean un desafío de manejo, cuando por razones perioperatorias, nos vemos obligados a interrumpir de forma brusca la administración de dichos fármacos, como el caso clínico que exponemos. en el mismo se aborda la problemática de contrarrestar los efectos de la deprivación de morfina a altas dosis intratecales en un paciente sometido a retirada del sistema intratecal, con una propuesta de manejo y los resultados clínicos observados

Manejo del dolor postoperatorio en artroplastia/artroscopia de rodilla en nuestro medio: Déficit de concurso del Servicio de Anestesiología

Objectives: The correct management of acute postoperative pain is becoming increasingly important for the progression of the patient during their hospital stay. Taking advantage of a change in the infrastructure of our complex, and being aware of the regular analgesic control required by certain patients, in this study we attempt to highlight the importance of this analgesic management being directed by the Anaesthetic Department. Material and methods: This study was performed in the Orthopaedic Surgical Unit of the Badajoz (Spain) University Hospital Complex, lasted 2 months, and included two working groups consisting of Group A (arthroplasty) with 33 patients and Group B (arthroscopy) with 15 patients. We collected the relevant data for subsequent analysis (descriptive observational study), as well a survey carried out on the physicians of the Traumatology Unit and nursing staff, which collected a series of items to establish an opinion on the concepts to study. Results: Two fundamental deficiencies were found. Firstly, the levels of pain perceived by the patients were higher than those desired, and secondly, the analgesic techniques that were being practiced were not the most adequate and were not multimodal. Conclusions: According to the results we consider the support of the Anaesthetic Department as fundamental in the management of postoperative pain, since the final satisfaction of the patient would improve greatly. Although they were not objectives of the study, the days in hospital and the appearance of morbidity associated with the surgery would surely be reduced based on the existing literature. Furthermore, the surveys carried out showed a lack of protocols, clinical attitudes and training that the physicians and nurses demand.Objetivos: Día a día se pone de relevancia la importancia que representa el tratamiento correcto del dolor agudo postoperatorio en el devenir del paciente durante su estancia hospitalaria. Aprovechando una variación de infraestructura en nuestro complejo, y percatándonos del regular control analgésico que se producía en determinados pacientes, en este trabajo pretendemos destacar la importancia que tiene que este manejo lo dirijan los servicios de Anestesiología. Material y métodos: El estudio, llevado a cabo en la Unidad de Cirugía Ortopédica del Complejo Hospitalario Universitario de Badajoz y cuya duración fue de 2 meses, se distribuyó en 2 grupos de trabajo. El grupo A (artroplastia) contaba con 33 pacientes y el grupo B (artroscopia), con 15 pacientes. Recogimos los datos pertinentes para el análisis posterior (estudio observacional descriptivo), así como una encuesta realizada a los facultativos del Servicio de Traumatología y personal de enfermería que recogen una serie de ítems para establecer un criterio sobre los conceptos a estudiar. Resultados: Se encontraron 2 déficits fundamentales: en primer lugar, los valores de dolor percibidos por los pacientes fueron mayores de los deseables y, en segundo lugar, las técnicas analgésicas que se ponían en práctica no eran las más adecuadas ni eran multimodales. Conclusiones: A partir de los resultados, estimamos fundamental el concurso de los servicios de Anestesiología en el manejo del dolor postoperatorio, ya que la satisfacción final del paciente se vería mejorada de gran manera. Aunque no sean objetivos del estudio, los días de ingreso hospitalario y la aparición de morbilidad asociada a la cirugía a buen seguro se verían reducidos fundamentándonos en la bibliografía existente. Además, las encuestas realizadas nos muestran el déficit de protocolos, actitudes clínicas y formación que reclaman médicos y personal de enfermería

Prioridades de investigación en términos de fluidoterapia perioperatoria y monitorización hemodinámica: encuesta de consenso Delphi del Subcomité de Fluidoterapia y Monitorización hemodinámica de la Sección de Hemostasia, Medicina Transfusional y Fluidoterapia (SHTF) de la Sociedad Española de Anestesiología y Reanimación (SEDAR)

Background Research in fluid therapy and perioperative hemodynamic monitoring is difficult and expensive. The objectives of this study were to summarize these topics and to prioritize these topics in order of research importance. Methods Electronic structured Delphi questionnaire over three rounds among 30 experts in fluid therapy and hemodynamic monitoring identified through the Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section of the Spanish Society of Anesthesiology and Critical Care. Results 77 topics were identified and ranked in order of prioritization. Topics were categorized into themes of crystalloids, colloids, hemodynamic monitoring and others. 31 topics were ranked as essential research priority. To determine whether intraoperative hemodynamic optimization algorithms based on the invasive or noninvasive Hypotension Prediction Index versus other management strategies could decrease the incidence of postoperative complications. As well as whether the use of renal stress biomarkers together with a goal-directed fluid therapy protocol could reduce hospital stay and the incidence of acute kidney injury in adult patients undergoing non-cardiac surgery, reached the highest consensus. Conclusions The Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section of the Spanish Society of Anesthesiology and Critical Care will use these results to carry out the research.Antecedentes La investigación sobre fluidoterapia y monitorización hemodinámica perioperatorias es difícil y costosa. Los objetivos del presente estudio fueron resumir y priorizar estas cuestiones, en orden de importancia investigadora. Métodos Cuestionario estructurado electrónico Delphi a lo largo de tres rondas entre 30 expertos en fluidoterapia y monitorización hemodinámica identificados a través del Subcomité de Fluidoterapia y Monitorización hemodinámica de la Sección de Hemostasis, Medicina Transfusional y Fluidoterapia de la Sociedad española de Anestesiología y Reanimación. Resultados Se identificaron 77 cuestiones, que se clasificaron en orden de priorización. Las cuestiones se categorizaron en temas de cristaloides, coloides, monitorización hemodinámica y otros. Se categorizaron 31 cuestiones como de prioridad investigadora esencial, para determinar si los algoritmos de optimización hemodinámica intraoperatorios basados en el Índice de predicción de hipotensión invasivo o no invasivo frente a otras estrategias de manejo podrían reducir la incidencia de complicaciones postoperatorias, así como si el uso de biomarcadores del estrés renal junto con un protocolo de fluidoterapia dirigido por objetivos podría reducir la estancia hospitalaria y la incidencia de insuficiencia renal aguda en pacientes adultos sometidos a cirugía no cardiaca, lográndose el más alto consenso. Conclusiones El Subcomité de Fluidoterapia y Monitorización hemodinámica de la Sección de Hemostasis, Medicina Transfusional y Fluidoterapia de la Sociedad española de Anestesiología y Reanimación utilizará estos resultados para la realización de investigació

Effect of Intraoperative High Positive End-Expiratory Pressure (PEEP) With Recruitment Maneuvers vs Low PEEP on Postoperative Pulmonary Complications in Obese Patients: A Randomized Clinical Trial.

IMPORTANCE An intraoperative higher level of positive end-expiratory positive pressure (PEEP) with alveolar recruitment maneuvers improves respiratory function in obese patients undergoing surgery, but the effect on clinical outcomes is uncertain

Effect of intraoperative high Positive End-Expiratory Pressure (PEEP) with recruitment maneuvers vs low PEEP on postoperative pulmonary complications in obese patients : a randomized clinical trial

IMPORTANCE An intraoperative higher level of positive end-expiratory positive pressure (PEEP) with alveolar recruitment maneuvers improves respiratory function in obese patients undergoing surgery, but the effect on clinical outcomes is uncertain. OBJECTIVE To determine whether a higher level of PEEP with alveolar recruitment maneuvers decreases postoperative pulmonary complications in obese patients undergoing surgery compared with a lower level of PEEP. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial of 2013 adults with body mass indices of 35 or greater and substantial risk for postoperative pulmonary complications who were undergoing noncardiac, nonneurological surgery under general anesthesia. The trial was conducted at 77 sites in 23 countries from July 2014-February 2018; final follow-up: May 2018. INTERVENTIONS Patients were randomized to the high level of PEEP group (n = 989), consisting of a PEEP level of 12 cm H2O with alveolar recruitment maneuvers (a stepwise increase of tidal volume and eventually PEEP) or to the low level of PEEP group (n = 987), consisting of a PEEP level of 4 cm H2O. All patients received volume-controlled ventilation with a tidal volume of 7 mL/kg of predicted body weight. MAIN OUTCOMES AND MEASURES The primary outcomewas a composite of pulmonary complications within the first 5 postoperative days, including respiratory failure, acute respiratory distress syndrome, bronchospasm, new pulmonary infiltrates, pulmonary infection, aspiration pneumonitis, pleural effusion, atelectasis, cardiopulmonary edema, and pneumothorax. Among the 9 prespecified secondary outcomes, 3 were intraoperative complications, including hypoxemia (oxygen desaturation with SpO(2) 1 minute). RESULTS Among 2013 adults who were randomized, 1976 (98.2%) completed the trial (mean age, 48.8 years; 1381 [69.9%] women; 1778 [90.1%] underwent abdominal operations). In the intention-to-treat analysis, the primary outcome occurred in 211 of 989 patients (21.3%) in the high level of PEEP group compared with 233 of 987 patients (23.6%) in the low level of PEEP group (difference, -2.3%[95% CI, -5.9% to 1.4%]; risk ratio, 0.93 [95% CI, 0.83 to 1.04]; P =.23). Among the 9 prespecified secondary outcomes, 6 were not significantly different between the high and low level of PEEP groups, and 3 were significantly different, including fewer patients with hypoxemia (5.0% in the high level of PEEP group vs 13.6% in the low level of PEEP group; difference, -8.6%[95% CI, -11.1% to 6.1%]; P <.001). CONCLUSIONS AND RELEVANCE Among obese patients undergoing surgery under general anesthesia, an intraoperative mechanical ventilation strategy with a higher level of PEEP and alveolar recruitment maneuvers, compared with a strategy with a lower level of PEEP, did not reduce postoperative pulmonary complications

Effect of Intraoperative High Positive End-Expiratory Pressure (PEEP) With Recruitment Maneuvers vs Low PEEP on Postoperative Pulmonary Complications in Obese Patients: A Randomized Clinical Trial (vol 321, pg 2292, 2019)

status: publishe